ismanagement of endotracheal (ET) tube cuff pressure (CP), defined as a CP that falls outside the recommended range of 20 to 30 cm H 2 O, is a frequent occur-rence during general anesthetics, with study findings ranging from 55% to 80%.1-4 Endotra-cheal tube cuffs are typically filled with air to a safe and adequate pressure of 20 to 30 cm H 2 Most manometers are calibrated in? 2001, 137: 179-182. Incidence of postextubation airway complaints in the study population. Sengupta, P., Sessler, D.I., Maglinger, P. et al. Clear tubing. We included ASA class I to III adult patients scheduled to receive general anesthesia with endotracheal intubation for elective surgical operation. Anesth Analg. Copyright 2017 Fred Bulamba et al. Ninety-three patients were randomly assigned to the study. 769775, 2012. C) Pressure gauge attached to pilot balloon of normal cuff reading 30 mmHg with cuff inflated. Figure 2. Secures tube using commercially approved tube holder. SP oversaw day-to-day study mechanics, collected data on many of the patients, and wrote an initial draft of manuscript. Managing endotracheal tube cuff pressure at altitude: a comparison of Previous studies suggest that this approach is unreliable [21, 22]. It helps us understand the number of visitors, where the visitors are coming from, and the pages they navigate. Note: prolonged over-inflation of the cuff can cause pressure necrosis of the tracheal mucosa. Striebel HW, Pinkwart LU, Karavias T: [Tracheal rupture caused by overinflation of endotracheal tube cuff]. mental status changes, such as confusion . 87, no. The intracuff pressure, volume of air needed to fill the cuff and seal the airway, number of tube changes required for a poor fit, number with intracuff pressure 20 cm H 2 O, and intracuff pressure 30 cm H 2 O are listed in Table 4. This result suggests that clinicians are now making reasonable efforts to avoid grossly excessive cuff inflation. The patients were followed up and interviewed only once at 24 hours after intubation for presence of cough, sore throat, dysphagia, and/or dysphonia. Figure 1. All patients with any of the following conditions were excluded: known or anticipated laryngeal tracheal abnormalities or airway trauma, preexisting airway symptoms, laparoscopic and maxillofacial surgery patients, and those expected to remain intubated beyond the operative room period. Up to ten pilots at a time sit in the . K. C. Park, Y. D. Sohn, and H. C. Ahn, Effectiveness, preference and ease of passive release techniques using a syringe for endotracheal tube cuff inflation, Journal of the Korean Society of Emergency Medicine, vol. - 20-25mmHg equates to between 24 and 30cmH2O. Thus, appropriate inflation of endotracheal tube cuff is obviously important. 106, no. PDF Improving Endotracheal Cuff Inflation Pressures - AANA 2, pp. This however was not statistically significant ( value 0.052). The cookie is used to identify individual clients behind a shared IP address and apply security settings on a per-client basis. PM, SW, and AV recruited patients and performed many of the measurements. Your trachea begins just below your larynx, or voice box, and extends down behind the . 5, pp. Symptoms of a severe air embolism might include: difficulty breathing or respiratory failure. The cuff was then briefly overinflated through the pilot balloon, and the loss of resistance syringe plunger was allowed to passively draw back until it ceased. This method has been achieved with a modified epidural pulsator syringe [13, 18], a 20ml disposable syringe, and more recently, a loss of resistance (LOR) syringe [21, 23, 24]. In our case, had the endotracheal tube been checked prior to the start of the case, the defect could have been easily identified which would have obviated the need for tube exchange. These cookies will be stored in your browser only with your consent. It has been demonstrated that, beyond 50cmH2O, there is total obstruction to blood flow to the tracheal tissues. C. Stein, G. Berkowitz, and E. Kramer, Assessment of safe endotracheal tube cuff pressures in emergency care - time for change? South African Medical Journal, vol. Previous studies suggest that the cuff pressure is usually under-estimated by manual palpation. At the University of Louisville Hospital, at least 10 patients were evaluated with each endotracheal tube size (7, 7.5, 8, or 8.5 mm inner diameter [Intermediate Hi-Lo Tracheal Tube, Mallinckrodt, St. Louis, MO]); at Jewish Hospital, at least 10 patients each were evaluated with size 7, 7.5, and 8 mm Mallinckrodt Intermediate Hi-Lo Tracheal Tubes; and at Norton Hospital, 10 patients each were evaluated with size 7 and 8-mm Mallinckrodt Intermediate Hi-Lo Tracheal Tubes. Intubation was atraumatic and the cuff was inflated with 10 ml of air. This method is cheap and reproducible and is likely to estimate cuff pressures around the normal range. Bouvier JR: Measuring tracheal tube cuff pressures--tool and technique. Inject 0.5 cc of air at a time until air cannot be felt or heard escaping from the nose or mouth (usually 5 to 8 cc). 