A Survey of Speech-Language Pathologists’ Experience With Clinical Cough Assessment

Abstract

Purpose:

The purpose of this study was to determine if students (clinicians-intraining) and clinicians of speech-language pathology assess cough during clinical swallow evaluations. We also sought to determine if participants received background education and training regarding implementation of clinical cough assessment. Finally, we aimed to identify participant interest in a cough assessment training program.

Method:

A clinician-researcher panel developed a 20-question survey to address specific aims. The final survey was distributed via social media and a clinical dysphagia website after two phases of revision.

Results:

A percentage (84.6%) of the survey participants reported that they assess cough in clinical swallow evaluations, mainly using subjective measures. The majority of clinicians reported no background education or skilled training to implement cough assessment. Background education and training was higher for participants outside the United States, although the total sample size of that group was small. Almost all participants (97.8%) were interested in a cough training program.

Conclusions:

Many practicing clinicians in this survey reported that they complete cough assessments, despite limited education and training to do so. However, they also reported high interest in participating in a clinical cough assessment training program, which would support the field of speech-language pathology and patients at risk of airway protective dysfunction.

Swallow and cough are airway protective behaviors that either prevent food and liquid from entering the airways or eject food and liquid after aspiration (Troche, Brandimore, Godoy, et al., 2014). Speech-language pathologists are very familiar with swallowing, spending approximately 40% of their time evaluating and treating dysphagia (ASHA SLP Healthcare Survey, 2019). However, speech-language pathologists may be less familiar with how to implement and interpret comprehensive cough assessments as part of the clinical swallow evaluation, despite cough’s role in airway protection.

In the United States, speech-language pathology (SLP) clinicians typically receive education and training in the evaluation and management of swallowing disorders during their academic studies (ASHA Certification Standards IVC and VB, 2020). Beyond academic training, clinicians are able to continuously educate themselves by attending a variety of webinars about evidence-based swallow assessment and management (i.e., ASHA Store, n.d.; Northern Speech Services, n.d.-b). Conversely, there seems to be limited content regarding cough as an airway protective behavior, in both academic coursework (ASHA, 2007; ASHA Certification Standards, 2020) and continuing education platforms (i.e., ASHA Store CE Swallowing Disorders, 2021; Northern Speech Services, n.d.-a). In fact, to our knowledge, there is no formal program that combines intensive education regarding the neurophysiological mechanisms of cough with a training that offers clinicians the opportunity to practice interpreting cough assessments.

Intensive education and training are likely necessary in order for clinicians to understand the utility and limitations of behavioral cough assessment in a clinical setting. Effective cough is the result of complex neural interactions that require detection of the airway irritant (Davenport, 2009; Mazzone & Undem, 2016) and production of high-expiratory airflow rates that create shearing forces capable of removing the irritant (i.e., aspirate material; Macklem, 1974). In research, quantitative measures of impaired cough sensation and production are significantly related to dysphagia with aspiration. Thus, disordered sensorimotor cough, or dystussia, often coexists with dysphagia and can stem from the same pathologies (Hegland et al., 2014, 2016; Hutcheson et al., 2017; Pitts et al., 2008; Plowman et al., 2016; Silverman et al., 2016; Smith-Hammond et al., 2009; Tabor-Gray et al., 2019; Troche, Brandimore, Okun, et al., 2014; Troche et al., 2016). Due to this relationship of airway protective dysfunction clinicians should also assess patients’ cough during clinical swallow evaluations (Garand et al., 2020).

Rumbach et al. (2018) described that 12.34% of clinicians in Australia always used reflex cough testing during their clinical swallow evaluations and that 66.88% never used it. Interestingly, when Perry et al. (2019) incorporated results from reflex cough testing into dysphagia diagnostic and management plans for patients poststroke, they found that patients had improved oral diets, as well as lower pneumonia and pneumonia-related readmission rates.

