Cough in adult cystic fibrosis: diagnosis and response to fundoplication

Therapy Outcomes for Teenage Athletes With Exercise-Induced Laryngeal Obstruction

PURPOSE

This study examined treatment outcomes of speech-language pathology intervention addressing exercise-induced laryngeal obstruction (EILO) symptoms in teenage athletes.

METHOD

A prospective cohort design was utilized; teenagers diagnosed with EILO completed questionnaires during initial EILO evaluations, posttherapy, 3-month posttherapy, and 6-month posttherapy. Questionnaires examined the frequency of breathing problems, the use of the techniques taught in therapy, and the use of inhaler. Patients completed the Pediatric Quality of Life (PedsQL) inventory at all time points.

RESULTS

Fifty-nine patients completed baseline questionnaires. Of these, 38 were surveyed posttherapy, 32 at 3-month posttherapy, and 27 at 6-month posttherapy. Patients reported more frequent and complete activity participation immediately posttherapy (p = .017) as well as reduced inhaler use (p = .036). Patients also reported a significant reduction in the frequency of breathing problems 6-month posttherapy (p = .015). Baseline PedsQL physical and psychosocial scores were below normative range and were not impacted by therapy. Baseline physical PedsQL score significantly predicted frequency of breathing difficulty 6-month posttherapy (p = .04), as better baseline scores were associated with fewer residual symptoms.

CONCLUSIONS

Therapy with a speech-language pathologist for EILO allowed for more frequent physical activity following therapy completion and decreased dyspnea symptoms 6-month posttherapy. Therapy was associated with a decrease in inhaler use. PedsQL scores indicated mildly poor health-related quality of life even after EILO symptoms improved. Findings support therapy as an effective treatment for EILO in teenage athletes and suggest that dyspnea symptoms may continue to improve following discharge as patients continue using therapy techniques.

Oral care considerations for people with cystic fibrosis: a cross-sectional qualitative study

OBJECTIVES

To investigate the attitudes of adults with Cystic Fibrosis (CF) towards dental attendance and any perceived barriers to treatment.

METHODS

A cross sectional survey in the form of a structured, anonymous questionnaire was used to obtain information regarding adults with CF's feelings towards dentists and dental treatment. The final version of the questionnaire was based on a collaborative effort between researchers at Cork University Dental School and Hospital and Cystic Fibrosis (CF) patient advocates from CF Ireland. Participants were recruited via CF Ireland's mailing list and social media channels. The responses underwent descriptive statistical analysis and inductive thematic analysis.

RESULTS

A total of 71 people (33 Male: 38 Female) over the age of 18 living with CF in the Republic of Ireland responded to the survey. 54.9% of respondents were unhappy with their teeth. 63.4% felt that CF had an impact on oral health. 33.8% were anxious about attending their dentist. Respondents believed that CF has impacted on their oral health due to the medications and dietary requirements involved, as well as tiredness and other side effects of CF. Reasons for being anxious about attending the dentist included cross infection concerns, issues with the dentist, with tolerating treatment, and with the teeth themselves. Respondents wanted dentists to be aware of the practicalities of dental treatment for people with CF, especially their discomfort with lying back. They also want the dentist to be aware of the impact that their medication, treatment and diet has on their oral health.

CONCLUSIONS

Over one third of adults with CF reported anxiety about attending the dentist. Reasons for this included fear, embarrassment, cross infection concerns and problems with treatment, especially being in the supine position. Adults with CF want dentists to be aware of the impact that CF can have upon dental treatment and oral health care.

Chronic cough-the limitation and advances in assessment techniques

Accurate and consistent assessments of cough are essential to advance the understanding of the mechanisms of cough and individualised the management of patients. Considerable progress has been made in this work. Here we reviewed the currently available tools for subjectively and objectively measuring both cough sensitivity and severity. We also provided some opinions on the new techniques and future directions. The simple and practical Visual Analogue Scale (VAS), the Leicester Cough Questionnaire (LCQ), and the Cough Specific Quality of Life Questionnaire (CQLQ) are the most widely used self-reported questionnaires for evaluating and quantifying cough severity. The Hull Airway Reflux Questionnaire (HARQ) is a tool to elucidate the constellation of symptoms underlying the diagnosis of chronic cough. Chemical excitation tests are widely used to explore the pathophysiological mechanisms of the cough reflex, such as capsaicin, citric acid and adenosine triphosphate (ATP) challenge test. Cough frequency is an ideal primary endpoint for clinical research, but the application of cough counters has been limited in clinical practice by the high cost and reliance on aural validation. The ongoing development of cough detection technology for smartphone apps and wearable devices will hopefully simplify cough counting, thus transitioning it from niche research to a widely available clinical application.

