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CFPhysio on exploring the huff

This episode of the CFStrong podcast is thanks to our collaboration with CFPhysio. Sit down with experts in their field, Dr Brenda Button, Kathleen Hall, and Esta Tannenbaum, physiotherapists who have worked with individuals with CF across the lifespan, and learn more about huffing. This technique is integral to all airway clearance in CF. Understanding more about what is being achieved in the airways when performing this technique will empower you to develop a huff that works for your airways. This is suitable for healthcare professionals and individuals with CF.

The ears are, as physio's, our most valuable tool, but they also need to be the individual with CF or the parent and caregiver’s most valuable tool when they're not in clinic with us and knowing what they need to be listening for.

Jen, CFPhysio


Jen Hauser: Hello, and welcome to the and CFStrong collaboration podcast series. My name is Jen Hauser. I’m a physiotherapist with almost 20 years’ experience in cystic fibrosis care and the project lead for Together with CFStrong, we have joined forces to bring to the CF community real life insights and personal experiences on all things physiotherapy and CF. is a not-for-profit organisation. Striving to deliver evidence-based education in CF physiotherapy management to healthcare workers and individuals impacted by CF. CFStrong is a website designed to inform, educate, and empower adults impacted by CF through the sharing of individual’s personal journeys of living with CF.  

We hope you find some value from listening to the podcasts we bring to you in this series. Please remember the content is not intended to replace your usual healthcare. Please discuss any concerns or questions you may have with your healthcare team. 

Jen: Today I have three physiotherapists in the studio with me to have a chat about the huff, the forced expiratory technique, and how we can use this technique to change the airflow in the airways to more effectively shift secretions, to check in with your lungs and to sweep the airways surfaces.  

I’d like to introduce Dr. Brenda Button, a physiotherapist who has had three decades of experience working across the lifespan in cystic fibrosis. Brenda is currently working at the Alfred Hospital in Melbourne Australia. Brenda has areas of interest in research and clinical expertise, including gastroesophageal reflux, urinary stressing incontinence, exercise testing, and more. Brenda is an advanced airway clearance instructor recognised internationally for her work.  

We also have Kathleen Hall, a physiotherapist with over 20 years’ experience working with adults with CF and non-CF bronchiectasis. Kathleen is also a senior lecturer in cardiothoracic physiotherapy at the Australian Catholic University, and also has a bespoke private practice catering for non-CF bronchiectasis and disordered, dysfunctional breathing. 

We have Esther Tannenbaum, a physiotherapist who has worked for over 25 years in the area of respiratory pediatrics, which has included working at children’s hospitals in Cape Town, London, and is currently working at the Royal Children’s Hospital in Melbourne. Esther’s main areas of interest has been CF, PCD, bronchiectasis, and acute respiratory disorders.  

What a great opportunity for those in the CF community, individuals with CF, parents and care givers and healthcare professionals to have these three experts in the studio today, and really looking forward guys to hearing some audio of huff techniques and listening to what you can share with us. 

Brenda Button: Thank you very much, Jen, for your introduction of all of us. I’m going to kick off by trying to describe to you what the airways look like and what happens when we do huffing from low, mid and high lung volumes.  

So, imagine a piece of blank paper in a horizontal position. And I’m going to, with my pencil draw a circle on the left-hand side, say the size of a tennis ball with another little circle inside the size of a ping pong ball. And coming out of that ping pong ball is a tube which is very narrow, where it comes out of the ping pong ball. And as it moves all the way to the end of the paper, it gets wider and wider until it’s quite wide, at the upper airways, which we’ll call the mouth. So this is a schema and the tennis ball is the schema of the whole lung. The ping pong ball is of your airway in the lung. And the tube is all of the airways put together from the small medium ones to the large ones at the very end.  

So, we’re going to start by taking a small breath in. So this ping pong ball sized part of the lung is going to expand a little. It’s going to be a little bit bigger and it’s going to have a slightly higher pressure than it had before we took that breath in. And that person huffs, which is a forced expiration out through the airway. It’s only going to go a little way before the pressure inside the airway and outside the airway is equal, which we call the equal pressure point.  

So, at that point where the pressure becomes equal, there is a squeeze effect. If there’s mucus there, rather like when the river flows under a bridge where the bridge it narrows the river, the water’s going to flow faster. If the airway gets a little narrower, if there’s mucus there or sputum or lung secretions, they’re going to move a little faster.  

