Comprehensive Physiology Wiley Online Library

Cough

Full Article on Wiley Online Library



Abstract

The sections in this article are:

1 General Considerations
2 Cough Description
2.1 Inspiration
2.2 Compression
2.3 Expiration
2.4 Cessation
3 Airflow
3.1 Forced Expiration
3.2 Flow Limitation
3.3 Flow Velocities
3.4 Flow Transients
4 Two‐Phase Cocurrent Flow
4.1 Mucus Properties
4.2 Two‐Phase Flow Regimes
4.3 Transient and Steady Flow
4.4 Particle Generation
4.5 Airway Deformation
4.6 Particle Deposition in Expiration
5 Conclusions
Figure 1. Figure 1.

Flow at airway opening (flow rate), spirometric volume change (air volume), subglottic pressure, and sound level during two representative coughs (top and bottom). Recordings on left are diagrammed on right. Positive flow phase is divided into increasing (A), constant (B), and decreasing (C) phases.

From Yanagihara et al.
Figure 2. Figure 2.

Flow () at airway opening (B) and esophageal pressure (A) during single cough in normal subject (left) and in subject with emphysema (right). Peak time derivative of pressure is ∼1,200 and 500 cmH2O/s for on and off transients, respectively, in normal subject but is less in emphysematous subject. In latter, esophageal pressure stays high throughout series of maneuvers that appears to include 6 or 7 glottis closures and reopenings. EXP, expiration; INSP, inspiration.

From Whittenberger and Mead
Figure 3. Figure 3.

progressive decreases in pressure at the downstream end of an excised dog trachea result in increasing flows only to critical condition. Dotted line connects open circles that show time‐dependent effects of stress relaxation (increased compressibility) of tracheal wall.

further increases in driving pressure (i.e., decreases in downstream pressure) do not increase flow or change pressure‐distance profile upstream of choke point but do decrease pressures (and cause decreases in cross‐sectional area) downstream from choke point (note downstream pressure recovery). Numbered points in A correspond to numbered lines in B. LPS, liters per second. [From Elliott and Dawson .]

Figure 4. Figure 4.

airway pressure (PLAT) vs. position during graded expiratory efforts in a normal subject at ∼50% vital capacity. Dashed lines, unknown pressure‐distance function from alveoli to first measured data points (note break in position axis).

difference between stagnation pressure (PTOT) and PLAT vs. position during same maneuvers. PTOT − PLAT, pressure associated with convective acceleration; alv, alveolus. [From Hoppin et al. .]

Figure 5. Figure 5.

Flow‐time plots for 3 maneuvers at same lung volume (A), coughs (B), and forced expirations (C) initiated at different lung volumes. Flow‐volume plots for maneuvers in B and C are superimposed on maximal expiratory flow‐volume curves. Same subject provided all data shown.

From Knudson et al.
Figure 6. Figure 6.

Five triggered transients initiated at different lung volumes (Vol), superimposed on subject's maximal expiratory flow‐volume curve. Amplitude of the supramaximal flow transient decreases less with lung volume than does maximal flow. RV, residual volume; TLC, total lung capacity, , flow.

From Knudson et al.
Figure 7. Figure 7.

Volume displaced from collapsing central airways is represented by total area under flow‐time curve () for supramaximal transient, less the area that represents volume coming from parenchyma during same time. Magnitude of latter is uncertain, however, because time course of rise in parenchymal flow to maximum flow () is uncertain (e.g., as shown by dashed and dotted lines). Stippled area shows probable minimum value of change in airway volume.

From Knudson et al.
Figure 8. Figure 8.

Sequential measurements on mucus sample, showing complex shear stress‐shear strain behavior, including shear thinning (decrease in viscosity with increasing shear rate) and shear destruction (changes in behavior after first exposure to high shear rates). For comparison, mucus shear rates are <10 s−1 during ciliary transport and may range well over 1,000 s−1 during cough.

From Lopez‐Vidriero et al. , by courtesy of Marcel Dekker, Inc
Figure 9. Figure 9.

Four basic regimes in two‐phase cocurrent flow. Range of associated gas velocities taken from engineering literature for large rigid conduits and ordinary Newtonian liquids. There is reason to think that lower velocities apply in the lung. Arrows, direction of flow.

From Leith
Figure 10. Figure 10.

pressure (ΔP)‐flow curves for dry tubes of various radii (r).

pressure‐flow curves for 8.5‐mm‐radius tube with fluid annulus that reduces inner radius to values indicated. Human tracheal radius is similar. [From Clarke et al. .]



Figure 1.

Flow at airway opening (flow rate), spirometric volume change (air volume), subglottic pressure, and sound level during two representative coughs (top and bottom). Recordings on left are diagrammed on right. Positive flow phase is divided into increasing (A), constant (B), and decreasing (C) phases.

From Yanagihara et al.


Figure 2.

