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Ng KB, Guiu Hernandez E, Haszard J, Macrae P, Huckabee ML, Cakmak YO. Transcutaneous auricular vagus nerve stimulation alters cough sensitivity depending on stimulation parameters: potential implications for aspiration risk. Front Neurosci 2024; 18:1265894. [PMID: 38406583 PMCID: PMC10885700 DOI: 10.3389/fnins.2024.1265894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/03/2024] [Indexed: 02/27/2024] Open
Abstract
Background Transcutaneous auricular vagus nerve stimulation (taVNS) is considered a safe and promising tool for limb rehabilitation after stroke, but its effect on cough has never been studied. It is known that the ear and larynx share vagal afferent pathways, suggesting that stimulating the ear with taVNS might have effects on cough sensitivity. The specific stimulation parameters used can influence outcomes. Objective To investigate the effect of various stimulation parameters on change in cough sensitivity, compared to the reference parameter of 25 Hz stimulation at the left concha (most commonly-used parameter for stroke rehabilitation). Design, setting, and participants: Randomized, single-blind, active-controlled, eight-period cross-over design conducted March to August 2022 at a New Zealand research laboratory with 16 healthy participants. Interventions All participants underwent eight stimulation conditions which varied by stimulation side (right ear, left ear), zone (ear canal, concha), and frequency (25 Hz, 80 Hz). Main outcome measures: Change in natural and suppressed cough threshold (from baseline to after 10 min of stimulation) assessed using a citric acid cough reflex test. Results When compared to the reference parameter of 25 Hz stimulation at the left concha, there was a reduction in natural cough threshold of -0.16 mol/L for 80 Hz stimulation at the left canal (p = 0.004), indicating increased sensitivity. For the outcome measure of suppressed cough threshold, there was no significant effect of any of the stimulation conditions compared to the active reference. Conclusion Since stroke patients often have cough hyposensitivity with resulting high risk of silent aspiration, using 80 Hz taVNS at the left canal may be a better choice for future stroke rehabilitation studies than the commonly used 25 Hz taVNS at the left concha. Treatment parameters should be manipulated in future sham-controlled trials to maximize any potential treatment effect of taVNS in modulating cough sensitivity. Clinical trial registration ACTRN12623000128695.
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Affiliation(s)
- Karen B. Ng
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
- University of Canterbury Rose Centre for Stroke Recovery and Research, Christchurch, New Zealand
| | - Esther Guiu Hernandez
- University of Canterbury Rose Centre for Stroke Recovery and Research, Christchurch, New Zealand
| | - Jillian Haszard
- Division of Health Sciences, Biostatistics Centre, University of Otago, Dunedin, New Zealand
| | - Phoebe Macrae
- University of Canterbury Rose Centre for Stroke Recovery and Research, Christchurch, New Zealand
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand
| | - Maggie-Lee Huckabee
- University of Canterbury Rose Centre for Stroke Recovery and Research, Christchurch, New Zealand
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand
| | - Yusuf O. Cakmak
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
- Point-of-Care Technologies Theme, Centre for Bioengineering, University of Otago, Dunedin, New Zealand
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Ntoumenopoulos G, Andersen T, Hardingham NM. Upper airway assessment and its implications for interventions by respiratory physiotherapists. Physiother Theory Pract 2024; 40:184-189. [PMID: 35904123 DOI: 10.1080/09593985.2022.2106916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 07/16/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND When noninvasive interventions such as chest physiotherapy fail, then more aggressive interventions for airway secretion clearance with nasotracheal airway suctioning may be required. Clinicians however have to insert the nasotracheal suction catheter "blindly" and the success of being able to trigger a cough and pass through the vocal folds with a suction catheter is low. CASE DESCRIPTION The patient, a 48-year-old male underwent a heart and lung transplant. Following extubation, the patient developed secretion retention with a weak ineffective cough and swallow and required physiotherapy interventions with frequent "blind" passes of nasotracheal suctioning. OUTCOMES The patient required nasotracheal suction with frequent multiple failed attempts before successful passage of the suction catheter to trigger a cough reflex and clear secretions. A combined physiotherapist and speech and language therapist intervention during fiberoptic endoscopic evaluation of swallow (FEES) was recorded to both evaluate swallow and passage of the suction catheter. The video illustrated the successful passage of a suctioning catheter through the vocal folds leading to an effective cough and airway clearance. DISCUSSION We present a case report demonstrating that it is feasible to visualize the upper airways during nasotracheal suctioning as an objective means to guide the more accurate successful insertion of the suction catheter past the vocal folds. Rather than "blind" placement of nasotracheal suction catheters visualization using transnasal laryngoscopy should be useful to increase chances of passing through the vocal folds.
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Affiliation(s)
| | - Tiina Andersen
- Norwegian Centre of Excellence for Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, Bergen, Norway
| | - Nicola M Hardingham
- Speech Pathology Department, St Vincent's Hospital, Sydney, Australia
- School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, Australia
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Al-Biltagi M, Bediwy AS, Saeed NK. Cough as a neurological sign: What a clinician should know. World J Crit Care Med 2022; 11:115-128. [PMID: 36331984 PMCID: PMC9136724 DOI: 10.5492/wjccm.v11.i3.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 03/24/2022] [Accepted: 04/26/2022] [Indexed: 02/06/2023] Open
Abstract
Cough is a common respiratory complaint driving patients to seek medical advice. Besides being a fundamental respiratory sign, it is also a crucial neurological sign. There are three main types of coughs: Reflex cough (type I), voluntary cough (type II), and evoked cough (type III). Cough is a reflex predominantly mediated by control centers in the respiratory areas of the brainstem, modulated by the cerebral cortex. Cough reflex sensitivity could be increased in many neurological disorders such as brainstem space-occupying lesions, medullary lesions secondary to Chiari type I malformations, tics disorders such as Tourette's syndrome, somatic cough, cerebellar neurodegenerative diseases, and chronic vagal neuropathy due to allergic and non-allergic conditions. Meanwhile, cough sensitivity decreases in multiple sclerosis, brain hypoxia, cerebral hemispheric stroke with a brainstem shock, Parkinson's disease, dementia due to Lewy body disease, amyotrophic lateral sclerosis, and peripheral neuropathy as diabetic neuropathy, hereditary sensory and autonomic neuropathy type IV, vitamin B12, and folate deficiency. Arnold's nerve ear-cough reflex, syncopal cough, cough headache, opioids-associated cough, and cough-anal reflex are signs that could help diagnose underlying neurological conditions. Cough reflex testing is a quick, easy, and cheap test performed during the cranial nerve examination. In this article, we reviewed the role of cough in various neurological disorders that increase or decrease cough sensitivity.