Now we need to move those on a little bit further through the medium sized airways. So now we’re going to take a medium size breath in, so that what used to be the size of a ping pong ball is now expanded further. It’s bigger. It’s got say, we use pressures of pluses. Let’s say it’s got three pluses of pressure in it. And as we do that huff, it’ll go through two pluses as it comes out of the airway down to one plus, which is the same pressure as outside the airway and our equal pressure point at that point will give a squeeze effect and the mucus will be squeezed along further down the airways towards the mouth.  

Now we’ve got a whole lot of mucus that’s sitting right up near the throat. We’re going to take a big breath in expand those alveoli in the lung. And as we do that huff, that pressure, let’s say it’s five pluses as you take that big breath in, it’s going to become four is going to become three through the middle airways till it becomes two. And when it gets right up near the mouth, it’s going to become one equal to the pressure outside the airway. And at that point there’s going to be this squeeze effect, and it’s going to then be squeezed out with a cough into the mouth where the person can then spit it out.  

So, with that in your mind, you try to imagine if we say, we’re going to do a huff from a small breath in, it works in the small airways. If we do it with a high lung volume or a big breath in, it’s going to have an effect closer to the mouth.  

So that’s my attempt to try to describe a picture, which I’m sure will be in, it’s the west diagram. And I’m going to hand over to Kathleen now to put that more into physiological terms and try and explain exactly what’s happening in the lung. Over to you, Kathleen. 

Kathleen Hall: Thank you, Brenda. I think that’s a great explanation. I suppose, the way I tend to teach people is that whole concept, as you said, very rightly about when the patients they’re creating that expiratory force, because huffing is an active technique.  

There’s a point at which the push from the outside of the lung onto the airway and the pressure inside of the airway becomes similar. And then there’s that narrowing. And as a result of that, there’s a bigger expiratory flow in front of it, plus dynamic compression and that’s pushing the sputum along. And us as respiratory physios, I think the thing is that we understand the respiratory physiology and manipulate it so that we work it to our patient’s advantage.  

So exactly what you said, if you’re thinking about the fact that you are going to move secretions from the peripheral to the central airways, albeit that beforehand, you’ve probably done other techniques to get air behind secretions and loosen them up. Huffing becomes very important to probably go through those stages.  

So, with that smaller breath and that slightly bigger squeeze, you are down in the periphery of the airway. So, you’re manipulating the equal pressure point and dynamic compression to occur there. And you might do a couple of huffs at that level and then it bubbles further up. So, you may choose with your patients to do a middle size breath and squeeze through the middle of the lungs, or even that larger breath, which is often then shorter and sharper on the breath out. But the equal pressure point and dynamic compression is occurring centrally.  

So, we manipulate by giving our patients these instructions about where the huffing is working to kind of move through the layers of the airways to move the secretions. And I think the other point that we’ll probably all talk about though, is remembering that squeezing an airway force is very important for shearing secretions off the airway walls. 

And by huffing, it creates what’s called an annular flow. However, if we over, get the patients to over squeeze, many of them have very floppy airways and you can just like with a big cough, which is too much pressure, close down the airways. So, it’s this balance. And I think what we’re all going to talk about is when we are listening, we’re listening to hear the volume, the squeeze, but not the over squeezing and the shutting down. That’s really important because they’re the keys that give us as clinicians an idea of whether the huff’s working or not, where potentially it’s working in the airways. That’s sort of my take on it. 

Esther Tannenbaum: I think if I can just bring in a, a pediatric perspective so often explaining that technique to children, we often use that toothpaste kind of squeeze method. So you’re starting with the toothpaste at the bottom of the tube, we want to get it to the top. So similarly at the bottom of the tube, we want to find that mucus, which is at the end of the lungs in the airways and we trying to squeeze and move it up, kind of tease it up as well. So it’s often just trying to find that link, just that comparison to understand what we are doing in their kind language and terms as well. 

Brenda: Lovely.  


Music Break 


Brenda: From there on, we might come up with an example Kathleen, do you want to play one of the examples and we’ll all have a listen, and then we can critique and maybe explain what we think is going on from the sound. 

Kathleen: All right.  

