Chest

Chest

Volume 150, Issue 6, December 2016, Pages 1341-1360
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Evidence-Based Medicine
Chronic Cough Due to Gastroesophageal Reflux in Adults: CHEST Guideline and Expert Panel Report

https://doi.org/10.1016/j.chest.2016.08.1458Get rights and content

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.

Section snippets

Summary of Recommendations and Suggestions

1. In adult patients with chronic cough, we suggest that the cough be managed according to a published management guideline that initially considers the most common potential etiologies as well as symptomatic gastroesophageal reflux (ungraded, consensus based).

Remarks: Common potential etiologies include environmental or occupational irritants, primary or secondary smoking, use of angiotensin-converting-enzyme (ACE) inhibitors, abnormal chest radiographic findings, asthma, upper airway cough

Methods

We used the published methodology of the American College of Chest Physicians (CHEST) Guideline Oversight Committee to select the Expert Cough Panel Chair and the International Panel of Experts to perform a systematic review and synthesis of evidence and to develop recommendations and practice management suggestions.19 After generating the key clinical questions for this systematic review, population, intervention, comparison, outcome (PICO) elements were derived to inform the literature

Results

This systematic review addressed two PICO questions. The results of the literature search for the first question appear in Figure 1. The search initially identified 1,870 citations. After the removal of 354 duplicates, 1,516 records were screened, with 541 being excluded on the basis of irrelevant titles and 119 on the basis of being relevant to pediatrics. Hence, 842 abstracts were reviewed. Among these, 14 were controlled medical trials potentially pertinent to PICO question #1. The results

Practice Recommendations/Suggestions

As delineated earlier, the findings of this systematic review were most informative with respect to the limitations of the available data pertinent to addressing PICO questions 1 and 2 on the identification and management of patients with suspected reflux-cough syndrome. The evidence described was of low quality and in most instances only tangentially related to the PICO questions. However, simply pointing out the limitations of the evidence base is not much use to the clinician in guiding

Future Studies to Narrow the Gaps in Knowledge

As is evident from this review, the relationship between reflux and chronic cough is complex with numerous variables at play. Clinical strategies for diagnosis and management remain controversial, and despite the considerable quantity of research reviewed herein, several fundamental questions that are potentially amenable to further studies remain unanswered.From a diagnostic viewpoint:

  1. 1.

    Are there specific findings related to acid or weakly acidic reflux from pH or pH-impedance studies that either implicate or vindicate

Summary

Our objective was to update the 2006 ACCP clinical practice guidelines for the diagnosis and treatment of chronic cough due to reflux using an evidence-based approach. To do so, we convened an International Panel of Experts to develop practice management suggestions from a systematic review of published evidence. After generating key clinical questions, PICO elements were derived to assist the literature review. The questions that formed the basis of the systematic review were the following:

Acknowledgements

Author contributions: P. J. K. and R. S. I. reviewed all the articles and independently abstracted data for the systematic review that formed the basis of the guideline portion of this manuscript. P. J. K. wrote the initial draft of this manuscript. All authors participated in the development of the key questions using the PICOTS format, reviewed the systematic review and this manuscript, participated in writing the final manuscript through suggested revisions, and agreed with all

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    DISCLAIMER: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://www.chestnet.org/Guidelines-and-Resources/Guidelines-and-Consensus-Statements/CHEST-Guidelines.

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