ICID > Clinical Management > Spinal Injuries > Manual Assisted Coughing  

Manual Assisted Coughing 

  • 1. Indications
  • 2. Clinical Management
  • 3. Patient Information
  • 4. Audit
  • 5. Evidence Base
  • 6. Appendices
  • 1. Indications

    1.1 Background Information

    A spontaneous effective cough is a reflex mechanism utilising maximum forced exhalation to clear irritants or secretions form the airway. [1] Assisted coughing is a long standing manual technique used in the assessment and treatment of spinal cord injured patients. When the spinal cord is damaged the respiratory muscles innervated below the level of the lesion become paralysed.[3] All acute lesions need prophylactic respiratory therapy as they are prone to hypostatic pneumonia. Paralysis of the intercostal muscles and / or the abdominal muscles results in severe impairment of forced expiration.[4],[5],[6] Assisted coughing is the term used to describe the way an individual can replace the function of the paralysed expiratory muscles by creating increased pressure underneath the working diaphragm. This is usually performed by an assistant on the patient, but some patients can learn to perform the technique on themselves; self assisted coughing.

    It should be noted that there are also mechanical devices which can provide an assisted cough using positive and negative pressure – this document does not cover these devices.

    1.2 Aim / Purpose

    The aim of this document is to provide guidance (based on the best available evidence) for use by staff to ensure that manual assisted coughing is carried out effectively to minimise the risk of respiratory complications.

    1.3 Patient Group

    Spinal cord injured patients. The cough mechanism will be altered in patients with neurological level of T11 and above. The higher the level of injury the more likely it is that the patients will require assistance with their coughing. Patients with complete spinal cord injury are at greater risk.[7]

    Assisted coughing is clinically indicated when:

    • Assessment of the patients' unassisted cough proves to be ineffective by clinical observation.[1]

    • Auscultation reveals evidence of retained secretions.

    • Auscultation or CXR reveals evidence of atelectasis. [1]

    • Post operatively for a patient who has had uppe rabdominal or thoracic surgery. [1]

    • In patients with a tracheostomy assisted coughing should be used in conjunction with tracheal suctioning to reduce the need for deep tracheal suctioning which can be harmful to the patient.

    Patients with a spinal cord injury of T12 and below will have innervated abdominal muscles and therefore should be able to cough effectively. However, there may be situations where assisted coughing is still appropriate to use, for example where there are associated chest injuries or abdominal complications.

    1.4 Exceptions / Contraindications

    Assisted coughing would be contraindicated if medical advice could not be sought in the presence of the following scenarios:

    • Unstable angina or arrhythmia or acute myocardial infarction. [1]

    • Extensive chest trauma, rib fractures / flail segment (osteoporosis, carcinoma)

    • Elevated intracranial pressure or known intracranial aneurysm. [1]

    • Untreated pneumothorax. [1]

    Assisted coughing may not be contraindicated in the following scenarios if appropriate modifications are employed:

    • Rib fractures or flail chest. [1]

    • Assess from CXR – radiology reports. Modify technique by moving hand position away from fracture sites.

    • Poor skin integrity

    • Assess by observation; modify hand position to avoid areas with poor integrity.

    • Pain [1]

    • Assess whether the patient requires additional analgesia before the assisted cough

    • Spasticity

    • Assess whether the patient requires additional antispasmodic medication, or other appropriate treatment prior to the cough.

    • Clotting disorders

    • Assess by INR; modify by using gentler technique.

    • Surgical emphysema

    • Implies possible rib fractures – rule out – see above.

    • Chest drain

    • Modify by moving hand position away from insertion of drain.

    • Bronchospasm [1]

    • Assess whether wheeze is true bronchospasm or sputum by auscultation, if wheeze: - modify technique by being gentler and using slower repetitions.

    • Skin hypersensitivity

    • Modify by minimising number of times you touch and remove your hands, use firm pressure; try using a towel or blanket to reduce the effect of discomfort of light touch.

    • Abdominal injury / paralytic ileus / abdominal wounds [2]

    • Assess by history, girth measurements, gentle palpation of the abdomen, and modify technique by moving hand position away from the abdomen up onto the rib cage, so that there is no pressure over the affected area.

    • Compromise of spinal alignment [1]

    • Assess by consulting medical staff; modify technique by utilising shoulder hold with unstable cervical injuries and supine position with thoracic and lumbar injuries.

