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• Older people with frailty are at high risk of developing pneumonia. • Pneumonia is associated with decreased cough strength. • Cough strength is related to inspiratory muscle strength. • Inspiratory muscle training improves cough strength in older people with frailty. • Inspiratory muscle training could prevent pneumonia in older people. To investigate the effect of inspiratory muscle training (IMT) on cough strength in older people with frailty. Single-blind randomized controlled trial. Day health care centers at 2 sites. Older people with frailty (N=60). Eligible people were randomly assigned to receive IMT program in addition to general exercise training (IMT group), or general exercise training alone (control group). The IMT group performed training using a threshold IMT device with the load set at 30% of maximum inspiratory mouth pressure in addition to the general exercise training program throughout the 8 weeks. The IMT took place twice a day and each session consisted of 30 breaths. Primary outcome was cough strength, measured as the cough peak flow (CPF), at the beginning and the end of the program. Data from 52 participants (26 in each group) were available for the analysis. The mean age was 82.6 years; 33% were men. The change in CPF at the end of the program was 28.7±44.4 L/min in the IMT group and −7.4±26.6 L/min in the control group. A linear regression model showed that the presence or absence of IMT was associated with changes in CPF (mean difference between groups, 36.3; 95% confidence interval, 16.7-55.9; effect size, 0.99). IMT may be a useful intervention to improve cough strength in frail older people. [Display omitted] [ABSTRACT FROM AUTHOR]

Abstract Purpose To report two-year survival after scheduled extubation in patients with pneumonia or acute respiratory distress syndrome (ARDS). Methods This was a prospective observational study performed in a respiratory ICU of a teaching hospital. Pneumonia or ARDS patients who successfully completed a spontaneous breathing trial were enrolled. Data were collected before extubation. Patients were followed up to two years by phone every 3 months. Results A total of 230 patients were enrolled in final analysis. One-, 3-, 6-, 12-, and 24-month survival was 77.4%, 63.8%, 61.3%, 57.8%, and 47.8%, respectively. Cox regression shows that Charlson comorbidity index (hazard ratio: 1.20, 95% confidence interval: 1.10–1.32), APACHE II score before extubation (1.11, 1.05–1.17), cough peak flow before extubation (0.993, 0.986–0.999), and extubation failure (3.96, 2.51–6.24) were associated with two-year mortality. To predict death within two years, the area under the curve of receiver operating characteristic was 0.79 tested by Charlson comorbidity index, 0.75 tested by APACHE II score, and 0.75 tested by cough peak flow. Two-year survival was 31% and 77% in patients with Charlson comorbidity index ≥ 1 and 58 and ≤ 58 L/min, respectively. Conclusions Comorbidity, disease severity, weak cough and extubation failure were associated with increased two-year mortality in pneumonia or ARDS patients who experienced scheduled extubation. It provides objective information to caregivers to improve decision-making process during hospitalization and post discharge.

• The key factors influencing preoperative cough strength in cardiac surgery patients include gender, age, left ventricular ejection fraction, presence of pulmonary arterial hypertension, inspiratory capacity, regular participation in exercise, and the capacity to effectively execute cough techniques. • This study emphasises the high incidence of diminished cough strength, found to be 60.3%, in preoperative cardiac surgery patients. • The findings underscore the necessity of assessing preoperative cough strength in cardiac surgery patients within future clinical practices. By doing so, appropriate interventions can be initiated at an early stage, aimed at preventing potential complications. Pulmonary complications often arise from ineffective coughing, yet limited research exists on the determinants of cough strength in patients undergoing cardiac surgery. The aim is to explore preoperative cough strength in patients scheduled for cardiac surgery and identify factors associated with diminished cough strength. A cross-sectional study was conducted on 330 adult patients admitted for cardiac surgery at a tertiary Grade A hospital in Jiangsu Province, China between August 2022 and February 2023. Cough strength was assessed using cough peak flow, with values below 270 L/min classified as reduced cough strength. The study adhered to the STROBE guidelines. The study comprised 228 males (69.1 %) and 102 females (30.9 %), aged 23 to 81 years. Types of cardiac surgery included coronary artery bypass surgery, heart valvuloplasty, or heart valve replacement among others. The mean preoperative cough peak flow was 250.38 ± 119.71 L/min, with 60.3 % of patients exhibiting reduced cough strength. A multiple linear regression analysis identified gender, age, exercise regimen, pulmonary arterial hypertension, left ventricular ejection fraction, inspiratory capacity, and proficiency in coughing techniques as primary factors affecting cough strength. Our findings indicate an association between diminished cough strength and factors such as female gender, advanced age, absence of systematic exercise, presence of pulmonary arterial hypertension, lower left ventricular ejection fraction, reduced inspiratory capacity, and inadequate mastery of coughing techniques. Healthcare staff should prioritize regular assessment of cough strength and manage the pertinent factors to enhance preoperative coughing ability. [ABSTRACT FROM AUTHOR]