Changing paradigms in the treatment of gastrointestinal complications of cystic fibrosis in the era of cystic fibrosis transmembrane conductance regulator modulators

Cystic fibrosis (CF) - although primarily a lung disease - also causes a variety of gastrointestinal manifestations which are important for diagnosis, prognosis and quality of life. All parts of the gastrointestinal tract can be affected by CF. Besides the well-known pancreatic insufficiency, gastroesophageal reflux disease, liver disease and diseases of the large intestine are important pathologies that impact on prognosis and also impair quality of life. Diagnosis and management of gastrointestinal manifestations will be discussed in this review. Since optimisation of CF therapy is associated with a significantly longer life-span of CF patients nowadays, also gastrointestinal malignancies, which are more common in CF than in the non-CF population need to be considered. Furthermore, novel evidence on the role of the gut microbiome in CF is emerging. The introduction of cystic fibrosis transmembrane conductance regulator (CFTR) protein modulators gives hope for symptom alleviation and even cure of gastrointestinal manifestations of CF.

Chronic cough in cystic fibrosis - the effect of modulator therapy on objective 24-hour cough monitoring

Cystic fibrosis (CF) is an autosomal recessive condition, deletion of phenylalanine at position 508 (F508del) being the most frequent mutation in CF patients. Kaftrio, also called Trikafta in the USA, (Vertex Pharmaceuticals Inc., Germany) is a licensed modulator therapy for CF patients with at least one F508del mutation [1]. Several clinical trials have demonstrated its efficacy [2]. However, the primary outcome measured in these studies was the change in per cent predicted of forced expiratory volume in 1 s (FEV₁), which was in the order of 10%, and thus may have a relatively low sensitivity in predicting efficacy, particularly in more severely affected patients [3].

This is a prospective observation of the effect of Kaftrio initiation in CF. An early and dramatic improvement in the objective measure of 24-h cough monitoring was observed, providing noninvasive, objective evidence of efficacy and compliance in CF.https://bit.ly/3LpnABB

Validation of a Spanish version of the Leicester Cough Questionnaire in cystic fibrosis

Cough is a main symptom in cystic fibrosis (CF). We aim to validate a Spanish version of the Leicester Cough Questionnaire (LCQ-Sp) to measure the impact of cough in CF bronchiectasis. A prospective longitudinal multicentre study was performed. Internal consistency and score changes over a 15-day period in stable state were assessed to analyse reliability. Concurrent validity was analysed by correlation with Saint George’s Respiratory Questionnaire (SGRQ) and convergent validity by assessing the association with clinical variables. Changes in scores between stable state and the first exacerbation were assessed to analyse responsiveness. 132 patients (29.73 ± 10.52 years) were enrolled in four hospitals. Internal consistency was high for the total score and good for the three domains (Cronbach’s α 0.81–0.93). The test–retest reliability showed an intraclass correlation coefficient of 0.86 for the total score. The correlation between LCQ-Sp and SGRQ scores was −0.74. The LCQ-Sp score negatively correlated with sputum volume, and the mean score decreased at the beginning of exacerbations (16.04±3.81 vs 13.91±4.29) with a large effect size. The LCQ-Sp is a reliable, repeatable and responsive instrument to assess the impact of cough in CF bronchiectasis and is responsive to change in the event of exacerbations.

Laparoscopic surgery in patients with cystic fibrosis: A systematic review

INTRODUCTION

Laparoscopic surgery may be advantageous for cystic fibrosis (CF) patients because it leads to fewer complications than open surgery. However, it could still lead to pulmonary and cardiovascular complications in CF patients. We aimed to systematically review the use of laparoscopic surgery in CF patients.

METHODS

A systematic review was performed in compliance with PRISMA guidelines. A literature search was performed using PubMed/MEDLINE, ScienceDirect, EMBASE, and Google Scholar, with "cystic fibrosis and laparoscopic surgery" and "cystic fibrosis and minimally invasive surgery" used as the search terms. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria were applied. The protocol was registered with the PROSPERO register.

