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