Coughing and Huffing

Techniques
NIMISHA B (MPT, DYHE)
ASSISSTANT PROFESSOR
SACPMS, MMC
MODAKKALLUR

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I. Cough and
Coughing
Techniques
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Cough – A Pulmonary defense mechanism
• Cough is an expiratory effort with a closed glottis.
• Also known as TUSSIS.
• An effective cough is necessary to eliminate respiratory obstructions and keep the lungs
clear.
• Airway clearance is an important part of management of patients with acute or chronic
respiratory conditions.
• The Normal Cough Pump
• A cough may be reflexive or voluntary.
• When a person coughs, a series of actions occurs as follows:
• Under normal conditions, the cough pump is effective to the seventh generation of bronchi.
(There are a total of 23 generations of bronchi in the tracheobronchial tree.)
• Ciliated epithelial cells are present up to the terminal bronchiole and raise secretions from
the smaller to the larger airways in the absence of pathology.

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Receptors
found in larynx, carina, bronchial branching upto 4th Broncho
pulmonary segments

Stimuli
• Cigarette Smoke
• Ammonia
• Acid And Alkaline
• Inflammatory Mediators And Mechanical Such As Mucus, Catheter ,
Dust

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•Types Of Cough
1.Acute (Lasts for short time, about 2 weeks)
2. chronic (Persistent type, last for over 4 weeks in adults (or over 8 weeks in children)
A cough that doesn’t produce mucus is called a dry or nonproductive cough.

Acute coughs 
Can be divided into infectious (caused by an infection) and noninfectious causes.
Infectious causes of acute cough include:
• Viral upper respiratory infections (the common cold)
• Sinus infections.
• Acute bronchitis (inflammation of the lining of the bronchial tubes of the lung).
• Pneumonia
• Whooping cough
• Croup in children.
Noninfectious causes of cough include:
• Flare-ups of chronic conditions such as chronic bronchitis
• Emphysema, asthma
• Environmental allergies
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 Causes of chronic cough include
• Chronic bronchitis
• Asthma
• Allergies
• COPD (chronic obstructive pulmonary disease)
• GERD ( Gastroesophageal reflux disease)
• Smoking
• Throat disorders, such as croup in young children
• some medications (e.g., ACE inhibitors)

 Chronic coughs in children are most often caused by asthma, but can also be from
conditions like post-nasal drip or GERD.
 Less common causes of chronic cough in adults include TB (tuberculosis), fungal infections
of the lung, and lung cancer. 6
Phases Of Cough
1. Irritant Phase
2.Inspiratory Phase
3. Compressive Phase
4. Expiratory / expulsive Phase

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1. Irritant phase
• A cough stimulus is initiated by irritation on trachea.
• By irritation an abnormal stimulus provokes sensory fibres in the airways to send
impulses to the brains medullary cough centre.
• Stimulus includes:
• Mechanical- foreign bodies , excess sputum, catheter
• Chemical- acid , alkali, smoking, other gaseous substances
• Thermal – cold air may stimulate sensory nerves to produce cough
• Inflammation - infection
• Conditions affected – for patients under general anesthesia, on sedatives

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2. Inspiratory phase
• Once the impulses are received, the cough center generates a reflex stimulation
of the respiratory muscles to initiate a deep inspiration.
• This stage provides the volume necessary for a forceful cough.
• At least 60% of the predicted vital capacity should achieve for an effective
coughing.
• Conditions affected : NMD affecting inspiratory muscles, pain (inhibit deep
breathing), RLD

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3. Compressive Phase
• The reflex nerve impulses causes closure of glottis.
• This is achieved by closure of vocal folds.
• This prepare abdominal and intercostal muscles to produce positive intrathoracic
pressure distal to glottis (> 100mmHg)
• contraction of abdominal and intercostal muscles lasts for 0.2 sec.
• This phase results in a rapid rise in intrapleural and alveolar pressures.
• Conditions affected : recurrent laryngeal nerve damage , patients on ET tube,
artificial airway.