87, no. All authors have read and approved the manuscript. The cuff was considered empty when no more air could be removed on aspiration with a syringe. Uncommon complication of Carlens tube. Document Type and Number: United States Patent 11583168 . W. N. Bernhard, L. Yost, D. Joynes, S. Cothalis, and H. Turndorf, Intracuff pressures in endotracheal and tracheostomy tubes. However you may visit Cookie Settings to provide a controlled consent. 2016 National Geriatric Surgical Initiatives, 2017 EC Pierce Lecture: Safety Beyond Our Borders, The Anesthesia Professionals Role in Patient Safety During TAVR (Transcatheter Aortic Valve Replacement). With approval of the University of Louisville Human Studies Committee and informed consent, we recruited 93 patients (42 men and 51 women) undergoing elective surgery with general endotracheal anesthesia from three hospitals in Louisville, Kentucky: 41 patients from University Hospital (an academic centre), 32 from Jewish Hospital (a private hospital), and 20 from Norton Hospital (also a private hospital). This adds to the growing evidence to support the use of the LOR syringe for ETT cuff pressure estimation. Upon inflation, folds form along the cuff surface, and colonized oropharyngeal secretions may leak through these folds. The regression equation indicated that injected volumes between 2 and 4 ml usually produce cuff pressures between 20 and 30 cmH2O independent of tube size for the same type of tube. Inflate the cuff of the endotracheal tube with sufficient air to seal the area between the trachea and the tube. The complaints sought in this study included sore throat, dysphagia, dysphonia, and cough. allows one to provide positive pressure ventilation. There are a number of strategies that have been developed to decrease the risk of aspiration, but the most important of all is continuous control of cuff pressures. . 965968, 1984. BMC Anesthesiol 4, 8 (2004). Cuff pressure is essential in endotracheal tube management. When considering this primary outcome, the LOR syringe method had a significantly higher proportion compared to the PBP method. Background Cuff pressure in endotracheal (ET) tubes should be in the range of 20-30 cm H2O. 8184, 2015. P. Sengupta, D. I. Sessler, P. Maglinger et al., Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure, BMC Anesthesiology, vol. Google Scholar. This is used to present users with ads that are relevant to them according to the user profile. Charles Kojjo, Agnes Wabule, and Nodreen Ayupo were responsible for patient recruitment and data collection and analysis. 30. 1995, 15: 655-677. Because nitrous oxide was not used, it is unlikely that the cuff pressures varied much during the first hour of the study cases. Terms and Conditions, PDF ENDOTRACHEAL INTUBATION ADULT PERFORMANCE CRITERIA EMS Policy No. 2545 However, complications have been associated with insufficient cuff inflation. The distribution of cuff pressures (unadjusted) achieved by the different care providers is shown in Figure 2. General anesthesia was induced by intravenous bolus of induction agents, and paralysis was achieved with succinylcholine or a non-depolarizing muscle relaxant. However, less serious complications like dysphagia, hoarseness, and sore throat are more prevalent [911]. If pressure remains > 30 cm H2O, Evaluate . Retrieved from. How much air is injected into the cuff is not a major concern for almost all anaesthetists and they usually depend on palpating the external cuff tense to judge is it too much, accurate or not enough? This cookie is set by Stripe payment gateway. statement and First, inflate the tracheal cuff and deflate the bronchial cuff. Cuff pressure in tube sizes 7.0 to 8.5 mm was evaluated 60 min after induction of general anesthesia using a manometer connected to the cuff pilot balloon. After deflating the cuff, we reinflated it in 0.5-ml increments until pressure was 20 cmH2O. 1). Morphometric and demographic characteristics of the patients were similar at each participating hospital (Table 1). chin anteriorly), no lateral deviation, Open mouth and inspect: remove any dentures/debris, suction any secretions, Holding laryngoscope in left hand, insert it