Background and Purpose-We sought to evaluate the efficacy of testing the laryngeal cough reflex in identifying pneumonia risk in acute stroke patients. Methods-We performed a prospective study of 400 consecutive acute stroke patients examined using the reflex cough test (RCT) compared with 204 consecutive acute stroke patients from a sister facility examined without using the RCT. The binary end point for the study outcome was the development of pneumonia. Results-Of the 400 patients examined with the RCT, 5 developed pneumonia. Of the 204 patients examined without the RCT, 27 developed pneumonia (PϽ0.001). Three of the 27 patients died in the rehabilitation hospital of respiratory failure secondary to pneumonia. Seven others were transferred to the emergency department with acute respiratory distress. Power analysis for this comparison was 0.99. There were no other significant differences between the 2 groups. Conclusions-A normal RCT after an acute stroke indicates a neurologically intact laryngeal cough reflex, a protected airway, and a low risk for developing aspiration pneumonia with oral feeding. An abnormal RCT indicates risk of an unprotected airway and an increased incidence of aspiration pneumonia. Alternate feeding strategies and preventive measures are necessary with an abnormal RCT. Clinical treatment algorithm and prescription of food, fluids, and medications are discussed on the basis of RCT results. (Stroke. 1999;30:1203-1207.)Key Words: aspiration Ⅲ cough Ⅲ pneumonia Ⅲ stroke Ⅲ videofluoroscopy A fter a stroke, one of the most challenging decisions clinicians face is instituting the prescription of fluids, foods, and oral medications safely. The question of whether it is safe to feed the patient has been left mostly to guesswork and to a trial-and-error approach. Physicians have historically deferred this dilemma to speech pathologists or other personnel. It is estimated that up to 38% of stroke victims die within the first month after stroke onset. 1,2 Pneumonia contributes to up to 34% of all stroke deaths and represents the third highest cause of mortality in the first month after stroke. Pneumonia has been estimated to occur in one third of all stroke victims and is the most common respiratory complication. 3 The Florida Hospital Association reports total charges for dysphagia and food/vomit pneumonitis to be $1.2 billion in 1997 for the state of Florida, increased from $1.1 billion in 1996. In 1996, Florida was ranked the 15th highest nationwide in charges for the following International Classification of Diseases, Ninth Revision codes: 787.2 (dysphagia) and 507.0 (food/vomit pneumonitis). 4,5 The effects of pneumonia development have been described in terms of individual cost of care. The development of pneumonia after stroke resulted in an additional financial burden of approximately $10 000 per event and extended hospital length of stay an average of 7 days. 6 Given the incidence of stroke, the prevalence of dysphagia, the risk of aspiration, and the effects of pneumonia in terms of morb...

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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.

Aspiration is a common result of stroke, and may lead to lung infections and pneumonia. Cough may prevent this aspiration and thus prevent the pneumonia.We review the four types of cough usually used to assess aspiration risk:voluntary cough (VC), reflex cough (RC), the laryngeal expiration reflex (LER), and cough on swallow (CoS). VC is easy to test but starts with an inspiration that may cause aspiration, and is controlled by cortico-brainstem pathways that may not be involved in influencing aspiration. RC also starts with an inspiration, and requires instrumental intervention, but is more relevant to protecting the lungs.The LER starts with an expiration, so is 'anti-aspiration', and is easy to test, but its neural mechanisms have not been fully analysed. CoS can be tested at the same time as direct observations of aspiration, but little is known about its neural mechanisms. Each method has its advocates, and the purpose of the review is to discuss how each may be applied and how the information from each may be assessed and valued.

VC is of limited use in screening subjects for aspiration pneumonia risk. A normal laryngeal cough reflex indicated a neurologically protected airway.