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4. Expiratory / Expulsive phase
• When the glottis is open, a large pressure gradient is established between alveoli
and the airway opening.
• Along with contraction of expiratory muscles, this pressure gradient causes a
violent expulsive flow of air from the lungs.
• High velocity gas flow combined with dynamic airway compression creates huge
shear forces that displace mucous from the airway walls into the air stream.
• Maximum expiratory flow which will clear intraluminal debris is effort
independent because it will be limited by dynamic compression of the airways.
• Conditions affected : NMD affecting abdominal muscles, pain

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MECHANIS
M OF COUGH Irritation on trachea
Sensory impulses to medullary centers via Vagus, Trigeminal,
Phrenic, Glossopharyngeal nerves
Deep inspiration occurs
Glottis closes
vocal cords tighten
Abdominal muscles contract
diaphragm elevates
causing an increase in intrathoracic (>100mmHg) and intra-
abdominal pressures
Glottis opens suddenly with explosive outflow of air at high
velocity (960km/hour)-
Causes expulsion of irritant substances out of RT. 12
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 Indications  Contraindications
• Post operative patients under GA • Active hemoptysis
• Cardiopulmonary conditions • If there is a chance of spread of
• Chronic maxillary sinusitis infection
• Asthma • Acute MI (controversial, mostly
• COPD we don’t teach in hospitals)
• Post viral reactive airway disease
syndrome
• Inhaled foreign bodies
• GERD

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Factors that Decrease the Effectiveness of the Cough Mechanism and
Cough Pump
The effectiveness of the cough mechanism can be compromised for a number of reasons
including the following:
1. Decreased inspiratory capacity
2. Inability to forcibly expel air
3. Decreased action of the cilia in the bronchial tree.
4. Increase in the amount or thickness of mucus.

1. Decreased inspiratory capacity:

• Inspiratory capacity can be reduced because of:
 Pain due to acute lung disease
 Rib fracture
 Trauma to the chest
 Recent thoracic or abdominal surgery
 Weakness of the diaphragm or accessory muscles of inspiration as a
result of a high spinal cord injury or neuropathic or myopathic disease
 Postoperatively, the respiratory center may be depressed as the result of general anesthesia,
pain, or medication. 15
2. Inability to forcibly expel air:
• The following factors contribute to a weak cough:
 A spinal cord injury above T12 and myopathic disease, such as muscular dystrophy, cause
weakness of the abdominal muscles, which are vital for a strong cough.
 Excessive fatigue as the result of critical illness
 A chest wall or abdominal incision causing pain
 A patient who has had a tracheostomy, even when the tracheostomy site is
covered.

3. Decreased action of the cilia in the bronchial tree:

• Action of the ciliated cells may be compromised because of:
 Physical interventions such as general anesthesia and intubation
 Pathologies such as COPD including chronic bronchitis
 Smoking also depresses the action of the cilia.

4. Increase in the amount or thickness of mucus:

• Occurs in:
 Pathologies (e.g., cystic fibrosis, chronic bronchitis) and pulmonary infections (e.g., pneumonia)
 Intubation irriates the lumen of the airways and causes increased mucus production
 Dehydration thickens mucus.
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Teaching an Effective Cough
• Because an effective cough is an integral component of airway clearance, a patient must be taught the
importance of an effective cough, how to produce an efficient and controlled voluntary cough, and when
to cough.
• The following sequence and procedures are used when teaching an effective cough.
1. Assess the patient’s voluntary or reflexive cough.
2. Have the patient assume a relaxed, comfortable position for deep breathing and
coughing.
3. Sitting or leaning forward usually is the best position for coughing.
4. The patient’s neck should be slightly flexed to make coughing more comfortable.
5. Teach the patient controlled diaphragmatic breathing, emphasizing deep inspirations.
6. Demonstrate a sharp, deep, double cough.
7. Demonstrate the proper muscle action of coughing (contraction of the abdominals). Have the
patient place the hands on the abdomen and make three huffs with expiration to feel the contraction
of the abdominals. Have the patient practice making a “K” sound to experience tightening the vocal
cords, closing the glottis, and contracting the abdominals.
8. When the patient has put these actions together, instruct the patient to take a deep but relaxed
inspiration, followed by a sharp double cough.
9. The second cough during a single expiration is usually more productive.
10. Use an abdominal binder or glossopharyngeal breathing in selected patients with inspiratory
or abdominal muscle weakness to enhance the cough, if necessary.
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Precautions for Teaching an Effective Cough
• Never allow a patient to gasp in air, because this increases the work
(energy expenditure) of breathing, causing the patient to fatigue more
easily. It also increases turbulence and resistance in the airways, possibly
leading to increased bronchospasm and further constriction of airways.
• A gasping action also may push mucus or a foreign object deep into air
passages.
• Avoid uncontrolled coughing spasms (paroxysmal coughing).
• Avoid forceful coughing if a patient has a history of a cerebrovascular
accident or an aneurysm. Have these patients huff several times to clear the
airways, rather than cough.
• Be sure that the patient coughs while in a somewhat erect or side-lying
posture.
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Coughing Techniques
Classified into
1. Active techniques
2. Assisted coughing techniques
3. Passive techniques