looking down its length, Slide down right side of mouth until the tonsils are seen, Now move it to the left to push the tongue centrally until the uvula is seen, Advance over the base of the tongue until the epiglottis is seen, Apply traction to the long axis of the laryngoscope handle (this lifts the epiglottis so that the V-shaped glottis can be seen), Insert the tube in the groove of the laryngoscope so that the cuff passes the vocal cords, Remove laryngoscope and inflate the cuff of the tube with 15ml air from a 20ml syringe, Attach ventilation bag/machine and ventilate (~10 breaths/min) with high concentration oxygen and observe chest expansion and auscultate to confirm correct positioning, Consider applying CO2 detector or end-tidal CO2 monitor to confirm placement, if it takes more than 30 seconds, remove all equipment and ventilate patient with a bag and mask until ready to retry intubation. 443447, 2003. volume4, Articlenumber:8 (2004) 10.1007/s001010050146. The study was approved by Makerere University College of Health Sciences, School of Medicine Research Ethics Committee (SOMREC), The Secretariat Makerere University College of Health Sciences, Clinical Research Building, Research Co-ordination Office, P.O. The cuff was then progressively inflated by injecting air in 0.5-ml increments until a cuff pressure of 20 cmH2O was achieved. 109117, 2011. Air | Appendix | Environmental Guidelines | Guidelines Library The Khine formula method and the Duracher approach were not statistically different. It does not store any personal data. Article 208211, 1990. Also, at the end of the pressure measurement in both groups, the manometer was detached, breathing circuit was attached to the ETT, and ventilation was started. Luna CM, Legarreta G, Esteva H, Laffaire E, Jolly EC: Effect of tracheal dilatation and rupture on mechanical ventilation using a low-pressure cuff tube. When should tracheostomy cuff be inflated deflated? We use this to improve our products, services and user experience. Anasthesiol Intensivmed Notfallmed Schmerzther. It is also likely that cuff inflation practices differ among providers. How to insert an endotracheal tube (intubation) for doctors and medical students, Video on how to insert an endotracheal tube, AnaestheticsIntensive CareOxygenShortness of breath. An initial intracuff pressure of 30 cmH2O decreased to 20 cmH2O at 7 to 9 hours after inflation. R. Fernandez, L. Blanch, J. Mancebo, N. Bonsoms, and A. Artigas, Endotracheal tube cuff pressure assessment: pitfalls of finger estimation and need for objective measurement, Critical Care Medicine, vol. Because one purpose of our study was to measure pressure in the endotracheal tube cuff during routine practice, anesthesia providers were blinded to the nature of the study. Below are the links to the authors original submitted files for images. PubMed CONSORT 2010 checklist. protects the lung from contamination from gastric contents and nasopharyngeal matter such as blood. What is the device measurements acceptable range? The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2253/4/8/prepub. In case of a very low pressure reading (below 20cmH, https://pdfs.semanticscholar.org/c12e/50b557dd519bbf80bd9fc60fb9fa2474ce27.pdf. In an experimental study, Fernandez et al. The total number of patients who experienced at least one postextubation airway symptom was 113, accounting for 63.5% of all patients. Pelc P, Prigogine T, Bisschop P, Jortay A: Tracheoesophageal fistula: case report and review of literature. The cookie is used to determine new sessions/visits. Perhaps the LOR syringe method needs to be evaluated against the no air leak on auscultation method. The study comprised more female patients (76.4%). This however was not statistically significant ( value 0.053) (Table 3). To obtain an adequate seal, it is recommended to inflate the cuff initially to a no-audible leak point at applied airway pressures of 20 cm H 2 O. Cuff Pressure Measurement Check the cuff pressure after re-inflating the cuff and if there are any concerns for a leak. Our secondary objective was to determine the incidence of postextubation airway complaints in patients who had cuff pressures adjusted to 2030cmH2O range or 3140cmH2O range. The chamber is set to an altitude of 25,000 feet, which gives a time of useful consciousness of around three to five minutes. Aire cuffs are "mid-range" high volume, low pressure cuffs. However, they have potential complications [13]. Methods With IRB approval, we studied 93 patients under general anesthesia with an ET tube in place in one teaching and two private hospitals. Secondly, this method