speech therapy exercises for chronic cough

Speech Therapy For Chronic Cough

Coughing is a natural reflex that helps clear out your throat and lungs.

It can prevent infection by propelling air out of your lungs and throat along with particles and irritants, such as mucus and dust.

Chronic cough, however, is a different story

Chronic cough is typically caused by another underlying factor or issue.

If you have a chronic cough, speech therapy can help.

While working with a specialist to address your underlying factors, a speech therapist can help address how your chronic cough affects your voice.

District Speech offers speech therapy in Washington DC , and we’ll work with you to figure out solutions for your chronic cough and help improve your condition and your communication.

This week on our speech therapy blog , we’re going to take a more detailed look at what chronic cough is and how a speech therapist can help.

What Is Chronic Cough?

A chronic cough is a cough that persists for more than eight weeks.

In some cases, a chronic cough can last for several months or even years.

Chronic cough isn’t a condition on its own.

Rather, it’s a symptom that results from another underlying condition that is stimulating your body’s natural cough reflex.

It can be a nuisance to live with and can disrupt your daily life.

How To Tell If You Have Chronic Cough

The obvious indication that you have a chronic cough is having a cough that lasts longer than eight weeks.

If you have a particular underlying cause of chronic cough, you may already be aware that you have it and why.

Some general symptoms of chronic cough can include:

• Feeling the need to cough or clear your throat frequently
• Having a hoarse or sore voice
• Disrupted sleep
• Mental and physical exhaustion
• Feeling social anxiety about coughing frequently

Keep in mind that if a chronic cough persists for a long time, it may affect and damage other parts of your respiratory system.

Having a persistent and violent cough may cause:

• Muscle pain
• Damage to your larynx
• Damage to blood vessels
• Presence of blood when coughing
• Fractured ribs
• Ruptured diaphragm

It’s important to monitor your symptoms in order to determine if your chronic cough can lead to more serious health issues.

What Causes Chronic Cough?

As we’ve already mentioned, chronic cough is a symptom of another existing health condition.

There are numerous underlying causes that can produce chronic cough.

Knowing what’s causing your chronic cough will help you address it.

Some causes of chronic cough include:

• Other breathing issues
• Gastrointestinal reflux disease (acid reflux, or GERD)
• Postnasal drip, typically caused by allergies or sinus problems
• Smoking tobacco
• Respiratory infections
• Chronic obstructive pulmonary disease
• Upper airway cough syndrome
• Blood pressure medications
• Overstimulated coughing reflex
• Frequently screaming, shouting, or otherwise misusing your voice

It’s worth noting, though, that the vast majority of cases of chronic cough aren’t caused by something life threatening.

What To Do If You Have A Chronic Cough

If you have a chronic cough, it’s essential to find out its underlying cause.

Speak to your primary care provider.

They’ll assess you in order to determine the cause.

Assessments for chronic cough may include a physical examination to look at your respiratory anatomy.

They will ask about your medical history and go over the duration and severity of your cough and other symptoms.

The most important thing is to make sure the cause of your chronic cough isn’t life threatening, like laryngeal cancer or emphysema .

Based on what’s causing your chronic cough, you and your primary care provider can discuss treatment options.

How Does A Chronic Cough Affect Your Voice?

Chronic cough is linked with a condition called irritable larynx syndrome, or ILS.

With ILS, a cough trigger will irritate your throat, causing you to cough.

That’s how coughing works, of course.

However, a chronic coughing habit can lead to your larynx becoming more sensitive.

That can cause the secretions that naturally occur in the back of your throat to become thicker and drier.

As a result, you feel the urge to clear the back of your throat, but all you’re doing is making it more irritated.

The more you clear your throat, the more irritated your throat will become, which will cause you to want to clear your throat more.

The cycle continues.

A cough is a traumatic event for your vocal folds.

The occasional one isn’t something to be worried about, but over a long period of time it can cause lasting effects on your voice.

This can include:

• A voice that sounds hoarse or strained
• A voice that gets tired quickly
• Sore vocal muscles
• The formation of vocal fold nodules

Tips To Reduce Chronic Cough

Addressing the underlying condition that’s causing your chronic cough can help get fully rid of it or manage its severity.

However, simply identifying where your chronic cough is coming from won’t make it go away.

Having a chronic cough can impact your quality of life.

But there are some strategies you can implement to help manage and reduce the severity and impact that your chronic cough has.

Some lifestyle changes that can help manage your chronic cough include:

• Stay hydrated – this helps thin your mucus
• Avoid known triggers of your cough, like mold or other irritants
• Drink some honey lemon tea to soothe your throat
• If you smoke, quit
• Avoid places with a lot of tobacco smoke
• Use a humidifier to keep the air from getting too dry

While these tips aren’t cures for your chronic cough, they may help reduce your symptoms.

How Can Speech Therapy Help With Chronic Cough?

A speech therapist will assess your medical history and the current severity of your symptoms.

They may also assess your voice, breathing, and posture, as well as the muscles in your neck and head.

Speech therapy treatment will vary from person to person based on their underlying cause and the symptoms they exhibit.

The aim of speech therapy for chronic cough is to help you manage your cough, and to soothe its effects.

This can include making you aware of potential triggers for your cough and how to avoid them.

A speech therapist can teach you strategies to help reduce your coughing frequency.

They can also teach you ways to keep your vocal folds healthy and functioning optimally.

Some specific speech therapy treatments for chronic cough include:

• Breath work
• Advice on changing your environment to reduce triggers
• Manual therapy for the neck, head, and upper body
• Voice therapy
• Counseling and support

Book Your Appointment With District Speech Today

If you have questions about chronic cough or are looking for ways to help manage your symptoms, we can help.

Living with a chronic cough can be frustrating and it may affect your physical and mental health.

At District Speech, our therapy team will work with you to manage your cough and help free your voice.

Book your appointment with District Speech today.

District Speech and Language Therapy specializes in speech therapy, physical therapy, and occupational therapy solutions, for both children and adults, in the Washington D.C and the Arlington Virginia areas.

• The Practice
• ENT Problems
• Patient Services
• Hearing Services
• Office Info:

• Dr. Chris Chang
• All Services & Procedures We Perform
• Complete List of ENT Problems
• Office Location

• The Human Voice
• Muscle Tension Dysphonia
• Vocal Cord Dysfunction
• Chronic Cough
• Cough & Cold Remedies for Children
• Zenker's Diverticulum
• Lump in the Throat (Globus Pharyngeus)
• Phlegmy Throat
• Chronic Throat Clearing
• Trouble Swallowing
• Neck Masses
• Thyroid Mass
• Parathyroid Mass
• Bump in the Mouth
• Acid Reflux (LPR)
• Black Hairy Tongue
• Burning Tongue Syndrome
• Halitosis (Bad Breath)
• Sialadenitis

• Allergy Info
• Hearing Loss
• Sinus Headache
• Balloon Sinuplasty
• Nasal Polyps
• Snotty Nose in Kids
• Nasal Obstruction
• Tonsillectomy & Adenoidectomy
• Deviated Septum
• Ear Fullness or Popping / Crackling
• Ear Infections
• Fungal Ear Infections
• Pictures of Ear Abnormalities
• Mystery Ear Pain
• Ear Clicking
• Obstructive Sleep Apnea
• Epistaxis (Nosebleeds)
• Migraine Headaches
• Contact Point Headaches
• Paralyzed Face

Chronic Cough and Laryngospasm Behavior Modification Therapy

Once all medical causes for a persistent chronic cough or laryngospasm attacks have been eliminated, a patient may finally be diagnosed with laryngeal sensory neuropathy, irritable larynx syndrome, neurogenic cough, vocal cord dysfunction, etc. Read more about chronic cough from a medical perspective here which further describes workup and treatment. Laryngospasm information can be found here .

Although medical treatment can stil be pursued, in such patients it is becoming recognized that voice therapy (under guidance from a qualified speech language pathologist or SLP) is beneficial to reduce signficantly a persistent cough or laryngospams attacks. Keep in mind that not all SLP are qualified, but those minority who are voice therapy trained probably are.

Through self-awareness exercises and therapy, patients are often able to decrease laryngeal sensory hyper-responsiveness leading to such symptoms. The SLP therapy program has several components that include behavior modification, cough suppression behaviour, and vocal hygiene training. This treatment should be differentiated from voluntary symptom suppression which does not appear to be helpful. For more info, see references below .

Described here is one behavior modification program patients with chronic cough or laryngospasm can start at home, though ideally such patients should work with a qualified SLP to address all necessary components to alleviate a hyper-irritated voicebox successfully. When performing these exercises, it is not just the motions, but also the self-awareness of how everything feels (much like what one experiences when performing yoga or meditation) that is just as important.

Respiratory Retraining

• Quiet rhythmic breathing: Exhale with shoulders relaxed. Abdominal movement should go in and out consistent with continuous exhalation and inhalation. • Breathing with vocal resistance: Exhale while sustaining /sh/, /f/, /z/ for increasing lengths of time • Pulsed exhalation: Produce pulse of air using /ha/ or /sha/ followed by sniffing in through the nose with closed mouth • Abdominal focus at rest: Lie flat with small book on stomach. Focus on elevation of book with inhalation and lowering of book with exhalation. When successful, straw breathing initiated to increase resistance while focusing on abdominal movement. These exercises are than expanded to include sitting and standing.

Additional patterns of modified respiration are than introduced.

1) In and out through the nose 2) In through nose, out through pursed lips 3) In and out through pursed lips 4) In through nose and out through a straw 5) In and out through a straw 6) Sniff in x 2 and out through pursed lips or straw. Vary length and bore of straw to increase or decrease resistance as needed 7) With time, introduce swallows (saliva, liquids, wet snacks, etc.) while performing above breathing patterns

All exercises should be practiced in one-minute increments. Exercises #1-5 should be practiced 2x per day for 3 weeks. Exercise #6 should be practiced 10x per day for 3 weeks.

During the first week, exercises should be performed in isolation without any distractions; always sitting down using a clock as a timing device. Emphasize slow emptying of lungs during exhalation before repeating sequence to minimize risk of hyperventilation. Monitor # of repetitions achieved in one minute.

