Cough Assessment Revisited
Over the years as an SLP working primarily with dysphagia, it has seemed like our focus on cough has come in and out of fashion. We used to be SO fixated on it that a cough in the room a few doors down during lunchtime at the hospital I worked at would send me dashing down the hallway! And then we learned more—that cough is not always a reliable indicator of a problem swallowing, that it can mean so many different things—and for a while we were maybe less interested.
Now, cough has taken on a whole new focus in swallow assessment as we learn about the relationship between cough strength and swallowing. Cough assessment can be a valuable part of our clinical evaluation and working to improve cough strength can be an addition to our plan of care.
In fact, I recently attended the meeting of the Dysphagia Research Society, and discussions of cough and the airway mechanisms and their relationship to swallowing were EVERYWHERE! It was such a fantastic look at the complexity of these systems and how they all come together, so I wanted to share with you all.
For a wonderful resource on this relationship, you really must check out the website of Dr. James Curtis, PhD, CCC-SLP, BCS-S. An Assistant Professor at Weill-Cornell and the Principal Investigator/Director of the Aerodigestive Innovations Research (AIR) Lab, Dr. Curtis investigates voice, cough, and swallowing. His website, found here, offers some excellent information on these mechanisms. Make sure to check out the tutorials on cough: they offer not only an overview of why we should be considering cough assessment and treatment, but also specifics on how to go about implementation.
I cannot offer resources on cough without mentioning Dr. Michelle Troche, PhD, CCC-SLP! Dr. Troche is a Professor and Program Director at Columbia University, she also directs the Laboratory for the Study of Upper Airway Dysfunction. She has MANY contributions to this topic in our field, but there one in particular I wanted to share: A webinar from The University of Wisconsin Division of Otolaryngology offers a Voice & Swallow Clinic Lecture Series. (I have mentioned this outstanding resource before!) The webinar is from a few years ago, and the free recording is available here. This particular webinar is no longer available for ASHA CEs but can be used as PDH (Professional development hours). There IS a current webinar in the series on cough management by Jacob Tangney, MS, CCC-SLP that is still available for ASHA CEs. (You will need to create a registration with the series to obtain credit.)
Bonus: If you would like some more information from Dr. Troche, here is a recording of a recent webinar from Aspire Medical in which she discusses Expiratory Muscle Strength Training via telehealth. You can see it here.
Finally, if you want a really great look at the literature, this comprehensive review by Dr. Justine Dallal-York (and the aforementioned Dr. Troche) is for you! The literature review, published in 2024, is open access, so you can download it as pdf or read it online in its entirety here.
So there you have it! I would love to know if you are currently incorporating cough assessment and/or treatment in your practice! Let me know here!
Recent Posts:
Pediatric Craniofacial Anomalies & Feeding and Swallowing
In our next look at unique patient journeys, I thought I would share some resources on feeding and swallowing in pediatric craniofacial anomalies. I had been thinking of sharing resources in this area for a little while now, and since July is recognized as National...
Dysphagia Awareness Month Resources
During Dysphagia Awareness Month, I typically try to share some stats and facts about dysphagia and swallowing with my social circle. This year, I decided to instead put some resources out there for patients and caregivers. I loved these resources (and the...
Swallowing in Head & Neck Cancer
As I mentioned a couple of months ago, I am starting a new series in which I will share resources that are specific to a unique patient journey. I am kicking off that series today focusing on swallowing in head and neck cancer. I chose this to start with not only...
Need to know more about a specific diagnosis?
Last month, we celebrated THREE years of “Life of Janie, SLP.” As much as I love what we have been doing in the past, I also recognize the importance of making changes… and so I am introducing a new recurring series here: Resources in Specific Populations. While we so...
Cheers to Three Years!
It’s so hard to believe that I have been sharing resources for THREE years now! Thank you to the many clinicians who responded to my polls, I have learned so much from all of you… and I hope that you have learned a few things from me! After all, that is one my...
Supporting People with Dysphagia
As clinicians, we are thinking about and working in the field of dysphagia so much that it can be easy to forget how completely unknown the concept of swallowing problems can be to the general public (see an upcoming discussion on this!). To a patient experiencing...
Strengthening the SLP-registered dietician collab
When I was a new SLP, I had a patient with dysphagia. I carefully conducted the clinical swallowing evaluation, talked to the patient and their family about how the dysphagia was impacting their life, completed an MBSS using a standardized approach and considered the...
