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Cures of the Cough without a Cause?
Miles Weinberger MD FAAAAI , Dennis Buettner
PII: S1081-1206(21)00352-5
DOI: https://doi.org/10.1016/j.anai.2021.05.004
Reference: ANAI 3597
To appear in: Annals of Allergy, Asthma Immunology
Received date: 6 April 2021
Revised date: 4 May 2021
Accepted date: 9 May 2021
Please cite this article as: Miles Weinberger MD FAAAAI , Dennis Buettner , Cures of
the Cough without a Cause?, Annals of Allergy, Asthma Immunology (2021), doi:
https://doi.org/10.1016/j.anai.2021.05.004
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©2021 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc.
1
Cures of the Cough without a Cause
Miles Weinberger MD FAAAAI1 miles-weinberger@uiowa.edu, Dennis Buettner2
1Visiting Clinical Professor of Pediatrics, University of California San Diego, Rady Children’s
Hospital Professor Emeritus, University of Iowa College of Medicine
2Research Associate: Habit Cough Association
Corresponding author: Miles Weinberger MD, Visiting Professor of Pediatrics, University of
California San Diego, Rady Children’s Hospital, Professor Emeritus, University of Iowa Web
site: www.milesweinberger.com, Phone: 760 487-5531, Address: 450 Sandalwood Court,
Encinitas CA 92024
Keywords:
Chronic Cough; Suggestion Therapy; Cure; Habit Cough; Refractory
Cures of the Cough without a Cause?
Chronic cough causes a severe burden on an individual’s quality of life. Approximately
sixteen million outpatients per year occur in the U.S. seek treatment for chronic cough.1 The
result is often multiple tests with no solution and polypharmacy that provides little relief. Over
40% of adults with chronic cough seen at specialized cough centers are reported to have no
identified cause.2,3
A prolonged persistent cough that followed the initial cough of a cold was described as
habitual in 1694.4 That description is consistent with histories obtained for habit cough (HC), a
troublesome disorder in children and adults. HC is characterized as a chronic, repetitive,
nonproductive daily cough, frequently with a barking or honking sound, that is absent once
2
asleep. Although sometimes with different terminology, HC has been recognized as a specific
syndrome in children.5-8 Evaluation of chronic cough in children identified 4% with habitual
cough.9 This disorder have been diagnosed 7 and 9 times per year at a U.S.7 and British8 referral
center, respectively.
A remedy for this disorder by “the art of suggestion” was described for children in 1966.5
Further demonstration of cough cessation by suggestion was described in a 1991 publication.6
From 1995 to 2014, a 15-minute session of suggestion therapy stopped cough in 81 of 85
children seen with HC at a University allergy and pulmonary clinic.7 Suggestion therapy was
also found to be effective by remote video conferencing (Skype®) for a 12-year-old
3
girl with 3 months of severe spasmodic coughing. That session was recorded and made available
on the Web at www.habitcough.com and on YouTube®
https://www.youtube.com/watch?v=jnQUvD8Qdj0 ; the clinical approach and verbal patter used
is described in a previous publication.10
During the latter half of 2019 through January 2021, emails from 54 parents described
cessation of chronic cough in their child from watching the video. All were contacted and
confirmed that their child’s cough had been consistent with HC. Ages ranged from 4 to 16 years
(median 10 years). Prior durations of cough ranged from less than 1 month to 6 years (median
4.5 months). Emails from 18 adults, both men and women in equal numbers, also described
cessation of their cough from watching the video. Subsequent contact confirmed the criteria for
diagnosis of HC in those adults. The ages of the adults ranged from 24 to 70 years (median 45
years). Their chronic daily nonproductive coughs, absent once asleep, had been present for 1 to
more than 20 years (median 6 years). The emails describing the experiences of children and
adults with HC came from 13 countries (Figure 1).
The following vignettes are provided as representations of the 54 children and 18 adults who
reported cessation of chronic cough from watching the video, essentially receiving suggestion
therapy by proxy.
