Acta Physiol 2007, 190, 351–358

Chest wall kinematics during cough in healthy subjects

B. Lanini,1 R. Bianchi,1 B. Binazzi,1 I. Romagnoli,1 F. Pala,1 F. Gigliotti1 and G. Scano1,2

1 Section of Respiratory Rehabilitation, Fondazione Don C. Gnocchi ONLUS (IRCCS), Pozzolatico, Firenze, Italy
2 Section of Respiratory Disease, Department of Internal Medicine, University of Florence, Firenze, Italy

Received 30 October 2006, Abstract

revision requested 11 December
2006,
revision received 1 February 2007,
accepted 8 February 2007
Correspondence: B. Lanini, MD,
Section of Respiratory
Rehabilitation, Fondazione Don C.
Gnocchi ONLUS (IRCCS), Via
Imprunetana124, 50020
Pozzolatico, Firenze, Italy.
E-mail: laninibarbara@yahoo.it
Aim: The study of kinematics of the chest wall (CW) could allow us to define
the relative deflationary contribution of its compartments during fits of
coughing. We hypothesized that if forces applied to the lung apposed rib cage
are not commensurate with those applied to the abdomen-apposed rib cage,
cough could result in rib cage distortion.
Methods: In 12 (five women) healthy subjects we evaluated the volumes of
CW (Vcw) and its compartments: the lung apposed rib cage, the abdomen
apposed rib cage and the abdomen, by optoelectronic plethysmography. The
loop of volume of the lung apposed rib cage/volume of the abdomen apposed
rib cage allowed the calculation of mean rib cage distortion, resulting in a
dimensionless number which, when multiplied by 100, gives percentage
distortion. Each subject performed voluntary single and prolonged coughing
efforts at functional residual capacity (FRC) and after maximal inspiration
(max). The normal level of mean distortion was set at <0.5%.
Results: The three compartments contributed to reducing end-expiratory
Vcw during cough at FRC and prolonged maximum cough, with the latter
resulting in the greatest CW deflation. Mean rib cage distortion did not differ
between men and women (P > 0.1), but tended to significantly increase from
single to prolonged Cough Max (1.3%  1.0 vs. 2.3%  1.6, respectively;
P ¼ 0.06).
Conclusion: Rib cage distortion may ensue during coughing, probably as a
result of uneven distribution of forces applied to the rib cage.
Keywords chest wall kinematics, cough, rib cage distortion.

Cough is a wide field that has been reviewed extensively
(McCool & Leith 1987, Bouros et al. 1995, Irwin et al.
1998). The existing descriptions and insights into basic
mechanisms of forced expiration and cough are reason-
ably satisfactory, but knowledge of thoracoabdominal
kinematics involved in cough is still rudimentary.
Increased information on the kinematics of the chest wall
(CW) would allow us to define the relative deflationary
contribution of its compartments during fits of coughing.
Studies about CW mechanics during cough are scarce and
carried out using linearized magnetometers which are
unreliable in conditions other than quiet breathing (QB).
Melissinos et al. (1978) reported that paradoxically the
abdominal diameter increases during decompression
while the rib cage diameter continuously decreases.
Morris et al. (1979) found that the two lateral high-
and low-level diameters of the rib cage moved in opposite
directions during voluntary cough in seven normal
subjects, with this paradoxical movement potentially
being the mechanism of cough fracture (Pearson 1957).
However, because the CW is likely to move with
more than two degrees of freedom during cough, when
the xiphopubic axis shortens (McCool 1995), magne-
tometers turn out to be inaccurate for partitioning CW
volumes (Vcw) into the contribution of rib cage and
abdomen. Studying fits of coughing by optoelectronic
plethysmography (OEP) in healthy subjects allows the
non-invasive assessment of Vcw during breathing with-
out any assumption of the number of degrees of
freedom of the CW (Cala et al. 1996).