• Note that SUPINE POSITION is not used for increasing LUNG VOLUME or not used in any of
the coughing techniques.
• PRONE is NOT frequently used as a posture for coughing because the position itself inhibits
the full use of diaphragm by preventing lower anterior chest and abdominal excursion
following a neurogenic insult. This forces the patient to use an alternate breathing pattern
that facilitates greater accessory muscle use.

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 1.Active 1.
2.
Double cough
Controlled cough
techniques 3. Series of 3 cough
4. Pump cough
5. Huffing
6. Splinted cough 1. Costophrenic assist
2. Heimlich of abdominal thrust
2. Assisted A. Therapist or
manual assisted
3.
4.
Anterior chest compression
Counter rotation

coughing B. Self assisted

1. Prone on elbow
2. Long sitting
techniques
C. Mechanical cough machine 3.
4.
Hands knee rocking
Standing self assisted
1. Tracheal tickle 5. Quadripod assisted
2. IPPB
3. Passive techniques 3.
4.
Nebulizer
Icing on paraspinal muscles
5. A suction effort
6. Hydration with warm water 20
1. Active techniques
1. Double cough – following deep inspiration patient performs 2
coughs in one breath. Second is more powerful than first
2. Controlled cough- The patient takes three deep breaths, exhaling
normally after the first two and then coughing firmly on third; the
first two breaths are believed to decrease atelectasis and increase
the volume of the cough
3. Series of three coughs - The patient takes a small breath and gives a
fair cough, then takes a bigger breath and gives a harder cough, and
finally takes a really deep breath and gives a forceful cough; this
technique allows patients to work their way up to a forceful cough
(for post op patients)
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4. Pump coughing - The patient takes a deep breath and then gives three short
easy coughs followed by three huffs (facilitates secretion clearance in patients
with air trapping – emphysema )
5. Huffing -
• The patient takes a deep inspiration and then air is forcefully exhaled as
in coughing except that the mouth is kept open (less stressful on the
patient and more effective than constant forced coughing, especially in
patients who tend to prolong the expiratory phase of a cough almost into a
wheeze, such as asthmatics and others with COPD).
• The patient makes a sound similar to “huff”

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6. Splinted cough -
Approximation of sutures on cough with pillow or hands by physiotherapist or
patient himself
• Indications : All post operative patients (bear hug position)

• Types of splinting : self assisted, therapist assisted, with the help of rib belt

• Positions for cough splinting:

• patient should be brought into long sitting positions from half lying
position with the help of PT or nurse in case of thoracotomy and
cardiac surgeries.
• Patients finds it easier to cough while sitting forward in bed away from
pillow.
• A high sitting position is adopted for the patients in wards and home
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• Ways of splinting :

1. In case of Sternotomy
Self assisted-
1. holding both hands across sternum and placing a pillow between the hand and anterior
aspects of chest
2. Place a small pillow over the incision and the pillow supported by dominant hand
followed by non – dominant hand

Therapist assisted:
1. PT support the incision by placing both hands on the anterior aspect of the chest and
maintaining equal pressure to minimize sternal movement.
2. Place dominant hand over the sternotomy incision and the other hand over the back
(same like bear hug hold) . Patient is bought to lean forward, vibration is given through
back hand and incision is supported during coughing.
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2. In case of abdominal surgeries
Self assisted :
a pillow or bed sheet supported by dominant hand and reinforced by non dominant hand
Therapist assisted:
for a laparotomy incision the patient should be high sitting position. The patient stands
behind the patient. Hands are reached towards the incision. Gentle firm pressure is
directed at holding the wound edges together.