Abby was a 15-year-old girl from New South Wales, Australia. For 5 years she
had a daily refractory, barking cough, absent during sleep. She had experienced
numerous invasive medical procedures and medication trials without benefit. The
cough interfered with social activity and school. Searching the Internet, her
mother found the YouTube video. She and Abby watched it, and her cough began
4
to diminish. With daily practice of what she had seen on the video, she was able
to completely cease daily coughing.
Caroline was a 12-year-old girl from Massachusetts who suffered from 6 years of
refractory daily chronic cough. Her mom stated: “In absolute desperation, I
stumbled across the video describing suggestion therapy for a 12-year-old girl
with chronic cough. We watched the video. It was as if she was in control of her
incessant cough for the first time.” She remains cough free and is confident that
she can control and stop any future HCs.
Riley was a 7-year-old girl from Wisconsin who began frequent coughing daily
for several months following a “bad cold.” Mother commented, “There was no
stop to it. Just so much coughing.” No benefit occurred from therapeutic trials by
her doctor. Advised by a pediatric pulmonologist to check out the video, mother
stated, “I finally decided to pull up the video on YouTube.Watching the video,
Riley said she could hold the cough back. And the coughing stopped, like
turning off a switchaccording to Riley’s mother.
Heather was a 70-year-old woman in Iowa, working as a municipal court judge,
with a 10-year history of chronic cough manifested by a spasm of cough every 10
minutes during the day. It was not present when sleeping. She reported that
5
watching the video convinced her that she also could learn to control her cough.
With only occasional coughs the following day, she has continued to be relatively
free of cough but indicates that it takes continued effort.
Rohini was a 24-year-old woman in Singapore with symptoms consistent with HC
for a year. Evaluation and treatment had been ineffective. Advised to watch the
video, she found she could control the cough despite the tickling sensation in her
throat.” She described the “tickling decreasing after 3 weeks and gone by 4
weeks of controlling her cough.
Were these cures? Without a systematic long-term follow-up, cure could be considered
hyperbolic. Berman, it the first description of success for HC by suggestion indicated freedom
from cough “during a long-term period of observation.”6 The authors of this letter have had
sufficient contact for a year or more of many, but not all, to postulate cures. No other treatment
of HC has provided sustained resolution of the HC disorder.
While chronic cough has a broad differential diagnosis, the clinical characteristics of HC
are generally distinguishable from organic causes of cough. Diagnosis may be confounded when
HC is present with an organic cause of cough, such as asthma or COPD. Early identification of
HC and use of suggestion therapy by direct contact, video conferencing, or by proxy, improves
quality of life and decreases medical costs. More data in adults is needed to determine the
relative proportion of adults with cough without a cause that is HC, a disorder treatable with
suggestion therapy.
6
Declaration of Competing Interests
We have no conflicts of interest, financial or otherwise regarding the contents of this submission.
Funding
No funding was used for this article.
References
1National Ambulatory Medical Care Survey: 2016. National SummaryTables. Table 10. Twenty
leading principal reasons for office visits, by patient’s sex: United States, 2016
https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_web_tables.pdf. Accessed
4/8/2021.
2 Smith JA, Woodcock A. Chronic cough. N Engl J Med. 2016 Oct 20;375(16):1544-1551.
3 Gibson PG. PG: Management of cough. J Allergy Clin Immunol Pract 2019;7:1724-1729.
4 Mercuruis F: Habitual cough, in The Spirit of Diseases. Published in 1694. Printed for Sarah
Hawkins in George-Tard, in Lambard-street.
5 Berman BA. Habit cough in adolescent children. Ann Allergy 1966; 24(1):4346.
6 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(6):579582.
7 Weinberger M, Hoegger M. The cough without a cause: the habit cough syndrome. J Allergy
Clin Immunol 2016;137:930-931.
8 Wright MFA, Balfour-Lynn IM: Habit-tic cough: Presentation and outcome with simple
reassurance. Pediatr Pulmonol. 2018; 53(4): 512516.
