Characteristics and Treatment of Chronic Cough in Pediatrics. Sally Gallena & Marie Kerins Loyola College in MD ASHA Convention

Transcription

1 Characteristics and Treatment of Chronic Cough in Pediatrics Sally Gallena & Marie Kerins Loyola College in MD ASHA Convention

2 Adducted Vocal Folds during voice (left) & cough (right)

3 What is Chronic Cough? A cough that: persists when there is no longer an active trigger Serves no purpose to the respiratory system Impacts the quality on one s life or those in their sphere Affects both pediatrics and adults

4 Etiologies of Chronic Cough Chronic Cough Neurologic Tourette s, Vagus nerve pathology Organic GERD, Asthma, Allergies, URTI Functional Habit, Psychogenic

5 Nonspecific Chronic Cough Wamboldt & Wamboldt Unknown etiology No active disease Usually absent during sleep Unresponsive to medications Labeled (often incorrectly): Habit Cough Tic Cough Psychogenic Cough

6 Mechanism for Cough NSCC Cycle 1. Physical trigger causes cough & airway sensitivity 2. Sensitive Airway tickle causes ongoing urge to cough despite absence of trigger 3. Cough is reinforced internally or externally while airway remains in sensitive state

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

8 SLP Treatment for NSCC continued Vertigan s and Colleagues Efficacy Study that was randomized & placebo controlled N=87 Adults all having a physical trigger Results: Treatment group more successful than controls for magnitude of improvement (reduction of all symptom scores following tx) Further investigation is needed * Pediatrics!

9 Purpose of this present study: 1. To describe physical, psychosocial, and family characteristics from a sample of 15 males and 15 females with chronic cough. 2. To determine if the therapy techniques used to treat them were successful. 3. To attempt to predict those variables leading to a successful treatment outcome.

10 Study Participants Thirty children age 7-16, average 11 yrs. Cough present most frequently for 1 6 months Diagnosed with chronic cough by a pulmonologist Illness ruled out through medical tests and pharmacological trials Excluded if family history of Tourette s disease

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

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

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

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

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

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

17 Study participants: Physical Characteristics Males (15) Females (15) Group URTI 73% (11) 60% (9) 66% (20) Allergies 40% (6) 40% (6) 40% (12) Fisher s Exact Comparison p =. 449 p = Asthma 33% (5) 26% (4) 30% (9) p = GERD 12% (2) 20% (3) 17% (5) p = 1.000

18 Physical Characteristic Summary All participants had at least one physical trigger for their cough: URI, allergy, asthma, GERD There were no significant differences between genders for any of the physical characteristics using Fisher s Exact Test

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

20 Results: Psychosocial Characteristics & Male to Female Comparison Increase in Stress Psychological Services Males (15) Females (15) Group 60% (9) 80% (12) 70% (21) 53% (8) 33% (5) 43% (13) Fisher s Exact Comparison p =. 426 p =.651 School Absence Professional Parent 73% (11) 47% (7) 60% (18) 87% (13) 100% (15) 93% (28) p =.263 p =.482

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

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

23 Parent ratings of cough resolution and therapy effectiveness Subjects Complete Partial No Change Therapy Effectiveness

24 Reported Success of Therapy cough resolution & tx effectiveness Description Complete & Very effective Complete & effective Composite score Group Performance 7 Success 70% (21) 6 Success.07% (2) Partial & very effective Ratings less than 6 6 Not successful <6 Not successful.03% (1) 20% (6)

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

26 Number of Treatment Sessions Attended Males Females Group 1 session 73% (11) 73% (11) 73%(22) 2 sessions 13% (2) 13% (2) 13% (4) 3 sessions 07% (1) 13% (2) 10% (3) 4 sessions 07% (1) 0 03% (1)

27 Summary: Number of Sessions Most subjects required only one treatment session to resolve their cough There were no gender differences in number of treatment sessions p = (Fisher s Exact test)

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

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

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

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

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

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

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

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