Hoarseness. DF This is an interesting question and one that I believe needs further attention. In my practice, patients often relate talking as a trigger for their chronic cough. The hypothesized mechanism for this is laryngeal, specifically vocal fold, hypersensitivity. To further evaluate this phenomenon, my colleagues and I conducted a blinded, cross-sectional study of 27 nonsmoking patients with chronic cough (>8 weeks refractory to maximum antireflux medication) to determine whether GERD was the cause of chronic cough. All patients underwent 24-hour acoustic recording synchronized with ambulatory pH- impedance monitoring, and cough, phonation, and pH- impedance events were recorded.
My colleagues and I conducted a study evaluating definitive treatment of reflux for cough, in which patients with a primary symptom of chronic cough underwent gastric fundoplication. Abnormal preoperative impedance was not associated with postoperative improvement of cough symptoms. Instead, predictors of improvement were concomitant typical GERD symptoms of heartburn and regurgitation, and a positive capsule pH test. Patients with chronic cough combined with one or both cofactors tended to improve with the gastric fundoplication. These findings indicate that irregular impedance testing by itself is not very predictive of extraesophageal reflux and that patients who have cough without traditional GERD symptoms often do not improve with reflux medication or surgical treatment.
RM Older studies of standard GERD therapy (PPIs) for patients with chronic cough were predominantly small observational studies. Some of these studies found that up to 70% of patients with chronic cough responded to PPIs. However, data from more recent randomized controlled trials suggest that PPIs for patients with chronic cough are not as effective as we initially believed. The most recent review from the Cochrane group found a lack of strong data supporting the practice of empiric PPI therapy for patients with chronic cough. The subgroup of patients who may respond best to PPIs are those with concomitant GERD symptoms such as heartburn and regurgitation or a positive pH study, but even within this subgroup, only approximately one third of patients will respond to PPIs. In one study of patients with chronic idiopathic cough and no heartburn, there was no difference in outcomes between the group that received high-dose PPIs and the group that received placebo.
It has recently been proposed that pharyngeal pH monitoring with a pH catheter placed 2 cm above the upper oesophageal sphincter is an accurate method to identify patients in whom abnormal reflux causes airway problems, 40 and that pharyngeal reflux is present click for more in 70% of patients with airway symptoms including cough. 41 At variance with GOR, pharyngeal reflux is uncommon in normal subjects. 41 The clinical usefulness of pharyngeal pH monitoring in the study of GOR related cough remains to be established.
Treatment of GOR related cough should be carefully tailored to the specific needs of each patient. 1, 47, 48 Treatment should be directed to both reduce the number of reflux events and change the chemical characteristics of the refluxing material. Since many factors may combine in the genesis of cough, 1 treatments for other established causes of chronic cough (such as asthma and rhinitis) should be added, especially when the response to antireflux treatment has been partial. Finally, treatment failure does not rule out GOR as the cause of chronic cough. 49 Reassessment of lifestyle measures, drug selection, dosage regimen, and length of treatment should be considered, together with the possibility of cough induced by non-acid reflux. 50 In some patients insensitive to any form of medical treatment, 31 surgery may be the most appropriate therapeutic option.