Flow () at airway opening (B) and esophageal pressure (A) during single cough in normal subject (left) and in subject with emphysema (right). Peak time derivative of pressure is ∼1,200 and 500 cmH2O/s for on and off transients, respectively, in normal subject but is less in emphysematous subject. In latter, esophageal pressure stays high throughout series of maneuvers that appears to include 6 or 7 glottis closures and reopenings. EXP, expiration; INSP, inspiration.

From Whittenberger and Mead


Figure 3.

progressive decreases in pressure at the downstream end of an excised dog trachea result in increasing flows only to critical condition. Dotted line connects open circles that show time‐dependent effects of stress relaxation (increased compressibility) of tracheal wall.

further increases in driving pressure (i.e., decreases in downstream pressure) do not increase flow or change pressure‐distance profile upstream of choke point but do decrease pressures (and cause decreases in cross‐sectional area) downstream from choke point (note downstream pressure recovery). Numbered points in A correspond to numbered lines in B. LPS, liters per second. [From Elliott and Dawson .]



Figure 4.

airway pressure (PLAT) vs. position during graded expiratory efforts in a normal subject at ∼50% vital capacity. Dashed lines, unknown pressure‐distance function from alveoli to first measured data points (note break in position axis).

difference between stagnation pressure (PTOT) and PLAT vs. position during same maneuvers. PTOT − PLAT, pressure associated with convective acceleration; alv, alveolus. [From Hoppin et al. .]



Figure 5.

Flow‐time plots for 3 maneuvers at same lung volume (A), coughs (B), and forced expirations (C) initiated at different lung volumes. Flow‐volume plots for maneuvers in B and C are superimposed on maximal expiratory flow‐volume curves. Same subject provided all data shown.

From Knudson et al.


Figure 6.

Five triggered transients initiated at different lung volumes (Vol), superimposed on subject's maximal expiratory flow‐volume curve. Amplitude of the supramaximal flow transient decreases less with lung volume than does maximal flow. RV, residual volume; TLC, total lung capacity, , flow.

From Knudson et al.


Figure 7.

Volume displaced from collapsing central airways is represented by total area under flow‐time curve () for supramaximal transient, less the area that represents volume coming from parenchyma during same time. Magnitude of latter is uncertain, however, because time course of rise in parenchymal flow to maximum flow () is uncertain (e.g., as shown by dashed and dotted lines). Stippled area shows probable minimum value of change in airway volume.

From Knudson et al.


Figure 8.

Sequential measurements on mucus sample, showing complex shear stress‐shear strain behavior, including shear thinning (decrease in viscosity with increasing shear rate) and shear destruction (changes in behavior after first exposure to high shear rates). For comparison, mucus shear rates are <10 s−1 during ciliary transport and may range well over 1,000 s−1 during cough.

From Lopez‐Vidriero et al. , by courtesy of Marcel Dekker, Inc


Figure 9.

Four basic regimes in two‐phase cocurrent flow. Range of associated gas velocities taken from engineering literature for large rigid conduits and ordinary Newtonian liquids. There is reason to think that lower velocities apply in the lung. Arrows, direction of flow.

From Leith


Figure 10.

pressure (ΔP)‐flow curves for dry tubes of various radii (r).

pressure‐flow curves for 8.5‐mm‐radius tube with fluid annulus that reduces inner radius to values indicated. Human tracheal radius is similar. [From Clarke et al. .]

