Global Physiology and Pathophysiology

of Cough
ACCP Evidence-Based Clinical Practice Guidelines
F. Dennis McCool, MD, FCCP

Objective: The anatomy and neurophysiology of cough has been reviewed in the preceding
section. The objective of this section is to describe how the varied anatomic components of the
respiratory system work in concert to produce an effective cough.
Methods: This was accomplished by reviewing (1) the factors needed to produce effective cough
pressures and gas velocity in the airways, and (2) the salient features of the interaction between
the airflow generated during a cough and the mucus that lines the tracheobronchial tree. The
MEDLINE database was searched for this review, and the search consisted of studies published
in English between 1960 and April 2004. Search terms were “cough mechanics” and “cough
physiology.”
Results: Inhaling to high lung volumes and glottic closure prior to the expiratory phase of cough
facilitate the generation of high intrathoracic pressures. These high intrathoracic pressures (1)
provide the driving force for airstream flow during cough and (2) dynamically compress the
central airways, which further enhances the cough airstream velocity.
Conclusions: High intrathoracic pressures are needed to generate the requisite cough expiratory
flows and airstream velocities. However, cough may be effective in individuals with mild-to-
moderate degrees of respiratory muscle weakness, as only modest increases in intrathoracic
pressure are needed to dynamically compress the large intrathoracic airways and increase cough
flow velocity. (CHEST 2006; 129:48S–53S)

Key words: expiratory flow; intrathoracic pressure; mucociliary clearance; mucous rheology; respiratory muscles

C ough serves to clear the airways when there are

(1) large amounts of inhaled material, (2) large
amounts of mucus due to excessive secretions or
impaired mucociliary clearance, and (3) large
amounts of abnormal substances such as edema fluid
or pus. Each cough involves a complex reflex arc.
The neurophysiology of this reflex has been reviewed
in the previous section. An effective cough depends
on the ability to drive gas at high linear velocities
through the airways, and on an effective interaction
between the flowing gas and mucus lining the air-
ways. These events depend on the capacity of the
respiratory muscles to increase intrathoracic pres-
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: F. Dennis McCool, MD, FCCP, Department
of Pulmonary and Critical Care Medicine, Memorial Hospital
of RI, 111 Brewster St, Pawtucket, RI 02860; e-mail:
F_McCool@brown.edu
sures and dynamically compress the airways. The
MEDLINE database was searched for this review,
and the search consisted of studies published in
English between 1960 and April 2004. Search terms
were “cough mechanics” and “cough physiology.”
Review of the Global Physiology of
Cough
Cough Mechanics
Cough mechanics can be evaluated by considering
the timing of the varied events that constitute cough.
The sequence of events that lead to an effective
cough has been previously described, and the phases
have been classified as inspiratory, compressive, and
expiratory (Fig 1).1–7 The initial phase of cough is
characterized by the inhalation of gas. The volume of
gas that is inhaled may be as little as 50% of tidal
volume or as great as 50% of vital capacity.8,9 During

48S Diagnosis and Management of Cough: ACCP Guidelines


Figure 1. Schematic diagram depicting changes in flow and
subglottic pressure during the inspiratory, compressive (COMP),
and expiratory phases of cough.
inspiration, the expiratory muscles are lengthened
and “strengthened.” The inhalation of a large volume
of gas will produce greater lengthening and will
optimize the expiratory length-tension relationship.
Thus, inhaling to high lung volumes will enable the
expiratory muscles to generate greater positive in-
trathoracic pressures for a given degree of neural
activation. Although a modest degree of positive
intrathoracic pressure is needed to generate expira-
tory flow, an effective cough can be achieved at
pressures much lower than the maximal pressure
that the expiratory muscles are capable of producing.
Thus, this initial phase of cough is not critical
because an effective cough can be accomplished by
inhaling small volumes.
The compressive phase of cough follows the initial
inspiratory phase. After inhaling a volume of air, the
glottis is closed and an expiratory effort ensues. At
the onset of the expiratory effort, the glottis closes
for about 0.2 s. Glottic closure maintains lung vol-
ume as intrathoracic pressures are building. Glottic
closure minimizes expiratory muscle shortening,
thereby promoting an “isometric” contraction of the
expiratory muscles, and allowing the expiratory mus-
cles to maintain a more advantageous force-length
relationship and to generate greater positive intra-
abdominal and intrathoracic pressures. The high
intrathoracic pressures developed during glottic clo-
sure may be as great as 300 mm Hg. The high
intraabdominal and intrathoracic pressures devel-
oped during this phase of cough can be transmitted
to the CNS and mediastinum, and underlie some of
the adverse cardiovascular, GI, genitourinary, mus-
www.chestjournal.org
culoskeletal, and neurologic complications associated
with cough (which are described in more detail in
their respective sections in these guidelines).