Nonreflex cough testing can be found in some clinical swallow evaluation tools, such as the Mann Assessment of Swallowing Ability (MASA; Mann, 2002), the Modified MASA (Antonios et al., 2010), and the Gugging Swallowing Screen (Trapl et al., 2007). These tools have clinicians ascribe a value based on voluntary cough strength, vocal quality, presence of cough, and perceived effectiveness of cough. They may also have clinicians rate the cough if it occurs during or after oral intake. However, these subjective methods may not be considered comprehensive or reliable. A review by Martino and colleagues found that the predictive value of perceived weak voluntary cough was not reproduced across studies, even from the same research group (2000). Additionally, a more recent study suggested variable agreement between clinicians who rated cough descriptions based on total cough number, vocal quality, strength, effectiveness, and whether they heard a cough or throat clear (Laciuga et al., 2016). Perceptual measures of cough effectiveness do not measure cough airflows or sensation. Thus, using those methods as sole components of a cough assessment may not be comprehensive enough to evaluate the complex sensorimotor aspects that can be impacted by disease or injury. Moreover, it is important to investigate whether SLP students (clinicians-in-training) and clinicians are adequately prepared to implement a thorough, systematic cough assessment based upon their educational and training backgrounds. Therefore, we developed a survey study and aimed to (a) determine if and how SLP students and clinicians assess cough in their clinical practice, (b) determine the percentage of SLP students and clinicians who received education and training experience(s) regarding cough assessment in the classroom or clinical setting, and (c) assess student and clinician interest in a potential clinical cough assessment training program.

We hypothesized that most participants would report that they assess(ed) cough in their clinical practice, but that less than 50% received formal education or training to do so. Because of the anticipated lack of cough assessment preparedness, we also hypothesized that more than half of the respondents would be interested in participating in a potential clinical cough assessment training program.

Method

Survey Development

We created and distributed A Survey of Clinical Cough Assessment Experience to SLP students and clinicians (see Figure 1). Because a master’s degree is not required to practice SLP in some regions of the world, we anticipated that student respondents would be enrolled in an undergraduate or graduate degree program. We also anticipated that clinician respondents would be practicing SLP with a bachelor hons or master’s degree.

Figure 1.

Twenty-item survey development, including two phases during which panel members critiqued and recommended modifications to improve question interpretation and answer options.

During Phase I of survey development (see Figure 1), the principal investigators created the initial draft of the survey. This included 15 questions regarding clinical experience and education related to cough assessment, as well as clinician interest, course delivery preference, and time allotment for potential future training programs. Investigators followed published guidelines to reduce bias and ambiguity in the survey items, as well as to ensure good conduct in data collection (Bowden et al., 2002; Kelly et al., 2003). For instance, each survey item was phrased with positive language (e.g., Do you feel competent with assessing cough? vs. Do you feel incompetent with assessing cough?). Advancement through the survey was not contingent upon participants’ answers, such that individuals were allowed to skip a question if they felt inclined to do so.

The initial 15-question survey was distributed to a panel that included six clinician researchers and one graduate student, all who specialized in studying airway protection. Instructions to panel members were to provide a statement summarizing their interpretation of each question’s meaning and a statement regarding whether the answer choices were comprehensive. If panel members had recommendations for adding, removing, or modifying questions or answer choices, they were able to include them in their statements of critique.

During the panel critique of Phase I, six members indicated that the answer options for seven questions were not all inclusive. The panel also discussed that three questions contained ambiguous terms or phrases that could lead to various interpretations. Other recommendations were to include the following: (a) familiar terminology to clinicians outside of North America, (b) an “unsure” answer choice for each question, (c) a follow-up question to determine why a clinician does not use cough assessment, (d) an item to identify patient populations with whom clinicians assess cough, (e) an item to identify other professionals who assess cough function, and (f) a self-rating regarding cough assessment competence.