References
 1. Acrivos, A. The breakup of small drops and bubbles in shear flows. Ann. NY Acad. Sci. 404: 1–11, 1983.
 2. Agnew, J. E., J. R. M. Bateman, N. F. Sheahan, A. M. Lennard‐Jones, D. Pavia, and S. W. Clarke. Effect of oral corticosteroids on mucus clearance by cough and mucociliary transport in stable asthma. Bull. Eur. Physiopathol. Respir. 19: 37–41, 1983.
 3. Agostoni, E., and W. O. Fenn. Velocity of muscle shortening as a limiting factor in respiratory air flow. J. Appl. Physiol. 15: 349–353, 1960.
 4. Anderson, G. H., and B. G. Mantzouranis. Two‐phase (gas‐liquid) flow phenomena. I. Pressure drop and hold‐up for two‐phase flow in vertical tubes. Chem. Eng. Sci. 12: 109–126, 1960.
 5. Aviado, D. M. Regulation of bronchomotor tone during anesthesia. Anesthesiology 42: 68–80, 1975.
 6. Banyai, A. L. A symptom connoting many causes and sequels. Chest 60: 355, 1971.
 7. Barach, A. L., G. J. Beck, H. A. Bickerman, and H. E. Seanor. Physical methods simulating mechanisms of the human cough. J. Appl. Physiol. 5: 85–91, 1952.
 8. Batchelor, G. K. Introduction to Fluid Dynamics. New York: McGraw‐Hill, 1969.
 9. Beck, G. J., and L. A. Scarrone. Physiological effects of exsufflation with negative pressure (E.W.N.P). Dis. Chest 29: 80–95, 1956.
 10. Berglund, E., B. S. Nilsson, B. Mossberg, and B. Bake (editors). Cough and expectoration. Eur. J. Respir. Dis. Suppl. 110: 1–262, 1980.
 11. Bertram, C. D., and T. J. Pedley. A mathematical model of unsteady collapsible tube behaviour. J. Biomech. 15: 39–50, 1982.
 12. Bickerman, H. A. Exsufflation with negative pressure (E.W.N.P). Elimination of radiopaque material and foreign bodies from bronchi of anesthetized dogs. Arch. Intern. Med. 93: 698–704, 1954.
 13. Bickerman, H. A. Bronchial drainage and phenomena of cough. In: Clinical Cardiopulmonary Physiology (2nd ed.), edited by B. L. Gordon. New York: Grune & Stratton, 1960, chapt. 31, p. 494–506.
 14. Bickerman, H. A., G. J. Beck, C. Gordon, and A. L. Barach. Physical methods simulating mechanisms of the human cough: elimination of radiopaque material from the bronchi of dogs. J. Appl. Physiol. 5: 92–98, 1952.
 15. Bircher, N., P. Safar, G. Eshel, and W. Stezoski. Cerebral and hemodynamic variables during cough‐induced CPR in dogs. Crit. Care Med. 10: 104–107, 1982.
 16. Blake, J. On the movement of mucus in the lung. J. Biomech. 8: 179–180, 1975.
 17. Brain, J. D., D. F. Proctor, and L. M. Reid (editors). Lung Biology in Health and Disease. Respiratory Defense Mechanisms. New York: Dekker, 1977, vol. 5.
 18. Brashear, R. E. Cough: diagnostic considerations with normal chest roentgenograms. J. Fam. Pract. 15: 979–985, 1982.
 19. Brown, A. L., and E. Archibald. The action of cough upon material in the tracheobronchial tract. Annu. Rev. Tuberc. 16: 111–122, 1927.
 20. Bucher, K. Pathophysiology and pharmacology of cough. Pharmacol. Rev. 10: 43–58, 1958.
 21. Burger, E. J., Jr., and J. Mead. Static properties of lungs after oxygen exposure. J. Appl. Physiol. 27: 191–197, 1969.
 22. Calvert, S., and B. Williams. Upward cocurrent annular flow of air and water in smooth tubes. AIChE J. 1: 78–86, 1955.
 23. Camner, P. Studies on the removal of inhaled particles from the lungs by voluntary coughing. Chest 80, Suppl. 6: 824–827, 1981.
 24. Camner, P., B. Mossberg, K. Phillipson, and K. Strandberg. Elimination of test particles from the human tracheo‐bronchial tract by voluntary coughing. Scand. J. Respir. Dis. 60: 56–62, 1979.
 25. Ciba Foundation. Respiratory Tract Mucus. New York: Excerpta Med., 1978. (Ciba Found. Symp. 54.)
 26. Clarke, S. W. The role of two‐phase flow in bronchial clearance. Bull. Physio‐Pathol. Respir. 9: 359–372, 1973.
 27. Clarke, S. W. Physical defences of the respiratory tract. Eur. J. Respir. Dis. Suppl. 126: 27–30, 1983.
 28. Clarke, S. W., J. G. Jones, and D. R. Oliver. Resistance to two‐phase gas‐liquid flow in airways. J. Appl. Physiol. 29: 464–471, 1970.
 29. Clarke, S. W., J. G. Jones, and D. R. Oliver. Factors affecting airflow through branched tubes. Bull. Physio‐Pathol. Respir. 8: 409–428, 1972.
