An alternative to neuromodulation for refractory chronic idiopathic cough
Dr Miles Weinberger, MD.
University of California San Diego, Encinitas, CA, United States
E-mail address: miles-weinberger@uiowa.edu
Download PDF below.
To the editor:
The manuscript of Nader Wehbi and colleagues [1] provides a rational approach to selection of treatment for 56 patients with a diagnosis of neurogenic cough.
Neurogenic cough has become essentially a default diagnosis when no other cause is identified [2].
I suggest that other considerations for both diagnosis and treatment be considered.
The term neurogenic cough is based on the hypothesis of a neural network involving the brain [2].
However, an alternative hypothesis is suggested by the work of Shapiro et al [3] who found increased mucosal nerve density in mucosal biopsies obtained by bronchoscopy in adult patients with chronic idiopathic cough.
Previous examination of mucosal biopsies obtained in similar patients by Irwin et al [4] had shown inflammation on H&E staining.
The authors of both of those publications [3,4] suggested that the inflammation and increased nerve density were from the incessant coughing the patients endured.
A vicious cycle is apparent. Chronic cough results in neuropathic inflammation in the airway that is felt by the patient as the nidus for the chronic coughing, i.e., chronic coughing causes the stimulus for the coughing.
Breaking that cycle by a psychological technique called suggestion therapy was consistent with my observations in children for the past 50 years and my recent experience in adults with idiopathic chronic refractory cough [5]. The application of suggestion therapy resulted in cessation of cough without any pharmacological involvement [5].
While this is radically different thinking than that proposed by others who have emphasized a complex neural pathway to be treated by neuromodulation [2], it is time to think outside the box.
The results of suggestion therapy as a means to provide cough cessation in both children and adults are illustrated in Fig. 2 of an extensive review of the subject [5].
Listening to interviews of 4 adults whose coughing stopped from suggestion therapy https://youtu.be/SKe424kiwkg (noted below) provides insights into the power of suggestion to provide cessation of cough.
The best efforts of neuromodulation described in Table 2 of the Wehbi article provide only variable incomplete improvement [1].
Further data at specialty cough centers are needed to determine if suggestion therapy can provide non-pharmacological benefit for a substantial number of adults with refractory chronic idiopathic cough.
Credit authorship contribution statement Miles Weinberger: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.
References
[1] Wehbi N, Lever A, Ahmadian D, Gleadhill C, Yip HT. Outcomes of a step-up approach to the treatment of neurogenic cough. Am J Otolaryngol 2024;45:104412.
[2] Altman KW, Noordzij JP, Rosen CA, Cohen S, Sulica L. Neurogenic cough. Laryngoscope 2015;125:1675–81.
[3] Shapiro CO, Proskocil BJ, Oppegard LJ, Blum ED, Kappel NL, Chang CH, et al. Airway sensory nerve density is increased in chronic cough. Am J Respir Crit Care Med 2021;203:348–55.
[4] Irwin RS, Ownbey R, Cagle PT, Baker S, Fraire AE. Interpreting the histopathology of chronic cough: a prospective, controlled, comparative study. Chest 2006;130: 362–70.
[5] Weinberger M, Buettner D, Anbar RD. A review, update,and commentary for the cough without a cause: facts and factoids of the habit cough. J Clin Med 2023;12: 1970. https://doi.org/10.3390/jcm12051970.
Received 18 August 2024 Available online 5 October 2024
Below is the work of Nader Wehbi and colleagues.
Abstract from: Outcomes of a step-up approach to the treatment of neurogenic cough
Introduction
Neurogenic cough (NC) is thought to be related to sensory neuropathy in the hypopharynx and larynx. Defined as a cough persisting longer than 8 weeks refractory to standard therapy, it is a diagnosis of exclusion when other common etiologies (asthma, gastroesophageal reflux disease (GERD), medication side effects) are ruled out. It affects roughly 11 % of Americans and can negatively impact quality of life.
Not medical advice.
Comments