Measurement of Voluntary Cough Production and Airway Protection in Parkinson Disease.

OBJECTIVE: To examine relations between peak expiratory (cough) airflow rate and swallowing symptom severity in participants with Parkinson disease (PD). DESIGN: Cross-sectional study. SETTING: Outpatient radiology clinic at an acute care hospital. PARTICIPANTS: Men and women with PD (N=68). INTERVENTIONS: Participants were cued to cough into an analog peak flow meter then swallowed three 20-mL thin liquid barium boluses. Analyses were directed at detecting potential relations among disease severity, swallowing symptom severity, and peak expiratory (cough) airflow rate. MAIN OUTCOME MEASURES: Peak expiratory (cough) airflow rate and swallow symptom severity. RESULTS: Peak expiratory (cough) airflow rate varied significantly across swallowing severity classifications. Participants with more severe disease displayed a significant, linear decrease in peak expiratory (cough) airflow rate than those participants with earlier stage, less severe disease. Swallowing symptom severity varied significantly across groups when comparing participants with less severe PD with those with more severe PD. Participants with early stage PD demonstrated little to no swallowing symptoms and had the highest measures of peak expiratory (cough) airflow rate. In contrast, participants with the most severe swallowing symptoms also displayed the lowest measures of peak expiratory (cough) airflow rate. CONCLUSIONS: Relations existed among PD severity, swallowing symptom severity, and peak expiratory (cough) airflow rate in participants with PD. Peak expiratory (cough) airflow rate may eventually stand as a noninvasive predictor of aspiration risk in those with PD, particularly those with later stage disease. Inclusion of peak expiratory (cough) airflow rates into existing clinical swallowing assessments may increase the sensitivity and predictive validity of these assessments.

Addressing Pneumococcal Vaccine Uptake Disparities among African-American Adults in the United States.

OBJECTIVE: Pneumococcal illnesses affect over one million Americans annually, making invasive pneumococcal disease (pneumonia) the most prevalent vaccine-preventable illness. Despite well-documented vaccine safety and efficacy, pneumococcal vaccine (PPSV23) uptake remains low, particularly among minorities. This study sought to define variables predicting PPSV23 uptake in eligible African-American (AA) adults. DESIGN AND SAMPLE: This was a cross-sectional study using a combined version of the Health Belief (HBM) and Precaution Adoption Process Models (PAPM). A convenience sample of 295 AA adults self-administered the Vaccine Uptake Questionnaire (VUQ). MEASURES: Bivariate chi-square analyses were conducted and significant variables evaluated using backward stepwise logistic regression. RESULTS: PPSV23 uptake was 32.2% (n = 95). Older age, female gender, vaccine awareness, increased knowledge, higher trust scores, perceived susceptibility, and presence of provider recommendation for PPSV23 predicted vaccine uptake. In regression modeling, age, awareness, and provider recommendation remained significant predictors with younger age, unawareness, and lack of provider recommendation decreasing the likelihood of vaccination. CONCLUSION: Three dimensions of the HBM (barriers, cues, and susceptibility) predicted PPSV23 uptake. With 147 (47.8%) unaware of PPSV23 existence prior to this study, adding the dimension "unaware" from the PAPM may strengthen the model and assist efforts to increase PPSV23 uptake among AA adults.

Use of Ecological Momentary Assessment to Measure Dyspnea in COPD.

Dyspnea is an unpredictable and distressing symptom of chronic obstructive pulmonary disease (COPD). Dyspnea is challenging to measure due to the heterogeneity of COPD and recall bias associated with retrospective reports. Ecological Momentary Assessment (EMA) is a technique used to collect symptoms in real-time within a natural environment, useful for monitoring symptom trends and risks of exacerbation in COPD. EMA can be integrated into mobile health (mHealth) platforms for repeated data collection and used alongside physiological measures and behavioral activity monitors. The purpose of this paper is to discuss the use of mHealth and EMA for dyspnea measurement, consider clinical implications of EMA in COPD management, and identify needs for future research in this area.

Temporary Transvenous Diaphragmatic Neurostimulation in Prolonged Mechanically Ventilated Patients: A Feasibility Trial (RESCUE 1).

Prolonged mechanical ventilation promotes diaphragmatic atrophy and weaning difficulty. The study uses a novel device containing a transvenous phrenic nerve stimulating catheter (Lungpacer IntraVenous Electrode Catheter) to stimulate the diaphragm in ventilated patients. We set out to determine the feasibility of temporary transvenous diaphragmatic neurostimulation using this device. DESIGN: Multicenter, prospective open-label single group feasibility study. SETTING: ICUs of tertiary care hospitals. PATIENTS: Adults on mechanical ventilation for greater than or equal to 7 days that had failed two weaning trials. INTERVENTIONS: Stimulation catheter insertion and transvenous diaphragmatic neurostimulation therapy up to tid, along with standard of care. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were successful insertion and removal of the catheter and safe application of transvenous diaphragmatic neurostimulation. Change in maximal inspiratory pressure and rapid shallow breathing index were also evaluated. Eleven patients met all entry criteria with a mean mechanical ventilation duration of 19.7 days; nine underwent successful catheter insertion. All nine had successful mapping of one or both phrenic nerves, demonstrated diaphragmatic contractions during therapy, and underwent successful catheter removal. Seven of nine met successful weaning criteria. Mean maximal inspiratory pressure increased by 105% in those successfully weaned (mean change 19.7 ± 17.9 cm H2O; p = 0.03), while mean rapid shallow breathing index improved by 44% (mean change -63.5 ± 64.4; p = 0.04). CONCLUSIONS: The transvenous diaphragmatic neurostimulation system is a feasible and safe therapy to stimulate the phrenic nerves and induce diaphragmatic contractions. Randomized clinical trials are underway to compare it to standard-of-care therapy for mechanical ventilation weaning.