3. In case of pelvic surgeries

Self assisted :
thighs should be adducted, by keeping a pillow in between thighs press the thighs each
other. Incision is supported by dominant hand followed by non dominant hand.
Therapist assisted :
same as above but PT support the incision

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4. In case of thoracotomy
Self assisted :
patient places the hand of the unaffected side as far round the affected ribs as possible
and applying firm pressure with the hand and forearm. The other hand reinforces the
hugging hold by clasping the opposite elbow and pulling it against the chest wall during
the cough
Therapist assisted :
• 1. bear hug hold : the anterior and posterior aspects of the affected side of the thorax
can be supported with the hands, while at the same time the forearm will stabilize the
whole chest and create a bear hug hold. In this hold the PT holds the opposite side
• 2. PT can hold from same side too. In this method therapist place hands anterior and
posterior to the incision. Therapist applies firm pressure with the hand

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2. Assisted coughing techniques
• If the patient’s cough remains ineffective despite appropriate
instruction and modifications, a number of manual assisted and self
assisted cough techniques or mechanical cough augmentation can
be used.
Its divided into .,
1. Therapist or manual assisted techniques – therapist hands are
used in assisting elicitation of cough

2. Self assisted techniques – patients themselves assist cough with

hands.

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A. Therapist or Manual assisted
coughing techniques
• Prior to perform techniques ; give instructions to the patient
to maximize four stages of coughing.
• The patient also actively participates by using his or her
arms, trunk, other body parts throughout the entire
procedure.

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a. Costophrenic Assist
• The Costophrenic assist can be used in both the supine and side lying positions.
• With the patient in the supine position, the therapist places the hands on the Costophrenic
angles of the patient’s rib cage.
• At the end of expiration the therapist applies a quick stretch down and in on the patient’s
lower chest to facilitate a stronger diaphragmatic and intercostal muscle contraction.
• During the patient’s inspiration, the therapist applies a series of three PNF repeated quick-
stretch contractions down and in to encourage maximal inspiration.
• The patient is asked to hold the deep inspiration for a few seconds.
• While instructing the patient to cough, the therapist applies strong pressure through the
hands in toward the central tendon of the patient’s diaphragm.
• The technique can be performed unilaterally (on the upper side only) while the patient is in
the side-lying position.
• This produces an asymmetric cough which can be beneficial for unilateral atelectasis.
• The patient who has limited bed mobility may benefit the most from this assisted cough
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technique
b. Heimlich-type Assist /
Abdominal thrust
• The Heimlich-type assist can be used in both the supine and side lying positions.
• With the patient in the supine position, the therapist places the heel of one hand inferior
to the patient’s xiphoid process and below the patient’s lower ribs.
• The patient is instructed to take in a deep breath and hold it.
• Then, just as the patient is instructed to cough, the therapist applies a quick push up and
in under the diaphragm with the heel of the hand.
• Patients with low neuromuscular tone or flaccid abdominal muscles tolerate this
procedure the best.
• In patients with increased neuromuscular tone, this technique is more effective when
performed in the side-lying position, following the same procedure.
• Because this technique can be uncomfortable for the patient, it should be used only
when other techniques are not effective and the need to cough is great.

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Combination of Heimlich-type Assist and
Costophrenic Assist
• The combination of Heimlich-type assist and Costophrenic assist can be used only
when the patient is in the side-lying position.
• The therapist uses one hand to assist lateral compression of the chest
(Costophrenic assist), while the other hand performs a Heimlich-type assist,
pushing up and in.
• Because it uses more planes of respiration, the combined technique is more
effective at clearing secretions than either technique used alone.

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c. Anterior Chest Compression
Assist
• The anterior chest compression assist technique can be used only when the
patient is in the supine position.
• The therapist puts one arm across the patient’s pectoral region to stabilize or
compress the upper chest while the other arm is placed either parallel on the
lower chest or abdomen or is placed as in the Heimlich-type technique, below
the xiphoid process.
• Inspiration is facilitated by the pressure on anterior chest, followed by a “hold.”
• Just as the patient is instructed to cough, the therapist applies a quick force with
both arms: down and back on the upper chest and up and back on the lower
chest or abdomen.

