A pilot study of coughing into the shirt to disrupt respiratory pathogen transmission

A pilot study of coughing into the shirt to disrupt respiratory pathogen transmission

Scientific evidence is lacking for the respiratory etiquette maneuver of coughing into the elbow.

Abstract
Background Scientific evidence is lacking for the respiratory etiquette maneuver of coughing into the elbow.
This pilot study introduces and evaluates a novel maneuver " coughing into the shirt” comparing effectiveness of
containing respiratory plumes to existing respiratory etiquette strategies.
Methods In this open-bench, observational respiratory etiquette pilot study, five healthcare workers performed
four respiratory etiquette maneuvers including: unobstructed, into the elbow, into a mask, and into the shirt.
Observational data for the cough maximal plume area, an area calculation, were collected using slow-motion video
recording. The various respiratory plume areas of the participants were compared to the unobstructed maneuver,
assessing the percent reduction of the maximal plume area.
Results All respiratory etiquette maneuvers significantly reduced the maximal plume area as compared to the
unobstructed condition (F(3,12)=18.56, P<0.005). Comparing the maximal plume area of the unobstructed
maneuver to the “into the shirt” maneuver, we found a 95.4% decrease for the “into the shirt” respiratory etiquette
maneuver (P<0.005). There was no statistically significant difference when comparing the obstructive maneuvers to
each other. Additionally, the maximal plume area from the “into the shirt” maneuver was 35.75% less than the “into the
elbow” maneuver (P=0.15). Comparing the maximal plume area of the “into the shirt” maneuver to the “into the mask”
maneuver, results were inconclusive, with an average difference of 2.24% (P=0.66).
Conclusions Coughing into the shirt may offer superior containment of the respiratory plume than coughing into
the elbow. Larger studies are warranted to validate these findings and guide future public health recommendations.
Study design Open bench, observational, cough etiquette pilot study comparing the into the shirt respiratory
etiquette maneuver to other respiratory etiquette maneuvers.

Matthew D. Steimle1

, Jacob Steenblik2*, Brandon D. King3

, Amy A. Gooch4

, Jeremy Baird3
, Jane Yee3
, Valerio Pascucci5
,

Margaret Carlson6

and Patrick Ockerse3

https://doi.org/10.1186/s12245-025-00892-6

2025

Peri Irawan

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