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Affiliation(s)
- Mohammed Al-Biltagi
- Department of Pediatrics, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Manama 26671, Bahrain
- Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta 31512, Al Gharbia, Egypt
- Department of Pediatrics, University Medical Center, Dr. Sulaiman Al Habib Medical Group, Manama 26671, Bahrain
| | - Adel Salah Bediwy
- Department of Chest Disease, Faculty of Medicine, Tanta University, Tanta 31512, Alghrabia, Egypt
- Department of Chest Disease, University Medical Center, King Abdullah Medical City, Arabian Gulf University, Manama 26671, Bahrain
- Department of Chest Diseases, University Medical Center, Dr. Sulaiman Al Habib Medical Group, Manama 26671, Bahrain
| | - Nermin Kamal Saeed
- Department of Pathology, Salmaniya Medical Complex, Ministry of Health, Kingdom of Bahrain, Manama 26671, Bahrain
- Department of Pathology, Irish Royal College of Surgeon, Busaiteen 15503, Almuharraq, Bahrain
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Pekacka-Egli AM, Herrmann J, Spielmanns M, Goerg A, Schulz K, Zenker E, Windisch W, Kulnik ST. Inhalation Therapy with Nebulized Capsaicin in a Patient with Oropharyngeal Dysphagia Post Stroke: A Clinical Case Report. Geriatrics (Basel) 2022; 7:geriatrics7020027. [PMID: 35314599 PMCID: PMC8938770 DOI: 10.3390/geriatrics7020027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 02/25/2022] [Accepted: 02/26/2022] [Indexed: 12/04/2022] Open
Abstract
Dysphagia and aspiration risk are common sequelae of stroke, leading to increased risk of stroke-associated pneumonia. This is often aggravated by stroke-related impairment of cough, the most immediate mechanical defense mechanism against aspiration. In humans, reflex cough can be repeatedly and safely elicited by inhalation of nebulized capsaicin, a compound contained in chili peppers. Could this cough-eliciting property of capsaicin support the recovery of stroke survivors who present with dysphagia and aspiration risk? We present a clinical case report of a 73-year-old man, admitted to inpatient stroke rehabilitation following a right middle cerebral artery infarct with subsequent dysphagia and hospital-acquired pneumonia. A course of daily inhalation therapy with nebulized capsaicin was initiated, triggering reflex coughs to support secretion clearance and prevent recurrence of pneumonia. Clinical observations in each inhalation therapy session demonstrate good patient response, safety and tolerability of nebulized capsaicin in this mode of application. Repeated Fiberoptic Endoscopic Evaluation of Swallowing (FEES) assessments show concurrent improvement in the patient’s swallowing status. Inhalation therapy with nebulized capsaicin may offer a viable treatment to facilitate coughing and clearing of secretions, and to minimize aspiration and risk of aspiration-related pneumonia post stroke. Further investigation in a randomized controlled trial design is warranted.
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Affiliation(s)
- Anna Maria Pekacka-Egli
- Department for Pulmonary Medicine and Sleep Medicine, Zürcher RehaZentren, Klinik Wald, 8636 Wald, Switzerland; (J.H.); (M.S.); (A.G.); (K.S.); (E.Z.)
- Department for Neurology and Neurorehabilitation, Zürcher RehaZentren, Klinik Wald, 8636 Wald, Switzerland
- Correspondence: ; Tel.: +41-55-256-69-70
| | - Jana Herrmann
- Department for Pulmonary Medicine and Sleep Medicine, Zürcher RehaZentren, Klinik Wald, 8636 Wald, Switzerland; (J.H.); (M.S.); (A.G.); (K.S.); (E.Z.)
- Department for Neurology and Neurorehabilitation, Zürcher RehaZentren, Klinik Wald, 8636 Wald, Switzerland
| | - Marc Spielmanns
- Department for Pulmonary Medicine and Sleep Medicine, Zürcher RehaZentren, Klinik Wald, 8636 Wald, Switzerland; (J.H.); (M.S.); (A.G.); (K.S.); (E.Z.)
- Department for Pulmonary Medicine, Faculty of Health, University Witten-Herdecke, 58455 Witten, Germany;
| | - Arthur Goerg
- Department for Pulmonary Medicine and Sleep Medicine, Zürcher RehaZentren, Klinik Wald, 8636 Wald, Switzerland; (J.H.); (M.S.); (A.G.); (K.S.); (E.Z.)
- Department for Neurology and Neurorehabilitation, Zürcher RehaZentren, Klinik Wald, 8636 Wald, Switzerland
| | - Katharina Schulz
- Department for Pulmonary Medicine and Sleep Medicine, Zürcher RehaZentren, Klinik Wald, 8636 Wald, Switzerland; (J.H.); (M.S.); (A.G.); (K.S.); (E.Z.)
- Department for Neurology and Neurorehabilitation, Zürcher RehaZentren, Klinik Wald, 8636 Wald, Switzerland
| | - Eveline Zenker
- Department for Pulmonary Medicine and Sleep Medicine, Zürcher RehaZentren, Klinik Wald, 8636 Wald, Switzerland; (J.H.); (M.S.); (A.G.); (K.S.); (E.Z.)
