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higher- and lower-starting-dose protocol patients, 98.4% dis-
charged with an aspirin prescription were still taking aspirin at 1
month, indicating low rates of long-term hypersensitivity-related
adverse events.
Our study shows that higher-starting-dose protocols (chal-
lenge or challenge-desensitization) for aspirin allergic patients
with CAD without a history of anaphylaxis can be as safe and
effective as lower-starting-dose protocols. Our center showed
success in a large number of patients with ACS, in most cases
before cardiac revascularization, without an increase in adverse
cardiovascular outcomes. There was a high median and cumula-
tive aspirin dose at reaction for all protocols, providing further
evidence that low starting doses are unnecessary. Our ndings
support our centers trend of replacing lower-starting-dose with
higher-starting-dose protocols, achieving aspirins antiplatelet
effect more quickly.
Emily H. Liang, MD
*
Cy Y. Kim, MD
y
Javed Sheikh, MD
*
Shefali A. Samant, MD
*
*
Department of Clinical Immunology and Allergy, Southern California
Permanente Medical Group, Los Angeles, California
y
Department of Cardiology, Southern California Permanente Medical
Group, Los Angeles, California
Shefali.A.Samant@kp.org
References
1. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 ACC/AHA guideline for
the management of patients with non-ST-elevation acute coronary syn-
dromes: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. Circulation. 2014;130:
2354e2394.
2. Feng CH, White AA, Stevenson DD. Characterization of aspirin allergies in
patients with coronary artery disease. Ann Allergy Asthma Immunol. 2013;
110(2):92e95.
3. Wong JT, Nagy CS, Krinzman SJ, et al. Rapid oral challenge-desensitization for
patients with aspirin-related urticaria-angioedema. J Allergy Clinc Immunol.
2000;105:997e1001.
4. Cortellini G, Caruso C, Romano A. Aspirin challenge and desensitization: how,
when and why. Curr Opin Allergy Clin Immunol. 2017;17:247e254.
5. Cortellini G, Romano A, Santucci A, et al. Clinical approach on challenge and
desensitization procedures with aspirin in patients with ischemic heart disease
and nonsteroidal anti-inammatory drug hypersensitivity. Allergy. 2017;72:
498e506.
6. Rossini R, Iorio A, Pozzi R, et al. Aspirin desensitization in patients with cor-
onary artery disease: results of the multicenter ADAPTED registry. Circ Car-
diovasc Interv. 2017;10:e004368.
7. Chopra AM, Diez-Villanueva P, Cordoba-Soriano JG, et al. Meta-analysis of
acetylsalicylic acid desensitization in patients with acute coronary syndrome.
Am J Cardiol. 2019;124(1):14e19.
8. Lee RU, Stevenson DD. Aspirin-exacerbated respiratory disease: evaluation and
management. Allergy Asthma Immunol Res. 2011;3(1):3e10.
9. White AA, Stevenson DD, Woessner KM, et al. Approach to patients with
aspirin hypersensitivity and acute cardiovascular emergencies. Allergy Asthma
Proc. 2013;34:138e142.
10. Al-Ahmad M, Rodriguez-Bouza T, Nurkic M. Establishing a safe administration
of ASA in cardiovascular patients with nonsteroidal anti-inammatory drug
hypersensitivity with skin and/or respiratory involvement. Int Arch Allergy
Immunol. 2018;175:237e245.
Unexpected and unintended cure of habit cough by proxy
In 1966, Dr Bernie Berman, a Boston allergist, described 6 children
with a chronic cough that could be stopped by the art of sugges-
tion.Dr Berman called this a habit cough.
1
This disorder has been
repeatedly described, sometimes with different terms but with the
same description of the characteristic sound of the cough, barking
or honking, and the absence of the cough once asleep.
2-8
The
frequency of habit cough diagnoses was reported at the rates of 7
per year at the University of Iowa
6
and 9 per year at the Brompton
Hospital in London England.
7
A median age for children with the
diagnosis was 10 years at both institutions.
8
Treatment at the
University of Iowa consisted of suggestion therapy. In 1991, I
described 9 patients who were successfully treated with suggestion
therapy. Seven who could be contacted, even years later, had sus-
tained benet. Subsequently, I reviewed our experience with 140
children seen from 1995 to 2014. Among 85 of those children who
were coughing when seen in the clinic, cessation of cough with
suggestion therapy was successful in 81. In this letter, I present
some unexpected and unintended additional observations related
to this disorder.
