Obstacles to implementing evidence-based guidelines.

Thanks to Dr Hillsman for his comments. The basic forced expiratory technique maneuversdescribed initiallybyThompsonand Thompson1 and later by Pryor et al2 did not include instruction to whisper “huff.” I agree that modifications to techniques previously established from a research base might add or detract from their efficacy. In retrospect, the readers might have been better served had I distinguished the role of the “whispered huff” as a teaching technique independent of the basic steps of the maneuver. That said, I disagree that this vocalization interferes with the huff maneuver. Vocalization of the soft “huff” actually promotes an open mouth and open glottis, up to the formation of the “ff” sound, which is more of a motion of the upper teeth meeting the lower lip at the end of the expiratory maneuver. The whisper is intended to be adjunctive to the maneuver, not to replace it. As the patient starts by initially whispering “huff,” the basic pattern is established, and the clinician builds on that effort, encouraging a stronger, more effective huff maneuver. The suggestion to whisper “huff” has been used for over 20 years in teaching huff technique to young children with cystic fibrosis and older patients with chronic obstructive pulmonary disease. I adopted this technique from clinicians who were successfully using it with children as young as 2 years old.3,4 During my work with older patients in the Veterans Affairs hospital and clinic system I found that instructing the patient to whisper “huff” was useful during initial sessions. These patients were so used to coughing (which starts with a closed glottis), often in uncontrolled paroxysmal spasms, that whispering “huff” helped them to control their breathing pattern and transition to the new open-glottis huff paradigm. As the technique is mastered, the “whisper” can (and possibly should) be dropped. Interestingly, I find huff and forced expiratory technique of great benefit specifically because the maneuvers do not require great concentration once learned, compared to other secretion-mobilization techniques, and I have had great success with both small children and geriatric patients with chronic obstructive pulmonary disease during severe exacerbations, when they can concentrate the least and need it the most. On a humorous note, with the really small children we used to call it the chicken cough and had them move their arms like wings, bringing them down to their sides during the huff maneuver, which made early instruction of the huff a part of their play activity. It certainly distracted the adults in the room, if not the children. Although it was not described in the early definitive studies, I believe that the adjunctive whisper of “huff” is a valuable aid in training the patient to differentiate the huff maneuver from a closed-glottis cough. My recommendation to use the whisper “huff” technique was based on training, experience, and anecdotal observations in instruction of a wide range of patients. To date, this teaching technique has not been rigorously studied in young children. Until such research is done I recommend an nof-1 approach5 to determine whether an individual patient who has difficulty learning the huff maneuver benefits from whispering “huff” while learning the maneuver.