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. 2013 Dec 1;189(3):543-51.
doi: 10.1016/j.resp.2013.08.009. Epub 2013 Aug 30.

Coordination of cough and swallow: a meta-behavioral response to aspiration

Teresa Pitts  1 , Melanie J Rose, Ashley N Mortensen, Ivan Poliacek, Christine M Sapienza, Bruce G Lindsey, Kendall F Morris, Paul W Davenport, Donald C Bolser
Affiliations

Coordination of cough and swallow: a meta-behavioral response to aspiration

Teresa Pitts et al. Respir Physiol Neurobiol. .

Abstract

Airway protections is the prevention and/or removal of material by behaviors such as cough and swallow. We hypothesized these behaviors are coordinated to respond to aspiration. Anesthetized animals were challenged with simulated aspiration that induced both coughing and swallowing. Electromyograms of upper airway and respiratory muscles together with esophageal pressure were recorded to identify and evaluate cough and swallow. During simulated aspiration, both cough and swallow intensity increased and swallow duration decreased consistent with rapid pharyngeal clearance. Phase restriction between cough and swallow was observed; swallow was restricted to the E2 phase of cough. These results support three main conclusions: 1) the cough and swallow pattern generators are tightly coordinated so as to generate a protective meta-behavior; 2) the trachea provides feedback on swallow quality, informing the brainstem about aspiration incidences; and 3) the larynx and upper esophageal sphincter act as two separate valves controlling the direction of positive and negative pressures from the upper airway into the thorax.

Keywords: Airway protection; Dysphagia; Dystussia; EMG; Pharyngeal clearance; Pharynx.

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Figures

Figure 1
Figure 1
Raw EMG traces of the coordination of cough and swallow. Swallow is denoted by circles and cough by arrows. The first panel is injection of water into the pharynx resulting in four swallows, and the second panel is coordinated coughs and swallows resulting from the aspiration protocol.
Figure 2
Figure 2
Histogram of swallow initiation and termination within the cough phases during the aspiration protocol. The occurrence and termination of swallows were plotted across cough phases that were segmented into quartiles. Swallows were executed primarily in the E2 cough phase. The solid line is swallow initiation as demarked by elevation of the hyoid and relaxation of the upper esophageal sphincter, and swallow termination was identified by increased tone to the upper esophageal sphincter following relaxation. There is one occurrence of a swallow being initiated during the E1 phase and four occurrences swallows being completed during the I phase of the subsequent cough (n=73 swallows from 17 animals).
Figure 3
Figure 3
Change in cough motor drive with injection of water into the oropharynx. Triangle denotes swallow. Note the increased rectus abdominis and parasternal electromyographic activity and expiratory esophageal pressure in the second cough.
Figure 4
Figure 4
Cannula was inserted into the trachea at the downward arrow. Cough cycles are noted with stars. Expiratory phasic thyropharyngeus EMG activity was suppressed, and cricopharyngeus EMG activity was increased at the onset of the tracheal stimulation. The cricopharyngeus EMG has dynamic activity during cough with the peak during the transition from the inspiratory to the expiratory phase.
Figure 5
Figure 5
Dual valve system hypothesis. The side by side circles represent the two valves, the larynx and the upper esophageal sphincter. Closure of the two valves is controlled by the thyroarytenoid and the cricopharyngeus muscles, respectively. The valve aperture is represented on a scale from white (maximum opening) to black (maximum closure). Note: during the expiratory phase of eupnea there is some thyroarytenoid activity. ** Thyroarytenoid and cricopharyngeal electromyogram waveform averages across multiple behavior occurrences during cough and swallow. The vertical gray line in the second and third panels is the midline marker of the behavior execution, and during cough this represents the transition from inspiration to active expiration.
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