Hypotussic cough in persons with dysphagia: biobehavioral interventions and pathways to clinical implementation.

Cough is a powerful, protective expulsive behavior that assists in maintaining respiratory health by clearing foreign material, pathogens, and mucus from the airways. Therefore, cough is critical to survival in both health and disease. Importantly, cough protects the airways and lungs from both antegrade (e.g., food, liquid, saliva) and retrograde (e.g., bile, gastric acid) aspirate contents. Aspiration is often the result of impaired swallowing (dysphagia), which allows oral and/or gastric contents to enter the lung, especially in individuals who also have cough dysfunction (dystussia). Cough hyposensitivity, downregulation, or desensitization- collectively referred to as hypotussia- is common in individuals with dysphagia, and increases the likelihood that aspirated material will reach the lung. The consequence of hypotussia with reduced airway clearance can include respiratory tract infection, chronic inflammation, and long-term damage to the lung parenchyma. Despite the clear implications for health, the problem of managing hypotussia in individuals with dysphagia is frequently overlooked. Here, we provide an overview of the current interventions and treatment approaches for hypotussic cough. We synthesize the available literature to summarize research findings that advance our understanding of these interventions, as well as current gaps in knowledge. Further, we highlight pragmatic resources to increase awareness of hypotussic cough interventions and provide support for the clinical implementation of evidence-based treatments. In culmination, we discuss potential innovations and future directions for hypotussic cough research.

Provision of Oral Care in the Cardiothoracic Intensive Care Unit: Survey of Nursing Staff Training, Confidence, Methods, Attitudes, and Perceived Barriers.

BACKGROUND: Poor oral health is associated with adverse outcomes in critical care settings. Although provision of oral care is a fundamental aspect of nursing practice, both formal training and practice among nursing staff remain unclear. METHOD: Cardiothoracic intensive care unit nurses were recruited to complete a 16-item survey regarding training, confidence, methods, prioritization, and barriers to provision of oral care. RESULTS: A total of 108 nurses participated (70% response rate). Formal training in oral care was reported by 38%, most frequently reported as less than 1 hour (53%) in duration. Of the respondents, 70% reported confidence in providing oral care. Nine methods and 16 products were identified, with variability in the frequency of provision. Prioritization of oral care was rated most frequently as moderate (53%), with 28% reporting barriers. CONCLUSION: Despite limited formal training, surveyed nurses reported confidence in providing oral care. Methods, frequency, and prioritization were variable. Both development of formal curricula and evaluation of adherence to standardized protocols for oral care are warranted. [J Contin Educ Nurs. 2023;54(7):313-321.].

A prospective examination of swallow and cough dysfunction after lung transplantation.

OBJECTIVES: Swallow and cough dysfunction are possible surgical complications of lung transplantation (LT). We examined voluntary cough strength, sensorimotor reflexive cough integrity, and swallow-related respiratory rate (RR) across swallowing safety and aspiration response groups in recovering LT recipients. METHODS: Forty-five LT recipients underwent flexible endoscopic evaluation of swallowing indexed by the validated Penetration Aspiration Scale. RR before and after a 3-ounce water drinking task was measured. Voluntary and reflexive cough screening were performed to index motor and sensory outcomes. T-tests, one-way ANOVAs, and chi-square (odds ratios) were used. RESULTS: 60% of patients exhibited laryngeal penetration (n = 27) and 40% demonstrated tracheal aspiration (n = 18); 72% (n = 13) demonstrated silent aspiration. Baseline RR was higher in aspirators versus non-aspirators (26.5 vs. 22.6, p = 0.04) and in silent aspirators compared to non-silent aspirators (27.9 vs. 20.7, p = 0.01). RR change post-swallowing did not differ between aspiration response groups; however, it was significantly higher in aspirators compared to non-aspirators (3 vs. -2, p = 0.02). Compared to non-silent aspirators, silent aspirators demonstrated reduced voluntary cough peak expiratory flow (PEF; 166 vs. 324 L/min, p = 0.01). PEF, motor and urge to cough reflex cough ratings did not differ between aspirators and non-aspirators. Silent aspirators demonstrated a 7.5 times higher odds of failing reflex cough screening compared to non-silent aspirators (p = 0.07). CONCLUSIONS: During the acute recovery period, all LT participants demonstrated some degree of unsafe swallowing and reduced voluntary cough strength. Silent aspirators exhibited elevated RR, reduced voluntary cough physiologic capacity to defend the airway, and a clinically distinguishable blunted motor response to reflex cough screening.

