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Barham WT, Alvarez-Amado AV, Dillman KM, Thibodeaux E, Nguyen ID, Varrassi G, Armstrong CJ, Howard J, Ahmadzadeh S, Mosieri CN, Kaye AM, Shekoohi S, Kaye AD. Laryngopharyngeal Reflux Pathophysiology, Clinical Presentation, and Management: A Narrative Review. Cureus 2024; 16:e67305. [PMID: 39301397 PMCID: PMC11412619 DOI: 10.7759/cureus.67305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 08/20/2024] [Indexed: 09/22/2024] Open
Abstract
Laryngopharyngeal reflux (LPR) is a common and often misinterpreted clinical entity responsible for various symptoms affecting the upper aerodigestive tract. This narrative literature review aims to review the pathophysiology, symptoms, and management of LPR, emphasizing the emerging understanding of gastric content reflux in aerodigestive tissue irritation. Understanding the pathophysiology of LPR will allow general practitioners and specialists to accurately recognize and treat a condition that causes substantial morbidity in the affected patients. Using evidence-based findings from randomized controlled trials, clinical studies, and meta-analyses, the present investigation aims to outline and unify previous research into LPR. A review of anatomical structures, pathogenic mechanisms, endoscopic findings in LPR, and clinical manifestations and treatment options are also discussed. Though controversy around the diagnosis and management of LPR persists, emerging research in cellular damage and diagnostic tools promises to provide increasingly accurate and reliable modalities for characterizing LPR. Hopefully, future research will unify the field and provide overarching guidelines for both primary care and specialists. The present investigation provides an integrated perspective on LPR, a clinically prevalent and complex disease.
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Affiliation(s)
- William T Barham
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
| | | | - Kathryn M Dillman
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
| | - Elise Thibodeaux
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Ivan D Nguyen
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
| | | | - Catherine J Armstrong
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Jeffrey Howard
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Chizoba N Mosieri
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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Khoma O, Park JS, Lee FM, Van der Wall H, Falk GL. Different clinical symptom patterns in patients with reflux micro-aspiration. ERJ Open Res 2021; 8:00508-2021. [PMID: 35083320 PMCID: PMC8784889 DOI: 10.1183/23120541.00508-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/26/2021] [Indexed: 11/20/2022] Open
Abstract
Background Pulmonary manifestation of gastro-oesophageal reflux disease (GORD) is a well-recognised entity; however, little primary reported data exists on presenting symptoms of patients in whom reflux micro-aspiration is confirmed. The aim of this study is to report symptoms and presenting patterns of a large group of patients with confirmed reflux micro-aspiration. Patients and methods Data was extracted from a prospectively populated database of patients referred to a tertiary specialist centre with severe, refractory or atypical reflux. Patients with reflux micro-aspiration on scintigraphy were included in this study. A separate group included patients with evidence of proximal reflux to the level of pharynx when supine and/or upright. Results Inclusion criteria were met by 243 patients with confirmed reflux micro-aspiration (33% males; mean age 59). Most common symptoms amongst patients with micro-aspiration were regurgitation (72%), cough (67%), heartburn (66%), throat clearing (65%) and dysphonia (53%). The most common two-symptom combinations were heartburn/regurgitation, cough/throat clearing, regurgitation/throat clearing, cough/regurgitation and dysphonia/throat clearing. The most common three-symptom combinations were cough/heartburn/regurgitation, cough/regurgitation/throat clearing and dysphonia/regurgitation/throat clearing. Cluster analysis demonstrated two main symptom groupings, one suggestive of proximal volume reflux symptoms and the other with motility/inflammatory bowel syndrome-like symptoms (bloat, constipation). Conclusion The combination of typical symptoms of GORD such as heartburn or regurgitation and a respiratory or upper aero-digestive complaint such as cough, throat clearing or voice change should prompt consideration of reflux micro-aspiration. Patients with reflux micro-aspiration most commonly present with a combination of regurgitation and/or heartburn and cough and/or throat clearinghttps://bit.ly/3GM8cNS
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Kum E, Guyatt GH, Devji T, Wang Y, Bakaa L, Lan L, Liu E, Mastrolonardo A, Couban R, O'Byrne PM, Satia I. Cough symptom severity in patients with refractory or unexplained chronic cough: a systematic survey and conceptual framework. Eur Respir Rev 2021; 30:210104. [PMID: 34261745 PMCID: PMC9518000 DOI: 10.1183/16000617.0104-2021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/18/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cough severity represents an important subjective endpoint in assessing the effectiveness of therapies for patients with chronic cough. Although cough-specific quality of life questionnaires exist, a widely available cough severity instrument with established measurement properties remains unavailable. AIMS To identify and summarise the results of studies reporting on the experience of patients with chronic cough and, in the process, develop a conceptual framework to inform development of a patient-reported outcome measurement (PROM) addressing cough severity. RESULTS We identified 61 eligible studies reporting on patient experience with chronic cough. Studies provided 82 potential items, of which 43 proved unique and relevant to cough severity. The urge-to-cough sensation and the cough symptom itself represented broad domains of cough severity. Two subdomains under urge-to-cough included frequency (1 item) and intensity (1 item). Five subdomains under cough symptoms included control (2 items), frequency (6 items), bout duration (1 item), intensity (8 items), and associated features/sequelae (24 items). CONCLUSIONS Our systematic survey and conceptual framework identified items and domains of cough severity in patients with refractory or unexplained chronic cough. The results support item generation and content validity for a PROM assessing cough severity.
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Affiliation(s)
- Elena Kum
- Dept of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon H Guyatt
- Dept of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Dept of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tahira Devji
- Dept of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuting Wang
- Dept of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Layla Bakaa
- Dept of Psychology, Neuroscience, and Behaviour, McMaster University, Hamilton, ON, Canada
| | - Lucy Lan
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Eva Liu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Rachel Couban
- Dept of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Paul M O'Byrne
- Dept of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, ON, Canada
| | - Imran Satia
- Dept of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Dept of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, ON, Canada
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Sandage MJ, Ostwalt ES, Allison LH, Cutchin GM, Morton ME, Odom SC. Irritant-Induced Chronic Cough Triggers: A Scoping Review and Clinical Checklist. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2021; 30:1261-1291. [PMID: 33989029 DOI: 10.1044/2021_ajslp-20-00362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Purpose The primary aim of this review was to identify environmental irritants known to trigger chronic cough through the life span and develop a comprehensive clinically useful irritant checklist. Method A scoping review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews, checklist, and explanation. English-language, full-text resources were identified through Medline, PsycINFO, SPORTDiscus, Web of Science, and ProQuest Dissertations and Theses Global. Results A total of 1,072 sources were retrieved; of these, 109 were duplicates. Titles of abstracts of 963 articles were screened, with 295 selected for full-text review. Using the exclusion and inclusion criteria listed, 236 articles were considered eligible and 214 different triggers were identified. Triggers were identified from North America, Europe, Africa, Asia, and Australia. Occupational exposures were also delineated. Conclusions A clinically useful checklist of both frequently encountered triggers and idiosyncratic or rare triggers was developed. The clinical checklist provides a unique contribution to streamline and standardize clinical assessment of irritant-induced chronic cough. The international scope of this review extends the usefulness of the clinical checklist to clinicians on most continents.
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Affiliation(s)
- Mary J Sandage
- Department of Speech, Language, and Hearing Sciences, Auburn University, AL
| | | | - Lauren H Allison
- Department of Speech, Language, and Hearing Sciences, Auburn University, AL
| | - Grace M Cutchin
- Department of Speech, Language, and Hearing Sciences, Auburn University, AL
| | | | - Shelby C Odom
- Department of Speech, Language, and Hearing Sciences, Auburn University, AL
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Paoletti G, Melone G, Ferri S, Puggioni F, Baiardini I, Racca F, Canonica GW, Heffler E, Malipiero G. Gastroesophageal reflux and asthma: when, how, and why. Curr Opin Allergy Clin Immunol 2021; 21:52-58. [PMID: 33369569 DOI: 10.1097/aci.0000000000000705] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Gastro-esophageal reflux is a possible cause of uncontrolled symptoms of asthma and should be actively investigated and treated before severe asthma is diagnosed and biological therapy started. RECENT FINDINGS Recent investigations on esophageal function and tissue biomarkers in patients with asthma and associated GERD have established a relevant role for esophageal motility and neuronal sensory abnormalities in linking the two diseases. Characterization of the underpinning inflammatory substrate has showed mixed results as both neutrophilic and eosinophilic type 2 inflammatory changes have been described. SUMMARY New findings regarding inflammatory mechanisms in GERD-associated asthma as well as new diagnostic tools to investigate functional esophageal abnormalities and characterize asthma endotype have identified potential treatable traits that may improve the clinical management and outcome of asthmatic patients with GERD.
