, Volume 33, Issue 6, pp 827–839 | Cite as

Implementing Cough Reflex Testing in a Clinical Pathway for Acute Stroke: A Pragmatic Randomised Controlled Trial

  • Makaela Field
  • Rachel Wenke
  • Arman Sabet
  • Melissa Lawrie
  • Elizabeth Cardell
Original Article


Silent aspiration is common after stroke and can lead to subsequent pneumonia. While standard bedside dysphagia assessments are ineffective at predicting silent aspiration, cough reflex testing (CRT) has shown promise for identifying patients at risk of silent aspiration. We investigated the impact of CRT on patient and service outcomes when embedded into a clinical pathway. 488 acute stoke patients were randomly allocated to receive either CRT or standard care (i.e. bedside assessment). Primary outcomes included confirmed pneumonia within 3 months post stroke and length of acute inpatient stay. Secondary outcomes related to the feasibility of implementing a CRT pathway and clinician and patient satisfaction. There was a non-significant reduction in pneumonia rates by 2.2% points in the CRT group (OR 0.32, 95% CI 0.06–1.62). There was a non-significant difference of 0.7 days (95% CI − 0.29 to 1.71 days) in length of stay between the standard care group and the CRT group. The CRT took on average 3 min longer to complete (p < 0.01) and resulted in a significant 6.7% increase in videofluoroscopic referrals (p = 0.02); however, these results are clinically insignificant. High patient and clinician satisfaction with CRT was found, with clinicians reporting additional knowledge and confidence in decision making for dysphagia management. Post hoc subgroup analyses according to stroke types were conducted and revealed no significant differences in pneumonia rates after adjustment for multiple comparisons. In conclusion, it was possible to implement a CRT pathway with minimal increases in clinician resources. While clinicians perceived CRT as beneficial in clinical decision making, the efficacy of CRT for reducing pneumonia rates in acute stroke remains to be established.

Clinical Trial Registration-URL: Unique identifier: ACTRN12616000724471


Dysphagia Deglutition Deglutition disorders Cough reflex testing Citric acid Stroke 



