Presentation of the Therapy Program for Management of Chronic Cough

Ribeiro, Vanessa Veis; Lopes, Leonardo Wanderley; Behlau, Mara

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Brief Communication • CoDAS 33 (3) • 2021 • https://doi.org/10.1590/2317-1782/20202020057 copy

Presentation of the Therapy Program for Management of Chronic Cough

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose

To present a proposal for speech-language pathology rehabilitation called the Therapy Program for Management of Chronic Cough (TMCC) for the treatment of refractory chronic cough.

Methods

TMCC was developed based on two stages: literature and clinical analysis. The literature analysis stage was carried out through the following procedures: electronic and manual search for articles and books published until June 2019 that included adult participants with chronic cough and intervention with speech-language pathology therapy; selection of sources; analysis of articles and books included; and, preparation of the initial version of the therapy program. The initial version of the therapy program resulting from literature analysis stage was submitted to clinical analysis stage through the following procedures: analysis by three judges; revision of the proposal by the authors; judges’ re-analysis; elaboration of the final version called the Therapy Program for Management of Chronic Cough (TMCC).

Results

TMCC synthesizes scientific knowledge and current clinical experience on the behavioral management of refractory chronic cough into a program with three main components, each one with specific objectives and strategies. TMCC consists of four sessions, with weekly frequency and duration between 30-45 minutes per session, executed in hierarchical phases, with specific objectives and strategies per session.

Conclusion

TMCC is a program structured to offer global cough rehabilitation. To obtain scientific evidence about its effectiveness is necessary, so that it can be used in clinical practice.

Keywords:
Larynx; Rehabilitation; Behavioral Therapy; Therapeutics; Cough

COMPONENT	STRATEGIES
Counseling on cough and laryngeal well-being	• Conduct counseling with the support of educational material on:
	○ Larynx (function, anatomy, normal movement, abnormal movement during cough)
	○ Chronic cough (cough physiology, protective function, threshold that triggers cough)
	○ Identification of triggers and development of voluntary control of cough (cough cycle; negative effects of repeated cough; laryngeal sensitivity as a source of cough; triggers; need and form of behavioral management to suppress cough from the cough cycle)
	○ Well-being and control of laryngeal irritating factors (type and mode of breathing; hydration; humidification of inhaled air; sucking non-medicinal gums; exposure to cigarettes and other drugs; exposure to sensory stimuli; consumption of dehydrating substances; management of Laryngopharyngeal Reflux)
Cough suppression, control and replacement	• Map the cough (identify cough triggers/alerts, anticipate when a cough is about to occur to implement a suppression, control or substitution strategy)
	• Hierarchical training of techniques:
	○ Distraction techniques
	◾ Drink water, suck ice/lollipop, chew gum/candy or wait for 5 to 10s to check if the urge to cough passes
	○ Technique for suppressing coughing or clearing throat with swallowing
	◾ Swallow suppression: swallow hard when you feel a tickle in the throat and the urge to cough or clear the throat (dry mouth/saliva, with a sip of water or with a non-medicated lollipop) - bending the head towards the chest and an isometric push with hands together (in public it can be performed without the use of hands)
	○ Breathing technique of cough control
	◾ Simulation of respiratory control in cough - Breathe gently, preferably through the nose, monitor breathing, identify breathing mode and type with hand support, blow quickly through the contracted lips simulating glottal closure/airway obstruction during cough. The patient should feel the effort in a similar way to coughing
	◾ Diaphragmatic breathing - inhale through the nose and exhale through the mouth, slow exhalation in maximum phonation time producing a dull fricative sound, using synesthetic tactile feedback with the hand on the abdomen
	◾ Sniff
Respiratory and laryngeal control	• Breathing training
	○ Guide and identify breathing rhythm and type
	○ Guide on body posture
	○ Pressure biofeedback technique - patient standing with an elastic resistance band around the abdomen for respiratory type localization feedback, inhale through the nose and exhale slowly through the mouth, decrease focus on inhalation and increase focus on the exhalation
	• Vocal training
	○ Reduce tension in the laryngeal accessory musculature
	• Cervical spine movements associated with facilitating sounds
	○ Adjust resonance focus
	• Humming sound
	○ Mobilize the vocal fold mucosa
	• Phonation in a latex tube immersed in water at a depth of 2 cm
	○ Decrease phonatory effort and supraglottic constriction
	• Humming sound
	• Aphonic breath in a latex tube immersed in water at a depth of 2 cm
	• Fricative sound
	○ Stabilize glottic closure
	• Phonation with frequency modulation in a latex tube immersed in water at a depth of 2 cm

