A chronic obstructive pulmonary disease patient cannot develop an effective cough. Which of the following would you recommend to help this patient generate a more effective cough?

1. Enhancing expiratory flow by bending forward at the waist
2. Using short, expiratory bursts or the "huffing" method
3. Using only moderate (as opposed to full) inspiration
4. Having the patient "tense" the neck muscles while coughing
a. 2 and 4 only
b. 1, 2, and 3 only
c. 3 and 4 only
d. 1, 2, and 4 only

ANS: B
Instruct the patient to slowly take in a moderately deep breath through his or her nose. To help enhance expulsion, have the patient exhale with moderate force through pursed lips, while bend-ing forward. This forward flexion of the thorax enhances expiratory flow by upward displace-ment of the abdominal contents. After three or four repetitions of this maneuver, encourage the patient to bend forward and initiate short staccato-like bursts of air. This technique relieves the strain of a prolonged hard cough, and the staccato rhythm at a relatively low velocity minimizes airway collapse. This technique has a modification called "huffing" whereby the patient is in-structed to make the sound of "huff, huff, huff" rapidly with his or her mouth open.