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Quad Coughs

Updated: Apr 18, 2020

Those pressure coughs were brutal, but boy do my lungs feel good! defines a cough as, "To expel air from the lungs suddenly, with a harsh noise, often involuntarily." We all do it, often without even thinking about it. However, quadriplegics do it with a style that perplexes some, concerns others and even scares a few.

One of the byproducts of a high-level quadriplegic is that their lung capacity is diminished to about one third of its former capability. Where that is noticed is while singing, although I have yet to have someone tell me they miss my golden pipes. Where it is most often noticed is when I need to cough. In those situations, we employ a technique known as a Quad Cough. The free medical dictionary defines this technique as, “A form of assisted coughing for patients with central nervous system disorders such as a spinal cord injury, who are unable to generate sufficient force to clear respiratory secretions. After maximal inspiration the patient coughs, while an assistant exerts gentle upward and inward pressure, with both hands on the abdomen. The increased intra-abdominal pressure produces a more forceful cough." I think the term maximal inspiration refers to the patient's pending expiration if they don't get help coughing soon! In real life, a Quad Cough more resembles something between defibrillation and abuse.

I have found that the techniques utilized by an assistant vary dramatically. When I was in rehab, I was given a breathing treatment 3-4 times a day by a physical therapist, who then followed up with a Quad coughing exercise. Since this went on 24 hours a day, I would see different therapists through their shifts. There was one guy that concerned me. He would climb into bed and kneel over me with a wild look in his eye, and push with a force that would not be defined as "gentle upward and inward pressure." By the time he finished, I was always glad for the structural integrity of the hospital bed. The tendency of most assistants, however, is the exact opposite. Their first concern is that they don't want to break your ribs. You want to encourage them in this regard. Beyond that, every assistant is different. I have one relative, who after carefully placing their hands in position, lurches violently forward to deliver something dramatically less than gentle upward and inward pressure. I am always afraid they are going to incur whiplash. On the other hand, my son reminds me of the physical therapist in the hospital, with a couple of exceptions. His approach is calm and unassuming. Don't let that fool you. He can deliver a blow worthy of the best of Joe Frazier. I also don't see a wild look in his eye. It's more one of payback for various aspects of his raising. My wife on the other hand, has become very nuanced in her approach. Before giving me a push, she will ask "small, medium, or large?"

The most interesting situations involving Quad coughs are those administered while we are in public. Many people pretend not to notice, but they are betrayed by the panicked look on their face when their eye inadvertently catches mine. Others suspect they are watching bad behavior, such as when a parent starts swatting their child in public. Once while in a restaurant, a nearby patron came over to see if everything was all right, giving me all the nonverbal signals that it was okay to expose my tormentor. Still others glance at us with a look of fateful resignation. If you were a mind reader, you would hear them say, "Damn, I knew it was a problem when they put that wheelchair at the table next to ours. Now this guy is going to die right in front of me."

I've often thought these forced coughs set a perfect stage for a Candid Camera moment. I wonder how people would react if, when we are out at a restaurant and I need a pressure cough, my wife were to stand, look around in a 360° arc and say very loudly before giving me the assistance, "Clear?" While it would be fun to catch people's reaction, I just don't think I have the heart for it.

There is a follow-up to this story. After almost 12 years, I successfully ran the gauntlet of medical documentation in order to procure a Phillips Cough Assist machine. It expands your lungs in a way that pressure coughs cannot, but it does not completely eradicate the need for pressure coughs. Now, more than ever, this device, this technique, and an albuterol nebulizer make my lungs feel better than ever! Who said you can’t teach an old dog new tricks?

Noticeably absent when we all left rehab was the instruction manual for dealing with the myriad of situations we would find ourselves in.Ask This Old Quad articles serve to fill in that vacuum, because we have all developed tricks of the trade that we believe would be valuable for others.Share your ideas and experience with us at

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