Ó 2007 The Authors

Journal compilation Ó 2007 Scandinavian Physiological Society, doi: 10.1111/j.1748-1716.2007.01701.x 351
Chest wall and cough Æ B Lanini et al. Acta Physiol 2007, 190, 351–358

Healthy subjects at rest breathe within the parameters
of their relaxation characteristics both for the CW as a
whole and for the rib cage in particular. Crawford et al.
(1983) and McCool et al. (1985) stated that the nearly
unitary behaviour of the rib cage during breathing must
require coordinated muscle activity ‘and that the
intrinsic stability of the rib cage, which presumably
varies substantially between individuals is not adequate
to account for it’ (McCool et al. 1985).
The three-compartment model of the CW (the
pulmonary rib cage, abdominal rib cage and abdomen)
(Kenyon et al. 1997) dictates that contraction of the
abdominal muscles has both a deflationary action on the
lower rib cage via their insertional component (the
rectus and obliquus muscles), and an inflationary action
via their non-insertional components (the tranversus
muscle), the net effect being such that upper rib cage
deflation is commensurate with lower rib cage deflation
(Kenyon et al. 1997). However, if forces applied to the
upper rib cage are out of proportion with those applied
to the lower rib cage, distortion might ensue during fits
of coughing. In this way the abdominal rib cage is
exposed to greater positive abdominal pressure (Pab) at
the end of expiration during cough (Man et al. 2003).
We therefore hypothesized that uneven distribution of
operating forces may result in rib cage distortion during
coughing.
Materials and methods
Subjects
We evaluated 12 (five women) non-smoking healthy
subjects (mean age 36.3  8.5 years), with normal lung
function (see Table 1). All were familiar with
pulmonary function techniques. The study was ap-
proved by the institutional Ethics Committee, and
informed consent was obtained from each subject.
Protocol
We evaluated voluntary single (s) and prolonged (p)
coughing performed at functional residual capacity
(FRC), and after a maximal inspiration (Max). The
subjects performed each of the four coughing man-
oeuvres: Cough FRCp, Cough FRCs, Cough Maxp,
Cough Maxs in a sitting position at least three times. We
chose the manoeuvre with the largest peak expiratory
flow for analysis.
Pulmonary function tests
Routine spirometry, obtained with subjects seated in a
comfortable armchair, was measured according to
European Community for Coal and Steel guidelines
(Quanjer et al. 1993). Lung volumes (FRC, vital capa-
city and total lung capacity) were measured with a body
plethysmograph (Autobox DL 6200; SensorMedics,
Yorba Linda, CA, USA). The normal values for lung
function were those of the European Community for
Coal and Steel (Quanjer et al. 1993).
Optoelectronic measurements
The OEP allows accurate three-dimensional computa-
tion of the Vcw based on coordinates from 89 surface
markers attached to the CW surface (Cala et al. 1996).
Details of this technique have been thoroughly des-
cribed previously (Lanini et al. 2003, Binazzi et al.
2006, Romagnoli et al. 2006). In brief, the coordinates

Table 1 Anthropometric and respiratory functional data of the subjects

Age (years) Sex (F/M) BMI (kg m)2) FEV1 (% pv) FEV1/VC (%) FRC (% pv) TLC (% pv) VC (% pv)

1 29 F 23.4 104 74 91 103 108

2 30 M 27.8 98 98 106 112 106
3 54 M 23.1 85 85 101 84 80
4 40 F 22.1 88 88 98 97 96
5 34 F 26.3 105 82 109 113 97
6 38 F 22.8 95 77 92 101 98
7 33 M 26.0 89 90 102 98 107
8 31 F 20.4 93 79 112 103 95
9 28 M 22.7 97 84 93 117 103
10 50 M 18.1 103 92 81 93 97
11 40 M 20.4 108 89 97 109 106
12 29 M 20.7 107 91 105 115 110
Mean 36.3 22.1 100.8 85.6 98.9 103.7 104.6
SD 8.5 3.0 11.6 5.5 8.8 9.9 12.6

BMI: Body Mass Index; FEV1, forced expiratory volume in the first second; FRC, functional residual capacity; TLC, total lung
capacity; VC, vital capacity; pv, predicted value; SD, standard deviation.

