‘Cough CPR’: Misinformation perpetuated by social media

      Sir,
      A recent article shared on social media was provocatively titled: "HOW TO SURVIVE A HEART ATTACK WHEN ALONE" [
      • Snopes
      How to survive a heart attack when alone.
      ]. The article describes a hypothetical scenario in which the reader is experiencing symptoms in-keeping with an acute coronary syndrome. The article goes on to state "victims [of a heart attack] can help themselves by coughing repeatedly and very vigorously". The article is confusing and conflates myocardial infarction with cardiac arrhythmia and even references the term 'CPR' in describing the coughing technique.
      Since it was first shared in 1999, this article appears to have periodically resurfaced over the years via various internet-based platforms. In response to the article and public interest in this technique, the British Heart Foundation, Resuscitation Council UK and American Heart Association issued statements advising against the use of 'Cough CPR' [

      British Heart Foundation. Could something called ‘cough CPR’ save my life? [Accessed 30 September 2018] at: https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/ask-the-experts/cough-cpr.

      ,
      • Resuscitation Council (UK)
      , ]. However, lay articles and messages endorsing this technique can still be found circulating on social media.
      As of 30th September 2018, 42,000 people had 'liked' and 418,000 people had ‘shared’ the article in question on social media. A search of the term “cough CPR” on Google returned 24,800 unique results. The ‘Google Trends’ function revealed fluctuation in worldwide popularity of the search term 'cough CPR' over the past 12 months.
      A PubMed search of ‘cough CPR’ returned 60 articles. Of these, 13 were case reports describing the use of a coughing technique, applied at the onset of unstable cardiac arrythmia, to maintain blood pressure and consciousness or revert patients back into sinus rhythm, summarised in Table 1. It is critical to note that, in all these examples, this technique was used in a controlled, monitored, in-hospital environment such as the cardiac catheter laboratory.
      Table 1Summary of reports describing the use of ‘cough CPR’ in humans.
      Author and YearReferenceSummary
      Jafary, 2008.Cough-assisted maintenance of perfusion during asystole. Can J Cardiol. 2008 Oct;24(10):e76.Case-report of a 65-year-old man undergoing coronary angiography. During the procedure, he developed asystole and was asked to cough immediately. Coughing produced an aortic systolic blood pressure of 80–100 mmHg and he reverted into sinus rhythm.
      Keeble, 2008.Triggering of the Bezold Reflex by reperfusion during primary PCI with maintenance of consciousness by cough CPR: a case report and review of pathophysiology. J Invasive Cardiol. 2008 Aug;20(8):E239–42.Case-report of a 50-year-old man undergoing primary angioplasty for acute inferior STEMI. During the procedure, he developed profound bradycardia associated with hypotension and presyncope. He was instructed to cough which generated arterial blood pressures of up to 200 mmHg and he maintained consciousness. His heart rate improved following atropine administration.
      Girsky, 2006.Images in cardiovascular medicine. Cough cardiopulmonary resuscitation revisited. Circulation. 2006 Oct 10;114(15):e530–1.Case-report of a 64-year-old man undergoing testing of an implantable cardioverter-defibrillator. Following induction of VF, spontaneous coughing produced an arterial blood pressure as high as 176 mmHg. Following an increase in sedation, VF without spontaneous coughing produced an arterial blood pressure of only 27 mmHg.
      Petelenz, 1998Self–administered cough cardiopulmonary resuscitation (c-CPR) in patients threatened by MAS events of cardiovascular origin. Wiad Lek. 1998;51(7–8):326–36.*unable to access full text.

      Abstract describes a study showing that in patients trained to recognise the onset of Morgani Adams Stokes events, coughing can prevent fainting and maintain consciousness until conventional CPR is performed.
      Saba, 1996.Sustained consciousness during ventricular fibrillation: case report of cough cardiopulmonary resuscitation. Cathet Cardiovasc Diagn. 1996 Jan;37(1):47–8.Case-report of a 54-year-old man undergoing coronary angiography. During the procedure, he developed VF. He was instructed to cough vigorously which produced a blood pressure of 120/50 mmHg. He underwent defibrillation and successfully reverted into sinus rhythm.
      Miller, 1994.Hemodynamics of cough cardiopulmonary resuscitation in a patient with sustained torsades de pointes/ventricular flutter. J Emerg Med. 1994 Sep-Oct;12(5):627–32.Case-report of a 43-year-old female undergoing coronary angiography. During the procedure, she developed Torsades de Pointes/ventricular flutter at a rate of 300-400 bpm. She was instructed to cough within 3–5 s of arrythmia onset. Coughing was continued, and she remained conscious until ROSC 62 s later (approximately 4 s after the 2nd defibrillation attempt and 80 ms after a cough generating a systolic aortic pressure of 128 mmHg).
      Mitton, 1993.Paroxysmal atrioventricular block in a healthy patient receiving spinal anesthesia: a case report. AANA J. 1993 Dec;61(6):605–9.*unable to access full text

