Impact of Chronic Cough: Why More Healthcare Providers Need Education

Transcription

1 Impact of Chronic Cough: Why More Healthcare Providers Need Education Gina R. Vess, MA CCC-SLP Duke Voice Care Center Division of Otolaryngology, Head/Neck Surgery

2 Outline Definition & purpose (acute vs. chronic) Side effects of chronic cough (physical, emotional) Healthcare costs/financial burdens Etiologies (medical, behavioral) Evaluation (case hx, questions, instrumental eval) Treatment Critical success factors

3 Common terms in Literature Chronic cough Habit cough Neurogenic cough VCD (phenotype of VCD with cough) Irritable larynx syndrome Psychogenic cough

4 Purpose of Cough End product of irritant receptors being activated in the airways A protective mechanism for the airway Beneficial to remove noxious substances Beneficial to increase mucocillary clearance All of this is helpful if cough is acute.

5 Cough: Defined as Chronic Greater than 3-8 weeks (Altman et al 2002, Bellanti J et al 2000, Philp E 1997, Pratter M et al 2006) NO benefit to the respiratory system or body (Irwin et al, 1998)

6 Chronic Cough: What Happens Intrathoracic pressures up to 300 mm Hg Expiratory velocities of 28,000 cm/sec (500 miles per hour) 85% of the speed of sound Systolic pressures approach 140 mm Hg (75 mm Hg with chest compressions) (Irwin et al 1998)

7 Presence of persistent airway inflammation may result in hyperresponsiveness (Kastelik et al 2002) Hypersensitive larynx is Spasm-ready (Morrison et al 1999)

8 Physical Complications of Chronic Cough Exhaustion/ fatigue (57-72%) Insomnia/ sleep deprivation (45-70%) Musculoskeletal pain (45%) Hoarseness (43%) Excessive perspiration (42%) Urinary incontinence (39-55%) Breathlessness (55%) Vomiting Syncope (Vertigan et al 2007, Irwin et al 1998)

9 Dysphonia as a Side Effect Glottal fry Rough, breathy quality Strained voice (Vertigan et al 2008) Laryngeal irritation and cough sensitivity in persons with CC could result in laryngeal tension as an attempted protective mechanism thus leading to impaired vocal quality. (Gibson & Vertigan 2009, Vertigan 2007)

10 Common QOL Side Effects Depression (53-55%) Interference with social life/ social isolation (64%) Worry about serious medical illness (98%) Self-consciousness/ embarrassment Guilt Feeling self conscious (55%) Life-style change (45%) of CC (Brignall et al 2008, Everett et al 2007, Irwin et al 1998)

11 Financial burden Burden to Healthcare & Patients Medications (often unnecessary) include steroids (oral, inhaled, & nasal) and antibiotic use Medications to treat the side effects (i.e. depression, lack of sleep) Multiple PCP and specialist visits Annual cost exceeds $1 billion (grossly underestimated considering time off work/lost productivity, unnecessary meds, etc.) (Irwin et al 1998)

12 Epidemiology CC is most common complaint in ambulatory health care settings for adults seeking nonemergent medical attention & 2 nd most common reason for general medical exam (Irwin et al 2006) 10-38% of a pulmonologist s outpatient practice (Irwin et al 2006) 12-42% of CC cases are refractory to traditional medical treatment (Hague 2005)

13 Epidemiology 856 cc questionnaires sent to public who requested info sheet after public broadcast in UK 373 completed questionnaires returned Mean age 65.3 years Median duration 6.5 years 75% were females 2% were smokers 66% had no other coexisting respiratory disesase 91% consulted GP 85% had a prescribed treatment 61% had seen at least 1 specialist Only 40% found a treatment which helped (Everett et al 2007)

14 Sex Difference in Cough Women are more likely to develop chronic cough due to lower threshholds for cough (Kastelik et al 2002)

