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Evidence-Based Medicine |

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

Peter J. Kahrilas, MD; Kenneth W. Altman, MD PhD; Anne B. Chang, FRACP PhD; Stephen K. Field, MD FCCP; Susan M. Harding, MD FCCP; Andrew P. Lane, MD; Kaiser Lim, MD FCCP FAAAAI; Lorcan McGarvey, MD FRCP; Jaclyn Smith, PhD FRCP; Richard S. Irwin, MD Master FCCP
Author and Funding Information

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://chestjournal.chestpubs.org/content/XXX.

This guideline document has been endorsed by the following organizations: American College of Allergy, Asthma, and Immunology (ACAAI); American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF); American Association for Respiratory Care (AARC); Asian Pacific Society for Respirology (APSR); and the Canadian Thoracic Society.

Conflict of Interests:

PJK, KWA, SKF, SMH, APL, KL, and LM report no financial or intellectual conflicts of interest pertinent to either PICO question #1 or #2.

ABC reports an intellectual conflict of interest pertinent to PICO question #1 as it assesses one paper that she authored; she reports no financial conflict of interest pertinent to either PICO question #1 or #2.

JS is a named inventor on a patent that describes novel techniques for detecting cough from sound recordings pertinent to PICO question #2. This patent is owned by the University Hospital of South Manchester and licensed to a medical device company. She reports no financial conflict of interest pertinent to either PICO question #1 or #2.

RSI discloses that he has no financial or intellectual conflicts of interest pertinent to either PICO question #1 or #2. Moreover, while RSI is the Editor in Chief of CHEST, the review and all editorial decisions regarding this manuscript were independently made by others.

Department of Medicine, Northwestern University’s Feinberg School of Medicine

φBobby R Alford Department of Otolaryngology, Baylor College of Medicine, Houston TX

§Menzies School of Health, Research and Respiratory Department, Lady Cilento Children’s Hospital, Queensland University of Technology, Queensland, Australia

XDivision of Respiratory Medicine, Department of Medicine, Cummings School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada

ΦUniversity of Alabama at Birmingham, Division of Pulmonary, Allergy and Critical Care Medicine

ξDepartment of Otolaryngology - Head and Neck Surgery, Division of Rhinology and Sinus Surgery, Johns Hopkins School of Medicine

ΩMayo clinic Rochester, Division of Pulmonary & Critical Care Medicine, Department of Medicine

#Queen’s University Belfast, Northern Ireland

δUniversity of Manchester and University Hospital of South Manchester, UK

ψUniversity of Massachusetts Medical School, Worcester, MA, USA

Correspondence: Peter J Kahrilas, Northwestern University, Feinberg School of Medicine, Department of Medicine, 676 St Clair St, 14th floor, Chicago, Illinois 60611-2951.


Copyright 2016, . All Rights Reserved.


Chest. 2016. doi:10.1016/j.chest.2016.08.1458
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Abstract

Background  We updated the 2006 ACCP clinical practice guidelines for management of reflux-cough syndrome.

Methods  Two 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 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) while lifestyle modifications and weight reduction may be beneficial in suspected reflux-cough syndrome, 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 82-100% of instances; 2) cough variant asthma and upper airway cough syndrome (UACS) from rhinosinus conditions were the most commonly reported etiologies; and 3) the reported prevalence of reflux-cough syndrome varied widely.

Conclusions  The panelists: 1) endorsed use of a diagnostic/therapeutic algorithm addressing common cough etiologies including symptomatic reflux, 2) advised that while 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 anti-reflux surgery or in whom there is strong clinical suspicion warranting diagnostic testing.


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