To Cough or Not to Cough

It is beneficial for persons with ALS to take some time each day for deep breathing and coughing exercises to keep the lungs free of troublesome secretions (see Living with ALS Manual 6: Adapting to Breathing Changes)

Especially after eating, persons with ALS may cough for a long time, due to food particles or saliva that is stuck in the throat. This is uncomfortable for persons with ALS and for those around them but the far greater and more serious problem is the depletion of available energy and strength that leaves the person fatigued and vulnerable.

The cause for this kind of coughing is an inadequate swallowing mechanism and weakened chest and abdominal muscles that fail to produce a strong enough cough to clear the offending food particles or saliva. A simple maneuver called “assisted coughing” may be all that is necessary. Caregivers can learn to do this procedure, or persons with ALS by themselves if they have adequate strength in their arms and hands.

The best position for assisted coughing is sitting upright and leaning slightly forward. Place a small pillow or a folded towel against the upper abdomen (about five inches above the navel). After the patient takes as deep a breath as possible, the caregiver with an open palm over the pillow – gives a gentle push (in and up) exactly at the moment of the cough. This push greatly enhances the cough and usually is enough to clear the airway.

The towel may also be used folded the long way and wrapped around the mid-body, with the caregiver standing behind the person with ALS and holding the towel ends. At the moment of the cough, the towel is pulled tight. The towel should be released immediately at the end of the cough. This effectively splints the weakened chest muscles and gives added strength to the cough. Occasionally a stronger method is required. This method uses the palm of the hand or even the fist. A push is required up and under the right lower rib just to the right of the sternum. (The stomach lies to the left and is to be avoided). Again, push exactly at the moment of the cough and then release.

Caution: Caution is in order against pressing directly over the stomach, especially if the person with ALS has eaten recently. The stomach lies in the upper part of the abdominal cavity with most of its pouch-like structure to the left of the sternum. If the force of the push is too strong it could cause regurgitation of food into the throat, and serious risks of choking or aspiration.

Practice to get just the right amount of force into the push. A person with ALS can guide the caregiver or the caregiver can try it on himself or herself to get just the right feel.

Another necessary skill for the caregiver is to learn the Heimlich Maneuver (call your local hospital or Red Cross Chapter for lessons). The Heimlich differs from the assisted cough in that it is for dislodging a large piece of food that is completely cutting off all air. If not cleared immediately, this kind of obstruction will end in death.

The Heimlich push uses the fist very strongly and directly under the sternum, usually with the person administering it standing behind. Slapping hard at the mid-back with an open palm exactly at the moment of cough remains a standard procedure for any kind of choking. However, it is essential to be timed with the cough or it is more harmful than beneficial.

The cough is usually our friend and is helpful. But if it is not doing its job and just wearing a patient out, try a little assisted coughing.

Excerpted from an article by Berry Scharf, R.N.
-- Rev. 5/96
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