The authors would like to thank all of the staff and participants for their assistance in this project.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Asadollahpour F, Baghban K, Asadi M, Naderifar E, Dehghani M. Oropharyngeal dysphagia in acute stroke patients. Zehadan J Res Med Sci. 2015;17(8):e1067.Google Scholar
  2. 2.
    Altman K, Yu G-P, Schaefer D. Consequences of dysphagia in the hospitalized patient. Impact on prognosis and hospital resources. Arch Otolaryngol Head Neck Surg. 2010;136:784–9.CrossRefGoogle Scholar
  3. 3.
    Aviv JE, et al. Silent laryngopharyngeal sensory deficits after stroke. Ann Otol Rhinol Laryngol. 1997;106(2):87–93.CrossRefGoogle Scholar
  4. 4.
    Nakagawa T, et al. High incidence of pneumonia in elderly patients with basal ganglia infarction. Arch Intern Med. 1997;157(3):321–4.CrossRefGoogle Scholar
  5. 5.
    Langmore S, Schatz K, Olson N. Endoscopic and videofluroscopic evaluation of swallowing and aspiration. Ann Otol Rhinol Laryngol. 1991;100:678–81.CrossRefGoogle Scholar
  6. 6.
    Amberson J. Aspiration bronchopneumonia. Int Clin. 1937;3:126–38.Google Scholar
  7. 7.
    Ramsey D, Smithard D, Kalra L. Silent aspiration: what do we know? Dysphagia. 2005;20(3):218–25.CrossRefGoogle Scholar
  8. 8.
    Ramsey D, Smithard D, Kalra L. Early assessment of dysphagia and aspiration in acute stroke patients. Stroke. 2003;34:1252–7.CrossRefGoogle Scholar
  9. 9.
    Smith Hammond C, Goldstein L, Horner R, Ying J, Gray L, Gonzalez-Rothi L, Bolser D. Predicting aspiration in patients with ischaemic stroke: comparison of clinical signs and aerodynamic measures of voluntary cough. Chest. 2009;135(3):769–77.CrossRefGoogle Scholar
  10. 10.
    Kulnik ST, et al. Higher cough flow is associated with lower risk of pneumonia in acute stroke. Thorax. 2016;71(5):474–5.CrossRefGoogle Scholar
  11. 11.
    Miles A, Moore S, McFarlane M, Lee F, Allen J, Huckabee ML. Comparison of cough reflex test against instrumental assessment of aspiraition. Physiol Behav. 2013;118:25–31.CrossRefGoogle Scholar
  12. 12.
    Morice AH, et al. ERS guidelines on the assessment of cough. Eur Respir J. 2007;29:1256–76.CrossRefGoogle Scholar
  13. 13.
    Miles A, Zheng IS, McLauchlan H, Huckabee ML. Cough reflex testing in Dysphagia following stroke: a randomized controlled trial. J Clin Med Res. 2013;5(3):222–33.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Guillen-Sola A, et al. Usefulness of citric cough test for screening of silent aspiration in subacute stroke patients: a prospective study. Arch Phys Med Rehabil. 2015;96(7):1277–83.CrossRefGoogle Scholar
  15. 15.
    Ware J, et al. Assessment tools: functional health status and patient satisfaction. Am J Med Qual. 1995;11:S50–4.Google Scholar
  16. 16.
    Zwarenstein M, et al. Improving the reporing of pragmatic trials: as extension of the CONSORT statement. BMJ. 2008;337:a2390.CrossRefGoogle Scholar
  17. 17.
    Rosenbek JC, et al. A penetration-aspiration scale. Dysphagia. 1996;11(2):93–8.CrossRefGoogle Scholar
  18. 18.
    Mann G, Hankey G, Cameron D. Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke. 1999;30:744–8.CrossRefGoogle Scholar
  19. 19.
    Ward EC, Conroy AL. Validity, reliability and responsivity of the Royal Brisbane Hospital outcome measure for swallowing. Asia Pac J Speech Lang Hear. 1999;4:109–29.CrossRefGoogle Scholar
  20. 20.
    Daniels SK, Foundas AL. Lesions localization in acute stroke patients with risk of aspiration. Am Soc Neuroimaging. 1999;9:91–8.CrossRefGoogle Scholar
  21. 21.
    Bland JM, Altman DG. Multiple significance tests: the Bonferroni method. BMJ. 1995;310(6973):170.CrossRefGoogle Scholar
  22. 22.
    Langmore S, et al. Predictors of aspiration pneumonia: how important is dysphagia. Dysphagia. 1998;13:69–81.CrossRefGoogle Scholar
  23. 23.
    Wakasugi Y, Tohara H, Hattori F, Motohashi Y, Nakane A, Goto S, Ouchi Y, Mikushi S, Takeuchi S, Uematsu H. Screening test for silent aspiraiton at the bedside. Dysphagia. 2008;23:364–70.CrossRefGoogle Scholar
  24. 24.
    Kallesen M, Psirides A, Huckabee ML. Comparison of cough reflex testing with videoendoscopy in recently extubated intensive care unit patients. J Crit Care. 2016;33:90–4.CrossRefGoogle Scholar
  25. 25.
    Hamdy S, et al. Recovery of swallowing after Dysphagic stroke relates to functional reorganization in the motor cortex. Gastroenterology. 1998;115:1104–12.CrossRefGoogle Scholar
  26. 26.
    Kishore AK, et al. How is pneumonia diagnosed in clinical stroke research? A systematic review and meta-analysis. Stroke. 2015;46(5):1202–9.CrossRefGoogle Scholar
  27. 27.
    Broadley S, et al. Predictors of prolonged dysphagia following acute stroke. J Clin Neurosci. 2002;10(3):300–5.CrossRefGoogle Scholar
  28. 28.
    Carnaby-Mann G, Lenius K. The bedside examination in dysphagia. Phys Med Rehabil Clin. 2008;19(4):747–68.CrossRefGoogle Scholar
  29. 29.
    Holmes S. A service evaluation of cough reflex testing to guide dysphagia management in the postsurgical adult head and neck patient population. Curr Opin Otolaryngol Head Neck Surg. 2016;24(3):191–6.CrossRefGoogle Scholar
  30. 30.
    Daniels S, Briley K, Priestly D, Herrington L, Weisberg L, Foundas M. Aspiration in patients with acute stroke. Arch Phys Med Rehabil. 1998;79:14–9.CrossRefGoogle Scholar
  31. 31.
    McCullough G, Rosenbek J, Wertz R, Coy S, Mann G, McCullough K. Utility of clinical swallowing examination measures for detecting aspiration post stroke. J Speech Lang Hear Res. 2005;48:1280–93.CrossRefGoogle Scholar
  32. 32.
    Laciuga H, Brandimore A, Troche M, Hegland K. Analysis of clinicians’s perceptual cough evaluation. Dysphagia. 2016;31:521–30.CrossRefGoogle Scholar
  33. 33.
    Foster A, et al. ‘That doesn’t translate’: the role of evidence-based practice in disempowering speech pathologist in acute aphasia management. Int J Lang Commun Disord. 2015;50(4):547–63.CrossRefGoogle Scholar
  34. 34.
    Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362(9391):1225–30.CrossRefGoogle Scholar
  35. 35.
    Reker D, et al. Postacute stroke guideline compliance is associated with greater patient satisfaction. Arch Phys Med Rahabil. 2002;83:750–6.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Gold Coast University HospitalSouthportAustralia
  2. 2.School of Allied Health SciencesGriffith UniversityGold CoastAustralia

Personalised recommendations