15 Etiologies of Cough Smoking (not seeking tx of cc) Lung pathology Asthma/bronchitis/ bronchiectasis/copd GERD Rhinitis or sinusitis Vocal fold neoplasms Tracheal stenosis ACE inhibitors (for HTN) Irritation to tympanic membrane Psychological issues Infectious croup Foreign body aspiration Multifactorial

16 Why is CC Often Refractory to Treatment? Based on multiple descriptive studies, cough was found to be: From single cause 38-82% of the time Multi-factorial 18-62% of the time Multiple causes include at least 3 diseases as much as 42% of the time (Altman et al 2002, Irwin et al 2006)

17 Office Management of the Patient with Chronic Cough COUGH acronym to describe etiologies Cough which worsens when supine suggests PND, GERD, bronchiectasis, chronic bronchitis, heart failure Cough with clear sputum suggests hypersensitivity Cough with purulent sputum implies chronic infection (sinusitis, bronchiectasis, TB) Cough with blood-tinged sputum points to cancer, TB, or bronchiectasis Cough which is non-productive is often due to ACE inhibitors (Dalal and Geraci 2010)

18 Triggers of Cough Talking / singing Laughing Strong odors Strong foods Change in air quality or temperature Patients must understand the difference between a trigger and an etiology

19 Chronic Cough Management: Pulmonologist Allergy specialist Speech pathologist Otolaryngologist Gastroenterologist Psychologist/psychiatrist Primary care physicians A Team Approach

20 Why SLPs Eval/Treat Cough Cough persisting despite treatment of medical etiologies suggests that hypersensitivity and behavioral factors may be precipitating cough. SLPs commonly treat the behavioral component of phonotrauma

21 Efficacy for Speech Path Intervention for CC Single, blind randomized placebo controlled trial of 87 patients with cc (despite med tx) Tx group Education, Cough control strategies, psychoeducational counseling, & vocal hygiene Placebo group Healthy lifestyle education 4 sessions, 30 min in duration over 2 months Statistically significant improvement in cough, voice, upper airway symptoms 38/43 successful in tx group (88%) 6/44 successful in placebo group (14%) (Vertigan et al 2006)

22 Further Efficacy Data for SLP Management of CC Cough Reflex Sensitivity Improves with Speech Language Pathology Management of Refractory Chronic Cough (Underlying cough sensitivity vs. more deliberate control) Improvement in QOL Decrease in cough frequency Decrease in cough reflex sensitivity (p<0.0001) (Ryan et al 2010)

23 VCD and Chronic Cough Treatment: Desensitization treatment Global Concept Symptom control & Patient Control Reduction/elimination of ALL triggers Medical Environmental Behavioral Emotional Team approach is critical

24 VCD/Cough Management Usually effective in a short # of speech pathology treatment sessions (2-4) if diagnosis & appropriate work-up has been completed. 4 sessions, 30 min duration over 2 month period for study on efficacy of SLP tx (Vertigan et al 2006)

25 Evaluation: Case History Medical History 1. Obtain Med Hx: Consider anatomical model & what disease processes can impact the larynx (e.g., allergies, reflux, asthma) 2. Determine if tests have been done to evaluate for ddx & etiologies (e.g., ears/nose/throat, lungs, heart, esophagus upper airway) (Testing does not appear standard across the board. e.g., often no tests for asthma but meds given for cough variant asthma) Critical Success Factor: Work with your med team to ensure appropriate pt work-up

26 Evaluation: Case History Medical History Inconsistent response to typical asthma treatments Cough variant asthma positive response to steroid inhalers & bronchodilators Chronic cough due to laryngeal hypersensitivity often will not only have no improvement to inhalers but often will be worse with inhalers

27 Evaluation- Case History Cough Symptoms 1. Nature: Dry vs. productive 2. Volitional vs. reflexive 3. Onset (precipitating events) 4. Frequency/timing 5. Duration 6. Associated symptoms/side effects Critical Success Factor: Establish baseline measure of cough to quantify improvement (May want to use QOL cough questionnaire also e.g., Leicster Cough Questionnaire (Birring et al 2010)