In early February 2019, I received an e-mail from the father of
a 12-year-old girl with a 3-month history of a repetitive daily
cough that was absent once asleep. His online search for help led
to me. He and his daughter were at a location 3000 miles from
me. Her pediatric pulmonologist was prescribing inhaled corti-
costeroids, which were providing no benet. Because she met the
criteria for habit cough, I undertook, for the rst time, delivering
my usual suggestion therapy
9
via Skype. Cessation of cough
occurred within 15 minutes. The girls father recorded the pro-
cedure and created a website (www.habitcough.com)that
contained his daughters history and an audiovisual recording.
The full video was also placed on YouTube (https://www.
youtube.com/watch?v¼jnQUvD8Qdj0&t¼670s).
Although the outcome of this patients treatment via Skype was
a satisfying experience, an unexpected and unintended effect of the
video was subsequently reported to me. I received unsought
e-mails from the parents of 3 children and 2 adults, indicating that
watching the young girl respond to suggestion therapy in the video
resulted in cessation of their chronic cough.
The rst of individuals these reached me in early April 2019.
The mother of a 10-year-old boy described her previously healthy
son who developed a dry hacking cough that has not stopped,
except at night when hesasleepafter a viral illness 2 months
earlier. His pediatrician prescribed steroids, azithromycin, 3
different antihistamines, montelukast (Singulair), amoxicillin and
clavulanate (Augmentin), albuterol and beclomethasone (QVAR),
benzonatate (Tessalon Perles), dextromethorphan (Robitussin
DM), and honey, with no benet. Chest radiography and labo-
ratory tests provided no diagnosis. The mother, a pediatric nurse,
had seen the video at www.habitcough.com and asked her son to
sit by her and watch the video. The mother indicated that he
immediately identied with [the patient]; he jumped right into it
and stopped coughing.An e-mail more than a month later
indicated that the previous coughing was still no longer present.
In May 2019, a mother of an 8-year-old girl sent me an e-mail
describing her daughter as having a bad cold several months
earlier that was followed by 2 months of a persistent daily cough
characteristic of the habit cough. Her physician obtained chest
radiography and prescribed asthma and allergy medications
without benet. A pulmonologist told her daughter to take
some ice water when you feel the cough coming on.None of the
measures were of benet. Searching for help on the internet, the
mother found the video on YouTube. While the 2 of them
watched the suggestion therapy procedure on the video, her
daughter commented excitedly, I can hold the cough back.This
Disclosures: The author has no conicts of interest to report.
Funding: None.
Letters / Ann Allergy Asthma Immunol 123 (2019) 507e525 515
was followed by cessation of coughing. Mother stated, THE
COUGHING STOPPED! Like turning off a switch.A subsequent
e-mail from the mother reported that the cough was still gone 4
days later.
In June 2019, I received an e-mail from the father of a 9-year-old
boy with a history of motor and vocal tics who had a persistent
repetitive chronic dry cough. The father indicated that the cough
occurred several times per minute and was not present when
asleep. When watching the video, the boy rst stated, Its different
than mine,but then associated what he was observing with his
own condition and found he could suppress the cough. The cough
was still gone the following day.
I also received e-mails from 2 adult women, 58 and 68 years old.
They both indicated that watching the 30-minute video and
following along with the dialogue resulted in cessation of their
chronic cough. One of the women stated, I listened to the video
and concentrated. It really works.The other woman commented,
Its amazing; mind over matter?
Habit cough causes considerable morbidity, including well-
intentioned iatrogenesis, unneeded testing, unnecessary medi-
cation, and even hospitalization.
9
Several variations of suggestion
are well documented as curative for habit cough.
1,4,5,8
The
current unanticipated and unintended observations reported in 3
children and 2 adults demonstrate further the amenability of
habit cough to suggestion. The clinical characteristics of
habit cough are sufciently distinct that the diagnosis can be
made by the typical history of a repetitive harsh, barking, or
honking cough, occurring up to several times per minute, that is
absent once asleep. No testing is needed for diagnosis, and no
medications are needed for treatment. Knowledge and skillful
interaction with the patient are the tools for diagnosing and
treating this disorder.
