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There Are Still Problems in Establishing a Diagnosis of Gastroesophageal Reflux-Related Chronic CoughGastroesophageal Reflux-Related Chronic Cough FREE TO VIEW

Hongli Jiang, MD; Bing Mao, MD
Author and Funding Information

From the Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University.

Correspondence to: Bing Mao, MD, Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Guoxue St No. 37, Chengdu, China; e-mail: 81489337@qq.com


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(1):e32. doi:10.1378/chest.14-0643
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To the Editor:

A recent study of 281 patients with extraesophageal syndromes of gastroesophageal reflux disease, of whom 50% had a cough, estimated that 52% of the overall US national annual economic burden of extraesophageal syndromes was attributable to proton pump inhibitor therapy.1 It is becoming increasingly important to identify patient populations likely to be responsive, avoiding unnecessary or inappropriate treatment. Xu et al2 should be congratulated on their study recently published in CHEST (June 2014) applying the Gastroesophageal Reflux Disease Questionnaire to predict patients with gastroesophageal reflux-induced chronic cough (GERC) who may be responsive to antireflux therapy. We have some questions and comments.

First, were any other common causes ruled out in the potential subjects with suspected GERC prior to participation? A prospective multicenter study showed that cough-variant asthma (32.6%), upper airway cough syndrome (18.6%), eosinophilic bronchitis (17.2%), and atopic cough (13.2%) are among the most common causes of chronic cough in China, with GERC in only 4.6% of cases.3 Xu et al2 did not report any information about bronchial provocation test, induced sputum test, peripheral blood eosinophil count, or serum IgE level, suggesting that some common causes of chronic cough could not have been included, which might lead to unnecessary invasive tests and excessive treatment. Additionally, other information, such as smoking, body weight, and lifestyle modification, was not reported, which would be useful and important.

Second, was it reasonable to establish the diagnosis based on favorable response to antireflux therapy? Empirical trial has been widely used in the diagnosis of GERC, since no diagnostic gold standard is available. However, diagnosis based exclusively on therapeutic response has been challenged with the increasing evidence4,5 that patients benefit little from acid-suppressive therapy and with the likely mechanisms of hypersensitivity and vagal reflex.

Third, we wonder about the presence of other causes of chronic cough in some patients. Cough in 8.0% of patients resistant to initial acid-suppression therapy was resolved using baclofen as an add-on therapy. Indeed, baclofen could improve refractory cough attributed to gastroesophageal reflux disease. However, baclofen, an agonist of γ-aminobutyric acid, has also been shown to inhibit refractory cough due to other causes. In such cases, other possible causes responsive to baclofen would be considered in addition to GERC, impairing the predictive value of the Gastroesophageal Reflux Disease Questionnaire.

References

Francis DO, Rymer JA, Slaughter JC, et al. High economic burden of caring for patients with suspected extraesophageal reflux. Am J Gastroenterol. 2013;108(6):905-911. [PubMed]
 
Xu X, Chen Q, Liang S, Lv H, Qiu Z. Comparison of Gastroesophageal Reflux Disease Questionnaire and multichannel intraluminal impedance pH monitoring in identifying patients with chronic cough responsive to antireflux therapy. Chest. 2014;145(6):1264-1270. [PubMed]
 
Lai K, Chen R, Lin J, et al. A prospective, multicenter survey on causes of chronic cough in China. Chest. 2013;143(3):613-620. [PubMed]
 
Chang AB, Lasserson TJ, Kiljander TO, Connor FL, Gaffney JT, Garske LA. Systematic review and meta-analysis of randomised controlled trials of gastro-oesophageal reflux interventions for chronic cough associated with gastro-oesophageal reflux. BMJ. 2006;332(7532):11-17. [PubMed]
 
Kahrilas PJ, Howden CW, Hughes N, Molloy-Bland M. Response of chronic cough to acid-suppressive therapy in patients with gastroesophageal reflux disease. Chest. 2013;143(3):605-612. [PubMed]
 

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References

Francis DO, Rymer JA, Slaughter JC, et al. High economic burden of caring for patients with suspected extraesophageal reflux. Am J Gastroenterol. 2013;108(6):905-911. [PubMed]
 
Xu X, Chen Q, Liang S, Lv H, Qiu Z. Comparison of Gastroesophageal Reflux Disease Questionnaire and multichannel intraluminal impedance pH monitoring in identifying patients with chronic cough responsive to antireflux therapy. Chest. 2014;145(6):1264-1270. [PubMed]
 
Lai K, Chen R, Lin J, et al. A prospective, multicenter survey on causes of chronic cough in China. Chest. 2013;143(3):613-620. [PubMed]
 
Chang AB, Lasserson TJ, Kiljander TO, Connor FL, Gaffney JT, Garske LA. Systematic review and meta-analysis of randomised controlled trials of gastro-oesophageal reflux interventions for chronic cough associated with gastro-oesophageal reflux. BMJ. 2006;332(7532):11-17. [PubMed]
 
Kahrilas PJ, Howden CW, Hughes N, Molloy-Bland M. Response of chronic cough to acid-suppressive therapy in patients with gastroesophageal reflux disease. Chest. 2013;143(3):605-612. [PubMed]
 
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