Voluntary Cough Testing as a Clinical Indicator of Airway Protection in Cervical Spinal Cord Injury

Laura Pitts, Valerie K. Hamilton, Erin A. Walaszek, Stephanie Watts*, Leora R. Cherney

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Objective: Voluntary cough testing (VCT) may be useful for determining aspiration risk in neurogenic dysphagia; however, has yet to be investigated in traumatic cervical spinal cord injury (tCSCI). The study explored if VCT may elucidate swallowing safety and kinematics related to airway protection in tCSCI survivors. Methods: Ten inpatients, 13–73 days post-tCSCI (7 incomplete injuries), completed VCT and a modified barium swallowing study that was analyzed via the Penetration Aspiration Scale (PAS) and norm-referenced measures of swallowing events related to airway protection. Spearman rho correlations explored relations among cough airflow, median PAS, and airway protection. Mann–Whitney U tests explored group differences based on clinical airway invasion (PAS > 2) and receiver operating characteristic statistics probed the sensitivity/specificity of VCT measures. Results: Safe (PAS > 2) and unsafe swallowers differed by cough volume acceleration (CVA) for the total sample and by inspiratory duration for incomplete injuries (p = 0.03, r > 0.7). A cut-off value of 24.8 L/s for CVA predicted airway invasion (AUC = 0.917, p = 0.03) with sensitivity = 100%/specificity = 75%. CVA correlated with delayed laryngeal vestibule closure during swallowing for both the total sample and for incomplete injuries (rs > 0.6, p < 0.05). Blunted peak flow and prolonged cough phases were associated with disordered laryngeal kinematics and prolonged bolus transit during swallowing (p < 0.05). Conclusions: Reduced CVA, blunted peak flow, and prolonged cough phases reflected PAS and disrupted mechanisms of airway protection in tCSCI survivors, demonstrating promise for VCT as a clinical assessment for post-tCSCI dysphagia. Level of Evidence: 3 Laryngoscope, 133:1434–1441, 2023.

Original languageEnglish (US)
Pages (from-to)1434-1441
Number of pages8
Issue number6
StatePublished - Jun 2023


  • Injury
  • cough
  • dysphagia
  • dystussia
  • neurogenic

ASJC Scopus subject areas

  • Otorhinolaryngology


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