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When the Coughing Won’t Stop

2019; American Speech–Language–Hearing Association; Volume: 24; Issue: 11 Linguagem: Inglês

10.1044/leader.ftr2.24112019.50

1085-9586

Laurie Slovarp, Anne E. Vertigan,

Asthma and respiratory diseases

You have accessThe ASHA LeaderFeature1 Nov 2019When the Coughing Won't StopMost patients with idiopathic chronic cough can benefit from a cough-suppression treatment provided by SLPs. But such treatment is often delayed if given at all. Why? Laurie Slovarp andPhD, CCC-SLP Anne VertiganPhD Laurie Slovarp Google Scholar , PhD, CCC-SLP and Anne Vertigan Google Scholar , PhD https://doi.org/10.1044/leader.FTR2.24112019.50 SectionsAboutPDF ToolsAdd to favorites ShareFacebookTwitterLinked In Bonnie's chronic cough started four years ago when she suffered from mycobacterium avium complex (a rare lung infection). The infection was effectively treated, but a dry, daily cough remained, sometimes producing coughing fits that made Bonnie gag. The cough was interfering with the 76-year-old's enjoyment of life. She could no longer go to yoga class or the symphony, two of her favorite pastimes. And her efforts to find treatment for the cough had been fruitless: She had seen at least four physicians, including a pulmonologist, an otolaryngologist, and an infectious disease specialist. She had undergone multiple tests, including chest X-ray, chest CT scan, pulmonary function testing, laryngoscopy, and 24-hour pH monitoring. None revealed a treatable cause for her cough. The physicians prescribed antibiotics and recommended the standard medications for reflux and rhinitis. Bonnie also tried all sorts of over-the-counter cough medications and codeine cough syrup—the only treatment that worked, but limited because it can be addicting. Frustrated, Bonnie consulted a second pulmonologist, who referred her to a speech-language pathologist for behavioral cough treatment. At first, Bonnie didn't pursue the referral. She was tired of seeing specialists and didn't see how an SLP could help with a cough. But then, a year later, she saw a newspaper article about the effectiveness of behavioral therapy for chronic cough. She decided to give the SLP a try and was ultimately grateful that she made that choice. We'll find out why a little later. Bonnie's experience is not unusual, given that chronic cough is one of the most common reasons for physician visits. According to a systematic review and meta-analysis published in 2016, chronic cough is estimated to affect 9% of the population worldwide and 12% of Americans and Europeans (see sources). It significantly affects patients' physical health and quality of life, and places a significant economic burden on patients and society. In most cases, the condition responds to medical therapy, such as smoking cessation; avoiding angiotensin-converting enzyme inhibitors (a medication used to treat hypertension that often has a side effect of cough); and treatment of lung pathology, gastroesophageal reflux disease, and rhinosinusitis or asthma. However, a substantial percentage of patients are not effectively treated medically. According to a 2015 survey of 1,120 people with chronic cough, 36% reported medications prescribed for their cough had no effectiveness (see sources). Cough that persists despite medical management is labeled as nonspecific, unexplained, idiopathic, or refractory chronic cough (RCC). The good news? About 80% of these patients can benefit from behavioral cough suppression therapy (BCST), which in the U.S. is usually provided by an appropriately trained SLP—typically one who works in the area of voice and upper airway disorders who has sought additional training. The bad news? According to a 2018 survey study of SLPs who administer BCST and patients treated with BCST, the average wait time for a BCST referral is more than two years. And, as with Bonnie, when patients do finally find a physician who suggests BCST with an SLP, they may doubt the approach's effectiveness. This means patients typically enter BCST as skeptics, giving us SLPs only one session to convince them that it can work. What is BCST? The four components of BCST include education, cough-suppression strategies, reducing laryngeal irritation, and psychoeducational counseling. Treatment also may need to address muscle tension dysphonia and/or paradoxical vocal fold motion, as these disorders co-occur in approximately 50% of patients with RCC (see sources). Let's take a closer look at the approach's four main pieces. Education The initial step in BCST, education, is key to overcoming patient skepticism. We