I. Inspiratory Phase
The first stage of a cough. Dust, mucus, stimuli, irritants trigger signals in the nervous system and brain, and suddenly up to 2.5 liters or almost half a gallon of air rushes into the lungs. The rima glottidis, the space between your vocal chords, is still open as you finish inhaling before it shuts. I try to picture what my vocal chords look like, twin pink membranes spread like stage curtains over my larynx, or voice box, with an opening that pushes back the curtains to reveal the gaping hole of my throat leading to the larynx. My rima glottidis suddenly snaps shut.
My rima glottidis has been snapping shut frequently last year. I started coughing at the beginning of September, easing out of the cough sometime in late November or early December. Whenever I inhaled too deeply, laughed too much, slept too little, gasped too suddenly, I erupted into spasms of violent coughs that vibrated my lungs. My abs and chest contracted as I folded into myself, burying my mouth in my elbow. The doctor said it was viral asthma, a pseudo-asthma that constricted my airways as though I was breathing through a straw, something I had to wait out with the crutch of an inhaler. And then a steroid inhaler. And then an attachment for the first inhaler that would concentrate the dosage. The cough died away before I decided to try the inhaler attachment.
The two weeks prior to Easter Break, I was coughing again. I thought it was just another sleep deprivation cough—a 4.5-hour night, a 1.5-hour night, a 5-hour night. The night after those two weeks of ragged craziness finished, I slept—but the damage was done. I was coughing up phlegm, discreetly spitting it into a Kleenex or the nearest sink.
My lower ribs have been hurting for at least three weeks. Some days it’s worse than others, from sensing mild discomfort to feeing like being stabbed with jabbing, cold air, broken rib pain. I hiked at Hocking Hills in south central Ohio with some guy friends on Good Friday. They told me to stop climbing. By the end of the day I was in pain with every step and every breath, so I tried to shuffle, stepping gently, slightly, barely lifting my feet above the roots, the dirt, the rocks, the grass, the branches.
Then, two times in one day over Easter Break, I coughed hard and couldn’t inhale afterwards. The first time, I knew the muscles in my throat weren’t going to work, and I felt I wouldn’t be able to inhale. I stood frozen for a few seconds, trying to pull air in but only hearing my own gasping excuse for a breath working around the constricted lump in my throat. I drank some water and shakily began to breathe again.
I woke up in the middle of the night coughing. This was worse than the daytime. I tried to inhale, couldn’t breathe. I got out of bed and stumbled to my desk, making raucous half-inhale breaths, trying to get air around the tight ache in my throat. I stood there, clutching my blue plastic Brita filter water bottle and my retainer. I could feel the oxygen flowing into my lungs, so I staggered back to bed. I rattled my retainer back into my mouth and lay there shaking, feeling spit or liquid in my airway, but I didn’t know what anyone could do and I was breathing again and everyone was probably asleep anyway since it was 2:30 a.m. I didn’t pick up my phone. I whimpered to myself. I fell asleep.
The doctor gave me antibiotics for residual bronchitis and told me that my lower rib cartilage was inflamed (the term he used might have been costochondritis) so I should take ibuprofen. At least my cough has a name.
I believe it was that night when I woke up again and got some water. But I don’t remember. Maybe I was dreaming about coughing. But I know when I woke up the next morning I felt an uneasy sinking in my chest.
It happened again around 4:20 a.m. another night. I woke up, coughed, couldn’t inhale, gasped and strangled and panicked and headed for the water bottle, the water bottle that helped me breathe. It didn’t. It hurt to try to breathe, a sharp and dull aching tightness at the back of my throat, at the top of my throat, that wouldn’t let air through even though I fought it, even though I instinctively kept trying, trying. I thought the word panic. The strangling sounds became rapid as I panicked, tried not to panic, tried to breathe, couldn’t breathe, ran down the hall, knocked on Grace’s door, stood gasping and shaking and slowly slowly slowly getting oxygen again.
II. Compressive Phase
The second stage of the cough is the compressive phase, when everything contracts, compresses, tightens, builds. The epiglottis, the cartilage flap that covers the trachea so food and other junk don’t go into your windpipe, closes over the trachea. The larynx is cut off. Muscles in your abdomen, muscles you use to expire and breathe, muscles everywhere, contract against the diaphragm, contract against each other. Building.
When your bronchial tubes, the tubes that bring air further into your lungs, are inflamed, you have bronchitis. This means you cough. Bronchitis is often caused by the rhinovirus, the same virus that causes colds. Bronchitis can be either acute or chronic. To have chronic bronchitis, you must cough for repeated stretches of time, at least three months at a time, at least two years in a row. Generally, when people have bronchitis, they have acute bronchitis. While the bronchitis itself may improve quickly in acute bronchitis, the actual cough may prolong itself for weeks afterwards. I’ve been coughing for approximately six weeks this time around. The last time, the viral asthma lasted three months.
