Predicting aspiration in patients with ischemic stroke: comparison of clinical signs and aerodynamic measures of voluntary cough.

BACKGROUND: Clinical signs often fail to identify stroke patients who are at increased risk of aspiration. We hypothesized that objective measure of voluntary cough would improve the accuracy of the clinical evaluation of swallow to predict those patients who are at risk. METHODS: A comprehensive diagnostic evaluation was completed for 96 consecutive stroke patients that included cognitive testing, a bedside clinical swallow examination, aerodynamic and sound pressure level measures of voluntary cough, and "gold standard" instrumental swallowing studies (ie, videofluoroscopic evaluation of swallow [VSE] or fiberoptic endoscopic evaluation of swallow [FEES]). Stroke severity was assessed retrospectively using the Canadian neurologic scale. RESULTS: Based on the findings of VSE/FEES, 33 patients (34%) were at high risk of aspiration and (66%) were nonaspirators. Clinical signs (eg, absent swallow, difficulty handling secretions, or reflexive cough after water bolus) had an overall accuracy of 74% with a sensitivity of 58% and a specificity of 83% for the detection of aspiration. Three objective measures of voluntary cough (expulsive phase rise time, volume acceleration, and expulsive phase peak flow) were each associated with an aspiration risk category (areas under the curves were 0.93, 0.92, and 0.86, respectively). Expulsive phase rise time > 55 m/s, volume acceleration < 50 L/s/s, and expulsive phase peak flow < 2.9 L/s had sensitivities of 91%, 91%, and 82%, respectively; and specificities of 81%, 92%, and 83%, respectively for the identification of aspirators. CONCLUSION: Objective measures of voluntary cough can identify stroke patients who are at risk for aspiration and may be useful as an adjunct to the standard bedside clinical assessment.

Prospective analysis of incidence and risk factors of dysphagia in spine surgery patients: comparison of anterior cervical, posterior cervical, and lumbar procedures.

STUDY DESIGN: A 3-year prospective, cohort study. OBJECTIVES: To compare the incidence and risk factors of dysphagia after anterior cervical (AC), posterior cervical (PC), and posterior lumbar (PL) spine procedures. SUMMARY OF BACKGROUND DATA: Dysphagia is a known risk of AC surgery; however, comprehensive postoperative swallow evaluations have not been performed for a comparative cohort of AC, PC, and PL surgery patients. METHODS: Eighty-three patients were enrolled in the study, including 38 undergoing AC, 19 PC, and 26 PL procedures. Preoperative and postoperative swallowing evaluations were performed by questioning for subjective swallowing complaints and performing objective radiographic examination. Patients with severe dysphagia leading to an increased risk of aspiration were identified and treated until recovery or for 3 to 9 months. RESULTS: Comparison of preoperative and postoperative swallowing complaints revealed a significant increase for AC patients (P < 0.01) and a trend for PC (P = 0.06) and PL (P = 0.09) patients. Eighteen (47%) AC, 4 (21%) PC, but no PL patients demonstrated dysphagia on postoperative videofluoroscopic swallow evaluation. Age (>60 years, P < 0.01) was associated with increased risk of radiologic evidence of dysphagia. Surgical level, instrumentation, operative time, and presence of myelopathy or other comorbidities were not. Over 70% (12 of 17) of AC patients with dysphagia followed recovered within 2 months, while 23% (4 of 17) required some level of compensatory swallowing behavior up to 10 months following surgery. CONCLUSION: Dysphagia is a common occurrence after AC procedures but was also found after PC procedures. Intubation alone was not a risk factor for postoperative dysphagia in this cohort.