A cough is a common symptom in pulmonary TB and other chronic respiratory infections including patients with lung infections due to MAC, other nontuberculous mycobacteria, fungal diseases, and paragonimiasis. On behalf of American College of Chest Physicians Dr.Peter J. Kahrilas at Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL and colleagues have come out with CHEST Guideline and Expert Panel Report on Chronic Cough due to Gastroesophageal Reflux in Adults.
The Montreal consensus has defined gastroesophageal reflux disease (GERD) as “a condition which develops when the reflux of stomach content causes troublesome symptoms and/or complications.Cough is a potential symptom of gastroesophageal reflux (GER), usually listed among the inventory of extraesophageal symptoms in GERD questionnaires
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).
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 syndrome due to a variety of rhinosinus conditions, nonasthmatic eosinophilic bronchitis, and suppurative lung disease. Often, more than one etiology is a contributing factor.
2. In adult patients with chronic cough suspected to be due to reflux-cough syndrome, we recommend that treatment include (1) diet modification to promote weight loss in overweight or obese patients; (2) head of bed elevation and avoiding meals within 3 hours of bedtime; and (3) in patients who report heartburn and regurgitation, proton pump inhibitors (PPIs), H2-receptor antagonists, alginate, or antacid therapy sufficient to control these symptoms (Grade 1C).
(1) While it is expected that GI symptoms will respond within 4-8 weeks, the literature suggests that improvement in cough may take up to 3 months. b) Head of bed elevation is suggested based on its utility for improving GI GERD symptoms while acknowledging that it has not been demonstrated to be beneficial for cough.
3. In adult patients with suspected chronic cough due to reflux-cough syndrome, but without heartburn or regurgitation, we recommend against using PPI therapy alone because it is unlikely to be effective in resolving the cough (Grade 1C).
4. In adult patients with chronic cough potentially due to reflux-cough syndrome who are refractory to a 3-month trial of medical antireflux therapy and are being evaluated for surgical management (antireflux or bariatric), or in whom there is strong clinical suspicion warranting diagnostic testing for gastroesophageal reflux, we suggest that they undergo esophageal manometry and pH-metry with conventional methodology (Grade 2C).
Esophageal manometry is done both to evaluate for a major motility disorder and to accurately position the pH electrode for the pH monitoring study. With conventional methodology, the pH electrode is placed 5 cm proximal to the lower esophageal sphincter, and the study is done off antisecretory medications after withholding PPI therapy for 7 days and H2 receptor antagonists for 3 days prior to the study. It was agreed by consensus of the Esophageal Diagnostic Advisory Panel composed of both gastroenterologists and surgeons that this is the only methodology with proven validity with respect to surgical outcomes.
5. In adult patients with chronic cough and a major motility disorder (eg, absent peristalsis, achalasia, distal esophageal spasm, hypercontractility) and/or normal acid exposure time in the distal esophagus, we suggest not advising antireflux surgery (Grade 2C).
Under the circumstances of a major motility disorder or normal esophageal acid exposure on esophageal pH-metry, there is no supportive controlled data for antireflux surgery and there is quantifiable risk to the procedure making for an unacceptable risk-benefit ratio.
6. In adult patients with chronic cough, adequate peristalsis, and abnormal esophageal acid exposure determined by pH-metry in whom medical therapy has failed we suggest antireflux (or bariatric when appropriate) surgery for presumed reflux-cough syndrome (Grade 2C).
With respect to defining adequate peristalsis, there is no consensus. Some consider any preserved peristalsis to be adequate while others stipulate that it must be at least 30% and others at least 50% of normal.
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Dr. Kamal Kant Kohli
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