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Abstract Background Cough strength is associated with short-term outcome in patients with scheduled extubation who successfully complete a spontaneous breathing trial (SBT). However, the long-term outcome is unclear. Methods This was a prospective observational study performed in a respiratory ICU of a teaching hospital. COPD patients who successfully completed a SBT were candidates. We enrolled the case who assessed the cough strength by cough peak flow (CPF) or semiquantitative cough strength score (SCSS, ranging from 0 = weak to 5 = strong). Patients were followed up to two years by phone every 3 months. Results A total of 215 patients were enrolled in current study. Among them, CPF and SCSS were measured in 214 and 208 cases, respectively. Strong cough was associated with a 16% decrease in the risk of two-year mortality (adjusted hazard ratio [HR] 0.84, 95%CI: 0.78–0.91) per 10 L/min increment of CPF. When it was tested by SCSS, decrease in the risk of two-year mortality per unit increment was 27% (adjusted HR 0.73, 95%CI: 0.62–0.86). Similar results were confirmed in the discharged patients. In all patients, the two-year mortality was 75%, 53%, and 38% in patients with CPF 90 L/min; and 85%, 70%, and 40% in patients with SCSS of 0–1, 2–3, and 4–5, respectively. Similar trend was found among the discharged patients whether it was assessed by CPF or SCSS. Conclusions In COPD patients, weak cough is associated with increased two-year mortality after a scheduled extubation. It provides objective information to caregivers to improve decision-making process during hospitalization and after discharge.

Kyphosis may reduce the force of coughing by affecting the factors related to cough peak flow (CPF). This study sought to compare cough strength and respiratory function between non-kyphotic and kyphotic elderly individuals and clarify the relationship between these factors. The non-kyphotic group comprised 17 elderly individuals with a kyphosis index of less than 15.1, while the kyphotic group comprised 21 elderly individuals with a kyphosis index of 15.1 or higher. Cough strength, respiratory function, respiratory muscle strength, and maximum phonation time were measured, and comparison between two groups and correlation analysis between variables were performed. CPF, vital capacity, maximum expiratory pressure (PEmax), maximum inspiratory pressure (PImax), and chest expansion at the xiphoid process were significantly lower in the kyphotic group than in the non-kyphotic group. There were significant negative correlations between kyphosis index and CPF (r = −0.37, p < 0.05), PEmax (r = −0.45, p < 0.01), PImax (r = −0.44, p < 0.01) and chest expansion at the xiphoid process (r = −0.38, p < 0.05). Our results demonstrated that cough strength was significantly lower in the kyphotic compared to non-kyphotic individuals. Furthermore, cough strength decreased with increased severity of kyphosis. [ABSTRACT FROM AUTHOR]