Pattern of sniff and blow transitioned into activities of daily living (not driving at this time). Focus now on practicing number of repetitions at least 10 separate times throughout the day. Maintain focus of complete exhalation before beginning new repetition. Week #3

As above, but pattern can now be practiced while driving. Week #4 and beyond

Patient begins to experiment with all of the above techniques during episodes of cough. Determine which strategy is most effective in managing episodes of cough.

As a reminder, this respiratory retraining is most effective within the context of other therapeutic maneuvers under the guidance of a voice therapist, self-awareness practiced at all times, and diligence in performing every day.

• Cough reflex sensitivity improves with speech language pathology management of refractory chronic cough. Cough (London, England), 6, 5. http://doi.org/10.1186/1745-9974-6-5. Link
• Efficacy of speech pathology management for chronic cough: a randomised placebo controlled trial of treatment efficacy. Thorax. 2006; 61(12): 1065–1069. Link
• Chronic Cough : A tutorial for speech-language pathologists. Journal of medical speech-language pathology, Vol. 15, no.3, 2007, pp. 189-206
• Speech pathology for chronic cough: a new approach. Pulm Pharmacol Ther. 2009 Apr;22(2):159-62. doi: 10.1016/j.pupt.2008.11.005. Epub 2008 Nov 21. Link
• Review series: chronic cough: behaviour modification therapies for chronic cough. Chron Respir Dis. 2007;4(2):89-97. Link
• Chronic cough and laryngeal dysfunction improve with specific treatment of cough and paradoxical vocal fold movement. Cough. 2009 Mar 17;5:4. doi: 10.1186/1745-9974-5-4. Link
• The role of voice therapy in the management of paradoxical vocal fold motion, chronic cough, and laryngospasm. Otolaryngol Clin North Am. 2010 Feb;43(1):73-83, viii-ix. doi: 10.1016/j.otc.2009.11.004. Link
• The Relationship Between Chronic Cough and Paradoxical Vocal Fold Movement: A Review of the Literature. Journal of Voice 20: 3, 466-480 (2006) Link

Related Blog Articles

• Chronic Cough Could be Due to Lung Cancer
• Does Milk Cause Increased Phlegm or Mucus Production?
• Whooping Cough Without the Whoop - The Bad Lingering Cough
• Chronic Cough due to Playing a Wind Instrument
• Personal Steam Inhalers/Humidifiers to Treat Cough and Congestion
• Diagnostic Test for Laryngeal Sensory Neuropathy (Chronic Cough)?
• Capsaicin Spray to Treat Neuropathic Chronic Cough
• Def Leppard's Guitarist Vivian Campbell's Chronic Cough Due to Lung Cancer
• New Reason for Chronic Cough... Playing the Trombone!
• Do Reflux Medications Increase Risk of Esophageal and Throat Cancer?
• Top 3 Reasons Why Your Child Can't Shake that Cough
• How Long Does it Take for a Cough to Clear Up?
• Laryngeal Sensory Neuropathy (LSN) Chronic Cough Treatment Failure
• Honey Helps Relieve Coughing in Kids
• Chronic Cough Due to Statins

Related Articles Readers Have Viewed

Any information provided on this website should not be considered medical advice or a substitute for a consultation with a physician. If you have a medical problem, contact your local physician for diagnosis and treatment. Advertisements present are clearly labelled and in no way support the website or influence the contents. Please note that as an Amazon Associate, we may earn small commissions from qualifying purchases from Amazon.com. Click to learn more.

Home | contact us | privacy | disclaimer

This info may not be copied or used without the express consent of DR CHRISTOPHER CHANG.

Purchase this course for $24.99

Keys to Treating Chronic Cough

Course description.

This course features Andrea H. Storie, M.Cl.Sc, CCC-SLP, a voice and upper airway therapist specializing in managing chronic cough. This conversational format explores the differential diagnosis and treatment of chronic cough due to laryngeal pharyngeal reflux (LPR), post-viral illness, or hyper-reactive neural reflex. In addition, Andrea explores the benefits of nasal breathing for managing chronic cough and demonstrates manual therapy techniques to treat chronic cough. Case studies provide examples to apply concepts and strategies to clinical situations.

Unlimited subscriptions start at $79 / Year

By the end of this course, participants will be able to:

About Presenters

Andrea Storie

M. Cl.Sc., CCC-SLP

Andrea Storie is a speech-language pathologist who graduated cum laude with a Bachelor of Science in Communication Disorders in 1991 and a Masters in Clinical Science in Speech Language Pathology in 1993 both from the University of Western Ontario in London, Ontario, Canada. Andrea completed her Clinical Fellowship at University Hospital in London Ontario and stayed on in a full-time position there until 1998. She then moved due to her husband’s job transfer to the US. She joined the phenomenal team at in Chapel Hill at the University of North Carolina where she was able to develop her interest and expertise in the areas of voice, swallowing and upper airway disorders. Andrea moved to Anderson in 2001 and eventually started the AnMed Voice Clinic. After 17 years of treating voice and swallowing outpatients in the Anderson area, she was thrilled to have the opportunity to join the Greenville ENT team in 2018 in order to move back to a teaching hospital environment and to work with such a fabulous multidisciplinary team. Andrea has taught the masters level voice disorders course at USC in Columbia and very much enjoy mentoring graduate students and new clinicians in the field of speech-language pathology. When not at work, Andrea spends much of her time in church volunteer work, particularly Haiti missions and with her family on her farm in Pendleton.

Mary Beth Hines

MS, CCC-SLP, COM®, QOM®, RYT® 200

Mary Beth Hines, MS, CCC-SLP, COM, QOM®, is a speech-language pathologist in Cincinnati, OH. After graduating from Tulane University in New Orleans, LA she worked in sales and marketing in Chicago and Boston. She returned to school to pursue a career in speech-language pathology and earned a Masters of Science in Communicative Disorders from the University of Redlands in 1999. She worked in adult rehabilitation in Los Angeles and Cincinnati, as well private practice specializing in orofacial myology. Mary Beth is the host of the podcast Keys for SLPs and a moderator for SpeechTherapyPD.com.

Additional Information

ASHA CE Provider approval and use of the Brand Block does not imply endorsement of course content, specific products or clinical procedures.

Course Timeline

Course Disclosure

Disclosure statement for andrea storie.

Disclosure Statement for Mary Beth Hines

• Upcoming Courses
• Plans and Pricing
• All Podcasts
• Speech Link
• Keys for SLPs
• SLP Learning Series
• Brainstorms: Functional Neurorehab for SLPs

Course Expiration

This will expired on . In order to get credit for this course it must be completed before this date.

AMBER RANDEL, AFP Senior Associate Editor

Am Fam Physician. 2016;93(11):950

Key Points for Practice

• Unexplained chronic cough should be diagnosed if cough persists for longer than eight weeks with no etiology identified.

• Multimodality speech pathology therapy is recommended for adults with unexplained chronic cough.

• A trial of gabapentin may also be used to treat chronic cough

From the AFP Editors

Persistent cough with an unknown etiology is difficult to treat and can significantly affect quality of life. Although the evidence for the diagnosis and treatment of adults with unexplained chronic cough is limited, the American College of Chest Physicians (ACCP) has released guidelines based on the best available evidence. Further study is needed to establish universal terminology and the optimal method of investigation.

Recommendations

Unexplained chronic cough should be diagnosed if cough persists for longer than eight weeks with no etiology identified after evaluation and supervised therapeutic trial(s) that follow published best-practice guidelines. Key to the definition of unexplained chronic cough are adequate assessment, investigation, and therapy.

Adults with unexplained chronic cough should undergo a guideline/protocol-based assessment, including objective testing for bronchial hyperresponsiveness and eosinophilic bronchitis, or a therapeutic corticosteroid trial.

Multimodality speech pathology therapy (e.g., education, counseling, cough suppression techniques, breathing exercises) is recommended for adults with unexplained chronic cough. A therapeutic trial of gabapentin (Neurontin) is also recommended. However, the evidence is limited, and there is a possibility of adverse effects. The risk-benefits profile should be discussed with the patient before initiating gabapentin and reassessed at six months.

Inhaled corticosteroids should not be used in patients with unexplained chronic cough and negative results on testing for bronchial hyperresponsiveness and eosinophilia (sputum eosinophils, exhaled nitric oxide). Proton pump inhibitors should not be used in patients with a negative workup for acid reflux disease.

Guideline source : American College of Chest Physicians

Evidence rating system used? Yes

Literature search described? Yes

Guideline developed by participants without relevant financial ties to industry? No

Published source : Chest . January 2016;149(1):27–44

Available at : http://journal.publications.chestnet.org/article.aspx?articleid=2451211

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, Assistant Medical Editor.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide .

Continue Reading

More in AFP

More in pubmed.

Copyright © 2016 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions  for copyright questions and/or permission requests.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

Copyright © 2024 SpeechPathology.com - All Rights Reserved

Chronic Cough: Management

This is Part 2 of a two-part series. Speech-language pathologists are uniquely poised to help patients with refractory chronic cough. Benefits of SLP management, ways for the SLP to provide education and counseling to patients and family, and cough suppression techniques to reduce laryngeal hypersensitivity and chronic cough are described in this course.

Part 1: Course 10828

Course Type : Video

CEUs/Hours Offered: ASHA/0.1 Introductory, Professional; IACET/0.1; Kansas LTS-S1370/1.0; SAC/1.0

Learning Outcomes

Course created on February 12, 2024

No more reviews to load.

Presented By

Lauren Fay MS CCC-SLP

Lauren Fay is a senior speech-language pathologist at Duke Voice Care Center. Lauren specializes in voice disorders, with particular interest in chronic cough, peri-operative voice rehabilitation, and tracheo-esophageal voice prosthesis management. She studied communication sciences and disorders and music at Baylor University, and earned her master’s degree in speech-language pathology from Vanderbilt University. Lauren completed a clinical fellowship dedicated to voice disorders at Philadelphia ENT Associates. She leads community and continuing education events at Duke, and chairs the student externship program. Lauren is a clinical instructor for the graduate-level Voice Disorders class at UNC-Chapel Hill, and frequently presents on topics related to voice and cough for continuing education events.

Course participation information

To ensure you are ready to participate, please complete our short Test Drive to prepare your computer to view the course.