Once the glottis is opened, the expiratory phase of
cough ensues, and the high intrathoracic pressures
developed during the compressive phase of cough
promote high expiratory flow rates. Initially, there is
a very brief blast of turbulent flow. This initial peak
of expiratory flow lasts about 30 to 50 ms and may
reach flow rates as great as 12 L/s. This burst of air
is due to the additive effects of the gas expired from
the distal parenchymal units and the gas displaced by
the central airways, which are compressed by the
high intrathoracic pressures.4,5,10 Although glottic
closure enhances this phase of cough, it is not
essential for an effective cough.1,9,11 For example,
individuals with a tracheostomy or endotracheal tube
can produce an effective cough by performing a
huffing maneuver, which is performed with an open
glottis. Accordingly, in patients with endotracheal
tubes, a tracheostomy need not be performed for the
express purpose of improving cough efficiency.
Recommendation
1. In patients with endotracheal tubes, tra-
cheostomy need not be performed to improve
cough effectiveness. Level of evidence, expert
opinion; net benefit, substantial; grade of recom-
mendation, E/A
Following the initial blast of air, there is a more
prolonged period characterized by lower expiratory
flows. This stage lasts 200 to 500 ms with sustained
flows in the range of 3 to 4 L/s.5 During this
timeframe, lung volume falls, transpulmonary pres-
sure decreases, and cough expiratory flows fall. As
expiratory flows diminish, the velocity of the air-
stream is reduced. Because the relationship between
expiratory flow and airstream velocity depends
on the cross-sectional area of the airways
(velocity ⫽ flow/cross-sectional area), the velocity of
the airstream increases as the net cross-sectional area
of the airways decreases for a given rate of expiratory
airflow. It follows that, as air flows from the periph-
ery of the lung to the central airways the velocity of
the gas increases. The velocity of gas in the more
central airways can be further enhanced by the
dynamic compression of these airways. For example,
when the tracheal cross-sectional area is dynamically
compressed to one fifth of its static cross-sectional
area, as may occur during the expiratory phase of
cough, the linear velocity of the gas would increase
by fivefold. Because the kinetic energy of the air-
stream is proportional to the square of the velocity of
CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 49S
the airstream, this degree of dynamic compression
increases its kinetic energy 25-fold.5 Increasing ki-
netic energy, in turn, enhances the removal of mucus
adhering to the airway wall.
Dynamic compression during cough results from
differences between intraluminal and extraluminal
airway pressures (called transmural airway pres-
sure). During a forced expiration, the transmural
pressure at the alveolus is the same as the recoil
pressure of the lung; namely, the increase in pleural
pressure is transmitted to the alveolus. However, as
expiratory flow ensues, the intraluminal pressure
becomes lower, due to the viscous forces, while
extraluminal pressure (pleural pressure) remains el-
evated. Thus, the airways downstream from the
alveolus are subject to dynamic compression. Nor-
mally, dynamic compression is initiated in the tra-
chea and mainstem bronchi at high lung volumes,
and extends to the more peripheral airways as lung
volume decreases, ensuring that the whole length of
the tracheobronchial tree is “coughed.”12 For this to
occur, high intrathoracic pressures must be sustained
throughout the expiratory effort.
