title: Determinants of cough effectiveness in patients with respiratory muscle weakness.
abstract: Experiments were undertaken to mechanistically define expiratory-muscle contribution to effectiveness of cough while controlling glottic movement. We hypothesized that electrical abdominal-muscle stimulation in patients with respiratory-muscle weakness produces effective coughs only when glottic closure accompanies coughs. In ten spinal-cord-injury patients, esophago-gastric pressure and airflow were recorded during solicited-coughs, coughs augmented by abdominal-muscle stimulation, and passive open-glottis exhalations. During solicited-coughs, patients closed the glottis initially; five were flow-limited, five non-flow-limited. Stimulations during solicited-coughs or open-glottis exhalations elicited similar driving pressures (changes in gastric pressure; p<0.001). Despite high driving pressures, stimulations induced flow-limitation only when patients transiently closed the glottis - not during open-glottis exhalations. That is, transient glottic closure enabled transmission of abdominal (driving) pressure to the thorax during cough, while impeding dissipation of intrathoracic pressure. In conclusion, transient glottic closure is necessary to render cough effective in patients with respiratory-muscle weakness, indicating that failure to close the glottis contributes to ineffective cough in weak tracheostomized patients and patients with bulbar disorders.
authors.affiliation: Loyola University of Chicago Stritch School of Medicine, Maywood, IL, United States; Hines Veterans Affairs Hospital, Hines, IL, United States. Electronic address: flaghi@lumc.edu.
authors.forename: Franco
authors.initials: F
authors.lastname: Laghi
authors.affiliation: Loyola University of Chicago Stritch School of Medicine, Maywood, IL, United States; Hines Veterans Affairs Hospital, Hines, IL, United States. Electronic address: maddipativ15@ecu.edu.
authors.forename: Veeranna
authors.initials: V
authors.lastname: Maddipati
authors.affiliation: Loyola University of Chicago Stritch School of Medicine, Maywood, IL, United States; Hines Veterans Affairs Hospital, Hines, IL, United States. Electronic address: timothy.schnell@gmail.com.
authors.forename: Timothy
authors.initials: T
authors.lastname: Schnell
authors.affiliation: Hines Veterans Affairs Hospital, Hines, IL, United States. Electronic address: langbein@comcast.net.
authors.forename: W Edwin
authors.initials: WE
authors.lastname: Langbein
authors.affiliation: Loyola University of Chicago Stritch School of Medicine, Maywood, IL, United States; Hines Veterans Affairs Hospital, Hines, IL, United States. Electronic address: mtobin2@lumc.edu.
authors.forename: Martin J
authors.initials: MJ
authors.lastname: Tobin
mesh_terms: D000009:Abdominal Muscles / Q000503:physiopathology; D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D003371:Cough / Q000175:diagnosis* / Q000209:etiology*; D004558:Electric Stimulation / Q000379:methods; D004576:Electromyography; D045853:Exhalation; D005260:Female; D005931:Glottis / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D018908:Muscle Weakness / Q000150:complications* / Q000209:etiology / Q000473:pathology*; D012132:Respiratory Muscles / Q000503:physiopathology*; D013119:Spinal Cord Injuries / Q000150:complications; D014109:Total Lung Capacity / Q000502:physiology
keywords: Abdominal muscles; Glottis; Neuromuscular electrical stimulation; Spinal cord injury; Tracheostomy