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Affiliation(s)
- Giovanni Paoletti
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Giulio Melone
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
| | - Sebastian Ferri
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Francesca Puggioni
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Ilaria Baiardini
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Francesca Racca
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
| | - Giorgio W Canonica
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Enrico Heffler
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Giacomo Malipiero
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
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Kang SY, Song WJ, Won HK, Chung SJ, Kim JY, Park HW, Morice AH, Cho SH. Cough persistence in adults with chronic cough: A 4-year retrospective cohort study. Allergol Int 2020; 69:588-593. [PMID: 32327301 DOI: 10.1016/j.alit.2020.03.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 03/20/2020] [Accepted: 03/23/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND There is very limited evidence regarding long-term prognosis of chronic cough. We examined longitudinal outcomes among patients with chronic cough, and explored predictors of cough persistence. METHODS A retrospective cohort was constructed of adults who had newly visited a specialist cough clinic in 2012-2013. All had undergone systematic investigation for chronic cough. The Hull Airway Reflux Questionnaire (HARQ) was administered to assess reflux cough symptoms. A follow-up survey was conducted in 2016-2017 to assess cough persistence. RESULTS From 418 candidates, 323 participated in the follow-up study; main analyses focused on patients with chronic persistent cough (n = 64; 19.8%) and remitted cough (n = 193; 59.8%). Compared with remitted cough group, chronic persistent cough group had more family history of chronic cough (17.2% vs. 4.7%, p = 0.001) and cold air-sensitive cough (62.5% vs. 44.6%, p = 0.013). The total HARQ score did not differ; however, two items (cough with eating and cough with certain foods) scored significantly higher in chronic persistent cough. In multivariate analyses, a family history of chronic cough (adjusted odds ratio 4.27 [95% confidence interval 1.35-9.89]), cold air-sensitive cough (2.01 [1.09-3.73]), and cough with eating (1.22 [1.02-1.45]) were associated with chronic persistent cough at 4 years. CONCLUSIONS Cough persists in about 20% of patients after 4 years following systematic assessment and treatments. Several cough characteristics, such as family history, cold air-sensitivity, or reflux cough, may be associated with cough persistence. Larger cohort studies are warranted to further understand long-term prognosis and confirm predictors of persistence in patients with chronic cough.
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Affiliation(s)
- Sung-Yoon Kang
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, South Korea; Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, South Korea
| | - Woo-Jung Song
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, South Korea; Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
| | - Ha-Kyeong Won
- Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, South Korea
| | - Soo Jie Chung
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, South Korea; Department of Pulmonology and Allergy, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, South Korea
| | - Ju-Young Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Heung-Woo Park
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, South Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Alyn H Morice
- Centre for Cardiovascular and Metabolic Research, Hull York Medical School, Castle Hill Hospital, University of Hull, Cottingham, United Kingdom
| | - Sang-Heon Cho
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, South Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
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The Predicative Clinical Features Associated with Chronic Cough That Has a Single Underlying Cause. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:426-432.e2. [PMID: 32693212 PMCID: PMC7368645 DOI: 10.1016/j.jaip.2020.06.066] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/27/2020] [Accepted: 06/30/2020] [Indexed: 12/14/2022]
Abstract
Background Few studies have investigated the usefulness of the clinical characteristics of cough in the diagnosis of chronic cough. Objective To evaluate the diagnostic value of clinical characteristics and concomitant symptoms of chronic cough in predicting its cause. Methods We recruited adult patients with chronic cough as a primary presenting symptom and identified those with a single underlying cause. Clinical features of cough were recorded with a custom-designed questionnaire and the relationships between clinical features and cause of cough were analyzed. Results A total of 1162 patients with a single underlying cause were enrolled. Nocturnal cough alone was a predictor of cough variant asthma (odds ratio [OR], 2.037; 95% CI, 1.003-4.139) with high specificity (97.6%) and low sensitivity (8.1%). Heartburn (OR, 2.671; 95% CI, 1.544-4.620), belching (OR, 2.536; 95% CI, 1.620-3.971), and acid regurgitation (OR, 2.043; 95% CI, 1.299-3.212) indicated gastroesophageal reflux–related cough with high specificity (85.5%-94.9%) and low sensitivity (22.8%-40.7%). Cough after meals had a high specificity (91.2%) and a low sensitivity (24.8%) for gastroesophageal reflux–related cough. Postnasal dripping (OR, 2.317; 95% CI, 1.425-3.767) and history of sinusitis (OR, 4.137; 95% CI, 2.483-6.892) were indicators for upper airway cough syndrome with high specificity (80.8% and 90.2%, respectively). Rhinitis/sinusitis-related symptoms showed moderate sensitivity (72.9%); however, they showed mild specificity (46.1%) for upper airway cough syndrome. Conclusions Cough timing, several concomitant symptoms associated with gastroesophageal reflux or rhinitis/sinusitis, and medical history are useful to indicate common causes of chronic cough.
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Morice AH, Millqvist E, Bieksiene K, Birring SS, Dicpinigaitis P, Domingo Ribas C, Hilton Boon M, Kantar A, Lai K, McGarvey L, Rigau D, Satia I, Smith J, Song WJ, Tonia T, van den Berg JWK, van Manen MJG, Zacharasiewicz A. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J 2020; 55:1901136. [PMID: 31515408 PMCID: PMC6942543 DOI: 10.1183/13993003.01136-2019] [Citation(s) in RCA: 400] [Impact Index Per Article: 100.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/01/2019] [Indexed: 01/07/2023]
Abstract
These guidelines incorporate the recent advances in chronic cough pathophysiology, diagnosis and treatment. The concept of cough hypersensitivity has allowed an umbrella term that explains the exquisite sensitivity of patients to external stimuli such a cold air, perfumes, smoke and bleach. Thus, adults with chronic cough now have a firm physical explanation for their symptoms based on vagal afferent hypersensitivity. Different treatable traits exist with cough variant asthma (CVA)/eosinophilic bronchitis responding to anti-inflammatory treatment and non-acid reflux being treated with promotility agents rather the anti-acid drugs. An alternative antitussive strategy is to reduce hypersensitivity by neuromodulation. Low-dose morphine is highly effective in a subset of patients with cough resistant to other treatments. Gabapentin and pregabalin are also advocated, but in clinical experience they are limited by adverse events. Perhaps the most promising future developments in pharmacotherapy are drugs which tackle neuronal hypersensitivity by blocking excitability of afferent nerves by inhibiting targets such as the ATP receptor (P2X3). Finally, cough suppression therapy when performed by competent practitioners can be highly effective. Children are not small adults and a pursuit of an underlying cause for cough is advocated. Thus, in toddlers, inhalation of a foreign body is common. Persistent bacterial bronchitis is a common and previously unrecognised cause of wet cough in children. Antibiotics (drug, dose and duration need to be determined) can be curative. A paediatric-specific algorithm should be used.
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Affiliation(s)
- Alyn H Morice
- Respiratory Research Group, Hull York Medical School, University of Hull, Hull, UK
| | - Eva Millqvist
- Dept of Internal Medicine/Respiratory Medicine and Allergology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Kristina Bieksiene
- Dept of Pulmonology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Surinder S Birring
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Dept of Respiratory Medicine, King's College Hospital, London, UK
| | - Peter Dicpinigaitis
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Christian Domingo Ribas
- Pulmonary Service, Corporació Sanitària Parc Taulí (Sabadell), Dept of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Michele Hilton Boon
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Ahmad Kantar
- Pediatric Cough and Asthma Center, Istituti Ospedalieri Bergamaschi, University and Research Hospitals, Bergamo, Italy
| | - Kefang Lai
- Dept of Clinical Research, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Representing the Chinese Thoracic Society
| | - Lorcan McGarvey
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - David Rigau
- Iberoamerican Cochrane Centre, Barcelona, Spain
| | - Imran Satia
- Dept of Medicine, Division of Respirology, McMaster University, Hamilton, ON, Canada
- University of Manchester, Division of Infection, Immunity and Respiratory Medicine, Manchester Academic Health Science Centre, Manchester, UK
| | - Jacky Smith
- University of Manchester, Division of Infection, Immunity and Respiratory Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Woo-Jung Song
- Airway Sensation and Cough Research Laboratory, Dept of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Representing the Asia Pacific Association of Allergy, Asthma and Clinical Immunology (APAAACI)
| | | | | | - Mirjam J G van Manen
- Dept of Respiratory Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Angela Zacharasiewicz
- Dept of Pediatrics, Teaching Hospital of the University of Vienna, Wilhelminen Hospital, Vienna, Austria
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Hanibuchi M, Saijo A, Mitsuhashi A, Takeji T, Kitagawa T. The clinical usefulness of a new hand-held device for fractional exhaled nitric oxide measurement, NIOX VERO®, for diagnosing the etiology of cough. THE JOURNAL OF MEDICAL INVESTIGATION 2020; 67:265-270. [PMID: 33148899 DOI: 10.2152/jmi.67.265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Cough is one of the most common symptoms seen in clinical practice, however the differential diagnosis is often difficult. The utility of fractional exhaled nitric oxide (FeNO) measurement in the differential diagnosis of the etiology of cough has been reported. NIOX VERO® (NOV) is a new hand-held device that will replace NIOX MINO®, but its diagnostic utility has not been fully elucidated in clinical practice. In this study, the performance of NOV for FeNO measurements was determined. We retrospectively analyzed 243 consecutive patients complaining cough. Among 243 patients, final diagnosis was cough variant asthma (CVA) in 74 (30.5%), bronchial asthma (BA) in 48 (19.8%), post-infectious cough (PIC) in 52 (21.4%), atopic chough (AC) in 24 (9.9%), gastroesophageal reflux disease (GERD) in 10 (4.1%), and Others in 35 (14.4%). FeNO values were significantly higher in CVA and BA as compared to PIC, AC, GERD, and Others. In the multivariate analysis, only FeNO value was identified as independent factors to discriminate CVA and non-CVA other than BA. These findings indicated that FeNO measured by using NOV could be used as a diagnostic marker of intractable cough, especially for the differential diagnosis of CVA from non-CVA. J. Med. Invest. 67 : 265-270, August, 2020.