- Department for Neurology and Neurorehabilitation, Zürcher RehaZentren, Klinik Wald, 8636 Wald, Switzerland
| | - Wolfram Windisch
- Department for Pulmonary Medicine, Faculty of Health, University Witten-Herdecke, 58455 Witten, Germany;
| | - Stefan Tino Kulnik
- Faculty of Health, Social Care and Education, Kingston University and St. George’s University of London, London SW17 0RE, UK;
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McGarvey L, Rubin BK, Ebihara S, Hegland K, Rivet A, Irwin RS, Bolser DC, Chang AB, Gibson PG, Mazzone SB. Global Physiology and Pathophysiology of Cough: Part 2. Demographic and Clinical Considerations: CHEST Expert Panel Report. Chest 2021; 160:1413-1423. [PMID: 33905678 PMCID: PMC8692102 DOI: 10.1016/j.chest.2021.04.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/15/2021] [Accepted: 04/18/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Cough characteristics vary between patients, and this can impact clinical diagnosis and care. The purpose of part two of this state-of-the-art review is to update the American College of Chest Physicians (CHEST) 2006 guideline on global physiology and pathophysiology of cough. STUDY DESIGN AND METHODS A review of the literature was conducted using PubMed and MEDLINE databases from 1951 to 2019 using prespecified search terms. RESULTS We describe the demographics of typical patients with cough in the clinical setting, including how cough characteristics change across age. We summarize the effect of common clinical conditions impacting cough mechanics and the physical properties of mucus on airway clearance. INTERPRETATION This is the second of a two-part update to the 2006 CHEST cough guideline; it complements part one on basic phenomenology of cough by providing an extended clinical picture of cough along with the factors that alter cough mechanics and efficiency in patients. A greater understanding of the physiology and pathophysiology of cough will improve clinical management.
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Affiliation(s)
- Lorcan McGarvey
- Wellcome-Wolfson Institute of Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland.
| | - Bruce K Rubin
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA
| | - Satoru Ebihara
- Department of Internal Medicine and Rehabilitation Science, Tohoku University Graduate School of Medicine, Sendai, Japan; Department of Rehabilitation Medicine, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Karen Hegland
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, FL
| | - Alycia Rivet
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, FL
| | - Richard S Irwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Massachusetts Medical School and UMass Memorial Medical Center, Worcester, MA
| | - Donald C Bolser
- Department of Physiological Sciences, University of Florida, Gainesville, FL
| | - Anne B Chang
- Division of Child Health, Menzies School of Health Research, Darwin, NT, Australia; Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Queensland's University of Technology, Brisbane, QLD, Australia
| | - Peter G Gibson
- Hunter Medical Research Institute, Newcastle, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Stuart B Mazzone
- Department of Anatomy and Neuroscience, The University of Melbourne, Melbourne, VIC, Australia
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Swallowing with Noninvasive Positive-Pressure Ventilation (NPPV) in Individuals with Muscular Dystrophy: A Qualitative Analysis. Dysphagia 2019; 35:32-41. [PMID: 30859305 DOI: 10.1007/s00455-019-09997-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 03/05/2019] [Indexed: 12/13/2022]
Abstract
The purpose of the study is to describe experiences of swallowing with two forms of noninvasive positive-pressure ventilation (NPPV): mouthpiece NPPV (M-NPPV) and nasal bilevel positive airway pressure (BPAP) in people with muscular dystrophy. Ten men (ages 22-42 years; M = 29.3; SD = 7.1) with muscular dystrophy (9 with Duchenne's; 1 with Becker's) completed the Eating Assessment Tool (EAT-10; Ann Otol Rhinol Laryngol 117(12):919-924 [33]) and took part in semi-structured interviews. The interviews were audio recorded, transcribed, and verified. Phenomenological qualitative research methods were used to code (Dedoose.com) and develop themes. All participants affirmed dysphagia symptoms via responses on the EAT-10 (M = 11.3; SD = 6.38; Range = 3-22) and reported eating and drinking with M-NPPV and, to a lesser extent, nasal BPAP. Analysis of interview data revealed three primary themes: (1) M-NPPV improves the eating/drinking experience: Most indicated that using M-NPPV reduced swallowing-related dyspnea. (2) NPPV affects breathing-swallowing coordination: Participants described challenges and compensations in coordinating swallowing with ventilator-delivered inspirations, and that the time needed to chew solid foods between ventilator breaths may lead to dyspnea and fatigue. (3) M-NPPV aids cough effectiveness: Participants described improved cough strength following large M-NPPV delivered inspirations (with or without breath stacking). Although breathing-swallowing coordination is challenging with NPPV, participants reported that eating and drinking is more comfortable than when not using it. Overall, eating and drinking with NPPV delivered via a mouthpiece is preferred and is likely safer for swallowing than with nasal BPAP. M-NPPV (but not nasal BPAP) is reported to improve cough effectiveness, an important pulmonary defense in this population.
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Determining Peak Cough Flow Cutoff Values to Predict Aspiration Pneumonia Among Patients With Dysphagia Using the Citric Acid Reflexive Cough Test. Arch Phys Med Rehabil 2018; 99:2532-2539.e1. [DOI: 10.1016/j.apmr.2018.06.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/04/2018] [Accepted: 06/11/2018] [Indexed: 11/20/2022]
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Won HK, Yoon SJ, Song WJ. The double-sidedness of cough in the elderly. Respir Physiol Neurobiol 2018; 257:65-69. [PMID: 29337268 DOI: 10.1016/j.resp.2018.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/07/2018] [Accepted: 01/11/2018] [Indexed: 12/11/2022]
Abstract
Cough is a physiological reflex to protect airways against aspiration, but also it is one of the most frequent problems that lead patients to seek medical care. Chronic cough is more prevalent in the elderly than younger subjects, and more challenging to manage due to frequent comorbidities and possible side effects from drug treatment. Meanwhile, cough reflex does not decrease with natural aging but is often impaired by pathologic conditions like stroke. The impairment in cough reflex may lead to fatal complication like aspiration pneumonia. In this paper, we reviewed epidemiology and clinical considerations for chronic cough in the elderly, and summarized aging-related changes in cough reflex and also possible ways to normalize cough reflex and prevent aspiration pneumonia.
