Determinants of cough effectiveness in patients with respiratory muscle weakness

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.