View Course Help

Full attendance is required, and the times you log in and out will be recorded and documented. If you log in to a live webinar late or if you log out early, you may not be able to earn CEU.

Passing an online exam and completing a course evaluation will be required to earn continuing education credit.

Live Webinars allow presenter and participant interaction. The exam and course evaluation for these courses must be completed within 7 days of the event.

On-demand courses include texts, video and audio recordings of live webinars, and multimedia formats. The exam and course evaluation for on-demand courses must be completed within 30 days of course registration.

To participate in the course, complete the exam and course evaluation, and earn continuing education credit, you must be a SpeechPathology.com member. Participants must complete the entire course; partial credit is not allowed.

SpeechPathology.com is committed to ensuring accessibility to the widest possible audience. We are continually improving the user experience for everyone. If you have questions, requests, or would like to report an accessibility-related issue, please email [email protected] . We will review your request and respond in a timely manner.

Visit our Contact us page or give us a call if you have questions.

American Speech-Language-Hearing Assn.

Introductory Level 0.1 ASHA CEUs

International Association for Continuing Education and Training

Continu ed , LLC, DBA SpeechPathology.com, is accredited by the International Association for Continuing Education and Training (IACET). Continu ed complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, Continu ed is authorized to issue the IACET CEU. continu ed , LLC, is authorized by IACET to offer 0.1 CEUs for this program.

Kansas Dept for Aging and Disability Services

Approved for 1 continuing education clock hour(s) for Kansas licensed Speech Pathologists by the Kansas Department for Aging and Disability Services. Long-Term Sponsorship number: LTS-S1370. California Speech-Language Pathology and Audiology Board: SpeechPathology.com is approved by the California Speech-Language Pathology and Audiology Board as a Continuing Professional Development Provider, approval number PDP 268. This course may meet the requirements for 1 hours of continuing education credit for SLPs as required by the California Speech-Language Pathology and Audiology and Hearing Aid Dispensers Board. The responsibility for determining whether or not this specific course counts toward an individual's requirements for license renewal is up to the individual. Please refer to the CA state board rules regarding allowable topics and self-study limits: http://www.speechandhearing.ca.gov/licensees/ce_req.shtml. Live webinars on SpeechPathology.com do not count as self-study courses toward California professional development requirements.

Speech-Language and Audiology Canada

Clinically certified members of Speech-Language and Audiology Canada (SAC) can accumulate continuing education equivalents (CEEs) for their participation with SpeechPathology.com. One hour of coursework equals 1 CEE. All SAC members are encouraged to participate in on-going education.

Our site uses cookies to improve your experience. By using our site, you agree to our Privacy Policy .

Chronic Cough and Throat Irritation

Including chronic throat clearing, fullness, pain, tightness, and/or hypersensitivity.

Chronic cough and throat irritation can disrupt your daily life. Breaking the cycles that cause these conditions requires care from voice specialists who are experienced in diagnosing and treating their root causes. Duke’s laryngologists and speech-language pathologists work together to discover what’s causing your chronic cough or throat irritation and to improve your symptoms.

Please check your filter options and try again.

About Chronic Cough and Throat Irritation

Chronic Cough Coughing is a natural response that helps protect your airway when you are sick or when food or liquid goes down the wrong way. However, coughing frequently when you are not sick, especially if the cough is dry and non-productive, may indicate a chronic cough. This can be caused by a dry or irritated throat, certain medications, medical conditions (such as acid reflux or allergies), or hypersensitivity in the throat after an acute upper respiratory infection like a common cold. Coughing (and throat clearing) irritates the delicate tissues of the voice box and can cause more coughing or throat clearing. Once the body is in a chronic cough pattern, it is difficult to break the cycle. 

Throat Irritation (Chronic Throat Clearing, Pain, Tightness, and/or Hypersensitivity) Throat irritation -- including frequent throat clearing, pain, tightness, or a sense that there is a constant lump or fullness in your throat -- can also occur when the throat is “stuck” in a pattern of hypersensitivity. It can be caused by coughing, vocal injury, or muscle tension. Sometimes, throat irritation can cause near-constant throat clearing, coughing, hoarseness, or painful swallowing, and it can disrupt daily life.

Duke Health offers locations throughout the Triangle. Find one near you.

Speech Therapy for Chronic Cough and Throat Irritation

Speech therapy is an integral part of treating chronic cough or other forms of throat irritation. Your speech-language pathologist will teach you how to use breathing strategies, voice exercises, and good vocal hygiene to help your throat recover from the constant irritation caused by chronic cough, throat clearing, and hypersensitivity of the voice box. These techniques will help you break the cycle of chronic cough and throat irritation.

Voice Therapy

Throat strain can be a symptom and also a cause of irritation -- creating a vicious cycle. In order to break the cycle of chronic throat irritation, you need to learn how to speak and use your throat without strain. A speech-language pathologist will guide you through vocal exercises to improve breathing, reduce throat strain, and find your optimal pitch and volume for strong, healthy speaking. Improving your voice will not only help you speak more easily and clearly, but it can reduce your throat irritation and cough.

Our team will take a detailed history of your symptoms to note patterns or triggers. A laryngologist -- an ear, nose, and throat (ENT) doctor with advanced training in voice and throat disorders -- will also evaluate whether any medical conditions, surgeries, or recent illnesses may have caused changes in your voice or throat. We will perform a head and neck examination and a visual examination of your voice box.

Videolaryngostroboscopy

This detailed visual exam helps us evaluate how your vocal cords vibrate when you speak or sing. A tiny camera attached to a small tube called an endoscope is inserted through your nose and into your throat. It allows us to see your vocal cords and larynx (voice box). A flashing strobe light simulates slow-motion video images of your vocal cords. The exam takes about two minutes, and your nose can be sprayed with topical anesthetic for comfort.

Your team will look for lesions, stiffness, paralysis, irregular movements, throat strain, or incomplete closure of the vocal cords. After the exam, your team will review the images with you to discuss your diagnosis and treatment plan. Videolaryngostroboscopy is essential to reaching an accurate diagnosis and determining the best treatment.

Duke University Hospital is proud of our team and the exceptional care they provide. They are why we are once again recognized as the best hospital in North Carolina, and nationally ranked in 11 adult and 10 pediatric specialties by U.S. News & World Report for 2024–2025.

Why Choose Duke

A Team of Experts At Duke, one of the few comprehensive voice centers in the Southeast, your care team will include laryngologists and speech-language pathologists specially trained to evaluate and treat people with voice problems and laryngeal disorders. Our team has years of experience treating chronic cough and throat irritation problems. 

Team Care Approach If you have other medical conditions that may contribute to your voice issues -- such as allergies, asthma, or acid reflux -- we will work with your other providers throughout Duke Health to ensure you receive the best care from an integrated team.

Chronic cough: A tutorial for speech-language pathologists

• September 2007
• Journal of Medical Speech-language Pathology 15(3)

• The University of Newcastle, Australia

• The University of Queensland

• Charles Sturt University
• This person is not on ResearchGate, or hasn't claimed this research yet.

Discover the world's research

• 25+ million members
• 160+ million publication pages
• 2.3+ billion citations
• MULTIDISCIP RESP MED
• Yamini Venkatraman

• Sindhu Kamath
• Radish Kumar B

• Ludovic de Gabory

• Karolina Krakowiak

• REV MAL RESPIR

• L. de Gabory

• Emerald J. Doll
• Brienne Ruel
• Michelle Adessa

• Darcey Hull
• Paul C. Bryson

• Syed B Mehdi

• Peter G Gibson

• S.M. Brugman
• J BEHAV THER EXP PSY
• Thomas L. Creer
• Antonie Hoffman
• A. Barney Alexander
• R.R. de A. Cardoso
• Pneumologie

• Jill Sartor Pierce
• T. Steuart Watson
• Florence B. Blager
• ACTA PSYCHIAT SCAND
• A S Zigmond

• E Scappaticci
• Recruit researchers
• Join for free
• Login Email Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google Welcome back! Please log in. Email · Hint Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google No account? Sign up

Jump to navigation

• Bahasa Malaysia

Speech and language therapy for chronic cough

Background to the question

People normally cough to protect and clear the airways. For example, when we have a chest infection, we cough to eject bacteria. Or when we breathe in dust, we cough to eject the dust. Some people have chronic, or long-term cough, due to a disease such as asthma, chronic obstructive pulmonary disease (COPD), or gastro-oesophageal reflux disease. However, some people have chronic cough for no obvious reason. This is known as unexplained (idiopathic/refractory) chronic cough (UCC). Coughing over months and years is unpleasant, causing a reduction in quality of life.

Current guidelines recommend the use of gabapentin (a drug usually used to control seizures and reduce nerve pain) to try to stop people with UCC from coughing. However, this drug has side effects including drowsiness.

Speech and language therapy (SLT) has been suggested as a non-drug-based option for managing UCC. Speech and language therapy would avoid the risks and side effects of medication.

Speech and language therapy aims to teach people to control their cough. The person is taught methods to help them suppress the urge to cough. Education is given with the intention to help people understand how the technique works and hopefully get them to stick with it. People also receive vocal hygiene information. Vocal hygiene involves techniques to reduce the trigger to cough. For example, vocal hygiene may involve helping someone breathe through their nose rather than their mouth and avoiding drinking alcohol and caffeine, which can worsen cough. They may also be given psychoeducational counselling to help them learn they have the means to control their cough.

This review assessed the latest evidence regarding the effectiveness of SLT in the management of UCC.

Study characteristics

We found two relevant studies to include in the review. Both studies were randomised controlled trials (a type of study in which participants are assigned to one of two or more treatment groups using a random method) in which participants had a diagnosis of UCC. Participants received either an intervention including SLT techniques or 'healthy lifestyle advice' as a control group. We chose to use health-related quality of life and serious adverse events to judge whether SLT is a useful intervention.

Main results

Only one of the studies comparing SLT to usual care reported data about quality of life (using a questionnaire). After four weeks, participants in the study who were receiving the SLT treatment, physiotherapy and speech and language therapy intervention (PSALTI), had on average an improvement in their quality of life compared to people in the control group. However, this benefit compared to control was short-lived and disappeared after four weeks. This means that although the treatment appeared to work in the shorter term, it may not improve quality of life in the longer term compared to usual care.