Huffing technique sound  

Kathleen: Okay. 

Brenda: I’ll kick off and say what I heard at the beginning was probably somebody with a lot of sputum and somebody with quite stable airways. They were able to actually put quite a lot of force behind that air and not get dynamic collapse. I don’t believe they were collapsing them down, and that is absolutely fine to as much force as you need to or can without collapsing them down, cause then it’s more efficient. And that’s what I heard there. I thought it was, they were very good huffs, but there was quite a lot of movement. They were being very efficient in pushing that mucus up the airway until they were ready to just do a nice, direct, effective cough without too much running away with coughing. 

Kathleen: And for me, the thing is listening to that, I would agree. I think subtly probably you could hear that there was a slightly bigger breath in the beginning and that longer— so it was down in the smaller airways. And I agree. I think one of the things with huffing I see clinically is sometimes people don’t actually create enough force. There’s this balance between we don’t want to collapse, but actually huffing can be very active. And if it’s done well, you can move a lot of secretions at once. But then the breath became bigger and slightly shorter because they’d moved up.  

I think for me, the thing is that probably with that patient, I could have got them to pause and do a little bit of relaxed breathing, not run four huffs in a row, which is what happened. Just because I think the pause might have allowed when they were shifting to that high volume huff, it might have been a bit more effective. 

And then I would’ve also paused and then actually said, now have one good breath and just cough once well, because that’s the other thing I see happening is—you never, certainly, I don’t like people running their huffs into a cough, because to cough, you need that volume of air. And so you get them to pause again, when you know, it’s right up high and just have one breath and it’s still not big pressure, but they have a cough it’s effective and they clear. And all of that is a lot more energy efficient for the patient as well. 

Esther: I was just going to say that just in terms of preventing that fatigue you said that beautifully, so it’s saving that energy. This sounds like a person who is very in tune with their body and quite experienced with huffing. So beautiful to hear. And also, like Brenda said, I could not hear any airway collapse. So, a real expert at doing huffs and there’s always some fine tweaking we can make with patients. Although as soon as they’re home, it’s about timing. I’m busy, got things to do. How do I do this physio as quickly as I can as well. So, it’s also balancing so many aspects of a person at home 

Kathleen: Could not agree more. 

Brenda: Having said all of that. Why don’t you play that again, Kathleen, so everyone can have a listen with all of our thoughts in mind. 

Huffing technique sound 

Brenda: Great. I have just two things I want to add there. Sometimes our people who are in a hurry, as Esther said, wanting to get off to school or uni or whatever, hurry it up and really put a lot of force behind it and a lot of force behind the cough and then they just find it doesn’t work and they just end up coughing, and huffing. And that’s when you need to take a step back and say, okay, I need to slow it down because they are shutting down the airways. So, it’s a very fine balance as we said before.  

And the other thing is Vander Scone, who’s a very well-known Dutch physio. He wrote in one of the articles that huffing is probably one of the most powerful airway clearance techniques that you’ll ever teach people who have lung disease and secretions. So, we should bear this in mind and learning to huff effectively and efficiently is one of the most powerful things anyone can ever learn 

Kathleen: Could not agree more 

Brenda: Do you want to go on and play the second recording for us to critique?  

Huffing technique sound 

Brenda: Who wants to go first? Esther, do you want to go first? 

Esther: It sounded like there was a lot of effort in the coughing, really working hard to mobilise that mucus and also having to work hard to control that cough at the end as well. Maybe a little bit of airway closure, I heard too, especially at the start. And then once it seemed to shift a little bit, there wasn’t as much airway closure that I was hearing as well. But I think I would potentially have gone back to do a little bit more of airway clearance, mobilising, moving, and then gone back to doing some more huffing just to make sure there wasn’t too much energy being used with those huffs. 

Brenda: I would agree with that. And I would also possibly a couple of times between those what sounded like about four huffs just said, stop and do some breathing control, because I think just getting, settling down the airways and then starting again might have been helpful. 