first assure patients there is an actual physiological cause for their cough. We discuss well-established evidence that patients with RCC have a hypersensitive cough reflex (see sources). Many studies have shown evidence of hypersensitivity of sensory receptors in the epithelial layer of the upper airway that are involved in regulating cough sensitivity. When functioning normally, these sensory receptors signal the brain to elicit cough in response to stimuli that would be harmful to the lungs—such as smoke, chemical fumes, or food/liquid. When these receptors are hypersensitive, non-noxious levels of stimuli—thermal (air temperature changes), mechanical (talking, laughing, swallowing), or chemical (strong odors/fumes)—can elicit cough. Emerging evidence also indicates that hypersensitivity can occur in certain areas in the brain (see sources). As a result of this evidence, the term cough hypersensitivity syndrome (CHS) has been proposed. In a 2014 European Respiratory Society taskforce survey, 43 of 44 chronic cough experts supported use of the term CHS as a useful etiologic term describing the primary cause of RCC. It's also important to help patients understand that coughing perpetuates the hypersensitivity and that suppressing the cough is possible and will cause no harm. Cough suppression In this part of treatment, we teach patients strategies to prevent or interrupt the cough. We guide them to identify the precipitating sensation, warning signal, or urge to cough, and then substitute a competing response: distraction techniques (for example, sucking on a non-medicated lozenge, chewing gum, sipping water), effortful swallow, relaxed throat breathing, cough-control breathing, and voice therapy techniques such as laryngeal deconstriction or modified accent method breathing. Each of these techniques promotes cough avoidance by involving the laryngeal structures in something different from coughing—attempting to replace the urge to cough with a different laryngeal sensation—or by promoting continuous airflow and/or phonation, which are contrary to coughing. Relaxed-throat and cough-control breathing promote sustained abduction of the laryngeal structures and continuous airflow. The accent method breathing is a voice therapy technique that focuses on promoting respiratory support with efficient phonation. We teach cough-control techniques in a hierarchy. We start under controlled conditions in the clinical setting, then have patients practice at home during asymptomatic periods. We explain that this is how they develop a motor pattern for the competing response that is strong enough to overcome the urge to cough. Patients may need multiple sessions to ensure that they learn to use the techniques accurately. And they must practice the techniques repeatedly and accurately to make them automatic. Once patients can suppress their cough, we deliberately expose them to known triggers so they can practice suppressing the cough. We encourage them to try this at home, too. Reducing laryngeal irritation This aspect of treatment involves hydration, vocal hygiene training (particularly reducing exposure to dehydrating substances and laryngeal irritants), and reduction of any phonotraumatic vocal behaviors, such as hard glottal attacks during phonation. We also urge patients to suck non-medicated hard candy or chew gum to increase the frequency of swallowing, thus relieving laryngeal irritation. We advise them to reduce behaviors that are dehydrating and irritating to the larynx—smoking, mouth breathing, and consuming excessive amounts of caffeine and alcohol. If they're prone to acid reflux, we recommend controlling it with medications and lifestyle changes such as raising the head of the bed, weight loss, and dietary changes. Psychoeducational counseling In counseling, we work on helping patients understand that behavior change, not medication, is what can fix their condition. And behavior change requires motivation to follow the treatment plan. Some patients may need help understanding that they don't have asthma or another such condition that can be treated with medication. We take care to validate patients' concerns about their condition and to acknowledge that they are not malingering. Patients may need support if emotional issues are a trigger for their cough. They may benefit from learning to identify physical changes in their larynx that occur in response to emotional stresses and to substitute alternative responses such as relaxing shoulders or slowing their rate of breathing. What makes it work? Not only have we seen BCST work for our own patients, but we've seen evidence for its efficacy