Tutorial on maximum inspiratory and expiratory mouth pressures in individuals with idiopathic Parkinson disease (IPD) and the preliminary results of an expiratory muscle strength training program.

Respiratory symptoms are recognized as sequelae of motor dysfunction in idiopathic Parkinson's disease (IPD) and these symptoms have the potential to cause problems with swallow, cough, voice and speech. Specifically, maneuvers that require rapid activation and coordination of upper airway and chest wall musculature become progressively impaired as motor dysfunction progresses during the natural course of the disease. This study reports on the maximum inspiratory and expiratory pressures produced by 28 participants (average age 64) diagnosed with moderate to severe IPD (average stage 2.5 with a range of 2.0-3.0). All measures were collected during the "medication on" state. Outcomes of a specific respiratory muscle strength training technique for improving maximum expiratory pressure are reported for three of the patients in this study. Techniques that focus on strengthening the respiratory muscles in patients with IPD (other than with low load breathing exercises), have not been previously reported. The results of this pilot study demonstrate that respiratory muscle weakness may be an important factor in the respiratory complications in IPD and that respiratory muscle strength training has the potential to improve expiratory muscle strength for this population. This improvement has the potential to positively impact high forced respiratory activities, such as forced breathing maneuvers, swallow, cough and speech functions that require greater magnitude and duration of expiration.

Concordance and discriminatory power of cough measurement devices for individuals with Parkinson disease.

BACKGROUND: Dysphagia and aspiration pneumonia are two causes of morbidity in Parkinson disease (PD). In PD, impaired airway clearance can lead to penetration of foreign material, resulting in a high prevalence of aspiration pneumonia and death. This study examines three different devices for measurement of peak airflow during voluntary cough in healthy control subjects and those with PD. Two simple and low-cost devices for measuring peak cough airflow were compared with the "gold standard" pneumotachograph. METHODS: Thirty-five healthy control subjects and 35 individuals with PD produced voluntary cough at three perceived strengths (weak, moderate, and strong cough) for each of the three devices. RESULTS: A significant difference in mean peak cough airflow was demonstrated for disease (F[1,56] = 4.0, P < .05) and sex (F[1,56] = 9.59, P < .003) across devices. The digital and analog meters were comparable to the gold standard demonstrating no significant difference (statistical) by device (digital vs analog) in receiver operating characteristic curve analysis. Both devices were discriminative of the presence of PD. CONCLUSIONS: The analog and digital peak airflow meters are suitable alternatives to the gold standard pneumotachograph due to their low cost, portability, ease of use, and high sensitivity relative to normative peak cough airflows. Voluntary cough airflow measures may serve as a noninvasive means of screening for aspiration risk in target populations. Additionally, quantification of cough strength through use of predetermined limens for weak, moderate, and strong cough may assist clinicians in better describing and tracking cough strength as a contributing factor to aspiration risk.

Combined modality treatment of adductor spasmodic dysphonia.

INTRODUCTION: The hallmark characteristic of adductor spasmodic dysphonia (ADSD) is irregular and uncontrollable spasms within the intrinsic laryngeal muscles, resulting in erratic disruption of normal voicing. METHODS: Using a random assignment and the inclusion of a behavioral sham to determine the effect of voice therapy after initial botulinum toxin type A (BTX-A) injections for ADSD, this study examined duration of injection benefit, perceived vocal quality of life from the Voice-Related Quality of Life (V-RQOL) scale, acoustic measures of vocal instability, and perceptual ratings of voice quality. Measures of these variables were collected before initial injection; 3, 7, and 12 weeks postinjection; and immediately before reinjection. Thirty-one individuals with ADSD participated in this study. One-third received no further intervention after BTX-A injection, one-third received a standard 5-week course of voice therapy after BTX-A injection, and one-third received a 5-week course of sham voice therapy after BTX-A injection. RESULTS AND CONCLUSIONS: Significant effects were observed on perceived quality of life and acoustic variables for all participants, over time. Participants who received voice therapy after BTX-A injection did not experience longer injection effect duration or significantly greater improvements in V-RQOL or acoustic variables than participants in BTX-A only or BTX-A plus sham therapy groups. Additionally, perceptual ratings of voice quality improved for all participants in response to BTX-A injection. For participants in this investigation, undertaking voice therapy did not appear to exert significant beneficial effects on the variables of interest.