RESULTS

Six studies met the predetermined inclusion criteria; accordingly, two studies provided high-quality evidence and four provided moderate-quality evidence. The interrater correlation was convincing (r_s  = .95, P = .02, two-tailed). Therefore, three quantitative studies and three qualitative studies were assessed and evidence-graded in accordance with the GRADE protocol.

CONCLUSION

The benefits of laparoscopic surgical interventions for patients with CF were supported with good evidential value and recognized as a safe and suitable surgical option.

Systems Biology and Bile Acid Signalling in Microbiome-Host Interactions in the Cystic Fibrosis Lung

The study of the respiratory microbiota has revealed that the lungs of healthy and diseased individuals harbour distinct microbial communities. Imbalances in these communities can contribute to the pathogenesis of lung disease. How these imbalances occur and establish is largely unknown. This review is focused on the genetically inherited condition of Cystic Fibrosis (CF). Understanding the microbial and host-related factors that govern the establishment of chronic CF lung inflammation and pathogen colonisation is essential. Specifically, dissecting the interplay in the inflammation–pathogen–host axis. Bile acids are important host derived and microbially modified signal molecules that have been detected in CF lungs. These bile acids are associated with inflammation and restructuring of the lung microbiota linked to chronicity. This community remodelling involves a switch in the lung microbiota from a high biodiversity/low pathogen state to a low biodiversity/pathogen-dominated state. Bile acids are particularly associated with the dominance of Proteobacterial pathogens. The ability of bile acids to impact directly on both the lung microbiota and the host response offers a unifying principle underpinning the pathogenesis of CF. The modulating role of bile acids in lung microbiota dysbiosis and inflammation could offer new potential targets for designing innovative therapeutic approaches for respiratory disease.

Current therapies for gastro-oesophageal reflux in the setting of chronic lung disease: state of the art review

The inter-relationship between chronic respiratory disease and reflux disease in the airway reflux paradigm is extremely complex and remains poorly characterised. Reflux disease is reported to cause or contribute to the severity of a number of respiratory tract diseases including laryngeal disorders, sinusitis, chronic cough, asthma, COPD, idiopathic pulmonary fibrosis, cystic fibrosis, bronchiectasis and bronchiolitis obliterans post lung transplant. It is now appreciated that reflux disease is not simply caused by liquid acid reflux but rather by a variety of chemical refluxates originating from the stomach and duodenum due to a number of different mechanisms. Reflux disease can be challenging to diagnose, particularly proving its role in the causation of direct respiratory epithelial damage. Significant advances in oesophageal assessment and gastric biomarkers have emerged in recent years as our understanding increases. There are a number of treatments available for reflux disease, both medical and surgical, but there is a paucity of large randomised trials to evaluate their efficacy in the setting of chronic respiratory disease. Everyday clinical practice, however, informs us that treatment failure in reflux disease is common. This clinical review summarises associations between reflux disease in the setting of chronic respiratory diseases and examines available evidence regarding potential therapeutic strategies.

Gastro-oesophageal reflux disease is prevalent among patients with chronic respiratory disease. A number of medical and surgical treatment options are available for GORD. This review examines available evidence in the setting of chronic lung disease.https://bit.ly/34TcMJS

Cystic Fibrosis and gastroesophageal reflux disease

Gastroesophageal reflux is common in children and adults with cystic fibrosis (CF). Pathological gastroesophageal reflux disease (GERD) is also frequent in patients of all ages with CF. This article reviews the pathophysiology, diagnostic work-up, management options, complications, and future directions in the evaluation and management of GERD - unique to and pertinent for - patients with CF in particular.

Effect of Ivacaftor on Objective and Subjective Measures of Cough in Patients with Cystic Fibrosis

Background and Objectives:

Cough is a major symptom in cystic fibrosis. Ivacaftor is a novel drug which targets the G551D mutation and has been demonstrated to improve lung function and weight in the long term. It also improves symptoms of extra-oesophageal reflux. We wanted to evaluate the effect of ivacaftor on cough in cystic fibrosis.

Methods:

In two patients with cystic fibrosis the Hull Airway Reflux Questionnaire (HARQ) was completed and objective cough counts were measured prior to and within 4 weeks after initiation of treatment with ivacaftor. Spirometry was also undertaken and weight checked at these time frames.