in the research literature, including a number of case series and two randomized control trials, one of which was a multi-site trial (see sources). A 2014 systematic review led by Sarah Chamberlain at London's King's College Hospital showed significantly reduced cough sensitivity, improved quality of life, and reduced cough severity and frequency following BCST (see sources). The exact mechanism behind the success of BCST is unknown. Studies have shown BCST results in reduced cough reflex sensitivity (see sources). We hypothesize that change is related to the "lose it" portion of the "use-it-or-lose-it" principle of neuroplasticity. In other words, by suppressing the cough over time, the neurological pattern(s) for the hyper-reactive cough response is "lost." The physiological mechanism for this change, however, is yet to be determined. It may be due to a reduction in expression of afferent cough receptors in epithelial airway tissue and/or changes to the central nervous system. Studies are underway to look at this mechanism, but for now, the answer is unknown. The therapy also may, at least in part, work by improving voluntary control over cough. There may also be an element of the placebo response following therapy. Patient experiences To see how BCST works with our own patients, let's return to our 76-year-old patient Bonnie, whose chronic cough kept her away from yoga and the symphony. At her first BCST session, Bonnie spoke with a slightly rough and strained vocal quality and coughed every few minutes. Her vocal quality and coughing worsened with continued talking. She couldn't read a paragraph aloud or sustain phonation without coughing. She scored 12.59 out of 21 on the Leicester Cough Questionnaire (LCQ), a patient-report outcome measure with physical, psychological, and social domain scores (a lower score indicates a worse cough). By the end of Bonnie's initial session she was able to suppress nearly all of her coughs with relaxed-throat breathing. And after less than five minutes of instruction on resonant voice, she was able to sustain phonation for more than 15 seconds without a cough. She was quite shocked at her success in just one session. Five weeks later, at her second session, she reported she could successfully suppress her cough nearly 90% of the time and felt the urge to cough much less often. Her LCQ score had increased to 19.7 and she felt comfortable attending yoga and the symphony again. Chelsea, 31, had a similar story. She had been dealing with a dry cough for more than a year. She couldn't identify a cause for her cough, but it began during a stressful time in her life. She was referred by a pulmonologist, the third physician she had seen for her cough, and had been treated with medications including antibiotics, nasal spray, steroids, cough drops, codeine, reflux medication, Tesselon Perles, and an inhaler. She underwent a chest X-ray, chest CT scan, asthma testing, and pulmonary function testing, which revealed no abnormalities. Numerous scents, talking, singing, laughing, stress, and exercise triggered Chelsea's cough. She also coughed with palpation to several points on the back of her neck and upper back. She avoided talking on the phone and attending social outings, and sometimes missed work. She even reported she had thrown out her back as a result of the cough. She scored 11.77 on the LCQ. Chelsea attended five sessions within six weeks. By her final session she tolerated all scents and tasks during urge-to-cough testing without coughing and with little to no urge to cough. She scored 19 on the LCQ at evaluation. Robin, 68, had been dealing with a chronic cough for more 20 years. She could not identify a specific onset to her cough, but had frequently suffered from severe bronchitis most of her life. In addition to a daily cough, she occasionally suffered from severe prolonged coughing spells, preceded by a "tickle" in her throat, that often led to gagging. Severe episodes had caused alarm in others around her—a physician once followed her into a public restroom out of concern. She and her husband slept in different rooms and she avoided many social functions, including church. She identified strong smells, smoke, bending over, crumbly foods, and change in air temperatures as triggers to her cough. Robin had tried reflux medication, nasal spray, essential oils, codeine cough syrup, an inhaler, and an antitussive drug, all with minimal benefit. Robin also complained of occasional dysphonia that happened at unpredictable times for no apparent reason. Her LCQ score at initial visit was 9.16. Robin attended three BCST sessions within six weeks. By