Incidence of a disorder or condition refers to the number of new cases identified in a specified time period.

Prevalence refers to the number of individuals who are living with the disorder or condition in a given time period.

• Although epidemiological studies of RCC are rare, RCC is estimated to occur in 4.0% of adults in the general population and approximately 27.9%–30.7% of individuals with chronic cough (Domínguez-Ortega et al., 2025; Hassan et al., 2026; Kukiełka et al., 2024).
• By comparison, chronic cough overall is estimated to affect 9.6%–11.8% of adults globally (Abozid et al., 2024; Song et al., 2015).
• Roughly 12.3 million adults in America have chronic cough, and approximately 31% of these individuals are chronic smokers (Meltzer et al., 2021).
• Across a number of studies, prevalence rates of chronic cough in children ranged from 1.1% to 21.9% (Chung et al., 2022).
• Older adults and individuals with allergies; reflux; a history of smoking; or comorbid respiratory, psychological, or cardiovascular disorders are at greater risk of developing chronic cough (Abozid et al., 2024; Jo & Song, 2019; Satia et al., 2021).
• Incidence rates also appear to increase with chronic and/or childhood exposures to environmental factors such as smoking, occupational irritants, and other air pollutants (Abozid et al., 2024; Jo & Song, 2019).

RCC is usually a dry, nonproductive cough, although the cough can intermittently be productive. The following symptoms are commonly associated with RCC (Digby et al., 2026; Song & Morice, 2017):

• dry, unproductive cough
• cough preceded by an urge to cough that is usually felt in the throat
• severe coughing bouts that can feel uncontrollable
• hypertussia—excessive cough triggered by low levels of tussive stimuli (e.g., smoke, fumes)
• allotussia—cough triggered by typically non-tussive stimuli (e.g., talking, laughing, fragrances, positional change, eating dry/crumbly foods)

Additional signs (e.g., hoarseness, runny or stuffy nose) may occur due to other conditions that may commonly occur alongside RCC (e.g., sinusitis). For more detailed information about the signs and symptoms of RCC, see Sonoda and Nayak (2024) and Chung et al. (2022).

RCC is caused by cough hypersensitivity, which is a maladaptive response to otherwise inoffensive stimuli (e.g., talking, perfume). This is opposed to a protective cough response, in which there is a physical need to clear the airway.

RCC can be triggered by any of the following factors:

• allergies
• asthma
• bronchitis
• chronic obstructive pulmonary disease (COPD)
• esophageal diseases
• gastroesophageal reflux (GERD), and laryngopharyngeal reflux (LPR)
• cough hypersensitivity syndrome, particularly in females
• postnasal drip (root causes of which include rhinitis and sinusitis), now commonly known as upper airway cough syndrome (UACS)
• medications (e.g., angiotensin-converting enzyme (ACE) inhibitors)
• smoking

For further information about the occupational/environmental contributions of RCC, please see Tarlo et al. (2016).

SLPs play a central role in the screening, assessment, diagnosis, and treatment of RCC. The professional roles and activities in speech-language pathology include

• clinical services, such as
  • diagnosis, assessment, planning, and treatment and
  • patient and care partner counseling/education, and
• large-scale programming, such as
  • disease prevention and advocacy,
  • staff and public education, and
  • research.

See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).

Appropriate roles for SLPs include, but are not limited to, the following:

• Screening individuals who present with signs and symptoms of RCC and determining the need for further assessment and/or referral to other services based on patient needs.
• Conducting a comprehensive assessment.
• Ensuring the cultural and linguistic appropriateness of diagnostic and treatment procedures (see ASHA’s Practice Portal pages on Cultural Responsiveness; Multilingual Service Delivery in Audiology and Speech-Language Pathology; and Collaborating With Interpreters, Transliterators, and Translators).
• Serving as an integral member of a team of physicians and other professionals working with individuals with RCC and their care partners (see ASHA’s resource on collaboration and teaming).
• Making evidence-based and patient-centered recommendations about the management of RCC in collaboration with the patient, their care partners, and the interprofessional treatment team (see ASHA’s resources on interprofessional education/interprofessional practice [IPE/IPP] and focusing care on individuals and their care partners).
• Educating and counseling people with RCC and their care partners.
• Educating other professionals on the needs of people with RCC and the role of SLPs in diagnosing and managing RCC.
• Remaining informed of research and new developments regarding RCC and helping to advance the knowledge base.

