Background and Purpose-We sought to evaluate the efficacy of testing the laryngeal cough reflex in identifying pneumonia risk in acute stroke patients. Methods-We performed a prospective study of 400 consecutive acute stroke patients examined using the reflex cough test (RCT) compared with 204 consecutive acute stroke patients from a sister facility examined without using the RCT. The binary end point for the study outcome was the development of pneumonia. Results-Of the 400 patients examined with the RCT, 5 developed pneumonia. Of the 204 patients examined without the RCT, 27 developed pneumonia (PϽ0.001). Three of the 27 patients died in the rehabilitation hospital of respiratory failure secondary to pneumonia. Seven others were transferred to the emergency department with acute respiratory distress. Power analysis for this comparison was 0.99. There were no other significant differences between the 2 groups. Conclusions-A normal RCT after an acute stroke indicates a neurologically intact laryngeal cough reflex, a protected airway, and a low risk for developing aspiration pneumonia with oral feeding. An abnormal RCT indicates risk of an unprotected airway and an increased incidence of aspiration pneumonia. Alternate feeding strategies and preventive measures are necessary with an abnormal RCT. Clinical treatment algorithm and prescription of food, fluids, and medications are discussed on the basis of RCT results. (Stroke. 1999;30:1203-1207.)Key Words: aspiration Ⅲ cough Ⅲ pneumonia Ⅲ stroke Ⅲ videofluoroscopy A fter a stroke, one of the most challenging decisions clinicians face is instituting the prescription of fluids, foods, and oral medications safely. The question of whether it is safe to feed the patient has been left mostly to guesswork and to a trial-and-error approach. Physicians have historically deferred this dilemma to speech pathologists or other personnel. It is estimated that up to 38% of stroke victims die within the first month after stroke onset. 1,2 Pneumonia contributes to up to 34% of all stroke deaths and represents the third highest cause of mortality in the first month after stroke. Pneumonia has been estimated to occur in one third of all stroke victims and is the most common respiratory complication. 3 The Florida Hospital Association reports total charges for dysphagia and food/vomit pneumonitis to be $1.2 billion in 1997 for the state of Florida, increased from $1.1 billion in 1996. In 1996, Florida was ranked the 15th highest nationwide in charges for the following International Classification of Diseases, Ninth Revision codes: 787.2 (dysphagia) and 507.0 (food/vomit pneumonitis). 4,5 The effects of pneumonia development have been described in terms of individual cost of care. The development of pneumonia after stroke resulted in an additional financial burden of approximately $10 000 per event and extended hospital length of stay an average of 7 days. 6 Given the incidence of stroke, the prevalence of dysphagia, the risk of aspiration, and the effects of pneumonia in terms of morb...

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The purpose of this study was to stimulate the laryngeal cough reflex using a nebulized, mild chemical irritant and to record an associated laryngeal evoked potential from the internal branch of the superior laryngeal nerve. The laryngeal evoked potential was obtained on ten normal subjects from the right internal branch of the superior laryngeal nerve. The electrodiagnostic setup included an active electrode placed just below the hyoid bone with a 4-cm separation and distal reference. A ground electrode was placed between the active and reference electrodes. The receptors and internal branch of the superior laryngeal nerve were stimulated by inhalation of a nebulized 20% solution of tartaric acid and normal saline. The time line was triggered by a pneumatic switch on initial inspiration of the nebulized tartaric acid. The electrodiagnostic settings were set at a sweep speed of 1 ms/division, a gain of 10 to 20 microV/division, and 20 to 2,000 filters. There were 132 variables recorded from the internal branch of the superior laryngeal nerve of the ten subjects. The mean peak distal latency was 1.66+/-0.42 ms with a 1.6 median, 1.6 mode, and 0.17 variance. The duration was 0.41 ms, and amplitude was 5.19+/-2.91 microV. In conclusion, the laryngeal evoked potential, the afferent component of the involuntary cough reflex, can be recorded from the internal branch of the superior laryngeal nerve after inhalation of tartaric acid-induced cough.

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