    • Osteporosis

    • Modify hand position to avoid areas of extreme disease [1]

    1.5 Options

    If the patient does not consent to the procedure the clinician should be satisfied that the patient is aware of the possible consequences. The clinician should discuss this with the patient as appropriate and document this fully.

    2. Clinical Management

    2.1 Staff & Equipment

    2.1.1 Staff

    Only members of staff who have received training in the procedure and been assessed as competent for the procedure may carry out the technique unsupervised. Members of patients' family or care team must be trained as above for use of the technique on a specific patient only.

    Patients performing self assisted cough without supervision should have been assessed as competent to perform this and should possess relevant knowledge and skills [1] related to:

    • Proper technique

    • Possible hazards and complications

    • Technique modification in response to outcomes of therapy

    • Assessment of outcomes of cough with regard to sputum, quantity, colour and other relevant characteristics

    • Appropriate response to changes in sputum production

    Ensure you have enough people to assist in the procedure.


    • Spinal stability (does the patient require a shoulder hold?) [2]

    • The size of the patients' chest (is a second person required?)

    • Thickness of the patients' secretions (is a second person required?)

    • Whether the patient is in bed or in a wheelchair (will assistance be needed to stabilise the chair)

    • The experience of the available staff (is a second person required?)

    • The upper body strength of the member of staff (is a second person required?)

    Ensure the bed is at a height where you can use your body weight to maximum effect hence minimising effort involved.

    • Take care not to lower the bed too far allowing any traction weights to touch the floor.

    • If the patient is sitting in a wheelchair decide on the best technique for yourself and the patient and position yourself accordingly. Section 2.2

    2.1.1 Equipment [1]

    • Support devices for the patient with incisional pain or chest wall pain during cough (e.g. folded blanket, pillow, palmed hands or other devices)

    • Container for collected expectorated sputum

    • PPE gloves, goggles, apron and mask

    • Teaching materials and models

    2.2 Method / Procedure

    There are many techniques that can be used to assist a patient's cough. The following list is not exhaustive and experienced staff may develop their own techniques for maximum effectiveness.

    Staff wishing to develop their own method should ensure the exceptions and contraindications are taken into account so that the general principles of assisted coughing are adhered to.

    Illustrations of techniques


    Patient in bed

    Patient in wheelchair

    One person techniques

    Method 1

    Method 2

    Method 3

    Method 8

    Method 9

    Method 10

    Two people techniques

    Method 4

    Method 5

    Method 6

    Method 7


    Self assisted coughing techniques

    In Bed.

    Appendix 5

    Monitoring [1]

    Items from the following list should be chosen as appropriate for monitoring a patient's response to cough technique

    • Patient response: pain, discomfort, dyspnoea

    • Sputum expectorated following colour to note consistency, odour, volume of sputum produced

    • Breath sounds

    • Presence of adverse neurological signs or symptoms following cough

    • Presence of any cardiac dysrhymias or alterations in haemodynamics following coughing

    • Measures of pulmonary mechanics, when indicated, may include forced vital capacity (FVC) and peak expiratory flow (PEF)

    Frequency [1]

    • Cough procedures should be performed as frequently as needed. No data exists to support specific frequency.

    • Cough procedures should be performed in conjunction with other methods to mobilise and remove secretions during therapy, if available a mechanical cough device may be used.

    2.3 Potential Complications

    • Unexplained increase in pain

    • Unexplained increase in spasm

    • Sudden onset of breathlessness

    • Central line displacement [1]

    • Gastro-oesophageal reflux [1]

    • Vomiting and retching [1]

    • Visual disturbances including retinal haemorrhage [1]

    If any or all of these are encountered seek a medical opinion urgently.

    • Bruising at the site of the operators hands.

    If bruising occurs it is likely that the technique used is too forceful and should be changed accordingly.

    Double check that none of the contraindications listed in section 1.4 have been missed.

    2.4 After Care

    Ensure the patient is comfortable prior to leaving them.

    Ensure that appropriate assisted coughing techniques are taught to the patient and/or their family/carers before discharge from the spinal unit.

    3. Patient Information

    3.1 Patient Information

    Chest Infections

    Understanding and Managing Respiratory Complications after SCI

    The purpose of the assisted cough and the methods to be used must be explained by the member of staff as part of seeking patient consent for the technique.