During Phase II of survey development (see Figure 1), the investigators compiled the panel’s feedback from Phase I and used it to modify the original questionnaire. A second version of the survey, which contained 19 questions, was distributed to the panel. Panel membership increased to 10, including three graduate students (two were added) and seven clinician researchers of SLP (two were added and one from Phase I did not continue into Phase II). To determine consensus during this phase, investigators provided the panel with the intended meaning for each survey question. Then the panel members indicated whether their interpretation of each question matched the intended meaning. They did so by stating “yes” or no” (see Table 1). Additionally, the panel was asked to indicate “yes” or “no” regarding whether the answer choices were all inclusive. There was 100% agreement between panel members regarding the interpretation of item intent for 15 questions. There was 90% agreement for the remaining questions due to one panel member recommending changes in order to ameliorate ambiguity. The investigators isolated these questions for review and modified the questions according to the specific feedback. For example, one question was interpreted as two-parts, so investigators separated it into two questions to improve clarity.

Table 1.

Example of Phase II survey development panel feedback form.

Survey question #	Interpretation of question intent	Does interpretation = intent? (Yes, No)	Sufficient answer choices? (Yes, No)
6	Target respondents: clinicians of speech-language pathology and asking if they had classroom education re: cough structures/function and its role in airway protection	YES	YES

There was 100% agreement regarding inclusiveness of answer options for 10 questions and 70%–90% agreement on the remaining items’ answer options. The panel members in disagreement recommended the addition of a “select all that apply” or “other” option with free-text capabilities for these survey items. Hence, the final agreed-upon survey included 20 questions and a wide variety of answer options that resulted from investigators’ and panel members’ collaborative efforts. The survey items pertained to the following general topics: demographics, educational background regarding components of cough function and cough assessment, training to implement clinical cough assessment, methods of clinical cough assessment, and interest in obtaining education and training to advance practice of clinical cough assessment.

The survey was created in Qualtrics (2005/2020), which provided a secure distribution platform and anonymity to all respondents. The survey infrastructure was programmed to prohibit participants from completing multiple submissions. The final survey, recruitment methods, and data collection procedures were approved by the University of Florida Institutional Review Board, and only responses from participants who provided consent were analyzed. See the Appendix for final version of the survey.

Target Respondents

Target survey respondents included current SLP students, as well as SLP clinicians who worked in a clinical setting within the past 5 years. Participants were recruited through a dysphagia website and social media platforms to which medical speech-language pathology students and clinicians subscribed. After providing the group moderators and administrators with the study information, investigators requested advertisement and distribution permission. The group moderator or administrator posted the recruitment message and link to the anonymous survey.

Statistical Analysis

Descriptive statistical reports were used to determine totals and percentages of answer choices pertaining to participants’ geographical location, education and training background regarding cough function, methods of clinical cough assessment, and interest and preference in a potential cough assessment training program. Descriptive statistics also determined the totals and percentages of clinical education and training regarding cough evaluation at various levels of higher education. Inferential statistics were not used because of varied group sizes and inability to control for many confounding variables.

Results

Survey Questions and Responses

Demographics

A total of 238 survey responses were collected between October 17, 2019 and March 20, 2020. Upon analysis, five responses were eliminated, as three were “preview” only, one was completed without consent, and another was incomplete. There was another incomplete survey, however, that participant answered 14/20 questions so it remained in the full data set. Because it was not mandatory for each participant to answer every question, and due to multiple answer options for some items, there were different response totals throughout the survey.

The first question in the survey inquired about clinician or student status. Responses indicated that there were 223 SLP clinicians and 10 SLP students who participated in the survey study. Question 2 asked participants to provide the name of the country in which they practiced SLP (no other information regarding location was requested due to privacy concerns). Participants who answered this question indicated that 194 (85.1%) practiced in the United States and 34 practiced in locations outside the United States (see Table 2). Various countries may require different educational preparation and training prior to practicing clinical speech-language pathology, which was also reflected in the survey results (see Table 2). Sixty-nine percent of participants reported working in acute care, inpatient and outpatient rehabilitation facilities, and/or skilled and long-term nursing facilities within the past 5 years (see Figure 2).

Table 2.

Demographic information regarding student or clinician of speech-language pathology status, highest degree earned, and geographical location of clinical practice.