Kathleen: And don’t you think that’s one of the, again, the art about it, this acknowledging that huffing can be done as a technique on its own for clearance, but often it is part of our cycles of airway clearance and getting the patients to learn to listen. And if it isn’t quite up high enough, rather than keeping huffing, it is better for them to go back, do another round of whatever they’re doing as part of their loosening. getting air behind secretions and then come back to the huffs and then they always sound juicier. The sputum is up far higher. It’s then easier to go through the couple of steps and clear. And again, that finding that balance with patients and then convincing them to do that can sometimes be quite difficult, but it in the end is, is better for them and nicer on the airways because this balance between over squeezing, tiring yourself out versus doing effective clearance 

Brenda: And in that person, coughing too soon can also be a problem. I know listening to Jean Chevalier, he believes if you cough too soon, you can actually push the mucus back down again. And he’s shown that in some of his bronchograms that they used to do in years gone by. So, I always encourage people to really wait until the mucus has bubbled right up to the throat and only cough when you know that if you do one good cough, you’re going to get a good blob of or good size amount of sputum up. And if not, then go back to the beginning and go and do another cycle. Do another cycle of huffing so that you might in one session where you might have done 10 runaway coughs in a row during that treatment session, you might only do three or four coughs during that treatment session, but with each one of them get up three or four times as much sputum. 

Esther: I think you mentioned that Kathleen as well in terms of, if the person has not mastered the huff and especially, we find that in pediatrics, in that they think there’s no value or use in doing it. So, I know often Brenda, you’ll say they, they come to me at the Alfred and look, we don’t do huffs. And I think it’s just as I say, they haven’t mastered it. It’s really difficult to do. And that comes down to us in terms of our education and support, encouraging them to continue to work with us, to try and get that perfect huff for them. And just how important it is in that assessment tool as well. Not just in how my treatment’s going, but in my day to day what mucus is in my lungs, what can I feel? So even before exercise or during exercise what am I feeling? And I think it’s one of the most important tools in that cycle of airway clearance. But it’s that education and it can take a lot out of the patient having to also be patient and listen and keep working with their bodies. Am I feeling secretions? Am I not? And that can be challenging too. 

Kathleen: I’ll ask you ladies this, do you find, so I often use huffing as probably the biggest thing after I’ve done a subjective in a, even a busy clinic, particularly with people that are telling me they haven’t got any sputum, they’re doing pretty well. I’ll ask them to do a small volume and a one of those long deep huffs and it all gurgles away. And they just look at me and I look back at them and I’m like, hmm, I think there might be a bit of secretion down there. Let’s think about your airway clearance again. And so, you can be used as an assessment tool. I agree. I don’t know, what do the rest of you do with huffing as part of assessment? 

Brenda: The other part of it too, is, I mean, people come to clinic and the doctors want a sputum sample and they say, oh, but I’ve got nothing there. I won’t be able to get one. You say, okay, well let’s just sit down and we go through, so some cycles of deep breathing and then we do some huffing and then we do that two or three times. It might only take seven or eight minutes. And by the end of it, generally, just as you’ve said, they are surprised to find that they actually can huff up and produce a sputum sample. So, I find that a very useful tool in a busy clinic to get hold of sputum. 


Music Break 


Kathleen: Esther did you want to say anything about—for probably Brenda and I, although life is changing with modulator therapy for all of us, patients often have secretions and it is far easier to teach huffing and this stage kind of huffing when there’s some secretions there to hear for all of us, but often with pediatric patients, that’s not the case. So how do you go about, do you still teach them huffing? I think you were saying that. And what are your thoughts? 

Esther: Look, we definitely do teach huffing as part of the cycle. It is tricky. We, we may start at the age of two or three, but it could be just very ad hoc, and it does depend on the child, their personality, their cognitive level. Can they sit still? There’s so much they’re learning and taking on in terms of physio, but I feel effectively we are better at teaching the five or six year olds and they do maybe master it by the age of eight. However, just remembering probably the age of five and six, they’re also learning lung function as well. And that’s quite a different technique to what we are teaching with huffing. So often I find teaching huffing at that age, it’s very forced. So, we have to come up with quite a few strategies just to teach them to get that balance of not just a sigh, because you do need a bit of a squeeze action, but it’s not too forced as well. 

Because often for some of the pediatric patients, something that’s very forced and fast in their minds might think that is effective. And that’s what we want to hear. So often for us, it’s really about mimicking, listening to us, doing the huffs with them. We do use huff tubes as well or potentially the mouthpiece and the round end, just because that’s a little bit smaller to fit in their mouths. And we use games. Whether we use puffing of butterflies or any other object that they’re interested in whether it’s pepper pig or bluey, we cut out little shapes with tissue paper. So, we encourage games, making it fun and creative.  