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d. Massery Counter rotation Assist
• The Massery counter rotation assist is performed in
patients with neurological disorders and spinal stability.
• The patient is positioned on his or her side, with the knees
bent and arms out in front of the head or shoulders.
• The cough assist is then performed by first giving an
accentuated end-expiratory quick compression of the
chest (patient into the flexed position) and then shifting
hands quickly to perform the extension move as the
patient takes a deep breath, which is held briefly at
maximum.
• Finally the therapist shifts hands quickly back to the flexion
position to perform a quick and forceful chest compression
as the patient gives a strong cough.
• This technique is extremely effective even in patients who
are incoherent or unresponsive.
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B. Self-assisted Cough Techniques
• There are a number of techniques that patients can be taught to augment their
own coughing efforts.
• Mainly used in neurologic patients.

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a. Long-sitting Self-assisted Cough for the
Patient With Quadriplegia
• The patient performs a self-assisted cough while positioned in a long-sitting posture with
arm support (Upper extremity).
• The patient extends the head and body backward while taking a maximal inspiration and
then coughs forcefully while throwing the head and upper body forward into a flexed
position (maximize exhalation), using internal rotation of possible.
• Commonly used in tetraplegics.

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b. Prone-on-elbows Head-flexion Self-
assisted Cough
• The prone-on-elbows head-flexion self-assisted cough technique is performed with
the patient prone on elbows.
• Although this technique produces a weaker cough due to inhibition of the diaphragm
and lower anterior chest movement, it is one that quadriplegics who have good head
and neck control and who can roll independently can perform on their own.
• The patient learns to take in a maximal inspiration while extending the head and
neck up and back as far as possible.
• The patient then coughs as forcefully as possible while throwing the head forward
and down into a completely flexed posture.
• The pattern can be assisted initially by the therapist to establish the desired moves
and gradually progressed to a resisted pattern to strengthen the accessory muscles.

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c. Long-sitting Self-assisted Cough for the
Patient With
• The long-sitting Paraplegia
self-assist for the patient with paraplegia is similar to that for the patient
with quadriplegia.
• The exception is that the patient’s hands may be placed on the back of the head in a
butterfly position and the patient throws the body forward onto the legs during the
cough/flexion phase, thereby using both the upper and lower chest.
• The patient must have good control of the trunk musculature in order to properly and
safely perform this technique

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d. Standing Self-assisted Coughs
• Patients with adequate standing balance and upper extremity support can perform any
of the previously described techniques in the standing position
• Performed using any combination of trunk, head, and extremity movement during the
cough and with appropriate modifications for the standing posture.

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e. Short-sitting Self-assisted Cough
• The patient is placed in a short-sitting position (e.g., in a wheelchair over the edge the bed
or at the side of the bed)
• The patient is instructed to place one hand over the other at the wrist and place them in
his or her lap.
• The patient extends the head and trunk backward while taking in a deep breath and then
flexes forward and pulls the hands up and under the diaphragm while coughing forcefully.
• During the cough, the patient pulls his or her hands up and under the diaphragm,
resembling the motion of a Heimlich maneuver.
• The hands mimic the abdominal muscles, which would ordinarily contract to push the
intestinal contents up and under the diaphragm to aid its recoil ability.
• Effective method for patients who have a weak diaphragms or abdominal musculatures
like SCI or spina bifida patients with C5 or below lesions.

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• Tetraplegics requiring trunk support usually cannot perform this, but most of the
paraplegics can perform it from an unsupported short sitting position.
• Patients who lack good upper extremity coordination (Parkinson's diseases, MS) cannot
perform the procedure quickly or forcefully enough to make it effective and usually
require assistance from another person.

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f. Hands-and-knees Rocking Cough
• The patient is on hands and knees(all four position) and rocks all the way forward into a
fully extended position while looking up and taking a deep breath.
• Then the patient coughs with a flexed head while rocking backward to the heels.
• Patient with generalized or spotty weakness throughout (e.g.., some SCI, head traumas,
Parkinson's, MS, CP, spina bifida patients), this method is perfect for incorporating many
functional goals into a single activity.