Janie’s Good Reads
As much as I enjoy reading research on swallowing (see my prior thoughts on this here and find more resources here), I also really love when someone else has done it for me! Add in some good writing, a few jokes, a meme or two, and I am hooked. This month, I thought I...
Clinical practice and research methods: best friends or worlds apart?
A couple months ago, we talked about reading research and how to investigate new interventions (big thank you again to Ed Bice for sharing his filtering tool—if you missed this, be sure to check it out at Life of Janie), and boy did this resonate with a lot of us!...
VARIBAR (barium sulfate) ABCs and FAQs
It’s getting hot out there… and it seems like our inboxes are heating up as well! We have noticed lately that we are getting an uptick in a few questions about VARIBAR products, and so I thought I would take a minute to send out some answers here!What is the carb...
INDICATIONS AND USAGE | IMPORTANT SAFETY INFORMATION
ENTERO VU™ (barium sulfate) oral suspension, 24% w/v
INDICATION:
Liquid E-Z-PAQUE (barium sulfate) oral suspension is indicated in adults and pediatrics for use in single contrast radiographic examinations of the esophagus, stomach, and small bowel to visualize the gastrointestinal tract (GI).
CONTRAINDICATIONS
ENTERO VU is contraindicated in patients with known or suspected perforation of the GI tract, known obstruction of the GI tract, high risk of GI perforation such as those with a recent GI perforation, acute GI hemorrhage or ischemia, toxic megacolon, severe ileus, post GI surgery or biopsy, acute GI injury or burn, or recent radiotherapy to the pelvis, high risk of aspiration such as those with known or suspected tracheo-esophageal fistula or obtundation, or known severe hypersensitivity to barium sulfate or any of the excipients.
VARIBAR® (barium sulfate)
INDICATIONS
VARIBAR® THIN HONEY (barium sulfate) oral suspension, VARIBAR® NECTAR (barium sulfate) oral suspension, and VARIBAR® THIN LIQUID (barium sulfate) oral suspension are radiographic contrast agents indicated for use in modified barium swallow examinations to evaluate the oral and pharyngeal function and morphology in adult and pediatric patients.
VARIBAR® HONEY (barium sulfate) oral suspension and VARIBAR® PUDDING (barium sulfate) oral paste are radiographic contrast agents indicated for use in modified barium swallow examinations to evaluate the oral and pharyngeal function and morphology in adult and pediatric patients 6 months of age and older.
IMPORTANT SAFETY INFORMATION
CONTRAINDICATIONS
These products should not be used in patients with known or suspected perforation of the gastrointestinal (GI) tract; known obstruction of the GI tract; high risk of GI perforation such as those with a recent GI perforation, acute GI hemorrhage or ischemia, toxic megacolon, severe ileus, post GI surgery or biopsy, acute GI injury or burn, or recent radiotherapy to the pelvis; high risk of aspiration such as those with known or suspected tracheo-esophageal fistula or obtundation; known severe hypersensitivity to barium sulfate or any of the excipients of the product used.
WARNINGS AND PRECAUTIONS
Hypersensitivity Reactions Barium sulfate preparations contain a number of excipients, including natural and artificial flavors, and may induce serious hypersensitivity reactions. The manifestations include hypotension, bronchospasm and other respiratory impairments, and dermal reactions including rashes, urticaria, and itching. A history of bronchial asthma, atopy, food allergies, or a previous reaction to a contrast agent may increase the risk for hypersensitivity reactions. Emergency equipment and trained personnel should be immediately available for treatment of a hypersensitivity reaction.
Intra-abdominal Barium Leakage The use of VARIBAR PRODUCTS is contraindicated in patients at high risk of perforation of the GI tract. Administration of VARIBAR PRODUCTS may result in leakage of barium from the GI tract in the presence of conditions such as carcinomas, GI fistula, inflammatory bowel disease, gastric or duodenal ulcer, appendicitis, or diverticulitis, and in patients with a severe stenosis at any level of the GI tract, especially if it is distal to the stomach. The barium leakage has been associated with peritonitis and granuloma formation.
Delayed Gastrointestinal Transit and Obstruction Orally administered barium sulfate may accumulate proximal to a constricting lesion of the colon, causing obstruction or impaction with development of baroliths (inspissated barium associated with feces) and may lead to abdominal pain, appendicitis, bowel obstruction, or rarely perforation. Patients with the following conditions are at higher risk for developing obstruction or baroliths: severe stenosis at any level of the GI tract, impaired GI motility, electrolyte imbalance, dehydration, on a low residue diet, taking medications that delay GI motility, constipation, pediatric patients with cystic fibrosis or Hirschsprung disease, and the elderly. To reduce the risk of delayed GI transit and obstruction, patients should maintain adequate hydration after the barium sulfate procedure. When administering VARIBAR PUDDING, consider the administration of laxatives.