We also looked for information about side effects or harms of the treatment. The same study reported that no one experienced serious side effects or harms during the study.

Other ways of measuring the impact of SLT were also considered, and in each case relevant data were only provided by one study. An improvement in objective cough counts (using a cough monitor), symptoms (using symptom scores), and clinical improvement was shown with SLT compared to controls. The included trials reported no difference for other secondary outcomes such as subjective measures of cough or cough reflex sensitivity (measured in the laboratory using airway irritants).

Quality of the evidence

The small number of high-quality, relevant studies found in this review means that we cannot be sure of the overall benefits of SLT in the management of UCC. Improvements in health-related quality of life were associated with the PSALTI intervention over a short period in one study, but further research is required to replicate this finding. Overall, more controlled trials are required to fully examine the potential of SLT for the management of UCC.

The paucity of data in this review highlights the need for more controlled trial data examining the efficacy of SLT interventions in the management of UCC. Although a large number of studies were found in the initial search as per protocol, we could include only two studies in the review. In addition, this review highlights that endpoints vary between published studies. The improvements in HRQoL (LCQ) and reduction in 24-hour cough frequency seen with the PSALTI intervention were statistically significant but short-lived, with the between-group difference lasting up to four weeks only. Further studies are required to replicate these findings and to investigate the effects of SLT interventions over time. It is clear that SLT interventions vary between studies. Further research is needed to understand which aspects of SLT interventions are most effective in reducing cough (both objective cough frequency and subjective measures of cough) and improving HRQoL. We consider these endpoints to be clinically important. It is also important for future studies to report information on adverse events.

Because of the paucity of data, we can draw no robust conclusions regarding the efficacy of SLT interventions for improving outcomes in unexplained chronic cough. Our review identifies the need for further high-quality research, with comparable endpoints to inform robust conclusions.

Cough both protects and clears the airway. Cough has three phases: breathing in (inspiration), closure of the glottis, and a forced expiratory effort. Chronic cough has a negative, far-reaching impact on quality of life. Few effective medical treatments for individuals with unexplained (idiopathic/refractory) chronic cough (UCC) are known. For this group, current guidelines advocate the use of gabapentin. Speech and language therapy (SLT) has been considered as a non-pharmacological option for managing UCC without the risks and side effects associated with pharmacological agents, and this review considers the evidence from randomised controlled trials (RCTs) evaluating the effectiveness of SLT in this context.

To evaluate the effectiveness of speech and language therapy for treatment of people with unexplained (idiopathic/refractory) chronic cough.

We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, trials registries, and reference lists of included studies. Our most recent search was 8 February 2019.

We included RCTs in which participants had a diagnosis of UCC having undergone a full diagnostic workup to exclude an underlying cause, as per published guidelines or local protocols, and where the intervention included speech and language therapy techniques for UCC.

Two review authors independently screened the titles and abstracts of 94 records. Two clinical trials, represented in 10 study reports, met our predefined inclusion criteria. Two review authors independently assessed risk of bias for each study and extracted outcome data. We analysed dichotomous data as odds ratios (ORs), and continuous data as mean differences (MDs) or geometric mean differences. We used standard methods recommended by Cochrane. Our primary outcomes were health-related quality of life (HRQoL) and serious adverse events (SAEs).

We found two studies involving 162 adults that met our inclusion criteria. Neither of the two studies included children. The duration of treatment and length of sessions varied between studies from four sessions delivered weekly, to four sessions over two months. Similarly, length of sessions varied slightly from one 60-minute session and three 45-minute sessions to four 30-minute sessions. The control interventions were healthy lifestyle advice in both studies.

One study contributed HRQoL data, using the Leicester Cough Questionnaire (LCQ), and we judged the quality of the evidence to be low using the GRADE approach. Data were reported as between-group difference from baseline to four weeks (MD 1.53, 95% confidence interval (CI) 0.21 to 2.85; participants = 71), revealing a statistically significant benefit for people receiving a physiotherapy and speech and language therapy intervention (PSALTI) versus control. However, the difference between PSALTI and control was not observed between week four and three months. The same study provided information on SAEs, and there were no SAEs in either the PSALTI or control arms. Using the GRADE approach we judged the quality of evidence for this outcome to be low.

Data were also available for our prespecified secondary outcomes. In each case data were provided by only one study, therefore there were no opportunities for aggregation; we judged the quality of this evidence to be low for each outcome. A significant difference favouring therapy was demonstrated for: objective cough counts (ratio for mean coughs per hour on treatment was 59% (95% CI 37% to 95%) relative to control; participants = 71); symptom score (MD 9.80, 95% CI 4.50 to 15.10; participants = 87); and clinical improvement as defined by trialists (OR 48.13, 95% CI 13.53 to 171.25; participants = 87). There was no significant difference between therapy and control regarding subjective measures of cough (MD on visual analogue scale of cough severity: −9.72, 95% CI −20.80 to 1.36; participants = 71) and cough reflex sensitivity (capsaicin concentration to induce five coughs: 1.11 (95% CI 0.80 to 1.54; participants = 49) times higher on treatment than on control). One study reported data on adverse events, and there were no adverse events reported in either the therapy or control arms of the study.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Elsevier - PMC COVID-19 Collection

Management of chronic refractory cough in adults

a Istituti Clinici Scientifici Maugeri IRCCS, Respiratory Rehabilitation of the Institute of Tradate, Tradate, Varese, Italy

b Department of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese-Como, Italy

Bianca Beghè

c Section of Respiratory Diseases, Department of Medicine, University of Modena and Reggio Emilia, Modena, Italy

Leonardo Michele Fabbri

d Section of Cardiorespiratory and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy

Alberto Papi

Antonio spanevello.

Cough is a common respiratory symptom that is considered to be chronic when it lasts more than eight weeks. When severe, chronic cough may significantly impact an individual's quality of life, and such patients are frequently referred for specialist evaluation. Current international guidelines provide algorithms for the management of chronic cough: in most cases, treatment of the underlying disease is sufficient to improve or resolve cough symptoms. Severe chronic cough may significantly affect patients' quality of life and necessitate frequent referral for specialist evaluations. In this narrative review, we summarize non-pharmacologic and pharmacologic management of adult patients with chronic cough of known cause that persists after proper treatment (chronic refractory cough, CRC) or chronic cough of unknown cause in adult patients . If chronic cough persists even after treatment of the underlying disease, or if the chronic cough is not attributable to any cause, then a symptomatic approach with neuromodulators may be considered, with gabapentin as the first choice, and opioids or macrolides as alternatives. Speech pathology treatment and/or neuromodulators should be discussed with patients and alternative options carefully considered, taking into account risk/benefit. Novel promising drugs are under investigation (e.g. P2×3 inhibitors), but additional studies are needed in this field. Speech pathology can be combined with a neuromodulator to give an enhanced treatment response of longer duration suggesting that non-pharmacologic treatment may play a key role in the management of CRC.

1. Introduction

Cough is a physiological response to mechanical and chemical stimuli due to irritation of cough receptors located mainly in the epithelium of the upper and lower respiratory tracts, pericardium, esophagus, diaphragm, and stomach. A complex reflex arc through the vagus, phrenic, and spinal motor nerves to the expiratory musculature generates an inspiratory and forced expiratory effort to clear the airways [1] . Under pathological conditions of known and unknown etiologies, chronic refractory cough (CRC) may become a major medical problem because patients may need to undergo repeated examinations before reaching a diagnosis, and/or try several treatments with sometimes poor symptom control, worsening their quality of life and increasing economic burden.

Cough is one of the most common respiratory symptoms to result in outpatient clinical referral. The initial assessment aims to classify duration and severity of the clinical presentation with guidelines from the American College of Chest Physicians (ACCP) listing three categories based upon duration: acute cough, lasting less than three weeks; subacute cough, lasting between three and eight weeks; and chronic cough, lasting more than eight weeks [2] , [3] , [4] . In the acute phase, when life-threating features are present, such as acute worsening of dyspnea, increased sputum production, hemoptysis, fever, and weight loss, management of underlying etiologies is an urgent priority. Sub-acute or chronic cough may become a bothersome symptom that significantly impairs quality of life, sometimes persisting for months or years after treatment.

In order to optimize and select a treatment for chronic cough, and particularly CRC, current guidelines suggest applying a diagnostic algorithm to identify possible underlying diseases [2] , [3] , [4] . In the majority of cases, a number of associated conditions are identified [5] , most commonly upper airway cough syndrome (formerly named postnasal drip), asthma, gastroesophageal reflux, eosinophilic bronchitis, and intolerance to drugs such as angiotensin converting enzyme inhibitors. Other well known triggers and diseases associated with cough include cigarette smoking, occupational irritants, foreign bodies, chronic obstructive pulmonary disease (COPD), chest neoplasms, bronchiectasis, cystic fibrosis, and interstitial lung diseases. After excluding these causes, triggers and diseases, some patients may experience chronic cough of unclear etiology, which is called ‘chronic idiopathic cough’ or ‘unexplained chronic cough’. The term CRC has also been introduced, which includes cough that persists despite optimal treatment of the underlying disease(s) [2] , [3] , [4] . In this review we focus on the management of CRC of known or unknown cause in adults.

Over the past decade, international guidelines have been developed to help physicians in clinical practice to diagnose, assess the severity of, and manage cough – particularly chronic cough [3] , [6] . These guidelines recommend identifying the potential causes of chronic cough and then suggest specific treatments for any underlying disease. Moreover, they address the treatment of cough in patients whose underlying disease remains unknown.

The prevalence of chronic cough has been estimated as up to 13% of the general population, and may be associated with significant impairment of quality of life, together with anxiety and depression [7] , [8] , [9] . This is especially common in patients who undergo numerous consultations and/or unsuccessful therapeutic trials before getting the diagnosis unexplained chronic cough or CRC. Therefore, there is increasing interest in understanding possible mechanisms for these clinical conditions.

In a previous perspective, we reviewed the definitions, mechanisms, and diagnosis of chronic cough in adults [10] . In this perspective we review the pharmacologic and non-pharmacologic management of chronic cough of known or unknown cause in adult patients.