Gas-Mucus Interactions
The purpose of cough is to clear the airways. For
cough to effectively remove mucus and particulates,
the secretions that line the airways must be dispersed
into the expiratory gas. The major physical forces
affecting the removal of secretions include the mean
velocity of the air stream and the rheologic proper-
ties of the mucus. The mean velocity of the air
stream is a major determinant of the type of airflow
that occurs in liquid. The generation of high gas
velocities promotes the dispersion of liquid mucus
into the air stream. At the high velocities that are
commonly encountered during cough (ie, ⬎ 2,500
cm/s), mucus is torn off and droplets are suspended
within the airway lumen. This flow pattern is termed
misty flow. At lower velocities, the mucus-gas inter-
action is less effective. Other factors may also be
operant in removing mucus at the high gas velocities
associated with misty flow. First, airflow, in the range
seen during a cough, can create waves of mucus.13
These waves may further enhance particle clear-
ance.14,15 Second, the airways behave more as col-
lapsible tubes than rigid pipes. During cough, they
may vibrate and their walls approximate each other,
further aiding in loosening mucus and promoting
clearance.4,5
The physical properties of mucus also affect cough
efficiency. In the framework of two-phase gas-liquid
flow, mucus clearance is directly proportional to the
depth of the mucus, and is inversely proportional to
its viscosity and elasticity.13,16 –20 Mucus properties
50S
that enhance transport by coughing may retard
transport by cilia. For example, increased elasticity
has a negative effect on mucus clearance by cough,
but it enhances the removal of secretions by ciliary
beating.21 To accommodate both mechanisms of
mucus clearance, mucociliary and cough, native mu-
cus may exhibit intermediate levels of viscosity. In
healthy individuals, cough may be effective in clear-
ing secretions down to the 7th to 12th of the total of
23 airway generations.4,22,23 It is possible that under
conditions of excess mucus production, in which the
serous layer has low viscosity close to that of water,
the effect of coughing can extend down to the level
of the respiratory bronchioles.
An alternate theory asserts that the removal of
airway secretions with cough has more to do with the
stimulation of ciliary activity rather than the disper-
sion of liquid into gas.24 The high-velocity of air
attained during cough may promote mucus clearance
by stimulating the mucociliary apparatus, changing
the rheologic characteristics of the periciliary fluid,
or increasing ciliary beat frequency. These changes
may be due to neural reflexes or to physical forces
acting directly on airway cells. Stress has been known
to open potassium channels in vascular endothelial
cells, increasing potassium flux out of the cell, result-
ing in hyperpolarization.25 The goblet cells may
respond similarly to shear stresses associated with
the rapid flows of cough or rapid inhalations. Neural
reflexes may be mediated by rapidly adapting recep-
tors in the lung that respond to rapid deflation or
inhalation by increasing mucus secretions.26 The
observed increase in mucociliary clearance induced
by high-frequency oscillatory flows may be due to a
similar mechanism.20 This alternate theory to en-
hanced ciliary function, however, is less likely than
the two-phase liquid gas theory as a mechanism
underlying the clearance of secretions with cough.
First, mucociliary clearance seems to operate at
optimum levels under circumstances in which there
is no cough, and, second, the removal of pathologic
secretions requires that they are physically detached
from the airway lining fluid.
Cough Inefficiency
Altered Cough Mechanics
Several factors may interfere with the capacity of
the respiratory system to produce the requisite pres-
sures and gas velocities needed for effective cough.
The initial phase of cough is accompanied by inhal-
ing a volume to near total lung capacity. Inhaling to
high lung volumes will optimize expiratory pressures,
and will enhance expiratory airflow and velocity. At
high lung volumes, the expiratory muscles are near
their optimal length and respiratory system elastic
Diagnosis and Management of Cough: ACCP Guidelines
recoil is increased; both factors will increase expira-
tory pressure during cough.27 Patients with neuro-
muscular disease and inspiratory muscle weakness
will inhale only a limited volume of air. Because the
inhaled volume is reduced, expiratory pressures, air
flow, and velocity will be diminished. However,
inspiratory muscle weakness must be profound to
affect this phase of cough as mild-to-moderate de-
grees of weakness may not result in restriction. By
contrast, expiratory muscle weakness may have more
severe ramifications regarding cough efficiency.