Background: Tracheal extubation failure after cardiac surgery is associated with diminished cough strength, albeit the information on cough strength in post-cardiac surgery patients is limited., Aim: To investigate the cough strength in patients after cardiac surgery before tracheal extubation and the related influencing factors., Study Design: A cross-sectional study was designed, with adherence to the STROBE guidelines. The participants were 528 patients undergoing open-heart cardiac surgery who were admitted to the Cardio Surgical Centre in a tertiary hospital in Nanjing, China, from August 2022 to September 2023. Cough peak flow (CPF) ≤60 L/min set as the cut-off value for evaluating diminished cough strength before tracheal extubation. Univariate analysis and multiple linear regression analysis were used to analyse the related influencing factors., Results: The mean CPF was 130.70 ± 50.58 L/min. A total of 76 (14.4%) patients exhibited a CPF of ≤60 L/min. Multiple linear regression analysis revealed that gender (B = 14.266, t = 2.456, p = .014), inspiratory capacity (IC) (B = 0.013, t = 3.755, p < .001), preoperative CPF (B = 0.086, t = 3.903, p < .001), muscle strength (B = 12.423, t = 4.242, p < .001), preoperative exercise regimen (B = 16.716, t = 4.236, p < .001) and pain levels (B = -8.115, t = -5.794, p < .001) significantly contributed to cough strength., Conclusions: Female gender, lower upper limb muscle strength, higher pain levels, lower preoperative CPF and IC, and the absence of systematic exercise were found to be associated with diminished cough strength., Relevance to Clinical Practice: Cough strength provides important auxiliary data in extubation decision-making. In addition, understanding its relevant factors can help identify the high-risk group of tracheal extubation failure and can help provide a strong theoretical basis for the development of personalized interventions., (© 2025 British Association of Critical Care Nurses.)

Background: Cough strength is associated with short-term outcome in patients with scheduled extubation who successfully complete a spontaneous breathing trial (SBT). However, the long-term outcome is unclear.Methods: This was a prospective observational study performed in a respiratory ICU of a teaching hospital. COPD patients who successfully completed a SBT were candidates. We enrolled the case who assessed the cough strength by cough peak flow (CPF) or semiquantitative cough strength score (SCSS, ranging from 0 = weak to 5 = strong). Patients were followed up to two years by phone every 3 months.Results: A total of 215 patients were enrolled in current study. Among them, CPF and SCSS were measured in 214 and 208 cases, respectively. Strong cough was associated with a 16% decrease in the risk of two-year mortality (adjusted hazard ratio [HR] 0.84, 95%CI: 0.78-0.91) per 10 L/min increment of CPF. When it was tested by SCSS, decrease in the risk of two-year mortality per unit increment was 27% (adjusted HR 0.73, 95%CI: 0.62-0.86). Similar results were confirmed in the discharged patients. In all patients, the two-year mortality was 75%, 53%, and 38% in patients with CPF < 60, 60-90, and > 90 L/min; and 85%, 70%, and 40% in patients with SCSS of 0-1, 2-3, and 4-5, respectively. Similar trend was found among the discharged patients whether it was assessed by CPF or SCSS.Conclusions: In COPD patients, weak cough is associated with increased two-year mortality after a scheduled extubation. It provides objective information to caregivers to improve decision-making process during hospitalization and after discharge. [ABSTRACT FROM AUTHOR]

BACKGROUND: A cough peak flow (CPF) of < 60 L/min was associated with increased risk of extubation failure after a successful spontaneous breathing trial (SBT). Passive cephalic excursion of the diaphragm (PCED), measured by ultrasonography during cough expiration, was reported to predict CPF in healthy adults. We hypothesized that PCED, diaphragm peak velocity, or both during cough, as measured by ultrasonography, might predict CPF and extubation outcomes in mechanically ventilated patients. This study attempted to identify associations of diaphragm movement during cough, as assessed by ultrasonography with simultaneously measured CPF, and to determine predictive values of ultrasonographic indices for extubation outcomes after a successful SBT. METHODS: In the study, 252 mechanically ventilated subjects with a successful SBT were enrolled in a prospective cohort study. Right hemidiaphragm passive cephalic excursion and peak velocity were measured by ultrasonography during voluntary cough expiration with maximum effort. CPF was measured simultaneously by ultrasonography. RESULTS: A multiple regression model adjusted for age and sex showed a significant association between PCED and CPF (P < .001, adjusted β coefficient 11.4, 95% CI 8.88-14.0, adjusted R2 = 0.287) and between diaphragm peak velocity and CPF (P < .001, adjusted β coefficient 1.71, 95% CI 1.91-2.24, adjusted R² = 0.235). The areas under the curves of PCED, diaphragm peak velocity, and CPF for extubation failure were 0.791 (95% Cl 0.668-0.914), 0.587 (95% Cl 0.426-0.748), and 0.765 (95% Cl 0.609-0.922), respectively. CONCLUSIONS: PCED on ultrasonography was significantly associated with CPF and extubation failure after a successful SBT. Future studies should investigate if this method is applicable for determination of tracheostomy decannulation in stable patients in general wards. [ABSTRACT FROM AUTHOR]

