Key Points for Practice
• If a patient's cough is likely due to GERD, treatment should consistently include lifestyle modifications and medical therapy to control reflux symptoms.
• In the absence of reflux symptoms, proton pump inhibitors should not be used alone for therapy.
• Esophageal manometry and pH-metry are recommended for certain adults with chronic cough if the cough is thought to be reflux related.
From the AFP Editors
In the decade since the American College of Chest Physicians (ACCP) last released practice guidelines on managing reflux-cough syndrome, evidence has yet to deliver the high-quality results needed to definitively answer the primary treatment questions that physicians have. In their updated guideline, the ACCP offers recommendations addressing: (1) whether treating gastroesophageal reflux disease (GERD) improves cough in patients with chronic cough, and (2) which clinical criteria suggest that chronic cough will respond to therapy.
Although a systematic review did not find any high-quality evidence to address the two main clinical questions, the ACCP found sufficient support to outline six core points of guidance.
The two most highly rated recommendations are based on low-quality evidence (e.g., findings from observational studies, case series, or flawed randomized controlled trials) and focus on nonsurgical interventions. First, if a patient's cough is likely due to GERD, treatment should consistently include promoting weight loss through diet modification in patients who are overweight or obese; counseling on sleeping with their head elevated and on meal avoidance three hours before bedtime; and initiating therapy (e.g., antacids, proton pump inhibitors, histamine H2 blockers) to control symptoms of heartburn and regurgitation. Second, if a patient has cough but no symptoms of heartburn or regurgitation, proton pump inhibitors alone are not likely to resolve the cough and should not be prescribed without coinciding lifestyle modifications. The potential benefits of each of these approaches were found to clearly outweigh any potential risks.
Three additional recommendations, also based on low-quality evidence, had a weaker rating because the balance of potential harms and benefits was difficult to determine. The ACCP suggests using esophageal manometry and pH-metry with conventional methodology in certain adults with chronic cough that is thought to be reflux related. Specifically, this recommendation applies to adults with a cough that has been unresponsive to antireflux therapy after three months and who are already considering surgical options or warrant diagnostic testing for GERD.
Antireflux surgery should not be advised if a patient with chronic cough has a major motility disorder or if esophageal pH-metry does not show abnormal acid exposure. The risk of surgery is not counterbalanced by any known benefit in either circumstance.
The ACCP advises physicians that antireflux surgery may have a role in treating chronic cough that is suspected of being related to reflux-cough syndrome if (1) peristalsis activity is sufficient, (2) abnormal acid exposure is determined, and (3) when cough is refractory to medical therapy.
Based on expert consensus, it is recommended that the evaluation of chronic cough in adults follow a management strategy endorsed in the medical literature. It is important to start from the assumption that cough may be caused by more common etiologies, as well as symptomatic GERD.
Guideline source: American College of Chest Physicians
Evidence rating system used? Yes
Literature search described? Yes
Guideline developed by participants without relevant financial ties to industry? No
Published source: Chest. December 2016;150(6):1341–1360