title: Predicting aspiration in patients with ischemic stroke: comparison of clinical signs and aerodynamic measures of voluntary cough.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Durham Veterans Affairs Medical Center, Durham, NC. Electronic address: smith390@mc.duke.edu.
authors.forename: Carol A
authors.initials: CA
authors.lastname: Smith Hammond
authors.affiliation: Center for Cerebrovascular Diseases, Duke University, Durham, NC.
authors.forename: Larry B
authors.initials: LB
authors.lastname: Goldstein
authors.affiliation: Institute for the Study of Health, University of Cincinnati Academic Health Center, Cincinnati, OH.
authors.forename: Ron D
authors.initials: RD
authors.lastname: Horner
authors.affiliation: Institute for the Study of Health, University of Cincinnati Academic Health Center, Cincinnati, OH.
authors.forename: Jun
authors.initials: J
authors.lastname: Ying
authors.affiliation: Department of Radiology, Duke University, Durham, NC.
authors.forename: Linda
authors.initials: L
authors.lastname: Gray
authors.affiliation: Brain Rehabilitation Research Center, Gainesville VAMC, Gainesville, FL.
authors.forename: Leslie
authors.initials: L
authors.lastname: Gonzalez-Rothi
authors.affiliation: Department of Physiological Sciences, University of Florida, Gainesville, FL.
authors.forename: Donald C
authors.initials: DC
authors.lastname: Bolser
mesh_terms: D000368:Aged; D003371:Cough / Q000503:physiopathology*; D003680:Deglutition Disorders / Q000175:diagnosis / Q000209:etiology; D005260:Female; D005471:Fluoroscopy; D006801:Humans; D008297:Male; D011015:Pneumonia, Aspiration / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology; D012123:Pulmonary Ventilation; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D020521:Stroke / Q000150:complications*