Incidence, risk factors, and sequelae of dysphagia mediated aspiration following lung transplantation.

BACKGROUND: We aimed to determine dysphagia profiles before and after lung transplantation (prevalence, incidence) and to examine predictors and health-related outcomes of aspiration in individuals undergoing lung transplantation. METHODS: A retrospective single-center study of consecutive adults undergoing lung transplantation and completing a postoperative videofluoroscopic swallowing study between 2017 and 2020 was conducted. The validated penetration aspiration scale indexed swallowing safety and clinical outcomes were extracted from electronic medical records. T-tests, chi square with odds ratios, and multivariable logistic regression were conducted. RESULTS: Two hundred five participants were identified who underwent lung transplantation and a postoperative swallowing exam. Of those who underwent both a pre- and postoperative swallowing exam (n = 170), preoperatively 83% demonstrated safe swallowing and 17% unsafe swallowing. Following lung transplantation, 16% demonstrated safe swallowing and 84% demonstrated unsafe swallowing (39% penetration, 45% aspiration). Independent predictors of postoperative aspiration were venous-venous extracorporeal membrane oxygenation (odds ratio [OR]: 6.7, confidence interval [CI]: 2.0-81.5) and reintubation (OR: 4.5, CI: 1.0-60.3), p < .05. Compared to non-aspirators, aspirators demonstrated higher odds of being discharged to a dependent care setting (OR: 2.3, CI: 1.2-4.5), p < .05. Aspirators spent significantly longer NPO (median = 138.0 hours, 25th percentile, 75th percentile = 75.7, 348.3) compared to non-aspirators (median = 85.0 hours, 25th percentile, 75th percentile = 48.0, 131.6, p < .001). CONCLUSIONS: Pre-existing dysphagia was low in this cohort of patients undergoing lung transplantation, however increased approximately 5-fold following lung transplantation and was associated with increased morbidity.

Discriminant Ability of the 3-Ounce Water Swallow Test to Detect Aspiration in Acute Postoperative Cardiac Surgical Patients.

Dysphagia is a common complication of cardiac surgery (CS) contributing to morbidity and mortality. Although early dysphagia detection is important, no current screening guidelines or validated tools exist in the cardiac intensive care setting. We therefore aimed to examine the discriminant ability of the 3-ounce water swallow test (3 oz. WST) to detect aspiration in acute postoperative CS patients. 196 postoperative CS patients were enrolled in this prospective single-center study. Participants completed the 3 oz. WST and a standardized Flexible Endoscopic Evaluation of Swallowing. Independent duplicate ratings of the penetration aspiration scale (PAS) were performed in a blinded fashion (100% agreement criteria). Receiver operating characteristic curve and area under the curve (AUC) analyses were performed with sensitivity, specificity, positive, and negative predictive values (PPV, NPV) derived. Fifty-four CS patients (28%) were confirmed aspirators (PAS ≥ 6), of whom 48% (n = 26) were silent aspirators (PAS = 8). Both the sensitivity and specificity of the 3 oz. WST to identify instrumentally confirmed aspiration was 63% (AUC: 0.63, 95% CI: 0.54, 0.72), and PPV was 39% and NPV 82%. The 3 oz. WST demonstrated fair discriminant ability to detect aspiration in acute postoperative CS patients. The high rate of silent aspiration may explain, in part, these findings given that the screening fail criteria include an overt cough response. In isolation, the 3 oz. WST does not represent a sensitive screen of aspiration in postoperative CS patients with a need to identify alternative screening tools for this setting.

