Peter J Kahrilas1, Kenneth W Altman2, Anne B Chang3, Stephen K Field4, Susan M Harding5, Andrew P Lane6, Kaiser Lim7, Lorcan McGarvey8, Jaclyn Smith9, Richard S Irwin10. 1. Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL. Electronic address: p-kahrilas@northwestern.edu. 2. Bobby R. Alford Department of Otolaryngology, Baylor College of Medicine, Houston, TX. 3. Menzies School of Health, Research and Respiratory Department, Lady Cilento Children's Hospital, Queensland University of Technology, Queensland, Australia. 4. Division of Respiratory Medicine, Department of Medicine, Cummings School of Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada. 5. Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL. 6. Division of Rhinology and Sinus Surgery, Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD. 7. Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic Rochester, Rochester, MN. 8. Department of Medicine, Queen's University Belfast, Belfast, Northern Ireland. 9. Department of Medicine, University of Manchester and University Hospital of South Manchester, England. 10. University of Massachusetts Medical School, Worcester, MA.
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. Copyright Â
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. Copyright Â
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