CHEST Guidelines-Chronic Cough Due to Gastroesophageal Reflux in Adults

Chronic Cough Due to Gastroesophageal Reflux in Adults

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The CHEST Guideline and Expert Panel Report updated the management practices for adults with chronic cough due to gastroesophageal reflux (GER). The report sought to address two key questions through a systematic review: whether GER therapy can improve or eliminate chronic cough, and whether there are minimal clinical criteria for predicting a patient's cough response to GER therapy.<br /><br />Upon review, the panel found a lack of high-quality studies directly addressing these questions, but several insights were gathered. A strong placebo effect was noted in studies on GER-related cough therapy. Weight loss and lifestyle modifications, such as diet alteration, appeared more effective for cough improvement than proton pump inhibitors (PPIs) alone, which showed no benefit in isolation. Consequently, it recommended avoiding crossover trial designs using PPIs due to potential carryover effects.<br /><br />An algorithmic approach for managing chronic cough resolved the condition in 82% to 100% of cases reviewed, identifying cough variant asthma and upper airway cough syndrome (UACS), which include sinus-related conditions, as the most frequent causes. The role of gastroesophageal reflux disease (GERD) varied widely as a potential cough contributor.<br /><br />The panel’s recommendations include utilizing a comprehensive diagnostic/therapeutic algorithm and considering lifestyle modifications (like weight loss and meal adjustments) for suspected reflux-cough syndrome, noting that PPI therapy alone is unlikely effective for patients without heartburn or regurgitation. For those not responding to conventional therapy and being considered for antireflux surgery, further physiological testing like esophageal manometry and pH-metry is advised.<br /><br />The report emphasizes the need for targeted future research to explore the roles of weakly acidic reflux, symptom profiles, and weight management in treating chronic cough associated with GERD. <br /><br />These guidelines offer consensus-based recommendations to help clinicians navigate the complex interplay between GER and chronic cough, emphasizing a methodical approach in diagnosis and management to optimize patient outcome.

Keywords

chronic cough

gastroesophageal reflux

GER therapy

placebo effect

lifestyle modifications

proton pump inhibitors

cough variant asthma

upper airway cough syndrome

diagnostic algorithm

antireflux surgery