Results:

In the first patient the HARQ score decreased from 29 to 11 and objective cough counts from 29 to 9 cough events per hour. Similarly in the second patient the HARQ score decreased from 13 to 9 and objective cough count from 76 to 5 cough events per hour. There was no significant change in spirometric parameters or weight.

Conclusion:

We have observed early subjective and objective improvement in cough measures on treatment with ivacaftor. We suggest that this improvement could be attributed to improvement of gastro-intestinal function and that cough metrics could be used as early and accurate end points of drug efficacy.

Bile acid aspiration in people with cystic fibrosis before and after lung transplantation

Cystic fibrosis (CF) is a genetic condition that is caused by abnormalities in the CF transmembrane conductance regulator (CFTR) gene. People with CF experience life-long morbidity and premature mortality, the vast majority of which is associated with lung disease.

Bile acids are detectable in the lower airway in advanced CF lung disease and persist after lung transplantationhttp://ow.ly/RTvNW

Validity of a Spanish Version of the Leicester Cough Questionnaire in Children With Cystic Fibrosis

BACKGROUND

Cystic fibrosis (CF) patients present chronic cough as one of the main symptoms, which has an important effect on quality of life and social relations. Our goal was to validate the Spanish version of the Leicester Cough Questionnaire (LCQ) in a group of children and teenagers with CF.

METHODS

After adapting to Spanish by standardized translation and retro-translation methodology, a sample of 58 stable CF patients from 7 to 18 years were recruited from three CF specialized centers in Spain. The questionnaire was administered twice; the second administration (LCQ2) was performed between 2-4 weeks later than the first one (LCQ1), in order to analyse the reliability and validity of the Spanish version. To correlate results with health related quality of life (HRQoL) we used the Cystic Fibrosis Questionnaire-Revised (CFQ-R).

RESULTS

Population was composed by 62% male, age 11.7 ± 3.1 years and body mass index (BMI) 19 ± 3 kg/m(2). Total scores from LCQ were: LCQ1 19 (17.75-21) vs LCQ2 19 (16-21) (P=.199). Cronbach's Alpha coefficient was 0.83 for the LCQtotal and for each specific domain was: 0.82 LCQphysical; 0.74 LCQpsychological and 0.62 LCQsocial. Intraclass correlation coefficient was: 0.69 LCQphysical; 0.59 LCQpsychological; 0.45 LCQsocial and 0.71 LCQtotal (good reliability). Relations with CFQ-R showed moderated and significant results: for the LCQtotal: respiratory symptom domain r = 0,51 (P<.001) and physical capacity domain r = 0,62 (P<.05).

CONCLUSION

The Spanish version of the Leicester Cough Questionnaire is reliable and valid for children and adolescents with CF and it has good relations with health related quality of life in this population.

Cystic fibrosis: a surgical matter?

BACKGROUND

Gastroesophageal reflux disease (GERD) is very common in patients with chronic lung diseases. We evaluated the incidence of GERD in young patients with cystic fibrosis (CF) and defined the characteristics of gastroesophageal reflux episodes analyzed by pH-multichannel intraluminal impedance (pH-MII) and esophagogastric scintigraphy.

PATIENTS AND METHODS

Since 2010, 31 patients with CF underwent pH-MII. Scintigraphy and upper endoscopy were performed in positive GERD patients. Forced expiratory volume in 1 second (FEV1%) predicted was detected.

RESULTS

pH-MII was positive in 17/31 (54.8%) patients (mean age: 12.4 years; range: 4-17 years). pH monitoring detected an average of 64.6 acid reflux events 4.4 episodes >5 minutes in duration. The DeMeester score was 38.5. Impedance identified a mean number of reflux episodes of 66 (65.2% acid; 32% weakly acidic; 2.8% nonacidic), 28% of which reached the proximal esophagus. Esophageal transit and gastric emptying were delayed in 6/13 (46.1%) and in 5/15 (33.3%) cases, respectively. No differences were found in lung function between positive and negative GERD patients (P=0.88).

CONCLUSIONS

Pediatric patients with CF have a high incidence of GERD with acidic events. These patients should be investigated with pH-MII and scintigraphy in order to make an early diagnosis and determine the most appropriate follow-up.

