habit cough syndrome and its variations - portal de la
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Habit Cough Syndrome and Its Variations
Miles Weinberger, M.D.Professor of Pediatrics
www.uihealthcare.com/allerpulm
Conflict of Interest Disclosure
Hey, if it was good enough for “W”, it’s good enough for me
Presenter Disclosures
Personal financial relationships with commercial, non-commercial, or tobacco interests relevant to medicine,
within past 3 years:
Miles Weinberger MD
Early Reports of Habit Cough
l Bernstein L reported a 12 y.o. girl and termed her problem “the barking cough of puberty.”Laryngoscope 1963;73:315-9.
l Berman BA reported 6 children was first to use the term “habit cough” and described cessation relying “solely on the art of suggestion” with a 2 year followup. Ann Allergy 1966;24:43-6.
Habit Cough Syndrome
Definition: Involuntary cough without an identified underlying organic reason.
Undesirable terminology:Psychogenic coughCough-tic
Laura B -15 Y.O. Girl With Cough for 9 Months
l Harsh, dry, barking coughl Coughing is incessant most of day, occurring
multiple times per minutel Rx with prednisone, theophylline, aerosol
bronchodilators - no responsel Two hospitalizations for IV Rx to treat coughl Prevents school attendance but good
student, many friends, likes school
Habit Cough SyndromeClassical Clinical Characteristics
l Loud, repetitive, dry, barking coughl Variations include softer formsl Duration of weeks or monthsl Irritating and disturbing to others -
prevents school attendancel Commonly misdiagnosed as asthmal No response to medicationl Absent once asleep
Habit Cough SyndromeMore Clinical Characteristics
l Mostly teens but down to age 5, both sexesl Symptom can be present weeks to monthsl Tests are normall Initial respiratory illness common with
change in cough soundl Secondary gain, school conflicts,
psychological issues not usually presentl Commonly in bright high achievers
Evaluation of Habit Cough
l Children with habit cough appeared bright and academically successful
l None had scores >1 SD above population mean in a psychological test (SCL 90 R) for somatization, obsessive-compulsiveness, anxiety, depression, etc.
l Increase in non-pathologic level on obsessive-compulsive scale
Lockshin, Lindgren, Weinberger, Koviach. Ann Allergy 1991;67:405 (from U of IA Ped All/Pulm Clinic)
Habit Cough SyndromeNatural History
Rojas, Sachs, Yunginger, O’Connell. Annals of Allergy 1991;66:106 (from the Mayo Clinic)
l Follow-up of 62 pts (34 m & 26 f) for mean length of 7.9 years
l Ages 4.6-15.6 (mean 10.5)l Mean duration till Dx - 7.6 monthsl Mean duration till resolution 6.1 monthsl 16 pts still coughing for mean of 5.9 years
from time of Dx
Habit CoughRx With Suggestion Therapy - Outcome
Lockshin, Lindgren, Weinberger, Koviach. Ann Allergy 1991;67:405 (from U of IA Ped All/Pulm Clinic)
l 8/9 patients treated successfully with 15 minute session, 1/9 required 30 minutes
l Minor relapses controlled with autosuggestion technique
l 1 required a 2nd session 9 days laterl All remained asymptomatic for median
of 2.2 years
Variation of Habit Cough Syndrome
l 6 y.o. boy with repeated throat clearing coughl Not a barking cough as previously shownl Parents describe it as coughingl Less disabling than classical habit coughl Primarily annoying to those around the child
Habit Respiratory Disorders
l Habit throat clearingl Habit sniffingl Habit nose blowingl Habit sneezing
Habit Sniffing From the Web
l “We have an 8 year old boy with a very, very frustrating sniffing habit. He sniffs on average about once every 10 seconds, and it isn't caused by a cold as far as we know, it is just habit.”
l “I have a 6 year old who recently started this too. It can make a person insane!”
