Episode 76: How to Improve an Ineffective Cough

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 . 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 .

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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 . 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 .

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 . 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 . 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 . 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 .

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 . 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 . 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 . 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 .

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 . 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 .

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 . 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 .

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 . 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 .

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 . 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 .