Gastrointestinal complications of cystic fibrosis

The cystic fibrosis transmembrane regulator protein (CFTR) is an ion channel in the apical surface of epithelial membranes that regulates other ion channels. Dysfunction of CFTR leads to the clinical entity of CF when mutations in CFTR are inherited in an autosomal recessive fashion. Although airway obstruction, inflammation, and infection are usually the most serious consequences of CFTR dysfunction because they lead to respiratory failure, CFTR dysfunction affects the intestinal tract and the pancreatic and hepatobiliary ducts in a similar fashion, leading to significant morbidity. This review outlines pathophysiology and common gastrointestinal ailments in the CF population along with current medical and surgical management.

Airway reflux, cough and respiratory disease

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.

Fundoplication in chronic intractable cough

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.

Gastroesophageal reflux in cystic fibrosis: current understandings of mechanisms and management

Cystic fibrosis (CF) is an inherited disease that affects both the lungs and the digestive system in children and adults. Thick mucus fills the gut and blocks lumens of the pancreas and hepatobiliary systems, creating insufficient pancreas function and liver disease. Chronic gastrointestinal (GI) complications, including intestinal obstruction, occur in neonates, and poor digestion and gastroesophageal reflux disease (GERD) in children. Although GI symptoms tend to improve with age, CF and associated GERD eventually create respiratory insufficiency; the only available treatment option at this stage is a bilateral lung transplant, which carries considerable morbidity and mortality. While GERD may reoccur as a complication of lung transplantation, GERD symptoms are often reduced following a fundoplication.

The impact of reflux burden on Pseudomonas positivity in children with cystic fibrosis

OBJECTIVES

Nonacid gastroesophageal reflux (GER), particularly in patients taking acid suppression, has been implicated as a cause of respiratory infections. We hypothesize that children with cystic fibrosis (CF) and a higher nonacid reflux burden have greater rates of Pseudomonas aeruginosa (Pa) infection than patients with a lower reflux burden.

STUDY DESIGN

We reviewed the multichannel intraluminal impedance (pH-MII) tracings of 35 patients with CF between 2003 and 2010. We compared the reflux profiles between those patients who were Pa positive and Pa negative.

RESULTS

The mean age was 13.5 ± 5.8 years. Twenty-seven patients (76%) were Pa positive. Ninety seven percent of patients were taking proton pump inhibitors during pH-MII testing. The mean percentage of time pH was <4 was 8.5 ± 12%. Pa patients had a significantly higher total, acid and proximal nonacid reflux burden (P < 0.009). There was a negative correlation between nonacid reflux burden and FEV1 (r = -0.397, P = 0.03) and between total number of reflux events and FEV1 (r = -0.474, P = 0.009). After adjusting for age and FEV1, total reflux burden remains significantly associated with Pa positivity (P = 0.055).

CONCLUSIONS

Increased reflux burden may predispose patients to Pa infection and worse lung function.

Cough hypersensitivity syndrome is an important clinical concept: a pro/con debate

The major etiologies of chronic cough are generally accepted to consist of upper airway cough syndrome (formerly postnasal drip syndrome), eosinophilic airway inflammation (asthma, nonasthmatic eosinophilic bronchitis), and gastroesophageal reflux disease (GERD). However, only a small percentage of patients with these very common conditions suffers from chronic cough. Furthermore, acute cough due to viral upper respiratory tract infection (URI) is almost always a transient, self-limited condition, yet in a small subgroup of patients, URI heralds the onset of chronic, refractory cough. The cough hypersensitivity syndrome has been proposed to explain the occurrence of chronic cough in a subgroup of patients exposed to the same putative triggers as the vast majority of the population in whom chronic cough does not result. Although conceptually the cough hypersensitivity syndrome may be intellectually satisfying, differences of opinion remain as to whether this newly recognized entity is of clinical significance, i.e., useful for the treatment of patients suffering from chronic cough. The Third American Cough Conference, held in New York in June 2011, provided an ideal forum for the debate of this issue between two internationally recognized authorities in the field of cough.

Gastric emptying and different types of reflux in adult patients with cystic fibrosis

BACKGROUND

Increased gastro-oesophageal reflux (GER) is common in patients with cystic fibrosis (CF). Previous studies showed delayed gastric emptying (GE) and a high prevalence of bile acids in saliva suggesting duodenogastro-oesophageal reflux (DGER).