is still provider-dependent as they decide when plunger drawback has ceased. Cite this article. Endotracheal intubation is a medical procedure in which a tube is placed into the windpipe (trachea) through the mouth or nose. The compliance of the tube was determined from the measured cuff pressure (cmH2O) and the volume of air (ml) retrieved at complete deflation of the cuff; this showed a linear pressure-volume relationship: Pressure= 7.5. A syringe is inserted into the valve and depressed until a suitable intracuff pressure is reached. Over-inflation of an endotracheal tube (ETT) cuff may lead to tracheal mucosal irritation, tracheal wall ischemia or necrosis, whereas under-inflation increases the risk of pulmonary aspiration as well as leaking anesthetic gas and polluting the environment. Catastrophic consequences of endotracheal tube cuff over-inflation such as rupture of the trachea [46], tracheo-carotid artery erosion [7], and tracheal innominate artery fistulas are rare now that low-pressure, high-volume cuffs are used routinely. Printed pilot balloon. APSF President Robert K. Stoelting, MD: A Tribute to 19 Years of Steadfast Leadership, Immediate Past Presidents Report Highlights Accomplishments of 2016, Save the Date! 1977, 21: 81-94. Cuff pressure should be maintained between 15-30 cm H 2 O (up to 22 mm Hg) . The air leak resolved with the new ETT in place and the cuff inflated. 686690, 1981. ETT cuff pressures would be measured with a cuff manometer following estimation by either the PBP method or the LOR method. The cookie is a session cookies and is deleted when all the browser windows are closed. ETTs were placed in a tracheal model, and mechanical ventilation was performed. A wide-bore intravenous cannula (16- or 18-G) was placed for administration of drugs and fluids. Using a laryngoscope, tracheal intubation was performed, ETT position confirmed, and secured with tape within 2min. - in cmH2O NOT mmHg. 22, no. ); and patients with known anatomical laryngeo-tracheal abnormalities were excluded from this study. A caveat, though, is that tube sizes were chosen by clinicians in our study and presumably matched patient size; results may well have differed if tube size had been randomly assigned. On the other hand, Nordin et al. In case of a very low pressure reading (below 20cmH2O), the ETT cuff pressure would be adjusted to 24cmH2O using the manometer. The data collected including the number visitors, the source where they have come from, and the pages visited in an anonymous form. Sanada Y, Kojima Y, Fonkalsrud EW: Injury of cilia induced by tracheal tube cuffs. 1992, 49: 348-353. Another study, using nonhuman tracheal models and a wider range (1530cmH2O) as the optimal, had all cuff pressures within the optimal range [21]. Air Embolism: Causes, Symptoms, and Diagnosis - Healthline To detect a 15% difference between PBP and LOR groups, it was calculated that at least 172 patients would be required to be 80% certain that the limits of a 95%, two-sided interval included the difference. 5, pp. leaking cuff: continuous air insufflation through the inflation tubing has been describe to maintain an adequate pressure in the perforated cuff; . Cuffed Endotracheal Tubes Presentation | Operation Airway Approved by the ASA House of Delegates on October 20, 2010, and last amended on October 28, 2015. We enrolled adult patients scheduled to undergo general anesthesia for elective surgery at Mulago Hospital, Uganda. Correspondence to A research assistant (different from the anesthesia care provider) read out the patients group, and one of the following procedures was followed. Nordin U, Lindholm CE, Wolgast M: Blood flow in the rabbit tracheal mucosa under normal conditions and under the influence of tracheal intubation. One such approach entails beginning at the patient and following the circuit to the machine. Cuff pressures were thus less likely to be within the recommended range (2030 cmH2O) than outside the range. Distractions in the Operating Room: An Anesthesia Professionals Liability? 2001, 55: 273-278. Although the ETT pilot balloon was noted to be appropriately tense to the touch, a small amount of air was added to the cuff. Young, and K. K. Duk, Usefulness of new technique using a disposable syringe for endotracheal tube cuff inflation, Korean Journal of Anesthesiology, vol. supported this recommendation [18]. AW contributed to protocol development, patient recruitment, and manuscript preparation. Results. 