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(Chest. 2000;117:1200-1201.)
© 2000 American College of Chest Physicians

Diaphragmatic Rupture*

A Complication of Violent Cough

Liziamma George, MD, FCCP; Shakaib U. Rehman, MD and Faroque A. Khan, MB, MACP, FCCP

* From the Division of Pulmonary Diseases (Dr. George) and the Department of Medicine (Dr. Khan), Nassau County Medical Center, Stony Brook, NY; and Johnson Clinic (Dr. Rehman), Rugby, North Dakota.

Correspondence to: Liziamma George, MD, FCCP, Attending, Division of Pulmonary Diseases, Nassau County Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554


   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 References
 
The cough is a complex physiologic response designed to protect airways from unwanted secretions and foreign materials. Violent and paroxysmal coughs are associated with many complications. In this article, we will discuss a patient who sustained diaphragmatic rupture as a result of violent coughing. The possible mechanisms of this rare complication are explained.

Key Words: complication • cough • diaphragmatic rupture • rib fracture.


   Introduction
TOP
 Abstract
 Introduction
Case Report
 Discussion
 References
 
The cough is an important defense mechanism for preventing foreign material from entering the tracheobronchial tree and for clearing excessive secretions from the lung. It is a complex reflex response to the stimulation of the cough receptors of the lung.1 Paroxysmal and violent coughing is associated with many complications.1 In this report, we describe a patient who sustained rib fractures and diaphragmatic rupture as a result of coughing.


   Case Report
TOP
 Abstract
 Introduction
 Case Report
Discussion
 References
 
A 61-year-old man came to the emergency department with complaints of cough, sore throat, and postnasal drip. The patient had a medical history of asthma, diabetes mellitus, and hypertension. He was treated with antibiotics and antihistamines for an upper respiratory tract infection and was sent home. The patient returned to the emergency department the next day with right lower chest pain following a bout of coughing. On examination, he had mild tenderness over his right lower chest. Bilateral rhonchi were heard on auscultation. The patient was discharged and was given acetaminophen (Tylenol; McNeil Consumer Products; Washington, PA) with codeine for musculoskeletal pain.

The patient returned to the physician the next day with worsening pain and shortness of breath. A physical examination showed ecchymosis of the right lower chest. The chest radiograph (Fig 1 ) and rib series revealed a displaced fracture of right seventh rib in the posterior axillary line. The patient was admitted to the hospital for observation. His condition worsened following admission. A physical examination showed flail chest and decreased breath sounds. A repeat chest radiograph revealed pleural effusion on the right side.



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  		Figure 1.. Chest radiograph taken on admission to the hospital revealing right lower lobe density with pleural effusion.

 
A CT scan of the chest (Fig 2 ) showed a rupture of the diaphragm with bowel loops in the chest and avulsion of the seventh rib in the costochondral margin



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  		Figure 2.. Chest CT scan showing diaphragmatic rupture and bowels in the thoracic cavity.

 
The patient underwent thoracotomy for the ruptured diaphragm. The medial part of the diaphragm had a large defect right below the sternal border. The defect measured 16 cm anteroposteriorly and 10 cm mediolaterally. The seventh and eighth ribs were fractured at the posterior axillary line and were avulsed at the costochondral junction forming the flail segment. The diaphragm and ribs were repaired, and the patient made an uneventful recovery.


   Discussion
TOP
 Abstract
 Introduction
 Case Report
 Discussion
References
 
The cough is a vital defense mechanism in the protection of airways from unwanted materials. When the cough receptors are stimulated by either mechanical or chemical stimuli, the process of cough begins.1 A cough has three different phases: the inspiratory phase, the compressive phase, and the expulsive phase. The inspiratory phase of a cough starts with a deep inspiration resulting in increased lung volumes and increased elastic recoil pressure. During the compressive phase, the glottis is closed and the expiratory muscles start to contract. As a result, the intrathoracic pressure increases to generate high-velocity flows for the expulsive phase of the cough. With the expulsive phase, the glottis opens and the high-pressure gradient generates rapid airflow. Both inspiratory and expiratory muscles are actively involved in coughing, and extreme changes in intrapleural pressure occur due to active contraction of these muscles.2 This intrathoracic pressure swings as well as repeated cough results in multiple complications.

