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Review
. 2024 Jun 12:5:1394110.
doi: 10.3389/fresc.2024.1394110. eCollection 2024.

Hypotussic cough in persons with dysphagia: biobehavioral interventions and pathways to clinical implementation

Justine Dallal-York  1 , Michelle S Troche  1
Affiliations
Review

Hypotussic cough in persons with dysphagia: biobehavioral interventions and pathways to clinical implementation

Justine Dallal-York et al. Front Rehabil Sci. .

Abstract

Cough is a powerful, protective expulsive behavior that assists in maintaining respiratory health by clearing foreign material, pathogens, and mucus from the airways. Therefore, cough is critical to survival in both health and disease. Importantly, cough protects the airways and lungs from both antegrade (e.g., food, liquid, saliva) and retrograde (e.g., bile, gastric acid) aspirate contents. Aspiration is often the result of impaired swallowing (dysphagia), which allows oral and/or gastric contents to enter the lung, especially in individuals who also have cough dysfunction (dystussia). Cough hyposensitivity, downregulation, or desensitization- collectively referred to as hypotussia- is common in individuals with dysphagia, and increases the likelihood that aspirated material will reach the lung. The consequence of hypotussia with reduced airway clearance can include respiratory tract infection, chronic inflammation, and long-term damage to the lung parenchyma. Despite the clear implications for health, the problem of managing hypotussia in individuals with dysphagia is frequently overlooked. Here, we provide an overview of the current interventions and treatment approaches for hypotussic cough. We synthesize the available literature to summarize research findings that advance our understanding of these interventions, as well as current gaps in knowledge. Further, we highlight pragmatic resources to increase awareness of hypotussic cough interventions and provide support for the clinical implementation of evidence-based treatments. In culmination, we discuss potential innovations and future directions for hypotussic cough research.

Keywords: airway; aspiration; cough; dysphagia; dystussia; hypotussia; swallowing; treatment.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Healthy, typical cough waveform (A) is compared to hypotussic cough waveform (B). A timely and coordinated cough rapidly reconfigures the ventilatory pattern to produce a three-phase airflow sequence (A). In eutussia (normal cough), (8, 9) this includes a period of initial inspiration, followed by laryngeal compression, and ballistic air expulsion during expiration (5, 7, 10, 20). In hypotussia (B), changes in slope and duration during inspiratory and expiratory phases with compression phase leak contribute to poor cough outcome metrics and manifest clinically as reduced cough effectiveness.
Figure 2
Figure 2
Pathophysiology of hypotussia in individuals with dysphagia. Across the neural axis, changes in sensation, motor control or sensorimotor integration involved in cough may contribute to hypotussia (12). Structural changes may limit one's ability to coordinate breathing and swallowing, or generate adequate pressure for high velocity airflows during cough. These may include: (1) altered compliance of the chest wall, (2) weak/spastic inspiratory (e.g., diaphragm, external intercostals) and expiratory (e.g., abdominals, obliques, internal intercostals) muscles, (3) vocal fold and upper airway pathologies (6, 10, 12, 18, 19). Disruptions in neural signaling of sensorimotor pathways may also contribute to hypotussia, including dysfunctional signal reception, transmission, processing, and/or output in one, or several neural substrates: (1) pulmonary, tracheobronchial, and laryngeal receptors that receive cough stimuli input (, , –27), (2) vagal afferents of the airways that transmit sensory input to the central nervous system, including internal superior (iSLN) and recurrent laryngeal nerves (RLN) [Box A] (10, 25, 26), (3) central pattern generators (CPG) for swallow, cough, and breathing integrate sensory input to generate a reconfigured respiratory CPG (rRCPG) to execute cough [Box B] (4, 28), and (4) subcortex and cortical structures involved with filtering, perceiving, and processing discriminative and affective characteristics of the sensory stimuli, leading to execution of volitional cough, or suppression/augmentation of reflexive cough (, , , , –27, 29). In summary, alterations to composite anatomy, musculature, or neural pathways involved in swallow, cough, and/or breathing may also result in hypotussia, compounding the impact of aspiration. iSLN, internal branch of the superior laryngeal nerve; RLN, recurrent laryngeal nerves; CPG, central pattern generator; rRCPG, reconfigured respiratory central patter generator.
Figure 3
Figure 3
A framework for treatment of hypotussic cough. E, external; I, internal.
See this image and copyright information in PMC

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