 30. Clarke, S. W., and D. Pavia (editors). Lung mucociliary clearance and the deposition of therapeutic aerosols. Chest 80, Suppl. 6: 789–924, 1981.
 31. Colebatch, J. Artificial coughing for patients with respiratory paralysis. Aust. NZ J. Med. 10: 201–212, 1961.
 32. Coleridge, J. C. G., and H. M. Coleridge. Afferent vagal C fibre innervation of the lungs and airways and its functional significance. Rev. Physiol. Biochem. Pharmacol. 99: 2–110, 1984.
 33. Compton, D., P. M. Hill, and J. D. Sinclair. Weightlifters' blackout. Lancet 2: 1234–1237, 1973.
 34. Criley, J. M., A. H. Blaufuss, and G. L. Kissel. Cough‐induced cardiac compression. Self‐administered form of cardiopulmonary resuscitation. J. Am. Med. Assoc. 236: 1246–1250, 1976.
 35. Dawson, S. V., and E. A. Elliott. Wave‐speed limitation on expiratory flow—a unifying concept. J. Appl. Physiol.: Respirat. Environ. Exercise Physiol. 43: 498–515, 1977.
 36. Dawson, S. V., and E. A. Elliott. Use of the choke point in the prediction of flow limitation in elastic tubes. Federation Proc. 39: 2765–2770, 1980.
 37. Dayman, H. Mechanics of airflow in health and in emphysema. J. Clin. Invest. 30: 1175–1190, 1951.
 38. Elliott, E. A., and S. V. Dawson. Test of wave‐speed theory of flow limitation in elastic tubes. J. Appl. Physiol.: Respirat. Environ. Exercise Physiol. 43: 516–522, 1977.
 39. Elliott, E. A., and S. V. Dawson. Fluid velocity greater than wavespeed and the transition from supercritical to subcritical flow in elastic tubes. Med. Biol. Eng. Comput. 17: 192–198, 1979.
 40. Evans, J. N., and M. J. Jaeger. Mechanical aspects of coughing. Pneumonologie 152: 253–257, 1975.
 41. Gandevia, B. The spirogram of gross expiratory tracheobronchial collapse in emphysema. Q. J. Med. 32: 23–31, 1962.
 42. Glaister, D. H., S. W. Clarke, and J. G. Jones. Oscillations in expiratory gas flow during a forced vital capacity manoeuvre (Abstract). Clin. Sci. 37: 567–568, 1969.
 43. Grotberg, J. B., and S. H. Davis. Fluid‐dynamic flapping of a collapsible channel: sound generation and flow limitation. J. Biochem. 13: 219–230, 1980.
 44. Haas, F. C. Stability of droplets suddenly exposed to a high velocity gas stream. AIChE J. 10: 920–924, 1964.
 45. Haldane, J. H. Micturition syncope: two case reports and a review of the literature. Can. Med. Assoc. J. 101: 712–713, 1969.
 46. Hamilton, W. F., R. A. Woodbury, and H. T. Harper, Jr. Arterial, cerebrospinal and venous pressures in man during cough and strain. Am. J. Physiol. 141: 42–50, 1944.
 47. Hamosh, P. Effect of shearing stress (SS) on the tracheal mucosa (Abstract). Am. Rev. Respir. Dis. 109: 694, 1974.
 48. Harris, R. S., and T. V. Lawson. The relative mechanical effectiveness and efficiency of successive voluntary coughs in healthy young adults. Clin. Sci. 34: 569–577, 1968.
 49. Hinze, J. O. Fundamentals of the hydrodynamic mechanism of splitting in dispersion processes. AIChE J. 1: 289–295, 1955.
 50. Hoppin, F. G., Jr., J. M. B. Hughes, and J. Mead. Axial forces in the bronchial tree. J. Appl. Physiol.: Respirat. Environ. Exercise Physiol. 42: 773–781, 1977.
 51. Huizinga, E. The “tussive squeeze” and the “bechic blast” of the Jacksons. Ann. Otol. Rhinol. Laryngol. 76: 923–934, 1967.
 52. Hyatt, R. E. Expiratory flow limitation. J. Appl. Physiol.: Respirat. Environ. Exercise Physiol. 55: 1–7, 1983.
 53. Hyatt, R. E., J. Mead, J. R. Rodarte, and T. A. Wilson. Changes in lung mechanics: flow‐volume relationship. In: Lung Biology in Health and Disease. The Lung in the Transition Between Health and Disease, edited by P. T. Macklem and S. Permutt. New York: Dekker, 1979, vol. 12, chapt. 5, p. 73–112.
 54. Irwin, R. S., W. M. Corrao, and M. R. Pratter. Chronic persistent cough in the adult: the spectrum and frequency of causes and successful outcome of specific therapy. Am. Rev. Respir. Dis. 123: 413–417, 1981.
 55. Irwin, R. S., M. J. Rosen, and S. S. Braman. Cough. A comprehensive review. Arch. Intern. Med. 137: 1186–1191, 1977.
 56. Ishii, M., and M. A. Grolmes. Inception criteria for droplet entrainment in two‐phase concurrent film flow. AIChE J. 21: 308–318, 1975.
 57. Ishii, M., and K. Mishima. Liquid transfer and entrainment correlation for droplet‐annular flow. Proc. Int. Heat Transfer Conf., 7th, Munich, 1982, vol. 5, p. 307–312.