Even mild-to-moderate degrees of expiratory muscle
weakness will adversely affect the expiratory pres-
sures and thereby the expiratory flows needed for an
effective cough.28,29 Thus, individuals with lower
cervical spinal cord injuries who exhibit profound
expiratory but mild inspiratory muscle weakness will
have a compromised cough. The inability to effec-
tively cough increases their risk of developing atel- Figure 2. Expiratory pressures are reduced with partial curari-
ectasis and pneumonia, which are frequent causes of zation (lower panel). Expiratory flows are only mildly reduced,
but the peaks in flow are absent with partial curarization.31
morbidity in patients with neuromuscular weak-
ness.30 Protussive mechanical aids may be especially
useful in augmenting cough by providing a negative
pressure at the mouth and enhancing expiratory flow-volume curves during expiration is absent
flow. However, these devices are only useful when (Fig 2). Individuals with profound expiratory muscle
expiratory flow is not limited by airways collapse weakness due to cervical spinal cord injury (ie, expi-
when suction is applied at the airway opening. Thus, ratory pressures in the range of only 8 to 36 cm H2O)
individuals with neuromuscular weakness, and no also have reduced expiratory flows.32 However, the
concomitant COPD, may benefit from these me- expiratory pressures are sufficient to cause dynamic
chanical aids (see section on “Nonpharmacologic airway compression, as suggested by the presence of
Airway Clearance Therapies” in these guidelines). plateaus of flow on isovolume pressure-flow curves.32
Weakness of the abdominal expiratory muscles may
also impair cough by impeding dynamic compression
Recommendation of the airways. When the abdominal wall expands
rather than contracts during cough, the expiratory
2. Individuals with neuromuscular weakness muscles perform work shortening the muscle rather
and no concomitant airway obstruction may than generating pressure. In addition, because the
benefit from mechanical aids to improve cough. passive abdomen is very compliant and expands
Level of evidence, low; net benefit, intermediate; during cough, some of the pressure generated by the
grade of recommendation, C expiratory muscles is dissipated across the abdomen.
Both factors limit the rise in intrathoracic pressure,
Expiratory muscle weakness also contributes to thereby hindering dynamic airway compression.10,31
cough inefficiency by limiting dynamic airway com-
pression, a condition that augments expiratory gas
Altered Mucus Rheology
velocity. Dynamic compression is needed to increase
gas velocity for a given flow rate and thereby en- Cough ineffectiveness may occur when the rheo-
hance the kinetic energy available to clear secretions. logical properties of mucus are altered. An effective
The relationship between expiratory muscle weak- cough requires that mucus is detached from the
ness and cough expiratory flows has been explored in epithelial surface and mobilized into the airstream.
healthy individuals and in those with neuromuscular Thus, sputum clearability depends on sputum tenac-
weakness. Expiratory muscle weakness has a more ity, which is the product of adhesiveness and cohe-
profound effect on expiratory pressures than expira- siveness. Increasing viscosity and elasticity will in-
tory flow. In partially curarized healthy subjects, crease tenacity and reduce cough effectiveness.
expiratory pressures are markedly reduced, whereas When the water content of mucus is decreased,
expiratory flows are only minimally reduced.31 How- viscosity,33 and elasticity34 are increased, thereby
ever, the spike in peak flow normally seen on cough inhibiting mucus clearance. The finding of decreased

www.chestjournal.org CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 51S

cough effectiveness in asymptomatic smokers com-
pared with nonsmokers35 supports the notion that
altered rheologic properties may initially impair
cough clearance, but when smokers become symp-
tomatic with excessive secretions, increases in mucus
thickness will aid cough clearance.36,37 In contrast to
the results of in vitro studies, cough effectiveness
may be independent of mucus viscoelasticity in
patients with COPD.38 The lack of a correlation
between mucus clearance by cough and the vis-
coelasticity of expectorated secretions may be ex-
plained by the narrow range of viscosity of the
sputum specimens38 in comparison to the previous in
vitro studies (0.3 to 1.7 vs 1 to 77 Pa/s, respective-
ly).13,18,19
Altered Mucociliary Function
The mucociliary apparatus serves to transport
secretions from the periphery to the more proximal
airways where they can then be cleared by cough.4
Smoking inhibits ciliary beating and would therefore
be expected to adversely affect mucociliary clearance.39
The effect of smoking on mucociliary clearance,
however, is controversial. Mucociliary clearance is
reduced in young, asymptomatic cigarette smokers
with normal pulmonary function.40,41 However,
clearance from the peripheral airways of asymptom-
atic smokers was no different than that of healthy
age-matched nonsmokers.42 The inability to find a
difference in mucociliary clearance between these
two groups may be due to the opposing effects of
smoking. It can either decrease mucociliary clear-
ance by inhibiting ciliary beating or increase it by
increasing peripheral airway secretions. However,
when smokers develop airways obstruction, muco-
ciliary clearance becomes impaired as this system is
overloaded with excessive secretions.43 Once smok-
ing leads to the development of COPD, cough
becomes a necessary adjunct to mucociliary clear-
ance.36,37
Conclusions
An effective cough constitutes an important host-
defense mechanism. High intrathoracic pressures
promote dynamic airway compression and are
needed to generate the requisite expiratory flows and
airstream velocities. However, only modest increases
in intrathoracic pressure are needed to narrow the
large intrathoracic airways and increase cough flow
velocity. Thus, cough may be effective in individuals
with mild-to-moderate degrees of respiratory muscle
weakness. Cough ineffectiveness may occur when
the respiratory muscles are severely weakened such
that the volume of air inhaled during the first phase
of cough is limited and/or the rise of intrathoracic
52S
pressures is severely limited during the second and
third phases of cough. Thus, in patients with diseases
that are likely to be associated with cough ineffec-
tiveness, the clinician should have a high index of
suspicion that such patients are at increased risk of
pneumonia, atelectasis, and respiratory failure, and
should monitor closely for these complications.