2. Cough hypersensitivity syndrome

The European Respiratory Society (ERS) Task Force introduced the term ‘cough hypersensitivity syndrome’ in 2014, and defined it as a ‘clinical syndrome characterized by troublesome coughing triggered by low levels of thermal, mechanical or chemical exposure’ [11] . In pathological conditions, inflammation of central and/or peripheral components of the cough reflex may be triggered by innocuous stimuli resulting in excessive coughing due to neuroinflammation defined as ‘cough reflex hypersensitivity’. Assuming cough hypersensitivity syndrome represents a common mechanism responsible for troublesome persistent cough of known or unknown causes, peripheral and central neural pathways for cough signal and receptors become new target for treatment and may help to understand clinical aspects of ‘difficult to treat cough’.

The concept of cough hypersensitivity syndrome includes both chronic troublesome cough of known cause that remains troublesome even after treatment of the underlying cause (CRC), and chronic idiopathic cough with no identifiable cause.

3. Which patients should be considered for speech pathology therapy and/or neuromodulatory therapy?

Most chronic respiratory diseases can manifest with chronic cough as one of the symptoms, although chronic cough is rarely the dominant symptom and it usually responds to treatment of the underlying disease. Unfortunately, with the exception of asthma, in which respiratory symptoms including cough are largely reversible upon treatment, chronic cough due to other chronic respiratory diseases, such as COPD or bronchiectasis, only partially responds to specific treatment. However, unless the cough remains hacking and troublesome, this partial response is usually sufficient, and does not require additional speech pathology and/or neuro-modulatory treatment. In fact, in most cases (including chronic respiratory infections, pneumonia, bronchiectasis, interstitial lung diseases, cystic fibrosis or productive cough in COPD) cough should be reduced but not abolished as it is an important defense mechanism. In contrast, such additional treatment should be considered for patients with one or more of these diseases when chronic cough remains hacking and troublesome even after adequate treatment of the underlying disease, and in those with chronic hacking and troublesome cough of unknown origin [2] , [3] , [4] . This additional approach to treatment may be non-pharmacologic and/or pharmacologic.

4. International guidelines for the treatment of chronic refractory cough

The two most influential guidelines for the management of cough, and particularly CRC, are: 1) those developed [4] and updated [2] by the ACCP, and 2) those developed by the ERS [3] . The definitions, classification, diagnosis and differential diagnosis, assessment of severity, and management (non-pharmacologic and pharmacologic) are similar in these guidelines, and we refer the reader to the original documents for a detailed description. In this review we focus on the management of CRC of known and unknown origin, describing all available approaches, but highlighting whether or not they are recommended by guidelines.

5. Non-pharmacologic treatment

As mentioned above, coughing is the sudden expulsion of air from the lungs through the upper airways when the vocal cords are open [1] , [6] , [12] . The increased tension in the larynx is involved in phonation, respiratory function as part of the conducting airways, and swallowing, with laryngeal motor dysfunction at any point potentially leading to dysphonia and triggering chronic cough [12] , [13] . Voice problems and vocal cord dysmotility have been estimated in up to 40% of adults with chronic cough [14] . Singing, talking and shouting are the activities most frequently associated with increased tension of the larynx and may be identified as a trigger of chronic cough. Phonation may be associated with a decreased lower esophageal sphincter tone, which in turn can promote acid reflux from the stomach and stimulate pressure receptors in the larynx, resulting in chronic cough [15] , which, together with stimulation of pressure receptors in the larynx, may lead to chronic cough.

The most common laryngeal motor dysfunction is vocal cord dysfunction (VCD), which consists of an involuntary vocal fold adduction during inspiration [14] . The link between voice problems and chronic cough is the rationale for the speech pathology approach in refractory cough [16] . Indeed, speech therapy, breathing exercises, cough suppression techniques, and patient counseling have been tried in the management of chronic cough. A systematic review reporting five studies of such interventions showed improved cough severity and frequency, although few studies used validated cough measurement tools [17] . The identification of specific components of this non-pharmacologic approach and its effectiveness on chronic cough was described by Vertigan et al. in a single-blind, randomized placebo-controlled trial [18] . Ninety-seven patients with refractory chronic cough were randomly assigned to the speech pathology intervention or placebo. Intervention consisted of four sessions over a two-month period by a qualified speech pathologist. The components of speech pathology treatment were education, vocal hygiene, cough suppressant strategies, and psychoeducational counseling. Chamberlain et al. conducted a multicenter randomized controlled trial in 75 patients with CRC, and observed an improvement in cough-specific quality of life (Leicester Cough Questionnaire) and cough frequency (Leicester Cough Monitor) as a consequence of implementing a combined physiotherapy and speech and language therapy intervention [19] .

The educational component should determine the reasons for coughing and outline the possible negative consequences of ongoing chronic cough. Patients should understand the goals of therapy, which are to suppress cough despite the triggering sensation, and enhance patients’ ability to voluntarily control the cough. Patients are taught to substitute a competing response, such as a distraction technique, cough suppression swallow, or relaxed throat breathing in order to reduce laryngeal constriction. Psychoeducational counseling should support patients and their control over their cough, emphasizing that cough is a response to irritating stimuli rather than a phenomenon outside of their control. Vocal hygiene education aims to reduce or prevent laryngeal irritation by avoiding passive smoking, avoiding mouth breathing, and behavioral management of gastroesophageal reflux. Broaddus-Lawrence et al. documented that strategies to reduce coughing and throat clearing in individuals with voice disorders improved voice quality [20] . In addition, Solomon et al. found a beneficial effect on the larynx of adequate hydration, including attenuating or delaying elevation of phonatory threshold pressure [21] . Further, Vertigan et al. found that speech pathology management was effective in terms of the global clinical assessment, symptom response and analysis of voice parameters [18] .

In a non-comparative study, Ryan et al. evaluated the presence of VCD in their participants and investigated the efficacy of speech pathology management for CRC in those with VCD. Subjects with VCD received speech pathology therapy from a speech pathologist in sessions every four weeks, which included education, vocal hygiene, cough suppression strategies, relaxed throat breathing techniques, and psychoeducational counseling [22] .

The terminology of breathing exercises varies among studies, but breathing control/diaphragmatic breathing and relaxed breathing control techniques have all been described as aiming to relax the throat, neck, and shoulder muscles whilst increasing abdominal excursion and reducing upper chest movement. A non-comparative retrospective study by Murry et al. was the only one to include breathing exercises as a sole intervention rather than a composite package of care [23] . Sixteen adults with chronic cough underwent 2–13 sessions of respiratory retraining exercises over a 4–23-week period. Patients with (VCD) and chronic cough reported an aberrant laryngeal sensation which tended to normalize following a limited course of respiratory retraining, with improvement in patients’ symptoms.

Ryan et al. documented a reduction in cough frequency following intervention using a validated objective outcome measure, the Leicester Cough Monitor [24] , [25] . Seventeen adults with chronic cough were assessed before, during, and after speech language pathology intervention by a qualified speech language pathologist over a period of 14–18 weeks.. This intervention also reduced laryngeal irritation, with subsequent lower cough sensitivity and lower urge to cough, whereas the cough threshold increased.

Patel et al. evaluated the effectiveness of outpatient-based cough physiotherapy in a pilot prospective observational study [26] . This study reported a significant reduction in cough frequency and an improvement in cough-related quality of life from the intervention, which consisted of education, counseling, cough control, breathing retraining, and vocal hygiene.

According to current ERS guidelines, multi-component physiotherapy/speech and language therapy interventions should be considered for CRC patients who wish an alternative to drug treatment [3] . The ACCP guidelines recommend identifying patients with oral-pharyngeal dysphagia, or the presence of conditions associated with high risk of aspiration, as they are potential candidates for speech pathology treatment [4] .

Despite the efficacy and advantages of speech pathology intervention, there is limited guidance in the literature as to when patients should be referred for treatment. Patients suitable for speech pathology intervention are those whose cough has persisted despite medical management. Speech pathology intervention may be particularly beneficial for patients with coexisting laryngeal disorders such as muscle tension dysphonia or inducible laryngeal obstruction [27] .

6. Pharmacologic treatment

6.1. neuromodulatory treatments.

Pathological mechanisms may affect central and peripheral neuromodulators or cause a hypersensitivity of the cough reflex. Most studies in CRC have focused on pharmacologic treatment or speech pathology treatment individually; few studies have evaluated the effectiveness of combined treatment. A randomized, double blind placebo-controlled trial by Vertigan et al. showed that combined treatment with pregabalin and speech pathology was more effective than speech pathology alone in terms of cough frequency, cough severity and cough-related quality of life [28] . In addition, the effect of the combined approach was still beneficial for the four weeks after cessation of pharmacological treatment ( Fig. 1 ) [28] .

Mean (95% CI) cough severity visual analog scale by visit and treatment group. Reproduced and modified with permission from Vertigan et al., Chest 2016 [28] .

A number of agents, both opioid and non-opioid, are thought to suppress cough via activity on the central cough center [2] , [3] , [11] , [12] . They modulate the enhanced neural sensitization, which is the key component of CRC. Codeine is the opiate traditionally used for cough, but despite widespread use data are limited (and conflicting) regarding efficacy in chronic cough, and a range of side effects have been reported. In a double-blind, placebo-controlled crossover study by Smith et al., 21 patients with COPD were randomly assigned to codeine 60 mg twice a day or placebo for one day [29] . No significant difference was noted between the groups in cough counts or subjective cough scores, although the study size was small and the dose of codeine low [29] . While codeine is not effective in chronic refractory cough, and not recommended by ERS guidelines ( Table 1 ) [3] , it may be useful in prolonged cough persisting after acute respiratory infections, including COVID-19 [30] .

Summary of guideline recommended options for the pharmacologic treatment of chronic refractory cough [2] , [2] , [12] .

Morphine is effective in some but not all patients, and limited data are available from prospective studies. In a double-blind crossover trial by Morice et al., 27 patients who had a persistent cough of greater than three months duration and who had failed specific treatment were randomly assigned to receive slow-release morphine (5 mg twice daily) or placebo for four weeks. Morphine improved daily cough severity scores, although the cough reflex was unaltered [31] . Somnolence and constipation are common side effects, yet despite this morphine is recommended by guidelines ( Table 1 ) [3] , [12] .

Tramadol is an opioid similar to codeine and morphine. A pilot prospective study by Dion et al. on 16 patients with neurogenic cough highlighted the antitussive properties of tramadol [32] . However, tramadol is neither recommended nor discouraged by guidelines ( Table 1 ) [2] , [3] , [12] .