Miles Weinberger, MD
Department of Pediatrics
University of California, San Diego
Rady Childrens Hospital
Encinitas, California
miles-weinberger@uiowa.edu
References
1. Berman BA. Habit cough in adolescent children. Ann Allergy. 1966;24:43e46.
2. KravitzH, Gomberg RM, Burnstine RC, Hagler S, Korach A. Psychogenic cough tic in
childrenand adolescents:nine case historiesillustrate the needfor re-evaluation of
this common but frequently unrecognized problem. Clin Pediatr. 1969;8:580e583.
3. Weinberg EG. Honking: psychogenic cough tic in children. S Afr Med J. 1980;
57:198e200.
4. Lokshin B, Lindgren S, Weinberger M, et al. Outcome of habit cough in children
treated with a brief session of suggestion therapy. Ann Allergy. 1991;67:
579e582.
5. Cohlan SQ, Stone SM. The cough and the bedsheet. Pediatrics . 1984;74:
11e15.
6. Weinberger M, Hoegger M. The cough without a cause: habit cough syndrome.
J Allergy Clin Immunol. 2016;137:930e931.
7. Wright MFA, Balfour-Lynn IM. Habit-tic cough: presentation and outcome with
simple reassurance. Pediatr Pulmonol. 2018;53:512e516.
8. Anbar RD, Hall HR. Childhood habit cough treated with self-hypnosis. Pediatrics.
2004;144:213e217.
9. Weinberger M. Commentary: the habit cough: diagnosis and treatment. Pediatr
Pulmonol. 2018;53:535e537.
The practical clinical relevance of rhinitis classication in children
with asthma
outcomes of the ControLAsmastudy
Asthma and rhinitis may share pathogenic mechanisms, and
extensive investigation has been devoted to exploring their
reciprocal impact. A recent prospective study investigated the
prevalence of rhinitis and its phenotypes, symptom severity, and
medication use in 619 children with asthma.
1
Rhinitis was found to
be a common asthma comorbidity (93.5%) and was refractory to
standard rhinitis medications. Perennial allergic rhinitis with sea-
sonal exacerbation caused by poly-allergy was common (34.2%),
mostly severe, and often associated with difcult-to-control
asthma. In line with previous evidence,
2,3
the study concluded
that poly-allergy should be considered a signicant risk factor for
poor control of asthma.
The Italian Society of Paediatric Allergy and Immunology
recently established a Study Group (ControLAsma) to evaluate
asthma control in children managed in clinical practice. In this
context, the group considers rhinitis a comorbidity worthy of
investigation. We therefore conducted a study aimed at evaluating
the prevalence and impact of rhinitis and its phenotypes on asthma
outcomes in a large group of children with asthma.
We enrolled and visited 333 children across 10 Italian pae-
diatric allergy centers. Information was gathered about asthma
duration, asthma control levels, and asthma severity grade ac-
cording to the Global Initiative for Asthma (GINA) guidelines.
4
Emergency department admissions, absences from school,
current use of medications, including inhaled and oral cortico-
steroids, were also reported, and also body mass index (BMI)
assessment. lung function testing, fractinoal exhaled nitric oxide
(FeNO) measurement, and childrens asthma control test score
(c-ACT). Children self-administered the children asthma control
test (c-ACT) questionnaire. The Review Ethics Committees
approved the study procedure, and written informed consent
was obtained from the parents of all children. Clinical data were
recorded on an electronic case report form approved for this
study.
Demographic and clinical characteristics are described using
means with standard deviation for normally distributed continuous
data (eg, age), medians with lower and upper quartiles for not
normally distributed data (eg, FeNO levels), and absolute frequency
and percentages for categorical data (eg, frequency of male sub-
jects). The normality of distribution was assessed by Shapiro-Wilk
W test. Normally distributed quantitative data were analyzed
using analysis of variance (ANOVA) followed by a Sheffè post hoc
test, and non-normally distributed quantitative data using a
Kruskall-Wallis test followed by Bonferronis correction. Compari-
son of frequency distributions was made by means of the
c
2
test or
Fishers exact test in case of expected frequencies less than 5,
followed by Bonferronis correction. Statistical signicance was set
Disclosures: None.