28 Evaluation: Case History Precipitating Cough Sxs Can the patient recognize subtle sensations leading to reflexive coughing (different than triggers). What triggers these episodes? Environmental (odors, humidity, etc) Positional changes (e.g. sxs occur at night GERD or PND/mouth breathing) Foods/ timing after meals Stress/ emotional triggers Critical Success Factor: Patient awareness

29 Evaluation: Case History Previous CC Treatment What has patient used for control of cough What worked and what hasn t worked? Critical Success Factor: Re-education about the effectiveness of past treatment (was pt being given med to tx cough or to treat etiology of cough)

30 Evaluation: Case History Vocal Hygiene Hydration vs. drying agents Caffeine Lozenges with menthol/eucalyptus Medications Phonotraumatic behaviors in addition to cc (Throat clearing, etc.) Does patient rinse after steroid inhalers? Nasal hygiene

31 Evaluation: Case History Swallowing Symptoms Dysphagia vs Hypersensitivity? Cough with foods or liquids as a trigger Very cold liquids/foods Very acidic foods (e.g., balsamic vinaigrette) Dry, crumbly foods (Gibson & Vertigan 2009) May need to evaluate swallowing function

32 Evaluation: Observations & Perceptual Analysis Objective Data Acoustic and aerodynamic assessments Other observations Upper body tension (with breathing and/or speaking) Breathholding Phonotrauma

33 Evaluation: Laryngoscopy or videolaryngostroboscopy Visualization of the larynx will ensure there is no undiagnosed disease or untreated etiology Common findings: Interarytenoid thickening/edema Signs of rhinitis (cobblestoning, thick mucus) Laryngeal erythema and edema Often there are NO discernible changes to the vocal folds

34 Evaluation: Laryngoscopy 50% of patients with chronic cough had abnormal pattern of vocal fold movement during respiration (similar to characteristic pattern of VCD) (Milgrom et al 1990) Critical Success Factor: Educ pts not unusual to have negative findings on laryngoscopic exam

35 Barriers to Improvement: Asking the Wrong Questions Cough questions should never be yes/no. Asking if a medication helped is too non-specific Patient should be asked Did that nasal steroid provide any improvement in your PND? Are you starting to feel less of a lump in the throat and less burning since starting the PPI. Patients may stop medication too prematurely because they perceive it isn t helping cough

36 Barriers to Improvement in CC Patient may have been treating 1 etiology at a time or looking for 1 cause. 60% said symptoms have not improved with any treatment (Everett et al 2007)

37 Behavior modification Treatment Overview: SLP Role Cough suppression Facilitation of efficient voicing Cognitive adjustment Vocal hygiene training Patient insight/awareness (Vertigan et al 2001, 2009)

38 Treatment: Patient Awareness Patterns to monitor (watch for decrease in) Duration Frequency Forcefulness Triggers Etiologic factors Decreased PND Decreased GERD/LPR symptoms Have patient keep a diary

39 Treatment: Cognitive Adjustment Eliminate pre-conceived notions about treatment ( I already tried that medication and it didn t work). RE-direct by saying: Were you thinking that medication would help your cough? If so, you may not have been focusing on whether it helped your PND, which leads to cough Cough is multi-factorial typically and if you were only treating one factor, you likely couldn t see improvement

40 Treatment: Cognitive Adjustment Inflammation/irritation not infection Redefinition of the illness was a critical component the patient, medical team, & family must relinquish the notion of an organic diagnosis in order for a good prognosis. (Gay et al 1987) No purpose for chronic cough (vs clearing out something noxious) Critical Success Factor: Must treat with 100% commitment to eliminate hypersensitivity (avoid concept of moderation)