However, sometimes we do find that their emphasis is on the butterfly where it’s flying and not what they’re actually doing. So, we kind of then backtrack a bit and work more with fogging up a mirror works really well. Or just a plastic lid cup. Just emphasizing also with our hands on their chest wall, moving away from the throat that the emphasis is that movement of air flow out of the lungs and not forcing things through their throat. So, education is paramount. We do it in small bits. We support the pediatric patient and the family as well, but huffing is crucial. And I think really over time it’s become more kind of at the focus at the head of our airway clearance rather than just coughing. 

Brenda: Fantastic. How about we have another, I think you’ve got another huff there to listen to Kathleen. 

Huffing technique sound 

Brenda: Why don’t you go first Kathleen, this time. 

Kathleen: So, I think in this case the patient probably was starting with a bigger volume. I’m assuming the secretions were a bit more central, but I was also hearing a hint of a wheeze in this patient. So, they probably, again, this balance between doing that bigger, forceful, bigger volume, forceful huff, but perhaps getting a bit of a wheeze happening, which we don’t necessarily want. But they only had to do a couple of huffs and then they actually had quite a reasonable volume of a cough and coughed and cleared.  

I probably would play around exactly what Esther just said. If I have any hint of hearing wheezing to try and encourage them more to keep their mouth and their glottis open, is I would give them a huff tube, which I think all of us would agree, you get to certainly with adults, the big thing is you’ve got to say to them, put it a fair way in your mouth because they often just want to put their lips around it. And that defeats the purpose of what it’s trying to do. For me, anyway, I find that can often take that we sound away and it’s just a little shorter, sharper, clearer huff, but I’d be interested to hear what other people think. 

Brenda: Yes. I agree with you. I think she went too big, too soon with too much of a high lung volume too soon. And then, but then she corrected herself and went back and started closer to the, to the lung in the medium sized airways. And I agree with you that there was probably too much force and there was a bit of a wheeze there. But in the end, she, she did clear sputum, but I agree with all of that. 

Kathleen: And then that’s the other thing having had this conversation, sorry, Esther you’ll probably say something is huffing is my experience is sometimes it can get, be hard to teach. And there’s another balance between educating people, but not getting the patient themselves too, hung up on it. You know, sometimes I feel if I go back a few times and correct too much, I’ve kind of oversold it and then they don’t do it properly at all. And sometimes something is better than nothing if it’s close to correct and it’s clearing the sputum. Because you don’t want them suddenly thinking we’re giving them this really hard technique that they can’t use. 

Esther: I was wondering whether for this patient, that technique suited that person best. That’s what they’re doing at home. So, I think sometimes it’s always listening to what they do first to see what’s working for them. And then we can try some really fine small tweaks where we need to, but I think if we make too many changes sometimes it, they’re not going to take it on board, as you’ve said as well. And I do wonder for some people who have very irritable airways, how they manage huffing best where sometimes just that big force and squeeze will really just move that mucus quickly, but yet might cause quite a bit of coughing effects as well. 

Brenda: And that brings me to something that I think is really important is that when we assess our people, doing their different techniques, sit and listen first. Listen very carefully and listen with an open mind. And if it’s working for them, don’t mess with it just because it maybe doesn’t fit exactly what the textbook says. And I think that’s really important cause if we teach them to become craftsmen of their tool and if they use their tool in a particular way, that’s a little different from ours, but it really works for them, then we should just leave it alone. 

Kathleen: If it isn’t broken, don’t fix it. Often, I often say that to patients around exactly. It’s fascinating to discuss all of this and see actually how similarly we all really think. Even though our practices might appear to be a bit different where, there’s much more similarity, isn’t there? 

Esther: Absolutely our role is so important to teach about the simplicity and effectiveness of huffing, what suits the individual. 

Brenda: And to be supportive and to be accepting and not become judgmental. Cause I think that’s when we lose them all, is when they think we’re judging them and we’re criticising them and it’s never right. You, I think that’s something that, that I learned from the teenagers, how important it is to be positive and accepting. 

Kathleen: Do you think another one would do one more? 

Brenda: Yes. 

Kathleen: Alright. 