2003, 29: 1849-1853. Chest. The cookie is used to enable interoperability with urchin.js which is an older version of Google analytics and used in conjunction with the __utmb cookie to determine new sessions/visits. Tube positioning within patient can be verified. Use of Tracheostomy Tube Cuff | Iowa Head and Neck Protocols Low pressure high volume cuff. 9, no. Product Benefits. None of these was met at interim analysis. 10, no. By clicking Accept, you consent to the use of all cookies. Smooth Murphy Eye. 21, no. The pressure reading of the VBM was recorded by the research assistant. 48, no. If more than 5 ml of air is necessary to inflate the cuff, this is an . We also appreciate the statistical analysis by Gilbert Haugh, M.S., and the editorial assistance of Nancy Alsip, Ph.D., (University of Louisville). The AAFP recommends inflating the cuff using air in 0.5-mL increments from a 3-mL syringe until no leak can be heard when the rebreathing bag is squeezed and the pressure in . The exact volume of air will vary, but should be just enough to prevent air leaks around the tube. Similarly, inflation of endotracheal tube cuffs to 20 cm H2O for just four hours produces serious ciliary damage that persists for at least three days [16]. Decrease the cuff pressure to 30 cm H2O by withdrawing a small amount of air from the balloon with a 10 mL syringe. 11331137, 2010. 14231426, 1990. It does not correspond to any user ID in the web application and does not store any personally identifiable information. The relationship between measured cuff pressure and volume of air in the cuff. 1: anesthesia resident; 2: anesthesia officer; 3: anesthesia officer student; 4: anesthesiologist. Endotracheal tube system and method - Viren, Thomas J. LOR group (experimental): in this group, the research assistant attached a 7ml plastic, luer slip loss of resistance syringe (BD Epilor, USA) containing air onto the pilot balloon. We recognize that people other than the anesthesia provider who actually conducted the case often inflated the cuffs. The anesthesia providers were either physician anesthetists (anesthesiologists or residents) or nonphysicians (anesthetic officer or anesthetic officer student). Pressure was recorded at end-expiration after ensuring that the patient was paralyzed. Numbers 110 were labeled LOR, and numbers 1120 were labeled PBP. ETT exchange could pose significant risk to patients especially in the case of the patient with a difficult airway. The size of ETT (POLYMED Medicure, India) was selected by the anesthesia care provider. PubMedGoogle Scholar. In most emergency situations, it is placed through the mouth. This has been shown to cause severe tracheal lesions and morbidity [7, 8]. Cuff pressure in . H. Jin, G. Y. Tae, K. K. Won, J. The cookie is created when the JavaScript library executes and there are no existing __utma cookies. Neither patient morphometrics, institution, experience of anesthesia provider, nor tube size influenced measured cuff pressure (35.3 21.6 cmH2O). - 10 mL syringe. CRNAs (n = 72), anesthesia residents (n = 15), and anesthesia faculty (n = 6) performed the intubations. Volume+2.7, r2 = 0.39 (Fig. Patients with emergency intubations, difficult intubations, or intubation performed by non-anesthesiology staff; pregnant women; patients with higher risk for aspiration (e.g., full stomach, history of reflux, etc. For example, Braz et al. Considering that this was a secondary outcome, it is possible that the sample size was small, hence leading to underestimation of the incidence of postextubation airway complaints between the groups. Airway 'protection' refers to preventing the lower airway, i.e. demonstrate the presence of legionellae in aerosol droplets associated with suspected bacterial reservoirs. Adequacy of cuff inflation is conventionally determined by palpation of the external balloon. Acta Anaesthesiol Scand. This was a randomized clinical trial. Crit Care Med. 2006;24(2):139143. In the control ETT, the cuff was inflated to 20 mm Hg to 22 mm Hg and not manipulated. Acta Anaesthesiol Scand. An endotracheal tube : provides a passage for gases to flow between a patients lungs and an anaesthesia breathing system . A CONSORT flow diagram of study patients. The author(s) declare that they have no competing interests. Conclusion. Water Cuff or Air Cuff? How To Tell The Difference - YouTube However, post-intubation sore throat is a common side effect of general anesthetic and may partly result from ischemia of the oropharyngeal and tracheal mucosa [810], and the most common etiology of non-malignant tracheoesophageal fistula remains cuff-related tracheal injury [11, 12]. After induction of anesthesia, a 71-year-old female patient undergoing a parotidectomy was nasally intubated with a TaperGuard 6.5 Nasal