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Sundar KM, Stark A, Morris MJ. Laryngeal Dysfunction Manifesting as Chronic Refractory Cough and Dyspnea: Laryngeal Physiology in Respiratory Health and Disease. Chest 2024; 166:171-186. [PMID: 38508333 DOI: 10.1016/j.chest.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/10/2024] [Accepted: 03/12/2024] [Indexed: 03/22/2024] Open
Abstract
TOPIC IMPORTANCE Laryngeal dysfunction as a cause of chronic refractory cough and episodic dyspnea is often missed, which results in unnecessary testing and delays in diagnosis. Understanding laryngeal roles in breathing and airway protection can help to appreciate the propensity to laryngeal dysfunction with aging, chronic lung disease, and sleep apnea. REVIEW FINDINGS The human larynx is a complex muscular structure that is responsible for multiple roles of breathing, vocalization, coughing, and swallowing. To undertake these activities, the larynx has a high density of sensory and motor innervation. In addition to common embryological origins with the pharynx and esophagus, with which many laryngeal activities are shared, somatomotor and autonomic pathways regulate emotional, cognitive, and complex motor sequence-planning activities within the larynx. Due to its unique location, the larynx is susceptible to infectious and gastroesophageal reflux-related insults. Couple this with key roles in regulation of airflow and mediation of airway protective reflexes, it is not surprising that neuropathic abnormalities and muscle dysfunction frequently develop. The expression of laryngeal dysfunction as hypersensitivity to mechanical, thermal, chemical, and other stimuli leads to exaggerated airway protective reflexes (laryngeal adductor reflex and cough reflex) manifesting as dyspnea and cough. SUMMARY Pulmonologists should incorporate assessment of laryngeal dysfunction during evaluation of chronic refractory cough and dyspnea. Recognition of laryngeal hypersensitivity in the patient with chronic refractory cough can identify patients who may benefit from cough suppression therapies. Similarly, timely identification of inducible laryngeal obstruction may not only resolve episodic dyspnea but lessen the need for unnecessary testing and treatments.
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Affiliation(s)
- Krishna M Sundar
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT.
| | - Amanda Stark
- Department of Otolaryngology-Head & Neck Surgery & Voice Disorders Center, University of Utah, Salt Lake City, UT
| | - Michael J Morris
- Pulmonary & Critical Care Service, Brooke Army Medical Center, JBSA Fort Sam Houston, TX
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Mittal A, Patel M, Wang D, Khrais A, Chyn ETY. Does Dysphagia Predict Inpatient Morbidity and Mortality in Geriatric Patients Admitted for Aspiration Pneumonia? Cureus 2023; 15:e39223. [PMID: 37337491 PMCID: PMC10276973 DOI: 10.7759/cureus.39223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 06/21/2023] Open
Abstract
Background Aspiration pneumonia is common in older adults admitted for community-acquired pneumonia and is associated with significant morbidity and mortality. Factors that put this population at higher risk of aspiration include cognitive impairment, neuromuscular dysfunction, and dysphagia. This study aimed to determine whether a concurrent diagnosis of dysphagia conferred a higher risk of complications in the elderly admitted for aspiration pneumonia. Methods The National Inpatient Sample 2001-2013 database was queried for patients, aged 65 or older, with a diagnosis of aspiration pneumonia using International Classification of Diseases, Ninth Revision (ICD-9) codes. Sepsis, respiratory failure, and intubation were identified with their respective ICD-9 codes. A chi-square test and binary logistic regression analysis were used to examine socio-demographic and complication variables, with a significance level of α <0.001. Results A total of 1,097,325 patients were admitted for aspiration pneumonia, of which 349,861 (24.2%) had dysphagia. After incorporating socio-demographic variables, the dysphagia group had a significantly lower likelihood of having sepsis (OR=0.72), respiratory failure (OR=0.92), intubation (OR=0.52), and inpatient mortality (OR = 0.59). Patients with dysphagia had a significantly higher likelihood of increased length of stay (OR=1.24). Conclusions Elderly patients admitted with aspiration pneumonia with a co-diagnosis of dysphagia were less likely to have inpatient morbidity and mortality compared to their counterparts. This may be due to improved speech evaluation and treatment in patients with dysphagia allowing for better control of macro and micro aspiration. Future research is needed to examine if universal speech therapy can reduce hospitalization and long-term mortality for such patients.