SLPs should also

• be familiar with anatomical structures and neurologic mechanisms involved in coughing (e.g., airway physiology and central cough mechanisms);
• be familiar with swallowing disorders to rule out aspiration or laryngeal penetration as a cause of coughing;
• have knowledge about voice disorders (to recognize underlying conditions that may cause or be associated with RCC);
• recognize deviations in structure and function as well as red flag symptoms (e.g., hemoptysis) that warrant further evaluation by a physician; and
• make appropriate referrals, as needed.

As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so. This includes maintaining and documenting the highest level of competence in the areas of practice and ensuring referral of patients to the most qualified practitioner in each area of practice in which the SLP is not highly qualified.

Assessment and treatment of RCC may require use of appropriate personal protective equipment due to potential exposure risks (e.g., a respirator to prevent airborne infection). Screening by an SLP may lead to a comprehensive assessment.

Physicians typically make the medical diagnosis of RCC. Patients may be referred to SLPs in cases of chronic cough after other medical treatments are unsuccessful or where the cause is undetermined. SLPs continue the process of assessment to determine the causes of cough hypersensitivity, such as cough responses to certain triggers (e.g., strong smells, cold air).

Screening

SLP screenings may trigger a referral for further assessment by a physician, an SLP, or both. Such screenings may be indicated during an evaluation of or treatment for a related disorder (e.g., voice disorder, inducible laryngeal obstruction [ILO] or dysphagia). For example, an SLP may note potential RCC when an individual reports a lingering cough. SLP treatment should be coordinated with medical management when appropriate. SLPs may also note results from the screening that suggest an underlying disease process. In this case, SLPs should make appropriate referrals.

Although a formal process for screening for RCC does not currently exist, SLPs may encounter patients with RCC during an evaluation of a related disorder (e.g., voice disorder or dysphagia). When this occurs, SLPs make an appropriate referral to a physician before treating RCC to ensure that potential underlying medical conditions are addressed. SLP treatment is coordinated with medical management when appropriate and only after medical assessment is complete. Medical assessment often includes chest imaging (i.e., chest X-ray or CT scan) and other evaluations that have been deemed appropriate by a physician.

Screening activities may include asking about the following things:

• duration, frequency, and pattern of cough (e.g., wet vs. dry, day vs. night)
• perceived swallowing problems (e.g., cough while eating or drinking)
• the presence of other co-occurring laryngeal symptoms (e.g., dysphonia, dyspnea, throat tightness, laryngeal irritation)

Comprehensive Assessment

RCC may be caused by an underlying disorder (e.g., chronic obstructive pulmonary disease) that warrants treatment by another professional (e.g., a gastroenterologist) prior to SLP intervention. In some cases, results of a medical assessment may indicate RCC instead of chronic cough. Assessment of RCC may involve a multidisciplinary team, which may include SLPs and medical, surgical, and rehabilitation specialists.

If an SLP is the first point of contact for a patient (e.g., in an outpatient setting), then that SLP considers the patient’s overall presentation, medical history, and current concerns and makes appropriate referrals to medical professionals.

SLPs help in the differential diagnosis of RCC by gathering a detailed case history and completing a chart review to gain the following information (Vertigan et al., 2007):

• the presence of associated causes of the cough
• characteristics of the cough—description, pattern, urge to cough and its sensation (e.g., tickle or irritation), onset, perception of control of the cough, and strategies to control the cough and effectiveness of those strategies
• the degree of concern about the cough
• dysphagia symptoms
• the onset, duration, and progression of the cough
• previous treatment for the cough and results of the treatment
• quality-of-life issues (e.g., urinary incontinence, sleep disruption, psychological distress) secondary to the cough and their impact on the individual with RCC

For further information on relevant aspects of case history, please see Vertigan and Gibson (2016).

