Contributed by William Gershan, MD
When asthma is suspected in children with coughing, wheezing, shortness of breath, or chest tightness, physicians often prescribe bronchodilators and inhaled steroids. If these treatments are not effective, other diagnoses should be considered. The following case describes a child thought to have asthma who was referred to the pediatric pulmonology clinic at University of Minnesota Masonic Children’s Hospital where she received a different diagnosis and successful therapy.
A 14-year-old girl presented to her physician with an intermittent dry cough and reported having it for 2 months following an upper respiratory infection. A chest radiograph was normal. Her pediatrician treated her with inhaled albuterol without benefit and then referred her to an allergy and asthma clinic where she was diagnosed with asthma and given an inhaled steroid (Qvar 80, 2 puffs twice a day). After several weeks, the cough remained. She was then referred to a pediatric pulmonologist at University of Minnesota Masonic Children’s Hospital.
The pediatric pulmonologist completed a physical examination and asked extensive questions about her known allergies, environment, pets, and the timing of symptoms. It was unclear whether the coughing occurred at night. Following a normal spirometry test without a significant bronchodilator response, the pulmonologist prescribed a bronchodilator again, and the patient was instructed to use the inhaler with an aerochamber. After 2 weeks, there was still no benefit. At this point the differential diagnosis included asthma, gastroesophageal reflux, postnasal drip, sinusitis, post-infectious cough, and habit cough. The pulmonologist asked the parents to observe the patient’s cough more closely, especially noting whether it was present when the girl slept. After 2 weeks, they reported that she was cough-free for 8 to 9 hours at night. The diagnosis then was habit cough (also known as psychogenic cough and cough tic), and the pulmonologist began behavioral therapy for the patient. He asked her to try to not cough for longer and longer periods and to take sips of lukewarm water to squelch the urge to cough. In 5 days, the cough was gone. One month later, the cough had not returned.
Behavioral therapy, also known as suggestion therapy, has been shown to eliminate habit cough even in 1 office visit. In a review of 20 years of cases, suggestion therapy was found to enable 95% of the 85 patients directly observed in clinic to completely stop coughing within 15 to 30 minutes.1 Instructions for at-home therapy sustained this success.
Habit cough should be ruled out before moving on to expensive diagnostic measures or unnecessary medications. A loud, chronic cough that occurs up to several times per minute and does not occur during sleep is often sufficient to make the diagnosis of this disorder.
While asthma-like symptoms are common in children, successful treatment of wheezing and cough in children can require careful assessment. Pediatric pulmonologists lend some insight.Continue reading