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Affiliation(s)
| | | | - Atsushi Mitsuhashi
- Department of Respiratory Medicine and Rheumatology, Graduate School of Biomedical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | | | - Tetsuya Kitagawa
- Department of Cardiovascular Surgery, Shikoku Central Hospital of the Mutual aid Association of Public School teachers, 2233 Kawanoe-cho, Shikoku-Chuo, 799-0193, Japan
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Clinical impact of gastroesophageal reflux disease in patients with subacute/chronic cough. Allergol Int 2019; 68:478-485. [PMID: 31182314 DOI: 10.1016/j.alit.2019.04.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/23/2019] [Accepted: 04/26/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND While gastroesophageal reflux disease (GERD) is one of the commonest causes of subacute/chronic cough along with cough-variant asthma (CVA) and rhinosinusitis, its clinical impact remains unknown. Therefore, we sought to investigate the impact of GERD in patients with subacute/chronic cough. METHODS Between April 2012 and March 2018, a total of 312 patients presenting subacute or chronic cough lasting for ≥3 weeks [median cough duration, 4.9 (0.7-434) months] underwent diagnostic tests. GERD symptoms and cough-specific QoL were evaluated through the Frequency Scale for Symptoms of Gastroesophageal reflux (FSSG) and the Japanese version of the Leicester Cough Questionnaire (J-LCQ). According to the FSSG domains, patients with GERD were arbitrarily categorized into 3 groups; acid-reflux predominant, dysmotility predominant, and pauci-symptoms groups, respectively. RESULTS The average scores of J-LCQ was 12.5 (SD3.7). One hundred-forty three were diagnosed as having GERD-related cough based on classical reflux symptoms including heartburn and characteristic triggers of cough such as phonation, rinsing, lying, and eating. Most of them (89.8%) had other causative diseases including CVA. Cough lasted longer (p = 0.019) and required a longer time until alleviation (p = 0.003) in patients with GERD than in those without GERD. They also scored lower J-LCQ than counterpart group (p < 0.0001). In terms of symptom stratification, dysmotility predominant group showed significant more response to specific GERD treatments than the remnants (p = 0.002). CONCLUSIONS These results indicate that GERD is associated with the aggravation of other causes including CVA. Particularly, dysmotility symptoms may be potential therapeutic target for GERD-related cough.
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Ghisa M, Della Coletta M, Barbuscio I, Marabotto E, Barberio B, Frazzoni M, De Bortoli N, Zentilin P, Tolone S, Ottonello A, Lorenzon G, Savarino V, Savarino E. Updates in the field of non-esophageal gastroesophageal reflux disorder. Expert Rev Gastroenterol Hepatol 2019; 13:827-838. [PMID: 31322443 DOI: 10.1080/17474124.2019.1645593] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Gastroesophageal reflux disease (GERD) is one of the most prevalent conditions in Western Countries, normally presenting with heartburn and regurgitation. Extra-esophageal (EE) GERD manifestations, such as asthma, laryngitis, chronic cough and dental erosion, represent the most challenging aspects from diagnostic and therapeutic points of view because of their multifactorial pathogenesis and low response to proton pump inhibitors (PPIs). In fact, in the case of EE, other causes must by preventively excluded, but instrumental methods, such as upper gastrointestinal endoscopy and laryngoscopy, have low specificity and sensitivity as diagnostic tools. In the absence of alarm signs and symptoms, empirical therapy with a double-dose of PPIs is recommended as a first diagnostic approach. Subsequently, impedance-pH monitoring could help to define whether the symptoms are GERD-related. Areas covered: This article reviews the current literature regarding established and proposed EE-GERD, reporting on all available options for its correct diagnosis and therapeutic management. Expert opinion: MII-pH could help to identify a hidden GERD that causes EE. Unfortunately, standard MII-pH analysis results are often unable to define this association. New parameters such as the mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index may have an improved diagnostic yield, but prospective studies using impedance-pH are needed.
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Affiliation(s)
- Matteo Ghisa
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Marco Della Coletta
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Ilenia Barbuscio
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Elisa Marabotto
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa , Genoa , Italy
| | - Brigida Barberio
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | | | - Nicola De Bortoli
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa , Pisa , Italy
| | - Patrizia Zentilin
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa , Genoa , Italy
| | - Salvatore Tolone
- Surgery Unit, Department of Surgery, University of Campania Luigi Vanvitelli , Caserta , Italy
| | - Andrea Ottonello
- Department of Surgical Science and Integrated Diagnostics, University of Genoa , Genoa , Italy
| | - Greta Lorenzon
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa , Genoa , Italy
| | - Edoardo Savarino
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua , Padua , Italy
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Takeda N, Takemura M, Kanemitsu Y, Hijikata H, Fukumitsu K, Asano T, Yamaba Y, Suzuki M, Kubota E, Kamiya T, Ueda T, Niimi A. Effect of anti-reflux treatment on gastroesophageal reflux-associated chronic cough: Implications of neurogenic and neutrophilic inflammation. J Asthma 2019; 57:1202-1210. [PMID: 31303089 DOI: 10.1080/02770903.2019.1641204] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Objective: Gastroesophageal reflux disease (GERD) is an important cause of chronic cough. Substance P (SP) has been implicated in the pathophysiology of cough. Proton pump inhibitors (PPIs) and prokinetic agents are the current treatment for GER-associated cough. The aim was to evaluate the effects of anti-reflux treatment and its associations with cellular and neurogenic inflammation.Methods: Thirty-seven patients with GER-associated cough suspected based on characteristic symptoms such as heartburn and worsening of cough by phonation and rising were recruited. A PPI, rabeprazole 20 mg daily, and a prokinetic agent, itopride 50 mg t.i.d., were administered for 4 weeks in a prospective, observational manner. Before and after treatment, subjective cough measures [visual analog scale (VAS) and the Japanese version of the Leicester Cough Questionnaire (J-LCQ)], the modified frequency scale for the symptoms of GERD [FSSG, consisting of 2 domains: acid-reflux (AR) and functional dyspepsia symptoms], sputum and plasma SP levels, and sputum cell differentials were examined. Patients with good response to treatment [Δ (decrease of) VAS >15 mm; n = 21) were compared with poor responders (ΔVAS ≤15 mm).Results: Anti-reflux treatment significantly improved the cough VAS, J-LCQ, and AR symptoms, and ΔVAS and ΔAR were significantly correlated. Decreases of plasma and sputum SP levels and sputum neutrophil counts were significantly greater in responders than in poor responders. Both baseline values and post-treatment changes of plasma SP and sputum neutrophils were significantly correlated for all patients.Conclusions: Successful treatment of GER-associated cough may be associated with the attenuation of neurogenic and neutrophilic inflammation.
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Affiliation(s)
- Norihisa Takeda
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Masaya Takemura
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Yoshihiro Kanemitsu
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Hisatoshi Hijikata
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Kensuke Fukumitsu
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Takamitsu Asano
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Yusuke Yamaba
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Motohiko Suzuki
- Department of Neuro-otolaryngology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Eiji Kubota
- Department of Gastroenterology and Metabolism, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Takeshi Kamiya
- Department of Gastroenterology and Metabolism, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Takashi Ueda
- Department of Anatomy and Neuroscience, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Akio Niimi
- Department of Respiratory Medicine and Clinical Immunology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
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Koskela HO, Lätti AM, Pekkanen J. Subfreezing air as a cough trigger and multiple triggers are strongly associated with the presence of asthma in chronic cough. Respir Med 2019; 153:26-30. [PMID: 31136929 DOI: 10.1016/j.rmed.2019.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/06/2019] [Accepted: 05/09/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Management of chronic cough relies on the recognition of cough background disorders. It is not known whether certain cough triggers are associated with specific background disorders. METHODS This was an e-mail study to public service employees of two towns in Finland. The questionnaire included twelve triggers. Current asthma was defined as doctor's diagnosis of asthma and current wheezing. Chronic rhinosinusitis was defined as either nasal blockage or nasal discharge and either facial pain/pressure or reduction/loss of smell for more than three months. Gastroesophageal reflux disease was defined as heartburn and/or regurgitation on at least one day a week during the last three months. Idiopathic cough was defined as absence of any of them. RESULTS There were 421 subjects with current cough that had lasted at least eight weeks. Subfreezing air as a cough trigger was associated with an adjusted odds ratio (aOR) of 7.27 (4.09-12.9), (p < 0.001), for current asthma. The number of cough triggers was largest in asthma, followed by chronic rhinosinusitis, gastroesophageal reflux, and idiopathic cough (7.05 (6.14-7.96), 4.94 (4.35-5.54), 4.60 (3.77-5.43), and 3.44 (3.02-3.86), respectively, p < 0.001). Presence of five or more triggers was associated with an aOR of 7.49 (3.96-14.2), (p < 0.001) for current asthma. Absence of any cough triggers increased the probability of idiopathic cough (aOR 2.71 (1.54-4.77), p = 0.001). CONCLUSIONS Subfreezing air as a cough trigger and multiple triggers are strongly associated with the presence of current asthma in chronic cough. Absence of any cough triggers increases the probability of idiopathic cough.