Funding Sources: None.
ControLAsma Study Groupmembers: Elisa Anastasio, Ilaria Brambilla, Carlo
Caffarelli, Loredana Chini, Riccardo Ciprandi, Paolo Del Barba, Valentina De Vittori,
Maria Elisa Di Cicco, Luciana Indinnimeo, Ahmad Kantar, Maddalena Leone, Amelia
Licari, Viviana Moschese, Roberta Olcese, Diego Peroni, Angela Pistorio, Michela
Silvestri, Anna Maria Zicari.
Authors contribution: MAT, MD, GM, and GC designed the study, GC wrote the
manuscript.
Letters / Ann Allergy Asthma Immunol 123 (2019) 507e525516
... The 9-year-old boy's cough, but not Tourette symptoms, was stopped readily by suggestion therapy that was provided by proxy. 5 A reference (reference 120 1 ) that was selected by the panel discussed tics and Tourette's syndrome as if that related to chronic cough. A verbal tic is not the same as a cough. ...
Chapter
Non-pharmacological control of cough is an important component in the management of chronic cough that is refractory to medical management. This chapter outlines the components of non-pharmacological approaches and evidence for treatment. The mechanisms underlying improvement in cough following non-pharmacological approaches are explored as well as the timing of non-pharmacological approaches with medical treatment.
Article
Full-text available
Cough is a natural process that protects the airway. Cough can occur spontaneously or voluntarily. It is considered chronic when it is present for longer than 4 weeks in children or 8 weeks in adults. In both, chronic cough causes patient distress and increased healthcare utilization. Etiologies of pediatric chronic cough include asthma, protracted bacterial bronchitis, tracheomalacia, habit cough, and various systemic disorders. While some diagnoses are identifiable by careful history alone, others require testing guided by specific pointers. Flexible fiberoptic bronchoscopy has been an important tool to identify etiologies of chronic cough that were not otherwise apparent. In adults, asthma and bronchitis are well-defined etiologies of chronic cough, but much chronic cough in adults is largely a conundrum. Reviews of adult chronic cough report that at least 40% of adults with chronic cough have no medical explanation. Gastroesophageal reflux and upper airway cough syndrome (a.k.a. post-nasal drip) have been common diagnoses of chronic cough, but those diagnoses have no support from controlled clinical trials and have been subjected to multiple published critiques. Cough hypersensitivity is considered to be an explanation for chronic cough in adults who have no other confirmed diagnosis. Gabapentin, a neuromodulator, has been associated with a modest effect in adults, as has speech pathology. While habit cough has not generally been a diagnosis in adults, there is evidence for a behavioral component in adults with chronic cough. Treatment for a specific diagnosis provides a better outcome than trials of cough suppression in the absence of a specific diagnosis. More data are needed for chronic cough in adults to examine the hypothesized cough hypersensitivity and behavioral management. This article reviews etiologies and the treatment of chronic cough in children and the conundrum of diagnosing and treating chronic cough in adults.
Article
Full-text available
Nine patients with habit cough, initially misdiagnosed as asthma, were treated during a period of sustained repetitive symptoms with a brief session of suggestion therapy. Symptoms had previously been present for up to 2 years (median = 2 months). Five had been hospitalized for the cough. Evaluation revealed no physiologic or radiologic abnormality. All patients became symptom free during a 15-minute session of suggestion therapy. During the subsequent week, one remained completely asymptomatic and 8 had transient minor relapses that were readily self-controlled. Seven of the 9 could be contacted for determination of long-term outcome at periods up to 9 years (median 2.2 years) after the session. Six were totally asymptomatic; one had occasional minor self-controlled symptoms. A standardized questionnaire assessing psychologic symptoms at the time of follow-up revealed no somatization nor emotional distress. In contrast to this apparent cure, others have reported extended periods of continued symptoms in the absence of a uniform treatment plan for suggestion therapy even though the correct diagnosis was made. We conclude that the classical habit cough syndrome is amenable to immediate relief and long-term cure in most cases with a single session of appropriate suggestion therapy.