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Affiliation(s)
- Ha-Kyeong Won
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sol-Ji Yoon
- Division of Geriatrics, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Woo-Jung Song
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
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Mills C, Jones R, Huckabee ML. Measuring voluntary and reflexive cough strength in healthy individuals. Respir Med 2017; 132:95-101. [DOI: 10.1016/j.rmed.2017.09.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 09/04/2017] [Accepted: 09/25/2017] [Indexed: 01/03/2023]
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Suntrup-Krueger S, Kemmling A, Warnecke T, Hamacher C, Oelenberg S, Niederstadt T, Heindel W, Wiendl H, Dziewas R. The impact of lesion location on dysphagia incidence, pattern and complications in acute stroke. Part 2: Oropharyngeal residue, swallow and cough response, and pneumonia. Eur J Neurol 2017; 24:867-874. [PMID: 28449405 DOI: 10.1111/ene.13307] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 04/03/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE Dysphagia is a well-known complication of acute stroke. Given the complexity of cerebral swallowing control it is still difficult to predict which patients are likely to develop swallowing dysfunction based on their neuroimaging. In Part 2 of a comprehensive voxel-based imaging study, whether the location of a stroke lesion can be correlated with further dysfunctional swallowing patterns, pulmonary protective reflexes and pneumonia was evaluated. METHODS In all, 200 acute stroke cases were investigated applying flexible endoscopic evaluation of swallowing within 96 h from admission. Lesions were mapped using patients' computed tomography/magnetic resonance images and these were registered to a standard space. The percentage of lesioned volume of 137 anatomically defined brain regions was determined on a voxel basis (FSL5.0). Region-specific odds ratios (ORs) were calculated with respect to the presence of oropharyngeal residue, delayed swallow response, insufficient cough reflex and occurrence of pneumonia during hospital stay. Colour-coded lesion location maps of brain regions with significant ORs were created (P < 0.05). RESULTS Lesion maps for residue and impaired swallow response depicted parietal-temporal areas of the right hemisphere. Limbic structures in the right hemisphere and sensory regions on the left were associated with cough reflex disturbance. There was no overlap of lesion maps for impaired swallow response and insufficient cough reflex or pneumonia, but substantial overlap between the last two conditions. CONCLUSIONS This study gives new insights on the cortical representation of single components of swallowing and airway protection behaviours. The lesion model may help to risk-stratify patients for dysphagia and pneumonia based on their brain scan.
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Affiliation(s)
| | - A Kemmling
- Institute of Neuroradiology, University Hospital Lübeck, Lübeck, Germany
| | - T Warnecke
- Department of Neurology, University of Münster, Münster, Germany
| | - C Hamacher
- Department of Neurology, University of Münster, Münster, Germany
| | - S Oelenberg
- Department of Neurology, University of Münster, Münster, Germany
| | - T Niederstadt
- Department of Clinical Radiology, University of Münster, Münster, Germany
| | - W Heindel
- Department of Clinical Radiology, University of Münster, Münster, Germany
| | - H Wiendl
- Department of Neurology, University of Münster, Münster, Germany
| | - R Dziewas
- Department of Neurology, University of Münster, Münster, Germany
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Abstract
This review examines the current level of knowledge and techniques available for the study of laryngeal reflexes. Overall, the larynx is under constant control of several systems (including respiration, swallowing and cough) as well as sensory motor reflex responses involving glossopharyngeal, pharyngeal, laryngeal, and tracheobronchial sensory receptors. Techniques for the clinical assessment of these reflexes are emerging and need to be examined for sensitivity and specificity in identifying laryngeal sensory disorders. Quantitative assessment methods for the diagnosis of sensory reductions and sensory hypersensitivity may account for laryngeal disorders, such as chronic cough, paradoxical vocal fold disorder, and muscular tension dysphonia. The development of accurate assessment techniques could improve our understanding of the mechanisms involved in these disorders.
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Lee SJ, Lee KW, Kim SB, Lee JH, Park MK. Voluntary Cough and Swallowing Function Characteristics of Acute Stroke Patients Based on Lesion Type. Arch Phys Med Rehabil 2015; 96:1866-72. [DOI: 10.1016/j.apmr.2015.06.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 06/29/2015] [Accepted: 06/30/2015] [Indexed: 02/09/2023]
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Britton D, Benditt JO, Merati AL, Miller RM, Stepp CE, Boitano L, Hu A, Ciol MA, Yorkston KM. Associations between laryngeal and cough dysfunction in motor neuron disease with bulbar involvement. Dysphagia 2014; 29:637-46. [PMID: 25037590 DOI: 10.1007/s00455-014-9554-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 06/21/2014] [Indexed: 02/07/2023]
Abstract
True vocal fold (TVF) dysfunction may lead to cough ineffectiveness. In individuals with motor neuron disease (MND), cough impairment in the context of dysphagia increases risk for aspiration and respiratory failure. This study characterizes differences and associations between TVF kinematics and airflow during cough in individuals with bulbar MND. Sequential glottal angles associated with TVF movements during volitional cough were analyzed from laryngeal video endoscopy examinations of adults with bulbar MND (n = 12) and healthy controls (n = 12) and compared with simultaneously collected cough-related airflow measures. Significant group differences were observed with airflow and TVF measures: volume acceleration (p ≤ 0.001) and post-compression abduction TVF angle average velocity (p = 0.002) were lower and expiratory phase rise time (p = 0.001) was higher in the MND group. Reductions in maximum TVF angle during post-compression abduction in the MND group approached significance (p = 0.09). All subjects demonstrated complete TVF and supraglottic closure during the compression phase of cough, except for incomplete supraglottic closure in 2/12 MND participants. A strong positive relationship between post-compression maximum TVF abduction angle and peak expiratory cough flow was observed in the MND group, though it was not statistically significant (r = 0.55; p = 0.098). Reductions in the speed and extent of TVF abduction are seen during the expulsion phase of cough in individuals with MND. This may contribute to cough impairment and morbidity.
