1. Therapist assisted

1. With the patient in a supine position, the therapist places the heel of one hand on the patient’s abdomen at the epigastric area. The other hand is placed on top of the first, either keeping the fingers open or interlocking them.
2. After the patient inhales as deeply as possibly, the therapist manually assists the patient as he or she attempts to cough. The abdomen is compressed with an inward and upward force, which pushes the diaphragm upward to cause a more forceful and effective cough.
3. This same maneuver can be performed with the patient in a chair. The therapist or family member can stand in back of the patient and apply manual pressure during expiration.
4. Precaution: Avoid direct pressure on the xyphoid process.

2. Self–assisted

1. While the patient is in a sitting position, he or she crosses the arms across the abdomen or places the interlocked hands below the xyphoid process.
2. After a deep inspiration, he or she pushes inward and upward on the abdomen with the wrists or forearms and simultaneously leans forward while attempting to cough.

Splinting
If incisional pain from recent surgery is restricting the cough, teach the patient to splint over the incision.

• Have the patient press the hands or a pillow firmly over the incision to support the painful area as he or she coughs.
• If the patient cannot reach the incision, the therapist should assist.

3. Humidification
If secretion are very thick, work with the patient after humidification therapy or ultrasonic nebulizer (USN) therapy, both of which enhance the mucociliary transport system and facilitate a productive cough.

4. Tracheal stimulation
Tracheal stimulation, sometimes called a tracheal tickle, may be used with infants or disoriented patients who cannot cooperate in the treatment.

1. This is somewhat uncomfortable maneuver, performed to elicit a reflexive cough.
2. The therapist places two fingers at the sternal, notch and applies a circular motion with pressure downward into the trachea to facilitate a reflexive cough.

Precautions

• Avoid uncontrolled coughing spasms (paroxysmal coughing).
• Avoid forceful coughing with patients who have a history of a cerebrovascular accident or aneurysm. Have these patients buff several times to clear the airways.
• Be sure that the patient coughs while in a somewhat erect posture.

Suctioning: Alternative to Coughing

1. Endotracheal suctioning may be the only means of clearing the airways in patients, who are unable to cough voluntarily or after reflex stimulation of the cough mechanism.
2. Suctioning is indicated in all patients with artificial airways.
3. The suctioning procedure will clear only the trachea and the main stem bronchi.
4. Precaution: Only individuals who have been instructed in proper suctioning technique should use this alternative means of clearing the airways. Suctioning, if performed incorrectly, can introduce an infection into the airways or damage the delicate mucosal lining of the trachea and bronchi. Improper suctioning can also cause hypoxemia, abnormal heart rates Atelectasis. A complete description of proper endotracheal suctioning technique is described in several references.