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Affiliation(s)
- Heikki O Koskela
- Unit for Medicine and Clinical Research, Pulmonary Division, Kuopio University Hospital, Kuopio, Finland; Kuopio University Hospital, PL 100, FI-70029, KYS, Finland; School of Medicine, Institute of Clinical Sciences, Faculty of Health Sciences, University of Eastern Finland, PL 1627, FI-70211, Kuopio, Finland.
| | - Anne M Lätti
- Unit for Medicine and Clinical Research, Pulmonary Division, Kuopio University Hospital, Kuopio, Finland; Kuopio University Hospital, PL 100, FI-70029, KYS, Finland; School of Medicine, Institute of Clinical Sciences, Faculty of Health Sciences, University of Eastern Finland, PL 1627, FI-70211, Kuopio, Finland.
| | - Juha Pekkanen
- Department of Public Health, University of Helsinki, PL 63, FI-00014, Helsinki, Finland; Environmental Health Unit, National Institute for Health and Welfare, PL 95, FI-70701, Kuopio, Finland.
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Abstract
Globus is an area of interest for many medical specialists including otorhinolaryngologists, gastroenterologist, allergists, and psychiatrists. It may be caused by an organic disease, but it is not uncommon that an underlying etiology remains unidentified even after a full workup has been performed. Patients who suffer from globus usually visit several physicians from different specialties without finding a solution for their symptoms. Identifying the underlying cause of globus is not always a simple task; therefore, structural or functional abnormalities of the thyroid, larynx, pharynx, and esophagus should be investigated. Gastroesophageal reflux disease is commonly considered to be the underlying cause after being identified in an otorhinolarygeal (ear, nose, and throat) evaluation, which is usually the first diagnostic step. In the last few years, an inlet patch in the proximal esophagus has been shown to be associated with globus, and its elimination has resulted in symptom resolution in some patients. Finally, globus can be associated with psychiatric disorders as well as oropharyngeal hypersensitivity that could be either chemical or mechanical. Treatment is directed toward an identified organic cause; in those with a functional disorder, the mainstay of therapy includes neuromodulators and psychiatric/psychological interventions.
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Diagnosis and Treatment of the Extraesophageal Manifestations of Gastroesophageal Reflux Disease. Ann Surg 2017; 265:63-67. [PMID: 27455157 DOI: 10.1097/sla.0000000000001907] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To review the clinical presentation, diagnosis, and treatment options available for management of extraesophageal manifestations of gastroesophageal reflux disease (GERD) and to compare the most recent technological advances to the existing guidelines. SUMMARY BACKGROUND DATA Extraesophageal manifestations of GERD include cough, laryngopharyngeal reflux (LPR), and asthma. Recent advances in diagnostic modalities may have outpaced the existing diagnostic and therapeutic clinical guidelines. METHODS We searched the MEDLINE, Cochrane, and Embase databases for articles pertaining to the presentation, diagnosis, and treatment of extraesophageal manifestations of reflux, specifically cough due to reflux, LPR, and asthma due to reflux. Search terms applied to 3 thematic topics: diagnosis, medical treatment, and surgical treatment. We had searched the bibliographies of included studies, yielding a total of 271 articles for full review. We graded the level of evidence and classified recommendations by size of treatment effect, according to the guidelines from the American Heart Association Task Force on Practice Guidelines. RESULTS One hundred twenty-eight articles met criteria for analysis. Our findings show that the diagnosis of cough, LPR, or asthma due to gastroesophageal reflux is difficult, as no criterion standard test exits. Also, patients often present without heartburn or regurgitation typical of GERD. Combined multichannel intraluminal impedance, the pH (MII-pH) monitoring system, and the symptom association probability (SAP) test might distinguish extraesophageal manifestations of reflux from idiopathic chronic cough, laryngitis due to other causes, and atopic asthma. In addition, extraesophageal manifestations of reflux are most effectively diagnosed with a stepwise approach incorporating empiric treatment and antisecretory therapy, combined MII-pH monitoring, and surgical intervention in few selected cases. CONCLUSIONS Recent studies demonstrate the potential diagnostic role of MII-pH monitoring. Surgical intervention provides resolution of extraesophageal symptoms less reliably than typical symptoms when the patient has GERD.
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Niimi A. Cough associated with gastro-oesophageal reflux disease (GORD): Japanese experience. Pulm Pharmacol Ther 2017; 47:59-65. [PMID: 28506663 DOI: 10.1016/j.pupt.2017.05.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/04/2017] [Accepted: 05/08/2017] [Indexed: 01/10/2023]
Abstract
Differences in the aetiology as well as patient background of chronic cough have been recognised among US, UK, and Japan. One of the marked differences has been the prevalence of gastro-oesophageal reflux disease (GORD), which has been one of the top three causes in Western countries. It was indeed uncommon or rare in Japan, but, with the increasing prevalence of GOR itself, chronic cough associated with GORD seems to have become more common. In this article, cough associated with GORD will be reviewed based on literature and our Japanese experience. Further, potentially broader relevance of GORD in chronic cough will also be mentioned, highlighting the potential importance of dysmotiliy/non-acid reflux.
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Affiliation(s)
- Akio Niimi
- Division of Respiratory Medicine and Allergy, Nagoya City University Hospital, Dept of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Japan.
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17
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Asano T, Takemura M, Fukumitsu K, Takeda N, Ichikawa H, Hijikata H, Kanemitsu Y, Uemura T, Takakuwa O, Ohkubo H, Maeno K, Ito Y, Oguri T, Nakamura A, Niimi A. Diagnostic utility of fractional exhaled nitric oxide in prolonged and chronic cough according to atopic status. Allergol Int 2017; 66:344-350. [PMID: 27693513 DOI: 10.1016/j.alit.2016.08.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/17/2016] [Accepted: 08/22/2016] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Cough-variant asthma (CVA) and cough-predominant asthma (CPA) are the major causes of persistent cough in Japan. The utility of fractional exhaled nitric oxide (FeNO) measurement in the differential diagnosis of persistent cough has been reported, but the influence of atopic status, which is associated with higher FeNO levels, on the diagnostic utility of FeNO has been unknown. METHODS We retrospectively analyzed 105 non-smoking patients with prolonged and chronic cough that were not treated with corticosteroids and anti-leukotrienes. RESULTS CPA was diagnosed in 37 patients, CVA in 40, and non-asthmatic cough (NAC) in 28. FeNO levels were significantly higher in the CPA [35.8 (7.0-317.9) ppb] and CVA [24.9 (3.1-156.0) ppb] groups than in the NAC group [18.2 (6.9-49.0) ppb] (p < 0.01 by Kruskal-Wallis test). The optimal cut-off for distinguishing asthmatic cough (AC; CPA and CVA) from NAC was 29.2 ppb [area under the curve (AUC) 0.74, p < 0.01]. Ninety-one percent of subjects with FeNO levels ≥29.2 ppb had AC. Meanwhile, 40% of AC patients had FeNO levels <29.2 ppb. Stratified cut-off levels were 31.1 ppb (AUC 0.83) in atopic subjects vs. 19.9 ppb (AUC 0.65) in non-atopic subjects (p = 0.03 for AUC). CONCLUSIONS Although high FeNO levels suggested the existence of AC, lower FeNO levels had limited diagnostic significance. Atopic status affects the utility of FeNO levels in the differential diagnosis of prolonged and chronic cough.
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Affiliation(s)
- Takamitsu Asano
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masaya Takemura
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
| | - Kensuke Fukumitsu
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Norihisa Takeda
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiroya Ichikawa
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hisatoshi Hijikata
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yoshihiro Kanemitsu
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takehiro Uemura
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Osamu Takakuwa
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hirotsugu Ohkubo
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Ken Maeno
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yutaka Ito
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tetsuya Oguri
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Atsushi Nakamura
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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18
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Study of IPF among patients with gastro-esophageal reflux disease. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2017. [DOI: 10.1016/j.ejcdt.2016.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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"Cold air" and/or "talking" as cough triggers, a sign for the diagnosis of cough variant asthma. Respir Investig 2016; 54:413-418. [PMID: 27886852 DOI: 10.1016/j.resinv.2016.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 06/27/2016] [Accepted: 07/10/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) is considered an alternative marker of eosinophilic airway inflammation and is sometimes incorporated in the diagnosis of asthma. However, many patients with cough variant asthma (CVA) demonstrate an FeNO in the normal range. Therefore, additional information is needed to confirm the diagnosis of CVA, particularly in patients with low FeNO levels. We aimed to investigate the feasibility of using cough triggers to help diagnose CVA. METHODS We studied 163 patients presenting with prolonged/chronic cough alone (including 104 CVA patients) who underwent FeNO measurements and an airway responsiveness test, and answered a questionnaire listing 18 cough triggers. The sensitivity and specificity of FeNO levels and cough triggers for the diagnosis of CVA were determined. RESULTS CVA patients showed higher FeNO levels than non-CVA patients. When the cut-off value of FeNO levels for the diagnosis of CVA was set at 22ppb, its sensitivity was 57%. CVA patients more frequently responded to "cold air" and "talking" as cough triggers than non-CVA patients. When the analysis was confined to those with a low FeNO (<22ppb) group, the sensitivity and positive predictive values of "cold air" and "talking" for the diagnosis of CVA were 36% and 70% for "cold air", and 44% and 74% for "talking", respectively. Their specificity was 81%. "Cold air" was associated with airway hyperresponsiveness in all patients with an emphasis on those with low FeNO levels. CONCLUSION "Cold air" and/or "talking" as cough triggers could be signs for the diagnosis of CVA, particularly when FeNO levels are low.