SESSION	PHASE	OBJECTIVES	STRATEGIES
1	-Sensory awareness	-Provide information about chronic cough	-Counseling on chronic cough, laryngeal well-being and control of laryngeal irritating factors with the support of educational material
		-Provide information on laryngeal well-being	-Map the cough
		-Anticipate when a cough will occur and control, suppress or replace the cough with strategies that interrupt its cycle	-Train distraction, control and suppression techniques in a clinical situation without the cough trigger (20 repetitions of 5 to 10 seconds each)
		-Train respiratory muscles	-Guide and identify breathing type and rhythm
		-Work PPAC	-Pressure biofeedback technique (3 minutes)
		-Reduce tension in the laryngeal accessory muscles	-Deaf fricative sound /s/ (1 minute)
			-Cervical movements associated with fricative deaf sound /s/ (2 minutes)
At home (5 times a day)			-Read educational counseling material
			-Train distraction, control and suppression techniques when asymptomatic (20 repetitions with 5 to 10 seconds each)
			-Deaf fricative sound /s/ (3 minutes)
			-Cervical movements associated with deaf fricative sound /s/ (3 minutes)
2	-Sensory awareness	-Anticipate when a cough will occur and control, suppress or replace the cough with strategies that interrupt its cycle	-Resume counseling and ask questions
	-Voluntary behavioral substitution	-Train respiratory muscles	-Train distraction, control and suppression techniques when symptomatic, exposing them to risky situations (20 repetitions with 5 to 10 seconds each)
		-Work PPAC	-Pressure biofeedback technique (3 minutes)
		-Reduce tension in the laryngeal accessory muscles	-Aphonic blow in latex tube immersed in water (3 minutes)
		-Adjust resonance focus	-Fricative sound in sound passage (1 minute)
		-Reduce phonatory effort and supraglottic constriction	-Cervical movements associated with fricative sound /v/ (2 minutes)
			- Nasal sound /m/ (3 minutes)
At home (5 times a day)			-Train distraction, control and suppression techniques when symptomatic, exposing to risk situations (20 repetitions with 5 to 10 seconds each)
			-Fricative sound in sonority passage (1 minute)
			-Cervical movements associated with fricative sound /v/ (2 minutes)
			- Nasal sound /m/ (3 minutes)
3	-Voluntary behavioral substitution	-Anticipate when a cough will occur and control, suppress or replace the cough with strategies that interrupt its cycle	-Resume counseling and ask questions
		-Train respiratory muscles	-Map the cough
		-Work PPAC	-Train the continuous use of distraction and suppression techniques with exposure to cough triggers (30 seconds each and gradually increasing the duration of exposure according to the patient's tolerance)
		-Reduce tension in the laryngeal accessory muscles	-Pressure biofeedback technique (3 minutes)
		-Adjust resonance focus	- Nasal sound /m/ (3 minutes)
		-Mobilize vocal fold mucosa	-Cervical movements associated with fricative sound /v/ (1 minute)
		-Reduce phonatory effort and supraglottic constriction	-Fricative sounds in sequence /v/ /z/ /j/ (2 minutes)
			-Phonation in latex tube immersed in water (3 minutes)
At home (5 times a day)			-Train continuous use of distraction and suppression techniques with exposure to cough triggers (30 seconds in the first workout and gradually increase the duration of exposure by 1s according to tolerance)
			-Rotation of shoulders associated with the fricative sound /v/ (3 minutes)
			-Nasal sound /m/ (3 minutes)
4	-Generalization	-Anticipate when a cough will occur and control, suppress or replace the cough with strategies that interrupt its cycle	-Resume counseling and ask questions
		-Train respiratory muscles	-Resume suppression and distraction techniques and ask questions
		-Work PPAC	-Nasal sound /m/ followed by vowels (3 minutes)
		-Adjust resonance focus	-Fricative sound /v/ followed by vowels (3 minutes)
		-Mobilize vocal fold mucosa	-Phonation in latex tube immersed in water with frequency modulation (3 minutes)
		- Reduce phonatory effort and supraglottic constriction
		-Stabilize glottic closure
At home (5 times a day)			-Train continuous use of distraction and suppression techniques with exposure to cough triggers (gradual increase in the duration of exposure as tolerated)
			-Nasal sound /m/ followed by vowels (3 minutes)
			-Fricative sound /v/ followed by vowels (3 minutes)

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E-mail: revista@codas.org.br

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[1] Conflict of interests: nothing to declare.