Ó 2007 The Authors

352 Journal compilation Ó 2007 Scandinavian Physiological Society, doi: 10.1111/j.1748-1716.2007.01701.x
Acta Physiol 2007, 190, 351–358
of the markers were tracked by four infrared charge-
coupled TV-cameras (two 4 m in front and two 4 m
behind the subject) at a sampling rate of 50 Hz.
Volumes were calculated from the surface triangulation
between the marker points. The total Vcw was modeled
as the sum of volume of the rib cage apposed to the lung
(Vrc,p), volume of the rib cage apposed to the abdomen
(Vrc,a) and volume of the abdomen (Vab) (see Fig. 4 in
Kenyon et al. 1997).
Rib cage distortion measurements
The undistorted rib cage configuration was defined by
plotting the Vrc,p loop against the Vrc,a loop during
tidal volume (VT) breathing. Rib cage distortion was
evaluated comparing the Vrc,p–Vrc,a plots to the
undistorted rib cage configuration in the volume range
of tidal breathing during Cough Maxp and Cough
Maxs. We used the method of Chihara et al. (1996) and
measured the perpendicular distance of the cough
configuration away from the relaxation line divided by
the value of Vrc,p at the insertion point. This results in a
dimensionless number which, when multiplied by 100,
gives percentage distortion. The method allows assess-
ment of inter-individual rib cage distortion. Based on
the data of Kenyon et al. (1997), the mean acceptable
rib cage distortion was arbitrarily set at <0.5%.
Statistical analysis
Data are presented as mean  SD. Differences between
values were tested by Student’s paired t-test. The Vcw
compartments during cough manoeuvres were com-
pared using two-way analysis of variance (anova). The
Bonferroni test was used for multiple comparisons.
P < 0.05 was considered to be statistically significant.
All statistical procedures were carried out using the
Statgraphics Plus 5.1 statistical package (Statistical
Graphics Corp., Rockville, MD, USA).
Results
Figure 1 shows the changes in the compartmental Vcw
during QB and the four cough manoeuvres (Cough
FRCs, Cough FRCp, Cough Maxs, Cough Maxp).
Compared with QB, the Vcw compartments during all
cough manoeuvres, but not the Vrc during Cough Maxs,
contributed to reducing end-expiratory volume dis-
placement of the CW (anova, P < 0.01); this is shown
in Figure 2 where the plots of Vrc/Vab at end-expiration
(EE) are all below the identity line during Cough Maxs.
Rib cage distortion means and ranges were assessed
by plotting Vrc,p vs. Vrc,a during Cough Maxs and
Cough Maxp in all subjects but one (subject no. 4, in
whom no change in Vab was found when she relaxed,
Ó 2007 The Authors
Journal compilation Ó 2007 Scandinavian Physiological Society, doi: 10.1111/j.1748-1716.2007.01701.x
B Lanini et al. Æ Chest wall and cough
with the plot being a vertical line). Some subjects with
minimal (no. 2) or null (no. 6, 8) distortion during
Cough Maxs exhibited an increased distortion during
Cough Maxp (Table 2). Group mean level of distortion
tended to be greater (P ¼ 0.06) during Cough Maxp
(2.3  1.6%; range 1  0.5%) than during Cough
Maxs (1.3  1.0%; range 0.9  0.6%), with maximal
distortion being approx. 5% in subject no. 12 during
Cough Maxp (Table 2). Nonetheless, distortion did not
differ during Cough Maxs and Cough Maxp in men
(1.2  0.5% and 2.4  0.1%, respectively, P ¼ ns) just
as in women (1.6  1.6% and 2.1  0.9%, respect-
ively, P ¼ ns), with no gender difference (P ¼ ns).
Individual cough lines are plotted on undistorted loops
in Figure 3. Cough lines were shifted down and to the
right, indicating for a given Vrc,a a lower than relaxed
Vrc,p in subjects no. 1, 3, 6, 7, 11 (in part) and 12
during Cough Maxs and in subjects no. 1, 5–7 and 8 (in
part) during Cough Maxp. Cough lines were shifted
upward and leftward in subjects no. 2, 5, 8–10 and 11
(in part) during Cough Maxs and in subjects no. 2, 3,
9–12 during Cough Maxp. Subjects no. 3, 5, 12 changed
the pattern of distortion from single to prolonged
cough.
Discussion
The novel findings in this study are as follows: (i) the
three compartments contribute to reducing end-expir-
atory Vcw during cough at FRC, prolonged maximum
cough and with the exception of the rib cage, during
single maximum cough; (ii) prolonged fits of maximum
cough result in the greatest CW deflation; and (iii)
mild to moderate levels of rib cage distortion were
found during both single and prolonged maximum
cough, with the difference being close to a significant
level (P ¼ 0.06). Had we studied more subjects the
difference would have reached statistical significance
(P < 0.05).
Comments on methodology
Previous studies on the effect of coughing on thoraco-
abdominal mechanics were carried out using magne-
tometers (Melissinos et al. 1978, Morris et al. 1979).
This non-invasive method considered the overall VT as
the sum of the concurrent changes in volume of the rib
cage (VTrc) and abdomen (VTab) (Konno & Mead
1967). Within limits, these two compartments can be
considered has having a single degree of freedom, so
that when appropriately calibrated, the summed motion
of the two parts yields VT. However, the validity of the
experimental calibration coefficients used to convert
one or two dimensions to volume is limited to the
conditions under which the calibration is performed and
353
Chest wall and cough Æ B Lanini et al. Acta Physiol 2007, 190, 351–358