Gabapentin and pregabalin are gamma aminobutyric acid (GABA) analogs that bind to the voltage-gated calcium channels and inhibit centrally neurotransmitter release. They are neuromodulators commonly used to control pain and epilepsy. Lee et al. reported data from 28 patients with chronic cough on the effectiveness of gabapentin: 68% had a clinically positive response, especially when laryngeal neuropathy was present; however, 17.8% complained of dizziness or somnolence [33] . In addition, Mintz et al. described six cases in which gabapentin was administered for intractable cough; complete resolution or a significant improvement in cough was observed in five of these cases [34] . Fatigue and drowsiness were reported as side effects [34] . Further, in a randomized trial by Ryan et al. in 62 patients who had experienced CRC for more than eight weeks, treatment with gabapentin for 10 weeks significantly improved cough-specific quality of life (Leicester Cough Questionnaire score), cough severity (visual analogue scale) and cough reflex sensitivity (defined by quantity of capsaicin needed to induce five coughs) with limited side effects, most commonly nausea, confusion, dizziness, dry mouth and fatigue ( Fig. 2 ) [35] . After withdrawal of gabapentin, there was reduced effectiveness, in terms of Leicester Cough Questionnaire and mean cough severity, further supporting its antitussive effect.

Mean efficacy variable score for gabapentin versus placebo, during and after treatment in terms of cough severity. The dose was escalated from Days 1–6, and reduced from Days 78–83. Treatment was stopped completely by Visit 4 (Week 12; dotted line). Reproduced and modified with permission from Ryan et al. Lancet 2012 [35] .

In a recent randomized clinical trial by Dong et al. gabapentin was compared to baclofen in the treatment of suspected refractory gastro-esophageal reflux-induced chronic cough [36] . Two hundred and thirty-four patients who failed an eight-week course of omeprazole and domperidone were recruited and randomly assigned to receive either gabapentin or baclofen for eight weeks. The authors concluded that the two drugs had similar therapeutic efficacy, but that gabapentin was preferable because of fewer side effects. These findings suggest that gabapentin does not act by reducing peripheral sensitization, but additional placebo-controlled randomized controlled trials are needed to explore how long a patient with CRC should remain on gabapentin to achieve resolution of symptoms. Gabapentin is recommended by current guidelines as a potential pharmacologic treatment for CRC ( Table 1 ) [2] , [3] , [12] .

Administration of pregabalin decreases levels of neurotransmitters such as glutamate, noradrenaline, and substance P [37] . In a case report by Li et al., pregabalin prescribed to alleviate postherpetic neuralgia also relieved the patient's chronic cough, with no serious adverse events reported after two years of follow-up [38] . Halum et al. documented its effectiveness on laryngeal sensory neuropathy through a retrospective study in 12 consecutive patients [37] . The risk/benefit of pregabalin versus gabapentin for the treatment of CRC needs to be carefully considered. The magnitude of change in the Leicester Cough Questionnaire and cough severity in this pregabalin study was greater than the gabapentin study [35] , [39] , however, adverse effects were more common with pregabalin than with gabapentin. Some aspects of the study design may have amplified the differences between gabapentin and placebo. First, the known CNS effects of gabapentin might have impacted treatment masking, thus favoring gabapentin. Second, baseline cough frequency was higher in the gabapentin group, although not significantly, providing more ‘space’ for a positive effect. Third, the population examined was highly selected, possibly identifying the optimal target population, but limiting the use of gabapentin to very few patients in real life. In addition, pregabalin has a greater abuse potential than gabapentin, most likely due to its more rapid absorption and faster onset of action. Pregabalin is a treatment option recommended by current guidelines ( Table 1 ) [2] , [3] , [12] .

Dextromethorphan is probably the most commonly used non-opioid agent for cough; it is considered to have opiate properties [40] . However, few studies have evaluated the efficacy of dextromethorphan in chronic cough, and those available were conducted in adults and used small sample sizes (16–99 patients in each study), with conflicting results [41] , [42] . Due to the absence of appropriately designed and powered randomized clinical trials, dextromethorphan is neither recommended nor discouraged by guidelines [2] , [3] , [12] .

Amitriptyline is a tricyclic antidepressant and inhibitor of serotonin reuptake that has been investigated by Jeyakumar et al. for the treatment of CRC due to post-viral vagal neuropathy [43] . In this prospective, randomized, controlled study in 28 patients, the majority of patients receiving amitriptyline achieved a complete response, whereas none of those receiving the combination of codeine and guaifenesin responded [43] . The authors do not report whether any patients experienced side effects during the study. Secondly, Bastian et al. conducted a prospective uncontrolled cohort study in 12 consecutive patients [44] . All patients were treated with a single dose of open label 10 mg of amitriptyline for 21 days. At least a 40% reduction in self-reported symptoms was recorded, suggesting that a trial of amitriptyline 10 mg (or of other anti-neuralgia type medications) may be helpful in chronic cough [44] . Finally, a retrospective case series by Norris et al. in 12 patients with recurrent laryngeal nerve sensory neuropathic symptoms documented improvement in neuropathic symptoms when treatment with amitriptyline over two months [45] . Four patients with no response or intolerable side effects were prescribed gabapentin [45] . Amitriptyline is neither recommended nor discouraged by guidelines ( Table 1 ) [2] , [3] , [12] .

Taking into account all the studies mentioned so far, several neuromodulators with at least one positive randomized controlled trial were evaluated. These therapies seem promising for the treatment of chronic cough. The CHEST Expert Cough Panel recommends only gabapentin ( Table 1 ) [2] , the risk-benefit profile to be reassessed after six months before continuing the drug. ERS guidelines recommend a trial of low dose slow-release morphine (5–10 mg twice daily) in adults with CRC. They also suggest a trial of gabapentin or pregabalin in adults with CRC [3] .

In conclusion, there are few effective treatments for cough with an acceptable therapeutic ratio; more selective agents with a more favorable side effect profile are needed.

A possible role of inhaled drugs in the management of CRC has been also investigated. Local anesthetics (e.g., lidocaine or bupivacaine) are currently used in the palliative management of cough associated with malignancies. In addition, an older study with ipratropium bromide reported a significant reduction in cough severity and a good safety profile in patients with chronic persistent cough, although the sample size was small ( N  = 14) and results have not been subsequently replicated [46] . Subsequent preclinical research suggests that tiotropium can directly modulate airway sensory nerve activity and thereby the cough reflex, through a mechanism unrelated to its anticholinergic activity [47] .

6.2. Experimental pharmacologic neuromodulatory treatments

The recognition that chronic cough is characterized by hypersensitivity of the peripheral and central neural pathways involved in cough has expanded the range of potential therapeutic targets currently under evaluation. A novel approach is to focus on molecular pathways rather than neural mechanisms [48] .

The primary vagal fibers mediating cough are A-fibers and C-fibers, which are responsive to mechanical and chemical stimuli, respectively [49] . P2×3 receptors are expressed by airway vagal afferent nerves and contribute to the hypersensitization of sensory neurons [50] . Based on laboratory studies, increased sensitivity of P2×3 receptors on the airway sensory nerve fibers (e.g., vagal afferent C fibers) could mediate sensitization of the cough reflex and could therefore be a potential cause of refractory cough [51] . Adenosine triphosphate (ATP) plays a significant role in the activation of sensory C fibers, and this activation is inhibited by blockade of P2×3 and P2×2/3 receptors. In a randomized, cross-over trial of 24 patients with refractory cough, an investigational P2×3 antagonist, gefapixant, previously known as AF-219, decreased cough counts during the two-week study blocks by 75% compared with placebo [51] . However, taste disturbance was noted in all patients taking gefapixant and caused six patients to withdraw from the study; nausea was also common (38%). In a Phase 2, double-blind, two-period study by Morice et al. there was a reduction in the cough reflex in patients treated with gefapixant 100 mg [52] . Two randomized, double-blind, placebo-controlled, two period crossover, dose-escalation studies by Smith et al. of gefapixant at lower doses has reported efficacy with fewer side effects [53] . Finally, in a multicenter randomized placebo-controlled parallel trial Smith et al. investigated the effect of gefapixant on chronic cough [54] . Data are available only as an abstract, in which the authors describe a significant improvement in the cough frequency when compared to placebo [54] . These results support a promising therapeutic target in development for P2×3 receptor hypersensitivity in refractory cough, but further study is needed to determine safety and efficacy in a larger number of patients.

Transient receptor potential (TRP) channels are present in abundance in the airways and are expressed in many cell types of the airway including primary sensory afferent nerves, epithelial cells and smooth muscle cells [48] . Several agents for pain are in development that target these receptors. However, since TRP channels are directly activated by changes in temperature, chemicals, mechanical stimulation, pH and osmolality, and may evoke cough, they been proposed also as treatments for chronic cough. Of particular interest in relation to cough are members of the vanilloid (TRPV1, TRPV4), anykrin (TRPA1) and melastatin (TRPM8) families. To date, pharmacologic modulation of TRP channels for the treatment of cough has been disappointing and remains to be investigated as a potential target for chronic cough. TRPV1 was the first channel to be considered as a key regulator of cough, but two Phase 2, double-blind crossover studies by Belvisi et al. and Khalid et al. on TRPV1 failed to show improvements in spontaneous cough frequency [55] , [56] . The TRPA1 channel is activated by a range of physical and chemical factors including cold temperatures, mechanical stimulation, inflammatory mediators and acrolein (a component of cigarette smoke). Although animal studies demonstrated effectiveness of TRPA1 antagonists in reducing cough in response to tussive challenges, in a double-blind placebo-controlled study in patients there was no reduction in cough frequency over 24 h, or no reduction in citric acid-induced cough [48] . TRPV4 is recognized as an osmosensor and responds to diverse stimuli including non-noxious temperatures, shear stress and mechanical stimulation. A clinical trial with the TRPV4 antagonist, GSK2798745, was terminated early, presumably due to lack of efficacy [48] . Finally, TRPM8 is activated by cooling compounds such as menthol, icilin and eucalyptol [48] .

