What is the best approach to manage cough in stroke patients?

Management of Cough in Stroke Patients

Stroke patients with cough require careful assessment of swallowing function and aspiration risk, with referral to a speech language pathologist (SLP) for detailed evaluation if any signs of aspiration are present. 1

Assessment of Aspiration Risk

Initial Evaluation

• Assess level of consciousness first:
  • Patients with reduced consciousness should not be fed orally until consciousness improves 1
  • Extremely lethargic patients or those with inconsistent alertness are at high aspiration risk 1

For Alert Patients

1. Water swallow test (3 oz volume):

   • Observe for signs of aspiration during swallowing:
     • Coughing during or after swallowing
     • Wet voice after swallowing
     • Throat clearing
     • Hoarse voice or dysphonia
     • Incomplete oral-labial closure 1

2. Voluntary cough assessment:

   • Ask patient to cough with maximum force
   • Evaluate for:
     • Weak or absent voluntary cough
     • "Wet/gurgly" quality to cough
     • Cough apraxia (inability to cough on command) 1

3. High-risk indicators requiring immediate referral:

   • Abnormal gag reflex
   • Impaired voluntary cough
   • Dysphonia
   • Cranial nerve palsies
   • High NIHSS score 1

Management Algorithm

Step 1: Risk Stratification

• High risk for aspiration:
  • Patients with brain stem infarctions
  • Multiple strokes
  • Large hemispheric lesions
  • Depressed consciousness 1

Step 2: Feeding Decisions

• If any signs of aspiration are present:
  • Refer for detailed swallowing evaluation by SLP 1
  • Consider videofluoroscopic modified barium swallow examination 1
  • Maintain NPO (nothing by mouth) status until evaluation complete 1

Step 3: Nutritional Support

• For patients who cannot safely swallow:
  • Short-term: nasogastric or nasoduodenal tube feeding 1
  • Long-term (if prolonged need anticipated): percutaneous endoscopic gastrostomy (PEG) tube 1

Step 4: Pneumonia Prevention

• Early mobilization when patient's condition is stable 1
• Frequent turning and proper positioning 1
• Oral care to reduce bacterial colonization 1
• Monitor for fever, which may indicate pneumonia 1
• Prompt antibiotic therapy if pneumonia develops 1

Important Caveats

1. A preserved gag reflex does not guarantee safe swallowing - many patients with intact gag reflex still aspirate 1

2. Subjective assessment of voluntary cough alone is unreliable for predicting aspiration risk - objective measurements are more accurate 1, 2

3. Respiratory muscle function and cough flow typically improve with time after acute stroke - a study showed significant improvements in respiratory muscle strength and voluntary cough flow within 28 days post-stroke 3

4. Respiratory muscle training has been studied but does not appear to significantly improve cough function or reduce pneumonia risk beyond natural recovery 3

5. Benzonatate is indicated for symptomatic relief of cough 4, but there's no specific evidence supporting its use in stroke patients with dysphagia, and it may mask important protective cough responses

6. Cough reflex testing using nebulized citric acid has been studied but hasn't shown significant reduction in pneumonia rates compared to standard evaluation 1

7. Left middle cerebral artery infarctions may be more likely to cause "cough apraxia" than right-sided infarctions, though the clinical significance remains uncertain 1

By following this systematic approach to assessing and managing cough in stroke patients, clinicians can reduce the risk of aspiration pneumonia and improve patient outcomes.