Characteristics and Treatment of Chronic Cough in Pediatrics

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Characteristics and Treatmentof Chronic Cough in
Pediatrics

• Sally Gallena Marie Kerins
• Loyola College in MD
• ASHA Convention

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Adducted Vocal Folds during voice (left) cough
(right)
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What is Chronic Cough?

• A cough that
• persists when there is no longer an active
  trigger
• Serves no purpose to the respiratory system
• Impacts the quality on ones life or those in
  their sphere
• Affects both pediatrics and adults

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Etiologies of Chronic Cough
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Nonspecific Chronic Cough Wamboldt Wamboldt

• Unknown etiology
• No active disease
• Usually absent during sleep
• Unresponsive to medications
• Labeled (often incorrectly)
• Habit Cough
• Tic Cough
• Psychogenic Cough

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Mechanism for Cough NSCC Cycle
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SLP Treatment for NSCC

• Blager and colleagues (1988)
• Modified voice therapy techniques
• Confined to adults (4)
• Conceptual definition of NSCC psychogenic
• Bauer and colleagues (2001)
• Similar format to Blager
• Confined to pediatrics (9)
• Conceptual definition of NSCC recognized
  subtypes habit psychogenic

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SLP Treatment for NSCC continued

• Vertigans and Colleagues
• Efficacy Study that was randomized placebo
  controlled
• N87 Adults all having a physical trigger
• Results Treatment group more successful than
  controls for magnitude of improvement (reduction
  of all symptom scores following tx)
• Further investigation is needed Pediatrics!

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Purpose of this present study

• To describe physical, psychosocial, and family
  characteristics from a sample of 15 males and 15
  females with chronic cough.
• To determine if the therapy techniques used to
  treat them were successful.
• To attempt to predict those variables leading to
  a successful treatment outcome.

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Study Participants

• Thirty children age 7- 16, average 11 yrs.
• Cough present most frequently for 16 months
• Diagnosed with chronic cough by a pulmonologist
• Illness ruled out through medical tests and
  pharmacological trials
• Excluded if family history of Tourettes disease

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Procedure

• Each subject evaluated at Loyola College
• SLP team graduate student and myself
• 1 team member evaluating and treating the child
• 2nd team member with parent in observation room
• 3 sources of evaluation information parent,
  child, referring physician

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Treatment Phase

• Hierarchy
• Education
• Anatomy of the airway action cycle of cough
  possible causes, role of therapy, expectations of
  the client
• Treatment for pre-cough tickle
• Sip swallow relaxed diaphragmatic breathing,
  Squeeze release (stress ball)
• Treatment for actual cough
• Blow with pursed lips, swallow, continuous gentle
  voicing

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Treatment Phase (continued)

• Differential reinforcement using cough chart with
  
• tallying done by the client
• Effectiveness of techniques
• Establishing locus of control
• Carry-over by observing parent
• Desensitization by exposing child to trigger
  words or behaviors, while child uses techniques

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Post Treatment Phase

• Parents were instructed in
• continuing use of techniques and differential
  reinforcement
• resumption of normal routine
• Request physician clearance for childs return to
  school
• One of SLP team members followed up with parents
  within 3-5 days to determine cough status and
  schedule an appointment if needed.

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Post Treatment Survey

• Survey developed by investigator
• Forty one surveys mailed with thirty-four
  returned (three incomplete and one outlier based
  upon age of the subject).
• Two survey items used for this study
• Rating of cough resolution following treatment
• 3 Complete, 2 partial, 1 unchanged
• Rating of therapy effectiveness
• 4 very effective, 3 effective, 2 somewhat
  effective,
• 1 not effective

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Results

• Question 1 What physical, psychosocial and
  family characteristics are most common to
  pediatrics with NSCC, as a group and by gender?

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Study participants Physical Characteristics
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Physical Characteristic Summary

• All participants had at least one physical
  trigger for their cough URI, allergy, asthma,
  GERD
• There were no significant differences between
  genders for any of the physical characteristics
  using Fishers Exact Test

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Results

• Question 1 What physical, psychosocial and
  family characteristics are most common to
  pediatrics with NSCC, as a group and by gender?

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Results Psychosocial Characteristics Male to
Female Comparison
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Psychosocial and Family Characteristics Summary

• High incidence of reported stress ?gt?
• One half of the males, one third of the females
  had received psychological services (assessment
  and/or counseling)
• Three-fourths of the males, one-half of the
  females had been absent from school
• All of the females and most of the males came
  from homes with minimally one professional parent
• There was no statistical significance between
  genders

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Results

• Question 2 - Are the modified voice therapy
  techniques successful in resolving NSCC by group
  and by gender?
• Operational definition of success
• Cough resolution score of 3 (complete)
• Effectiveness score of 4 (very) or 3 (effective)
• Composite score of 6 or 7

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Parent ratings of cough resolution and therapy
effectiveness
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Reported Success of Therapy cough resolution tx
effectiveness
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Results Summary of Success

• 77 (23) subjects reported complete resolution of
  cough with therapy as very effective or effective
• Comparison of subjects reporting effectiveness
  ratings of 3 or 4 to those rating 1 or 2 was
  significant p .039 (Binomial test)
• There were no gender differences in success
  ratings

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Number of Treatment SessionsAttended
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Summary Number of Sessions

• Most subjects required only one treatment session
  to resolve their cough
• There were no gender differences in number of
  treatment sessions p 1.000 (Fishers Exact
  test)

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Results

• Question 3 - What predicts a successful treatment
  outcome?
• Logistic regression analysis with predictor
  variables length of time cough was present,
  stress onset, psychological diagnosis, prior
  counseling, missed school, age
• Lack of significance
• Larger sample size needed

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Discussion

• A physical trigger precedes NSCC
• Most apt to be diagnosed with NSCC one to six
  months following onset
• High report of stress (transition, discord,
  illness, increased pressure)
• Primary and secondary gains from the cough
  (school absence, increased attention, etc.)
• The implications of professional parents
• (High expectations, Compliance, Finances)

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Discussion

• Most subjects resolved their cough quickly and
  reported cessation of throat tickle
• Separation of therapy techniques (pre-cough urge
  vs. cough)?
• Differential reinforcement (manipulated and
  natural consequences)?
• Parent education and involvement?

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Discussion

• Why were six subjects unsuccessful?
• Are there subtypes of NSCC?
• Habit cough those that responded successfully
  to intervention (24/30)
• Psychogenic cough those that did not respond
  successfully (4/6)
• Not ready to relinquish the illness
• Tic cough inability to control the cough urge
  despite the desire to do so (1/6)
• Cough associated with oral hypersensitivity (1/6)

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Study Limitations

• No random assignment or placebo control
• Investigator was one of the therapists
• Possible problems associated with survey studies
• Lack of objective methodology to assess cough
  frequency/severity or validate reports of stress
• Sample size
• Long-term follow up of tx success

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Summary

• The initial diagnosis of chronic cough is within
  the scope of the physician
• Treatment is within the scope of the SLP
• Recommendations for further assessment, based
  upon reduced treatment success requires a team
  approach

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Summary

• Based upon this study, most pediatrics with NSCC
  can be successfully treated by the SLP, using the
  cough reduction plan within a few treatment
  sessions, provided
• the child is willing
• the parent is involved
• the diagnosis is accurate
• the therapist is knowledgeable

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Future Research

• Continue to add to this study for differential
  diagnostic (subtype) information
• Compare treated to non-treated pediatrics with
  NSCC
• Use objective pre and post treatment measures in
  addition to survey data