Coughing is the primary defence mechanism against foreign bodies in the central airways and can quantitatively be assessed by cough peak flow (CPF). We conducted a narrative review of the literature on CPF, which is most commonly used for evaluating cough strength. This review regards the method for measurement of CPF, the cough-related factors influencing CPF, the clinical significance of CPF evaluation, and a novel cough strength prediction method using cough sounds. Furthermore, this review presents various cutoff thresholds that predict extubation failure in patients on mechanical ventilation, acute respiratory failure, and aspiration risk. The published clinical evidence of CPF demonstrates reasonable diagnostic accuracy, predictive power, and validity, although additional studies on the non-contact measurement of CPF via cough sounds with better-quality methodologies are required. [ABSTRACT FROM AUTHOR]

Abstract A crucial step in the transition from mechanical ventilation to extubation is the successful performance of a spontaneous breathing trial (SBT). The American College of Chest Physicians (ACCP) Guidelines recommend removal of the endotracheal tube upon successful completion of a SBT. However, this does not guarantee successful extubation as there remains a risk of re-intubation. Guidelines have outlined ventilator liberation protocols, selected use of non-invasive ventilation on extubation, early mobilization, and dynamic ventilator metrics to prevent and better predict extubation failure. However, a significant percentage of patients still fail mechanical ventilation discontinuation. A common reason for re-intubation is having a weak cough strength, which reflects the inability to protect the airway. Evaluation of cough strength via objective measures using peak expiratory flow rate is a non-invasive and easily reproducible assessment which can predict extubation failure. We conducted a narrative review of the literature regarding use of cough strength as a predictive index for extubation failure risk. Results of our review show that cough strength, quantified objectively with a cough peak expiratory flow measurement (CPEF), is strongly associated with extubation success. Furthermore, various cutoff thresholds have been identified and can provide reasonable diagnostic accuracy and predictive power for extubation failure. These results demonstrate that measurement of the CPEF can be a useful tool to predict extubation failure in patients on MV who have passed a SBT. In addition, the data suggest that this diagnostic modality may reduce ICU length of stay, ICU expenditures, and morbidity and mortality.

BACKGROUND: The incidence of community-acquired pneumonia (CAP) is relatively high in elderly subjects. Cough peak flow (CPF) is an objective indicator of cough strength, and CPF evaluation might be useful to assess whether food intake can be restarted. We aimed to examine whether cough strength assessed with CPF can be used as an indicator of the aspiration risk when restarting food intake in elderly subjects with CAP. METHODS: This cross-sectional study included 82 elderly subjects with CAP between August 2016 and March 2018. CPF was measured using a peak flow meter, and we performed the repetitive saliva-swallowing test (RSST), which is a videoendoscopic evaluation of swallowing and is used to assess dysphagia and aspiration. Receiver operating characteristic (ROC) curve analysis was performed. The cutoff value was determined, and the area under the ROC was calculated. RESULTS: The areas under the RSST and CPF curves were 0.87 and 0.83, respectively. The RSST value for identifying the aspiration risk was 2.5 swallows. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were 70.0%, 71.7%, 2.5, and 0.42, respectively. The CPF for identifying the aspiration risk was 190 L/min. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were 82.6%, 69.4%, 2.7, and 0.25, respectively. CONCLUSIONS: Our findings suggest that cough strength assessed with CPF can be used as an indicator of the aspiration risk when restarting food intake in elderly subjects with CAP and that CPF evaluation is not inferior to the RSST. However, CPF evaluation should be performed together with swallowing screening tests to determine the aspiration risk. [ABSTRACT FROM AUTHOR]

