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Predictors of Peak Expiratory Cough Flow in Individuals with Amyotrophic Lateral Sclerosis

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Abstract

Dystussia is prevalent in individuals with amyotrophic lateral sclerosis (ALS), leading to a diminished physiologic capacity to effectively defend the airway. We aimed to identify predictors of peak expiratory cough flow rate in individuals with ALS. One hundred and thirty-four individuals with a confirmed diagnosis of ALS (El-Escorial criteria revised) completed the ALS Functional Rating Scale-Revised (ALSFRS-R) and underwent pulmonary function and cough spirometry testing. Pearson’s correlation coefficients and hierarchical multiple regression modeling were conducted to determine predictors of voluntary cough peak expiratory flow rate (p < 0.05). The full model including age, bulbar disease, cough spirometry metrics, and respiratory parameters had a marginal R2 = 0.635, F (7, 126) = 30.241, p < 0.0005, adjusted R2 = 0.61. Maximum expiratory pressure, compression phase, and vital capacity did not contribute and were therefore removed (p < 0.05). The most parsimonious predictive model included age, bulbar disease, peak inspiratory flow rate and duration, peak expiratory rise time, and inspiratory pressure generation with a marginal R2 = 0.543. Although expiratory pressure generation has historically served as the therapeutic target to improve dystussia in ALS, the current dataset highlighted that the inability to quickly and forcefully inspire during the inspiratory phase of voluntary cough places patients at a mechanical disadvantage to generate subsequent high-velocity expiratory airflow to clear the airway. Thus, therapeutic training programs that include both inspiratory and expiratory strength targets may optimize airway clearance capacity in this challenging patient population.

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Acknowledgements

The authors would like to acknowledge Amber Anderson, Lauren DiBiase, and Jennifer Chapin for assisting with data collection. We would also like to thank the patients and caregivers who make this research possible.

Funding

This study was funded by the National Institute of Neurological Disorders and Stroke (1R01 NS100859), the University of Florida Breathing Research and Therapeutics Training Program (National Institute of Heart Lung and Blood T32HL134621), and the Dr. Jon and Nancy Wilkins Fellowship for ALS Research Fund.

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Authors and Affiliations

  1. Center for Collaborative Research, NOVA Southeastern University, Fort Lauderdale, FL, USA

    Lauren Tabor Gray

  2. Aerodigestive Research Core, University of Florida, Gainesville, FL, USA

    Lauren Tabor Gray, Kasey L. McElheny & Emily K. Plowman

  3. Department of Anesthesiology and Orthopedics, College of Medicine, University of Florida, Gainesville, FL, USA

    Terrie Vasilopoulos

  4. Department of Neurology, University of Florida, Gainesville, FL, USA

    James Wymer & Emily K. Plowman

  5. Department of Physical Therapy and Center for Respiratory Research and Rehabilitation, University of Florida, Gainesville, FL, USA

    Barbara K. Smith

  6. Speech, Language and Hearing Science Department, University of Florida, Gainesville, FL, USA

    Emily K. Plowman

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Contributions

LTG, KM, JW, and EPK were involved in the clinical treatment and data collection of these patients. LTG, KM, TV, and EKP were involved in data management and statistical analysis. LTG, KM, BKS, JW, and EKP drafted the manuscript. LTG, KM, and EKP were involved in study conceptualization and oversight. All authors reviewed the manuscript.

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Correspondence to Lauren Tabor Gray.

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Tabor Gray, L., McElheny, K.L., Vasilopoulos, T. et al. Predictors of Peak Expiratory Cough Flow in Individuals with Amyotrophic Lateral Sclerosis. Dysphagia 38, 719–725 (2023). https://doi.org/10.1007/s00455-022-10503-8

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