Chronic Cough: A Tutorial for Speech-Language Pathologists

Article excerpt

There is emerging evidence for the efficacy of speech pathology intervention for individuals with chronic cough (CC) that persists despite medical treatment, but there are limited resources available to assist speech-language pathologists to manage this perplexing condition. The purpose of this article is to outline a treatment approach for speech pathology management of CC. The article provides an overview of medical treatment for CC, a profile of patients with CC including the association with paradoxical vocal fold movement, voice problems, and psychological issues. A protocol for management of this condition including evaluation, treatment, patient education, and the importance of motivation and compliance are provided. This article provides a practical orientation for clinicians who are less experienced in managing individuals with CC.

**********

Chronic cough (CC) is defined as a cough persisting for longer than 8 weeks (Pratter, Brightling, Boulet, & Irwin, 2006). Although there are multiple etiologies for CC and complexities surrounding its management, the majority of individuals with CC respond to medical management. There is emerging evidence to support the effectiveness of speech pathology treatment for CC that persists despite medical management (Blager, 2000; Gay, Blager, Bartsch, & Emery, 1987; Murry, Tabaee, & Aviv, 2004; Russell, 1991; Vertigan, 2001). Individuals with CC are generally not referred to speech pathologists until their cough is judged to be refractory to medical treatment and therefore represent a skewed proportion of the total population with CC. The theoretical basis and efficacy of speech pathology intervention for CC have been reported in previous studies (Vertigan, Theodoros, Gibson, & Winkworth, 2006a, 2006b). There is however a need for resources that outline treatment protocols to assist speech pathologists in their management of individuals with CC. The objectives of this article is to provide an overview of medical management of CC, describe the typical profile of adults with CC, and outline a protocol for assessment and management of adults with CC from the speech pathologist's perspective.

DEFINITION AND TERMINOLOGY

Cough can be classified as either acute or chronic. Chronic cough can be subdivided into cough that responds to medical treatment and cough that is refractory to medical treatment. Chronic cough can be refractory to medical treatment in up to 20% of cases (Ing & Breslin, 1997; Kardos, 2000; Lawler, 1998; Marchesani, Cecarini, Pela, & Sanguinetti, 1998), and a number of labels such as psychogenic habit cough (Gay et al., 1987), idiopathic cough (McGarvey, 2005), psychogenic cough (Pierce & Watson, 1998), habit cough (Blager, Gay, & Wood, 1988), and refractory cough (Murry et al., 2004) have been used to describe this condition. This range of terms may reflect the underlying beliefs in the etiology of persisting cough. In this article the term CC will be used to describe cough that persists despite medical management.

MEDICAL MANAGEMENT OF CHRONIC COUGH

Medical management of CC involves measuring the severity of the condition and determining the underlying cause (Chung, 2003b). The most common causes of CC are smoking, lung pathology, medications such as angiotensin converting enzyme (ACE) inhibitors, asthma, postnasal drip syndrome, and gastroesophageal reflux (GER) disease. Within the field of respiratory medicine, CC is managed according to the anatomic diagnostic protocol (ADP) (Irwin et al., 1998). This protocol encompasses a systematic approach to identifying and treating the suspected underlying etiology or etiologies of the cough through specific diagnostic testing and empiric treatment trials.

The ADP commences with the history and physical examination. If the history identifies the use of medications such as ACE inhibitors then alternative medications may be used. …