 58. Jackson, C. Cough: bronchoscopic observations on the cough reflex. J. Am. Med. Assoc. 79: 1399–1404, 1922.
 59. Jaeger, M. J. Coughing and forced expiration at reduced barometric pressure (Abstract). Federation Proc. 31: 322, 1972.
 60. James, R. E. Extra‐Alveolar Air Resulting from Submarine Escape Training: A Post‐Training Roentgenographic Survey of 170 Submariners. Groton, CT: US Navy Bureau of Medicine and Surgery, 1968. (Submarine Med. Res. Lab. Naval Submarine Med. Center Rep. No. 550.)
 61. Jones, J. G., and S. W. Clarke. Dynamics of cough. Br. J. Anaesth. 42: 280–285, 1970.
 62. Jones, J. G., S. W. Clarke, and D. R. Oliver. Two‐phase gas‐liquid flow in airways. Br. J. Anaesth. 41: 192–193, 1969.
 63. Jones, J. G., R. B. Fraser, and J. A. Nadel. Prediction of maximum expiratory flow rate from area‐transmural pressure curve of compressed airway. J. Appl. Physiol. 38: 1002–1011, 1975.
 64. Jones, J. G., R. B. Fraser, and J. A. Nadel. Effect of changing airway mechanics on maximum expiratory flow. J. Appl. Physiol. 38: 1012–1021, 1975.
 65. Kataoka, I., M. Ishii and K. Mishima. Generation and size distribution of droplet in annular two‐phase flow. J. Fluids Eng. 105: 230–238, 1983.
 66. Katz, R. M. Cough syncope in children with asthma. J. Pediatr. 77: 48–51, 1970.
 67. Kikuchi, Y., H. Sasaki, K. Sekizawa, K. Aihara, and T. Takishima. Force‐velocity relationship of expiratory muscles in normal subjects. J. Appl. Physiol.: Respirat. Environ. Exercise Physiol. 52: 930–938, 1982.
 68. King, M. Rheological requirements for optimal clearance of secretions: ciliary transport versus cough. Eur. J. Respir. Dis. Suppl. 110: 39–45, 1980.
 69. King, M., H. K. Chang, and M. E. Weber. Resistance of mucus‐lined tubes to steady and oscillatory airflow. J. Appl. Physiol.: Respirat. Environ. Exercise Physiol. 52: 1172–1176, 1982.
 70. King, M., and P. T. Macklem. Rheological properties of microliter quantities of normal mucus. J. Appl. Physiol.: Respirat. Environ. Exercise Physiol. 42: 797–802, 1977.
 71. Knudson, R. J., and D. E. Knudson. Effect of muscle constriction on flow‐limiting collapse of isolated canine trachea. J. Appl. Physiol. 38: 125–131, 1975.
 72. Knudson, R. J., J. Mead, and D. E. Knudson. Contribution of airway collapse to supramaximal expiratory flows. J. Appl. Physiol. 36: 653–667, 1974.
 73. Korpás, J., and Z. Tomori. Progress in Respiration Research. Cough and Other Respiratory Reflexes, Basel: Karger, 1979, vol. 12.
 74. Lambert, R. K. The use of a computational model for expiratory flow to simulate the effects of two airway abnormalities. Aust. Phys. Eng. Sci. Med. 4: 100–108, 1981.
 75. Lambert, R. K., T. A. Wilson, R. E. Hyatt, and J. R. Rodarte. A computational model for expiratory flow. J. Appl. Physiol.: Respirat. Environ. Exercise Physiol. 52: 44–56, 1982.
 76. Langlands, J. The dynamics of cough in health and in chronic bronchitis. Thorax 22: 88–96, 1967.
 77. Larson, S. J., A. Sances, Jr., J. B. Baker, and D. H. Reigel. Herniated cerebellar tonsils and cough syncope. J. Neurosurg. 40: 524–528, 1974.
 78. Lawson, T. V., and R. S. Harris. Assessment of the mechanical efficiency of coughing in healthy young adults. Clin. Sci. 33: 209–224, 1967.
 79. Leith, D. E. Cough. Phys. Ther. 48: 439–447, 1968.
 80. Leith, D. E. Cough. In: Lung Biology in Health and Disease. Respiratory Defense Mechanisms, edited by J. D. Brain, D. F. Proctor, and L. M. Reid. New York: Dekker, 1977, vol. 5, pt. II, chapt. 15, p. 545–592.
 81. Leith, D. E. Mammalian tracheal dimensions: scaling and physiology. J. Appl. Physiol.: Respirat. Environ. Exercise Physiol. 55: 196–200, 1983.
 82. Leith, D. E. Cough development. Am. Rev. Respir. Dis. 131: S39–S42, 1985.
 83. Lockhart, R. W., and R. C. Martinelli. Proposed correlation of data for isothermal two‐phase two‐component flow in pipes. Chem. Eng. Prog. 45: 39–49, 1949.
 84. Lopez‐Vidriero, M. T., I. Das, and L. M. Reid. Airway secretion: source, biochemical and rheological properties. In: Lung Biology in Health and Disease. Respiratory Defense Mechanisms, edited by J. D. Brain, D. F. Proctor, and L. M. Reid. New York: Dekker, 1977, vol. 5, pt. I, chapt. 9, p. 289–356.
