Chest
Volume 129, Issue 1, Supplement, January 2006, Pages 80S-94S
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Supplement
Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines
Chronic Cough Due to Gastroesophageal Reflux Disease: ACCP Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.129.1_suppl.80SGet rights and content

Objectives:

To critically review and summarize the literature on cough and gastroesophageal reflux disease (GERD), and to make evidence-based recommendations regarding the diagnosis and treatment of chronic cough due to GERD.

Design/methodology:

Ovid MEDLINE literature review (through March 2004) for all studies published in the English language and selected articles published in other languages such as French since 1963 using the medical subject heading terms “cough,” “gastroesophageal reflux,” and “gastroesophageal reflux disease.”

Results:

GERD, singly or in combination with other conditions, is one of the most common causes of chronic cough. In patients with normal chest radiographic findings, GERD most likely causes cough by stimulation of an esophageal-bronchial reflex. When GERD causes cough, there may be no GI symptoms up to 75% of the time. While 24-h esophageal pH monitoring is the most sensitive and specific test in linking GERD and cough in a cause-effect relationship, it has its limitations. In addition, there is no general agreement on how to best interpret the test, and it cannot detect non-acid reflux events. Therefore, when patients fit the clinical profile that has a high likelihood of predicting that GERD is the cause of cough, antireflux medical therapy should be empirically instituted. While some patients improve with minimal medical therapy, others require more intensive regimens. When empiric treatment fails, it cannot be assumed that GERD has been ruled out as a cause of chronic cough. Rather, an objective investigation for GERD is then recommended because the empiric therapy may not have been intensive enough or medical therapy may have failed. Surgery may be efficacious when intensive medical therapy has failed in selected patients who have undergone an extensive objective GERD evaluation.

Conclusions:

Accurately diagnosing and successfully treating chronic cough due to GERD can be a major challenge.

Section snippets

PREVALENCE OF GERD AS A CAUSE OF COUGH

When the diagnosis of chronic cough due to GERD is based on a favorable response (eg, elimination of or improvement in cough) to specific GERD treatment, prospective before-and-after intervention studies9, 10, 11, 12, 13, 14 have revealed that GERD, singly or in combination with other conditions, is one of the most common causes of chronic cough in adults in the world. The prevalence in these studies ranged from 5 to 41%. While it is not clear what accounts for the variation in prevalence,

PATHOPHYSIOLOGY

Knowledge of what is known about where and how GERD can cause cough provides a framework for understanding what has been learned about diagnosis and treatment.17 Although GERD can stimulate the afferent limb of the cough reflex by irritating the upper respiratory tract without aspiration (eg, the larynx) and by irritating the lower respiratory tract by microaspiration or macroaspiration, there is evidence from a randomized and controlled study by Ing and colleagues18 that strongly suggests that

RECOMMENDATION

1. In patients with chronic cough due to GERD, the term acid reflux disease, unless it can be definitively shown to apply, should be replaced by the more general term reflux disease so as not to mislead the clinicians into thinking that all patients with cough due to GERD should improve with acid-suppression therapy. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A

Clinical Presentation

There is nothing about the character and timing of the cough due to GERD that distinguishes it from other causes of cough.31 It can present as a cough-phlegm (ie, productive cough) syndrome, just like chronic bronchitis from cigarette smoking, as well as a dry cough. It occurs nocturnally in only a minority of patients,31 and it can be “silent” from a GI standpoint up to 75% of the time.4

On the other hand, GERD should always be considered as a possible cause of chronic cough when patients also

RECOMMENDATIONS

2. In patients with chronic cough who also complain of typical and frequent GI complaints such as daily heartburn and regurgitation, especially when the findings of chest-imaging studies and/or clinical syndrome are consistent with an aspiration syndrome, the diagnostic evaluation should always include GERD as a possible cause. Level of evidence, low; benefit, substantial; grade of recommendation, B

3. Patients with chronic cough who have GI symptoms that are consistent with GERD or who fit the

TREATMENT

Based on the apparent heterogeneity of patient populations with differing pathogenetic mechanisms and differing risk factors that can adversely affect GERD, it is not likely that all patients will theoretically respond to the same treatment. A review of the literature on the treatment of cough due to GERD, which is summarized in Table 2, supports this statement. The review suggests the following: that when medical therapy is effective, some patients with cough due to GERD will favorably respond

RECOMMENDATIONS

14. In patients who meet the clinical profile predicting that silent GERD is the likely cause of chronic cough or in patients with chronic cough who also have prominent upper GI symptoms consistent with GERD, an empiric trial of medical antireflux therapy is recommended. Level of evidence, low; benefit, substantial; grade of recommendation, B

15. For treating the majority of patients with chronic cough due to GERD, the following medical therapies are recommended: (a) dietary and lifestyle

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