Assessment activities may include any of the following approaches:

• voice assessment, including laryngeal visualization (e.g., stroboscopy, endoscopy)
• observation of breathing and coughing patterns and neck/muscle tension
• symptom and quality-of-life questionnaires
• a trial of cough suppression strategies
• an evaluation of cough characteristics, including the following:
  • unproductive versus productive cough
  • the presence and frequency of coughing bouts,
  • the frequency and description of the urge to cough (including the location of the urge)
  • the ability to suppress cough and how it is suppressed

Cough triggers and their impact are considered during assessment. Cough triggers may include any of these activities:

• talking, laughing, and singing
• fragrances, fumes, and smoke
• exercise
• cold air
• positional changes
• eating or drinking
• physical or psychological stress

SLPs consult with other disciplines to perform differential diagnosis and to rule out other reasons that may lead to coughing. Team members may include:

• allergists,
• pulmonologists,
• respiratory therapists,
• otolaryngologists,
• neurologists,
• primary care physicians, and
• psychologists.

Decisions about goals and treatment options are made in partnership with the individual, their care partner, and other professionals involved in treatment. SLPs may implement strategies to address RCC as part of a multidisciplinary team either during or after medical treatment.

Treatment considers the factors that influence each individual’s unique experience (e.g., culture, language, identity, social determinants of health). Treatment is tailored to that person’s circumstances and priorities and considers the impact RCC has on their function and participation.

See ASHA’s resources on interprofessional education/interprofessional practice (IPE/IPP) and focusing care on individuals and their care partners and Practice Portal page on Cultural Responsiveness.

Comprehensive multidisciplinary treatment of RCC may include

• medical (including pharmacotherapy) and/or surgical management of underlying causes;
• indirect or compensatory treatment via environmental, dietary, and lifestyle modification; and
• direct intervention by an SLP.

SLP Intervention for RCC

The goal of SLP treatment for RCC is to reduce cough hypersensitivity and improve voluntary control over the cough and respiratory symptoms. This is primarily done by coaching individuals to consistently suppress or manage their cough when there is no legitimate need to cough via cough suppression therapy (CST). Additionally, SLPs may teach individuals to interrupt the cough or substitute a competing response at the first sign of an urge to cough. The ultimate goal is for the individual to control a cough when they have the urge to cough (Slovarp et al., 2025).

Ideally, treatment focuses on improving the quality of life for people with RCC (Jin & Kim, 2020). Education and counseling about RCC to individuals and their care partners can help address this.

SLP services are coordinated with medical management of the underlying cause and should be implemented after ruling out or addressing other contributing factors (Murry et al., 2006).

Treatment activities may include the following (each of which is discussed in greater detail immediately below this list):

• Educating the individual about RCC and its treatment
• Teaching cough suppression strategies
• Respiratory retraining
• Laryngeal hygiene training
• Adherence monitoring

Educating the individual about RCC and its treatment—this includes the following:

• discussing the difference between acute cough and RCC
• emphasizing that a nonproductive cough does not have physiological benefits
• establishing cough suppression as a safe and achievable goal
• emphasizing the importance of high adherence to suppressing every unnecessary cough to facilitate a neuroplastic change in cough sensitivity
• emphasizing the importance of adhering to medications prescribed by physicians to manage cough
• explaining cough hypersensitivity

Teaching cough suppression strategies—this includes the following:

• Cough suppression swallow—swallowing instead of coughing when the urge to cough occurs to interrupt the cough cycle and reduce laryngeal irritation.
• Box breathing—a controlled breathing exercise involving equal-duration inhalation, breath hold, exhalation, and breath hold (e.g., 4 seconds each) to promote relaxation and regulate breathing.
• Diaphragmatic breathing—breathing via engaging the diaphragm muscle in order to disrupt the urge to cough.
• Effortful swallowing—swallowing forcefully with the tongue pressed against the roof of the mouth.
• Graded exposure and desensitization—a behavioral approach in which patients are gradually and systematically exposed to cough triggers while practicing cough-control strategies to reduce hypersensitivity and increase tolerance to those triggers over time.
• Laryngeal relaxation strategies—relaxed phonation, circumlaryngeal massage diaphragmatic breathing when typical breathing elicits visible upper body and/or neck tension.
• Open throat posture—a relaxed laryngeal and pharyngeal posture characterized by reduced constriction and a sensation of throat widening during breathing or phonation.
• Pursed-lip breathing—slowly breathing in through the nose, puckering the lips, and then slowly exhaling through pursed lips (Hicks et al., 2008).
• Relaxed throat breathing—abducting the vocal folds throughout the breathing cycle. It is achieved by a quick sniff in through the nose followed by prolonged exhalation through a semi-occluded oral opening (e.g., pursed lips while producing a strident sound such as /s/, through a thin straw, or through a loosely closed fist).
• Semi-occluded vocal tract exercises—voicing tasks that partially narrow the vocal tract at some point above the vocal folds (e.g., lip trills, tongue trills, straw phonation) to produce resonant voice.
• Silent laughing or giggling posture—assuming the physical posture of laughing (e.g., open mouth, relaxed facial expression, slight exhalation) without producing sound, which can help reduce laryngeal tension and interrupt the urge to cough.
• Sipping or guzzling water or other liquids.
• Substituting coughing with other behaviors or distractions, such as
  • sucking on ice or nonmedicated candy,
  • swallowing dry or with sips of water, or
  • cognitive distractions (e.g., doing crossword puzzles, reading).
• Yawn-sigh technique—using the natural functions of yawning and sighing to reduce the throat tightness and laryngeal constriction that accompany the urge to cough.
• Masako maneuver—holding the tongue between teeth while swallowing.

Please see ASHA’s Practice Portal page on Voice Disorders for further information, as many of the strategies above are also used with voice treatment.

Respiratory retraining—The goal of respiratory retraining is to reduce laryngeal tightness and breath-holding. Respiratory retraining includes teaching the individual various breathing exercises that they can do to expand the rib cage or abdominal area during inhalation to avoid abnormal breathing such as clavicular breathing patterns and shoulder/neck tension. Abnormal breathing patterns can cause laryngeal muscle tension and can contribute to an individual’s cough (Jeffrey et al., 2024). Care should be taken not to emphasize too much abdominal muscle activity (particularly on exhalation), as this can cause laryngeal tension. Examples of specific approaches include

• diaphragmatic breathing,
• a slower respiratory rate,
• coordinated breathing, and
• relaxed exhalation.

Laryngeal hygiene training—Poor laryngeal hygiene contributes to irritation of laryngeal tissues, and laryngeal irritation is more likely to lead to urge to cough. SLPs may implement the following strategies:

Identifying and reducing unhealthy vocal hygiene behaviors, such as these:

• shouting
• talking loudly over noise
• throat clearing
• breathing excessively dry or polluted air
• poor hydration

Implementing practices to reduce vocally traumatic behaviors (e.g., voice conservation) and promoting healthy vocal hygiene practices, such as these:

• drinking plenty of water
• talking at a moderate volume

Adherence monitoring—Adhering to treatment recommendations (especially cough suppression) is an important part of treatment. The goal of CST is to reduce cough sensitivity, and constant repetition is important to elicit neuroplastic change. The following strategies may be implemented to optimize cough suppression adherence:

• Educating patients about the fact that neuroplastic change requires consistency and constant repetition.
• Emphasizing to patients the importance of trying to suppress every cough and trying to interrupt and stop each coughing bout when suppression is impossible.
• Directly asking patients during every session about their adherence to cough suppression and mutually problem-solving with the patient if adherence is low (e.g., below 90%).