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Affiliation(s)
- Deanna Britton
- Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific Street, Box 356490, Seattle, WA, 98195, USA,
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Monroe MD, Manco K, Bennett R, Huckabee ML. Citric acid cough reflex test: Establishing normative data. SPEECH LANGUAGE AND HEARING 2014. [DOI: 10.1179/2050572814y.0000000041] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Kulnik ST, Rafferty GF, Birring SS, Moxham J, Kalra L. A pilot study of respiratory muscle training to improve cough effectiveness and reduce the incidence of pneumonia in acute stroke: study protocol for a randomized controlled trial. Trials 2014; 15:123. [PMID: 24725276 PMCID: PMC4021694 DOI: 10.1186/1745-6215-15-123] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 03/28/2014] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND After stroke, pneumonia is a relevant medical complication that can be precipitated by aspiration of saliva, liquids, or solid food. Swallowing difficulty and aspiration occur in a significant proportion of stroke survivors. Cough, an important mechanism protecting the lungs from inhaled materials, can be impaired in stroke survivors, and the likely cause for this impairment is central weakness of the respiratory musculature. Thus, respiratory muscle training in acute stroke may be useful in the recovery of respiratory muscle and cough function, and may thereby reduce the risk of pneumonia. The present study is a pilot study, aimed at investigating the validity and feasibility of this approach by exploring effect size, safety, and patient acceptability of the intervention. METHODS/DESIGN Adults with moderate to severe stroke impairment (National Institutes of Health Stroke Scale (NIHSS) score 5 to 25 at the time of admission) are recruited within 2 weeks of stroke onset. Participants must be able to perform voluntary respiratory maneuvers. Excluded are patients with increased intracranial pressure, uncontrolled hypertension, neuromuscular conditions other than stroke, medical history of asthma or chronic obstructive pulmonary disease, and recent cardiac events. Participants are randomized to receive inspiratory, expiratory, or sham respiratory training over a 4-week period, by using commercially available threshold resistance devices. Participants and caregivers, but not study investigators, are blind to treatment allocation. All participants receive medical care and stroke rehabilitation according to the usual standard of care. The following assessments are conducted at baseline, 4 weeks, and 12 weeks: Voluntary and reflex cough flow measurements, forced spirometry, respiratory muscle strength tests, incidence of pneumonia, assessments of safety parameters, and self-reported activity of daily living. The primary outcome is peak expiratory cough flow of voluntary cough, a parameter indicating the effectiveness of cough. Secondary outcomes are incidence of pneumonia, peak expiratory cough flow of reflex cough, and maximum inspiratory and expiratory mouth pressures. DISCUSSION Various novel pharmacologic and nonpharmacologic approaches for preventing stroke-associated pneumonia are currently being researched. This study investigates a novel strategy based on an exercise intervention for cough rehabilitation. TRIAL REGISTRATION Current Controlled Trials ISRCTN40298220.
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Affiliation(s)
- Stefan Tino Kulnik
- Stroke Research Team, Department of Clinical Neuroscience, Institute of Psychiatry, King’s College London, PO Box 41, Denmark Hill, London SE5 8AF, UK
| | - Gerrard Francis Rafferty
- Department of Respiratory Medicine and Allergy, School of Medicine, King’s College London, Chest Unit, Cheyne Wing, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Surinder S Birring
- Division of Asthma, Allergy & Lung Biology, School of Medicine, King’s College London, Chest Unit, Cheyne Wing, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
| | - John Moxham
- Department of Respiratory Medicine and Allergy, King’s Health Partners, Chest Unit, Cheyne Wing, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Lalit Kalra
- Stroke Research Team, Department of Clinical Neuroscience, Institute of Psychiatry, King’s College London, PO Box 41, Denmark Hill, London SE5 8AF, UK
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Tomori Z, Donic V, Benacka R, Jakus J, Gresova S. Resuscitation and auto resuscitation by airway reflexes in animals. Cough 2013; 9:21. [PMID: 23968541 PMCID: PMC3828820 DOI: 10.1186/1745-9974-9-21] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 08/19/2013] [Indexed: 11/19/2022] Open
Abstract
Various diseases often result in decompensation requiring resuscitation. In infants moderate hypoxia evokes a compensatory augmented breath - sigh and more severe hypoxia results in a solitary gasp. Progressive asphyxia provokes gasping respiration saving the healthy infant - autoresuscitation by gasping. A neonate with sudden infant death syndrome, however, usually will not survive. Our systematic research in animals indicated that airway reflexes have similar resuscitation potential as gasping respiration. Nasopharyngeal stimulation in cats and most mammals evokes the aspiration reflex, characterized by spasmodic inspiration followed by passive expiration. On the contrary, expiration reflex from the larynx, or cough reflex from the pharynx and lower airways manifest by a forced expiration, which in cough is preceded by deep inspiration. These reflexes of distinct character activate the brainstem rhythm generators for inspiration and expiration strongly, but differently. They secondarily modulate the control mechanisms of various vital functions of the organism. During severe asphyxia the progressive respiratory insufficiency may induce a life-threatening cardio-respiratory failure. The sniff- and gasp-like aspiration reflex and similar spasmodic inspirations, accompanied by strong sympatho-adrenergic activation, can interrupt a severe asphyxia and reverse the developing dangerous cardiovascular and vasomotor dysfunctions, threatening with imminent loss of consciousness and death. During progressive asphyxia the reversal of gradually developing bradycardia and excessive hypotension by airway reflexes starts with reflex tachycardia and vasoconstriction, resulting in prompt hypertensive reaction, followed by renewal of cortical activity and gradual normalization of breathing. A combination of the aspiration reflex supporting venous return and the expiration or cough reflex increasing the cerebral perfusion by strong expirations, provides a powerful resuscitation and autoresuscitation potential, proved in animal experiments. They represent a simple but unique model tested in animal experiments.