3 3
End expiratory volume
2 2 End inspiratory volume
1 1

Vrc, p (l)
Vcw (l)
0 0
–1 –1
–2 –2
–3 –3

QB

Cough FRCs

Cough FRCp

Cough Maxs

Cough Maxp

QB

Cough FRCs

Cough FRCp

Cough Maxs

Cough Maxp
3 3

2 2

1 1
Vrc, a (l)

Vab (l)
0 0

–1 –1

–2 –2

–3 –3

QB

Cough FRCs

Cough FRCp

Cough Maxs

Cough Maxp
QB

Cough FRCs

Cough FRCp

Cough Maxs

Cough Maxp

Figure 1 Chest wall kinematics during cough. Vcw: volume of the chest wall; Vrc,p: volume of pulmonary apposed rib cage; Vrc,a:
volume of abdomen apposed rib cage; Vab: volume of abdomen; QB: quiet breathing; Cough FRCs: a single fit of cough at
functional residual capacity; Cough FRCp: prolonged cough at functional residual capacity; Cough Maxs: a single fit of cough after
Max; Cough Maxp: prolonged cough after Max. Values are mean and SE.

does not apply to different conditions, such as use mouthpieces, nose clip or face masks, which may
respiratory effort during cough, laughing, hyperventila- alter the movements of the mouth and cheeks and the
tion whatever obtained. In addition, particularly in a respiratory system response (Weissman et al. 1984,
clinical setting, adequate calibration data may be McCool et al. 1986). OEP allowed Aliverti et al. (1997)
difficult to obtain because of poor subject cooperation. and Kenyon et al. (1997) to recently revise the mech-
It has also been shown that the CW moves with more anism underlying rib cage distortion in healthy humans.
than two degrees of freedom even during breathing at The two rib cage compartments are mechanically
rest (Ward et al. 1992) and indeed the rib cage has been coupled to each other (Ward et al. 1992) with the
recently described as a two-compartment system: the rib relationship between volume of pulmonary rib cage
cage apposed to the lung (pulmonary rib cage, RCp) (Vrc,p) and volume of abdominal rib cage (Vrc,a)
and the rib cage apposed to the abdomen (RCa) (Ward defining the undistorted rib cage configuration during
et al. 1992, Kenyon et al. 1997). OEP has been recently QB (Kenyon et al. 1997). Accordingly, we evaluated rib
developed that allows the non-invasive assessment of cage distortion during cough as the displacement of
Vcw during breathing without any assumption of the Vrc,p/Vrc,a line away from the relaxed rib cage
number of degrees of freedom of the CW (Cala et al. configuration during QB.
1996). The choice of the OEP system in this study was
based on two fundamental principles: firstly, to safe-
Comments on results
guard the naturalness of cough and secondly, to
guarantee the highest accuracy in measuring lung As shown, Vab and Vrc contribute to deflating CW with
volumes. The lack of interference of the system with cough at FRC and prolonged maximum cough; in
natural breathing is as a result of the fact that it does not contrast, Vrc did not contribute to deflating the Vcw