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Morice AH. Developing antitussives the clinician's pipeline-what do we need? J Thorac Dis 2014; 6:S735-8. [PMID: 25383208 DOI: 10.3978/j.issn.2072-1439.2014.08.40] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 08/22/2014] [Indexed: 02/05/2023]
Abstract
The evolving concept of cough hypersensitivity, an over activity of the afferent sensory nerves in the upper airways, has given new insights into the pathophysiology underlying chronic cough. Armed with this new information drug development aimed at reducing cough reflex sensitivity to normal has, for the first time, led to successful clinical studies. This review outlines the concepts underlying the inflammatory processes leading to cough hypersensitivity and demonstrates how knowledge of the molecular pharmacology of hypersensitivity provides a lead into drug targets. Initial hope that antagonists of TRP receptors would reduce clinical cough has been disappointing. Drugs such as theobromine, thalidomide and AF 219 which all have activity on afferent sensory nerves have shown promise in clinical trials. Large-scale phase three clinical studies are required to confirm these exciting findings.
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Affiliation(s)
- Alyn H Morice
- Head Cardiorespiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, UK
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Abstract
Globus is a topic of interest for many specialties including otorhinolaryngology, gastroenterology and psychiatry/psychosomatic medicine, but, although many hypotheses have been suggested, key questions about its aetiology remain. This Review provides an overview of the extensive literature concerning this topic and discusses the quality of the evidence to date. Globus has been associated with oropharyngeal structural lesions, upper oesophageal sphincter disorders, oesophageal disorders, GERD, psychosocial factors and psychiatric comorbidity. However, findings are often contradictory and the literature remains highly inconclusive. Indeed, with the exception of patients with structural-based globus, the Rome III criteria for functional globus only apply to a subgroup of patients with idiopathic globus. In clinical reality, there exists a group of patients who present with idiopathic (nonstructural) globus, but nevertheless have dysphagia, odynophagia or GERD-exclusion criteria for globus diagnosis according to Rome III. The symptomatology of patients with globus might be broader than previously thought. It is therefore crucial to approach globus not from one single perspective, but from a multifactorial point of view, with focus on the coexistence and/or interactions of different mechanisms in globus pathogenesis. This approach could be translated to clinical practice by adopting a multidisciplinary method to patients presenting with globus.
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Smith JE, Morjaria JB, Morice AH. Dietary intervention in the treatment of patients with cough and symptoms suggestive of airways reflux as determined by Hull airways Reflux Questionnaire. Cough 2013; 9:27. [PMID: 24380385 PMCID: PMC3883462 DOI: 10.1186/1745-9974-9-27] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 12/18/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic cough is a common and distressing symptom. Gastro-oesophageal reflux is a common cause of chronic cough however the symptom complex in cough is not confined to classic peptic symptoms. Dyspeptic symptoms have previously been shown to respond to dietary modifications and weight loss. We hypothesised that weight reduction maybe a useful non-pharmacological strategy in reducing reflux cough in the obese. METHODS Subjects with cough were recruited from Hull Cough Clinic. They were randomised to one of two open parallel groups; one receiving the traditional dietary modifications and the other weight reduction advice in the form of an Energy Prescription (EP). Cough symptoms, using the Leicester cough questionnaire (LCQ) and dietary intake were measured at the start and end of the study. RESULTS Thirty-three patients were recruited and 20 patients completed the study. Mean weight loss was 3.1 kg (p < 0.001) and reported an improvement in the LCQ (mean improvement 3.1); which is greater than the clinically significant score of 1.3. . Moreover, secondary outcomes showed a significant association between baseline high calorie (r = -0.24; p < 0.001) and fat intake (r = -0.36; p = 0.001), and LCQ scores. CONCLUSION A high calorie and fat intake is strongly correlated with cough score. Irrespective of diet, weight loss is associated with a reduction in cough symptoms. Asking patients to lose weight by reducing fat and calorie intake may be a simple strategy to ameliorate this intractable condition. TRIAL REGISTRATION The study was approved by the local research ethics committee (South Humber Local Research Ethics Committee; REC04/Q1105/62). The study was registered with the Research and Development Department, Clinical Governance Directorate, Hull and East Yorkshire Hospitals NHS Trust (reference number R0086).
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Affiliation(s)
- Joanna Elizabeth Smith
- Nutrition & Dietetics Department, Castle Hill Hospital, Hull & East Yorkshire NHS Trust, Castle Road, Cottingham, East Yorkshire HU16 5JQ, UK
| | - Jaymin Bhagwanji Morjaria
- Respiratory Medicine, University of Hull & East Yorkshire Hospitals NHS Trust, Kingston upon Hull, UK
| | - Alyn Hugh Morice
- Respiratory Medicine, University of Hull & East Yorkshire Hospitals NHS Trust, Kingston upon Hull, UK
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Cobeta I, Pacheco A, Mora E. The Role of the Larynx in Chronic Cough. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2013. [DOI: 10.1016/j.otoeng.2013.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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24
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Extra-Esophageal Manifestations of Gastroesophageal Reflux Disease: Diagnosis and Treatment. Drugs 2013; 73:1281-95. [DOI: 10.1007/s40265-013-0101-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Ates F, Vaezi MF. Approach to the patient with presumed extraoesophageal GERD. Best Pract Res Clin Gastroenterol 2013; 27:415-31. [PMID: 23998979 DOI: 10.1016/j.bpg.2013.06.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 06/27/2013] [Accepted: 06/28/2013] [Indexed: 01/31/2023]
Abstract
Reflux related cough, asthma and laryngitis are frequently encountered and are considered part of extraoesophageal syndromes. The diagnosis of extraoesophageal reflux is difficult due to the lack of gold standard diagnostic criteria. Esophagogastroduodenoscopy and esophageal pH monitoring are inadequate diagnostic tools for due to poor sensitivity and specificity. For this reason, empirical PPI therapy is recommended as an initial approach to diagnose and treat the potential underlying cause of these symptoms in patients without alarm symptoms. Diagnostic testing with esophageal pH and/or impedance monitoring and esophageal motility testing is usually reserved for those who continue to be symptomatic despite a trial of therapy with PPIs. Recent developments have increased our understanding of this difficult to treat group of patients but more research into reflux related extraoesophageal symptoms are needed to better diagnose and treat this group.
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Affiliation(s)
- Fehmi Ates
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, C2104-MCN Nashville, TN, USA
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Katle EJ, Hatlebakk JG, Steinsvåg S. Gastroesophageal reflux and rhinosinusitis. Curr Allergy Asthma Rep 2013; 13:218-23. [PMID: 23371037 DOI: 10.1007/s11882-013-0340-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Gastro-esophageal reflux disease (GERD) and chronic rhino-sinusitis (CRS) are prevalent disorders. Coexistence by chance is to be expected in a number of patients. Coexistence due to shared pathogenic mechanisms is controversial. In this paper, we have described the characteristics of GERD and CRS epidemiologically, diagnostically, and pathophysiologically, and reviewed the existing data about a potential role of gastro-esophageal reflux (GER) in the pathogenesis of CRS. A causal link between GERD and CRS has so far not been sufficiently documented. However, some studies do indicate a correlation. Hence, anti-reflux measures should be considered as an option in CRS, particularly in patients where conventional medical and surgical treatment is insufficient.
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Pacheco A, Cobeta I. Refractory chronic cough, or the need to focus on the relationship between the larynx and the esophagus. Cough 2013; 9:10. [PMID: 23552099 PMCID: PMC3687571 DOI: 10.1186/1745-9974-9-10] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 03/11/2013] [Indexed: 12/14/2022] Open
Abstract
In this review we question the current way of handling tackle a problem of chronic cough, especially by the excessive number of patients who can not find complete relief from your cough by anatomical diagnosis of universal use. From the field of Otolaryngology new perspectives arise now considering the larynx as a preferential afferent stimuli cough reflex arc. Also the constitution laryngopharyngeal reflux gas and new approaches to non-acid reflux and the local action of pepsin in laryngeal deserving of a joint review, which can illuminate new ways to handle the problem of chronic refractory cough. We believe that the chronic cough syndrome hpersensitivity as more precise label for chronic cough, should place particular emphasis on laryngeal sensory neuropathy as cough and reflux the influence that may have on their maintenance, and thereby causes definitely wide related to the syndrome if the larynx is incorporated, place greater number of afferent nerves of chronic cough, which are sure to cover much of the case of refractory cough remain without a satisfactory solution. The close collaboration between Otolaryngology, Gastroenterology and Pneumology in a patient with refractory chronic cough seems now an unavoidable necessity.
