Relation between Glasgow coma score and cough reflex

doi:10.1016/S0140-6736(94)92155-5

The Lancet

Volume 343, Issue 8908, 21 May 1994, Pages 1261-1262

https://doi.org/10.1016/S0140-6736(94)92155-5 Get rights and content

Abstract

How unconscious does a patient need to be, to be intubated without drugs? In 76 comatose patients (Glasgow coma score [GCS] ≤8) who were treated consecutively in an emergency department, the integrity of the cough reflex was not related to GCS. All comatose patients must be treated as if their airway is compromised but even at the lowest coma scores, there are many patients whose airway reflexes are sufficiently intact to make procedures such as endotracheal intubation difficult and dangerous without drugs. The state of the airway should be assessed independently of conscious level.

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Lastly, some studies have examined reflex cough in patients with reduced level of consciousness. In their short report from 1994, Moulton and Pennycook [38] describe a sample of 76 patients admitted at the emergency department, who presented in a comatose state (Glasgow Coma Scale scores from 3 to 8) due to drug overdose, alcohol intoxication, head injury, post-ictal state, etc. The presence of cough reflex was assessed during airway management procedures such as suctioning, i.e. using a mechanosensory stimulus, and described as normal, attenuated or absent.
Nasotracheal suctioning (NTS) is a procedure commonly performed by respiratory physiotherapists and nurses to remove excess respiratory secretions from the tracheobronchial tree in a self-ventilating, non-intubated and non-tracheotomized patient. NTS is an important treatment modality for patients with acute secretion retention who are at high risk of progressive respiratory deterioration and arrest. However, NTS is a blind invasive procedure with risk of serious adverse events, and the patient experience of NTS is often extremely negative.
Capsaicin, a substance extracted from cayenne pepper, elicits reflex coughs when inhaled. It is hypothesized that capsaicin-induced reflex cough may offer an alternative treatment option to NTS. It is suggested that repeated reflex cough bouts, elicited through inhalation of nebulized capsaicin via a facemask, could achieve clearance of retained secretions from the tracheobronchial tree to the oropharynx, thereby avoiding the need for NTS.
This hypothesis is supported by preliminary cough flow data from a stroke trial. Stroke patients underwent assessments of peak cough flow (PCF, a measure of cough effectiveness) of both maximal volitional cough and capsaicin-induced reflex cough. In a sub-group of 20 stroke patients with weak volitional cough (mean PCF 220 L/min, SD 80), PCF of capsaicin-induced reflex cough was on average 184 L/min (SD 130) higher than PCF of subjects’ maximal volitional cough effort. Cough flow traces indicate a pattern of cough augmentation during consecutive reflex cough bouts.
It is suggested that the hypothesis may best be tested in a pragmatic applied clinical study, i.e. through the application of nebulized capsaicin in relevant clinical situations, as opposed to observational or experimental physiological studies.
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Citation Excerpt :
It has been suggested that the Glasgow Coma Scale (GCS) may be useful in guiding the requirement for ETI, as a patient with decreased consciousness and loss of protective airway reflexes may be predisposed to respiratory failure and aspiration injury (10,11). However, the correlation between the GCS score and the risk of aspiration is poor (12,13). Additionally, previous studies have shown that patients with a decreased GCS score may be safely observed and it does not mandate ETI (10,14).
Drug overdose is the leading cause of injury-related fatality in the United States, and respiratory failure remains a major source of morbidity and mortality.
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Potential advantages of rapid sequence intubation are blunting of the sympathetic response, preoxygenation, and possibly a lower risk of aspiration. Because most comatose patients have intact gag reflexes, sympathetic responses occur and may have harmful effects.32 A common practice is to use lidocaine to blunt the gag response to intubation but it has not been conclusively shown either good or bad.33,34
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Short reportsRelation between Glasgow coma score and cough reflex

Abstract

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The advanced trauma life support student manual

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Short reports
Relation between Glasgow coma score and cough reflex