Ó 2007 The Authors

354 Journal compilation Ó 2007 Scandinavian Physiological Society, doi: 10.1111/j.1748-1716.2007.01701.x
Acta Physiol 2007, 190, 351–358 B Lanini et al. Æ Chest wall and cough
Table 2 Rib cage distortion

Subject no. Cough Maxs (%) Cough Maxp (%)

1 3.67 (2.9–4.3) 3.45 (2.7–4.1)

2 0.69 (0.6–0.8) 3.21 (2.7–3.9)
3 1.88 (1.2–2.5) 2.40 (1.0–2.8)
5 1.85 (0.5–2.9) 1.96 (1.4–2.6)
6 0.33 (0.3–0.4) 1.39 (1.3–1.4)
7 1.38 (0.5–1.8) 0.43 (0.2–0.6)
8 0.38 (0.1–0.5) 1.54 (0.6–2.2)
9 0.75 (0.3–1.2) 0.40 (0.2–0.5)
10 1.89 (1.5–2.3) 4.49 (3.8–5.1)
11 0.97 (0.4–1.7) 1.30 (0.7–2.0)
12 0.86 (0.7–1.1) 5.03 (4.8–5.3)
Mean 1.3 2.3
SD 1.0 1.6
P value 0.06

Each value is the mean of three measurements and ranges in

parenthesis.
Cough Maxs, single fit of coughing after maximal inspiration;
Figure 2 Plot of changes (D) in end expiratory volume of Vrc
Cough Maxp, prolonged cough after maximal inspiration.
and Vab during Cough Maxs. VrcEE: end expiratory volume of
rib cage; VabEE: end expiratory volume of abdomen. Dotted
line is identity line.

action of the diaphragm and other inspiratory muscles

with a single maximum cough. Possible reasons might (Coryllos 1937, Melissinos et al. 1978, Morris et al.
involve either or both of the following: (i) relatively 1979, Melissinos et al. 1981, Bouros et al. 1995,
small pressure production of expiratory rib cage mus- Kyroussis et al. 1996); (ii) inflating action operating
cles during expulsive phase because of antagonistic on the rib cage by non-insertional muscular component

7.5 13.8 13.8 6.4

7.4 13.7 13.7 6.3
7.3 13.6
Vrc,p (l)

13.6 6.2
V rc,p (l)

Vrc,p (l)
Vrc,p (l)

7.2 13.5 6.1

7.1 13.5 13.4
7.0 6.0
13.4 13.3
6.9 13.2 5.9
6.8 n1 13.3 n2 13.1 n3 5.8 n5
6.7 13.2 13.0 5.7
1.85 1.90 1.95 2.00 2.05 2.10 3.35 3.40 3.45 3.50 3.55 2.70 2.75 2.80 2.85 2.90 2.95 3.00 1.76 1.78 1.80 1.82 1.84 1.86 1.88 1.90 1.92 1.94 1.96
Vrc,a (l) Vrc,a (l) Vrc,a (l) Vrc,a (l)

10.6 11.3
10.4 11.2 8.65
Vrc,p (l)

11.1 8.60
Vrc,p (l)

10.2
Vrc,p (l)

11.0 8.55
10.0
8.50
9.8 10.9
8.45
9.6 10.8 n7
n6 8.40 n8
9.4 10.7 8.35
2.70 2.75 2.80 2.85 2.90 2.95 3.00 2.12 2.14 2.16 2.18 2.20 2.22 2.24 2.26 2.28 2.18 2.20 2.22 2.24 2.26 2.28 2.30 2.32
Vrc,a (l) Vrc,a (l) Vrc,a (l)

