2.2: Assisted Coughing Techniques

Key Points

1. A thorough auscultation examination will provide a baseline to help determine which techniques to use and to determine effectiveness of the techniques
2. Assisted Breathing and Coughing Techniques can only be performed with patients who have a stable spine and no rib fractures.

Note

For each of the following techniques, be prepared to discuss the indications, precautions and contraindications.

Techniques done in supine:

• Costophrenic assist: at the end of expiration, the therapist gives a quick stretch to the diaphragm and intercostals to facilitate more complete inhalation by compressing the chest at the costophrenic angle toward the central tendon of the diaphragm. This is done several times to fill the lungs. The patient is then instructed to hold the air in the lungs. As the patient gets ready to cough, the therapist performs a diaphragmatic assist by applying a strong pressure up and in toward the central tendon.

Costophrenic assist

• Heimlich-type assist: the therapist places the heel of his or her hand just below the patient’s xiphoid process and presses up and in toward the central tendon as the patient coughs. While this is a very effective technique, it is also very uncomfortable for the patient. It may also elicit undesired muscle tone. Thus, it is used only when other techniques are found to be ineffective.

Heimlich-type assist

Exercise \(\PageIndex{1}\)

What are some contraindications for the above coughing activities?

• Anterior chest compression: the therapist places one arm across the patient’s pectorals and the other parallel to it on the lower abdomen or in the position used in the Heimlich-type assist. After the patient takes a maximal breath, the therapist pushes down to help the patient cough. The greatest force is applied through the lower chest during expulsion.

Anterior chest compression

Techniques done in sidelying:

• Costophrenic assist: in sidelying, the excursion of the anterior chest wall is now done with gravity-eliminated while lateral excursion becomes anti-gravity. In addition, greater balance is required making this a good progression for working on trunk stability for the patient moving from supine to upright. This technique is asymmetrical. Which segment of the lung is this technique effective for?

Costophrenic Assist

• Heimlich-type assist: this is the same as previously described. The only variation involves positioning the patient with both hips and knees flexed. In this reflex inhibiting posture, the chances of eliciting high muscle tone are diminished.
• Combined costophrenic and Heimlich-type assist: the therapist uses both hands at the same time, one to provide a costophrenic assist to lateral excursion and one to provide a Heimlich assist to anterior excursion. Because two planes of respiration are used to remove excretions this method is more effective than either one used alone.​​​​​​​

Combined costophrenic Heimlich-type assist

• Massery counter-rotation assist: the therapist provides a quick stretch facilitation to the pectorals and the hip hikers at the end of expiration to maximize the next few inhalations. The therapist then facilitates inspiration by stretching along the inferior border of the scapula in an oblique and upward manner while pulling the hip in a downward and posterior fashion. After several breaths have been taken to fill the lungs as much as possible. The therapist positions her hands as she would for the quick stretch but compresses on exhalation. The patient’s chest is squeezed in all three planes of respiration making this a very effective method of assistive cough. It is important to follow a true diagonal in both the physical assistance and the compression of the chest so that air is forced out of the lungs. This method has an additional advantage because the rotation component will act to inhibit the development of abnormal muscle tone. Finally, because it does not require active participation on the part of the patient, this technique can be used with incoherent or unresponsive patients.

Massery counter-rotation assist

Techniques done in prone:

Head Flexion assist: the patient is positioned prone on his or her elbows. The patient then extend his head and neck up and back as far as possible, while taking a deep breath. Then, the patient is instructed to cough out as hard as possible while throwing his head forward and down. Because the diaphragm is inhibited in this position this cough will be a fairly weak one and thus should not be the only method of assisted coughing utilized.

Techniques done in sitting:

• Quad long sitting assist: the patient sits in a long sitting position with UE support. The therapist instructs the patient to breathe in as deeply as possible while extending neck and upper back fully onto his or her arms. The patient is to cough out forcefully while throwing his entire upper body into a flexed position. A pillow on his legs will prevent injury while falling forward onto his legs.
• Para long sitting assist: the technique is the same as described above only more vigorous because of the action of the innervated trunk musculature of the individual with paraplegia
• Short-sitting self-assist: The patient is positioned in a shortsitting posture. Both hands are held in the lap with one hand over the other at the wrist. The patient will extend his trunk while inhaling deeply. As the patient coughs, both hands are moving up to the abdomen, compressing the diaphragm in a Heimlich-type maneuver. Most patients can learn to use this technique independently although individuals with tetraplegia will need trunk support to prevent them from falling too far forward.

Technique done in hands-and-knees:

The patient is positioned in an all-fours position. He is instructed to rock forward into a fully extended position while inhaling deeply and then to cough out while moving forcefully back onto his heels with a flexed head posture.

Think about what deficits predispose each of the patients in the cases to respiratory complications. Which of the preceding techniques, if any, would be appropriate for each of them? Be prepared to state your rationale for your choices. What will your evaluation and treatment consist of during the early stages of care?