    4. Audit

    4.1 Standards

    An assisted cough can be judged as being effective if:

    • PEF is measured at 270 - 360L/min or more.

    • The patient expresses relief / clearance of immediate secretions

    • The cough sounds strong in comparison to an unassisted cough

    • The patient expectorates orally or swallows secretions.

    • Secretions can be cleared with shallow tracheal suctioning only.

    • Clinical observation of improvement. [1]

    4.2 Patient Survey

    Any patient who requires assisted coughing will be asked to provide verbal feedback on the following:

    • Overall comfort and effectiveness of the technique.

    • Their preferred technique.

    • Whether staff are able to assist them when required.

    • Their ability to direct the procedure.

    • Staff receptiveness to patient direction.

    4.3 Risk Management

    Each patient must be assessed for his or her individual need for assisted coughing.

    With reference to section 1.4 exceptions / contraindications must be considered during the risk assessment and appropriate action taken to minimise risk.

    Other considerations will include those areas highlighted in section 2.1.

    Where staff have individual needs which mean they are not able to perform this technique they must carry out their own risk assessment with their manager.

    Infection Control issues [1]

    Cough is a source of droplet nuclei (aerosols) that can remain suspended in the air for hours and are associated with transmission of tuberculosis and other airborne pathogens. Care must be taken to minimise exposure of staff.

    • If a patient is known or suspected to have sputum transmitted pathogens (MRSA, pseudomonas, TB etc.) then personal protective equipment should be used including mask, or goggles to minimise exposure to airborne pathogens.

    • Universal precautions should be followed.

    5. Evidence Base

    5.1 Sources of information

    1. AARC Clinical Practice Guideline on Directed Cough, reprinted from RESPIRATORY CARE (Respir Care 1993; 38:495-499) (click on this link to access this document: http://www.rcjournal.com/cpgs/dccpg.html)

    2. Pryor JA, Prasad SA, (2008) 4th Ed .Physiotherapy for Respiratory and Cardiac Problems. Chapter 16, Spinal Cord Injury, Kathryn Harris & Trudy Ward. Churchill Livingston, London

    3. Cohn JR 1993 Pulmonary management of the patient with spinal cord injury. Trauma Quarterly 9(2): 65–71

    4. Roth EJ, Lu A, Primack S, Oken J, Nussbaum S, Berkowitz M, Powley S 1997 Ventilatory function in cervical and high thoracic spinal cord injury. American Journal of Physical Medicine & Rehabilitation 76 (4): 262–267

    5. Wang AY, Jaeger RJ, Yarkony GM, Turba RM 1997 Cough in spinal cord injured patients: the relationship between motor level and peak expiratory flow. Spinal Cord 35: 299–302

    6. Gouden P 1997 Static respiratory pressures in patients with post-traumatic tetraplegia. Spinal Cord 35: 43–47

    7. Linn WM, Adkins RH, Gong H, Waters RL 2000 Pulmonary function in chronic spinal cord injury: a cross-sectional survey of 222 Southern California adult outpatients. Archives of Physical Medicine and Rehabilitation 81: 757–763

    6. Appendices

    Appendix 1

    Respiratory Competency

    Appendix 1

    Appendix 2

    Illustrated Method 1

    Appendix 2

    Appendix 3

    Illustrated Method 2

    Appendix 3

    Appendix 4

    Illustrated Method 3

    Appendix 4

    Appendix 5

    Illustrated Method 4

    Appendix 5

    Appendix 6

    Illustrated Method 5

    Appendix 6

    Appendix 7

    Illustrated Method 6

    Appendix 7

    Appendix 8

    Illustrated Method 7

    Appendix 8

    Appendix 9

    Illustrated Method 8

    Appendix 9

    Appendix 10

    Illustrated Method 9

    Appendix 10

    Appendix 11

    Illustrated Method 10

    Appendix 11

    Appendix 12

    Self Assisted Coughing In Bed

    Appendix 12

    Appendix 13

    Self Assisted Coughing In Wheelchair

    Appendix 13

    Appendix 14

    The Guide to Living with a Spinal Cord Injury


    Appendix 15

    Understanding and Managing Respiratory Complications

    Document Owner Kathryn Harris 
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