Recommendation
3. In patients with ineffective cough, the
clinician should be aware of and monitor for
possible complications, such as pneumonia, at-
electasis, and/or respiratory failure. Level of
evidence, low; net benefit, substantial; grade of
recommendation, B
Summary of Recommendations
1. In patients with endotracheal tubes,
tracheostomy need not be performed to
improve cough effectiveness. Level of evi-
dence, expert opinion; net benefit, substantial;
grade of recommendation, E/A
2. Individuals with neuromuscular weak-
ness and no concomitant airway obstruction
may benefit from mechanical aids to im-
prove cough. Level of evidence, low; net ben-
efit, intermediate; grade of recommendation, C
3. In patients with ineffective cough, the
clinician should be aware of and monitor for
possible complications, such as pneumonia,
atelectasis, and/or respiratory failure. Level
of evidence, low; net benefit, substantial; grade
of recommendation, B
References
1 Bucher K. Pathophysiology and pharmacology of cough.
Pharmacol Rev 1958; 10:43–58
2 Langlands J. The dynamics of cough in health and in chronic
bronchitis. Thorax 1967; 22:88 –96
3 Lawson TV, Harris RS. Assessment of the mechanical effi-
ciency of coughing in healthy young adults. Clin Sci 1967;
3:209 –224
4 Leith DE. Cough. New York, NY: Marcel Dekker, 1977
5 McCool FD, Leith DE. Pathophysiology of cough. Clin Chest
Med 1987; 2:189 –195
6 Ross BB, Gramiak R, Rahn H. Physical dynamics of the
cough mechanism. J Appl Physiol 1955; 8:264 –268
7 Whittenberger JL, Mead J. Respiratory dynamics during
cough. 1952; 48:414 – 418
8 Harris RD, Lawson TV. The relative mechanical effectiveness
and efficiency of successive voluntary coughs in healthy young
adults. Clin Sci 1968; 34:569 –577
Diagnosis and Management of Cough: ACCP Guidelines
 9 Yanagihara N, VonLeden H, Werner-Kukuk E. The physical
parameters of cough: the larynx in a normal single cough.
Acta Otolaryngol 1966; 61:495–510
10 Knudson RJ, Mead J, Knudson DE. Contribution of airway
collapse to supramaximal expiratory flows. J Appl Physiol
1974; 36:653– 667
11 VonLeden H, Isshiki N. An analysis of cough at the level of
the larynx. Arch Otolaryngol 1965; 81:616 – 625
12 Leith DE. Cough. Bethesda, MD: American Physiology
Society, 1986
13 King M, Brock G, Lundell C. Clearance of mucus by
simulated cough. J Appl Physiol 1985; 58:1776 –1785
14 Clarke SW, Jones JG, Oliver DR. Resistance to phase gas-
liquid flow in airways. J Appl Physiol 1970; 29:464 – 471
15 Kim CS, Brown LK, Lewars GG, et al. Deposition of aerosol
particles and flow resistance in mathematical and experimen-
tal airway models. J Appl Physiol 1983; 55:154 –163
16 Albers GM, Tomkiewicz RP, May MK, et al. Ring distraction
technique for measuring surface tension of sputum: relation-
ship to sputum clearability. J Appl Physiol 1996; 81:2690 –
2695
17 Rubin BK. Therapeutic aerosols and airway secretions. J
Aerosol Med 1996; 9:123–130
18 King M. The role of mucus viscoelasticity in cough clearance.
Biorheology 1987; 24:589 –597
19 King M, Zahm JM, Pierrot D, et al. The role of mucus gel
viscosity spinnability and adhesive properties in clearance by
simulated cough. Biorheology 1989; 26:747–752
20 King M, Zidulka A, Phillips DM, et al. Tracheal mucus
clearance in high-frequency oscillation: effect of peak flow
rate bias. Eur Respir J 1990; 3:6 –13
21 King M. Relationship between mucus viscoelasticity and
ciliary transport in guaran gel/frog palate model system.