Coughing is the primary defence mechanism against foreign bodies in the central airways and can quantitatively be assessed by cough peak flow (CPF). We conducted a narrative review of the literature on CPF, which is most commonly used for evaluating cough strength. This review regards the method for measurement of CPF, the cough-related factors influencing CPF, the clinical significance of CPF evaluation, and a novel cough strength prediction method using cough sounds. Furthermore, this review presents various cutoff thresholds that predict extubation failure in patients on mechanical ventilation, acute respiratory failure, and aspiration risk. The published clinical evidence of CPF demonstrates reasonable diagnostic accuracy, predictive power, and validity, although additional studies on the non-contact measurement of CPF via cough sounds with better-quality methodologies are required.

Although cough peak flow (CPF) is an important measurement for evaluating the risk of cough dysfunction, some patients cannot use conventional measurement instruments, such as spirometers, because of the configurational burden of the instruments. Therefore, we previously developed a cough strength estimation method using cough sounds based on a simple acoustic and aerodynamic model. However, the previous model did not consider age or have a user interface for practical application. This study clarifies the cough strength prediction accuracy using an improved model in young and elderly participants. Additionally, a user interface for mobile devices was developed to record cough sounds and estimate cough strength using the proposed method. We then performed experiments on 33 young participants (21.3 ± 0.4 years) and 25 elderly participants (80.4 ± 6.1 years) to test the effect of age on the CPF estimation accuracy. The percentage error between the measured and estimated CPFs was approximately 6.19%. In addition, among the elderly participants, the current model improved the estimation accuracy of the previous model by a percentage error of approximately 6.5% (p < 0.001). Furthermore, Bland-Altman analysis demonstrated no systematic error between the measured and estimated CPFs. These results suggest that the developed device can be applied for daily CPF measurements in clinical practice.

Cough peak flow (CPF) is a measurement for evaluating the risk of cough dysfunction and can be measured using various devices, such as spirometers. However, complex device setup and the face mask required to be firmly attached to the mouth impose burdens on both patients and their caregivers. Therefore, this study develops a novel cough strength evaluation method using cough sounds. This paper presents an exponential model to estimate CPF from the cough peak sound pressure level (CPSL). We investigated the relationship between cough sounds and cough flows and the effects of a measurement condition of cough sound, microphone type and participant’s height and gender on CPF estimation accuracy. The results confirmed that the proposed model estimated CPF with a high accuracy. The absolute error between CPFs and estimated CPFs were significantly lower when the microphone distance from the participant’s mouth was within 30 cm than when the distance exceeded 30 cm. Analysis of the model parameters showed that the estimation accuracy was not affected by participant’s height or gender. These results indicate that the proposed model has the potential to improve the feasibility of measuring and assessing CPF.

Abstract: The aim of this study was to develop a clinical prediction model to inform decisions about the timing of extubation in burn patients who have passed a spontaneous breathing trial (SBT). Rapid shallow breathing index, voluntary cough peak flow (CPF) and endotracheal secretions were measured after each patient had passed a SBT and just prior to extubation. We used multiple logistic regression analysis to identify variables that predict extubation outcome. Seventeen patients failed their first trials of extubation (14%). CPF and endotracheal secretions are strongly associated with extubation outcome (p <0.0001). Patients with CPF≤60L/min are 9 times as likely to fail extubation as those with CPF>60L/min (risk ratio=9.1). Patients with abundant endotracheal secretions are 8 times as likely to fail extubation compared to those with no, mild and moderate endotracheal secretions (risk ratio=8). Our clinical prediction model combining CPF and endotracheal secretions has strong predictive capacity for extubation outcome (area under receiver operating characteristic curve=0.96, 95% confidence interval 0.91–0.99) and therefore may be useful to predict which patients will succeed or fail extubation after passing a SBT. [Copyright &y& Elsevier]

