Reflex vs. volitional cough differences amongst head and neck cancer survivors characterized by time since treatment and aspiration status

https://doi.org/10.1016/j.resp.2021.103702Get rights and content

Highlights

  • Reflex cough airflows are reduced vs to volitional cough airflows.

  • Cough airflows are reduced for aspirators vs non-aspirators.

  • Cough airflows are reduced for those recently s/p treatment vs long term survivors.

Abstract

Background

The aim of this study was to investigate differences in reflexive and volitional cough airflows in advanced stage head and neck cancer survivors as it relates to aspiration status and time since treatment. The hypothesis is that those who aspirate several years after treatment completion would demonstrate reduced airflows for all cough parameters compared to those recently status post treatment completion given the known progressive deterioration associated with radiotherapy.

Methods

Demographic and airflow data during both reflexive and volitional cough tasks and aspiration status as determined during fiberoptic endoscopic evaluation of swallow function were collected from 33 Head and Neck Cancer (HNC) survivors.

Results

Omnibus MANOVA for dependent airflow variables and independent variables aspiration status, time since treatment and cough type (reflex or volitional) was significant (F(3,1) = 184, p < 0.000) indicating that peak expiratory flow rates (PEFR) were reduced under reflex (mean PEFR 1.88 SD 0.7) versus volitional (mean PEFR 2.3, SD 0.7) cough types; reduced for aspirators versus non-aspirators (F(2,1) = 4.1, p = 0.04) and reduced for those in the subacute versus chronic phase status post Intensity Modulated Radiotherapy (IMRT) (F(2,1) = 10.05, p = 0.002).

Conclusion

Findings of reduced reflexive compared to volitional cough airflows in head and neck cancer survivors are consistent with those from both healthy and other diseased populations. Additional findings that aspirators demonstrate reduced cough airflows compared to non-aspirators supports the hypothesis. Surprisingly, those recently status post treatment completion show worse cough airflows compared to those remotely status post treatment completion.

Section snippets

Purpose

Disordered cough, or dystussia, is commonly associated with disordered swallowing, or dysphagia (Pitts et al., 2012), which is a leading cause of toxicity and mortality among Head and Neck cancer (HNC) survivors following treatment completion (Langerman et al., 2007). Over half of these survivor’s experience dysphagia following multimodal therapy (Langendijk et al., 2009) a third of which is characterized as silent, or ingestion of material below the glottis without cough (Langerman et al., 2007

Methods

This cross-sectional convenience sample included 33 HNC survivors (Fig. 1) aged 43–80 years old (average 64 years) all of whom received doses of at least 45 Gray (Gy) to head and neck cancer subsites (Table 1). This demarcation was chosen based on existing literature positing that doses of 45 Gy or more to structures involved in swallow results in degradation of this function (Eisbruch et al., 2004). Bilateral mobility of the true vocal folds was verified through endoscopic observation and

Procedures

Cough airflow metrics were obtained using established methods (Hegland et al., 2016) wherein participants were outfitted with a facemask covering the nose and mouth and coupled to a pneumotachograph (MLT 1000, ADInstruments Inc; Colorado Springs, CO) and differential pressure transducer. Airflow measures were recorded after volume calibration with 3-liter Vitalograph syringe (McKesson; Cork, Ireland). Airflow signals were recorded to LabChart7 (ADInstruments) with proprietary software for

Statistical analysis

Descriptive statistics were used to summarize group data; including mean, median, range and standard deviations. Homogeneity within each group was determined with one-way analysis of variance and none of the dependent variables (sex, age, diagnose site, tumor/nodal stage, pack-per-year smoking history or total dose to site) violated Levene’s statistic. To determine differences in the primary outcome of cough airflow (peak expiratory flow rate: PEFR, peak expiratory flow rise time: PEFRT, and

Results

Participants were three months to six years status post treatment completion, 12 of whom were within the subacute phase of treatment completion (average five months) and 21 of whom were in the chronic phase (12 or more months, average 30 months or 2.5 years). The most common site was oral cavity 39 % (n = 13) and pharynx (n = 7) followed by larynx (n = 5), salivary (n = 4) and other head and neck (n = 4); most laryngeal/hypopharyngeal primaries did not meet inclusionary criteria. Eight of those

Discussion

Reflexive cough is a cough in response to tussigenic stimulation of peripheral sensory receptors. Sensory receptors in the laryngeal epithelium are comprised of nociceptive afferents (Yamamoto and Sakada, 1986) responsible for sensing pain and temperature. These include free nerve endings which are comprised of both Aδ and C-fibers (Schulze et al., 1993). Aδ-fibers detect pressure, cold temperature and reliably produce a cough in response to either mechano- or chemostimulation, both of which

Authors’ contributions

AF and KH formulated methods, AF and YM carried out experimental protocol, AF prepared manuscript with edits from NS, NC and KH.

Consent to participate

All participants provided verbal and written informed consent.

Ethical approval

The protocol received ethical approval in accordance with the Declaration of Helsinki from the University of Florida Institutional Review Board.

Declaration of Competing Interest

The authors report no declarations of interest.

Acknowledgements

Funding provided by NIH common fund SPARC #OT2OD023854 and Neal Pitts Foundation.

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  • This work is an elaboration of a poster presentation given November, 2019 at the Annual meeting of the American Speech and Hearing Association and virtual podium presentation given March, 2020 at the annual meeting of the Dysphagia Research Society.

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