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C. Mechanical Insufflator–Exsufflator /
Cough machine
• Mechanical insufflation– exsufflation (MI-E) involves a mechanical device (the Cough
Assist insufflator– exsufflator that assists patients in clearing bronchial secretions by
mimicking the physiological effects of a cough through increased peak cough flow.
• Positive air pressure is delivered into the airways (most often via a face or oronasal mask
or connection to an artificial airway), gradually providing a deep inspiration.
• This is followed by an immediate and abrupt change to negative pressure, which provokes
a rapid expiration.
• The expiratory flow created by the device is usually strong enough to elicit a powerful
cough
• Commonly used in conjunction with other airway clearance techniques in patients with
neuromuscular disease and muscle weakness due to central nervous system injury, MI-E
treatments consist of about five positive-to-negative pressure cycles followed by 20 to 30
seconds of normal or ventilator breathing.
• The series is repeated five or more times per session.
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• During upper respiratory tract infection, patients often perform three or more sessions
per day.
• MI-E has demonstrated efficacy in mobilizing secretions in patients with neuromuscular
disorders, reducing the incidence of nasotracheal suctioning, tracheotomy and invasive
mechanical ventilation, and hospitalization, and increasing survival time.
• It can be safely administered by trained nonprofessional caregivers.
• Complications associated with the use of MI-E are rare.
• They include
• gastric and abdominal distension (which can be avoided by reducing the
insufflation pressure to achieve an inspired volume that is less than the
inspiratory reserve volume),
• aggravation of Gastro esophageal reflux,
• hemoptysis,
• chest and abdominal discomfort,
• acute CV effects, and
• pneumothorax
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3. Passive coughing techniques
1. Tracheal tickle – used for patients coming out of anaesthesia
2. A suction effort may produce coughing effort
3. Nebulizer with spacer and medications – esp. for children's
(albuterol, hypertonic saline, Formoterol, Budesonide, ipratropium )
4. Icing on paraspinal muscles elicit cough reflex
5. Hydration with warm water – loosening of secretions
6. IPPB assisted coughing – for patients with NMD
Three consecutive steps are there:
A) Hyper insufflation using the IPPB device,
B) Glottis closure, and
C) Final cough.
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A) Inspiratory pressure for hyper insufflation was delivered with an IPPB device using a
mouthpiece or full face-mask.
• Air leakage through the patient’s nose was prevented with a nose clip, if needed.
• Patients were asked to let the IPPB device blow up their lungs ‘‘like a balloon’’ and watch
the applied volume on the display of the pneumotachygraph.
• The highest volume measured was defined as maximum insufflation capacity (MIC).

B) In a second step, patients were asked to close their glottis after hyper insufflation and
to hold the inspired volume at MIC level for 1 or 2 sec.

C) Finally, cough was generated by maximum contraction of expiratory muscles, followed

by opening of the glottis.
Two days of intensive training with 5–6 training sessions of 10 min were considered
sufficient to adequately perform the technique.

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Disadvantages of cough
• Coughing causes tracheal collapse
• Adults have increased bronchial wall instability : prone for more collapsibility
• People with COPD have more collapsible airways
• Repeated coughing causes fatigue, discomfort

Complications of cough
• Tussive syncope (the intrathoracic pressure becomes so high that venous return to
the heart is impaired. The cardiac output falls and the patient becomes very dizzy,
progressing to unconsciousness.)
• bronchospasm
• Loss of bladder control (urinary incontinence)
• Fractured ribs
• Increases BP and decreases Cardiac output 49
 II. Huffing and
Huffing Techniques

