Habit cough is a very disruptive, brash, brassy cough. Many children with this type of cough do not realize they are coughing habitually.
Habit cough virtually always has an organic origin. The child will have had a cough from an asthma exacerbation, pneumonia, or a common cold. He or she becomes stuck in a cycle of cough, irritation, throat-clearing, more irritation, and more cough.14
The situation can be likened to a fire alarm that keeps going off despite the fact that the fire has been put out. There is often a very dramatic flourish to the cough with arm waving, back-arching, chest-heaving, and head-bobbing. The cough typically is very annoying and anxiety-provoking for caregivers.
The etiology of habit cough is unique from that of other coughs in that lung function is preserved. Habit cough is completely absent during sleep and usually during distraction, such as when the child is undergoing lung-function testing. Comorbid symptoms are rare and physical examination is entirely normal.
Habit cough does not respond to bronchodilators, steroids, antibiotics, or antitussive medications. These options usually have been exhausted by the time the diagnosis of habit cough is reached. Habit cough frequently leads to multiple office or hospital visits with no change in the clinical course.14
Such exercises as breathing through pursed lips, huffing and puffing, or blowing against resistance can help relieve the child’s airway irritation and urge to cough. Having the child suck on sugar-free candy and take frequent sips of water can help keep the youngster’s laryngeal structures lubricated and reduce irritation, and can serve as good distractions from coughing. Caregivers should be encouraged to give the child positive reinforcement by praising or rewarding the patient for controlling the cough.
Anecdotally, one simple technique that has been used successfully by this practitioner centers on calling attention to the cough by asking the patient to stop coughing while the clinician talks to the parent. Games can be an effective method for making the child more cognizant of the habit cough.
For example, explain to the child that the cough has control of his or her life and the life of their caregivers, and now it’s time to take back control. Then have the child keep score: If he or she can keep from coughing, he or she wins a point; otherwise, the point goes to the cough.
Treating habit cough is challenging and requires great patience. No single therapy will always work. It is important to note, however, that absence of a treatment plan can result in prolonged, continued symptoms.14
Asthma is by far the most common cause of a chronic or recurrent cough. A diagnosis of asthma should always be considered for any child with recurrent cough, whatever the presumed previous etiology was called (for example, pneumonia, croup, bronchitis).
A nighttime cough is the most common type of asthma cough,15 and is included as part of the assessment for asthma control in the National Heart, Lung, and Blood Institute guidelines for the diagnosis and management of asthma.16 A cough first thing in the morning and a cough with exercise are also very characteristic of asthma.
An asthma cough can take one of two forms, bronchospasm or wheezing, but is often a mix of both. Bronchospasm occurs when a deep inhalation provokes coughing fits (three or more coughs in a row). These coughing fits are characterized by spasms of rapid-succession coughs that can make administration of inhaled medications difficult.
Wheezing is a hallmark of asthma with a biphasic musical component. There is often a vibratory quality to the cough even if the wheeze is not audible. In these cases the cough is frequently dry, but because excess mucus production is part of the pathophysiology of asthma, the cough can become “wet.”
All patients with asthma should have a written asthma-management plan in place (Table 2). This document should include specific information on medications to be used, dosage and dosing frequency, and when to seek emergent care.
Table 2. Key sections of an asthma management plan
|Daily controller medication
|When experiencing symptoms such as coughing, wheezing, or chest tightness:
|What to do if your fast-acting medication is not working:
Acutely, the first-line treatment for asthma is the use of fast-acting bronchodilators by means of nebulization or metered-dose inhalation. There is no difference between nebulized or metered-dose inhaler administration, if done technically correctly.17
The fast-acting bronchodilators work on beta-2 receptors in the airway to induce smooth-muscle relaxation and enhance ciliary beat frequency, thereby improving air flow. The beta-2 agonists include albuterol (Accuneb, Proair, Proventil, Ventolin), levalbuterol (Xopenex), and pirbuterol (Maxair); ipratropium bromide (Atrovent) is another fast-acting bronchodilator but must be used in conjunction with one of the beta-2 agonists.
Salmeterol (Serevent) and formoterol (Foradil, Perforomist) are long-acting bronchodilators and are not indicated for use in the treatment of acute asthma. Treatment frequency is based on asthma severity but is typically every three to four hours in mild disease.
In some cases, clinicians can advise patients to do repeat treatment cycles in a shorter time frame to get symptoms quickly under control, and then resume the administration schedule of every three hours. Our practice uses a “back-to-back-to-back” cycle in which a patient may do a treatment every 20 minutes for one hour, but then must contact the provider on call.
When bronchodilators are insufficient to abort asthma symptoms, the next step is to use systemic steroids, either orally or parenterally. Studies indicate that short bursts with dexamethasone have been used successfully in place of longer courses of prednisolone.18 However, dexamethasone has a longer half-life and is more potent, so repeated use should be done with caution.
Access to steroids should be part of every asthma management plan. Patients—particularly those with severe disease—should be advised to keep a supply at home and should be given explicit instructions to contact their health-care provider when using these medications. Use of daily controller medication with inhaled corticosteroids should be considered in any child requiring systemic steroids, or when bronchodilators are used more than three times a week on a regular basis.16
Several adjunct therapies are available for the emergent treatment of acute asthma, including magnesium sulfate, terbutaline, and heliox, a helium/oxygen mixture. Discussion of these treatments is beyond the scope of this article.