Talking All Things Cardiopulm
This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences.The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation.
Talking All Things Cardiopulm
Episode 76: How to Improve an Ineffective Cough
There are a number of reasons why a cough may be ineffective. It all starts with assessing the four phases of a cough. Once the inefficiency is highlighted it’s time to work on improving it.
Pending which phase is most affected, depends on how you will approach the interventions. Whether you are utilizing posture, applying manual pressure or aiming for time, there is something beneficial for each person. More importantly are the consequences of this improvement.
Tune is as we break it all down.
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Welcome to Talking All Things Cardiopulm. I am your host, r Rachel Barisi, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring cardiopalm to the forefront of conversation. Thanks for joining me today, and let's get after it.
Rachele Burriesci:Today's episode is sponsored by Jane. You might already be familiar with the name, but if it's new to you, jane is a HIPAA compliant clinic management software and EMR. Chasing down patients or clients for important information isn't anyone's idea of a good time, especially when there are forms to be filled, payments to be processed and consents to be collected. That's why Jane has designed user-friendly online intake forms so you can gather all of the information you need prior to the employment, whether that's health history, insurance details or credit card on file. Jane will even send a friendly reminder 24 hours before a patient's appointment if they haven't completed their intake forms yet, saving you from having to manually follow up. To see Jane in action, head to the show notes and click that link to book a personalized demo, and if you're ready to get started, you can use the code CARDIOPULM1MO at the time of signup for a one-month grace period applied to your new account. Thanks again, jane. All right, welcome back.
Rachele Burriesci:We are officially in September. It's September, Not sure how it happened. I keep saying it. This has been just one of those years. It's flying by and even though Christmas has already been up in Costco for a few weeks, I'm not quite ready for that yet. I'm fine with fall coming this year. I'm usually very don't rush my life and I'm still very much that way. I like to literally take the most out of summer and the warm weather, but we've had some up and down weather and some just weird August altogether. Today was actually 60 for most of the day and I just got hot. I think. If you're on YouTube, my cheeks are actually quite pink from doing some work outside. But it's September. Happy belated Labor Day, happy new semester, wherever you're at. If you're just, you know regular adulting and it's just another month. Happy September.
Rachele Burriesci:What I wanted to talk about today was how to improve an ineffective cough. I've talked about the phases of a cough, but I and I talked a little bit about some how to improve it in some sense. But I wanted to spend a little bit more time on that today. So, especially in the acute care setting. Um, there can be a number of reasons that makes a person's cough ineffective and it all starts with that assessment. And I think you can go back to episode 33 or so and I talk all about how to assess a cough. You essentially have to assess that cough before you can really give any intervention to improve it. But today's focus is really going to be on the improvement of said cough, and every patient is going to be different and every patient is going to have a different focus.
Rachele Burriesci:Essentially, you're going to focus on the phase that is ineffective, and sometimes patients will have more than one phase that is really just not doing its job, probably from never being taught how to appropriately cough, never having to have to think about that, and then likely compounded with some other change that has occurred in their current situation, whether it's being recently intubated or extubated, whether it's having a sternotomy or some other incision that it's causing pain with coughing. Maybe someone's post tracheostomy, maybe they've been bed bound for a number of weeks due to, you know, septic shock or some other reason that they may have been in the ICU for quite some time. All of those things can lead to ineffectiveness. So, after assessing your cough and just to go through it quickly, we have four phases of the cough. Phase one is inspiration, phase two is glottal closure, phase three is abdominal contraction and phase four is exposure. Essentially, when you're assessing that cough, you want to pay attention and observe all of those phases, but you also want to pay attention to what might be lacking.
Rachele Burriesci:So if someone is having an issue with phase one, essentially they have an ineffective inhale, lots of reasons to have an ineffective inhale. If that is your focus to increase inhale, besides just cuing your person to take a bigger breath or to increase the time of their inhale increase the time of their inhale you can essentially use posture to help assist with this, and this can be especially effective in patients who are in the ICU setting. Maybe they're not mobilizing much yet. You can still have some impact on posture, even in the bed. Obviously, it will be much improved if you're able to sit up.
Rachele Burriesci:But it starts with the eyes. So when you're cuing your person to inhale, you actually want them to look up, and I want you to do it with me. So we're just going to inhale through our nose and look up. Okay, so we're going to breathe in and exhale, look down, inhale, look up, exhale, look down and what you likely have noticed is, as soon as your eyes go up, what wants to follow suit Neck extension. So then eyes up, neck extension, shoulders, back, trunk extension can literally help increase the size of your inhale. So we're just going to do that Eyes up, head back, shoulders, back, trunk extension and then we're going to do the opposite on exhale Eyes down, shoulders forward and crunch a little bit.