12.6 11.1 15.4

12.5 10.7 11.0 15.2
12.4 10.7 10.9 15.0
Vrc,p (l)

Vrc,p (l)
Vrc,p (l)

Vrc,p (l)

12.3 10.6 14.8

10.8
10.6 14.6
12.2 10.7
10.5 14.4
12.1 10.5 10.6 14.2
12.0 n9 10.4 n 10 10.5 14.0 n 12
n 11
11.9 10.4 10.4 13.8
3.64 3.66 3.68 3.70 3.72 3.74 3.76 3.78 3.80 2.65 2.70 2.75 2.80 2.85 2.90 3.1 3.2 3.3 3.4 3.5 3.55 3.60 3.65 3.70 3.75 3.80 3.85 3.90
Vrc,a (l) Vrc,a (l) Vrc,a (l) Vrc,a (l)

Figure 3 Rib cage distortion during single and prolonged fits of cough after maximal inspiration. Vrc,p: volume of pulmonary
apposed rib cage; Vrc,a: volume of abdomen apposed rib cage; dotted loop: quiet breathing; continuous line: Cough Maxs; dashed
line: Cough Maxp.

Ó 2007 The Authors

Journal compilation Ó 2007 Scandinavian Physiological Society, doi: 10.1111/j.1748-1716.2007.01701.x 355
Chest wall and cough Æ B Lanini et al. Acta Physiol 2007, 190, 351–358

Figure 4 Plots of gastric pressure (Pga) vs. esophageal pressure (Pes). The thick identity line is zero Pdi isopleth; continuous and
dashed lines define Pdi over tidal volume during Cough Maxs and Cough Maxp, respectively in subjects 6, 7, 9, 11. Pdi is the trans-
diaphragmatic pressure. For explanation see text.

(transversus muscle) of Pab was not counterbalanced
by deflating action of insertional muscle component
(external and internal obliquus and rectus muscles) of
Pab.
Melissinos et al. (1978) reported that the abdominal
diameter increased while the rib cage diameter continu-
ously decreased during decompression. In a preliminary
report Morris et al. (1979) studied the CW configur-
ation during voluntary cough in seven normal subjects.
By using linearized magnetometers, they monitored
antero-posterior diameter of both rib cage (RCa-p) and
abdomen (Abda-p), and lateral diameters of the rib cage
at high (RCH-L) and low (RCL-L) levels. CW diameters
decreased abruptly during the compression phase,
except for RCa-p. With the glottis opened, RCa-p and
RCH-L showed a rapid inward motion while RCL-L and
Abda-p either held their positions constant, or more
commonly moved outwards in paradoxical function. As
a consequence, the two lateral diameters of the rib cage
moved in opposite directions during cough. We are
aware of the difficulty of comparing the present results
with the preliminary data of Morris et al. (1979) and
Melissinos et al. (1978), because of the different tech-
niques. However, it is likely that we found smaller
distortion because we measured volume distortion,
whereas Morris et al. (1979) and Melissinos et al.
(1978) measured rib cage dimension, a circumstance
under which deducing volume from a single dimension
would lead to a systematic overestimation of the volume
of the rib cage apposed to the abdomen (Kenyon et al.
1997).
Unitary behaviour of the rib cage requires that the net
pressures acting on the two rib cage compartments be
equal, and this would require considerable coordination
of the respiratory muscles, the diaphragm, rib cage and
abdominal muscles (Crawford et al. 1983, McCool
et al. 1985, Aliverti et al. 1997, Kenyon et al. 1997).
The net pressure acting on rib cage compartments must
therefore be closely similar. Inasmuch as the abdominal
rib cage is exposed to a large positive inflating Pab at EE
during cough (Man et al. 2003), this must be counter-
balanced by a strong deflating expiratory action result-
ing from active contraction of the expiratory muscles.
Because the insertional component of the abdominal

