Efficacy of Behavioral Therapy for Chronic Refractory Cough

Chronic cough is defined as cough persisting for more than eight weeks. It is a common clinical problem that significantly impairs patients' physical, psychological, and social quality of life. Chronic cough remains a diagnostic and therapeutic challenge despite systematic evaluation and treatment of common etiologies such as asthma, gastroesophageal reflux disease .

A substantial proportion of patients continue to experience persistent symptoms and are increasingly classified under the umbrella of cough hypersensitivity syndrome, characterized by an exaggerated cough response to low-level mechanical, chemical, or thermal stimuli .

Laryngeal hyperresponsiveness represents a central pathophysiological feature of upper air way cough syndrome and is associated with heightened sensory and motor responses of the larynx, leading to symptoms such as throat irritation, dysphonia, frequent throat clearing, and cough triggered by talking, laughing, cold air, or exposure to strong odors.

Pharmacological therapies often provide limited or inconsistent benefit in those patients,prompting growing interest in non-pharmacological approaches, particularly behavioral cough suppression therapy delivered by speech-language pathologists.

Behavioral therapy is a multimodal intervention incorporating patient education, cough suppression techniques, breathing retraining, vocal hygiene counseling, and strategies aimed at reducing laryngeal irritation and maladaptive cough behaviors and improve voluntary control of the urge to cough.

Randomized controlled trials and observational studies have demonstrated that behavioral therapy can significantly reduce cough frequency, cough reflex sensitivity, and cough-related quality-of-life impairment, with particular benefit observed in patients with prominent laryngeal symptoms and heightened urge-to-cough.

A recent meta-analysis of 12 randomized and self-controlled trials provides robust evidence for Behavioral Cough Suppression Therapy (BCST), showing it significantly improves Leicester Cough Questionnaire scores and reduces objective cough frequency in patients with refractory or unexplained chronic cough.

Furthermore, a specific protocol known as Physiotherapy and Speech and Language Therapy Intervention (PSALTI) has demonstrated a 41% reduction in cough frequency in clinical trials.

Despite the Advantages of speech pathology intervention, there is limited guidance in the literature on when patients should be referred for treatment. Also, heterogeneity in patient selection, diagnostic criteria, and outcome measures highlights the Need for further evaluation of the Efficacy of behavioral therapy in well-defined population with laryngeal hyperresponsivness.

Inclusion criteria

• Eligible participants are adults aged ≥18 years i.e. normal chest radiograph.
• participants with chronic cough persisting for more than eight weeks that is refractory to standard medical treatment for common causes of chronic cough, including asthma, gastroesophageal reflux disease .
• Participants are required to exhibit clinical features suggestive of laryngeal hyperresponsiveness, such as cough triggered by phonation, laughter, cold air, or irritant exposure, with associated laryngeal symptoms including throat irritation, dysphonia, or frequent throat clearing.

Exclusion criteria

• Patients are excluded if they are current smokers or had ceased smoking within six months
• patients have evidence of active pulmonary or cardiac disease, recent respiratory tract infection, recent angiotensin-converting enzyme inhibitor use.
• significant structural laryngeal pathology, neurological disorders affecting cough reflex control, or inability to comply with study procedures.
• Head &neck pathology e.g sinusitis, glottal insufficiency or primary muscle tension dysphonia