In the beginning phase of treatment, SLPs typically recommend using cough suppression strategies in the individuals’ daily environment whenever an urge to cough is felt, while also trying to avoid known cough triggers. Once the patient has gained confidence in their ability to suppress cough, the SLP may suggest no longer avoiding known cough triggers and even intentional exposure to known cough triggers (e.g., odors, exercise, eating certain foods). The rationale for this approach is rooted in principles of neuroplasticity. Specifically, the more frequently an urge to cough is successfully suppressed, the more likely cough sensitivity will be reduced via neuroplasticity.
See Soni et al. (2017) for information on behavior modification treatment and Vertigan et al. (2007, 2026) for further information.

Billing for RCC Services

Providing appropriate procedure codes for evaluation and treatment is an important aspect of successfully billing for services. Payer policies often outline specific coverage guidelines and list relevant Current Procedural Terminology (CPT; American Medical Association, 2026) codes from the International Classification of Diseases and Related Health Problems (10th Revision, Clinical Modification; World Health Organization, 2019).

Although individuals with RCC may not present with dysphonia, respiratory and laryngeal functions are substrates of the speech system. SLPs use diagnostic and procedure codes for assessment and treatment of voice to represent these services. Payer policies regarding the coverage of RCC vary. SLPs working with private insurance should verify coverage on the basis of each individual.

For more information about coding, see the following ASHA resources:

• New CPT Evaluation Codes for SLPs
• Medicare CPT Coding Rules for Speech-Language Pathology Services
• Coding for Reimbursement Frequently Asked Questions: Speech-Language Pathology

Service Delivery

Format—Although SLP services are often delivered one-on-one and in person, telepractice and group formats have been found to be feasible and efficacious (Salois et al., 2025; Slovarp et al., 2025).

Provider—Behavioral CST in the United States is typically provided by an SLP with specialized training and experience in the evaluation and management of chronic cough and other upper airway disorders. Care is ideally coordinated with the referring physician and other members of the medical team to ensure appropriate medical evaluation and management of contributing conditions. Treatment may also involve home program components that are self- or care partner–administered following SLP training.

Dosage—The number and frequency of sessions are individualized based on symptom severity, response to treatment, patient needs, and comorbidities. Following an initial course of treatment, some individuals may benefit from additional sessions or periodic follow-up.

Timing—Behavioral intervention is generally initiated after appropriate medical evaluation has excluded or adequately managed treatable causes of chronic cough. Therapy may also be provided concurrently with medical management as part of a multidisciplinary approach, particularly for patients with refractory or unexplained chronic cough.

Setting—Assessment and treatment for chronic cough can be provided in a variety of settings (e.g., ENT clinics, private practices, home, outpatient hospital clinics).

ASHA Resources

• Aerosol Generating Procedures (AGPs)
• Cough: A Review of Anatomy and Physiology
• Focusing Care on Individuals and Their Care Partners
• Person-Centered Focus on Function: Voice [PDF]
• SLP’s Role in Evaluation and Treatment of Cough Function
• Sniffs, Gasps, and Coughs: Irritable Larynx Syndrome Across the Lifespan
• Treatment for Cough: Two Sides to the Story

Other Resources

• American Academy of Allergy, Asthma & Immunology
• American Thoracic Society: Cough [PDF]
• Refractory Chronic Cough (RCC): Clinical Reference (CHEST Foundation)
• Chronic Cough Resources and Videos

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Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who participated in the development of the Refractory Chronic Cough (RCC) page:

• Marie E. Jetté, PhD, CCC-SLP
• Laurie J. Slovarp, PhD, CCC-SLP

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Refractory Chronic Cough. [Practice Portal]. https://www.asha.org/practice-portal/clinical-topics/refractory-chronic-cough