Ó 2007 The Authors

356 Journal compilation Ó 2007 Scandinavian Physiological Society, doi: 10.1111/j.1748-1716.2007.01701.x
Acta Physiol 2007, 190, 351–358
muscles is a major contributor to this expiratory action
it plays a key role in minimizing rib cage distortion
(Kenyon et al. 1997). Herein lies the explanation for
minimal rib cage distortion (<0.5%) at every level of
incremental exercise (Aliverti et al. 1997, Kenyon et al.
1997) in healthy subjects. It follows that one of the
principal reasons for distortion is that the pressure
acting on the part of the rib cage apposed to the costal
surface of the lung is quite different from that acting on
the part apposed to the abdomen.
We performed some additional experiments indica-
ting that rib cage distortion is in part as a result of the
above reasons. Esophageal (Pes) and gastric (Pga)
pressures were measured via balloon catheters as
previously described (Romagnoli et al. 2006). Because
esophageal and gastric balloons might have disturbed
the naturalness of cough, to minimize these potential
effects we selected five subjects from among those
who had previously experienced positioning of bal-
loons for other studies with no negative experience.
However, in one of the five subjects no pressure
measurement was obtained as a result of her inability
to provide reproducible measurements of Pes because of
esophageal spasms. As shown in Figure 4, Pga values
exceeded the Pes values (positive Pdi) in subjects no. 6
and 7 who for a given Vrc,a exhibited a lower than
relaxed Vrc,p during cough manoeuvres. We reasoned
that a constant positive transdiaphragmatic pressure
(Pdi ¼ Pga)Pes), of different amounts, would lead to
the pattern exhibited by subjects no. 1, 3, 7 and 12
during single fits of maximum cough, and in subjects
no. 1, 5–8 during prolonged fits of maximum cough. On
the other hand, a positive Pdi was also found in subjects
no. 9 and 11 (Fig. 4) who for a given Vrc,a exhibited a
greater than relaxed Vrc,p during cough manoeuvres.
We believe that inherent stiffness, or variability in
intrinsic stability of the rib cage (McCool et al. 1985)
could have substantially contributed to the latter
pattern. Nonetheless, the role of axial strain of either
compartment in the absence of distortion would
produce stress on the other; this cannot be excluded
a priori.
Finally, in confirming unpublished data by Morris
et al. (see Bouros et al. 1995) we have found that the
CW did not significantly differ between men and
women during fits of coughing.
In conclusion, the present results confirm our starting
hypothesis that a noticeable rib cage distortion ensues
during coughing if the action of the muscle force acting
on the lower rib cage is not commensurate with the
force acting on the upper rib cage.
Conflict of interest
We declare that there are no conflicts of interest.
Ó 2007 The Authors
Journal compilation Ó 2007 Scandinavian Physiological Society, doi: 10.1111/j.1748-1716.2007.01701.x
B Lanini et al. Æ Chest wall and cough
References
Aliverti, A., Cala, J.S., Duranti, R., Ferrigno, G., Kenyon,
C.M., Pedotti, A. et al. 1997. Human respiratory muscle
actions and control during exercise. J Appl Physiol 83,
1256–1269.
Binazzi, B., Lanini, B., Bianchi, R. et al. 2006. Breathing pat-
tern and kinematics in normal subjects during speech, sing-
ing and loud whispering. Acta Physiol 186, 233–246.
Bouros, D., Siafakas, N. & Green, M. 1995. Cough physio-
logical and pathophysiological considerations. In: C. Rous-
sos (ed.) The Thorax, pp. 1335–1354. Marcel Dekker Inc.,
New York.
