1.1 Background Information
A spontaneous effective cough is a reflex mechanism utilising maximum forced exhalation to clear irritants or secretions form the airway.  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. 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.,, 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.
Assisted coughing is clinically indicated when:
Assessment of the patients' unassisted cough proves to be ineffective by clinical observation.
Auscultation reveals evidence of retained secretions.
Auscultation or CXR reveals evidence of atelectasis. 
Post operatively for a patient who has had uppe rabdominal or thoracic surgery. 
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. 
Extensive chest trauma, rib fractures / flail segment (osteoporosis, carcinoma)
Elevated intracranial pressure or known intracranial aneurysm. 
Untreated pneumothorax. 
Assisted coughing may not be contraindicated in the following scenarios if appropriate modifications are employed:
Rib fractures or flail chest. 
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.
Assess whether the patient requires additional analgesia before the assisted cough
Assess whether the patient requires additional antispasmodic medication, or other appropriate treatment prior to the cough.
Assess by INR; modify by using gentler technique.
Implies possible rib fractures – rule out – see above.
Modify by moving hand position away from insertion of drain.
Assess whether wheeze is true bronchospasm or sputum by auscultation, if wheeze: - modify technique by being gentler and using slower repetitions.
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 
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 
Assess by consulting medical staff; modify technique by utilising shoulder hold with unstable cervical injuries and supine position with thoracic and lumbar injuries.
Modify hand position to avoid areas of extreme disease 
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.