Voltage-gated sodium channels (NaV) mediate the initiation and propagation of action potentials in afferent sensory nerves and represent a potential therapeutic target for cough. Lidocaine, a non-selective NaV channel blocker, has been used clinically to alleviate cough and has been reported to be safe [57] . However, a Phase 2 double-blind crossover study using a novel blocker targeting a subtype selective inhibition of the NaV1.7 (GSK2339345) failed to illustrate an antitussive response [58] .

The tachykinins, substance P, neurokinin A and neurokinin B are released both from the peripheral endings of afferent nerves (predominately C-fibers) and from central neural structures. The tachykinin receptor, neurokinin 1 receptor, has gained attention as a target for chronic cough treatment. In a Phase 2, double-blind study (VOLCANO-1) by Smith et al. on 244 patients, significant improvements in objective cough frequency and sustained reductions in daytime cough frequency were documented [59] .

Nicotinic acetylcholine receptors, or nAChRs, respond to the neurotransmitter acetylcholine and to nicotine and are found in the central and peripheral nervous system. Dicpinigaitis et al. studied the alpha7 (α7) subtype of the nAChRs, which is responsible for the antitussive effect of nicotine through the activation of GABAergic interneurons in the brainstem [60] .

Azithromycin belongs to the class of macrolide antibiotics. It is commonly used in the treatment of a variety of infections, including community-acquired respiratory tract infections and mycobacterial infections, and macrolide antibiotics also have anti-inflammatory actions. Hodgson et al. investigated the potential effects of azithromycin on chronic cough in a randomized, double-blind, placebo-controlled study [61] . Treatment with azithromycin for eight weeks failed to improve health status in patients with chronic cough when compared with placebo.

Erythromycin was studied by Yousaf et al. in a randomized, double-blind, placebo-controlled parallel trial; the authors documented no difference in the change in cough frequency between the erythromycin and placebo group, although there was a significant difference in the change in sputum neutrophils over a 12 week period (a reduction with erythromycin and an increase with placebo) [62] .

PA-101 is a novel formulation of cromolyn sodium and thought to act as a mast cell stabilizer. In a randomized placebo-controlled trial by Birring et al. PA-101 was delivered via a high efficiency eFlow nebulizer to 52 patients with idiopathic pulmonary fibrosis and chronic cough [63] . No treatment benefit was observed for PA101 [63] .

In conclusion, there have been important developments in elucidating pathophysiological mechanisms underlying chronic cough. Additional information regarding neurobiology has introduced a number of novel pharmacological treatment options, including drugs targeting the P2×3 receptor, which seems to be the most promising.

7. Conclusions

Cough is one of the most common respiratory symptoms, and is defined as chronic when it lasts for more than eight weeks. In the majority of cases, it represents the most troublesome symptom of common respiratory and non-respiratory diseases. If chronic cough persists even after treatment of the underlying disease, or if the chronic cough is not attributable to any cause, then a symptomatic approach with neuromodulators may be considered, with gabapentin as the first choice [2] , [3] , [12] , and opioids or macrolides as alternatives. Speech pathology treatment and/or neuromodulators should be discussed with patients and alternative options carefully considered, taking into account risk/benefit.

Novel promising drugs are under investigation (e.g. P2×3 inhibitors), but additional studies are needed in this field. Speech pathology can be combined with a neuromodulator to give an enhanced treatment response of longer duration suggesting that non-pharmacologic treatment may play a key role in the management of CRC. International guidelines, based on consensus opinion and observational data, provide detailed investigation and treatment algorithms [2] , [3] , [12] . However, there are broad national and international differences in the delivery of health care resulting in differences in available diagnostic tests and management strategies, both in primary and specialist care. Quality of life is frequently impaired in patients with chronic cough, who often also have increased economic burden. Smith et al. provides a simplified approach through four steps: identification and treatment of obvious causes; focused testing for, and treatment, of asthma, gastroesophageal reflux and rhinosinusitis; investigations to rule out rarer causes of cough; and management of idiopathic or refractory chronic cough [12] . The lack of knowledge or limited economical resources in several areas may be handled by identification of referral centers for multidisciplinary management (respiratory physician, ear, nose and throat specialist, gastroenterologist, psychologist, lung function and molecular biology lab, respiratory physiotherapist and speech therapist) of chronic refractory cough and the feasibility of clinical trials to implement this field.

Declaration of Competing Interest

Acknowledgements.

Editorial support (in the form of critically reviewing the content written by the authors, and editing for grammar and journal style) was provided by David Young of Young Medical Communications and Consulting Ltd.

Laryngeal Control Therapy

Laryngeal control therapy is a specialized speech-language pathology treatment that helps patients prevent or quickly resolve episodes of chronic cough or shortness of breath.

Cough/Throat Clearing Suppression Therapy 

Cough suppression therapy is a behavioral treatment for chronic cough that integrates a combination of strategies to reduce the severity, duration, and frequency of symptoms. Patients are referred for cough suppression therapy when their providers feel there is a behavioral component and a degree of laryngeal/throat hyperreactivity or hypersensitivity (neurogenic laryngeal hypersensitivity) triggering the cough. 

First, your voice pathologist with help you identify specific triggers and warning signs before the cough/throat clearing occurs. Triggers can include a “tickle” in the throat, the sense of a lump or mucus in the throat, certain smells (perfume, smoke, chemical irritants), or activities (talking, yelling, eating, lying down).    We introduce cough suppression techniques and breathing exercises to prevent or more quickly resolve an episode of coughing. Therapy also includes extensive education on strategies to improve laryngeal health and hygiene as we work on desensitizing nerve receptors in the throat to reduce cough-reflex sensitivity. Sometimes, cough suppression therapy is recommended in conjunction with medication or other treatments recommended by your otolaryngologist or laryngologist.  It takes mindfulness of behaviors and being willing to implement changes to reduce or resolve a cough that’s been present for months to years. We have seen this work time and time again, working in partnership with the patient to gradually reduce the urge and pattern of coughing. We typically work with patients for 1-3 sessions.  Together we can reduce the impact the cough has on your quality of life! 

Respiratory Retraining Therapy 

Respiratory retraining (laryngeal control) therapy is a behavioral treatment for Paradoxical Vocal Fold Motion Disorder (PVFM) .This condition is characterized by the vocal folds partially or almost fully coming together during inhalation (breathing in). This temporary airway restriction results in difficulty breathing in, the sensation of the throat tightening or closing off, and may also cause a noise with inhalation (stridor).  Your voice pathologist will help you identify specific triggers and warning signs of your episodes of shortness of breath. Triggers may include strong odors/perfumes, physical exercise, temperature changes, coughing, or stress/strong emotions. We teach you a set of breathing exercises designed to keep the vocal folds open and the throat relaxed. When possible, we trigger episodes then coach you through resolution of the breathing problem while in-office for real world applicability. The goal of respiratory retraining therapy is to reduce the effort it takes to breathe and to retrain the breath cycle to prevent this type of shortness of breath. 

Perhaps the most important aspect of respiratory retraining therapy is reassuring the person that there is no physical or structural problem (no organic/physical obstruction of the airway). Studies have shown that while people may feel short of breath, oxygen levels typically remain high and within normal limits. Consequently, teaching patients to learn how to control their breathing through relaxed and intentional inhalation/exhalation will prevent and minimize the severity of possible PVFM “attacks.” 

How long would I need to attend laryngeal control therapy? 

Initially, our voice pathologists may see patients on a frequent and regular basis (one to two times a week), depending on the severity and frequency of symptoms. On average, patients are seen for a total of two to five sessions until therapy goals are achieved and the patient is able to suppress or resolve PVFM independently. 

Care and Treatment

Chronic Cough

Vocal Cord Dysfunction/Paradoxical Vocal Fold Movement

Voice and Swallowing Center

131 Miller St.

Winston-Salem, NC 27103

Appointments

Insurance Accepted

This chart is a list of the most common health insurance plans we accept. This list is subject to change. Please check your individual plan to confirm their participation and the coverage allowed. Due to the different physician groups and hospitals within the Wake Forest Baptist system, physician services and hospital services are billed separately. Please remember that health insurance coverage varies, so some services may not be covered. If you don’t see your plan or you have questions, please call our Customer Service Center at 877-938-7497 . We will do our best to work with you and your plan.

WFUHS - Wake Forest University Health Sciences (professional services) NCBH - North Carolina Baptist Hospital (Includes Davie) LMC - Lexington Medical Center CHC - Cornerstone Healthcare Wilkes - Wilkes Regional Medical Center HPR - High Point Regional N/A - Not applicable to services provided at facility and/or CHC NC - Not Contracted, very low to no volume for facility and/or CHC

Wake Forest Baptist Health Managed Care/MA Contracts - April 2024

AETNA CONNECTED NC ACA/Exchange:  Accepted at all locations

AETNA NC PREFERRED+ : Accepted at all locations

AETNA (PPO & HMO): Accepted at all locations

AETNA MEDICARE:  Accepted at all locations

AETNA WHOLE HEALTH:  Accepted at all locations

ALIGNMENT HEALTHCARE MEDICARE ADVANTAGE:  Accepted at all locations

AMBETTER OF NC:   Accepted at all locations

AMERIHEALTH CARITAS NEXT ACA/Exchange:   Accepted at all locations 

BCBSNC (PPO & HMO):  Accepted at all locations

BCBS HIGH PERFORMANCE (NATIONAL NETWORK):  Accepted at all locations

BLUE LOCAL WITH ATRIUM HEALTH:  Accepted at all locations

BLUE MEDICARE:  Accepted at all locations

BLUE VALUE:  Accepted at all locations

CAROLINA BEHAVIORAL HEALTH: Accepted at WFUHS, NCBH and CHC (not applicable to services provided at LMC, Wilkes and High Point)

CIGNA: Accepted at all locations

CIGNA BEHAVIORAL HEALTH: Accepted at WFUHS, NCBH and High Point (not applicable to services provided at LMC, CHC and Wilkes)

CIGNA HEALTHSPRING MEDICARE ADVANTAGE: Accepted at WFUHS, NCBH, LMC, CHC and High Point (not applicable to services provided at Wilkes)

CIGNA LIFESOURCE (TRANSPLANTS): Accepted at WFUHS and NCBH (not applicable to services provided at LMC, CHC, Wilkes and High Point) 