Huffing technique sound 

Brenda: So that was one right at the very end where she had a lot of sputum in her upper airway, it probably wasn’t terribly elegant, but it certainly worked for her, I think. 

Kathleen: And I would agree there wasn’t a lot of energy in that. It just, it was one of those, a big high-volume huff, one or two, it came up and then there wasn’t a need for big forceful coughs because they cleared and that is the end product of what you want to see happen, really. 


Music Break 


Brenda: And I think another thing that I want to say at this point in time maybe we need to cause our time is getting short, start talking about briefly about gene modulators and people not having so much sputum and not hearing all these sounds, how we manage that. And how exercise is becoming so much more a part of our airway clearance and how important it is to be combining huffing with exercise so that when exercise is an airway clearance technique, it’s exercise plus huffing intermittently to make sure we are actually clearing those secretions. Do we want to add something? 

Kathleen: I would just say that’s very much the mantra in our clinic. I explain to patients that you still need to be checking so that assessment to see if there are secretions there, but if exercise is going to be— and absolutely accepting that this could be the main part of airway clearance for many of our patients that jiggling it around with the exercise isn’t enough, you’ve still got to give the sputum some direction and flow and that’s what the huffing does. And so, if you’re going to turn it into airway clearance, my attitude is, and what I would like them to do is to do their bouts of exercise, but intermittently add the different levels of huffs to just see and hear what might be rolling around and clear efficiently what’s there. And then from my perspective, they get the big tick that they’re probably doing good airway clearance, as well as their exercise. 

Esther: I think there is that acknowledgement, if there isn’t much because you can’t feel it or hear it, it is harder trickier to pick up some of the techniques such as huffing. However, it’s still really important to learn the different grades and why we do them. So even in pediatrics as well, with those who seem to have minimal mucus, we still encourage huffing during any of the airway clearance techniques. And just even with exercise the running around activity that we do it’s important one of the processes and steps of ensuring that the lungs are as clear and healthy as possible. 

Brenda: And that’s where I very much like Jen’s comment about sweeping the airways. So, it’s a way of just getting that air flow through them from the small to the medium, to the large and hearing. Our ears become our most important, and for people with lung disease, their ears need to become the really important things and to listen to what they’re hearing. So often it’s a checking mechanism and that like that comment about sweeping the airways. So, I think that’s something that really fits well with exercise as airway clearance. 

Jen: I’m going to jump in here because you mentioned my name. We’re mindful of time and we know with these podcasts, people don’t have a lot of time to listen. Hopefully you’ve all just done your 30 minutes of high intensity interval training whilst you’ve been listening to the podcast and doing a few huffs to check in and we know we need to wrap up soon, but I think Brenda the talk about sweeping in that assessment of our airways, but also the value of the ears is one of the things that drove this idea to get the airway clearance sounds on But also, these podcasts is that the ears are as physio’s our most valuable tool, but they also need to be the individual with CF or the parent and caregiver’s most valuable tool when they’re not in clinic with us and knowing what they need to be listening for. 

Obviously, the person with CF has the added advantage they can feel in their airways, what they need to feel. And I think moving forward in the modulator era is as Esther has experienced in pediatrics for individuals that are relatively asymptomatic and don’t have this big sputum load, we still need to really promote huffing as an assessment tool. And that sweeping, when we sweep our hard floors at home, we don’t get a huge amount in the dust pan and brush each day. But if we don’t do it every day, there’s big clumps that get caught under those chair legs, which we miss. And is that going to be where an infection is brewing, and we miss it and that the patient gets into trouble with an exacerbation. So, I think as physios, we are going to have to move forward being extremely innovative in how we educate and how we empower individuals to have belief in their airways. 

I certainly know you guys touched on so many valuable points in that 30 minutes. And one of the big things is to help individuals with CF and parents feel confident in mastering a technique that works for them and it doesn’t have to be perfect. We want to teach them the science and we want them to understand what they should be feeling and hearing, but they have to create that to work for themselves. And as you, you all said it might, we need to listen first with no judgment and say to them, is it working for you? You know, do they look like they’re using too much energy? Do they look like they’re in pain? Do they say, actually I hate this technique. I’m not going to use it. And then we need to work with them and coach them with tweaks, or if it’s working for them, don’t touch it and just give them that space to just feel they can master their technique. They are in the driver’s seat. We are here just guiding them alongside and hoping that they can get the best out of their airway clearance techniques and huff being such an integral part of that. So, let’s put cough to bed. The last cough at the end can happen and can be effective, but let’s go the mantra of the huff, whether it’s with airway clearance, exercise or just a daily meditation. 