Article
Full-text available
To better understand factors associated with the development and persistence of habit cough and to report use of self-hypnosis for this condition. A retrospective chart review was performed for 56 children and adolescents with habit cough. Interested patients were instructed in self-hypnosis for relaxation and to help ignore the cough-triggering sensation. The patients' mean age was 10.7 years. The cough was triggered by upper respiratory infections in 59%, asthma in 13%, exercise in 5%, and eating in 4%. Onset of the cough occurred as early as 2 years, and its average duration was 13 months (range, 2 weeks to 7 years). There was a high incidence of abdominal pain and irritable bowel syndrome in the 50% of the patients who missed more than 1 week of school because of their cough. Among the 51 patients who used hypnosis, the cough resolved during or immediately after the initial hypnosis instruction session in 78% and within 1 month in an additional 12%. Habit cough is triggered by various physiologic conditions, related frequently to other diagnoses, and it is associated with significant school absence. Self-hypnosis offers a safe efficient treatment.
Article
Objectives: Our therapeutic approach to a habit/tic cough is simple reassurance in a single consultation. To quality assure our practice, we followed up children to determine outcomes at least 3 months after diagnosis. Design: Consecutive children diagnosed over 6 years were studied. Medical records were analyzed retrospectively and parents answered a scripted verbal survey. Results: Fifty-five patients were diagnosed (median age 9.9 years), with a median cough duration of 3 months (IQR 2-7.5 months, range up to 3 years). In 51/55 (93%) cases, cough was absent during sleep. 51/55 (93%) received prior medications with median 3 therapeutic trials, none of which resolved the cough. Follow-up was possible in 39/55 (71%) children after a median duration of 1.9 years. In 32/39 (82%), the cough had resolved completely (59% within 4 weeks, including 12% on the day), and it improved in 6/39 (15%). In the 26/39 (67%) parents who said they believed the diagnosis, there was 96% resolution of the cough, versus the 13/39 (33%) who were sceptical or disbelieving, when there was only 54% resolution. 7/39 (18%) children were later diagnosed with a tic disorder, functional symptoms, or a behavioural/psychiatric disorder. Conclusions: Habit cough can be diagnosed from the characteristic history; the crucial question is whether the cough disappears during sleep. We have shown successful long term outcomes following a single consultation with simple reassurance, but it is important that the child and parents believe the explanation. It is not uncommon for subsequent tic disorders or behavioral issues to emerge.
Article
Of 33 patients with psychogenic cough tic, 31 were successfully treated using an unusual reinforced suggestion technique. The cough usually follows an incidental upper respiratory tract infection and persists as a loud paroxysmal barking or honking sound for weeks to months. Paroxysms occur all day but cease with sleep. The diagnosis is often delayed for weeks to months while the patient is exposed to an increasing intensity of diagnostic procedures and therapy. Thirty percent of some 20 patients previously reported in the literature had been hospitalized. The reinforced suggestion technique depends upon the physician's convincing the patient that the persistent cough has weakened the chest muscles, which are now unable to contain the cough, and that a bedsheet tightly wrapped around the chest will provide the necessary support to stop the cough within 24 to 48 hours. The typical patient can produce the cough on command, has an ambivalent response to the prospect of care, is unconcerned about his symptoms, submits willingly to the examination and procedures, and is kept out of school for the duration of the cough. Findings on physical examination are normal except for abnormal gag and corneal reflexes. The gag reflex was depressed in six and absent in 20 of the 31 patients. The corneal reflex was depressed in 16 and absent in 5 of the 31 patients. These abnormal responses help to corroborate the psychogenic etiology. Early recognition of the nonorganic nature of this syndrome will reduce parental anxiety, loss of school time, risk of iatrogenic complications, and unnecessary medical and hospital expense.
Article
Psychogenic cough tic is a troublesome complaint. The cough is a noisy bark or honking, repeated frequently while the child is awake, but absent during sleep. Clinical and laboratory findings are negative, and cough suppressants and other medications are ineffective. The cough usually starts in the winter months and may be preceded by an upper respiratory tract infection. School phobia is frequently a contributory cause, but other psychological problems must also be considered. Treatment is usually by suggestion and identification of the underlying psychological problem. In some cases tranquillizers may be required.
Commentary: the habit cough: diagnosis and treatment.
  • Weinberger M.