 85. Lorin, M. I. Mechanical defense mechanisms of the respiratory system. In: Pulmonary Physiology of the Fetus, Newborn and Child, edited by E. M. Scarpelli. Philadelphia, PA: Lea & Febiger, 1975, chapt. 10, p. 220–238.
 86. Loudon, R. G. Cough in health and disease. In: Current Research in Chronic Obstructive Lung Disease. Washington, DC: US Govt. Printing Office, 1968, p. 41–53. (Proc. 10th Aspen Emphysema Conf., Arlington, VA, 1968.)
 87. Loudon, R. G., and R. M. Roberts. Droplet expulsion from the respiratory tract. Am. Rev. Respir. Dis. 95: 435–442, 1967.
 88. Loudon, R. G., and G. B. Shaw. Mechanics of cough in normal subjects and in patients with obstructive respiratory disease. Am. Rev. Respir. Dis. 96: 666–677, 1967.
 89. Macklem, P. T. Physiology of cough. Ann. Otol. Rhinol. Laryngol. 83: 761–768, 1974.
 90. Macklem, P. T., R. G. Fraser, and W. G. Brown. Bronchial pressure measurements in emphysema and bronchitis. J. Clin. Invest. 44: 897–905, 1965.
 91. Macklem, P. T., and N. J. Wilson. Measurement of intra‐bronchial pressure in man. J. Appl. Physiol. 20: 653–663, 1965.
 92. Macklin, M. T., and C. C. Macklin. Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions: interpretation of clinical literature in light of laboratory experiment. Medicine Baltimore 23: 281–357, 1944.
 93. Mahalingam, R., and M. A. Valle. Momentum transfer in two‐phase flow of gas‐pseudoplastic liquid mixtures. Ind. Eng. Chem. Fundam. 11: 470–477, 1972.
 94. Marazzini, L., F. Vezzoli, and G. Rizzato. Intrathoracic pressure development in chronic airways obstruction. J. Appl. Physiol. 37: 575–578, 1974.
 95. Marriott, C. The viscoelastic nature of mucus secretion. Chest 80, Suppl. 6: 804–808, 1981.
 96. Matthay, R. A., M. A. Matthay, and D. R. Dantzker (editors). Cardiovascular‐pulmonary interaction in normal and diseased lungs. In: Clinics in Chest Medicine. Philadelphia, PA: Saunders, 1983, vol. 4, p. 99–325.
 97. McIntosh, H. D., E. H. Estes, and J. V. Warren. The mechanism of cough syncope. Am. Heart J. 52: 70–82, 1956.
 98. Mead, J. Expiratory flow limitation: a physiologist's point of view. Federation Proc. 39: 2771–2775, 1980.
 99. Mead, J., J. M. Turner, P. T. Macklem, and J. B. Little. Significance of the relationship between lung recoil and maximum expiratory flow. J. Appl. Physiol. 22: 95–108, 1967.
 100. Melissinos, C., E. Bruce, and D. Leith. Factors affecting pleural pressure during cough in normal man (Abstract). Clin. Res. 24: 643A, 1976.
 101. Melissinos, C. G., E. N. Bruce, D. E. Leith, and J. Mead. Flow and pressure during cough in normal subjects (Abstract). Clin. Res. 25: 421A, 1977.
 102. Melissinos, C. G., D. E. Leith, J. S. Brody, E. Bruce, and J. Mead. Thoracoabdominal mechanics in spontaneous cough (Abstract). Am. Rev. Respir. Dis. 117: 372, 1978.
 103. Miller, H. C., G. O. Proud, and F. C. Behrle. Variations in the gag, cough, and swallow reflexes and tone of the vocal cords as determined by direct laryngoscopy in newborn infants. Yale J. Biol. Med. 24: 284–291, 1952.
 104. Mognoni, P., F. Saibene, G. Sant'Ambrogio, and E. Agostoni. Dynamics of the maximal contraction of the respiratory muscles. Respir. Physiol. 4: 193–202, 1968.
 105. Morgan‐Hughes, J. A. Cough seizures in patients with cerebral lesions. Br. Med. J. 2: 494–496, 1966.
 106. Munsell, W. P. Pneumomediastinum. J. Am. Med. Assoc. 202: 689–693, 1967.
 107. Mygind, N., M. H. Nielsen, and M. Pedersen (editors). Kartagener's syndrome and abnormal cilia. Eur. J. Respir. Dis. Suppl. 127: 1–167, 1983.
 108. Nadel, J. A. (editor). Lung Biology in Health and Disease. Physiology and Pharmacology of the Airways. New York: Dekker, 1980, vol. 15.
 109. Natelson, S. E., and W. Molnar. Malfunction of ventriculoatrial shunts caused by the circulatory dynamics of coughing. J. Neurosurg. 36: 283–286, 1972.
 110. Negus, V. E. The Comparative Anatomy and Physiology of the Larynx. New York: Grune & Stratton, 1949.
 111. Newhouse, M., J. Sanchis, and J. Bienenstock. Lung defense mechanisms. N. Engl. J. Med. 295: 990–998, 1976.