RAE tube using a C-MAC KARL STORZ GmbH & Co. KG Mittelstrae 8, 78532 Tuttlingen, Germany, video-laryngoscope. Reed MF, Mathisen DJ: Tracheoesophageal fistula. Endotracheal Tube Cuff Inflation Pressure Varieties and Response to We conducted a single-blinded randomized control study to evaluate the LOR syringe method in accordance with the CONSORT guideline (CONSORT checklist provided as Supplementary Materials available here). The primary outcome of the study was to determine the proportion of cuff pressures in the optimal range from either group. To achieve the optimal ETT cuff pressure of 2030cmH2O [3, 8, 1214], ETT cuffs should be inflated with a cuff manometer [15, 16]. We therefore also evaluated cuff pressure during anesthesia provided by certified registered nurse anesthetists (CRNAs), anesthesia residents, and anesthesia faculty. The high incidence of postextubation airway complaints in this study is most likely a site-specific problem but one that other resource-limited settings might identify with. This is the routine practice in all three hospitals. The patient was maintained on isoflurane (11.8%) mixed with 100% oxygen flowing at 2L/min. Conventional high-volume, low-pressure cuffs may not prevent micro-aspiration even at cuff pressures up to 60 cm H2O [2], although some studies suggest that only 25 cm H2O is sufficient [3]. J Trauma. 2013 Aug;117(2):428-34. doi: 10.1213/ANE.0b013e318292ee21. 56, no. 6, pp. Kim and coworkers, who evaluated this method in the emergency department, found an even higher percentage of cuff pressures in the normal range (2232cmH2O) in their study. The cookies store information anonymously and assign a randomly generated number to identify unique visitors. Underinflation increases the risk of air leakage and aspiration of gastric and oral pharyngeal secretions [4, 5]. 28, no. Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. 1982, 154: 648-652. Previous studies have shown that the incidence of postextubation airway symptoms varies from 15% to 94% in various study populations [7, 9, 11, 27] and could be affected by the method of interview employed, such as the one used in our study (yes/no questions). 31. 5, pp. In low- and middle-income countries, the cost of acquiring ($ 250300) and maintaining a cuff manometer is still prohibitive. muscle or joint pains. CAS But opting out of some of these cookies may have an effect on your browsing experience. (PDF) Pressures within air-filled tracheal cuffs at altitude--an in There is a relatively small risk of getting ETT cuff pressures less than 30cmH2O with the use of the LOR syringe method [23, 24], 12.4% from the current study. We designed this study to observe the practices of anesthesia providers and then determine the volume of air required to optimize the cuff pressure to 20 cmH2O for various sizes of endotracheal tubes. This is an open access article distributed under the, PBP group (active comparator): in this group, the anesthesia care provider was asked to reduce or increase the pressure in the ETT cuff by inflating with air or deflating the pilot balloon using a 10ml syringe (BD Discardit II) while simultaneously palpating the pilot balloon until a point he or she felt was appropriate for the patient. 6, pp. There was a linear relationship between measured cuff pressure (cmH2O) and volume (ml) of air removed from the cuff: Pressure = 7.5. if GCS <8, high aspiration risk or given muscle relaxation), Potential airway obstruction (airway burns, epiglottitis, neck haematoma), Inadequate ventilation/oxygenation (e.g. Google Scholar. Every patient was wheeled into the operating theater and transferred to the operating table. Used to track the information of the embedded YouTube videos on a website. 4, no. The magnitude of effect on the primary outcome was computed for 95% CI using the t-test for difference in group means. Another viable argument is to employ a more pragmatic solution to prevent overly high cuff pressures by inflating the cuff until no air leak is detected by auscultation. One study, for instance, found that cuff pressure exceeded 40 cm H2O in 40-to-90% of tested patients [22]. 4, pp. However, there was considerable variability in the amount of air required. chest pain or heart failure. These were adopted from a review on postoperative airway problems [26] and were defined as follows: sore throat, continuous throat pain (which could be mild, moderate, or severe), dysphagia, uncoordinated swallowing or inability to swallow or eat, dysphonia, hoarseness or voice changes, and cough (identified by a discomforting, dry irritation in the upper airway leading to a cough).