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Affiliation(s)
- Zoltan Tomori
- Department of Human Physiology Faculty of Medicine, University of PJ Safarik,
Kosice, Slovakia
| | - Viliam Donic
- Department of Human Physiology Faculty of Medicine, University of PJ Safarik,
Kosice, Slovakia
| | - Roman Benacka
- Department of Pathophysiology, Faculty of Medicine, University of PJ Safarik,
Kosice, Slovakia
| | - Jan Jakus
- Jessenius Faculty of Medicine in Martin, Comenius University, Bratislava,
Slovakia
| | - Sona Gresova
- Department of Human Physiology Faculty of Medicine, University of PJ Safarik,
Kosice, Slovakia
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17
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Lee SC, Kang SW, Kim MT, Kim YK, Chang WH, Im SH. Correlation Between Voluntary Cough and Laryngeal Cough Reflex Flows in Patients With Traumatic Brain Injury. Arch Phys Med Rehabil 2013; 94:1580-3. [DOI: 10.1016/j.apmr.2012.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 10/25/2012] [Accepted: 11/01/2012] [Indexed: 02/07/2023]
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Miles A, Zeng IS, McLauchlan H, Huckabee ML. Cough reflex testing in Dysphagia following stroke: a randomized controlled trial. J Clin Med Res 2013; 5:222-33. [PMID: 23671548 PMCID: PMC3651073 DOI: 10.4021/jocmr1340w] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2013] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Significant health issues and service delivery costs are associated with post-stroke pneumonia related to dysphagia. Silent aspiration is known to increase pneumonia and mortality in this population. The utility of cough reflex testing (CRT) for reducing pneumonia in acute stroke patients was the subject of this randomised, controlled trial. METHODS Patients referred for swallowing evaluation (N = 311) were assigned to either 1) a control group receiving standard evaluation or 2) an experimental group receiving standard evaluation with CRT. Participants in the experimental group were administered nebulised citric acid with test results contributing to clinical decisions. Outcomes for both groups were measured by pneumonia rates at 3 months post evaluation and other clinical indices of swallowing management. RESULTS Analysis of the data identified no significant differences between groups in pneumonia rate (P = 0.38) or mortality (P = 0.15). Results of CRT were shown to influence diet recommendations (P < 0.0001) and referrals for instrumental assessment (P < 0.0001). CONCLUSIONS Despite differences in clinical management between groups, the end goal of reducing pneumonia in post stroke dysphagia was not achieved.
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Affiliation(s)
- Anna Miles
- Department of Communication Disorders, The University of Canterbury, 66 Stewart St, Christchurch 8011, New Zealand
- Speech Science, School of Psychology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Irene S.L. Zeng
- Centre for Clinical Research and Effective Practice, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand
| | - Helen McLauchlan
- Counties Manukau District Health Board, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand
| | - Maggie-Lee Huckabee
- Swallowing Rehabilitation Research Laboratory at the New Zealand Brain Research Institute, Department of Communication Disorders, The University of Canterbury, 66 Stewart St, Christchurch 8011, New Zealand
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19
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Miles A, Huckabee ML. Intra- and inter-rater reliability for judgement of cough following citric acid inhalation. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2013; 15:209-215. [PMID: 22873621 DOI: 10.3109/17549507.2012.692812] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This study investigated the inter-rater and intra-rater reliability of subjective judgements of cough in patients following inhalation of citric acid. Eleven speech-language pathologists (SLPs) currently using cough reflex testing in their clinical practice (experienced raters) and 34 SLPs with no experience using cough reflex testing (inexperienced raters) were recruited to the study. Participants provided a rating of strong, weak, or absent to 10 video segments of cough responses elicited by inhalation of nebulized citric acid. The same video segments presented in a different sequence were re-evaluated by the same clinicians following a 15-minute break. Inter-rater reliability for experienced raters was calculated with a Fleiss' generalized kappa of .487; intra-rater reliability was higher with a kappa of .700. Inexperienced raters showed similar reliability, with kappa values for inter-rater and intra-rater reliability of .363 and .618, respectively. In conclusion, SLPs demonstrate only fair-to-moderate reliability in subjectively judging a patient's cough response to citric acid. Experience in making cough judgements does not improve inter-rater reliability significantly. Further validity and reliability research, including an evaluation of the effect of training on judgement reliability, would be beneficial for guiding clinical policies.
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Affiliation(s)
- Anna Miles
- University of Canterbury, Christchurch, New Zealand.
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20
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Abstract
Studies on cough have come a long way but many shortfalls still exist. These shortfalls can be attributed to: the lack of randomized controlled studies with a focus on cough; studies not using robust cough outcome measures, poor definition of target groups in studies and guidelines, the lack of safe and efficacious treatments; difficulty in defining etiological factors, and the lack of data on the predictors of response to therapies for cough dominant etiologies. Addressing shortfalls in cough therapy that focuses on improving the lives of people with cough requires a systematic approach that includes better medications, high quality studies, improved multidisciplinary guidelines and education (of both health professionals and patients). To achieve new cough therapeutics requires an improved understanding of cough in humans (i.e., not just in animals). Development of new medications without substantial adverse events is long awaited for cough.