Rachele Burriesci:The reason why posture is so effective in increasing that inhale has to actually do with the anatomical structures right. So the pleura is attached to the inner chest wall. It also has attachments to the neck. So as soon as we extend our head and shoulders, we're actually going to get pulling, stretching of our lung tissue. So this can also be effective with patients who have disease processes like restrictive lung disease, because it's literally helping increase expansion. You're also moving in the direction of the rib cage, so you're moving in an anatomically efficient position. As we inhale, rib cage comes up. So everything that's going to encourage that is going to help encourage a bigger inhale.
Rachele Burriesci:We could take it a step further and throw shoulder flexion into inhale and this could be very beneficial for patients who have spinal cord injury, where you're utilizing the whole upper body chest, head, neck to increase inhale size, obviously pending level of injury. But eyes up is very effective, and if you have a person who is literally unable to mobilize yet, just utilizing eyes up, eyes down can be very effective. And if you have a person who is literally unable to mobilize yet, just utilizing eyes up, eyes down can be very effective. So, to be clear, eyes up, neck extension, shoulders back, trunk extension, shoulder flexion all help increase inhale. Then we have phase two to think about, and phase two is glottal closure, and we know glottal closure happens when we have a hold, and this is why I like to utilize inspiratory holds to help train a more effective cough, because you are sequencing two phases of that cough for practice. So if you have inefficiencies at glottal closure as well, or you just have some poor sequencing, which can happen a lot of times with weakness, you can do all of the things we just mentioned eyes up, neck extension, trunk extension, shoulder flexion and then at the top of that, inhale, encourage a hold, and you can help improve that hold time by literally counting time. So if we're inhaling for two, we can hold for two, and if you're just working on phase one and two, you don't necessarily have to add a count for exhale, especially when there's weakness and inefficiencies. I like to focus on that inefficiency versus adding too many steps to someone who might already have some sequencing issues. So just practicing inhale hold, inhale hold can be that lead up to improving a cough.
Rachele Burriesci:Phase three is abdominal contraction. So again a number of reasons why we might not have appropriate abdominal contraction. Maybe we have increased obesity and we just don't have good abdominal musculature. Still you tend to get good contraction even if you have adipose tissue surrounding. Again we might have a spinal cord injury type situation. We might have another neurologic disorder that's causing weakness of the trunk musculature and again it could be sequencing. So I see it a lot in our COPD patients where they start having this inappropriate diaphragmatic movement. Sometimes it's paradoxical, or sometimes they're trying to utilize their abs inappropriately to improve their breath and that will sort of follow its way through to a cough. So one of the ways to help with that, when you're getting that like outward push on the abdomen when it should be an inward contraction, is actually to place your hand on the abdomen and provide pressure.
Rachele Burriesci:Now the technical term for this is considered the Heimlich maneuver. The Heimlich maneuver is an up and in thrust during that abdominal contraction sequencing to expulsion. So there's a timing piece to it. It is typically educated or encouraged to be used with a patient that has spinal cord injury, where they don't actually have the ability to perform said abdominal contraction. With that being said, it's not necessarily encouraged or it can be risky to use with a patient with spinal cord injury because it can cause a reflex that actually worsens said cough and can cause a problem for that patient.
Rachele Burriesci:I actually use this technique more commonly with patients who have ICU weakness or COPD. When I was in pulmonary rehab this was one of the techniques I used with 60% of my patients because they just have such poor sequencing and poor abdominal contraction. So although it's considered a Heimlich technique, I really tried to encourage not being overly aggressive with this technique. Less is more. Sometimes just placing a little forward up and in pressure is enough to encourage that phase three and provide that counter pressure that needs to exist, especially if it's the first time you're doing it with a patient. Really don't go hard and fast in because you might lose all trust and it's not. It doesn't feel great. The other thing that you can do is teach this to the patient so that they can do it on their own. So now they're taking their hands, placing it over their abdomen and once they get past phase one and two, as they're about to go for expulsion, that they're providing an up and in pressure and again, I don't encourage it to be a thrust, I almost encourage it to be more of like a splint, a brace, and that tends to be enough to counteract that opposing force and basically do what you need it to do.
Rachele Burriesci:In the same moment we can throw that posture back in. So, as we talked about earlier on inhale, we're going eyes up, neck extension, trunk extension, eyes up, neck extension, trunk extension right at that phase three. After the hold you're switching to eyes down, neck down, trunk flexion and you can see as you start to flex that trunk, you're going to get basically folding at that abdominal area, which is also going to provide an appropriate force for phase three. So you're using posture to help improve inhale and you can use posture to help improve phase three, that abdominal contraction. So you're going to provide a manual force as well as posture and you can teach your patient to do this themselves, posture, and you can teach your patient to do this themselves. And then for phase four, expulsion, there's not much you can teach except give them a goal, and so the magic number for expulsion is typically three.