 112. O'Connor, G. E., and T. W. F. Russell. Heat transfer in tubular fluid‐fluid systems. Adv. Chem. Eng. 10: 1–53, 1978.
 113. Olsen, C. R., A. E. Stevens, N. B. Pride, and N. C. Staub. Structural basis for decreased compressibility of constricted tracheae and bronchi. J. Appl. Physiol. 23: 35–39, 1967.
 114. Palombini, B., and R. F. Coburn. Control of the compressibility of the canine trachea. Respir. Physiol. 15: 365–383, 1972.
 115. Pavia, D., J. R. M. Bateman, and S. W. Clarke. Deposition and clearance of inhaled particles. Bull. Eur. Physiopathol. Respir. 16: 335–366, 1980.
 116. Pavia, D., P. P. Sutton, J. E. Agnew, M. T. Lopez‐Vidriero, S. P. Newman, and S. W. Clarke. Measurement of bronchial mucociliary clearance. Eur. J. Respir. Dis. Suppl. 127: 41–56, 1983.
 117. Pavia, D., P. P. Sutton, M. T. Lopez‐Vidriero, J. E. Agnew, and S. W. Clarke. Drug effects on mucociliary function. Eur. J. Respir. Dis. Suppl. 128: 304–317, 1983.
 118. Pedersen, A., E. Sandoe, E. Hvidberg, and M. Schwartz. Studies on the mechanism of tussive syncope. Acta Med. Scand. 179: 653–661, 1966.
 119. Perry, R. H., C. H. Chilton, and S. D. Kirkpatrick (editors). Chemical Engineers' Handbook (4th ed.). New York: McGraw‐Hill, 1963.
 120. Pfeffer, R. (editor). Fourth international conference on physicochemical hydrodynamics. Ann. NY Acad. Sci. 404: 1–536, 1983.
 121. Phipps, R. J. The airway mucociliary system. In: Respiratory Physiology III, edited by J. G. Widdicombe. Baltimore, MD: University Park, 1981, vol. 23, chapt. 5, p. 213–260. (Int. Rev. Physiol. Ser.)
 122. Pryor, J. A., B. A. Webber, M. E. Hodson, and J. C. Batten. Evaluation of the forced expiration technique as an adjunct to postural drainage in treatment of cystic fibrosis. Br. Med. J. 2: 417–418, 1979.
 123. Rayl, J. E. Tracheobronchial collapse during cough. Radiology 85: 87–92, 1965.
 124. Rice, D. A. Sound speed in pulmonary parenchyma. J. Appl. Physiol.: Respirat. Environ. Exercise Physiol. 54: 304–308, 1983.
 125. Richardson, P. S., and A. C. Peatfield. Reflexes concerned in the defence of the lungs. Bull. Eur. Physiopathol. Respir. 17: 979–1012, 1981.
 126. Riley, R. L. Disease transmission and contagion control. Am. Rev. Respir. Dis. 125: 16–19, 1982.
 127. Roe, P. F., and B. N. Kulkarni. Pneumomediastinum in children with cough. Br. J. Dis. Chest 61: 147–150, 1967.
 128. Rohrer, F. Die Mechanik des Hustens. Schweiz. Med. Wochenschr. 2: 765–767, 1921.
 129. Ross, B. B., R. Gramiak, and H. Rahn. Physical dynamics of the cough mechanism. J. Appl. Physiol. 8: 264–268, 1955.
 130. Rossman, C. M., R. Waldes, D. Sampson, and M. T. Newhouse. Effect of chest physiotherapy on the removal of mucus in patients with cystic fibrosis. Am. Rev. Respir. Dis. 126: 131–135, 1982.
 131. Scherer, P. W. Mucus transport by cough. Chest 80, Suppl. 6: 830–833, 1981.
 132. Scherer, P. W., and L. Burtz. Fluid mechanical experiments relevant to coughing. J. Biomech. 11: 183–187, 1978.
 133. Schneider, A. P., II, W. R. Daws, and R. D. Adams. The coughing child. Postgrad. Med. 74: 258–260, 1983.
 134. Schoenberg, B. S., J. F. Kuglitsch, and W. E. Karnes. Micturition syncope—not a single entity. J. Am. Med. Assoc. 229: 1631–1633, 1974.
 135. Schroter, R. C., and M. F. Sudlow. Flow patterns in models of the human bronchial airways. Respir. Physiol. 7: 341–355, 1969.
 136. Shapiro, A. H. Steady flow in collapsible tubes. J. Biomech. Eng. 99: 126–147, 1977.
 137. Sharpey‐Schafer, E. P. Effects of coughing on intrathoracic pressure, arterial pressure, and peripheral blood flow. J. Physiol. London 122: 351–357, 1953.
 138. Sharpey‐Schafer, E. P. The mechanism of syncope after coughing. Br. Med. J. 2: 860–863, 1953.
 139. Sharpey‐Schafer, E. P. Effect of respiratory acts on the circulation. In: Handbook of Physiology. Circulation, edited by W. F. Hamilton. Washington, DC: Am. Physiol. Soc., 1965, sect. 2, vol. III, chapt. 52, p. 1875–1886.
 140. Simonsson, B. G., F. M. Jacobs, and J. A. Nadel. Role of autonomic nervous system and the cough reflex in the increased responsiveness of airways in patients with obstructive airway disease. J. Clin. Invest. 46: 1812–1818, 1967.