Participant group	Number of responses	Percentage of responses
Student of speech-language pathology	10	4.3
Clinician of speech-language pathology	223	95.7
Degree status
Bachelor’s + clinician	8	3.4
Master’s + clinician	177	76.0
Clinical doctorate + clinician	3	1.3
PhD + clinician	16	6.9
Other (student status or not reported)	29	12.4
Geographical location
Australia	3	1.3
Brazil	4	1.8
Canada	5	2.2
New Zealand	2	0.9
South Africa	2	0.9
United Kingdom	9	4.0
United States	194	85.1
France, Germany, Greece, Ireland, Italy, Norway, Singapore, Slovakia, and Turkey	1 each	Each < 1.0
No response	5	2.0

Figure 2.

Percentages of clinical settings where survey participants reported working within the past 5 years. ENT = ear, nose, and throat clinics.

Educational Background Regarding Cough Function

Half of the SLP students and 33.6% of clinicians reported that they will receive, or have already received, classroom instruction regarding anatomy and physiology of cough pertaining to airway protection (see Figure 3A). A larger percentage of clinicians outside the United States (56.3%) received this coursework compared with those clinicians practicing in the United States (31.2%; see Figure 3B).

Figure 3.

Percentages of survey participants who reported experience with education and training regarding cough assessment in clinical swallow evaluations during academic studies according to (A) student or clinician status, (B) geographical location within or outside the United States, and (C) PhD or master’s degree status at the time of survey participation.

When combining master’s, SLP clinical doctorate, and PhD education levels, 32.1% of clinicians indicated that they did receive coursework regarding cough, 56.9% did not, and 11.0% had no answer or were unsure. Seven out of 16 clinicians with research doctorates had this background education pertaining to cough during their academic studies (see Figure 3C).

Training to Implement Clinical Cough Assessment

This section of the survey sought to inquire about whether students and clinicians received skilled training to implement cough assessment in a clinical setting. Sixty percent of students and 19.7% of clinicians responded that they did receive this type of training in their academic programs (see Figure 3A). A larger percentage (50%) of clinicians reported that they received training about cough evaluation outside of their academic training, from either workshops or continuing education courses.

Regarding geographical location, 18.3% of SLP clinicians in the United States, and 31.2% outside the United States, reported that they received this training in their academic studies (see Figure 3B). Furthermore, there was a greater percentage of participants who were trained to implement cough assessment if they reported having a research doctorate (31.2%) versus a master’s degree (15.8%; Figure 3C).

Use of Clinical Cough Assessment

One hundred and forty-three participants (84.6%) reported that they clinically evaluated cough (see Figure 4A). Of those that did not, they indicated that it was due to lack of training, lack of time, or because another professional completed the cough evaluation. The majority of participants indicated that evaluation of cough is within the scope of practice for many health care professionals, such as clinicians of SLP (13.7%); pulmonologists (12.6%); respiratory therapists (13.4%); ear, nose, and throat physicians (11.8%); respiratory physiologists (9.2%); primary care physicians (8.4%); nurses (7.4%); physician assistants (6.8%); students of SLP (7.0%); physical therapists (4.2%); occupational therapists (1.9%); nurse assistants (1.7%); and home care staff/support workers (< 1%). The remaining percentage of participants reported that they were unsure about the answer to this survey item.

Figure 4.

(A) Percentages of survey participants who reported using cough assessment in clinical practice and those who reported not using cough assessment according to various reasons. Clinicians who reported use of cough assessment identified the (B) evaluation methods, which primarily consisted of subjective measures during clinical or instrumental swallow evaluations or during induced cough testing. Less frequently reported measures included objective (peak flow meter), quantitative (urge to cough rating), and other (endoscopy, manometer for respiratory pressures).

