Curing the Chronic Cough

Imagine Diane, a 56-year-old retired teacher who hasn’t been able to finish a single sentence in years without a violent, chest-shaking cough. She’s seen every specialist, tried every inhaler, and has been told for the hundredth time that her "lungs look clear." This is a refractory chronic cough. It’s essentially a glitch in the airway’s alarm system that incessantly goes off even though there are no intruders at the door. Diane is socially isolated, her ribs are sore from the constant strain, and she feels like her body is no longer her own. 

I personally see many patients who fit this description. The doctor wants to rule out dysphagia as a potential cause of the patient’s endless cough, which started as an unwanted visitor and quickly became a permanent roommate. Yes, there are times when coughing can be attributed to dysphagia, but more often than not, it is completely unrelated to swallowing, especially if it is happening during and outside of meals. Attributing a chronic cough to dysphagia is sort of like attributing chronic migraines to an occasionally noisy neighbor. Not helping the issue, but likely not causing it either. 

Still, with the volume of referrals I’ve been receiving for this condition, I thought it was best to have some answers for my patients. And part of this answer came in the form of a recent article by Slovarp et al., which introduced me to behavioral cough-suppression therapy. A great starting point for patients who aren’t keen on pharmaceuticals. It’s a natural strategy that can be used any time the patient is having trouble. And with zero side effects.

But does it work? Before we find out, let’s talk about what a refractory chronic cough even is…

What is a Refractory Chronic Cough?

Think of a refractory chronic cough like a hypersensitive car alarm. In a normal body, the alarm only goes off if someone tries to break in (like a virus or a piece of food). In refractory chronic cough, the alarm is so sensitive that a light breeze or a loud noise sets it off, and once it starts, it won't stop. And a false alarm that won’t turn off can be maddening in any context, but this is especially the case when the alarm is going off in your chest.

So, what can we do about it?

Behavioral Cough-Suppression Therapy

Behavioral cough-suppression therapy is specifically for patients whose chronic cough persists despite medical treatment. This therapy essentially retrains a hypersensitive nervous system to stop reacting when the reaction is the problem. It helps the patient ignore those non-threatening triggers. It dials down those false alarms. 

The treatment delivered in the Slovarp study focused on four primary components:

1. Education: Participants learn about the nature of chronic cough, specifically that it often becomes a self-perpetuating cycle where the physical act of coughing further irritates the larynx, leading to more coughing. Sometimes a mirror is all we need to see that we, above all else, are in fact the problem (and the solution).

2. Then, patients are trained to recognize the subtle "tickle" or sensation in the throat that precedes a cough. Whatever it looks and feels like to the patient, their goal is to identify it as soon as it happens.

3. Next, we introduce the cough-suppression techniques, which are the core of the therapy. When the urge to cough is identified, the patient uses specific, competing behaviors to interrupt the sequence. These include:

1. Suppression Breaths: Taking small, controlled sips of air.

2. Effortful Swallows: Engaging the throat muscles to "reset" the laryngeal area.

3. Distraction: Using mental or physical shifts to move focus away from the laryngeal irritation.

4. Finally, reducing laryngeal irritants through lifestyle changes, such as increased hydration and improved oral hygiene, helps keep the vocal folds moist and lowers the baseline level of irritation.

A cough often isn’t just a cough when it goes on for longer than 3 weeks. And patients seem to understand this intuitively when the multiple medications they’ve taken don’t seem to be helping them make much progress. What seems simple and straightforward on the outside is actually a complex interplay of multiple issues occurring simultaneously. Behavioral cough-suppression therapy uses a multi-pronged approach to address a multi-pronged problem.

This behavioral therapy is like teaching the car's owner how to manually reset the car. It doesn't remove the alarm; it re-trains the system to recognize that light breeze as it’s happening and not to identify it as a threat anymore. 

And boy, does that help get things off our chests.

So while it's tempting to simply pop a pill, putting in the work involved with behavioral therapy may give us better results, for longer, and without the unwanted side effects. And the results speak for themselves. 

Three BIG Results:

1. An incredible 98% of participants (almost everyone!) saw a significant improvement in their quality of life.

2. For those who used cough-monitoring apps, their hourly cough rate dropped by 68%, and their long coughing fits decreased by a staggering 78%.

3. Long-Lasting Relief: These results weren't just a flash in the pan; the benefits held steady at both the one-week and one-month follow-ups.

If you could put this kind of behavioral therapy into a pill, imagine what people would pay for it? They’d be flocking to the pharmacy in droves. And BCST isn’t a new treatment either. I honestly didn’t know much about it before I took a deep dive into this article, but as it turns out, it’s been around for a while (And has been effective for just as long). 

But there’s a massive shortage of trained clinicians to provide it. The article goes even further, showing that telehealth groups are just as efficacious as one-on-one sessions, essentially opening the door for thousands of people who previously lived too far from an SLP to get help (Fingers crossed for better telehealth regulations in the near future!).

So, what happened to Diane?

When pharmaceutical interventions didn’t work, she didn’t lose hope. To tame her cough, she trained the brain behind the bark with the help of her SLP. Today, Diane can sit through a movie, have a dinner conversation, and—most importantly—finish a sentence without discomfort. By using a low-risk, high-impact behavioral approach, she quieted the alarms and increased the volume on the things that matter in her life.

What’s your experience? Have you ever tried behavioral techniques for a persistent cough? Tell us about it.

Reference: Slovarp, L. J., Salois, J. R., Roberts, K., Ehli, E., Majors, M., Rosenleaf, M., ... & Rosenleaf, M. (2025). Telehealth group behavioural cough-suppression therapy for refractory chronic cough using a rolling enrolment model. ERJ Open Research, 11(6), 00658-2025. https://doi.org/10.1183/23120541.00658-2025