I went to the doctor again. He thought I might have a sinus infection. I went to Urgent Care. They took a chest X-ray. They asked questions. They don’t know what’s wrong—my lungs are clear, so maybe it’s a combination of a respiratory infection, stress, and lack of sleep. My friend thinks it could be vocal cord dysfunction, when your vocal cords do the opposite of what they should, sweeping shut when they should be sweeping open. My mom thought it could be allergies or pneumonia. She mailed me medicine. The doctors prescribed medicine. My friends offered to loan me medicine. My desk is turning into a pharmacy—a ProAir HFA albuterol sulfate inhaler, a Pulmicort Flexhaler, Tussin DM Max, expired ibuprofen, AllerEase (a bottle of fexofenadine hydrochloride tablets from Mom), a box of homeopathic indoor allergy tablets (also from Mom), Ciprofloxacin antibiotics (for my supposed sinus infection), and saline nasal spray. Boxes. Bottles. Pills.
No one knows what’s wrong.
In this third phase of the cough, the air rushes out of your lungs as your vocal cords relax and your epiglottis flies open (TOOK OUT 100 mph). This should expel the mucus, the dust, the irritants, the stimuli that triggered the cough.
My friends are afraid to make me laugh—I cough. I run around playing Frisbee—I cough. I climb rock formations on hikes—I cough. My classmates tell me they’re worried I’m going to keel over, dying after a coughing fit. Conversation lulls as they wait to see if I’ll keep breathing. The girls in my dorm tell me they want to cry because my cough sounds so painful. My mom offers medical advice from every friend she talks to. My friends tell me to take it easy, to slow it down, to sleep, to drink water, to breathe in steam, to take ibuprofen, to use my inhaler, to think about something else, to not panic when I can’t breathe.
How am I supposed to not panic when I can’t breathe? How can I calmly relax when I’m not getting oxygen, when I desperately try to inhale, when I have an aching tightness in my throat that won’t go away, when not even drinking water helps me breathe?
I have a water bottle and an inhaler in arm’s reach at night, just in case. But I’m afraid. For two or three nights after the last episode, I developed a gaping pit in my stomach as I quavered at the thought of going to sleep. What if I wake up and can’t breathe, and this time I can’t recover? Not breathing was terrifying, felt weird, hurt, frightened my friends, frightened me, and please, please, I don’t want to wake up unable to breathe again, with my throat tight and trying to inhale with just a painful sore nothing as a result.
I’ve tried to analyze a pattern of when I can’t breathe, but there are too many variables. Was it lack of sleep? Did I or didn’t I use my inhaler? Was I on antibiotics? Does it happen every other day? Every fourth day? Every week? I’m afraid it will strike tonight.
IV. Relaxation Phase
In this final phase, the muscles relax. The cough is done, and hopefully the irritant is expelled, dislodged, removed.
One of two Hebrew words for “breath” is neshamah, and it refers to physical breathing and to life and spirit, especially to life and breath as given by God. It is used in Bible verses such as Isaiah 42:5: “Thus says God the LORD, Who created the heavens and stretched them out, Who spread forth the earth and that which comes from it, Who gives breath to the people on it, And spirit to those who walk on it.” It also appears in Daniel 5:23, when Daniel says, “[T]he God who holds your breath in His hand and owns all your ways. . .” The other Hebrew word for breath in the Bible, ruach, has more of a psychological connotation to it, focusing on our will.
I remembered the neshamah verses and tried to read about them, think about them, cling to them as I sat quivering, not going to bed, feeling slightly nauseous because I didn’t know if I would or wouldn’t breathe that night. I pictured God’s hands, huge calloused palms that hold the oceans and planets and galaxies. And my breath. I couldn’t picture my breath—is it in individual measured doses for each time I inhale? Or has God decided a set quantity of oxygen that I will consume in my life, and I’m just gradually, steadily working through my set oxygen supply? What does not breathing look like in God’s palms—how does He hold our non-breaths? I don’t know. I couldn’t picture the breath, but I could envision hands, open palms, giving me each inhale, exhale, inhale, exhale.
Thinking about those verses didn’t stop me from quivering or from having a sick feeling in my gut. They didn’t stop me from slumping into a chair and nearly crying when I returned from Urgent Care with no answers. They didn’t stop the panic I felt when I couldn’t breathe, when my throat tightened and ached and I tried to breathe, I need to breathe, please let me breathe.
But I cling to them. And in a way, even though I still had to fight to keep calm, those verses did settle something in my mind, settle something deep in my chest past all those bronchioles and diaphragm and aching ribs and costochondritis, making me look beyond the fear and the stabbing pain to something bigger, greater, stronger, calmer. God is the giver of life, the owner and guard over my neshamah, someone invisible holding an invisible gift, a daily moment-by-moment grace.
I don’t know when that grace will run out, when those palms will not hold any more air for me. Maybe it will be tonight. Maybe not. I don’t know. In spite of the ache, in spite of the terror, however, He still holds the breath I have.
And those palms that now hold my breath will reach down and hold me when my breath runs out.