Methods and Interpretation of Cough Assessment

This survey item received 655 responses, suggesting that participants may use a combination of qualitative and quantitative measures of cough assessment (see Figure 4B). The most commonly reported method of evaluation was qualitative, whereby clinicians reported use of perceptual judgment of cough presence and strength during voluntary coughing (28.0%), during clinical swallowing evaluation with oral intake (29.1%), and/or during instrumental swallowing evaluation with oral intake (27.6%). Forty-three percent of participants reported feeling competent with interpreting these perceptual measures. There was a smaller percentage of respondents that reported the use of quantitative tools, such as peak flow meters (6.8%) and urge-to-cough ratings (4.4%). There was also a smaller percentage of participants (14.1%) who reported competence with interpretation of quantitative results. Forty percent (6/16) of clinicians with a PhD reported use of peak flow meters, whereas 26.7% (4/16) reported use of an urge-to-cough rating scale. When asked if results of a cough assessment should influence plans of care, 85.3% of participants indicated “yes,” 12.5% “unsure,” and 2.2% “no.”

Patient Populations in Which to Assess Cough

This was a multiselection survey item that received 1,250 responses. Accounting for approximately 70% of the responses were patient populations with neurological conditions: poststroke (16.6%), neurodegenerative disease (16.0%), neuromuscular disease (14.0%), traumatic brain injury (12.1%), and/or postcervical spine surgery (10.9%). The frail elderly patient population accounted for 14.1% of responses and head and neck cancer for 12.4%. Pediatrics, postsurgical trauma, chronic refractory cough, and intellectual disability patient populations comprised the remaining responses.

Interest in Clinical Cough Assessment Training

Responses indicated that 97.8% of the participants were interested in a formal cough assessment training program. The majority of participants preferred an online format of training that would last 1–2 or 3–5 hr (61.5%). Others indicated that they preferred several hours of training be distributed across days (26.2%). The remaining participants preferred in-person training, a hybrid approach, or were not interested.

Discussion

Survey results supported all three hypotheses and gave rise to themes that warrant discussion and action beyond this article. First, up to 80% of all participants reported that they did not receive education or training to understand and evaluate the cough mechanism during their academic experiences. However, almost 85% of clinicians reported that they assess cough in a wide range of clinical populations and that cough assessment results should influence clinical care. This discrepancy between preparedness and clinical practice begs the following questions: “How do clinicians know how to assess cough?” and “Are they accurately interpreting the results?” The answers to these questions may be found in the content of workshops and seminars that many survey participants attended. However, at this time, there is no formal program that specifically trains clinicians to complete and interpret cough assessments, nor is there a program that trains competency to improve accuracy and reliability of cough assessment interpretation. Survey results indicated that there is potentially more focus on background education regarding cough as an airway protective mechanism in higher education (i.e., SLP clinical doctorate or PhD), as a large proportion of those with a research doctorate reported use of quantitative and objective tools for evaluation. Furthermore, there may be a greater focus on this type of education and training in locations outside the United States, based on these survey results. Future studies may serve to describe and compare the learner outcomes in various speech-language pathology programs across the globe, specifically at the bachelor’s and master’s degree levels.

Second, the primary methods for assessing cough were reported as qualitative or subjective in nature. This was also the type of assessment in which many clinicians deemed themselves most competent. The lack of education and training during clinicians’ bachelor’s or master’s level studies may explain the limited use of objective measures that specifically quantify the physiology of a cough behavior, particularly in the United States and from a small number of survey participants across the globe. This is not to suggest that qualitative or subjective measures do not have a place in the clinical assessment of cough function; it simply highlights a knowledge gap between clinical preparation and clinical practice regarding comprehensive cough assessment that includes a variety of evaluation tools.

Previous research suggests that cough assessment training may improve perceptual ratings of cough production. For example, Miles et al. (2014) provided clinicians with background education on the cough mechanism, as well as training to improve judgment accuracy for cough presence and strength. After the training, the interrater reliability regarding the presence of cough improved but the reliability regarding strength remained fair when comparing results with a previous study without training (Miles & Huckabee, 2013). Although training may improve reliability of perceptual cough ratings, it may need to be modified in order to optimize its predictability of dysphagia during clinical swallow evaluations.

