Chronic Refractory Cough: A Case Study

Weekly Teaching Tip – Sep. 12, 2016
by Anna Siciliano

This paper presents a successful behavioral case study in treatment of chronic refractory cough in a 60 year old adult female. Efficacy for treating chronic cough is discussed along with common treatments. Discussion focuses on therapy approaches used and the patient’s report of changes in quality of life after treatment.
In recent years, the treatment of cough has become an important part of the caseload of the Voice Therapist/Speech Language Pathologist working in a multi-disciplinary Voice Center. In our particular Voice Center, Vocal Cord Dysfunction/Laryngo-spasm and associated cough are among the top diagnoses we are asked to treat. Vertigan and Gibson (1) found that 20% of cough cases are refractory or resistant to medical treatments. It is important to distinguish between cough that responds to medical treatment and cough that fails to respond to traditional medical treatment. This paper will focus on treatment of refractory chronic cough or specifically chronic unexplained cough that persists despite medical treatment.

In their randomized control study Verigan and Gibson (1) found that 87% of patients with refractory cough benefited from speech pathology treatment. Other studies such as Blager et al (2), have shown the benefits of voice therapy techniques when used with cough patients. Chamberlin, Birring and Garrod (3)reviewed non- pharmacological interventions for chronic cough and found these interventions to be helpful in reducing cough and improving quality of life. Treatment of chronic cough can be satisfying and highly rewarding, but it can also be a challenge for speech pathologist.
Chronic cough is described as a cough that lasts over 8 weeks in adults (4).It is estimated that 12% of the population suffers from cough of unknown origin (1). These patients are often treated with inhaled steroids and antihistamines or decongestants. By the time these patients arrive at the voice center, they are often discouraged and confused.

Cough without the presence of lung disease or other organic etiology has sometimes been described as psychogenic cough. Papers have been written reviewing positive outcomes with behavioral modification for psychogenic cough (5). Though behavior modification techniques may provide the desired outcome, namely deceased
frequency of cough, behavior modification paired with education and breathing strategies can result in a more stable outcome.

Participant

Our patient is a 60 year old female who had dealt with chronic cough for 25-30 years. She had seen several medical specialists including: Pulmonologists, Allergists, Gastroenterologists, Otolaryngologists, Psychologists and alternative medicine practitioners. She had also been to a Neurologist and had CT scans and MRI’s to rule out brain pathology.

MH, had undergone extensive medical testing which failed to reveal physiological etiology for cough. She had done chest x-rays, pulmonary function tests, methacholine challenge testing, allergy testing and endoscopy. She was under the care of a pulmonologist and had tried nebulizers and inhalers. These did not improve her cough. She had tried reflux medicine in the past, but was currently not taking reflux medication. She had tried a low dose of Amitriptyline, but stopped this medication shortly after starting it as her primary care physician felt Amitriptyline was contra-indicated with her other depression medication.

MH described her problem as coughing, throat irritation, and throat closing up at times. She reported cough triggers including: cold drinks, foods, perfumes, smoke or cleaning products. She avoided public places such as church buildings and movie theaters due to her cough. Throat sensations included excessive mucous, difficulty swallowing dry foods, sensation of lump in the throat, sharp scratchy feeling, need for throat clearing, and a dry feeling in her throat.

MH filled out an extensive case history. Her Dyspnea Index score was 11/40 and she judged her breathing to be a moderate problem. She filled out the Leicester cough questionnaire and the Reflux Symptom Index. She reported fatigue due to severe coughing episodes. She reported decreased socialization due to her cough.

MH also had a diagnosis of depression and anxiety. She felt her depression was stable with medication, but she experienced anxiety in social settings due to the possibility of coughing.

MH came to our clinic in hope of getting botox injections into the larynx to decrease her cough. Together with our Laryngologist we did a flexible scope video stroboscopic evaluation. Vocal folds were without mass or lesion and mild erythema was seen in the posterior glottis. We did not see vocal fold adduction on inhalation as described in patients with PVFM (paradoxical vocal fold movement). The patient was given the diagnosis of Irritable Larynx with Chronic cough.

Treatment plan

Education
Treatment for patient MH included a review of findings from flexible scope video
stroboscopy. We have found it helpful with our cough and PVFM patients to provide general education about the vocal folds and their function as: a valve for breathing, a valve for swallowing and a vibrating system for sound production. During the case history portion of the evaluation, we try to get a sense about cognitive abilities, education background and learning style of the patient. We attempt to explain anatomy and breathing function on a level the patient can understand and remember.

MH was eager to learn more about the structures for breathing, swallowing and voice production. She was shown the recording of her exam and she asked good questions. She was given a color print of a video still shot with the vocal folds in an open position. She was encouraged to visualize this open “V” shape when she felt a cough coming on.

Cough Suppression
MH was taught cough suppression strategies including: making posture changes and body movements (7), sip and swallow water, massage to the strap muscles of the neck (8) and Yawn Sign technique. She was taught ways to cut the coughing episode short.

Vocal Hygiene
Information was given about ways to keep the larynx and vocal tract healthy. Teaching about hydration was important to share with the patient.(8). Reflux education was given using a handout with colored pictures of foods and liquids to avoid. Education was completed about the importance of avoiding laryngeal irritants including smoke, alcohol, and acidic foods.