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• Huffing, also called rapid forced expiration, is exhaling through the open mouth (but
not with maximal effort).
• It is an effective alternative for many patients who are unable to cough well.
• It can be performed at various lung volumes:
a huff from mid- to low lung volume will help mobilize more peripheral secretions,
whereas one from mid- to high lung volume will mobilize secretions from the larger, more
proximal airways.
• A huff from total lung capacity (TLC) increases the peak expiratory flow rate from 0.66 to
7.76 L/sec, which is nearly that produced by a cough (8.14 L/s).
• Huffing moves sputum from small airways to larger airways, from there they are
removed by coughing. Coughing alone doesn’t remove sputum from small airways.
• Huffing produces less airway compression than coughing and therefore is safer for
patients with unstable airways
• In patients with respiratory muscle weakness, manual support can be added to huffing
to increase the expiratory force
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Indications
• Post surgical pain ( rib fracture )
• Chronic increased sputum production : CF, CB
• Acute increased sputum production
• Poor expansion
• Sputum retention
• SOBAR / SOBOE
• Bronchiectasis
• Atelectasis
• Respiratory muscle weakness
• Mechanical ventilation
• Asthma
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Mechanism
• During huffing or forced expiration, the pleural pressure becomes positive and equals the
alveolar pressure at a point along the airway called the equal pressure point, usually in the
segmental bronchi.
• Towards the mouth from this point, the transmural pressure gradient is reversed so that
pressure outside the airway is higher than inside, thus squeezing the airway by a process
known as dynamic compression.
• This limits airflow, but the squeezing of airways mouth wards of this point mobilizes
secretions.
• At high lung volumes, the equal pressure point is more proximal because pleural pressure
decreases and alveolar elastic recoil pressure increases.
• It is thought that huffing at low lung volume mobilizes secretions from the more distal airways.
• To counteract airway closure, the huffing phase of the cycle is interspersed with deep
breathing.
• Relaxed abdominal breathing is also interspersed to reduce risks of bronchospasm, paroxysms
of coughing or desaturation 53
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Method of application:
• The patient takes a deep inspiration and then air is forcefully exhaled as in coughing
except that the mouth is kept open (less stressful on the patient and more effective than
constant forced coughing, especially in patients who tend to prolong the expiratory phase
of a cough almost into a wheeze, such as asthmatics and others with COPD).
• The patient makes a sound similar to “huff”.
• Example., fogging a pair of glass with warm breath.

Huffing practice
• Practice huffing with cardboard tubes.
• Try small versus large breaths through cardboard tubes.
• Try short versus long expiration
• Begin in a sitting position with chin slightly upward
• Use diaphragm to breathe in slowly
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• Hold the breath for 2-3secs
• Force the breath out mouth in 1 quick burst of air
• Make sure back of the throat is kept open
Note down.,
• Flexibility is encouraged to suit the individual - The number of huffs can vary
(preferably 1 or 2 at a time) and the force of the huff can vary greatly.
• Huffing should be delayed or modified if it causes bronchospasm, fatigue or
spasms of coughing (Unnecessary huffing or coughing closes airways and
stimulates the bronchospasm)
• Huffing can sometimes be substituted for coughing immediately after eye or
cranial surgery, or in the presence of an aneurysm.
• A huff is a modified cough and it is reported to clear mucus from the seventh
generation of bronchi and beyond.
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 Effective versus Ineffective
Huffing
Effective Huffing Ineffective Huffing
• Mouth open, O shaped to keep glottis • Mouth half or almost closed
open
• Expiration always starting from high LV
• Forced expiration
• Abdominal muscles not used
• from middle to low LV to move
peripheral secretion • Sounds like hissing or blowing
• From high to middle LV to move more • Mouth shapes for “e” sound
proximal secretions • Incorrect quality of expiration
• Muscles of abdomen and CW contract • Too vigorous or long, producing paroxysmal
• Sounds like a sigh, but forced coughing
• Rate of expiratory flow varies with the • Too gentle
• Individual., • Too short
• Disease process • Catching or grunting at the back of the throat
57
• Degree of airflow obstruction
References
• Https://www.Emedicinehealth.Com/coughs/article_em.Htm
• Watchie, Joanne - Cardiovascular and pulmonary physical therapy: a clinical manual -
2nd ed.
• Physiotherapy in respiratory care an evidence-based approach to respiratory and cardiac
management third edition - Alexandra Hough
• Techniques in cardiopulmonary physiotherapy – Subin Solomon, Pravin Aaron
• Physiotherapy for respiratory and cardiac problems - Jennifer A pryor , Barbara A
Webber - Second edition
• Principles and practice of cardiopulmonary physical therapy third edition edited by:
Donna Frownfelter
• Cardiopulmonary physical therapy – Irwin S Tecklin
• Reid, W. Darlene. Clinical management notes and case histories in cardiopulmonary
physical therapy / W. Darlene Reid, Frank Chung
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