Cough Up the Facts

Speech Pathologists who treat dysphagia often rely on a patient’s cough as a marker of aspiration. Other healthcare professionals have been educated that coughing is a sign of swallowing difficulty. How accurate is this statement in the geriatric population and what are other reasons a patient may be exhibiting a cough?

Many researchers have looked at the relationship between cough and dysphagia. Daniels published research on this topic in 1997 and again in 1998. The studies found that cough was associated with aspiration in 61% of 59 subjects (Daniels 1997) and 70% of 53 subjects (Daniels 1998). This information would inform SLPs that cough is often not a product of aspiration.

Some common causes of cough in the geriatric population:

• Reflux: There are reports that 25% or more of chronic cough cases are associated with gastroesophageal reflux (Madanick 2013).
• Medications: Ace Inhibitors have been reported to cause a cough in up to 35% of users (Dicpinigaitis 2006). Additionally, beta blockers induce
  bronchoconstriction which can lead patients to display a chronic chough, especially in those with underlying respiratory compromise (Tafreshi 1999).
• Cold bolus in the presence of esophageal dysmotility: Cold slows the passage of food through the esophagus and may cause a cough response in those with decreased esophageal emptying (Elvevi 2013).

It may be thought that coughing coupled with a wet vocal quality during the swallow would be a more conclusive indicator of aspiration or penetration verses coughing alone. Warm (2000) analyzed voice samples that were collected during modified barium swallow studies. She found that there was no association between the presence of a wet voice and penetration or aspiration. This led her to conclude that wet phonation was not considered diagnostic in detecting penetration/aspiration.

Because cough is related to common geriatric syndromes and medications, it is imperative that clinicians use an instrumental study to verify that a particular patient is coughing as a clinical sign of aspiration before using it as such in the course of patient diagnosis, intervention, documentation or communication.

References:
1. Daniels, S., Brailey, K., Priestly, D., Herrington, L., Weisberg, L., Foundas, A. Aspiration in patients with acute stroke. Arch Phys Med Rehabil (1998)79:14–19.
2. Daniels, S., McAdam,P., Brailey, K., Foundas, A. Clinical assessment of swallowing and prediction of dysphagia severity. Am J Speech Lang Pathol (1997) 6:17–24.
3 Dicpinigaitis P. Angiotensin-converting enzyme inhibitor-induced cough: ACCP evidence-based clinical practice guidelines. Chest (2006) 129(1 Suppl):169S-173S.
4. Elvevi, A., Bravi,I., Mauro,A., Pugliese, D., Tenca, A., Cortinovis,I., Milani,S., Conte,D., Penagini, R. Effect of cold water on esophageal motility in patients with achalasia and non-obstructive dysphagia: a high-resolution manometry study. J Neurogastroenterol Motil. (2014) 20(1): 79–86.
5. Madanick, R. Management of GERD-related chronic cough. Gastroenterol Hepatol (2013) 9(5): 311–313.
6. Tafreshi M., Weinacker A. Beta-adrenergic-blocking agents in bronchospastic diseases: a therapeutic dilemma. Pharmacotherapy (1999).19(8):974-8.
7. Warms,T., Richards, B. “Wet Voice” as a predictor of penetration and aspiration in oropharyngeal dysphagia. Dysphagia (2000) 15:84–88.