Habit Sneezing
l 8 y.o. girl admitted with continuous sneezing for a week
l Initiated from a bug up her nose at onset.l Continuous sneezing sincel Interfering with normal activity and sleepl Stopped with suggestion therapy using
inhaled aerosol of dilute lidocaine as alternative to sensation stimulating sneeze
Habit Sneezing
Suggestion Therapy – Principle
l Provide alternative response to the sensation that produces the cough, throat clearing, sniffing, or sneezing
l Empower the patient with the ability to resist the urge
Rx With Suggestion Therapy - Method
l Physician must have confidence in successl Focus patient’s attention on suppressing
cough, i.e. resisting the urgel Acknowledge that the urge is difficult to resistl Provide alternative response to sensation
n Sipping tepid watern Inhaling an aerosol
l Explain cough
l Reinforce even brief successesl Emphasize that patient, not physician, is
controlling coughl Acknowledge that the sensation is still there
and to remain focused on resisting the urgel Provide auto-suggestion technique for
relapses
Rx With Suggestion Therapy - Method
Suggestion Therapy - Method
l Success usual in about 15 minutes
l Emphasize autosuggestion for minor relapses
Complicated Habit Cough
l 9 y.o. girl with symptoms typical of Habit Cough
l Successfully treated with suggestion Rxl Returned in a week with behavioral
polydipsia/pulyureal Successful treatment of behavioral
polydipsia/pulyureal Returned in a week with behavioral
polyphagia
Other Treatments in the Medical Literature for Habit Cough
l The bedsheet (Cohlan et al. Pediatrics 1984;74:11-15)n Tight bedsheet wrapped around the child’s chestn Child is suggested that cough is a perpetuation of initial illness that
has weakened his chest musclesn Suggestion given that the bedsheet will help strengthen the chest
muscles and decrease the cough
l Behavior management alternative (Lavigne et al. Pediatrics 1991;87:532-7)
n Initial illness acknowledgedn Child told that decreasing the frequency of cough would gradually
decrease the habit of coughingn Parents recording frequency of coughn Several days to weeks required
Treatment Proposed for Throat Clearing
l Throat clearing associated with hyperawareness of pharyngeal mucus.
l Sipping ice cold carbonated water to break the cycle
l 63% of 72 patients had improved symptoms score
Acharya et al. J Laryngol Otol;2007;121:354-7
Medical Literature for Treatment of “Psychogenic Intractable Sneezing”
l 4 children describedl Treated with psychotherapyl Gradual cessation in hospital over 1-2 days
Bergmen et al. J Pediatrics 1984;105:496-8.
Similar Cough that is not Habit9 Y.O. Girl With Cough for 2 Years
l Harsh, dry, barking coughl Paroxysmal coughing with post-tussive
emesisl Rx with bronchodilators, theophylline,
prednisone - no responsel Severely Cushingoid from prednisonel Several hospitalizationsl Nightly awakening from cough
Donna E -9 Y.O. Girl With Cough for 2 Years
View through the flexible fiberoptic bronchoscope with topical anesthesia
and light sedation
Tracheomalacia - treatment
l Behaviorally – successful for some mild cases (Wood RE. Localized tracheomalacia or bronchomalacia in children with intractable cough. J Pediatr 1990;116:404-406)
l Aortopexy – stenting the trachea using a stitch between the sternum and the aorta to place tension on the connective tissue between the aorta and anterior wall of the trachea
Donna E -9 Y.O. Girl With Cough for 2 Years
Treated with aortopexy.
Flexible fiberoptic bronchoscopy with topical anesthesia and light sedation repeated.
History of A.K.l 4 y.o. with harsh barking cough
l Present since infancy
l Dx as asthma
l Allergy skin testing negative
l Rx with cromolyn, Singulair, prn albuterol, and multiple courses of steroids
l Equivocal response to all treatment
Upper Airway of A.K. Through Flexible Bronchoscope
Najada A, Weinberger M. Unusual cause of chronic cough in a four-year-old cured by uvulectomy. Pediatr Pulmonol 2002;34;144-146.
3.y.o. girl with chronic cough
l No response to bronchodilators
l No response to prednisolone
l No response to antibiotic
l No airway inflammation on BAL
l No bacteria on BAL
epiglottis
Tonsillar tissue
Gurgel RK, Brookes JT, Weinberger MM, Smith RJ. Chronic Cough and Tonsillar Hypertrophy: A Case Series. Ped Pulmonol 2008;43:1147–1149.
Other Causes of Cough
l Acute viral bronchitis (or tracheobronchitis)
l Asthmal M. Or C. Pneumoniael Aspirationl Cystic fibrosisl Primary ciliary dyskinesia
What About Post-Nasal Drip?
l A diagnostic label that is unhelpfull No accepted definitionl Mucus dripping down the back of the throat
not consistently associated with coughl Presence of post-nasal drainage with cough
likely indicates inflammation of lower airway in addition to the upper airway
Morice AH. Post-nasal drip syndrome – a symptom to be sniffed at? PulmonaryPharmacology & Therapeutics 2004;17:343-5.
Other Habit Respiratory Disorders Susceptible to Suggestion Therapy
l Habit throat clearingl Habit sniffingl Habit nose blowingl Habit Sneezing
Summaryl Repetitive cough, throat clearing sniffing,
sneezing may start as a disease process but be perpetuated as habit
l Absence of symptoms once asleep is characteristic of the habit cough and related habit syndromes
l Medications not effectivel Treat behaviorally
