Respiratory Futures recently caught up with Claire Slinger, Consultant Speech and Language Therapist at Lancashire teaching Hospitals NHS Foundation Trust. In the article below, Claire shares about the opportunities provided by Speech and Language Therapists, non-pharmacological cough suppression therapy, and how these can work together to positively impact the lives of patients.
What are some of the current methods of non-pharmacological cough suppression therapy being used in the UK?
Speech and language therapists (SLTs) work with respiratory teams to offer patients a non-pharmacological approach to managing symptoms of cough. This is known as cough control, or cough suppression therapy (CST).
SLTs have a role in the assessment and management of chronic cough, contributing to assessment of other laryngeal symptoms the patients may also have, including a feeling of something stuck in their throat (globus), swallowing issues, issues with voice changes/loss and breathlessness due to laryngeal dysfunction (known as inducible laryngeal obstruction or ILO).
SLTs who have undergone specialist training and who are experienced can assess the upper airway of people who have a chronic cough to assess for upper airway dysfunction, or structural factors in the upper airway that may contribute to chronic cough symptoms. They can also assess for upper airway mucus hypersecretion or retention of secretions in the upper airway, and if any endobronchial mucus is expectorated when they cough.
SLTs work in this area focuses on a framework which includes providing the patients with education about the nature of chronic cough, and how in cough hypersensitivity, the cough serves no physiological purpose, and can become self-perpetuating. SLTs also engage the patients in Psychoeducation, instructing them that therapy is quite hard work, and definitely not a “quick fix” and encouraging patients to take on the onus of self-efficacy and managing their cough using behavioural management.
SLTs will also focus on advising patients on how to manage and optimise the overall health of the upper airway and how to minimise behaviours that may serve to add to irritation, such as voice misuse and throat-clearing behaviours.
Finally, SLTs will educate the patient on how to manage their urge to cough by way of techniques to control this urge. This can range from simple sips of fluids to techniques to open up the upper airway and reduce tension. We advise patients do not hold their breath to try to control their cough, as this encourages very tight closure if the upper airway, which in some patients can actually make things worse for them.
Why is development in this type of therapy important?
It is important to offer patients a choice for either when they have exhausted all other medical options, or if they do not wish to use treatments such as low-dose morphine sulphate, either due to side effects, or other relevant factors. SLT cough control therapy can be used as an adjunct to pharmacotherapy. It offers a cost-effective, and effective method of empowering patients to manage their own symptoms.
It is important to offer patients a choice for either when they have exhausted all other medical options, or if they do not wish to use treatments such as low-dose morphine sulphate, either due to side effects, or other relevant factors.
There is some evidence that the benefits can last over a year in some patients, and can impact positively on other self-care behaviours, such as medication adherence for other conditions, as part of the therapy involves encouragement of self-efficacy and symptom monitoring.
SLT also offers a sustainable model, as it can be delivered remotely, and takes up to four sessions for the patient to be fully guided in how to apply the techniques and when, with longer-term impact on symptoms, if sustained.
Are there any particular improvements in the delivery of cough suppression therapy that you hope to see more of in the UK?
It would be great to see SLT services for chronic cough as commissioned services, integrated into Respiratory teams. This in turn may lead to effective workforce planning to include SLTs.
The integration of SLTs into secondary care provision for multi-professional cough clinics in secondary care would also be of benefit to patients, to have the option of non-pharmacological input for cough control earlier in their journey and closer to home. Often it takes some patients years before they are referred to a specialist cough clinic, which can be often some distance from their home.
Further research capability and prospective large cohort studies as to the efficacy of cough control therapy are also needed in order to evidence the outcomes we see in clinical practice. This would help sift out which are the essential elements in the cough control package to help refine it and make it the most effective for patients.
Finally, access to a network specialist clinician-advisors who have experience in working with patients with chronic cough would help develop more SLTs to be confident practitioners in this area. The development of diagnostic hubs may also be of benefit if the patients could be assessed by a specialist centre for medical and co-morbid factors that may be impacting on their chronic cough, and then if the patient is thought to have cough hypersensitivity, they could see an SLT locally who can be supported to deliver the intervention locally.
How should non-pharmacological cough suppression methods be used in conjunction with drug treatments?
There is some research that suggests a combination of cough control techniques and pharmacological treatments led to enhanced efficacy. Therefore, it would be useful to do further study into this. I would suggest, depending on what the patients’ preferences are, that if a combination be thought to be a good option for the patient, then as early as possible, with monitoring as to if weaning of the pharmacological agent may be possible.
The patient choice in this would be a primary factor, and as cough control therapy can take more effort than medication use, the patient’s readiness, motivation and ability to engage in cough control therapy may need to be factored in.
How are speech and language therapists involved in the delivery of non-pharmacological cough suppression methods?
SLTs have the skills to help patients achieve behaviour change, and the knowledge of the upper airway and how to use the techniques to educate the patients on how to do this. SLTs also have the skills to work with the patients on other overlapping symptoms, such as issues with swallowing, changes to their voice and inducible laryngeal obstruction, as these may all overlap in people who have a chronic cough.
SLTs who typically specialise in this area work in a respiratory setting in a multi-disciplinary setting. However, as more SLTs become interested in delivering this treatment, there may be some who are based in a secondary care setting and who are accessing support to deliver the therapy.
What impact can both speech and language therapists and non-pharmacological cough suppression therapies have on the quality of life of patients?
After many years of input/assessment, patients can feel a little disenfranchised when it is suggested they see an SLT. However, over the course of therapy, once they are engaged in the process, the patient has the potential to significantly impact on their quality of life, and often in clinic we see patients engaging in behaviours and activities that they had been avoiding or stopped altogether through concern over coughing paroxysms.
As SLT input is holistic, we see an impact not just on their ability to control their cough symptoms, but can positively impact on other areas of life, such as socialising, general mood and participation levels, as well as relationships, as this is where the unseen impact of chronic cough can really impact on patients and their loved ones.