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Affiliation(s)
- Adalberto Pacheco
- Chronic Cough Unit, Pneumology Service, Hospital Ramón y Cajal, Madrid, Spain
- Otolaryngology Department, Hospital Ramón y Cajal, Madrid, Spain
| | - Ignacio Cobeta
- Otolaryngology Department, Hospital Ramón y Cajal, Madrid, Spain
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Pacheco A, Cobeta I, Wagner C. Refractory Chronic Cough: New Perspectives in Diagnosis and Treatment. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.arbr.2013.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
This article discusses the current state of knowledge regarding the relationship between gastroesophageal reflux disease (GERD) and pulmonary and ear/nose/throat manifestations of reflux and outlines the recent developments in the diagnostic and treatment strategies for this difficult group of patients. Upper gastrointestinal endoscopy and pH monitoring are poorly sensitive for diagnosing reflux in this group of patients. Instead it is recommended that in those without warning symptoms, an empiric trial of proton-pump inhibitors be the initial approach to diagnosing and treating the potential underlying cause of these extraesophageal symptoms.
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Management of patients with chronic cough using a clinical protocol: a prospective observational study. COUGH 2013; 9:2. [PMID: 23347748 PMCID: PMC3565860 DOI: 10.1186/1745-9974-9-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 01/18/2013] [Indexed: 11/10/2022]
Abstract
Background and aims Chronic cough is a common symptom the aetiology of which can be challenging to diagnose. Diagnostic protocols for chronic cough have required the use of specialist investigations which are not always easily available. We wanted to determine whether patients with chronic cough can be successfully managed using a clinical algorithm. Methods 112 consecutive patients with chronic cough were prospectively recruited into this study. They were assessed by history, physical examination, chest radiograph, spirometry and reversibility to nebulised salbutamol. A clinical diagnosis was made and the patient had an 8-week trial of appropriate therapy. Further therapeutic trials were carried out depending on response to treatment and the possible differential diagnoses. Investigations were carried out in cases of failed clinical trials and to exclude specific pathology. The “clinical arm” comprised patients managed on the basis of clinical assessment and without any investigations. The “investigative arm” comprised those who needed further investigations. Results 81 (72%) were managed in the clinical arm. Of these 74 (66%) were discharged following response to therapy. 31 (28%) patients were converted to the investigative arm after failure of diagnosis in the clinical protocol. The commonest causes of cough were gastroesophageal reflux, asthma and chronic rhinitis. 51 (45.5%) patients responded to therapy based on diagnosis at initial assessment while a further 23 (20.5%) patients responded to sequential clinical trials for the commonest causes of cough. Cough severity score improved by a mean of 3.6 points on a numeric response score (from 0–10, p < 0.0001). Conclusion It is possible to manage a majority of chronic cough patients successfully using a protocol based on presenting symptoms and therapeutic trials for the common causes of cough.
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Cobeta I, Pacheco A, Mora E. The role of the larynx in chronic cough. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2013; 64:363-8. [PMID: 23305863 DOI: 10.1016/j.otorri.2012.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 09/24/2012] [Accepted: 10/10/2012] [Indexed: 12/16/2022]
Abstract
Cough lasting more than 8 weeks is considered chronic. If the classic causes of chronic cough have been discarded, vagus nerve sensory disturbances are currently considered the most important etiological cause. Patients with chronic cough of laryngeal origin have associated symptoms such as globus, dysphagia, dysphonia, dyspnoea and/or stridor. These patients are more likely to have paradoxical vocal fold movement. There is a higher cough reflex sensibility and neuropathic laryngeal response, mainly caused by viral infection or reflux. The cough associated with reflux has 2 mechanisms: Exposure to acid in the distal oesophagus (gastroesophageal reflux) and microaspiration of oesophageal contents into the larynx and tracheo-bronchial tree (pharyngo-laryngeal reflux). Laryngeal neuropathy hypersensitivity responds well to speech therapy as a treatment for refractory chronic cough. Because chronic cough is a sign of laryngeal sensory, neuropathy can improve with neuroleptic drugs such as amitriptyline and gabapentin.
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Affiliation(s)
- Ignacio Cobeta
- Unidad de Voz, Servicio de Otorrinolaringología, Hospital Universitario Ramón y Cajal, Madrid, España.
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Abstract
It is increasingly accepted that the effects of gastro-oesophageal reflux are not limited to the gastrointestinal tract. The adjacent respiratory structures are also at risk from material ejected from the proximal oesophagus as a result of the failure of anatomical and physiological barriers. There is evidence of the influence of reflux on several respiratory and otorhinological conditions and although in many cases the precise mechanism has yet to be elucidated, the association alone opens potential novel avenues of therapy to clinicians struggling to treat patients with apparently intractable respiratory complaints. This review provides a description of the airway reflux syndrome, its effects on the lung and current and future therapeutic options.
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Affiliation(s)
- Ian D Molyneux
- Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, UK
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Refractory chronic cough: new perspectives in diagnosis and treatment. Arch Bronconeumol 2012; 49:151-7. [PMID: 23165122 DOI: 10.1016/j.arbres.2012.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 09/14/2012] [Accepted: 09/26/2012] [Indexed: 02/01/2023]
Abstract
In patients with chronic cough, nearly 40% of the population does not experience definitive improvement of their cough despite correctly applying the anatomic diagnosis. In many of these patients with refractory cough, laryngeal symptoms are frequent. The region of the larynx/pharynx is configured as a bridge between the esophagus and the upper and lower respiratory tract. The association of reflux in patients with chronic cough and symptoms such as globus pharyngis, itchiness or the need to clear one's throat have recently been given attention due to the possibility of joint therapeutic intervention of the gastroesophageal reflux and larynx, both with new medications as well as with laryngeal rehabilitation therapies, with observed benefits in the disappearance of chronic cough in cases that had been previously labeled as refractory.
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Faruqi S, Sedman P, Jackson W, Molyneux I, Morice AH. Fundoplication in chronic intractable cough. COUGH 2012; 8:3. [PMID: 22812601 PMCID: PMC3499264 DOI: 10.1186/1745-9974-8-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 06/29/2012] [Indexed: 12/15/2022]
Abstract
Background Airway reflux is a common cause of chronic cough and this is often refractory to medical therapy. Surgery in the form of Nissen fundoplication has been highly successful in the treatment of the classic reflux symptoms of heartburn and dyspepsia. There is a paucity of data regarding response to fundoplication in patients presenting with chronic cough. Methods We retrospectively reviewed the case notes of patients from the Hull Cough Clinic who had undergone Nissen fundoplication over the past 6 years. Demographic details, duration of symptoms, presence of other symptoms, results of oesophageal studies, outcome and complications were recorded. Patients were contacted by post and asked to complete a questionnaire detailing current symptoms. In a subgroup with continued troublesome cough 24 hour pharyngeal pH measurements were undertaken. Results Forty seven patients underwent fundoplication. The average duration of pre-operative cough was 8 years. Gastro intestinal symptoms were present in the majority. In 30 (64%) patients a positive response to treatment was recorded. Mild dysphagia or bloating was seen in 18 patients following surgery. Four patients needed repeat surgical intervention for modification of fundoplication. One patient developed aspiration pneumonia eight weeks following surgery and died of a myocardial infarction. Two thirds of patients with persisting cough had evidence of airway reflux on pharyngeal pH monitoring. Conclusion In these patients with intractable cough a long term response rate of 63% represents a useful therapeutic option. Treatment failure is more frequent than for classic peptic symptoms and may be related to persistent gaseous reflux.
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Affiliation(s)
- Shoaib Faruqi
- Department of Cardiovascular and Respiratory Studies, Castle Hill Hospital, Hull York Medical School, University of Hull, Cottingham, HU16 5JQ, UK.