Cala, S.J., Kenyon, C.M., Ferrigno, G. et al. 1996. Chest wall
and lung volume estimation by optical reflectance motion
analysis. J Appl Physiol 81, 2680–2689.
Chihara, K., Kenyon, C. & Macklem, P.T. 1996. Human rib
cage distortability. J Appl Physiol 81, 437–447.
Coryllos, P.N. 1937. Action of the diaphragm in cough. Am J
Med Sci 194, 523–535.
Crawford, A.B.H., Dodd, D. & Engel, L.A. 1983. Changes in
the rib cage shape during quiet breathing, hyperventilation
and single inspiration. Respir Physiol 54, 197–209.
Irwin, R.S., Boulet, L.P., Cloutier, M.M. et al. 1998. Managing
cough as a defence mechanism and as a symptom. A con-
sensus panel report of the American College of Chest Phy-
sicians. Chest 114, 133S–181S.
Kenyon, C.M., Cala, S.J., Yan, S. et al. 1997. Rib cage
mechanics during quiet breathing and exercise in humans.
J Appl Physiol 83, 1242–1255.
Konno, K. & Mead, J. 1967. Measurement of the separate
volume changes of rib cage and abdomen during breathing.
J Appl Physiol 22, 407–422.
Kyroussis, D., Polkey, M.I., Hughes, P.D. et al. 1996.
Abdominal muscle strength measured by gastric pressure
during maximal cough (abstract). Thorax 51 (Suppl. 3), A45.
Lanini, B., Bianchi, R., Romagnoli, I. et al. 2003. Chest wall
kinematics in patients with hemiplegia. Am J Respir Crit
Care Med 168, 109–113.
Man, W.D.C., Kyroussis, D., Fleming, T.A. et al. 2003. Cough
gastric pressure and maximum expiratory mouth pressure in
humans. Am J Respir Crit Care Med 168, 714–717.
McCool, D.F. 1995. Non invasive methods for measuring
ventilation. In: C. Roussos (ed.) The Thorax, pp. 1049–
1070. Marcel Dekker Inc., New York.
McCool, D.F. & Leith, D.E. 1987. Pathophysiology of cough.
Clin Chest Med 8, 189–195.
McCool, F.D., Loring, S.H. & Mead, J. 1985. Rib cage dis-
tortion during voluntary and involuntary breathing acts.
J Appl Physiol 58, 1703–1712.
McCool, F.D., Kelly, K.D., Loring, S.H., Greaves, I.A. &
Mead, J. 1986. Estimates of ventilation from body surface
measurements in unrestrained subjects. J Appl Physiol 61,
1114–1119.
Melissinos, C.G., Leith, D.E., Brody, J.S., Bruce, E. & Mead, J.
1978. Thoracoabdominal mechanic in spontaneous cough
(abstract). Am Rev Respir 117, 372.
Melissinos, C.G., Bruce, E., Goldman, M.D., Elliott, E. & Mead,
J. 1981. Pattern of diaphragmatic activity during forced
expiratory vital capacity. J Appl Physiol 51, 1515–1525.
357
Chest wall and cough Æ B Lanini et al.
Morris, A.J.R., Siafakas, N. & Green, M. 1979. Thor-
acoabdominal motion and pressures during coughing
(abstract). Thorax 34, 421.
Pearson, J.E.G. 1957. Cough fracture of the ribs. Br J Tuberc
Dis Chest 51, 251–254.
Quanjer, P.H., Tammeling, G.J., Cotes, J.E. et al. 1993. Lung
volumes and forced ventilatory flows. Report Working Party
Standardization of lung function tests, European Commu-
nity for Steel and Coal. Official Statement of the European
Respiratory Society. Eur Respir J 6 (Suppl. 16), 5–40.
358 Journal compilation Ó 2007 Scandinavian Physiological Society, doi: 10.1111/j.1748-1716.2007.01701.x
Acta Physiol 2007, 190, 351–358
Romagnoli, I., Gorini, M., Gigliotti, F., Bianchi, R., Lanini, B.,
Grazzini, M. et al. 2006. Chest wall kinematics, respiratory
muscles action and dyspnoea during arm vs. leg exercise in
humans. Acta Physiol (Oxf) 188, 233–246.
Ward, M.E., Ward, J.W. & Macklem, P.T. 1992. Analysis of
human chest wall motion using a two-compartment rib cage
model. J Appl Physiol 72, 1338–1347.
Weissman, C., Askanazi, J., Milic-Emili, J. & Kinney, J.M.
1984. Effect of respiratory apparatus on respiration. J Appl
Physiol 57, 475–480.
Ó 2007 The Authors