Perceptual characteristics regarding cough productions may provide information to clinicians regarding the function of the mechanism, much like perceptual qualities of speech production provide information regarding types of dysarthria (Darley et al., 1969) or dysphonia (Stemple et al., 2018). However, there is no platform for clinicians to routinely practice rating healthy and dysfunctional cough productions, which likely contributes to inconsistent reliability. Laciuga et al. (2016) described variable agreement between clinicians when they were asked to ascribe qualitative features to coughs after listening to various productions. There was disagreement regarding differentiation between a cough and throat clear, as well as between perceptual features of cough (i.e., strong/weak, effective/ineffective, breathy, and strained), much like what was discussed in Miles et al. (2014). General trends suggested that clinicians rated a cough as strong or effective when objective cough measurements indicated high expiratory peak flow. Conversely, when peak expiratory flow rates were low, clinicians tended to judge the cough as weak or ineffective. As such, an ideal training may be one that pairs perceptual ratings with objective parameters that can be accessed in clinical settings.

The complexity of the cough mechanism necessitates the expansion and increased formality of cough assessment in patients at risk for dysphagia. Improved education and training pertaining to cough is essential for SLP clinicians to competently implement a comprehensive cough assessment. It may be that most participants in this survey acknowledge this gap between clinical education and clinical practice, since many indicated interest in a formal clinical cough assessment training program. Previous literature suggests that perceptual means of assessment must be correlated with objective and quantitative measures to provide a more thorough understanding of the complex airway protective system (Watts et al., 2016). We speculate that this type of integrated training program would yield the best results in terms of speech-language pathology clinical knowledge about cough and how to accurately assess it in the future.

Limitations

This survey had limitations that are typically controlled for in other types of studies. Because it was not mandatory for each participant to answer each question, the total number of responses for survey items varied, depending upon whether participants skipped items or whether they could select multiple options. For instance, one item received 169 responses, whereas another received 1,495 responses. On the basis of the heterogeneity of the sample and nature of the survey responses, we could not use inferential statistics to analyze the results, which limited us to descriptive statistics.

The extent of education and training that was received during the participants’ academic studies (or professional workshops) was not described (nor was it asked in the survey), so we cannot comment on the adequacy of previous training for cough assessment.

Finally, we acknowledge the possibility of sampling error and bias. We did not ask participants to provide the names of the academic or research institution if they were students or researchers; thus, it is possible that some of these participants attend institutions where principal investigators research cough and dysphagia. Additionally, because we recruited from medical SLP platforms, only those interested in cough may have participated. It is difficult to determine the true response rate for the survey, as there are thousands of members that belong to each recruitment platform and these members likely belong to many of the social media pages from which we recruited. Nonetheless, out of thousands of eligible participants, a total sample of 233 responses may indicate a low response rate.

Conclusions

Despite the body of literature that supports a strong correlation between dystussia and dysphagia, there is limited education and training regarding formal clinical cough assessment as a component to the clinical swallow evaluation. Thus, it is essential that students and clinicians are provided opportunities to advance their knowledge regarding the anatomical and neurophysiological aspects of cough. It is also important that they are provided a platform to practice perceptual and objective methods of cough assessment to improve reliability and accuracy of results. Findings from this survey indicate that many students and clinicians acknowledge the need for additional education and training regarding cough assessment. With that additional knowledge and practice, future clinicians, and currently practicing clinicians, will be better equipped to evaluate airway protection in a comprehensive manner.

Appendix

A Copy of the Survey Completed by 223 Speech-Language Pathology (SLP) Clinicians and 10 SLP Students

