Clinical instruction in sets of 3 increases the likelihood that our already overwhelmed patients can remember and use these techniques. The System of, 3 breaths with breath-holds followed by the 3 coughs after the 3rd breath-hold will be utilized as our primary framework of instruction.
Prior to all directed cough maneuvers the patient is instructed in slow deep diaphragmatic breathing and breath hold. These slow deep breaths with sustained inspiration are used both in preparation for the maneuvers and between sets of cough instruction. These controlled breaths are directed at re-expanding lung, introducing air behind retained secretions, and helping the patient reduce dyspnea and the tendency toward convulsive cough. All 3 of these effects are more likely accomplished if the deep breaths are accompanied by a breath hold.
1) Step One - PreparationBoth of the basic directed cough maneuvers I will describe are always preceded by the same initial instruction. Coach the patient to take their first slow moderately deep breath. Say slowly and out loud for the patient, “hold it, hold it, hold it” in a fashion that results in at least at three second breath hold. (Another set of 3) Encourage the patient to exhale normally. The patient is instructed to take second somewhat deeper breath and again coached to, “hold it, hold it, hold it”, encouraging a slightly longer breath hold. Encourage the patient to exhale normally. For the 3rd and concluding breath the patient is encouraged to inhale to near maximum and couched again to, “hold it, hold it, hold it”, while preparing the patient to perform one of the secretion clearance methods below.
2) Step Two - The Three Step CoughAfter the 3rd deep breath and breath-hold instruct the patient produce 3 small coughs from the same deep inspiration. Immediately have the patient inhale again to near maximal inspiration and coach them one again to, “hold it, hold it, hold it”, and then encourage 3 slightly more vigorous coughs from the same held breath. And finally, encourage the patient one final time to inhale maximally and to, “hold it, hold it, hold it”, and produce 3 final vigorous coughs from the final breath-hold. The patient is then encouraged to return to slow moderately deep diaphragmatic breathing with a periodic breath hold. Additional instruction, performance and return demonstration can be repeated as appropriate. As compared a traditional single step cough, this system increases the patient’s control of their cough and decreases incisional pain. This technique would be most suitable for patient’s you do not suspect of airway collapse associated with cough and with minimal suspicion of mucus plugging.
If any time during the directed cough the patient begins to lose control of their cough immediately instruct the patient to take a somewhat deep breath (not maximal) and help them control the breath by instructing them to “hold it, hold it, hold it”. A primary trigger of paroxysmal coughing is an uncontrolled coughing to full exhalation. Avoiding this full cough exhalation by encouraging a moderately deep inspiration and breath hold can help many patients control the paroxysmal cough tendency.
As always, as mentioned above, return the patient to slow deep diaphragmatic breathing and breath hold between sets of cough maneuvers.
3) Step Three – The Alternative of Three Step HuffingThis alternative technique is potentially most useful in patients where you may be concerned with airway closure during cough. The identical preparation and sequence is used but the typical closed glottis cough is replaced buy the open glottis forced expiratory technique. Rather than the 3 sets of increasing vigorous 3 step coughs, the patient is instructed in the performance of 3 sets of increasing vigorous 3 step “huffs”. The huff technique is performed nearly identically to the above mentioned three-step cough with an open glottis “Huff” replacing the typical closed glottis cough.
Huff maneuvers (forced expiratory technique) have been traditionally considered a method of mobilizing secretions without generation high expiratory flows and its accompanying airway collapse with patients with less patent airways.
Coaching of directed cough by the practitioner must still be aimed at optimizing the individual components of airway clearance as discussed in the related training but it must always be reinforced in such a manner as to not overwhelm the patient.