Aspiration Pneumonitis The use of VARIBAR PRODUCTS is contraindicated in patients with trachea-esophageal fistula. Oral administration of barium is associated with aspiration pneumonitis, especially in patients with a history of food aspiration or with compromised swallowing mechanism. Vomiting following oral administration of barium sulfate may lead to aspiration pneumonitis. In patients at risk for aspiration, begin the procedure with a small ingested volume of VARIBAR PRODUCTS. Monitor the patient closely for aspiration, discontinue administration of VARIBAR PRODUCTS if aspiration is suspected, and monitor for development of aspiration pneumonitis.
Systemic Embolization Barium sulfate products may occasionally intravasate into the venous drainage of the GI tract and enter the circulation as a "barium embolus" leading to potentially fatal complications which include systemic and pulmonary embolism, disseminated intravascular coagulation, septicemia and prolonged severe hypotension. Although this complication is exceedingly uncommon after oral administration of a barium sulfate suspension, monitor patients for potential intravasation when administering barium sulfate.
ADVERSE REACTIONS
The most common adverse reactions are nausea, vomiting, diarrhea, and abdominal cramping. Serious adverse reactions and fatalities include aspiration pneumonitis, barium sulfate impaction, intestinal perforation with consequent peritonitis and granuloma formation, vasovagal and syncopal episodes.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
Please click here for full Prescribing Information for VARIBAR® THIN LIQUID (barium sulfate) oral suspension.
Please click here for full Prescribing Information for VARIBAR® THIN HONEY (barium sulfate) oral suspension.
Please click here for full Prescribing Information for VARIBAR® NECTAR (barium sulfate) oral suspension.
Please click here for full Prescribing Information for VARIBAR® HONEY (barium sulfate) oral suspension.
Please click here for full Prescribing Information for VARIBAR® PUDDING (barium sulfate) oral paste.
VARIBAR is manufactured by E-Z-EM Canada Inc., for E-Z-EM, Inc., a subsidiary of Bracco Diagnostics Inc., Princeton, NJ 08540.
VARIBAR is a registered trademark of E-Z-EM, Inc.
Cough Assessment Revisited
In our next look at unique patient journeys, I thought I would share some resources on feeding and swallowing in pediatric craniofacial anomalies. I had been thinking of sharing resources in this area for a little while now, and since July is recognized as National Cleft and Craniofacial Awareness and Prevention Month, this seemed like the perfect time! Working with these kiddos can be so very rewarding, but it also requires a specialized skill set and a comprehensive approach.
If this is a new topic area for you, a great place to start is this 2016 article in the ASHA Perspectives by Claire Kane Miller, PhD, MHA, CCC-SLP and Lauren Madhoun PHD, CCC-SLP, “Feeding and Swallowing Issues in Infants With Craniofacial Anomalies.” This article is a comprehensive look at the subject and offers an overview of terminology, types of anomalies, and descriptions of equipment. (Please note that this article is 10 years old, so I would suggest reaching out the manufacturers listed to check for updates/more information on equipment!) If you love the topic and want to dig into the science a little further, check out “Breast Milk Feeding Practices and Barriers and Supports Experienced by Mother–Infant Dyads With Cleft Lip and/or Palate” by Dr. Madhoun.
These particular patients require support by an interdisciplinary team (well, all patients do, but the collaborative approach is especially intense here) and a webinar that really highlights this can be found on the website of the American Board of Swallowing and Swallowing Disorders. “Craniofacial Disorders and Feeding-Swallowing: A Collaborative Approach Across the Continuum of Care” features Brenda Thompson, M.A., CCC-SLP, BCS-S, CNT, Brian Pann, MD, and Angelo A. Leto Barone, MD. It’s just $29 (cheaper for ABSSD affiliates), and discusses this team approach as well as considerations for feeding and take-home strategies.
For a wonderful resource on this relationship, you really must check out the website of Dr. James Curtis, PhD, CCC-SLP, BCS-S. An Assistant Professor at Weill-Cornell and the Principal Investigator/Director of the Aerodigestive Innovations Research (AIR) Lab, Dr. Curtis investigates voice, cough, and swallowing. His website, found here, offers some excellent information on these mechanisms. Make sure to check out the tutorials on cough: they offer not only an overview of why we should be considering cough assessment and treatment, but also specifics on how to go about implementation.