Are you a student of SLP or are you a clinician of SLP? SLP student SLP clinician Other (free-text typed option) In which country are you a student or clinician? (Scrolling list of all country options) What is your highest level of education associated with your student or clinician status? Obtaining a bachelor’s (Hons) degree in order to practice SLP Obtaining a master’s degree in order to practice SLP Bachelor’s (Hons) degree + clinician of SLP Master’s degree + clinician of SLP SLPD + clinician of SLP PhD + clinician of SLP Other (free-text typed answer) For students of SLP: In a classroom setting, will you receive, or have you received, coursework regarding anatomy and physiology of cough, as it pertains to airway protection? Yes No Not sure I am a clinician of SLP For students of SLP: In a classroom and/or clinical setting, will you receive, or have you received, training regarding evaluation of cough function? Yes No Not sure I am a clinician of SLP For clinicians of SLP: Did you have classroom-based coursework regarding anatomy and physiology of cough, as it pertains to airway protection? Yes No Not sure I am a student of SLP For clinicians of SLP: When you were a student of SLP, did you receive training regarding evaluation of cough function in a classroom and/or clinical setting? Yes No Not sure I am a student of SLP For clinicians of SLP: During your clinical practice, have you attended workshops or courses outside of the workplace that have focused on evaluation of cough function? Yes No Not sure I am a student of SLP For clinicians of SLP: What are the settings in which you worked the past 5 years? Select all that apply. Acute care Inpatient rehabilitation Long-term acute care Sub-acute care (skilled nursing facility) Outpatient ENT Outpatient rehabilitation University clinic Long-term care facility (nursing home) Private practice Telehealth Home health School Research None I am a student of SLP Other (with free-text typed answer) For students and clinicians of SLP: Which of the following best describes the method(s) by which you evaluate(d) cough function? Select all that apply. I do/did not assess cough Ask patient to voluntarily cough and judge presence/absence and strength Judge presence/absence and strength of reflexive/reactive cough after aspiration event during instrumental assessment of swallowing Judge presence/absence and strength of cough during any part of a clinical swallowing evaluation of oral intake Judge presence/absence and strength of cough during cough reflex testing (with use of a cough-inducing stimulus such as nebulized citric acid, tartaric acid, capsaicin, or water) Use of peak flow meter Use of urge to cough rating Not sure Other (with free-text typed answer) For students and clinicians of SLP: In which patient population(s) do/did you evaluate cough function? Select all that apply. I do/did not assess cough function Poststroke Neurodegenerative disease Neuromuscular disease Head and neck cancer Frail elderly Postcervical spine surgery/procedure Traumatic brain injury Pediatrics Other (with free-text typed answer) For students and clinicians of SLP: If you do not clinically evaluate cough function, please select a reason why. I do evaluate cough I am untrained It is not in the SLP scope of practice There is/was a lack of time It was already completed by another professional Not sure Other (with free-text typed answer) For students and clinicians of SLP: Do other professionals with whom you work evaluate cough function? Yes No Not sure For students and clinicians of SLP: Select all of the professional(s) who can evaluate cough function: Clinicians of SLP Students of SLP ENTs Nurses Nurse assistants Occupational therapists Physical therapists Pulmonologists Primary physicians Physician assistants Respiratory therapists Respiratory physiologists Not sure Other (with free-text answer) For students and clinicians of SLP: Do you feel competent with interpreting results from a clinical evaluation of cough function? Select all that apply. Yes, for objective results Yes, for subjective results No, for objective results No, for subjective results I do/did not assess cough For students and clinicians of SLP: Do you think the results of a clinical evaluation of cough function should influence plan of care recommendations? Yes No Not sure For students and clinicians of SLP: If there was a formal clinical cough training program, would you be interested in participating in the program? Yes No For students and clinicians of SLP: Which format of instruction for a cough training program do you prefer? Select all that apply. Online, module-based Online, webinar In-person I am not interested in cough training Other (free-text answer option) For students and clinicians of SLP: Which allotment of time do you prefer for online training? Select all that apply. 1–2 hr for only 1 day 3–5 hr for only 1 day 6–8 hr for only 1 day Up to 8–10 hr, completed independently over the course of 10 days I only prefer in-person training I am not interested in cough training For students and clinicians of SLP: Which allotment of time do you prefer for in-person training? Select all that apply. 1–2 hr for only 1 day 3–5 hr for only 1 day 6–8 hr for only 1 day I only prefer online training I am not interested in cough training

We thank you for your time spent taking this survey. Your response has been recorded.