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Affiliation(s)
- Anmol Mittal
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Mansi Patel
- Department of Geriatrics, Mount Sinai Hospital, New York, USA
| | - Daniel Wang
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Ayham Khrais
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Eric Tien Yen Chyn
- Department of Geriatrics, Rutgers University New Jersey Medical School, Newark, USA
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Abd Aziz ZH, Katas H, Omar MS, Mohamed Shah N, Yusop SM. Formulation and Cost-Effectiveness of Fluid Gels as an Age-Appropriate Dosage Form for Older Adults with Dysphagia. Dysphagia 2021; 37:1022-1034. [PMID: 34518932 DOI: 10.1007/s00455-021-10365-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 08/30/2021] [Indexed: 12/14/2022]
Abstract
Dysphagia is associated with increased dependency and treatment costs, whereby patients resort to extemporaneous compounding that may further increase the number of adverse events and medical errors. In the management of dysphagia, increasing the bolus viscosity of medication such as fluid gels can be practiced. This study aimed to prepare and characterize the fluid gels as well as to estimate the cost of using fluid gels and compare it to the conventional practice of extemporaneous preparation of thickened liquid. Fluid gels were formulated using gellan gum and determined for physicochemical characteristics and in vitro drug release profile. The cost-based price of the fluid gel was estimated and compared to the cost of administering standard medication as well as administering thickened liquid using thickening powder. Fluid gels exhibited good physicochemical properties with the viscosity within nectar and honey consistency. A similar dissolution profile to the reference was observed for the 0.5% w/v gellan gum fluid gel and exhibiting the Higuchi release model. The price for 100 mL unit of 50 mg/mL paracetamol/acetaminophen and 20 mg/mL ibuprofen fluid gel was estimated to be about USD2.30 and USD2.37, respectively. A dose of 1000 mg paracetamol and 400 mg ibuprofen fluid gel was estimated to be about USD0.46 and USD0.47, respectively, which is lower than the cost of administering the same dose using extemporaneous thickened liquid. Fluid gels could be a cost-effective formulation for delivering medication in patients with dysphagia and can be developed on a profitable scale.
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Affiliation(s)
- Zul Hadif Abd Aziz
- Centre for Drug Delivery Technology, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur Campus, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur, Malaysia
| | - Haliza Katas
- Centre for Drug Delivery Technology, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur Campus, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur, Malaysia.
| | - Marhanis Salihah Omar
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur, Malaysia
| | - Noraida Mohamed Shah
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur, Malaysia
| | - Salma Mohamad Yusop
- Department of Food Sciences, Faculty of Science and Technology, Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia
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Warraich M, Bolaji P, Das S. Posterior circulation stroke presenting as a new continuous cough: not always COVID-19. BMJ Case Rep 2021; 14:14/1/e240270. [PMID: 33431481 PMCID: PMC7802704 DOI: 10.1136/bcr-2020-240270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
A 19-year-old man was admitted with a 2-week history of continuous cough along with a day history of acute onset unsteadiness and hiccups. Given the current pandemic, he was initially suspected to have COVID-19, however he tested negative on two occasions. Subsequent brain magnetic resonance imaging (MRI)confirmed a small left acute and subacute lateral medullary infarction with chest X-ray suggesting aspiration pneumonia with right lower lobe collapse. This is a distinctive case of posterior circulation stroke presenting with a new continuous cough in this era of COVID-19 pandemic. We anticipate based on MRI findings that his persistent cough was likely due to silent aspiration from dysphagia because of the subacute medullary infarction. It is therefore imperative that healthcare workers evaluate people who present with new continuous cough thoroughly to exclude any other sinister pathology. We should also be familiar with the possible presentations of posterior circulation stroke in this pandemic era.
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Affiliation(s)
| | - Paul Bolaji
- Stroke Medicine, New Cross Hospital, Wolverhampton, UK
| | - Saugata Das
- Stroke Medicine, New Cross Hospital, Wolverhampton, UK
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Association between nasal patency and orofacial myofunctional changes in patients with asthma and rhinitis. Eur Arch Otorhinolaryngol 2021; 278:2371-2377. [PMID: 33389007 DOI: 10.1007/s00405-020-06518-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To verify the association between orofacial myofunctional changes and nasal patency. METHOD Observational study of 43 children and adolescents with asthma and/or rhinitis, aged between 5 and 14 years, from May 2017 to September 2019. Patients underwent peak nasal inspiratory flow (PNIF) for nasal patency assessment and orofacial myofunctional assessment. Clinical data were obtained from an interview on the day of the patients' medical evaluation. The relationship between orofacial myofunctional changes and PNIF was analyzed using a logistic regression model. Estimates were reported as odds ratio (OR) and 95% confidence interval (95%CI). We evaluated multicollinearity using the variance inflation factor and analyzed the adjusted fit with the Akaike information criterion and McFadden's R2 metric; p value < 0.05 was considered statistically significant. RESULTS Inadequate positioning of the mandible (OR = 11.22; 95%CI 1.83-69; p = 0.009) and the presence of tension in the facial muscles during the swallowing of liquid (OR = 4.61; 95%CI 1.31-16.20; p = 0.017) were associated with altered PNIF in children and adolescents with asthma and rhinitis. CONCLUSION Children and adolescents with asthma and rhinitis along with reduced nasal patency presented orofacial myofunctional changes, such as inadequate positioning of the jaw and the presence of tension in the facial muscles during swallowing of liquid.
