Chronic Cough Due to Gastroesophageal Reflux in Adults: CHEST Guideline and Expert Panel Report.
BACKGROUND
We updated the 2006 ACCP clinical practice guidelines for management of reflux-cough syndrome.


METHODS
Two population, intervention, comparison, outcome (PICO) questions were addressed by systematic review: (1) Can therapy for gastroesophageal reflux improve or eliminate cough in adults with chronic and persistently troublesome cough? and (2) Are there minimal clinical criteria to guide practice in determining that chronic cough is likely to respond to therapy for gastroesophageal reflux?


RESULTS
We found no high-quality studies pertinent to either question. From available randomized controlled trials (RCTs) addressing question #1, we concluded that (1) there was a strong placebo effect for cough improvement; (2) studies including diet modification and weight loss had better cough outcomes; (3) although lifestyle modifications and weight reduction may be beneficial in suspected reflux-cough syndrome, proton pump inhibitors (PPIs) demonstrated no benefit when used in isolation; and (4) because of potential carryover effect, crossover studies using PPIs should be avoided. For question #2, we concluded from the available observational trials that (1) an algorithmic approach to management resolved chronic cough in 82% to 100% of instances; (2) cough variant asthma and upper airway cough syndrome (UACS) (previously referred to as postnasal drip syndrome) from rhinosinus conditions were the most commonly reported causes; and (3) the reported prevalence of reflux-cough syndrome varied widely.


CONCLUSIONS
The panelists (1) endorsed the use of a diagnostic/therapeutic algorithm addressing causes of common cough, including symptomatic reflux; (2) advised that although lifestyle modifications and weight reduction may be beneficial in suspected reflux-cough syndrome, PPIs demonstrated no benefit when used in isolation; and (3) suggested that physiological testing be reserved for refractory patients being considered for antireflux surgery or for those in whom there is strong clinical suspicion warranting diagnostic testing.
Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL. Electronic address: p-kahrilas@northwestern.edu.
Peter J
PJ
Kahrilas
Bobby R. Alford Department of Otolaryngology, Baylor College of Medicine, Houston, TX.
Kenneth W
KW
Altman
Menzies School of Health, Research and Respiratory Department, Lady Cilento Children's Hospital, Queensland University of Technology, Queensland, Australia.
Anne B
AB
Chang
Division of Respiratory Medicine, Department of Medicine, Cummings School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.
Stephen K
SK
Field
Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL.
Susan M
SM
Harding
Division of Rhinology and Sinus Surgery, Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD.
Andrew P
AP
Lane
Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic Rochester, Rochester, MN.
Kaiser
K
Lim
Department of Medicine, Queen's University Belfast, Belfast, Northern Ireland.
Lorcan
L
McGarvey
Department of Medicine, University of Manchester and University Hospital of South Manchester, England.
Jaclyn
J
Smith
University of Massachusetts Medical School, Worcester, MA.
Richard S
RS
Irwin
D000328:Adult; D002908:Chronic Disease; D003371:Cough / Q000209:etiology* / Q000517:prevention & control; D019317:Evidence-Based Medicine; D005260:Female; D005764:Gastroesophageal Reflux / Q000150:complications* / Q000517:prevention & control; D006801:Humans
cough; evidence-based medicine; gastroesophageal reflux disease; guidelines