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Pacheco A, Faro V, Cobeta I, Royuela A. Chronic Cough With Limited Response to Treatment and Incidence of Gastroesophageal Reflux. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.arbr.2012.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Tos crónica de escasa respuesta al tratamiento e incidencia de reflujo gastroesofágico. Arch Bronconeumol 2012; 48:197-201. [DOI: 10.1016/j.arbres.2012.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 02/01/2012] [Accepted: 02/01/2012] [Indexed: 01/10/2023]
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Matsumoto H, Tabuena RP, Niimi A, Inoue H, Ito I, Yamaguchi M, Otsuka K, Takeda T, Oguma T, Nakaji H, Tajiri T, Iwata T, Nagasaki T, Jinnai M, Matsuoka H, Mishima M. Cough triggers and their pathophysiology in patients with prolonged or chronic cough. Allergol Int 2012; 61:123-32. [PMID: 22377525 DOI: 10.2332/allergolint.10-oa-0295] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 07/21/2011] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The character or timing of chronic cough is considered to be unpredictable for diagnosing its cause. However, the associations of cough triggers with cough pathophysiology remains unknown. METHODS We developed a closed questionnaire listing 18 triggers that were reported by ≥1% of 213 patients in a retrospective survey. Using this questionnaire, patients with cough-predominant or cough-variant asthma (n = 140) and those with non-asthmatic cough (54) were asked whether their cough was induced by the listed triggers. Associations of triggers with causes of cough, airway sensitivity to inhaled methacholine, exhaled nitric oxide (NO) levels, number of sensitizing allergens, and scores from gastroesophageal reflux (GER) questionnaires were examined. Factor analysis was used to categorize variables, including the 12 most common cough triggers, diagnosis of asthmatic cough, airway sensitivity, and exhaled NO levels. RESULTS "Cold air" and "fatigue/stress" induced cough more often in asthmatic coughers than in non-asthmatic coughers. "Spices" and "meals" induced cough more frequently in GER-coughers (n = 19). Patients who marked "cold air" as the trigger were more sensitive to inhaled methacholine and showed higher exhaled NO levels than those who did not mark this trigger. The "post-nasal drip" trigger was associated with elevated exhaled NO levels, and this association was mainly exhibited by patients with cough-predominant asthma. The triggers "pollen" and "mold smell" were associated with a number of sensitizing allergens. The number of triggers was weakly associated with GER scores. By factor analysis, "cold air," "fatigue/stress," asthmatic cough, airway hypersensitivity, and elevated NO levels were categorized into the same factor. CONCLUSIONS Several cough triggers may reflect the pathophysiology of prolonged or chronic cough.
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Affiliation(s)
- Hisako Matsumoto
- Department of Respiratory Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan. −u.ac.jp
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Faruqi S, Molyneux ID, Fathi H, Wright C, Thompson R, Morice AH. Chronic cough and esomeprazole: a double-blind placebo-controlled parallel study. Respirology 2012; 16:1150-6. [PMID: 21707852 DOI: 10.1111/j.1440-1843.2011.02014.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVE Gastro-oesophageal reflux has been implicated in the pathogenesis of chronic cough. Guidelines on management suggest a therapeutic trial of anti-reflux medication. Esomeprazole is a proton pump inhibitor licensed for the long-term treatment of acid reflux in adults and we compared the effects of esomeprazole and placebo on patients with chronic cough. METHODS This was a prospective, single-centre, randomized, double-blind, placebo-controlled, parallel group study conducted over 8weeks. Fifty adult non-smokers with chronic cough and normal spirometry were randomized. Patients completed cough-related quality-of-life and symptom questionnaires and subjective scores of cough frequency and severity at the beginning and end of the study. They also kept a daily diary of symptom scores. Citric acid cough challenge and laryngoscopic examination were performed at baseline and the end of the study. The primary outcome was improvement in cough score. RESULTS There were no differences in cough scores in the placebo and treatment arms of the study although some significant improvements were noted when compared to baseline. In the cough diary scores there was a trend towards greater improvement in the treatment arm in patients with dyspepsia. CONCLUSIONS Esomeprazole did not have a clinically important effect greater than placebo in patients with cough. It suggests a marked placebo effect in the treatment of cough.
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Affiliation(s)
- Shoaib Faruqi
- Division of Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, UK.
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Pacheco A, Faro V, Cobeta I, Royuela A, Molyneux I, Morice AH. Gastro-oesophageal reflux, eosinophilic airway inflammation and chronic cough. Respirology 2011; 16:994-9. [PMID: 21651646 DOI: 10.1111/j.1440-1843.2011.02010.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVE Patients with eosinophilic airway inflammation (EAI) often show a therapeutic response to corticosteroids. Non-invasive methods of diagnosing EAI are potentially useful in guiding therapy, particularly in conditions such as chronic cough, for which corticosteroids may not be the first-line treatment. METHODS The value of exhaled nitric oxide (ENO) in the diagnosis of EAI was prospectively investigated in a cohort of 116 patients with chronic cough of varying aetiology. An optimum cut-off value was derived for differentiating between EAI and non-EAI causes of chronic cough. As the diagnosis was gastro-oesophageal reflux in 70 patients (60.3% of the total), the possible relationship between ENO and EAI in the presence or absence of reflux was subsequently investigated. RESULTS The optimum value of ENO for differentiating EAI (32% of patients) from non-EAI causes of cough was 33 parts per billion (sensitivity 60.5%, specificity 84.6%). In the subgroup of patients with reflux, ENO was highly specific for the diagnosis of EAI (sensitivity 66%, specificity 100%). Conversely, in the patients without reflux, ENO did not discriminate between cough due to EAI or other causes (sensitivity 100%, specificity 28.9%). CONCLUSIONS These results suggest that the presence or absence of reflux should be taken into consideration when interpreting ENO measurements in the diagnosis of chronic cough associated with EAI.
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Affiliation(s)
- Adalberto Pacheco
- Pneumology Service, Chronic Cough Unit, CIBER Epidemiología y Salud Pública (CIBERESP), Hospital Ramón y Cajal, Madrid, Spain.
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Pacheco-Galván A, Hart SP, Morice AH. Relationship between gastro-oesophageal reflux and airway diseases: the airway reflux paradigm. Arch Bronconeumol 2011; 47:195-203. [PMID: 21459504 DOI: 10.1016/j.arbres.2011.02.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 02/02/2011] [Accepted: 02/04/2011] [Indexed: 12/21/2022]
Abstract
Our understanding of the relationship between gastro-oesophageal reflux and respiratory disease has recently undergone important changes. The previous paradigm of airway reflux as synonymous with the classic gastro-oesophageal reflux disease (GORD) causing heartburn has been overturned. Numerous epidemiological studies have shown a highly significant association of the acid, liquid, and gaseous reflux of GORD with conditions such as laryngeal diseases, chronic rhinosinusitis, treatment resistant asthma, COPD and even idiopathic pulmonary fibrosis. However, it has become clear from studies on cough hypersensitivity syndrome that much reflux of importance in the airways has been missed, since it is either non- or weakly acid and gaseous in composition. The evidence for such a relationship relies on the clinical history pointing to symptom associations with known precipitants of reflux. The tools for the diagnosis of extra-oesophageal reflux, in contrast to the oesophageal reflux of GORD, lack sensitivity and reproducibility. Unfortunately, methodology for detecting such reflux is only just becoming available and much additional work is required to properly delineate its role.
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Affiliation(s)
- Adalberto Pacheco-Galván
- Servicio de Neumología, Unidad de Asma y Tos de Difícil Manejo, Hospital Ramón y Cajal, Madrid, Spain.
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Kamimura M, Mouri A, Takayama K, Mizutani T, Hamamoto Y, Iikura M, Furihata K. Cough challenge tests involving mechanical stimulation of the cervical trachea in patients with cough as a leading symptom. Respirology 2011; 15:1244-51. [PMID: 20920133 DOI: 10.1111/j.1440-1843.2010.01859.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Challenge tests involving chemical stimulation by inhalation of capsaicin or citric acid are currently used to assess cough sensitivity. We investigated the clinical usefulness of cough challenge tests based on mechanical stimulation. METHODS A total of 347 patients (126 men and 221 women) were enrolled in the study, including 161 patients with asthma, 116 with cough-variant asthma, 27 with acute upper respiratory tract viral infections, 25 with acute bronchitis, four with pneumonia, three with chronic bronchitis and 11 with cough of unknown aetiology. Three modes of mechanical stimulation were assessed: the cervical trachea was compressed softly with the fingers several times (tracheal compression test); the trachea was stretched by retroflexion of the neck for 5 s (tracheal stretch test); and a vibrating tuning fork was placed on the cervical trachea for 20 s (tuning fork test). The relationships between phonation-induced cough and the results of these tests were assessed. RESULTS The cough detection rate was 27.7% with the tracheal compression test, 39.8% with the tracheal stretch test and 36.9% with the tuning fork test. An itchy sensation with or without cough was noted by about 50% of subjects undergoing each of the tests. Provocation of cough and an itchy sensation during each test was significantly more frequent in subjects with phonation-induced cough. Tests were usually negative after improvement of the cough with treatment. CONCLUSIONS Mechanical stimulation of the cervical trachea is a feasible cough challenge test that may be useful for evaluating disease activity.
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Affiliation(s)
- Mitsuhiro Kamimura
- Department of Pulmonology, National Hospital Organization Disaster Medical Center, Tachikawa-shi, Tokyo, Japan.