AIM

To assess different types of reflux (acid, weakly acidic and bile) and their relationship with rate of GE in adult CF patients.

METHODS

Gastric emptying was assessed in 33 CF patients using breath tests, reflux was monitored in 42 patients using impedance-pH-metry and 14 CF patients underwent combined impedance-pH-Bilitec monitoring.

RESULTS

Delayed GE was found in 33%, increased GER (predominantly acid) in 67% and pathological DGER in 35% of the CF patients. There was a significant correlation between oesophageal bile and acid exposure (P < 0.0001, r = 0.85). Patients with increased DGER had a higher proximal extent of reflux compared to those without DGER [17 (9-35) vs. 5 (1-12), P = 0.04]. There was no correlation between GE and reflux parameters, however, in a subgroup of 10 patients studied by impedance-pH-Bilitec and GE, there was a strong correlation between GE rate and bile exposure (P = 0.005, r = 0.83).

CONCLUSIONS

Delayed gastric emptying is present in 1/3 of patients with cystic fibrosis. There is a subgroup of these patients with both delayed gastric emptying and increased acidic duodenogastro-oesophageal reflux with high proximal extent and risk of aspiration. Controlled studies should be performed to evaluate the effect of prokinetics or antireflux surgery on the clinical cystic fibrosis evolution in these patients.

Effect of different pH criteria on dual-sensor pH monitoring in the evaluation of supraesophageal gastric reflux in children

BACKGROUND AND AIM

Existing tests for supraesophageal gastric reflux (SEGR) that focus on pH drops <4 in the proximal esophagus have had limited sensitivity and specificity. The aim of the present study was to evaluate the effect of newly proposed pH criteria on SEGR detection.

PATIENTS AND METHODS

Twenty-four-hour dual-sensor pH tracings of 32 patients were reviewed. Proximal esophageal pH data were evaluated according to the conventional definition of pH drop <4 and 2 proposed definitions: pH drop <5.5 while upright and <5.0 while supine and pH drop of >10% from a running baseline. For each potential SEGR event, the preceding 1-minute window was examined for corresponding distal acid reflux.

RESULTS

Of the 542 distal acid reflux events detected, 200 were associated with a proximal pH drop <4; this number increased to 295 using the definition of proximal pH drop <5.5 (upright)/<5.0 (supine) and 301 using the definition of proximal pH drop >10%. A proportion of proximal events, however, was not associated with distal acid reflux: 21 of 200 (10.5%) proximal pH <4 events, 119 of 414 (29%) proximal pH <5.5 (upright)/<5.0 (supine) events, and 272 of 573 (47%) proximal pH drop >10% events lacked a preceding or simultaneous drop in distal pH <4.

CONCLUSIONS

Although the use of more liberal pH criteria increased the diagnostic yield for SEGR events with dual-sensor monitoring, a significant proportion of proximal pH events did not correlate with distal acid reflux. These events could represent either false-positive measurements or association with weakly acid reflux.

Future directions in treating cough

Cough is a common and troublesome symptom that can be difficult to treat. New therapeutic options that are safe and more effective than those currently available are needed. In this article, the authors offer opinion on future directions in the treatment of cough, with a particular emphasis on the clinical syndrome associated with cough reflex hypersensitivity. In addition, the article provides an overview of some of the diagnostic technologies and promising drug targets likely to emerge from current clinical and scientific endeavor.

Quality of life in patients with chronic cough

Chronic cough is a relatively common symptom for which effective, acceptable treatments are lacking. Many patients suffer frequent coughing over several years without resolution and this has significant physical, social and psychological consequences. The recent development of cough-specific quality-of-life tools now allows quantification of the burden of coughing both in patients specifically presenting with chronic cough and also in common respiratory conditions.

The management of cough: a clinical year in review

As the number of published articles in the field of cough increases year on year, it is sometimes helpful to pause and review what might have passed us by. This "Clinical Year in Review" provides an opportunity to reflect on a number of important studies reported in the area of both adult and pediatric cough. It would be impossible to cover all the important published literature; therefore, this effort has been confined to selected topics published in the last 12 months with direct relevance to the clinical management, measurement, and treatment of cough. While this article reflects a personal commentary of the literature, it is hoped that it will contribute to improving "evidence-based" care for the many individuals burdened with a troublesome cough.