Breathing
MH was observed to be a shallow breather. She also had excessive muscle tension in the strap muscles of the neck and she held her larynx in a high position. She was taught diaphragmatic breathing in the supine position initially. We then moved to working on breathing exercises while sitting, standing and walking down a long hall. She was asked to practice her breathing at least 5 times a day when she was not coughing. She was given a home program including a cough journal and a breathing graph. She was also taught the Buteyko Nose Clearing Technique (10) as she complained of nasal congestion.

Rescue Breathing Strategies
MW was taught strategies to avoid cough. These strategies are similar to those we use for PVFM patients and include: exhale on a /sh/ or /s/ sound while visualizing open vocal folds and start diaphragmatic breathing, get up move about the room doing a torso swing and side bends with light vocalization(11), 3 sniffs in and one long exhale out (12), massage to strap muscle of the neck and mindful breathing.

Desensitization
As MH progressed in therapy we presented smells in effort to desensitize the cough response. We asked her to bring in a bag of items that she had previously had difficulty with. These included perfumes and cleaning items. Using breathing strategies and visual imagery of an open throat, MH was able to learn to smell the items and continue breathing. If she felt the urge to cough she was able to use rescue breathing, and cough suppression strategies.

Assignments
MH avoided quiet places such as her local church building, libraries, movie theaters, and opera houses. She had given up many social activities due the severity of her cough. As her confidence in therapy grew, she was asked to visit one quiet place per week. She was hesitant at first but then grew enthusiastic about testing her new skills. Before our last therapy session, she attended a local opera with her brother. She made it through the opera without coughing but did employ here cough suppression and breathing strategies.

Carry Over
MH was reluctant to be discharged from therapy. She liked being held accountable for daily practice and weekly outings. Therefore she was scheduled for a recheck at one month and 3 months post discharge. During these sessions we reviewed breathing, discussed how to handle difficult situations and made a list of ways to challenge herself. She developed a bucket list of sorts including activities that she previously had not considered a possibility due to the severity of her cough.

Counseling
Though our degree is not in psychology, it is known that voice therapy often includes counseling and motivational interviewing. (13) Expressing empathy and encouraging self-efficacy help the patient make long term changes. Chronic cough patients often have negative memories associated with cough episodes. Providing a listening, non-judgmental ear helps the patient work through past traumas associated with cough. MH continued attending monthly counseling sessions with her Psychologist. She was encouraged to share information about chronic cough, laryngeal irritants and breathing strategies. She reported that as she coughed less, her anxiety decreased. As she ventured out to public places, her feelings of isolation lessoned.

Expression
We received a long thank you letter from patient MH three months post discharge from voice therapy. She was preparing for a vacation that required her to fly by plane, an activity she previously avoided. She reported that two components of therapy were particularly helpful: 1. Viewing the recording of her flexible laryngoscopic exam and being given a picture of her abducted vocal folds, and 2. Being given tools to use when a coughing episode started. She reported feeling ready, prepared and armed with strategies. She also shared that as she practiced her breathing many times daily, the instance of cough significantly reduced.

Summary
In our experience, Chronic Cough can be treated similarly to Vocal Cord Dysfunction /PVFM. Education is crucial to build a knowledge base that the patient can work from. Building a trusting relationship with the patient, encourages the patient to follow through with home practice. There is strong evidence that voice therapy by a qualified Speech Pathologist is effective in treating chronic refractory cough (14). Reducing the frequency of chronic cough gives the patient improved quality of life. Further research is needed for chronic cough that does not respond to behavioral therapy.

References:
1. Vertigan AE, Gibson PG. Lung. 2012 Feb; 190(1):35-40.
2. Blager F, Gay M, Wood R. Voice therapy techniques adapted to treatment of habit cough; pilot study. Journal of Communication Disorders. 1998;21: 393-400.
3. Chamberlin S, Birring S, Garrod, R. LUNG. 2014 May; 192:75-85
4. Morice AH, McGarvey L, Pavord I, BTSG (2006) Recommendations for the Management of Cough in Adults. Thorax 2006; 61 Suppl 1:1-24.
5. Watson, TS, Heindl B, Journal of School Psychology. 1996 Vol. 34, No.4: 365-378. Behavioral Case Consultation with Parents and Teachers: An Example Using Differential Reinforcement to Treat Psychogenic Cough
6. Vertigan A, Theodoros D, Gibson P, Winkworth A. Efficacy of speech pathology management for chronic cough; a randomized, single blind, placebo controlled trial of treatment efficacy. Thorax. 2006; 22 (5):581-9
7. The Myofascial Release Manual. Manheim, C, Medicine and Health
8. Myofascial Release for Voice and Swallowing Disorders: CIAO seminars
Orlando Florida 2013
9. Hartley NA, Thibeault, SL. Systemic hydration; relating science to clinic practice in vocal health. Journal of Voice 2014:28 (5):652
10. Close Your Mouth. Clinic Handbook for Perfect Health, Mckeown, P, Buteyko Books, Loughwell, Moycullen Co. September 2004
11. D’Antoni ML, Harvey PL, Fried MD. Journal of Voice, September 1995 Vol. 9, Issue 3, pages 308-311 Alternative Medicine: Does it Play a Role in the Management of Voice Disorders?
12. Blager F Cough: Increasingly seen with and without VCD. Presented at: Advances in the Diagnosis and Treatment of Vocal Cord Dysfunction Conference, National Jewish Medical and Research Center; 2003; Denver Colorado
13. Behrman, A, American Journal of Speech Language Pathology. 2006;15:215-225. Facilitating behavioral change in voice therapy; The relevance of motivational interviewing.
14. Vertigan A, Gibson P. Speech Pathology Management of Chronic Refractory Cough, Compton Publishing 2016