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Relationship Between Gastro-Oesophageal Reflux and Airway Diseases: The Airway Reflux Paradigm. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/s1579-2129(11)70046-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Morice AH, Faruqi S, Wright CE, Thompson R, Bland JM. Cough Hypersensitivity Syndrome: A Distinct Clinical Entity. Lung 2010; 189:73-9. [PMID: 21240613 DOI: 10.1007/s00408-010-9272-1] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 11/07/2010] [Indexed: 11/28/2022]
Affiliation(s)
- A H Morice
- Cardiovascular and Respiratory Studies, Castle Hill Hospital, Hull York Medical School, University of Hull, Castle Road, Cottingham, East Yorkshire HU16 5JQ, UK
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Gastroesophageal reflux and idiopathic pulmonary fibrosis: a review. Pulm Med 2010; 2011:634613. [PMID: 21738875 PMCID: PMC3115688 DOI: 10.1155/2011/634613] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 11/16/2010] [Indexed: 12/14/2022] Open
Abstract
The histological counterpart of idiopathic pulmonary fibrosis is usual interstitial pneumonia, in which areas of fibrosis of various ages are interspersed with normal lung. This pattern could be explained by repeated episodes of lung injury followed by abnormal wound healing responses. The cause of the initiating alveolar epithelial injury is unknown, but postulated mechanisms include immunological, microbial, or chemical injury, including aspirated gastric refluxate. Reflux is promoted by low basal pressure in the lower oesophageal sphincter and frequent relaxations, potentiated by hiatus hernia or oesophageal dysmotility. In susceptible individuals, repeated microaspiration of gastric refluxate may contribute to the pathogenesis of IPF. Microaspiration of nonacid or gaseous refluxate is poorly detected by current tests for gastroesophageal reflux which were developed for investigating oesophageal symptoms. Further studies using pharyngeal pH probes, high-resolution impedance manometry, and measurement of pepsin in the lung should clarify the impact of reflux and microaspiration in the pathogenesis of IPF.
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Labenz J. Facts and fantasies in extra-oesophageal symptoms in GORD. Best Pract Res Clin Gastroenterol 2010; 24:893-904. [PMID: 21126702 DOI: 10.1016/j.bpg.2010.08.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Revised: 08/27/2010] [Accepted: 08/31/2010] [Indexed: 01/31/2023]
Abstract
Extra-oesophageal symptoms are common in patients with GORD, but a causal relationship is the exception rather than the rule. In the absence of specific diagnostic procedures capable of identifying patients who might respond to antireflux therapy, clinical suspicion should prompt empirical high-dose PPI treatment. pH-/impedance monitoring on PPI may help to exclude a pathogenic role of gastro-oesophageal reflux in patients refractory to PPIs. While there is some evidence that subgroups of patients with chronic cough of unknown origin or difficult-to-control asthma, who also suffer from typical reflux symptoms, may benefit from PPI therapy, the existence of the disease entity reflux laryngitis must be viewed with a certain scepticism. Clinically silent acid reflux is not a reliable predictor of the success of antireflux treatment in asthmatics. The role of antireflux surgery in the management of extra-oesophageal symptoms remains unclear. Overall, based on current evidence fantasy clearly dominates the facts.
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Affiliation(s)
- J Labenz
- Department of Internal Medicine & Gastroenterology, Diakonie Klinikum Jung-Stilling, Siegen, Germany.
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Abstract
PURPOSE OF REVIEW Extraesophageal reflux disease is a common clinical presentation to gastroenterology as well as ear, nose and throat, allergy, and asthma clinics. The diagnosis and management of this condition is challenging. We review the current dilemma in this area and discuss the latest studies which help guide our therapies for patients with suspected extraesophageal reflux. RECENT FINDINGS Diagnostic approach to patients with extraesophageal reflux disease involved the use of insensitive tools, which have hampered the ability to correctly identify patients at risk. Empiric trial using proton pump inhibitors is still the recommended initial approach to those suspected of having reflux as the cause for extraesophageal symptoms such as asthma, chronic cough, or laryngitis. Diagnostic testing should be reserved to those unresponsive to therapy. Most recent studies suggest that ambulatory impedance/pH monitoring performed on therapy may be most likely to help exclude reflux as the cause for persistent symptoms. Recent randomized placebo-controlled studies on chronic laryngitis, cough, and asthma have been disappointing in showing benefit of acid suppressive therapy. SUMMARY Gastroduodenal reflux may cause symptoms such as chronic cough, asthma, or laryngitis. However, we are currently limited in our diagnostic ability to identify the subgroup of patients who might respond to acid suppressive therapy. Impedance/pH monitoring may be a step in the right direction; however, outcome studies are needed to better understand the role of acid or nonacid reflux in patients with extraesophageal symptoms.
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Abstract
Chronic cough is a common symptom with significant morbidity. We report a case of a 51-year-old woman who presented with chronic cough. She recently had received a diagnosis of glaucoma and had started receiving therapy with topical latanoprost. The onset of cough coincided with the use of latanoprost. We performed a citric acid cough challenge while the patient was receiving latanoprost and repeated the challenge after therapy with the drug was stopped. The initial cough challenge revealed marked hypersensitivity of the cough reflex. After stopping therapy with latanoprost for 10 days, the cough sensitivity was reduced significantly. Within 3 days of recommending therapy with latanoprost, the cough sensitivity increased to the initial value. This case illustrates that the topical application of latanoprost can markedly increase cough sensitivity, which is reversible on stopping administration of the drug. Moreover, the case reflects the clinical manifestation of the effect of topical latanoprost therapy on cough reflex, which, to our knowledge, has never been reported in the medical literature.
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Affiliation(s)
- Ahmed Fahim
- Department of Cardiovascular and Respiratory Studies, Castle Hill Hospital, Cottingham, UK.
| | - Alyn H Morice
- Department of Cardiovascular and Respiratory Studies, Castle Hill Hospital, Cottingham, UK
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The cough hypersensitivity syndrome: a novel paradigm for understanding cough. Lung 2009; 188 Suppl 1:S87-90. [PMID: 19809853 DOI: 10.1007/s00408-009-9185-z] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Accepted: 09/17/2009] [Indexed: 10/20/2022]
Abstract
For many years patients with chronic cough have been investigated in an attempt to diagnose the cause of the cough. Here I suggest that the overwhelming majority of patients with chronic cough have a single diagnosis: cough hypersensitivity syndrome. This is demonstrated by the homogeneous nature of the clinical history and investigational results of patients attending cough clinics. The hypersensitivity facet of the syndrome is demonstrated by objective testing with capsaicin and other protussive agents. Within the cough hypersensitivity syndrome there are different phenotypes. Those patients with a predominantly Th2-type immune response will develop eosinophilic inflammation and either cough-variant asthma or eosinophilic bronchitis. Those with predominantly heartburn symptoms will have a phenotype that reflects GERD and cough. However, the similarities between the different phenotypes far outweigh differences in a unifying diagnosis of the cough hypersensitivity syndrome, providing a more rational understanding of chronic cough.
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Fathi H, Moon T, Donaldson J, Jackson W, Sedman P, Morice AH. Cough in adult cystic fibrosis: diagnosis and response to fundoplication. Cough 2009; 5:1. [PMID: 19149907 PMCID: PMC2634760 DOI: 10.1186/1745-9974-5-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Accepted: 01/18/2009] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Gastroesophageal reflux is one of the most common causes of chronic cough in the general population. Reflux occurs frequently in patients with cystic fibrosis (CF). We undertook laparoscopic Nissen fundoplication in adult CF patients with a clinical diagnosis of reflux cough who had failed conventional medical therapies. OBJECTIVE We determined the response to the surgical route in the treatment of intractable reflux cough in CF. METHOD Patients with refractory cough were assessed by 24 h pH monitoring and oesophageal manometry. Pre-and post-operation cough, lung function and exacerbation frequency were compared. Cough was assessed by the Leicester Cough Questionnaire (LCQ), lung function by spirometry and exacerbation frequency was defined by comparing the postoperative epoch with a similar preoperatively. RESULTS Significant abnormalities of oesophageal function were seen in all patients studied. 6 patients (2 females), with the mean age of 34.5 years consented to surgery. Their mean number of reflux episodes was 144.4, mean DeMeester score was 39.2, and mean lower oesophageal sphincter pressure 12.4 mmHg. There was a small change in the FEV1 from 1.03 L to 1.17 (P = 0.04), and FVC improved from 2.62 to 2.87 (P = 0.05). Fundoplication lead to a marked fall in cough with the total LCQ score increasing from 11.9 to 18.3 (P = 0.01). Exacerbation events were reduced by 50% post operatively. CONCLUSION Whilst there is an obvious attention to respiratory causes of cough in CF, reflux is also a common cause. Fundoplication is highly effective in the control of reflux cough in CF. Significant reduction in exacerbation frequency may indicate that reflux with possible aspiration is a major unrecognised contributor to airway disease.
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Affiliation(s)
- Hosnieh Fathi
- Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, East Yorkshire, HU16 5JQ, UK
| | - Tanya Moon
- Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, East Yorkshire, HU16 5JQ, UK
| | - Jo Donaldson
- Dietetics Department, Castle Hill Hospital, Castle Road, Cottingham, East Yorkshire, HU16 5JQ, UK
| | - Warren Jackson
- Gastro-Intestinal Physiology Laboratory, Castle Hill Hospital, Cottingham, East Yorkshire, HU16 5JQ, UK
| | - Peter Sedman
- Division of Upper Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Hull Royal Infirmary, Anlaby Road, Hull, HU3 2JZ, UK
| | - Alyn H Morice
- Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, East Yorkshire, HU16 5JQ, UK
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