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Affiliation(s)
- Anne B Chang
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
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21
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Ebihara S, Ebihara T. Cough in the elderly: A novel strategy for preventing aspiration pneumonia. Pulm Pharmacol Ther 2011; 24:318-23. [DOI: 10.1016/j.pupt.2010.10.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 09/21/2010] [Accepted: 10/02/2010] [Indexed: 02/04/2023]
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Widdicombe J, Addington W, Fontana G, Stephens R. Voluntary and reflex cough and the expiration reflex; implications for aspiration after stroke. Pulm Pharmacol Ther 2011; 24:312-7. [DOI: 10.1016/j.pupt.2011.01.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 01/24/2011] [Accepted: 01/28/2011] [Indexed: 01/31/2023]
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Abstract
This review is an update of recent advances in our understanding of cough suppressants and impairment of cough. Low-dose oral morphine has recently been shown to significantly suppress chronic cough, but the side effect profile of this opioid may limit its widespread utility. Several studies have demonstrated a dissociation between the efficacy of antitussives in some metrics of pathologic cough and their effects on cough sensitivity to inhaled irritants. The relevance of widely used inhaled irritants in understanding pathologic cough and its response to antitussives is questionable. A recent advance in the field is the identification and measurement of an index of sensation related to cough: the urge to cough. This measure highlights the potential involvement of suprapontine regions of the brain in the genesis and potential suppression of cough in the awake human. There are no new studies showing that mucolytic agents are of value as monotherapies for chronic cough. However, some of these drugs, presumably because of their antioxidant activity, may be of use as adjunct therapies or in selected patient populations. The term dystussia (impairment of cough) has been coined recently and represents a common and life-threatening problem in patients with neurologic disease. Dystussia is strongly associated with severe dysphagia and the occurrence of both indicates that the patient has a high risk for aspiration. No pharmacologic treatments ae available for dystussia, but scientists and clinicians with experience in studying chronic cough are well qualified to develop methodologies to address the problem of impaired cough.
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Affiliation(s)
- Donald C Bolser
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL 32610-0144, USA.
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Addington WR, Stephens RE, Phelipa MM, Widdicombe JG, Ockey RR. Intra-abdominal pressures during voluntary and reflex cough. COUGH 2008; 4:2. [PMID: 18447952 PMCID: PMC2427048 DOI: 10.1186/1745-9974-4-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Accepted: 04/30/2008] [Indexed: 02/08/2023]
Abstract
Background Involuntary coughing such as that evoked from the larynx, the laryngeal cough reflex (LCR), triggers a coordinated contraction of the thoracic, abdominal and pelvic muscles, which increases intra-abdominal pressure (IAP), displaces the diaphragm upwards and generates the expiratory force for cough and airway clearance. Changes in the IAP during voluntary cough (VC) and the LCR can be measured via a pressure catheter in the bladder. This study evaluated the physiological characteristics of IAP generated during VC and the LCR including peak and mean pressures and calculations of the area under the curve (AUC) values during the time of the cough event or epoch. Methods Eleven female subjects between the ages of 18 and 75 underwent standard urodynamic assessment with placement of an intravesicular catheter with a fiberoptic strain gauge pressure transducer. The bladder was filled with 200 ml of sterile water and IAP recordings were obtained with VC and the induced reflex cough test (RCT) using nebulized inhaled 20% tartaric acid to induce the LCR. IAP values were used to calculate the area under the curve (AUC) by the numerical integration of intravesicular pressure over time (cm H2O·s). Results The mean (± SEM) AUC values for VC and the LCR were 349.6 ± 55.2 and 986.6 ± 116.8 cm H2O·s (p < 0.01). The mean IAP values were 45.6 ± 4.65 and 44.5 ± 9.31 cm H2O (NS = .052), and the peak IAP values were 139.5 ± 14.2 and 164.9 ± 15.8 cm H2O (p = 0.07) for VC and LCR, respectively. Conclusion The induced LCR is the involuntary rapid and repeated synchronous expiratory muscle activation that causes and sustains an elevated IAP over time, sufficient for airway protection. VC and LCR have different neurophysiological functions. Quantification of the LCR using AUC values and mean or peak IAP values may be useful as a clinical tool for determining neurophysiological airway protection status and provide a quantitative assessment of changes in a patient's functional recovery or decline.
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26
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Groneberg-Kloft B, Feleszko W, Dinh QT, van Mark A, Brinkmann E, Pleimes D, Fischer A. Analysis and evaluation of environmental tobacco smoke exposure as a risk factor for chronic cough. COUGH 2007; 3:6. [PMID: 17475014 PMCID: PMC1884172 DOI: 10.1186/1745-9974-3-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Accepted: 05/02/2007] [Indexed: 11/11/2022]
Abstract
Exposure to environmental tobacco smoke (ETS) and active tobacco smoking has been shown to increase symptoms of bronchial asthma such as bronchoconstriction but effects on other respiratory symptoms remain poorly assessed. Current levels of exposure to tobacco smoke may also be responsible for the development of chronic cough in both children and adults. The present study analyses the effects of tobacco smoke exposure as potential causes of chronic cough. A panel of PubMed-based searches was performed relating the symptom of cough to various forms of tobacco smoke exposure. It was found that especially prenatal and postnatal exposures to ETS have an important influence on children's respiratory health including the symptom of cough. These effects may be prevented if children and pregnant women are protected from exposure to ETS. Whereas the total number of studies adressing the relationship between cough and ETS exposure is relatively small, the present study demonstrated that there is a critical amout of data pointing to a causative role of environmental ETS exposure for the respiratory symptom of cough. Since research efforts have only targeted this effect to a minor extent, future epidemiological and experimental studies are needed to further unravel the relation between ETS and cough.
