Chronic Cough Due to Gastroesophageal Reflux in Adults: CHEST Guideline and Expert Panel Report

Abstract

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.

Keywords: cough; evidence-based medicine; gastroesophageal reflux disease; guidelines.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for key question 1: Can therapy intended to treat gastroesophageal reflux improve or eliminate cough in adults with refractory chronic cough? PICO = population, intervention, comparison, outcome.

Figure 2

PRISMA flow diagram for key question 2: Are there minimal clinical criteria to guide clinical practice in determining that a patient’s chronic cough is likely to respond to therapy for gastroesophageal reflux? See Figure 1 legend for expansion of abbreviations.