9 Chang AB, Robertson CF, Van Asperen PP, Glasgow NJ, Mellis CM, Masters IB. A
multicenter study on chronic cough in children: burden and etiologies based on a standardized
management pathway. CHEST 2012; 142(4):943950.
10 Weinberger M, Lockshin B. When is cough functional, and how should it be treated? Breathe
2017;13:22-30.
7
Figure 1. Emails from April 2019 to January 2021 reporting cessation of habit cough from
viewing a video of successful chronic cough cessation by suggestion therapy. Red markers -
children, blue - adults. Plus signs physician contacts regarding habit cough treatment. Stars -
authors.
8
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Key points: Habit cough is most commonly characterised by a repetitive loud barking cough that persists for prolonged periods.The cough interferes with normal activity and substantially decreases the quality of life.The sine qua non is the total absence of this troublesome cough once asleep.The age distribution ranges from 4 years to late adolescence, with 85% of cases occurring from 8 to 14 years of age; similar cough in adults is much less common and poorly characterised.Pharmacological treatment is ineffective.A simple behavioural approach called suggestion therapy has been applied with success by many physicians.The natural history in the absence of treatment can result in persistence for months to years. Educational aims: To increase awareness of functional cough as a non-organically caused symptom in children and adolescents.To provide the means of diagnosing a functional cough based on the distinguishing characteristics of this cause of chronic cough.To understand the principles of treating a functional cough with a simple behavioural technique called suggestion therapy. Summary: Involuntary cough without an identified underlying organic reason has been given various names and recommended treatments. Current experience in children and adolescents suggests that "habit cough" best describes this entity, and suggestion therapy is a highly effective treatment that most physicians can learn.
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.
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People with chronic cough can experience significant quality-of-life impairment. New concepts based around cough reflex hypersensitivity are leading to improved management strategies and showing promise in relieving the distress from persistent cough. The clinical cough assessment seeks to classify patients on the basis of symptom duration, and to identify and manage exposures and diseases that activate the afferent limb of the cough reflex. Cough hypersensitivity is also addressed by managing laryngeal dysfunction with speech pathology therapy and managing central cough reflex sensitization with neuromodulators. There are prospects for novel therapies based around several new treatment targets.
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
The evaluation of chronic cough should address the possibilities of asthma, gastroesophageal reflux disease, and postnasal drip and may require more specialized investigations. For patients with refractory chronic cough, other treatment approaches may be necessary.
Article
Background: While the burden of chronic cough in children has been documented, etiologic factors across multiple settings and age have not been described. In children with chronic cough, we aimed (1) to evaluate the burden and etiologies using a standard management pathway in various settings, and (2) to determine the influence of age and setting on disease burden and etiologies and etiology on disease burden. We hypothesized that the etiology, but not the burden, of chronic cough in children is dependent on the clinical setting and age. Methods: From five major hospitals and three rural-remote clinics, 346 children (mean age 4.5 years) newly referred with chronic cough (> 4 weeks) were prospectively managed in accordance with an evidence-based cough algorithm. We used a priori definitions, timeframes, and validated outcome measures (parent-proxy cough-specific quality of life [PC-QOL], a generic QOL [pediatric quality of life (PedsQL)], and cough diary). Results: The burden of chronic cough (PC-QOL, cough duration) significantly differed between settings (P = .014, 0.021, respectively), but was not influenced by age or etiology. PC-QOL and PedsQL did not correlate with age. The frequency of etiologies was significantly different in dissimilar settings (P = .0001); 17.6% of children had a serious underlying diagnosis (bronchiectasis, aspiration, cystic fibrosis). Except for protracted bacterial bronchitis, the frequency of other common diagnoses (asthma, bronchiectasis, resolved without specific-diagnosis) was similar across age categories. Conclusions: The high burden of cough is independent of children’s age and etiology but dependent on clinical setting. Irrespective of setting and age, children with chronic cough should be carefully evaluated and child-specific evidence-based algorithms used.
National Ambulatory Medical Care Survey: 2016 National Summary Tables. Table 10. Twenty leading principal reasons for office visits, by patient's sex: United States.
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