Numerous complications are associated with coughing. These include syncope, rupture of subconjunctival nasal and anal veins, bradycardia, pneumomediastinum,3 pneumothorax, incontinence, the rupture of muscles, the herniation of the lung through the intercostal space,4 and the fracture of ribs.1 The fracture of ribs can be explained by either of two different theories. The first mechanism of rib fracture in cough is similar to that of stress fractures.5 6 When force (muscle contraction) is applied to an object (a rib), the object is subjected to stress. The stress will cause deformation of the object. When the deformation exceeds the elastic limit of the object, it undergoes inelastic deformation. Repeated trauma, as in paroxysms of cough, can produce inelastic deformation in the most vulnerable part of the ribs, the middle third. This will result initially in minor cracks of the ribs and later, as the trauma continues, in fractures. Fractures can occur in any rib, but the ones most commonly involved are the fifth to 10th ribs.6

The second mechanism of rib fracture may be due to opposing muscle forces acting on the ribs. The diaphragm is mainly an inspiratory muscle. The costal part of the diaphragm is attached to the lower six ribs and their cartilage. The muscles of expiration are the chest wall muscles, which include the internal intercostals, the triangularis sterni, the serratus posterior, the quadratus lumborum, and the abdominal muscles (including the external and internal oblique, the rectus abdominis, and the diaphragm).7 The diaphragm also acts as an expiratory muscle during activities requiring high intrathoracic pressure like coughing, vomiting, and sneezing.2 This expiratory activity of the diaphragm is related directly to the intrapleural pressure and follows the expiratory activity of the transversus abdominis muscle. It is speculated that the diaphragmatic contraction will help to stabilize the thoracic cavity during the expulsive phase of cough. The study by Oechsli7 describes a fracture line starting from a point 4 cm from the costochondral junction of the fourth rib running obliquely caudad and laterally to the ninth rib in the midaxillary line. This line falls on the muscular attachments of the external oblique and serratus anterior muscles. The opposing actions of these muscles on the same ribs can result in fractures. Simultaneous contraction of the shoulder girdle muscles, especially of the serratus anterior, also contributes to the rib fractures by pulling the ribs upward and laterally while the abdominal muscles pull the ribs medially and downward.7

The most common cause of diaphragmatic rupture is trauma. Seven percent of thoracic injuries and 22% of thoracoabdominal injuries are associated with diaphragmatic injury. Left-sided ruptures are five times more common than right-sided injuries. During forced respiratory movements, the muscles of the abdominal wall contract pushing the diaphragm upward and the ribs inward and downward. A sudden and forceful Valsalva maneuver can result in the lack of coordination of different muscles of expiration.8 This can contribute to the rupture of the diaphragm. Since both the diaphragm and abdominal muscles are attached to the lower ribs, this kind of opposing action can result in rib fractures. In the presence of existing rib fractures, antagonistic actions of muscles on different fragments of ribs probably contribute to the tearing of the diaphragm.

Our patient had paroxysmal coughing as a result of bronchitis and sustained rib fractures that resulted in flail chest and rupture of the diaphragm, which required surgical intervention. To our knowledge, this is the first report of diaphragmatic rupture as a result of paroxysmal coughing. The patient’s symptoms started after an episode of violent coughing, and continued coughing contributed to the rib fractures and the diaphragmatic rupture. The patient required surgical repair for the diaphragm and fractured ribs, leading to an uneventful recovery.

Received for publication April 16, 1998. Accepted for publication October 18, 1999.


   References
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. Irwin, RS, Rosen, MJ, Braman, SS (1977) Cough a comprehensive review. Arch Intern Med 137,1186-1191[Abstract]
  2. Kobayashi, I, Kondo, T, Ohta, Y, et al (1992) Expiratory activity of the inspiratory muscles during cough. Jpn J Physiol 42,905-916[CrossRef][ISI][Medline]
  3. Chiba, Y, Kakuta, H (1995) Massive subcutaneous emphysema, pneumomediastinum, and spinal epidural emphysema as complication of violent coughing: a case report. Auris Nasus Larynx 22,205-208[Medline]
  4. Sloth-Nielson, J, Jurik, AG (1989) Spontaneous intercostal pulmonary hernia with subsegmental incarceration. Eur J Cardiothorac Surg 3,562-564[Abstract]
  5. Roberge, RJ, Morgenstern, MJ, Osborn, H (1984) Cough fracture of the ribs. Am J Emerg Med 2,513-517[CrossRef][ISI][Medline]
  6. Derbes, VJ, Haran, T (1954) Rib fractures from muscular effort with particular reference to cough. Surgery 35,294-321[ISI][Medline]
  7. Oechsli, WR (1936) Rib fractures from cough: report of twelve cases. J Thorac Surg 5,530-534
  8. Nakadi, BE, Vanderhoeft, P (1990) Effort rupture of diaphragm. Thorax 45,715[Abstract]



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