Biorheology 1980; 17:249 –254
22 Scherer P, Burtz L. Fluid mechanical experiments relevant to
coughing. J Biomech 1978; 11:183–187
23 Scherer PW. Mucus transport by cough. Chest 1981; 80:830 –
833
24 Bennett WD, Foster WM, Chapman WF. Cough enhanced
mucus clearance in the normal lung. J Appl Physiol 1990;
69:1670 –1675
25 Puchelle E, Zahm JM, Girard F, et al. Relationships to
sputum properties in chronic bronchitis. Eur J Respir Dis
1980; 61:254 –264
26 Yu J, Schultz HD, Goodman J, et al. Pulmonary rapidly
adapting receptors reflexly increase airway secretion in dogs.
J Appl Physiol 1989; 67:682– 687
27 McCool FD, Mead J. Dyspnea on immersion: mechanisms in
patients with bilateral diaphragm paralysis. Am Rev Respir
Dis 1989; 39:275–276
28 Kreitzer SM, Saunders NA, Tyler HR, et al. Respiratory
www.chestjournal.org
muscle function in amyotrophic lateral sclerosis. Am Rev
Respir Dis 1978; 117:437– 447
29 Siebens AA, Kirby NA, Poulos DA. Cough following trans-
section of spinal cord at C-6. Arch Phys Med Rehabil 1974;
45:1–5
30 McCrory DC, Samsa GP, Hamilton BB, et al. Treatment of
pulmonary disease following cervical spinal cord injury: evi-
dence report/technology assessment number 27. Rockville,
MD: Agency for Healthcare Research and Quality, 2001;
Publication No. 01-E014
31 Arora NS, Gal TJ. Cough dynamics during progressive expi-
ratory muscle weakness in healthy curarized subjects. J Appl
Physiol 1981; 51:494 – 498
32 Estenne M, VanMuylem A, Gorini M, et al. Evidence of
dynamic airway compression during cough in tetraplegic
patients. Am J Respir Crit Care Med 1994; 150:1081–1085
33 Lifschitz MI, Denning CR. Quantitative interaction of water
and cystic fibrosis sputum. Am Rev Respir Dis 1970; 102:
456 – 458
34 Slih DK, Litt M, Kan MA, et al. Effect of nondialyzable solids
concentration and viscoelaticity on ciliary transport of tra-
cheal mucus. Am Rev Respir Dis 1977; 115:989 –995
35 Bennett WD, Chapman WF, Gerrity TR. Ineffectiveness of
cough for enhancing mucus clearance in asymptomatic smok-
ers. Chest 1992; 102:412– 416
36 Camner P, Mossberg M, Philipson K, et al. Elimination of
test particles from the human tracheobronchial tract by
voluntary coughing. Scand J Respir 1979; 60:56 – 62
37 Oldenburg FA, Dolovich MB, Montgomery JM, et al. Effects
of postural drainage, exercise and cough on mucus clearance
in chronic bronchitis. Am Rev Respir Dis 1979; 120:739 –745
38 Hasani A, Pavia D, Agnew JE, et al. Regional lung clearance
during cough and forced expiration technique (FET): effects
of flow and viscoelasticity. Thorax 1994; 49:557–561
39 Iravani J, Melville GN. Long-term effect of cigarette smoke
on mucociliary function in animals. Respiration 1974; 31:358
40 Foster WM, Langenback EG, Bergofsky EH. Disassociation
in the mucociliary function of central and peripheral airways
of asymptomatic smokers. Am Rev Respir Dis 1985; 132:633–
639
41 Lourenco RV, Klimer M, Borowski CJ. Deposition and
clearance of 2 ␮m particles in the tracheobronchial tree of
normal subjects: smokers and nonsmokers. J Clin Invest 1971;
50:1411–1420
42 Agnew JE, Lopez-Vidriero MT, Pavia D, et al. Functional
small airways defence in symptomless cigarette smokers.
Thorax 1986; 41:524 –530
43 Isawa T, Teshima HT, Ebina A, et al. Mucociliary clearance
mechanism in smoking and non-smoking normal subjects.
J Nucl Med 1984; 25:352–359
CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT 53S