This study aimed to evaluate an objective measure of cough strength, the peak cough expiratory flow (PCEF), as a predictive criterion of success or failure of extubation. Patients under mechanical ventilation for more than 24 h who successfully passed the spontaneous breathing trial were included in the study. Just before extubation, PCEF was measured with an electronic flowmeter. A total of 130 patients were included. The median duration of mechanical ventilation before extubation was 8 days (4–17). Fourteen patients (10.8%) failed extubation. The sole factor significantly associated with extubation failure was the measure of PCEF. The patients who did not cough at order had a higher rate of extubation failure than those who did ( P = 0.03). The mean PCEF of patients who failed extubation (36.3 ± 15 l/min) was significantly lower than the one of patients who succeeded (63.6 ± 32 l/min) ( P < 0.001). The optimal cut-off value of PCEF was 35 l/min. Overall, an inability to cough at order or a PCEF ≤35 l/min predicted extubation failure with a sensitivity of 79% and a specificity of 71%. The risk of extubation failure was 24% for the patients who did not cough at order or with a PCEF ≤35 l/min and 3.5% for those with a PCEF >35 l/min [RR = 6.9 (95% CI, 2–24); P = 0.002]. This study confirmed the interest of measuring the PCEF to predict extubation outcome in patients having successfully passed the spontaneous breathing trial. [ABSTRACT FROM AUTHOR]

• The PMV group displayed a lower cough reflex and cough strength than the SMV group. • The mRNA expression of TRPV1 in the tracheal tissues was similar in both groups. • TRPV1 expression in the central airway may not account for cough reflex impairment. • Cough dysfunction after PMV highlights the need to implement effective airway management measures and rehabilitation. Cough is a pivotal airway protective reflex, yet the effects of prolonged mechanical ventilation (PMV) on cough function are unknown. This study compared the cough function in subjects with PMV (≥ 21 days, n = 29) and those with short-term mechanical ventilation (SMV, ≤ 7 days, n = 27). Cough reflex sensitivity was measured by capsaicin provocation concentrations after extubation. The cough strength of respiratory muscles was assessed by involuntary cough peak expiratory flow (iCPEF). The mRNA expression of transient receptor potential vanilloid 1 (TRPV1), a cough sensor activated by capsaicin, in tracheal tissues was determined. We found that cough reflex sensitivity and iCPEF were significantly lower in the PMV group than in the SMV group. The tracheal expression of TRPV1 was similar in both groups, suggesting that changes in TRPV1 expression may not be a contributing factor. Our finding regarding the cough dysfunction after PMV highlights the need to implement effective airway clearance management and rehabilitation in this population. [ABSTRACT FROM AUTHOR]

Abstract: The airway defensive response to tussive agents, such as capsaicin, is frequently assessed by counting the number of cough sounds, or expulsive events. This method does not identify or differentiate important respiratory events that occur in the respiratory muscles and lungs, which are critical in assessing airway defensive responses. The purpose of this study was to characterize the airway defensive behaviours (cough and expiration reflex) to capsaicin exposure in humans. We observed complex motor behaviours in response to capsaicin exposure. These behaviours were defined as cough reacceleration (CRn) and expiration reflex (ERn), where n is the number of expulsive events with and without a preceding inspiratory phase, respectively. Airway defensive responses were defined in terms of frequency (number of expulsive events), strength (activation of abdominal muscles) and behaviour type (CRn vs. ERn). Thirty-six subjects (15 females, 24±4yr) were instrumented with EMG electrodes placed over the rectus abdominis (RA), external abdominal oblique (EO) and the 8th intercostal space (IC8). A custom-designed mouth pneumotachograph was used to assess the airflow acceleration, plateau velocity and phase duration of the expulsive phase. Subjects inhaled seven concentrations of capsaicin (5–200μM) in a randomized block order. The total number of expulsive events (frequency) and the sum of integrated EMG for the IC8, RA and EO (strength) increased in a curvilinear fashion. Differentiating the airway defense responses into type demonstrated predominately CR1 and CR2 (i.e. inspiration followed by one and two expulsive events, respectively) with very few ER''s at <50μM capsaicin. At higher concentrations (>50μM) ER''s with one or more expulsive events (⩾ER1) appeared, and the number of CR''s with three or more expulsive events (⩾CR3) increased. The decrease in EMG activation and airflow measurements with each successive expulsive event suggests a decline in power and shear force as the number of expulsive events increased. Therefore, the airway defensive response to capsaicin is a complex motor pattern that functions to coordinate ER''s and CR''s with differing numbers of expulsive events possibly to prevent aspirations and keep air moving to promote clearance. [Copyright &y& Elsevier]