I cannot offer resources on cough without mentioning Dr. Michelle Troche, PhD, CCC-SLP! Dr. Troche is a Professor and Program Director at Columbia University, she also directs the Laboratory for the Study of Upper Airway Dysfunction. She has MANY contributions to this topic in our field, but there one in particular I wanted to share: A webinar from The University of Wisconsin Division of Otolaryngology offers a Voice & Swallow Clinic Lecture Series. (I have mentioned this outstanding resource before!) The webinar is from a few years ago, and the free recording is available here. This particular webinar is no longer available for ASHA CEs but can be used as PDH (Professional development hours). There IS a current webinar in the series on cough management by Jacob Tangney, MS, CCC-SLP that is still available for ASHA CEs. (You will need to create a registration with the series to obtain credit.)
Bonus: If you would like some more information from Dr. Troche, here is a recording of a recent webinar from Aspire Medical in which she discusses Expiratory Muscle Strength Training via telehealth. You can see it here.
Finally, if you want a really great look at the literature, this comprehensive review by Dr. Justine Dallal-York (and the aforementioned Dr. Troche) is for you! The literature review, published in 2024, is open access, so you can download it as pdf or read it online in its entirety here.
So there you have it! I would love to know if you are currently incorporating cough assessment and/or treatment in your practice! Let me know here!
Recent Posts:
Pediatric Craniofacial Anomalies & Feeding and Swallowing
In our next look at unique patient journeys, I thought I would share some resources on feeding and swallowing in pediatric craniofacial anomalies. I had been thinking of sharing resources in this area for a little while now, and since July is recognized as National...
Dysphagia Awareness Month Resources
During Dysphagia Awareness Month, I typically try to share some stats and facts about dysphagia and swallowing with my social circle. This year, I decided to instead put some resources out there for patients and caregivers. I loved these resources (and the...
Swallowing in Head & Neck Cancer
As I mentioned a couple of months ago, I am starting a new series in which I will share resources that are specific to a unique patient journey. I am kicking off that series today focusing on swallowing in head and neck cancer. I chose this to start with not only...
Need to know more about a specific diagnosis?
Last month, we celebrated THREE years of “Life of Janie, SLP.” As much as I love what we have been doing in the past, I also recognize the importance of making changes… and so I am introducing a new recurring series here: Resources in Specific Populations. While we so...
Cheers to Three Years!
It’s so hard to believe that I have been sharing resources for THREE years now! Thank you to the many clinicians who responded to my polls, I have learned so much from all of you… and I hope that you have learned a few things from me! After all, that is one my...
Supporting People with Dysphagia
As clinicians, we are thinking about and working in the field of dysphagia so much that it can be easy to forget how completely unknown the concept of swallowing problems can be to the general public (see an upcoming discussion on this!). To a patient experiencing...
Strengthening the SLP-registered dietician collab
When I was a new SLP, I had a patient with dysphagia. I carefully conducted the clinical swallowing evaluation, talked to the patient and their family about how the dysphagia was impacting their life, completed an MBSS using a standardized approach and considered the...
Janie’s Good Reads
As much as I enjoy reading research on swallowing (see my prior thoughts on this here and find more resources here), I also really love when someone else has done it for me! Add in some good writing, a few jokes, a meme or two, and I am hooked. This month, I thought I...
Clinical practice and research methods: best friends or worlds apart?
A couple months ago, we talked about reading research and how to investigate new interventions (big thank you again to Ed Bice for sharing his filtering tool—if you missed this, be sure to check it out at Life of Janie), and boy did this resonate with a lot of us!...
VARIBAR (barium sulfate) ABCs and FAQs
It’s getting hot out there… and it seems like our inboxes are heating up as well! We have noticed lately that we are getting an uptick in a few questions about VARIBAR products, and so I thought I would take a minute to send out some answers here!What is the carb...
INDICATIONS AND USAGE | IMPORTANT SAFETY INFORMATION
Do not use in cases of known or suspected esophageal obstruction or to dislodge foreign bodies. Do not use more than the maximum recommended dosage in 24‐hour period. Do not use the maximum dosage of this product for more than two weeks, except under the advice and supervision of a physician.
Talk Soon,
US-VARH-2500014 12/25