her second session, she was able to suppress her cough approximately 50% of the time and no longer had voice complaints. By her final session, she could suppress her cough up to 90% of the time and scored 18.49 on the LCQ. Her husband had returned to their bedroom and she was back to attending, and even singing in, church. Improving accessibility Why does it take so long for patients to seek help? Anecdotal evidence suggests that many physicians are not aware of BCST or are hesitant to recommend it because they don't understand how it works. Research published over the last several years has helped, but the progress is slow. We need to do more to have BCST recognized as a credible treatment option. Early management guidelines for RCC (for example, 2006 American College of Chest Physicians [CHEST] guidelines) did not mention BCST as a treatment option or mentioned BCST only as a potential last resort with no mention of established efficacy. Although speech-language pathology/BCST was included in the 2016 CHEST Guideline and Expert Panel for Unexplained Cough and in the 2019 European Respiratory Society Guidelines for Chronic Cough, it was not included in the 2018 CHEST Guideline and Expert Panel for Classification of Cough as a Symptom in Adults and Management Algorithms. Additional research—on the underlying mechanisms at work during BCST, optimization of the approach, identifying appropriate candidates for BCST, and the risk-benefit ratio of BCST trials at different points in management algorithms—will likely improve physician awareness and reduce wait time for patients. In the meantime, however, non-research efforts to increase physician and patient awareness of BCST as a potential treatment option appear to be helpful. In the past year, we received inquiries from many people with chronic cough and several physicians following a University of Montana news release and a local newspaper article on chronic cough research and BCST. Several patients ultimately opted for—and were effectively treated with—BCST. SLPs who are trained in BCST can promote the treatment within our multidisciplinary teams, particularly our respiratory medicine colleagues. In our experience, these colleagues are often more than keen to have our involvement in caring for this population. Although there is no formal training and competency assessment program for BCST, there are several ways SLPs can obtain competency. Professional conferences where voice and/or upper airway disorders are covered (including the ASHA Convention) commonly include presentations and/or short courses on chronic cough that frequently include BCST. Clinicians can also learn by studying research articles and texts on speech-language pathology management of chronic refractory cough and related disorders. Sources Blager, F. B., Gay, M. L., & Wood, R. P. (1988). Voice therapy techniques adapted to treatment of habit cough: A pilot study. Journal of Communication Disorders, 21(5), 393–400. CrossrefGoogle Scholar Chamberlain Mitchell, S. A., Garrod, R., Clark, L., Douiri, A., Parker, S. M., Ellis, J., … Birring, S. S. (2017). Physiotherapy, and speech and language therapy intervention for patients with refractory chronic cough: A multicentre randomised control trial. Thorax, 72(2), 129–136. CrossrefGoogle Scholar Chamberlain, S., Birring, S. S., & Garrod, R. (2014). Nonpharmacological interventions for refractory chronic cough patients: Systematic review. Lung, 192(1), 75–85. CrossrefGoogle Scholar Chamberlain, S. A., Garrod, R., Douiri, A., Masefield, S., Powell, P., Bucher, C., …, Birring, S. S. (2015). 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CrossrefGoogle Scholar Author Notes Laurie Slovarp, PhD, CCC-SLP, is an associate professor in the School of Speech, Language, Hearing and Occupational Sciences at the University of Montana and supervises graduate students at Rocky Mountain Ear, Nose, and Throat Center. She is an affiliate of ASHA Special Interest Groups 3, Voice and Upper Airway Disorders; and 13, Swallowing and Swallowing Disorders (Dysphagia). [email protected] Anne Vertigan, PhD, is the manager of speech pathology for John Hunter and Belmont hospitals in Newcastle, Australia, and conjoint associate professor in the School of Medicine and Public Health at the University of Newcastle, Australia. [email protected] Additional Resources FiguresSourcesRelatedDetails Volume 24Issue 11November 2019 Get Permissions Add to your Mendeley library History Published in print: Oct 31, 2019 Metrics Downloaded 19,587 times Topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2019 American Speech-Language-Hearing AssociationLoading ...