Rachele Burriesci:Aim for three coughs out. Now you're not going to be able to get to three if you don't take a big enough inhale. So if even getting one strong one is appropriate, then that's what you aim for. Or maybe you aim for two to see if you can get a little more out of that expulsion phase. Aim for two when you practice this on your own and just try a cough, and we can do it together. We're going to aim for just one expulsion. Place your hand on your abdomen, now aim for two expulsions, and now aim for three expulsions. What you're going to notice on that third cough is that you're going to get more abdominal contraction. So if you can aim for that three, it's like that magic number. It tends to help the phase three as well.
Rachele Burriesci:Now, a lot of times, and sequencing is the biggest issue, and in my opinion this is the hardest thing to train, and there are a number of reasons again that can cause sequencing issue, especially in our neurologic population. But sometimes it's just you know a weakness thing and they just haven't practiced this and coordinating is really difficult for them, is really difficult for them. You can break it down into different pieces so you can just practice inspiratory holds where you're going for like maybe three seconds in three seconds hold and then exhale. Or maybe you practice the second end of the phases where you're actually practicing a forceful exhale. Sometimes the power is really what's lacking. So sometimes I'll have my patients practice as if they're blowing out candles and if you've heard me speak before, that is not usually my cue for a normal exhale, because we don't normally blow out with every breath. But in this situation where power is important, you're going to actually get abdominal contraction and a forceful exhale. So you could practice big inhale and then, as you're coordinating, you could maybe concentrate on a little bit longer hold, concentrate on a bigger inhale. It depends on your patient's learning process. It depends on how difficult or how much difficulty they're having with the coordination for this, where you take a narrow straw and you have them practice breathing in hold, blow through the small straw, because that's going to be increased resistance for them. We can also talk about in the back end of this, that RMT using a respiratory muscle trainer could be very effective in improving an overall cough.
Rachele Burriesci:But another training tool in the mix. An overall cough, but another training tool in the mix, the last I got one more. If you're working on expulsion, the other thing you can do is actually practice holding exhale. So one of the ways you can do this is by holding a vowel sound, and this can actually help with a number of things. This is actually a great pre and post technique. It's sometimes called the ah time, where you're holding the vowel ah or a right Ah and you time it and you're trying to increase volume and length of that time. That can also help train that exhale, but it's better for improving eccentric control, and a cough is more concentric control. So you can use different techniques to sort of manipulate the phase that they're having difficulty with.
Rachele Burriesci:But the one thing I do want to say that I didn't say earlier is if glottal closure is not possible for whatever reason paralysis, maybe, a problem post-extubation, maybe they have a trach you can utilize huff cough as a more effective way to get them to move that mucus versus trying to really train the hold when it's not actively happening yet. With that being said, if this patient is someone that has a trach, we can also add one more tip into this, and that is after the inhale. Since they can't get the hold, they would actually cover their tracheostomy with two fingers and then go for a normal expulsion. So there's a number of things that we can do right, but really the main picture here is that you are focusing on the inefficiencies that you found in the assessment of the call what phase do they have an issue, what phase are they lacking, what phase is ineffective and why and then focus your intervention on that phase, and sometimes you're going to have to string a few of them together. Sometimes you just focus on one and everything else improves. Sometimes it's getting upright right. Just positional change can help that person to have a more effective cough, especially if they've been in a supine position.
Rachele Burriesci:But there's a number of things that we can do. We can use posture, eyes up, neck extension, shoulder flexion, trunk extension, practicing how to hold to really get good glottal closure and using it as a rep right Like do inspiratory holds as a rep, do inspiratory holds as a rep? Then focusing on the abdominal contraction expulsion with eyes down, neck flexion, trunk flexion, with potential overpressure at the abdomen to create that forceful counterpressure, to actually get that force out. And then, for expulsion, just concentrate on how many, and that usually is enough to get them to extend that exhale. Enough If you got them to increase that inhale Because, remember, increasing inhale is going to increase power. So everything works hand in hand.
Rachele Burriesci:Sometimes it's really just a sequencing issue. So use different cues, use demonstration, use tactile cues, utilize posture. If you are using shoulder flexion for inhale, same is true for exhalation, and you're going to go forceful arms down into that trunk flexion can actually be helpful as well to create some of that power, and that's actually a technique that's used quite a bit with spinal cord injuries as well. So lots of different things that you can do to really create, or help create, a more effective cough, and sometimes that is the most beneficial thing you can do for your patient because likely that's going to improve their ability for gas exchange, which is then going to make them more efficient in doing everything else. So if you can help them have an effective cough, you can improve gas exchange and overall improve mobility.
Rachele Burriesci:All right, I hope that was helpful for you. If you have any questions about how to improve a cough or maybe you have a difficult patient. Reach out to you. If you have any questions about how to improve a cough or maybe you have a difficult patient, reach out to me. If you need more one-on-one mentoring, click that link below and I would be happy to help. All right, I hope you all have a wonderful day, an awesome weekend and whatever you have to do again after it.
