None listed
Conditions
Brief summary
Chronic obstructive pulmonary disease (COPD) is the 4th leading cause of death after cancer, heart disease and stroke, and is the second major cause of health loss in older adults. Reported prevalence of swallowing disorders in COPD varies from 17% to 85% and a poor self-awareness of swallowing difficulties has been demonstrated (Clayton 2007). One implication of poor swallowing in COPD is the entry of food/fluid into the wind pipe (aspiration) which can trigger a protective cough but can also occur silently with no obvious signs (silent aspiration). Aspiration can cause aspiration pneumonia, which could be contributing to a worsening or ‘exacerbation’ of COPD. 30 consecutive patients admitted to North Shore Hospital (NSH, Waitemata District Health Board; WDHB) with exacerbation of COPD as primary diagnosis will be approached for screening by a speech & language therapist (SLT) using a cough reflex test (CRT). This test involves administering citric acid via nebuliser with the aim of triggering a cough which will be subjectively categorised by the researcher as strong, weak or absent. Absent cough suggests reduced throat sensitivity. The CRT will be followed by a fiberoptic endoscopic evaluation of swallowing (FEES), which involves passing a videoscope through the nasal cavity to directly observe the passage of food and fluid through the throat. A standardised rating scale will be used to rate the swallow as normal or abnormal (aspiration) and whether a cough response to protect the airway is triggered or not (silent aspiration). The study will seek to explore whether there is an association between absent cough on CRT and silent aspiration on FEES, investigating the value of the CRT as a screening tool in COPD. The participants’ medical charts will be monitored until medically ‘stable.’ The CRT and FEES will then be repeated prior to discharge, to investigate whether any differences exist in the cough response and/or swallow function when in stable condition.
Interventions
Exploring the relationship between cough reflex testing (CRT) and silent aspiration in acute exacerbation of chronic obstructive pulmonary disease (COPD).
All participants will receive a cough reflex test post recruitment to the study.
A 2ml placebo dose of 0.9% sodium chloride without citric acid will first be administered through a face mask and nebuliser for 15 seconds, to normalise the patient to the face mask method. Should the patient cough in response to the placebo, it will be repeated t
Exploring the relationship between cough reflex testing (CRT) and silent aspiration in acute exacerbation of chronic obstructive pulmonary disease (COPD). All participants will receive a cough reflex test post recruitment to the study. A 2ml placebo dose of 0.9% sodium chloride without citric acid will first be administered through a face mask and nebuliser for 15 seconds, to normalise the patient to the face mask method. Should the patient cough in response to the placebo, it will be repeated twice more. Should coughing persist, the participant will be excluded from the study as either task comprehension difficulties or hypersensitivity of the cough reflex will have been demonstrated. 2ml of citric acid diluted in 0.9% saline solution to provide a 0.4mol/L concentration will be administered for up to three trials of 15 seconds each, and the participant responses to the citric acid will be subjectively rated as either absent, weak or strong. Trials will discontinue when two consistent responses are achieved. A 30 second interval will occur between trials to avoid tachyphylaxis. For the purpose of the study, a response qualifies as a cough when a two forced expulsive manoeuvres against a closed glottis are heard within one respiratory cycle as recommended by the ERS Guidelines (2007). The cough reflex test will be repeated with all participants once deemed medically stable and/or cleared for hospital discharge.
Sponsors
Waitemata District Health Board
Study design
Allocation
Non-randomised trial
Intervention model
Single group
Primary purpose
Diagnosis
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
50 consecutive patients admitted to North Shore Hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD) as primary diagnosis or reason for admission will be approached for participation in the study. Hospital admission lists will be screened daily to identify eligible patients.
Exclusion criteria
Deemed palliative as per medical team (identifying aspiration for these patients would unlikely change their medical management and reversibility of cough reflex is considered unlikely); Neurological or neuromuscular impairments or progressive neurological disease e.g. stroke, bulbar and pseudobulbar palsy, Parkinson’s Disease, Multiple Sclerosis, Dementia, Motor Neurone Disease (to avoid referral bias due to known associations with dysphagia); Endotracheal intubation within previous three months (based on Mokhlesi et al., 2002); Previous or current tracheostomy; Cognitive impairment which would preclude obtaining informed consent; Current active smoking (smoking blunts cough reflex; Dicpinigaitis, 2003); Reported clinical symptoms or diagnosis of gastro-oesophageal reflux disease (GORD; can cause reduced Lx sensitivity; Phua et al., 2005); Known or suspected swallowing impairment unrelated to COPD; Previous head and/or neck surgery, injury or radiation; Current use of angiotensin-converting enzyme (ACE inhibitors; promotes cough & increases tussive effect; Morice et al., 1987); Current use of opiates (opiates have an antitussive effect; Morice et al., 2007). Known contraindications for FEES e.g. recent base of skull/facial fracture, recent history of severe/life-threatening epistaxis, sino-nasal and anterior skull base tumours/surgery, nasopharyngeal stenosis (guided by Royal College of Speech & Language Therapists, 2007).
Outcome results
None listed