Brenda: Absolutely. 

Kathleen: Brenda did you have something?  

Brenda: Can we say one very last thing about runaway coughs, cough, cough, cough, cough, cough, coughing. One of the most valuable lessons I learned from John Shal in Belgium was that that will cause us to lose elasticity in our lungs. And he uses the example of take a piece of elastic. And if you keep on stretch, stretch, stretch, stretch, stretching it for two weeks. By the end of that, it’s just going to end up being this limp piece of elastic. Our lungs all start with elasticity, very elastic when we are born. And if we spend many, many years cough, cough, cough, cough, cough, cough, cough, cough, cough, cough, cough, cough, coughing. We just stretching those lungs unnecessarily. So, to limit people from unnecessary, unproductive coughing, so that we preserve the elasticity of the lungs, cause it’s the elasticity of the lungs that cause us to get the air out of our lungs. 

And we don’t want to develop emphysema in early adult years because we’ve lost the elasticity. And I think that’s something that alerting our patients to that as they grow up and as they get older is only cough when you know, you’re going to be able to produce sputum effectively without a long runaway cough. Not to mention that they could become really tired and head achy and that can make them hate airway clearance more than anything. Just coughing. Coughing takes such a lot out of you in your musculoskeletal system, back pain, shoulder pain. And especially as people get older coughing can become a major problem. And I think if we can start when they’re very young teaching that only cough when you need to, when you’re ready and then emphasise that throughout life. 

Kathleen: Could not agree more, Brenda, I think that was the point too earlier— so one of my little bug bears is that you often see people have taught people to huff and they huff and keep going until they have almost squeezed the airway down and it triggers those coughs, all of which are completely inefficient. So, learning to control that little point of stopping the huff short of that, then doing another controlled huff, which bubbles things up higher. And then if it’s right up high, that idea that you just have a breath with a bit of volume of air and just one cough and it’s actually not, it’s still force. But it’s not the same as those little paroxysmal. So absolutely learning to get rid of that habit, cause it’s often a habit and changing it with other techniques is important. And I don’t know if anyone wants to touch on some ways to help people who have got go into paroxysmal coughing stop, if you’ve found some things that can help patients with that. Because I think that is something that they have to learn, if we’ve got time, 

Jen: I’m going to actually use that as our little teaser for the next podcast that I invite you all to come along to because as Brenda already knows, once you step foot in this studio, you never get away with not coming back. 

Brenda: And there’s a lot to say about coughing effectively and lots to say. 

Jen: And certainly we had a lot of feedback in the focus groups from both physios and individuals with CF to have some information on about runaway paroxysmal coughing. So, thank you, Kathleen. You’ve just nominated yourself for that next session.  

I think what we’ve also really learned through this session, how valuable as we said to listen to sounds, but I would really love to canvas the idea that moving forward, we actually invite some individuals with CF, kids and adults and get them into the studio if they feel comfortable so that we can have a listen to their airways because the, the sound does get distorted on those recordings that we’re using. So, and every physio is going to hear something different. And so is a patient, but yes, very mindful of time and aware of all three of you and your very busy schedules.  

We’re so extremely grateful here at to have you all in the studio today and continuing to share your experience and your passion for teaching and empowering individuals with CF to improve their overall healthcare.  

We hope you’ve enjoyed listening to this podcast. Please make sure that you check out other podcasts that are on and also CFStrong because this continues to be a series that we are working on in collaboration with CFStrong, thanks to the Circle of Care grant through Cystic Fibrosis Tasmania. So, thank you to everyone being involved. Great to have all three of you in the studio. And we will look forward to another chat in the future. 

CFPhysio strives to deliver evidence-based education in CF physiotherapist management that is accessible to all. Their mission is to educate and empower healthcare workers (involved in the care of individuals with CF) and all those impacted by CF in physiotherapy. Visit CFPhysio to learn more.

This podcast was published in July 2022. If you would like to share your story, please contact us at We’d love to hear from you and so would our listeners.