Vocal Fold Mobility Impairment After Cardiovascular Surgery: Incidence, Risk Factors, and Sequela.

BACKGROUND: We aimed to determine the incidence and contributing risk factors of vocal fold mobility impairment (VFMI) in postoperative cardiovascular patients and evaluate the impact of VFMI on health-related outcomes. METHODS: This single-site prospective study enrolled adults undergoing sternotomy or thoracotomy procedures who underwent a fiberoptic laryngoscopy examination within 72 hours of extubation. Potential demographic and surgical risk factors and health-related outcomes were collected. A blinded laryngologist assessed VFMI and mucosal injury. Descriptives, univariate and multivariable regression analyses with odds ratios (OR) were performed. RESULTS: Of 185 eligible examinations, VFMI was confirmed in 25% of patients (7 complete, 39 partial VFMI) with left-sided involvement in 83% of cases. Laryngeal mucosal injury included granuloma (38%), posterior cricoid hypertrophy (37%), edema (29%), bruising (23%), and hemorrhage (9%). Independent risk factors for complete VFMI were aortic arch procedure (odds ratio 6.1), body mass index less than 25 (OR: 7.2), and African-American or Hispanic race (OR: 6.0). Patients with two or more identified risk factors had a 33.0 increased odds of complete VFMI compared with patients not having two or more risk factors. Compared with patients having normal vocal fold motion, patients with complete VFMI had a 2.7 increased odds of pneumonia, 5.7 higher odds of reintubation, a 7.3 times higher odds of death, and increased length of hospital stay and cost of care (P < .05). CONCLUSIONS: Interdisciplinary postoperative care and laryngoscopy examination are recommended for high-risk patients to facilitate early detection and improve patient outcomes.

Swallowing screening practice patterns for nurses in the cardiac surgery intensive care unit.

AIMS AND OBJECTIVES: The current study surveyed nurse practice patterns for performing swallowing screens in an academic cardiac intensive care unit (ICU). It aimed to index: training and levels of confidence in conducting dysphagia screens; screening methods employed; timing and frequency of implement; and subsequent plan of care in identified high-risk patients. BACKGROUND: Swallowing impairment (dysphagia) is common following cardiac surgery and associated with significant morbidity and mortality. Early and accurate detection of dysphagia is therefore critical to afford implementation of interventions to optimise patient care. Currently, no validated instruments or guidelines exist for nursing screening of dysphagia in this setting. METHODS: An anonymous and voluntary 10-item mixed-methods online survey was conducted using Qualtrics software. Nonprobability purposive sampling was utilised to recruit nurses working in an academic 24-bed cardiac ICU. Thematic analysis using operationally defined coding, SRQR checklist and descriptive statistics were employed. RESULTS: Sixty-nine nurses completed the survey during a 1-month period, representing an 84% response rate. Formal training in performing swallowing screens was reported in 18.6% of nurses. In rank order, reported level of confidence was the following: "moderately" (49%); "somewhat" (35%); "not" (13%); and "very" (3%). The majority of nurses performed screens within 1 hr (40.6%) or between 1-4 hr (43.8%) of extubation. Fifteen different methods were utilised to screen swallowing function by nurses who reported a total of 31 different clinical signs indicative of dysphagia. CONCLUSIONS: Survey data of practicing nurses in an academic cardiac ICU revealed limited formal training in swallowing screening methodology, a high degree of variability in screening methods employed and low levels of agreement for dysphagia signs. RELEVANCE TO CLINICAL PRACTICE: Data highlight a knowledge gap and need for the development of formal education and validated rapid nursing dysphagia screening tools for standardised implementation in the cardiac surgery ICU setting.