 141. Smaldone, G. C., and E. H. Bergofsky. Delineation on flow‐limiting segment and predicted airway resistance by movable catheter. J. Appl. Physiol. 40: 943–952, 1976.
 142. Smaldone, G. C., H. Itoh, D. L. Swift, and H. N. Wagner, Jr. Effect of flow‐limiting segments and cough on particle deposition and mucociliary clearance in the lung. Am. Rev. Respir. Dis. 120: 747–758, 1979.
 143. Sneddon, S. L. Fluid Mechanics and Physiology of Cough. Boston, MA: Harvard School of Public Health, 1979. PhD thesis.
 144. Sneddon, S. L., and J. D. Brain. Steady expiratory flow in dog lungs: an isovolume preparation. J. Appl. Physiol.: Respirat. Environ. Exercise Physiol. 51: 1331–1337, 1981.
 145. Srivastava, R. P. S. Liquid film thickness in annular flow. Chem. Eng. Sci. 28: 819–824, 1973.
 146. Sturgess, J., A. J. Palfrey, and L. Reid. Rheological properties of sputum. Rheol. Acta 10: 36–43, 1971.
 147. Sutherland, J. M., and J. H. Tyrer. “Cough syndrome” with suggestions as to the possible role played by cerebral atherosclerosis. Med. J. Aust. 1: 39–42, 1965.
 148. Sutton, P. P., R. A. Parker, B. A. Webber, S. P. Newman, N. Garland, M. T. Lopez‐Vidriero, D. Pavia, and S. W. Clarke. Assessment of the forced expiration technique, postural drainage and directed coughing in chest physiotherapy. Eur. J. Respir. Dis. 64: 62–68, 1983.
 149. Tatterson, D. F., J. C. Dallman, and T. J. Hanratty. Drop sizes in annular gas‐liquid flow. AIChE J. 23: 68–76, 1977.
 150. Von Leden, H., and N. Isshiki. An analysis of cough at the level of the larynx. Arch. Otolaryngol. 81: 616–625, 1965.
 151. Wanner, A. Clinical aspects of mucociliary transport. Am. Rev. Respir. Dis. 116: 73–125, 1977.
 152. Warwick, W. J. Mechanisms of mucous transport. Eur. J. Respir. Dis. Suppl. 127: 162–167, 1983.
 153. Weaver, D. S., and M. P. Paidoussis. On collapse and flutter phenomena in thin tubes conveying fluid. J. Sound Vib. 50: 117–132, 1977.
 154. Webster, P. M., R. P. Sawatzky, V. Hoffstein, R. Leblanc, M. J. Hinchey, and P. A. Sullivan. Aeroelastic modelling of expiratory flow limitation (Abstract). Federation Proc. 42: 1008, 1983.
 155. Webster, P. M., N. Zamel, M. Hinchey, and P. A. Sullivan. Clearance of viscous material from artificial trachea by flow‐limitation induced wall oscillation (Abstract). Am. Rev. Respir. Dis. 123: 178, 1981.
 156. Whittenberger, J. L., and J. Mead. Research in tuberculosis and related subjects. Respiratory dynamics during cough. Transactions Natl. Tuberc. Assoc., 48th Annu. Meet., New York, 1952, p. 414–418.
 157. Widdicombe, J. G. Respiratory reflexes. In: Handbook of Physiology. Respiration, edited by W. O. Fenn and H. Rahn. Washington, DC: Am. Physiol. Soc., 1964, sect. 3, vol. I, chapt. 24, p. 585–630.
 158. Widdicombe, J. G. Mechanism of cough and its regulation. Eur. J. Respir. Dis. Suppl. 110: 11–15, 1980.
 159. Williams, B. Cerebrospinal fluid pressure changes in response to coughing. Brain 99: 331–346, 1976.
 160. Williams, B. Cough headache due to craniospinal pressure dissociation. Arch. Neurol. 37: 226–230, 1980.
 161. Wilson, T. A., R. E. Hyatt, and J. R. Rodarte. The mechanisms that limit expiratory flow. Lung 158: 193–200, 1980.
 162. Wolff, R. K., M. B. Dolovich, G. Obminski, and M. T. Newhouse. Effects of exercise and eucapnic hyperventilation on bronchial clearance in man. J. Appl. Physiol.: Respirat. Environ. Exercise Physiol. 43: 46–50, 1977.
 163. World Health Organization. Opiates and Their Alternates for Pain and Cough Relief. Geneva: World Health, 1972, p. 1–19. (Tech. Rep. Ser. No. 495.)
 164. Yanagihara, N., H. Von Leden, and E. Werner‐Kukuk. The physical parameters of cough: the larynx in a normal single cough. Acta Oto‐Laryngol. 61: 495–510, 1966.
 165. Yih, C. Stability of a non‐Newtonian liquid flowing down an inclined plane. Phys. Fluids. 8: 1257–1262, 1965.
 166. Yih, C. Fluid Mechanics. New York: McGraw‐Hill, 1969.

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David E. Leith, James P. Butler, Steven L. Sneddon, Joseph D. Brain. Cough. Compr Physiol 2011, Supplement 12: Handbook of Physiology, The Respiratory System, Mechanics of Breathing: 315-336. First published in print 1986. doi: 10.1002/cphy.cp030320