Chronic Cough: Evaluation of Patients’ Motivation to Undergo Cough Suppression Therapy
Introduction
Chronic cough is a persistent cough lasting greater than eight weeks with a prevalence rate of 9%–33% in the United States.1 In addition to cough, patients may also report shortness of breath (SOB), dysphagia, and dysphonia significantly affecting the their quality of life.2 Etiologies of chronic coughing are wide including laryngeal irritation, vagal neuropathy, esophageal motility disorders, gastroesophagal reflux disease (GERD), allergy, sinonasal dysfunction, and pulmonary pathologies such as obstructive and restrictive lung disease.1 Initial management is often facilitated through a primary care physician (PCP) including over-the-counter cough suppressants and anti-tussive lozenges.1 As the cough becomes persistent and burdensome, patients seek further evaluation and treatment with specialists, including laryngologists.1 Recent studies have noted the importance of a multi-disciplinary treatment team including but not limited to otolaryngology- head and neck surgery (OHNS), pulmonology, allergy and immunology, and speech-language pathology.1
Current medical/surgical interventions for chronic cough include neuromodulator medications like amitriptyline chloride, baclofen, pregabalin, nortriptyline, gabapentin, antireflux therapy including proton pump inhibitors (PPI)/H2 receptor blockers, superior laryngeal nerve blocks (SLN), Botulinum toxin injection, and vocal fold augmentation in ambulatory clinics.3, 4, 5, 6 Behavioral interventions with speech-language pathologists (SLP) include education on the voluntary control of cough, psychoeducational counseling, laryngeal control strategies to suppress cough, and optimization of laryngeal hygiene (ie: adequate hydration, reduced laryngeal irritation).7,8 Primary treatment mechanisms may include identifying cough triggers, control of the cough suppression reflex through relaxed breathing, and increased cough threshold.9 However, the exact physiological mechanism of cough suppression therapy has yet to be determined.
The Transtheoretical Model (TTM) of behavior change may be a useful way to conceptualize a patient's ability and readiness to make changes in behavioral therapy. Van Leer et al. examined application of the TTM in voice therapy to provide an organizing framework for understanding behavior change in voice therapy. The authors proposed that principles of health behavior change can aid speech pathologists in understanding and estimating readiness for voice therapy.10 Exploring the TTM of change by motivational interviewing may strengthen physician-patient relationships and in turn contribute to behavioral changes. Motivational interviewing is defined as a collaborative discussion to investigate a person's intrinsic factors and desires for change to influence positive changes.11 Information regarding patient's intentions are elucidated by open-ended questions, internal reflection, and support.11 It has previously been utilized by physicians to help patients overcome numerous chronic conditions not limited to hypertension and diabetes mellitus.12,13 As a result, motivational interviewing may have a promising role in inducing behavioral change in patients with chronic cough.
When examining the efficacy of cough suppression therapy, a recent systematic review of 184 studies found that two to four cough suppression therapy sessions may improve the quality of life in patients with chronic cough, although further trials are required to assess the efficacy of behavioral therapy.14 A prospective study conducted by Slovarp and colleagues found that greater than 50% of patients reported a notable improvement of their chronic cough after cough suppression therapy.15 Moreover, previous literature has reported, in addition to factors like severity and duration of disease, patients who feel comfortable seeking care are more amenable to behavioral therapy.16
Current gaps in literature include understanding the motivating factors that prompt patients to seek further evaluation with SLP as well as the physician's role in motivational interviewing.16 Therefore, the primary aim of this study was to identify and address the current deficits in healthcare provider understanding of specific factors that motivate patients to seek cough suppression therapy.
Section snippets
Methods
This study is a prospective cross-sectional survey approved by the institutional review board (IRB) at Wake Forest Baptist Medical Center (WFBMC). This study examined 36 adult patients at Wake Forest Voice and Swallowing Center between April 2021 and August 2021. The inclusion criteria were as follows: greater than or equal to eighteen years of age, all self-identified genders not limited to male/female/transgender/nonbinary/gender nonconforming, patients evaluated for a new chief complaint of
Results
In this study, 21 patients (58.33%) identified as female, 15 patients (41.20%) identified as male, and no patients identified as other genders or nonbinary. The mean age (SD) of the patients who presented with chronic cough was 57.75 (12.12) years old. The mean presenting cough suppression index (CSI) was 19.39 (10.28). The mean cough duration was 8.69 (12.10) years. 32 patients (88.89%) tried one or more prescription medications. (Table 1)
All patients included in this study with chronic cough
Discussion
Participants from our patient population displayed demographic findings consistent with a recent study conducted by Madden and collegues.17 Majority of the patients who participated in our study identified as female (58%) similar to studies reporting from 62% to 83%.15,17 Additionally, this study found a similar mean age of participants at 58 years of age compared to previous literature.15,18,19
As aforementioned, chronic cough has been shown to have a significant impact in a patient's quality
Conclusion
Patients’ motivation to seek behavioral cough suppression therapy may be influenced by their desire to improve their quality of life both medically and socially. This study addresses patients’ desires to pursue a lesser-known treatment option for chronic cough to aid clinicians in understanding the relationship between symptomatology and patient motivation, appropriately counseling their patients, and improving methods to assess candidacy for behavioral treatment.
Disclaimer
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Acknowledgments
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Cited by (1)
Chronic Cough: Evaluation of Patients' Success in Completing Cough Suppression Therapy
2022, Journal of VoiceCitation Excerpt :After signing informed consent, patients completed a standard questionnaire developed by a fellowship-trained laryngologist and a SLP specializing in voice and upper airway disorders.18 The survey was developed to address common patient-reported factors for pursuing CST, as illustrated in Figure 1.18 Survey data was extracted by the research team in a non-blinded fashion.
Presentations: The Fall Voice Conference podium presentation on October 23, 2021 in Miami, Florida.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, not-for-profit sectors.
Conflicts of interest: Lyndsay L. Madden, DO is a consultant for Lumenis. The remaining authors have no financial disclosures or conflict of interests relevant to this manuscript.