      Abstract describes a case report of a 36-year-old male under subarachnoid block anaesthesia. During the procedure, he developed complete AV block and was instructed to cough as hard as possible. Following administration of adrenaline and approximately 40 s of cough-CPR he reverted into type 1, second-degree AV block. A further 15 minutes later he reverted into sinus rhythm.
      Commerford, 1992.Cough–cardiopulmonary resuscitation--a useful manoeuvre. Resuscitation. 1992 Aug-Sep;24(1):89–90.Case-report of a 51-year-old female undergoing coronary angiography. During the procedure, she developed Torsade de Pointes, resulting in hypotension. She was instructed to cough vigorously at l-3 s intervals and remained conscious until she spontaneously reverted into sinus rhythm. The manoeuvre resulted in a mean arterial blood pressure of 50 mmHg.
      Rieser, 1992.The use of cough-CPR in patients with acute myocardial infarction. J Emerg Med. 1992 May-Jun;10(3):291–3.*unable to access full text

      Abstract describes a case report of a patient with acute anterior MI. Patient developed VF and underwent cough-CPR and thrombolysis in the emergency department.
      Miller, 1989.Cough-cardiopulmonary resuscitation in the cardiac catheterization laboratory: hemodynamics during an episode of prolonged hypotensive ventricular tachycardia. Cathet Cardiovasc Diagn. 1989 Nov;18(3):168-71.*unable to access full text

      Abstract describes a case-series of patients undergoing coronary angiography. These patients developed malignant ventricular arrythmias and cough-CPR was used to maintain systemic arterial blood pressure and consciousness until definitive therapy was administered. The maximum duration in which cough-CPR was successfully used was 75-90 s.
      Criley, 1986.Modifications of cardiopulmonary resuscitation based on the cough. Circulation. 1986 Dec;74(6 Pt 2):IV42-50.Summary article including a description of a male patient undergoing coronary angiography who developed VF. Cough-CPR was used for 39 s until defibrillation. During VF, Cough-CPR produced peak blood pressures of over 100 mmHg and was successful in maintaining consciousness for up to 93 s.
      Niemann, 1980.Cough-CPR: documentation of systemic perfusion in man and in an experimental model: a "window" to the mechanism of blood flow in external CPR. Crit Care Med. 1980 Mar;8(3):141–6.Clinical study of seven male patients aged 36-53 with unstable cardiac rhythms including: VF (4 patients), asystole (2 patients) and high degree AV block (1 patient). Six patients were undergoing coronary angiography and 1 patient was on CCU. Cough-CPR was utilised initially in all cases until definitive treatment or spontaneous reversion into sinus rhythm.
      Criley, 1976.Cough-Induced Cardiac Compression Self-administered Form of Cardiopulmonary Resuscitation. JAMA. 1976;236(11):1246–1250.Case-series of eight patients undergoing coronary angiography who developed VF. Three of these patients remained conscious 24–39 s by coughing every 1–3 s. The mean aortic systolic pressure induced by cough was 139.7 mmHg. All patients survived to hospital discharge.
      A study by LoMauro and Aliverti [
      • Antonella LoMauro A.
      • Aliverti A.
      Blood shift during cough: negligible or significant?.
      ] provides new information regarding the effects of coughing on blood flow. The authors found that in healthy participants, deep, vigorous coughing can result in measurable fluctuations in intra-thoracic and intra-abdominal pressure which displaces significant volumes of blood from the thorax via the thoracic and the abdominal pump mechanisms. Although this provides a plausible mechanism by which cerebral perfusion might be maintained initially during unstable cardiac arrythmia, the authors are careful not to advocate for the use of ‘cough resuscitation’.
      The fact that the inaccurate message regarding ‘cough CPR’ has persisted for almost 20 years, highlights a failure to educate the public regarding the difference between a heart attack and cardiac arrest. The information contained in the ‘cough CPR’ article may pose a serious risk to patients. If the ‘advice’ is followed by someone experiencing a myocardial infarction, this may cause delay in contacting emergency services and may lead to harm.
      So, what should we do about it? Firstly, if we see this article being shared on social media, it is our duty to inform the relevant person that the message they are sharing is inaccurate and is potentially dangerous. Second, a social media campaign focusing on dispelling this myth may be required to help counter the spread of misinformation.

      Conflicts of interest

      None.

      References

        • Snopes
        How to survive a heart attack when alone.
        ([Accessed 30 September 2018] at:)2018
        www.snopes.com/fact-check/cough-cpr/
      1. British Heart Foundation. Could something called ‘cough CPR’ save my life? [Accessed 30 September 2018] at: https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/ask-the-experts/cough-cpr.

        • Resuscitation Council (UK)
        Statement on cough CPR.
        ([Accessed 30 September 2018] at:)2018
        • American Heart Association
        Cough CPR.
        ([Accessed 30 September 2018] at:)2017
        • Antonella LoMauro A.
        • Aliverti A.
        Blood shift during cough: negligible or significant?.
        Front Physiol. 2018; 9: 501https://doi.org/10.3389/fphys.2018.00501