Background: A cough peak flow (CPF) of < 60 L/min was associated with increased risk of extubation failure after a successful spontaneous breathing trial (SBT). Passive cephalic excursion of the diaphragm (PCED), measured by ultrasonography during cough expiration, was reported to predict CPF in healthy adults. We hypothesized that PCED, diaphragm peak velocity, or both during cough, as measured by ultrasonography, might predict CPF and extubation outcomes in mechanically ventilated patients. This study attempted to identify associations of diaphragm movement during cough, as assessed by ultrasonography with simultaneously measured CPF, and to determine predictive values of ultrasonographic indices for extubation outcomes after a successful SBT., Methods: In the study, 252 mechanically ventilated subjects with a successful SBT were enrolled in a prospective cohort study. Right hemidiaphragm passive cephalic excursion and peak velocity were measured by ultrasonography during voluntary cough expiration with maximum effort. CPF was measured simultaneously by ultrasonography., Results: A multiple regression model adjusted for age and sex showed a significant association between PCED and CPF ( P < .001, adjusted β coefficient 11.4, 95% CI 8.88-14.0, adjusted R 2 = 0.287) and between diaphragm peak velocity and CPF ( P < .001, adjusted β coefficient 1.71, 95% CI 1.91-2.24, adjusted R 2 = 0.235). The areas under the curves of PCED, diaphragm peak velocity, and CPF for extubation failure were 0.791 (95% Cl 0.668-0.914), 0.587 (95% Cl 0.426-0.748), and 0.765 (95% Cl 0.609-0.922), respectively., Conclusions: PCED on ultrasonography was significantly associated with CPF and extubation failure after a successful SBT. Future studies should investigate if this method is applicable for determination of tracheostomy decannulation in stable patients in general wards., Competing Interests: The authors have no conflicts to disclose., (Copyright © 2021 by Daedalus Enterprises.)

Background: The incidence of community-acquired pneumonia (CAP) is relatively high in elderly subjects. Cough peak flow (CPF) is an objective indicator of cough strength, and CPF evaluation might be useful to assess whether food intake can be restarted. We aimed to examine whether cough strength assessed with CPF can be used as an indicator of the aspiration risk when restarting food intake in elderly subjects with CAP., Methods: This cross-sectional study included 82 elderly subjects with CAP between August 2016 and March 2018. CPF was measured using a peak flow meter, and we performed the repetitive saliva-swallowing test (RSST), which is a videoendoscopic evaluation of swallowing and is used to assess dysphagia and aspiration. Receiver operating characteristic (ROC) curve analysis was performed. The cutoff value was determined, and the area under the ROC was calculated., Results: The areas under the RSST and CPF curves were 0.87 and 0.83, respectively. The RSST value for identifying the aspiration risk was 2.5 swallows. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were 70.0%, 71.7%, 2.5, and 0.42, respectively. The CPF for identifying the aspiration risk was 190 L/min. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were 82.6%, 69.4%, 2.7, and 0.25, respectively., Conclusions: Our findings suggest that cough strength assessed with CPF can be used as an indicator of the aspiration risk when restarting food intake in elderly subjects with CAP and that CPF evaluation is not inferior to the RSST. However, CPF evaluation should be performed together with swallowing screening tests to determine the aspiration risk., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2020 by Daedalus Enterprises.)

