Treat aspiration pneumonia like a boss

Coupage, or chest percussion, helps expell pulmonary and bronchial secretions by stimulating the cough reflex

Coupage with flat hands is useless at best (left) while coupage with cupped hands is effective (right).

With a 25 percent death rate, aspiration pneumonia should be taken seriously. Treatment traditionally includes hospitalization, IV fluids and antibiotics (often a cephalosporin combined with enrofloxacin), oxygen therapy, nebulization, and coupage.

Coupage, or chest percussion, helps expell pulmonary and bronchial secretions by stimulating the cough reflex.

Performing coupage

  • Stand behind the patient and place one hand on each side of the thorax. Importantly, your hands must be cupped so that air is present between the palm of your hand and the thoracic wall. This is critical. Using your hands flat is ineffective at best.
  • “Clap” the thorax in rhythm: right, left, right, left. Each hand needs to go over the entire chest. Clapping from caudal to cranial helps with airway clearance.
  • Keep hands cupped. The air trapped between your cupped hands and the chest wall creates a vibratory energy that is transmitted to the lungs and helps loosen secretions. The importance of keeping hands cupped has been measured. With cupped hands, the frequency generated is 5 to 10 Hertz, which can liquefy mucus. With flat hands, the frequency is higher, which doesn’t modify secretions. The speed and strength required are difficult to explain, but they can be compared to the pace of a galloping horse, or someone applauding or burping a baby.
  • Use common sense to adjust the strength used relative to the size and overall health of the patient. A period of adaptation may be required. Several short sessions are better initially, with the goal of increasing the duration to about 5 minutes, three to four times daily, as long as the patient is coughing.
  • Do not use antitussives, as the goal is to encourage the patient to cough to expel secretions. Maintaining the patient’s hydration intravenously and through nebulization encourages this process.
  • Use a nebulizer to create tiny droplets that can reach the smallest airways and keep the mucociliary escalator functional. Droplets should therefore be smaller than 3 µm. A vaporizer or a humidifier is therefore inappropriate. In a pinch, the patient (cat or dog) can be brought into the bathroom every time someone takes a shower.
  • Consider adding various medications to the nebulizer: antibiotics, mucolytic (N-acetyl-cysteine), or albuterol (bronchodilator). The efficacy of such medications is controversial.
  • Always perform coupage following nebulization. Secretions, once loosened and moved into the airways, induce coughing, which helps expulsion.
  • Engage in brief exercise to help with expectoration. A short leash walk may be all you can do with a compromised patient, even if it’s around the treatment room.
  • Remember to turn over weak patients regularly to improve ventilation of both lungs.
Five coupage dont’s

1) Don’t use flat hands.
2) Don’t do coupage before nebulization.
3) Don’t clap both sides of the chest
at the same time.
4) Don’t clap too gently.
5) Don’t clap too violently.

Visit to view a video that can illustrate to team members and clients the correct way to perform coupage.

When it is done well, coupage is a simple, cheap, and effective component of the treatment of aspiration pneumonia.

Dr. Phil Zeltzman is a board-certified veterinary surgeon and author. His traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. Visit his websites at and

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