CRESCENT PPO (ASHEVILLE): Accepted at WFUHS and NCBH (not contracted, very low to no volume for LMC, CHC, Wilkes and High Point)

DEVOTED HEALTH (MEDICARE ADVANTAGE):  Accepted at all locations DIRECT NET: Accepted at WFUHS, NCBH, LMC, Wilkes and High Point (not contracted, very low to no volume for CHC)

FIRST HEALTH NETWORK:  Accepted at NCBH, LMC, Wilkes and High Point (not contracted, very low to no volume for WFUHS and CHC)

FIRSTCAROLINACARE (PINEHURST, NC): Accepted at NCBH (not contracted, very low to no volume for WFUHS, LMC, CHC, Wilkes and High Point)

GATEWAY HEALTH ALLIANCE (VIRGINIA):  Accepted at WFUHS and NCBH (not contracted, very low to no volume for LMC, CHC, Wilkes and High Point) 

HEALTHGRAM (formerly PRIMARY PHYSICIAN CARE): Accepted at WFUHS, NCBH and LMC (not contracted, very low to no volume for CHC, Wilkes and High Point)

HEALTHTEAM ADVANTAGE:  Accepted at all locations

HUMANA CHOICECARE:  Accepted at all locations

HUMANA MEDICARE ADVANTAGE:  Accepted at all locations

LIBERTY ADVANTAGE (MEDICARE ADVANTAGE): Accepted at WFUHS and NCBH (not applicable to services provided at LMC, CHC, Wilkes and High Point)

MAGELLAN (BEHAVIORAL HEALTH): Accepted at WFUHS, NCBH and CHC (not applicable to services provided at LMC, Wilkes and High Point)

MEDCOST:  Accepted at all locations

MEDCOST ULTRA: Accepted at WFUHS, NCBH, LMC, Wilkes and High Point (not applicable at CHC)

PHCS/MULTIPLAN: Accepted at NCBH, CHC, LMC and High Point (not contracted, very low to no volume for WFUHS and Wilkes)

OPTUMHEALTH (TRANSPLANTS - APPLICABLE TO NCBH/WFUHS ONLY): Accepted at WFUHS and NCBH (not applicable to services provided at LMC, CHC, Wilkes and High Point)

PREFERRED CARE OF VA INC:  Accepted at WFUHS and NCBH (not contracted, very low to no volume for LMC, CHC, Wilkes and High Point)

SOUTHERN HEALTH SVCS (COVENTRY-PPO ONLY): Accepted at WFUHS, NCBH and CHC (not contracted, very low to no volume for LMC, Wilkes and High Point)

TWIN COUNTY (VIRGINIA):  Accepted at WFUHS and NCBH (not contracted, very low to no volume for LMC, CHC, Wilkes and High Point)

UNITED BEHAVIORAL HEALTH: Accepted at WFUHS, NCBH, CHC and High Point (not applicable to services provided at LMC and Wilkes)

UNITED BEHAVIORAL HEALTH INTENSIVE OUTPATIENT PROGRAM (WFUHS ONLY): Accepted at WFUHS (not applicable for services provided at NCBH, LMC, CHC, Wilkes and High Point)

UNITED HEALTHCARE:  Accepted at all locations

UNITED HEALTHCARE ESSENTIALS ACA/EXCHANGE:  Accepted at all locations

UNITED HEALTHCARE MEDICARE:  Accepted at all locations

VA CCN:  Accepted at all locations

WELLCARE (MEDICARE ADVANTAGE):  Accepted at all locations

LMC ONLY: Contracts specific to support Lexington employer groups, low volume NATIONAL PROVIDER NETWORK/MEDICAL RESOURCES

CHC ONLY : Contracts specific to support CHC TRICARE

WFUHS - Wake Forest University Health Sciences (professional services) NCBH - North Carolina Baptist Hospital (Includes Davie) LMC - Lexington Medical Center CHC - Cornerstone Healthcare Wilkes - Wilkes Regional Medical Center HPR - High Point Regional N/A  - Not applicable to services provided at facility and/or CHC NC  - Not Contracted, very low to no volume for facility and/or CHC

Referring Physicians

At Atrium Health Wake Forest Baptist we understand the importance of referrals. Our Physician Liaisons partner with referring physicians in our community and beyond to provide information on our physicians and clinical services. Full list of new physicians .

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Cough suppression therapy: does it work?

Affiliation.

• 1 King's College London, Division of Asthma, Allergy and Lung Biology, Denmark Hill, London SE5 9RS, UK.
• PMID: 23524013
• DOI: 10.1016/j.pupt.2013.03.012

Cough suppression therapy (CST), also known as cough suppression physiotherapy and speech pathology management is a promising non-pharmacological therapeutic option for patients with refractory chronic cough. CST may consist of education, improving laryngeal hygiene and hydration, cough suppression techniques, breathing exercises and counselling. It is an out-patient therapy delivered in 2-4 sessions. There is evidence to support the efficacy of CST: a randomised controlled trial reported a significant reduction in cough symptoms and other studies have reported improved cough related quality of life, reduced cough reflex hypersensitivity and cough frequency. The mechanism of action of CST is not clear, but it has been shown to reduce cough reflex sensitivity, paradoxical vocal fold movement (PVFM) and extrathoracic hyperresponsiveness. Further research is needed to determine the optimal components of CST, the characteristics of patients in whom it is most effective and to increase the understanding of its mechanisms of action. The effectiveness of CST in other respiratory conditions such as asthma, pulmonary fibrosis, chronic obstructive pulmonary disease and sarcoidosis should also be investigated.

Keywords: Chronic cough; Cough suppression; Idiopathic chronic cough; Physiotherapy; Refractory chronic cough; Speech and language therapy.

Copyright © 2013. Published by Elsevier Ltd.

PubMed Disclaimer

Similar articles

• Speech pathology for chronic cough: a new approach. Gibson PG, Vertigan AE. Gibson PG, et al. Pulm Pharmacol Ther. 2009 Apr;22(2):159-62. doi: 10.1016/j.pupt.2008.11.005. Epub 2008 Nov 21. Pulm Pharmacol Ther. 2009. PMID: 19061964 Review.
• Physiotherapy and Speech and Language therapy intervention for chronic cough. Birring SS, Floyd S, Reilly CC, Cho PSP. Birring SS, et al. Pulm Pharmacol Ther. 2017 Dec;47:84-87. doi: 10.1016/j.pupt.2017.04.001. Epub 2017 Apr 4. Pulm Pharmacol Ther. 2017. PMID: 28389257 Review.
• Physiotherapy, and speech and language therapy intervention for patients with refractory chronic cough: a multicentre randomised control trial. Chamberlain Mitchell SA, Garrod R, Clark L, Douiri A, Parker SM, Ellis J, Fowler SJ, Ludlow S, Hull JH, Chung KF, Lee KK, Bellas H, Pandyan A, Birring SS. Chamberlain Mitchell SA, et al. Thorax. 2017 Feb;72(2):129-136. doi: 10.1136/thoraxjnl-2016-208843. Epub 2016 Sep 28. Thorax. 2017. PMID: 27682331 Clinical Trial.
• Non-pharmacological interventions for chronic cough: The past, present and future. Chamberlain Mitchell SAF, Ellis J, Ludlow S, Pandyan A, Birring SS. Chamberlain Mitchell SAF, et al. Pulm Pharmacol Ther. 2019 Jun;56:29-38. doi: 10.1016/j.pupt.2019.02.006. Epub 2019 Feb 23. Pulm Pharmacol Ther. 2019. PMID: 30807836 Review.
• Improvement in health status following cough-suppression physiotherapy for patients with chronic cough. Patel AS, Watkin G, Willig B, Mutalithas K, Bellas H, Garrod R, Pavord ID, Birring SS. Patel AS, et al. Chron Respir Dis. 2011;8(4):253-8. doi: 10.1177/1479972311422547. Epub 2011 Oct 11. Chron Respir Dis. 2011. PMID: 21990570 Clinical Trial.
• Awareness and practices of Speech Language Pathologists (SLPs) working with chronic cough in India: a call for action. Venkatraman Y, Acharya V, Kamath S, Gunjawate D, B RK. Venkatraman Y, et al. Multidiscip Respir Med. 2024 Aug 1;19(1):959. doi: 10.5826/mrm.2024.959. Multidiscip Respir Med. 2024. PMID: 39093011 Free PMC article.
• Management of non-pharmacologic therapy for chronic refractory cough: Mechanism, composition, applicable population, and assessment. Peng Y, Zhang T, Yuan L, Xu X, Yu L. Peng Y, et al. Heliyon. 2023 Sep 21;9(10):e20351. doi: 10.1016/j.heliyon.2023.e20351. eCollection 2023 Oct. Heliyon. 2023. PMID: 37810829 Free PMC article. Review.
• Cough desensitization treatment for patients with refractory chronic cough: results of a second pilot randomized control trial. Slovarp LJ, Reynolds JE, Tolbert S, Campbell S, Welby S, Morkrid P. Slovarp LJ, et al. BMC Pulm Med. 2023 Apr 28;23(1):148. doi: 10.1186/s12890-023-02423-6. BMC Pulm Med. 2023. PMID: 37118696 Free PMC article. Clinical Trial.
• Cough desensitization treatment: A randomized, sham-controlled pilot trial for patients with refractory chronic cough. Slovarp L, Reynolds JE, Bozarth-Dailey E, Popp S, Campbell S, Morkrid P. Slovarp L, et al. Respir Med. 2022 Mar;193:106739. doi: 10.1016/j.rmed.2022.106739. Epub 2022 Jan 15. Respir Med. 2022. PMID: 35091204 Free PMC article. Review.
• Treatment of urinary incontinence in women with chronic obstructive pulmonary disease-a randomised controlled study. Haukeland-Parker S, Frisk B, Spruit MA, Stafne SN, Johannessen HH. Haukeland-Parker S, et al. Trials. 2021 Dec 11;22(1):900. doi: 10.1186/s13063-021-05816-2. Trials. 2021. PMID: 34895285 Free PMC article. Clinical Trial.

Publication types

• Search in MeSH

Related information

• Cited in Books

LinkOut - more resources

Full text sources.

• Elsevier Science

Other Literature Sources

• scite Smart Citations
• MedlinePlus Health Information
• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.