Cough peak flow (CPF) is a measurement for evaluating the risk of cough dysfunction and can be measured using various devices, such as spirometers. However, complex device setup and the face mask required to be firmly attached to the mouth impose burdens on both patients and their caregivers. Therefore, this study develops a novel cough strength evaluation method using cough sounds. This paper presents an exponential model to estimate CPF from the cough peak sound pressure level (CPSL). We investigated the relationship between cough sounds and cough flows and the effects of a measurement condition of cough sound, microphone type and participant’s height and gender on CPF estimation accuracy. The results confirmed that the proposed model estimated CPF with a high accuracy. The absolute error between CPFs and estimated CPFs were significantly lower when the microphone distance from the participant’s mouth was within 30 cm than when the distance exceeded 30 cm. Analysis of the model parameters showed that the estimation accuracy was not affected by participant’s height or gender. These results indicate that the proposed model has the potential to improve the feasibility of measuring and assessing CPF. [ABSTRACT FROM AUTHOR]

Purpose: To explore the association between cough strength and outcomes in elderly patients who received noninvasive ventilation (NIV) due to acute respiratory failure caused by pneumonia., Materials and Methods: We enrolled patients ≥65years old with acute respiratory failure caused by pneumonia. Just before NIV treatment, cough strength was assessed on a cough-strength scale graded from 0 to 5. Patients graded 0-2 were defined as having no/weak coughs and those graded 3-5 were defined as having moderate/strong coughs., Results: We enrolled 349 patients in this study. The prevalence of no/weak cough was 24% (84/349). Moderate/strong cough patients had lower NIV failure (92/265 [34.7%] vs. 67/84 [79.8%], p<0.01) and lower hospital mortality (85/265 [32.1%] vs. 60/84 [71.4%], p<0.01) than no/weak cough patients. In multivariate logistic regression analysis, we also found that no/weak cough was an independent risk factor for NIV failure (odds ratio=13.83, 95% confidence interval: 6.01-31.81) and death in hospital (odds ratio=4.41, 95% confidence interval: 2.49-7.81)., Conclusions: In pneumonia patients ≥65years old, no/weak cough is associated with NIV failure and death in hospital. NIV must be used only with caution in no/weak cough patients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Cough reflex testing is a validated tool for identifying patients at risk of silent aspiration. However, inter- and intra-rater reliabilities of perceptual judgements of cough strength are sub-optimal. Although there are clinically established methods for measuring volitional cough strength, no similar methods are identified for reflexive cough strength. This study evaluated three measurement methods of voluntary and suppressed reflexive cough strength., Methods: Fifty-three healthy subjects (≥50 years) participated in this study. Participants produced 'strong' and 'weak' voluntary coughs and suppressed reflexive coughs to incremental doses of citric acid. Peak and area under the curve (AUC) measurements were taken of pressure, airflow, and acoustics., Results: There was no dose effect of citric acid on measures of reflexive cough strength. Strong voluntary coughs were stronger than reflexive coughs for all measures (p < 0.001) and weak voluntary coughs were stronger than reflexive coughs for two measures (AUC pressure: p < 0.020; peak flow: p < 0.004). AUC pressure and peak flow had the highest correlations and effect sizes. Correlations were low between voluntary and reflexive cough strength for all measures (r ≤ 0.46)., Conclusion: Assessing strength of reflexive cough, rather than voluntary cough, is highly desirable in the dysphagic population. Pressure and flow provide the most useful objective measurements., (Copyright © 2017. Published by Elsevier Ltd.)

Insufficient cough strength has a major role in extubation and decannulation outcomes. Cough capacity can be easily evaluated by measuring flows during coughing. Values vary depending on whether cough flows are measured through the mouth or through a tracheostomy or endotracheal tube. It is important to standardize these measurements and start using them routinely in the extubation and decannulation processes. Values of cough peak flow >160 L/min measured at the mouth or a value of cough PEF >60 L/min measured at the endotracheal tube suggest successful decannulation or extubation., (Copyright © 2014 Sociedade Portuguesa de Pneumologia. Published by Elsevier España, S.L.U. All rights reserved.)