Clinical utility of voluntary cough peak expiratory flow outcomes to screen aspiration status in head and neck cancer survivors

Peak expiratory flow of voluntary cough (PEF) is a physiologic metric indexing an individual’s physiologic capacity to defend the airway by expelling tracheal aspirate. PEF can be obtained in an objective, quick and inexpensive manner in busy clinical settings, with demonstrated discriminant ability to detect unsafe swallowing in neurogenic populations. This study examined the discriminant ability of voluntary cough PEF to classify aspiration status in head and neck cancer (HNC) patients post-radiotherapy (RT). This was a secondary analysis of a prospective clinical trial of disease-free HNC survivors. Patients referred for modified barium swallow (MBS) studies ≥ 3 months post-RT underwent voluntary cough PEF assessment. Aspiration was defined as a worst Penetration-Aspiration Scale (PAS) score ≥ 6. Logistic regression and ROC assessed associations between maximum PEF (PEFmax) and aspiration. Optimal thresholds were determined using Youden Index and classification accuracy. Among 152 participants, mean PEFmax was 447.6 ± 118.5 L/min. Aspirators (51/152; 34%) exhibited 13% lower PEFmax than non-aspirators (mean difference: 61.8 L/min). Lower PEFmax was significantly associated with aspiration, with a modest 5% increase in odds per 10 L/min decrease (OR = 1.005; 95% CI: 1.002–1.008; p = 0.003). The optimal threshold (≤ 475 L/min) achieved 72.5% sensitivity and 48.5% specificity; individuals below this threshold had 2.5-fold greater odds of aspiration. Voluntary cough PEF may serve as an adjunctive rapid and pragmatic objective clinical metric for consideration in aspiration screening in HNC survivors. While moderate specificity limits stand-alone use, its simplicity makes it valuable in triage and surveillance in both resource-rich and resource-limited settings.