Chest
SupplementDiagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice GuidelinesChronic Cough Due to Gastroesophageal Reflux Disease: ACCP Evidence-Based Clinical Practice Guidelines
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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