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Affiliation(s)
- Beatrix Groneberg-Kloft
- Division of Allergy Research, Charité – Universitätsmedizin Berlin, Free University and Humboldt-University, D-13353 Berlin, Germany
| | - Wojciech Feleszko
- Department of Pediatric Pneumology and Allergy, The Medical University Children's Hospital, PL-01-184 Warsaw, Poland
| | - Quoc Thai Dinh
- Department of Medicine, Charité – Universitätsmedizin Berlin, Free University and Humboldt-University, D-13353 Berlin, Germany
| | - Anke van Mark
- Institute of Occupational Medicine, University zu Lübeck, D-23538 Lübeck, Germany
| | - Elke Brinkmann
- Department of Prevention, Norddeutsche Metall-Berufsgenossenschaft, D-30173 Hannover, Germany
| | - Dirk Pleimes
- Division of Allergy Research, Charité – Universitätsmedizin Berlin, Free University and Humboldt-University, D-13353 Berlin, Germany
| | - Axel Fischer
- Division of Allergy Research, Charité – Universitätsmedizin Berlin, Free University and Humboldt-University, D-13353 Berlin, Germany
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Abstract
We review cough from premature birth, mature neonatal life, in childhood and adult life, and in old age. There is a regrettable lack of definitive studies, but many clues in the literature. The cough reflex seems weak in premature infants, but develops with maturity. It is pronounced in childhood, but there seem to be no studies comparing its strength then with that in adulthood. In old age the cough may weaken, as indicated by the prevalence of aspiration pneumonia. These changes are presumably related to the development and degeneration of the afferent and central nervous pathways for cough, which may be reflected in the changes in laryngeal muscle function with age. There is much evidence that age influences the development of the respiratory system in general, and of the immune system which would affect the degree, frequency and clinical issues of cough. Other factors that limit our understanding of the changes in cough with age include the reporting of cough by parents in infants and carers in old age and the use of different diagnostic criteria throughout life. Age-related variation in cough sensitivity seems to be well established, but its quantitation and mechanisms require much further research.
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Affiliation(s)
- Anne B Chang
- Department Respiratory Medicine, Royal Children's Hospital, Herston, Queensland 4029, Australia.
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29
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Widdicombe J, Eccles R, Fontana G. Supramedullary influences on cough. Respir Physiol Neurobiol 2006; 152:320-8. [PMID: 16621735 DOI: 10.1016/j.resp.2006.02.018] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Revised: 02/28/2006] [Accepted: 02/28/2006] [Indexed: 01/28/2023]
Abstract
The evidence for supramedullary influences on cough is largely indirect. Cough can be voluntarily induced or inhibited, functions usually thought to reside in the cerebral cortex. A sensation of 'urge-to-cough' usually precedes cough due to an airway irritant stimulus, and this may well involve the cerebral cortex. In conditions with interruption of the pathways between the cortex and the brainstem, such as strokes and Parkinson's disease, voluntary cough may be inhibited without disruption of reflex cough from the larynx or lower airways. 'Habit cough', like Tourette's syndrome, is assumed to be cortically mediated. Placebos and many treatments based on complementary medicine are effective in inhibiting clinical cough, and the site of action is likely to be the cerebral cortex. In sleep and in anaesthesia cough is depressed and, again, this seems likely to be at a cortical level. However there are few or no experimental or clinical observation as to the localization and functions of supramedullary areas responsible for cough. It is a field of research wide open for exploration.
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Wagner U, Staats P, Fehmann HC, Fischer A, Welte T, Groneberg DA. Analysis of airway secretions in a model of sulfur dioxide induced chronic obstructive pulmonary disease (COPD). J Occup Med Toxicol 2006; 1:12. [PMID: 16759388 PMCID: PMC1559628 DOI: 10.1186/1745-6673-1-12] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2005] [Accepted: 06/07/2006] [Indexed: 01/08/2023] Open
Abstract
Hypersecretion and chronic phlegm are major symptoms of chronic obstructive pulmonary disease (COPD) but animal models of COPD with a defined functional hypersecretion have not been established so far. To identify an animal model of combined morphological signs of airway inflammation and functional hypersecretion, rats were continuously exposed to different levels of sulfur dioxide (SO2, 5 ppm, 10 ppm, 20 ppm, 40 ppm, 80 ppm) for 3 (short-term) or 20–25 (long-term) days. Histology revealed a dose-dependent increase in edema formation and inflammatory cell infiltration in short-term-exposed animals. The submucosal edema was replaced by fibrosis after long-term-exposure. The basal secretory activity was only significantly increased in the 20 ppm group. Also, stimulated secretion was significantly increased only after exposure to 20 ppm. BrdU-assays and AgNOR-analysis demonstrated cellular metaplasia and glandular hypertrophy rather than hyperplasia as the underlying morphological correlate of the hypersecretion. In summary, SO2-exposure can lead to characteristic airway remodeling and changes in mucus secretion in rats. As only long-term exposure to 20 ppm leads to a combination of hypersecretion and airway inflammation, only this mode of exposure should be used to mimic human COPD. Concentrations less or higher than 20 ppm or short term exposure do not induce the respiratory symptom of hypersecretion. The present model may be used to characterize the effects of new compounds on mucus secretion in the background of experimental COPD.
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Affiliation(s)
- Ulrich Wagner
- Department of Medicine, Pulmonary and Critical Care Division, Philipps-University, Baldingerstr., D-35043 Marburg, Germany
- Department of Medicine/Respiratory Medicine, Klinik Löwenstein, Geißhölzle 62, D-74245 Löwenstein, Germany
| | - Petra Staats
- Department of Medicine, Pulmonary and Critical Care Division, Philipps-University, Baldingerstr., D-35043 Marburg, Germany
| | - Hans-Christoph Fehmann
- Department of Medicine, Pulmonary and Critical Care Division, Philipps-University, Baldingerstr., D-35043 Marburg, Germany
| | - Axel Fischer
- Allergy-Centre-Charité, Otto-Heubner-Centre, Pneumology and Immunology, Charité – Universitätsmedizin Berlin, Free and Humboldt-University Berlin, Augustenburger Platz 1 OR-1, D-13353 Berlin, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Str. 1 OE 6870, D-30625 Hannover, Germany
| | - David A Groneberg
- Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Str. 1 OE 6870, D-30625 Hannover, Germany
- Institute of Occupational Medicine, Charité – Universitätsmedizin Berlin, Free and Humboldt-University Berlin, Ostpreussendamm 111, D-12207 Berlin, Germany
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