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Carvalho-Oliveira M, Salles C, Terse R, D'Oliveira A. Association between severe asthma and changes in the stomatognathic system. J Bras Pneumol 2017; 42:423-428. [PMID: 28117472 PMCID: PMC5344090 DOI: 10.1590/s1806-37562015000600006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 05/31/2016] [Indexed: 11/22/2022] Open
Abstract
Objective: To describe orofacial muscle function in patients with severe asthma. Methods: This was a descriptive study comparing patients with severe controlled asthma (SCA) and severe uncontrolled asthma (SUA). We selected 160 patients, who completed a sociodemographic questionnaire and the 6-item Asthma Control Questionnaire (ACQ-6), as well as undergoing evaluation of orofacial muscle function. Results: Of the 160 patients evaluated, 126 (78.8%) and 34 (21.2%) presented with SCA and SUA, respectively, as defined by the Global Initiative for Asthma criteria. Regardless of the level of asthma control, the most frequent changes found after evaluation of muscle function were difficulty in chewing, oronasal breathing pattern, below-average or poor dental arch condition, and difficulty in swallowing. When the sample was stratified by FEV1 (% of predicted), was significantly higher proportions of SUA group patients, compared with SCA group patients, showed habitual open-mouth chewing (24.8% vs. 7.7%; p < 0.02), difficulty in swallowing water (33.7% vs. 17.3%; p < 0.04), and voice problems (81.2% vs. 51.9%; p < 0.01). When the sample was stratified by ACQ-6 score, the proportion of patients showing difficulty in swallowing bread was significantly higher in the SUA group than in the SCA group (66.6% vs. 26.6%; p < 0.01). Conclusions: The prevalence of changes in the stomatognathic system appears to be high among adults with severe asthma, regardless of the level of asthma control. We found that some such changes were significantly more common in patients with SUA than in those with SCA.
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Affiliation(s)
- Mayra Carvalho-Oliveira
- . Programa de Controle da Asma e Rinite Alérgica da Bahia - ProAR - Salvador (BA) Brasil.,. Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal da Bahia, Salvador (BA) Brasil
| | - Cristina Salles
- . Escola Bahiana de Medicina e Saúde Pública, Salvador (BA) Brasil
| | - Regina Terse
- . Departamento de Pediatria, Faculdade de Medicina, Universidade Federal da Bahia, Salvador (BA) Brasil
| | - Argemiro D'Oliveira
- . Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal da Bahia, Salvador (BA) Brasil.,. Programa de Pós-Graduação em Medicina e Saúde, Universidade Federal da Bahia, Salvador (BA) Brasil
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Steidl E, Ribeiro CS, Gonçalves BF, Fernandes N, Antunes V, Mancopes R. Relationship between Dysphagia and Exacerbations in Chronic Obstructive Pulmonary Disease: A Literature Review. Int Arch Otorhinolaryngol 2014; 19:74-9. [PMID: 25992155 PMCID: PMC4392502 DOI: 10.1055/s-0034-1376430] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 04/01/2014] [Indexed: 12/31/2022] Open
Abstract
Introduction The literature presents studies correlating chronic obstructive pulmonary disease to dysphagia and suggesting that the aspiration laryngeal phenomenon related to changes in the pharyngeal phase contributes significantly to the exacerbation of symptoms of lung disease. Objectives This study aimed to conduct a literature review to identify the relation between dysphagia and exacerbations of chronic obstructive pulmonary disease. Data Synthesis We found 21 studies and included 19 in this review. The few studies that related to the subject agreed that the presence of dysphagia, due to lack of coordination between swallowing and breathing, may be one of the triggering factors of chronic obstructive pulmonary disease exacerbation. Conclusions The review noted that there is a relationship between dysphagia and exacerbations of chronic obstructive pulmonary disease, identified by studies demonstrating that the difficulties associated with swallowing may lead to exacerbation of the disease. There was difficulty in comparing studies by their methodological differences. More research is needed to clarify the relationship between dysphagia and exacerbations of chronic obstructive pulmonary disease, making it possible to develop multiprofessional treatment strategies for these patients, catered to specific needs due to the systemic manifestations of the disease.
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Affiliation(s)
- Eduardo Steidl
- Post-Graduation Student, Department of Speech Therapy, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Carla Simone Ribeiro
- Department of Physiotherapy, Centro Universitário Franciscano, Santa Maria, RS, Brazil
| | - Bruna Franciele Gonçalves
- Post-Graduation Student, Department of Speech Therapy, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Natália Fernandes
- Department of Speech Therapy, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | - Vívian Antunes
- Department of Physiotherapy, Centro Universitário Franciscano, Santa Maria, RS, Brazil
| | - Renata Mancopes
- Department of Speech Therapy, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
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