41 Treatment: Cognitive Adjustment To get patient compliance with recommendations, pt must believe there is no infection Use endoscopy Use information from MD work-ups, etc. Use visuals such as anatomical diagrams

42 Treatment: Vocal Hygiene/ Cognitive Adjustment Change patient s perception of mucus Discuss viscosity as it relates to perception of amount of mucus Goal is to thin the mucus not eliminate it. Must not volitionally cough/throat clear (inflammation not infection)

43 Increase hydration /reduce caffeine/alcohol if warranted Treatment: Vocal Hygiene Ensure rinsing after inhaled steroids Ensure patient is taking medications as prescribed Timing of GERD medications Angle of nasal steroid

44 Treatment: Behavioral Modifications Avoid/eliminate throat clearing and volitional coughing Dry swallow Sips of water Talk through the mucus Vocalize scales (VFEs)

45 Treatment: Behavioral Modifications Determine subtle symptoms preceding cough in order to implement cough interruption strategies Cough interruption strategies Dry swallows, liquid swallows, chewing gum (act of repetitive swallowing), Breathing through tightly pursed lips (Blager et al 1988) Watch for signs of upper body tension, clavicular breathing, strap muscle tension, postural misalignment Breathing strategy should never be unnatural or forced

46 Treatment: Behavioral Modifications (Cognitive Adjustment) If the cough occurs despite distraction methods- Decrease the forcefulness of cough or duration of cough by interrupting the cough using tightly pursed lips (cough through pursed lips) Make sure patient understands the goal of this exercise or it will not be successful Interruption will not prevent further coughing (in the short term) but gradually desensitizes the larynx Interruption decreases phonotrauma & hypersensitivity from ongoing coughing

47 Treatment: Behavioral Modifications Treat voice symptoms (particularly if increasing pressure on larynx) (i.e., cough triggered by talking) Eliminate MTD, glottal fry/ reduced airflow with speaking (and breath holding) with typical voice therapy (usually only a few sessions)

48 Critical Success Factors Cough may persist due to hypersensitivity SLP management of behavioral factors may be beneficial Work with medical team to ensure appropriate work-up Establish baseline measure of cough to quantify improvement Patient awareness (of subtle sensations)

49 Critical Success Factors Re-education about how to evaluate the effectiveness of past treatment Negative findings on laryngoscopic exam or other exams does not indicate that it is psychogenic Treat aggressively to eliminate hypersensitivity (avoid concept of moderation) Desensitization requires managing all contributing factors simultaneously.

50 References A.E. Vertigan, D. G. T., P.G. Gibson, A.L. Winkworth (2006). "Efficacy of speech pathology management for chronic cough: a randomised placebo controlled trial of treatment efficacy." Thorax 61: Anne E. Vertigan, D. G. T., Peter Gibson, and Alison L. Winkworth (2006). "The Relationship Between Chronic Cough and Paradoxical Vocal Fold Movement: A Review of the Literature." Journal of Voice 20(3): Anne E. Vertigan, D. G. T., Peter Gibson, and Alison L. Winkworth (2007). "Voice and Upper Airway Symptoms in People with Chronic Cough and Paradoxical Vocal Fold Movement." Journal of Voice 21(3): Anne E. Vertigan, D. G. T., Alison L. Winkworth, and Peter G. Gibson (2008). "A Comparison of Two Approaches to the Treatment of Chronic Cough: Perceptual, Acoustic, and Electroglottographic Outcomes." Journal of Voice 22(5): Bhavin Dalal, M., Stephen A. Geraci, MD (2010). "Office Management of the Patient with Chronic Cough." The American Journal of Medicine xx(x). Everett, e. a. (2007). "Chronic persistent cough in the community: a questionnaire survey." Cough 3(5). Florence B. Blager, M. L. G., Raymond P. Wood (1988). "Voice Therapy Techniques Adapted to Treatment of Habit Cough: A Pilot Study." Communication Disorders 21: Henry Milgrom, M., Philip Corsello, MD, Michael Freeman, PhD, Florence B. Blager, PhD, Raymond P. Wood, MD (1990). "Differential Diagnosis and Management of Chronic Cough." Pulmonary Disorders Comprehensive Therapy 16(10): 46- Huisman, e. a. (2007). "Reliability and validity of a Dutch version of the Leicester Cough Questionnaire." Cough 3(3). Irwin, R. S. M., FCCP; Boulet, Louis-Philipe MD, FCCP; Cloutier, Michelle M. MD, FCCP; Fuller, Richard MD; Gold, Philip M. MD, FCCP; Hoffstein, Victor MD, FCCP; Ing, Alvin J. MD; McCool, F. Dennis MD, FCCP; O'Byrne, Paul MD, FCCP; Poe, Robert H. MD, FCCP; Prahash, Udaya B.S. MD, FCCP; Pratter, Melvin R. MD, FCCP; Rubin, Bruce K. MD, FCCP (1998). "Managing Cough as a Defense Mechanism and as a Symptom: A Consensus Panel Report of the American College of Chest Physicians." Chest 114(2 Supplement 2): 133S -181S.

51 Jack A. Kastelik, R. H. T., Imran Aziz, Josephine C. Ojoo, Anthony E. Redington, and Alyn H. Morice (2002). "Sexrelated Differences in Cough Reflex Sensitivity in Patients with Chronic Cough." American Journal of Respiratory and Critical Care Medicine 166: Kate Brignall, B. J., Surinder S. Birring (2008). "Quality of Life and Psychosocial Aspects of Cough." Lung 186(Suppl 1): S55-S58. Kenneth W. Altman, M., PhD, C. Blake Simpson, MD, Milan R. Amin, MD, Mona Abaza, MD, Ron Balkissoon, MD, and Roy R. Casiano, MD (2001). Cough and paradoxical vocal fold motion. Annual Meeting of the American Academy of Otolaryngology - Head and Neck Surgery, Neurolaryngology Subcommittee Panel. Denver, Liam Polley, N. Y., Liam Heaney, Chris Cardwell, Eimear Murtagh, John Ramsey, Joseph MacMahon, Richard W. Costello, and Lorcan McGarvey (2008). "Impact of Cough Across Different Chronic Respiratory Diseases: Comparison of Two Cough-Specific Health-Related Quality of Life Questionnaires." Chest 134: Martha Gay, M., Florence Blager, PhD, Kathy Bartsch, LSW II, Charles F. Emery, PhD, Anne K. Rosenstiel-Gross, PhD, and Jamie Spears (1987). "Psychogenic Habit Cough: Review and Case Reports." Journal of Clinical Psychiatry 48(12): Murray Morrison, L. R., and A.J. Emami (1999). "The Irritable Larynx Syndrome." Journal of Voice 13(3): 447- Peter G. Gibson, A. E. V. (2009). "Speech pathology for chronic cough: A new approach." Pulmonary Pharmacology and Therapeutics 22: Peter V. Dicpinigaitis, R. T., and Gisela Banauch (2006). "Prevalence of Depressive Symptoms Among Patients With Chronic Cough." Chest 130(6): Ryan, e. a. (2010). "Cough reflex sensitivity improves with speech language pathology management of refractory chronic cough." Cough 6(5). S.S. Birring, B. P., A.J. Carr, S.J. Singh, M.D.L. Morgan, I.D. Pavord (2003). "Development of a symptom specific health status measure for patients with chronic cough: Leicester Cough Questionnaire (LCQ)." Thorax 58: Teresa E. Pitts, C. M. S. (2000). "Laryngeal Contribution to Cough." Perspectives on Voice and Voice Disorders: 90 Thomas Murray, C. S. (2010). "The Role of Voice Therapy in the Management of Paradoxical Vocal Fold Motion, Chronic Cough, and Laryngospasm." Otolaryngology Clinics of North America 43: