A causal relationship between cough and gastroesophageal reflux disease (GERD) has been established: a pro/con debate

[Specialist Guidelines of The German Respiratory Society for Diagnosis and Treatment of adult Patients Suffering from Cough]

This is the 4th edition of the Cough Guidelines of the German Respiratory Society written by respiratory, gastroenterology, ear-nose-throat specialists, including respiratory physiotherapists and speech pathology specialists; importantly, a patient representative was also involved.Compared with earlier versions we used a new methodology: after discussion in the guidelines group, we asked and answered the 12 most important and most frequent "key" questions regarding the clinical practice. The extent of the guideline could thus be significantly reduced.We added a short scientific background to each of the answers including the most recent references. The recommendations and statements were created in consensus and graded as strong, or weak. If sufficient literature was not available, we suggested discussing joint decisions with the patient.The 12 key questions are as follows:- Key question 1: The classification of cough (acute, i. e. up to three weeks duration; chronic, i. e. after 8 weeks duration and subacute in between) did not change, but we added "cough with or without expectoration as an additional classification aspect with therapeutic consequences.- Key question 2: Acute and subacute cough are mostly (but not exclusively) due to the common cold. They are the first or second most frequent symptom prompting patients to seek medical (or pharmacist's) care. Antibiotic therapy is strongly discouraged for common cold- Key question 3: We defined "Red flags" for mandatory immediate diagnostic for acute cough, which usually does not require such diagnostic procedures- Key question 4: Chronic cough overview of the most common causes for- Key question 5: Cough in acute SARS-CoV-2 infection and in long COVID - Key question 6: Refractory chronic cough and idiopathic chronic cough, two recently established entities were explained more in detail- Key question 7: To upper airway cough syndrome - Key question 8: Gastro-oesophageal-reflux-related cough - Key question 9: Cough-variant asthma and non-asthmatic eosinophilic bronchitis - Key question 10: Overview of drugs causing cough - Key question 11: Basic and personalized (due to the individual history) diagnostic procedures for patients with cough- Key question 12: Physiotherapy, speech therapy and pharmacotherapy for cough.

Identifying causal relationships between gastroesophageal reflux and extraesophageal diseases: A Mendelian randomization study

Traditional observational and in vivo studies have suggested an etiological link between gastroesophageal reflux disease (GERD) and the development of extraesophageal diseases (EEDs), such as noncardiac chest pain. However, evidence demonstrating potential causal relationships is lacking. This study evaluated the potential causal relationship between GERD and EEDs, including throat and chest pain, asthma, bronchitis, chronic rhinitis, nasopharyngitis and pharyngitis, gingivitis and periodontal disease, cough, using multiple Mendelian randomization (MR) methods, and sensitivity analysis was performed. The Mendelian randomization Pleiotropy RESidual Sum and Outlier and PhenoScanner tools were used to further check for heterogeneous results and remove outliers. MR with inverse-variance weighted (IVW) showed a significant causal relationship between GERD and EEDs after Bonferroni correction. IVW results indicated that GERD increased the risk of chronic rhinitis, nasopharyngitis and pharyngitis (odds ratio [OR] = 1.482, 95% confidence interval [CI] = 1.267-1.734, P < .001], gingivitis and periodontal disease (OR = 1.166, 95% CI = 1.046-1.190, P = .001), throat and chest pain (OR = 1.585, 95% CI = 1.455-1.726, P < .001), asthma (OR = 1.539, 95% CI = 1.379-1.717, P < .001), and bronchitis (OR = 1.249, 95% CI = 1.168-1.335, P < .001). Sensitivity analysis did not detect pleiotropy. Leave-one-out analysis shows that MR results were not affected by individual single nucleotide polymorphisms. The funnel plot considers the genetic instrumental variables to be almost symmetrically distributed. This MR supports a causal relationship among GERD and EEDs. Precise moderation based on causality and active promotion of collaboration among multidisciplinary physicians ensure high-quality diagnostic and treatment recommendations and maximize patient benefit.

Increased Sensitivity of Cough Reflex is Not the Mechanism of Cough Attributed to Laryngopharyngeal Reflux

OBJECTIVES

In laryngopharyngeal reflux (LPR) patients acid reaches laryngopharyngeal area and stimulates/sensitizes respiratory nerve terminals mediating cough. We addressed several hypothesis: if stimulation of respiratory nerves is responsible for coughing then acidic LPR should correlate with coughing and proton pump inhibitor (PPI) treatment should reduce both LPR and coughing. If sensitization of respiratory nerves is responsible for coughing then cough sensitivity should correlate with coughing and PPI should reduce both coughing and cough sensitivity.

STUDY DESIGN/METHODS

In this prospective single center study, patients with positive reflux symptom index (RSI > 13) and/or reflux finding score (RFS > 7) and ≥1 LPR episode/24 hours were enrolled. We evaluated LPR by dual channel 24-hour pH/impedance. We determined number of LPR events with pH drop at levels 6.0, 5.5, 5.0, 4.5, and 4.0. Cough reflex sensitivity was determined as lowest capsaicin concentration causing at least 2/5 coughs (C2/C5) by single breath capsaicin inhalation challenge. For statistical analysis C2/C5 values were -log transformed. Troublesome coughing was evaluated on the scale 0-5.

RESULTS

We enrolled 27 LPR patients. The number of LPR events with pH 6.0, 5.5, 5.0, 4.5, and 4.0 was 14[8-23],4[2-6],1[1-3],1[0-2] and 0[0-1], respectively. There was no correlation between number of LPR episodes at any pH level and coughing (Pearson range -0.34 to 0.21, P = NS). There was no correlation between cough reflex sensitivity C2/C5 and coughing (R = -0.29 to 0.34, P = NS). Of patients that completed PPI treatment, 11 had RSI normalized (18.36 ± 2.75 vs. 7 ± 1.35, P < 0.01). There was no change in cough reflex sensitivity in PPI-responders. C2 threshold was 1.41 ± 0.19 vs. 1.2 ± 0.19 (P = 0.11) before and after PPI.

CONCLUSIONS

No correlation between cough sensitivity and coughing and no change in cough sensitivity despite improvement of coughing by PPI argue that an increased cough reflex sensitivity is not mechanism of cough in LPR. We identified no simple relationship between LPR and coughing suggesting that this relationship is more complex.

The role of smoking and alcohol in mediating the effect of gastroesophageal reflux disease on lung cancer: A Mendelian randomization study

Observational studies have suggested a positive association between gastroesophageal reflux disease and lung cancer, but due to the existence of confounders, it remains undetermined whether gastroesophageal reflux disease (GERD) has a causal association with lung cancer. Therefore, Mendelian randomization (MR) analyses were applied to investigate the relationship between the two conditions. Two-sample Mendelian randomization analysis was utilized with summary genetic data from the European Bioinformatics Institute (602,604 individuals) and International Lung Cancer Consortium, which provides information on lung cancer and its histological subgroups. Furthermore, we used two-step Mendelian randomization and multivariable Mendelian randomization to estimate whether smoking initiation (311,629 cases and 321,173 controls) and alcohol intake frequency (n = 462,346) mediate any effect of gastroesophageal reflux disease on lung cancer risk. The Mendelian randomization analyses indicated that gastroesophageal reflux disease was associated with and significantly increased the risk of lung cancer (ORIVW = 1.35, 95% CI = 1.18-1.54; p = 1.36 × 10-5). Smoking initiation and alcohol intake frequency mediated 35% and 3% of the total effect of gastroesophageal reflux disease on lung cancer, respectively. The combined effect of these two factors accounted for 60% of the total effect. In conclusion, gastroesophageal reflux disease is associated with an increased risk of lung cancer, and interventions to reduce smoking and alcohol intake may reduce the incidence of lung cancer.

Heartburn as a Marker of the Success of Acid Suppression Therapy in Chronic Cough

Purpose

Gastro-oesophageal reflux disease (GORD) is commonly thought to play an important role in chronic cough and patients are often empirically treated with acid suppression therapy. We sought to investigate the response rate to acid suppression treatment in patients with and without heartburn attending two specialist cough clinics.

Methods

A retrospective review of 558 consecutive patients referred to two specialist cough clinics was performed (UK and USA). Patients who were treated with acid suppression were included and their documented response to treatment was collected. Binary logistic regression was used to ascertain the value of reported heartburn in predicting the response of chronic cough to acid suppression therapy.

Results

Of 558 consecutive referrals, 238 patients were excluded due to missing data or cough duration of < 8 weeks. The remaining 320 patients were predominantly female (76%), with mean age 61 yrs (± 13) and 96.8% non-smokers, with chronic cough for 36 (18–117) months. Of 72 patients with heartburn, 20 (28%) noted improvement in their cough with acid suppression, whereas of 248 without heartburn, only 35 (14%) responded. Patients reporting heartburn were 2.7 (95% C.I. 1.3–5.6) times more likely to respond to acid suppression therapy (p = 0.007).

Conclusion

In specialist cough clinics, few patients report a response of their chronic cough to acid suppression therapy. Nonetheless, heartburn is a useful predictor substantially increasing the likelihood of benefit.

Different clinical symptom patterns in patients with reflux micro-aspiration

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

Chronic cough caused by choledochoduodenal fistula: a case report

Background

Chronic cough is characterized by cough as the only or main symptom, with a duration of more than 8 weeks and no obvious abnormality in chest X-ray examination. Its etiology is complex, including respiratory disease, digestive system disease, circulation system disease, and psychological disease. Although a set of etiological diagnosis procedures for chronic cough have been established, it is still difficult to diagnose chronic cough and there are still some patients with misdiagnosis.

Case presentation

We present a case of a 54-year-old female patient who had chronic cough for 28 years. Physical examination had no positive signs and she denied any illness causing cough like tuberculosis, rhinitis. Recurrent clinic visits and symptomatic treatment didn’t improve the condition. Finally, gastroscopy identified the possible etiology of choledochoduodenal fistula that was proved by surgery. And after surgery, the patient's cough symptoms were significantly improved.

Conclusion

We report a rare case of chronic cough caused by choledochoduodenal fistula which demonstrates our as yet inadequate recognition of the etiology and pathogenesis. Written informed consent was obtained from the patient.

Positive bronchoalveolar lavage pepsin assay associated with viral and fungal respiratory infections in children with chronic cough

OBJECTIVE

To assess the association between commonly obtained endoscopic and serologic data and bronchoalveolar lavage pepsin assay (BAL) results in children with chronic cough.

STUDY DESIGN

We performed a retrospective chart review of 72 children with a BAL pepsin obtained through our Aerodigestive Center over an 18-month period. BAL outcomes include evidence of viral, bacterial, or fungal infection, presence of lipid-laden macrophages, and cytology (eosinophils, neutrophils, and lymphocytes). Gastrointestinal outcomes include esophagogastroduodenoscopy (EGD) and pH impedance probe findings. Other characteristics include serum eosinophils, neutrophils, and lymphocytes; spirometry; FeNO; and IgE.

RESULTS

Seventy-two patients underwent BAL pepsin testing. Median age was 4.9 years, 30.6% had severe persistent asthma, and 59.2% were on reflux medication. There was an association between positive BAL pepsin assay and positive viral panel (p = .002) or fungal culture (p = .027). No significant association found between positive BAL bacterial culture; BAL cytology; the presence of BAL lipid-laden macrophages; IgE; spirometry; FeNO; CBC neutrophil, eosinophil, or lymphocytes; pH impedance testing parameters; or EGD pathology.

CONCLUSIONS

BAL pepsin is associated with a positive BAL viral PCR or fungal culture. Lack of correlation between pepsin-positivity and pH-impedance parameters or EGD pathology suggests microaspiration may be due to an acute event (such as a respiratory infection) rather than chronic gastroesophageal reflux disease. This may be especially true in the presence of a positive viral panel or fungal culture when a BAL pepsin is obtained.

Gastroesophageal Reflux Disease-Associated Chronic Cough: A Population-Based Analysis of Patient Presentations in the United States

Gastroesophageal reflux disease is an extremely prevalent illness in the United States; however, clinicians report that its association with chronic cough is often overlooked and undiagnosed. We used the CERNER Health Facts® database to analyze the statistical prevalence. Our findings indicate that there is a minority of patients who are untreated for this common complaint. We propose considering this on the differential diagnosis and following current treatment guidelines with proton pump inhibitors to effectively treat this complaint.

Aerodigestive Disease in Dogs

Aerodigestive disorders (AeroDs) in people encompass a wide range of clinical syndromes, reflecting the complex relationship between the respiratory and digestive tracts. In veterinary medicine, aspiration is used interchangeably with aspiration pneumonia. Although aspiration pneumonia is a common disorder in dogs, it does not reflect the breadth of AeroDs. Unfortunately, AeroDs rarely are investigated in veterinary medicine because of lack of clinical recognition, limitations in available diagnostics, and the fact that AeroDs may be caused by occult digestive disease. Recognizing patients with AerodD represents an area of significant clinical importance that may provide additional areas of clinical intervention.

The role of ambulatory 24-hour esophageal manometry in clinical practice

High-resolution manometry revolutionized the assessment of esophageal motility disorders and upgraded the classification through the Chicago Classification. A known disadvantage of standard HRM, however, is the inability to record esophageal motility function for an extended time interval; therefore, it represents only a more snapshot view of esophageal motor function. In contrast, ambulatory esophageal manometry measures esophageal motility over a prolonged period and detects motor activity during the entire circadian cycle. Furthermore, ambulatory manometry has the ability to measure temporal correlations between symptoms and motor events. This article aimed to review the clinical implications of ambulatory esophageal manometry for various symptoms, covering literature on the manometry catheter, interpretation of findings, and relevance in clinical practice specific to the evaluation of non-cardiac chest pain, chronic cough, and rumination syndrome.

Chronic cough in adults

Cough, a defense mechanism for clearing the airways of secretions, exudate, or foreign bodies, may become a troublesome symptom. Chronic cough, one of the most frequent symptoms requiring medical attention, is often not due to identifiable causes in adults. Chronic productive cough defines chronic bronchitis, and thus is present in 100% of these patients, and frequently in patients with bronchiectasis, cystic fibrosis, and chronic infectious respiratory diseases. However, chronic cough is most frequently dry. Thus, chronic cough in adults is a difficult syndrome requiring multidisciplinary approaches, particularly to diagnose and treat the most frequent identifiable causes, but also to decide which patients may benefit by treating the central cough hypersensitivity by neuromodulatory therapy and/or non-pharmacologic treatment (speech pathology therapy). Recent guidelines provide algorithms for diagnosis and assessment of cough severity; particularly chronic cough in adults. After excluding life-threatening diseases, chronic cough due to identifiable causes (triggers and/or diseases), particularly smoking and/or the most frequent diseases (asthma, chronic bronchitis, chronic obstructive pulmonary disease, eosinophilic bronchitis, and adverse reactions to drugs [angiotensin-converting enzyme inhibitors and sitagliptin]) should be treated by avoiding triggers and/or according to guidelines for each underlying disease. In patients with troublesome chronic cough due to unknown causes or persisting even after adequate avoidance of triggers, and/or treatment of the underlying disease(s), a symptomatic approach with neuromodulators and/or speech pathology therapy should be considered. Additional novel promising neuromodulatory agents in clinical development (e.g., P2X3 inhibitors) will hopefully become available in the near future.

Indian consensus on gastroesophageal reflux disease in adults: A position statement of the Indian Society of Gastroenterology

The Indian Society of Gastroenterology developed this evidence-based practice guideline for management of gastroesophageal reflux disease (GERD) in adults. A modified Delphi process was used to develop this consensus containing 58 statements, which were generated by electronic voting iteration as well as face-to-face meeting and review of the supporting literature primarily from India. These statements include 10 on epidemiology, 8 on clinical presentation, 10 on investigations, 23 on treatment (including medical, endoscopic, and surgical modalities), and 7 on complications of GERD. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The prevalence of GERD in India ranges from 7.6% to 30%, being  < 10% in most population studies, and higher in cohort studies. The dietary factors associated with GERD include use of spices and non-vegetarian food. Helicobacter pylori is thought to have a negative relation with GERD; H. pylori negative patients have higher grade of symptoms of GERD and esophagitis. Less than 10% of GERD patients in India have erosive esophagitis. In patients with occasional or mild symptoms, antacids and histamine H2 receptor blockers (H2RAs) may be used, and proton pump inhibitors (PPI) should be used in patients with frequent or severe symptoms. Prokinetics have limited proven role in management of GERD.

Updates in the field of non-esophageal gastroesophageal reflux disorder

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.

THE ROLE OF THE TRANSDIAPHRAGMATIC PRESSURE GRADIENT IN THE PATHOPHYSIOLOGY OF GASTROESOPHAGEAL REFLUX DISEASE

ABSTRACT Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract in the Western world. GERD pathophysiology is multifactorial. Different mechanisms may contribute to GERD including an increase in the transdiaphragmatic pressure gradient (TPG). The pathophysiology of GERD linked to TPG is not entirely understood. This review shows that TPG is an important contributor to GERD even when an intact esophagogastric barrier is present in the setting of obesity and pulmonary diseases.

Determinants of reflux-induced chronic cough

OBJECTIVE

Gastro-oesophageal reflux is considered to be an important contributing factor in chronic unexplained cough. It remains unclear why some reflux episodes in the same patient causes cough while others do not. To understand more about the mechanism by which reflux induces cough, we aimed to identify factors which are important in triggering cough.

DESIGN

In this multicentre study, 49 patients with reflux-associated chronic cough were analysed using 24-hour pH-impedance-pressure monitoring. The characteristics of reflux episodes that were followed by cough were compared with reflux episodes not associated with cough.

RESULTS

The majority (72.4%) of the reflux episodes were acidic (pH<4). Compared with reflux episodes that were not followed by cough, reflux episodes that were followed by a cough burst were associated with a higher proximal extent (p=0.0001), a higher volume clearance time (p=0.002) and a higher acid burden in the preceding 15 min window (p=0.019) and higher reflux burden in the preceding 30 min window (p=0.044). No significant difference was found between the two groups when looking at the nadir pH, the pH drop, the acid clearance time or the percentage of reflux episodes which were acidic.

CONCLUSIONS

The presence of a larger volume of refluxate and oesophageal exposure to reflux for a longer period of time seems to play an important role in inducing cough, while the acidity of the refluxate seems to be less relevant. This helps explain the observation that most patients with chronic cough tend not to benefit from acid inhibitory treatment.

Non-astmatic Eosinophilic Bronchitis

Non-asthmatic eosinophilic bronchitis (NAEB) is eosinophilic inflammation of the respiratory tract, without any bronchospasm. In this article, we want to draw attention to the NAEB. It should also be considered in differential diagnosis of chronic cough. Eosinophilia is present in all induced or spontaneous sputum samples of NAEB patients. NAEB patients and asthmatic patients have similar airway inflammation. Remarkably, NAEB mainly occurs in the lower airways. Unlike asthma, mast cells in NAEB are active in the bronchial epithelium. Diagnosis is based on the clinical, radiological, and spirometric measurements of other causes of chronic cough (Post-nasal discharge syndrome, asthma, gastroesophageal reflux etc.) and the assessment of inflammation in the lower respiratory tract. Airway inflammation can be assessed by sputum induction. The main treatment is anti-inflammatory therapy with inhaled corticosteroids and taking protective measures if inflammation is due to occupational exposure or allergen inhalation. If NAEB is untreated, it may be transient, episodic, or persistent; rarely, long-term oral steroid treatment may be required in patients. There is a requirement for studies that investigate the role of non-invasive markers of chronic inflammation associated with NAEB and the effectiveness of other treatments.

Chronic cough: clinical characteristics and etiologies of 510 cases

BACKGROUND/AIM

To investigate the clinical features and underlying etiologies of chronic cough (CC).

MATERIALS AND METHODS

Five hundred and ten CC patients were enrolled. The phases, characteristics and associated clinical manifestations of CC among the gastroesophageal reflux cough (GERC), cough-variant asthma (CVA), and upper airway cough syndrome (UACS) groups were compared, and the diagnostic values of each group were evaluated by multiple regression analysis.

RESULTS

In the 510 patients, 404 had CC with single etiology-GERC (n = 175), CVA (n = 134), and UACS (n = 95). The characteristic features of GERC included gastric acid backflow symptoms such as sour-tasting regurgitation, heartburn, endoscopic esophagitis, poststimulation cough, frequent throat clearing, daytime mono-cough, and feelings of heaviness and pain in the chest. Patients with CVA typically exhibited sensitivity to smog and other irritants; the cough occurred mostly at night, and was associated with positive bronchodilator and provocation test results. The typical features of UACS included a history and/or symptoms of rhinitis, retropharyngeal postnasal drip, and wet cough occurring mostly during the daytime. The diagnostic specificities of above factors were >70%.

CONCLUSION

The most common causes of CC include GERC, CVA, and UACS, and their diagnosis is based on the characteristics of the underlying disease.

Inhaled Beta Agonist Bronchodilator Does Not Affect Trans-diaphragmatic Pressure Gradient but Decreases Lower Esophageal Sphincter Retention Pressure in Patients with Chronic Obstructive Pulmonary Disease (COPD) and Gastroesophageal Reflux Disease (GERD)

BACKGROUND

Chronic obstructive pulmonary disease (COPD) patients have a high incidence of gastroesophageal reflux disease (GERD) whose pathophysiology seems to be linked to an increased trans-diaphragmatic pressure gradient and not to a defective esophagogastric barrier. Inhaled beta agonist bronchodilators are a common therapy used by patients with COPD. This drug knowingly not only leads to a decrease in the lower esophageal sphincter (LES) resting pressure, favoring GERD, but also may improve ventilatory parameters, therefore preventing GERD.

AIMS

This study aims to evaluate the effect of inhaled beta agonist bronchodilators on the trans-diaphragmatic pressure gradient and the esophagogastric barrier.

METHODS

We studied 21 patients (mean age 67 years, 57 % males) with COPD and GERD. All patients underwent high-resolution manometry and esophageal pH monitoring. Abdominal and thoracic pressure, trans-diaphragmatic pressure gradient (abdominal-thoracic pressure), and the LES retention pressure (LES basal pressure-transdiaphragmatic gradient) were measured before and 5 min after inhaling beta agonist bronchodilators.

RESULTS

The administration of inhaled beta agonist bronchodilators leads to the following: (a) a simultaneous increase in abdominal and thoracic pressure not affecting the trans-diaphragmatic pressure gradient and (b) a decrease in the LES resting pressure with a reduction of the LES retention pressure.

CONCLUSION

In conclusion, inhaled beta agonist bronchodilators not only increase the thoracic pressure but also lead to an increased abdominal pressure favoring GERD by affecting the esophagogastric barrier.

Chronic cough and a normal chest X-ray - a simple systematic approach to exclude common causes before referral to secondary care: a retrospective cohort study

Chronic cough is common in the community and can cause significant morbidity. It is not clear how closely treatment guidelines are used in general practice, or how often specialist referral is indicated. We aimed to assess the management of chronic cough in primary care before referral to a cough clinic, and to assess the outcome of managing chronic cough with an approach of simple investigation and empirical treatment trials. Data were extracted from the records of all patients attending a district general hospital respiratory clinic over a two-year period with isolated chronic cough lasting ⩾8 weeks. The clinic assessed symptoms with a cough-severity visual analogue scale and the Leicester Cough Questionnaire. Among 266 patients, the most frequent diagnoses were asthma (29%), gastro-oesophageal reflux (22%) and angiotensin-converting enzyme inhibitor use (14%). In all, 12% had unexplained chronic cough. Common diagnoses had often not been excluded in primary care: only 21% had undergone spirometry, 86% had undergone chest radiography and attempts to exclude asthma with corticosteroids had been made only in 39%. In the clinic few investigations were conducted that were not available in primary care. Substantial improvements in symptoms occurred with a median (interquartile range) total of 2 (2–3) clinic visits. We estimated that 87% of patients could have been managed solely in primary care; we did not identify distinguishing characteristics among this group. Most cases of chronic cough referred to secondary care could be managed with a simple and systematic approach, which is potentially transferrable to a community setting.

Regulation of cough by neuronal Na(+)-K(+) ATPases

The Na(+)-K(+) ATPases play an essential role in establishing the sodium gradients in excitable cells. Multiple isoforms of the sodium pumps have been identified, with tissue and cell specific expression patterns. Because the vagal afferent nerves regulating cough must be activated at sustained high frequencies of action potential patterning to achieve cough initiation thresholds, it is a certainty that sodium pump function is essential to maintaining cough reflex sensitivities in health and in disease. The mechanisms by which Na(+)-K(+) ATPases regulate bronchopulmonary vagal afferent nerve excitability are reviewed as are potential therapeutic strategies targeting the sodium pumps in cough.

Republished: symptomatic reflux disease: the present, the past and the future

The worldwide incidence of GORD and its complications is increasing along with the exponentially increasing problem of obesity. Of particular concern is the relationship between central adiposity and GORD complications, including oesophageal adenocarcinoma. Driven by progressive insight into the epidemiology and pathophysiology of GORD, the earlier belief that increased gastroesophageal reflux mainly results from one dominant mechanism has been replaced by acceptance that GORD is multifactorial. Instigating factors, such as obesity, age, genetics, pregnancy and trauma may all contribute to mechanical impairment of the oesophagogastric junction resulting in pathological reflux and accompanying syndromes. Progression of the disease by exacerbating and perpetuating factors such as obesity, neuromuscular dysfunction and oesophageal fibrosis ultimately lead to development of an overt hiatal hernia. The latter is now accepted as a central player, impacting on most mechanisms underlying gastroesophageal reflux (low sphincter pressure, transient lower oesophageal sphincter relaxation, oesophageal clearance and acid pocket position), explaining its association with more severe disease and mucosal damage. Since the introduction of proton pump inhibitors (PPI), clinical management of GORD has markedly changed, shifting the therapeutic challenge from mucosal healing to reduction of PPI-resistant symptoms. In parallel, it became clear that reflux symptoms may result from weakly acidic or non-acid reflux, insight that has triggered the search for new compounds or minimally invasive procedures to reduce all types of reflux. In summary, our view on GORD has evolved enormously compared to that of the past, and without doubt will impact on how to deal with GORD in the future.

Clinical perspective - cough: an unmet need

Cough is among the most common complaints for which individuals worldwide seek medical attention. The vast majority of cases of acute cough (<3 weeks duration) are due to acute viral upper respiratory tract infection (URI) (common cold). Fortunately, acute cough is typically transient and self-limited. However, should severe and/or persistent acute cough require pharmacological treatment, satisfactory therapeutic options are scarce. Narcotic antitussives are limited by unacceptable side effects at therapeutic doses, and most over-the-counter (OTC) remedies are not supported by adequate clinical trials. The goal in chronic cough (>8 weeks duration) is to meticulously evaluate and treat all potential underlying etiologies. Despite thorough investigation, a significant minority of patients will suffer refractory, unexplained cough. For this challenging population, safe, effective, non-narcotic antitussive therapies are desperately needed.

[Persistent coughs in children and adolescents]

A persistent cough lasting more than 4-8weeks should lead to a diagnostic workup. A detailed history and a full clinical examination, with a chest X-ray, are essential for initial assessment. Most reported causes of chronic cough in children are post-nasal drip syndrome, cough variant asthma (a spirometry with test of bronchodilator responsiveness should be attempted in children old enough to perform the manoeuvres). GERD is often suspected but a causal relationship is difficult to establish. Protracted bacterial bronchitis, post-infectious cough (B. pertussis, Mycoplasma) and somatoform respiratory disorders (including hyperventilation syndrome) are also common. Signs which are pointers suggesting an underlying respiratory or systemic disease require further investigation: inhaled foreign bodies, cystic fibrosis and chronic lung diseases with bronchiectasis, airway abnormalities, interstitial lung diseases need to be considered. Recent reports of refractory coughs have identified features of a sensory neuropathy disorder, and might explain persistent cough triggers.

Chronic dry cough: Diagnostic and management approaches

Cough is the most common symptom for which medical treatment is sought in the outpatient setting. Chronic dry cough poses a great diagnostic and management challenge due to myriad etiologies. Chronic cough has been commonly considered to be caused by gastroesophageal reflux, post-nasal drip or asthma. However, recent evidences suggest that many patients with these conditions do not have cough, and in those with cough, the response to specific treatments is unpredictable at best. This raises questions about the concept of a triad of treatable causes for chronic cough. This article discusses the mechanism and etiology of cough, along with recent advances in the field of cough, highlighting some of the diagnostic and management challenges.

The association of premorbid diseases with chronic rhinosinusitis with and without polyps

PURPOSE OF REVIEW

To review the recent insights regarding the epidemiology of adult chronic rhinosinusitis (CRS), with particular attention to its association with other premorbid conditions. Identifying premorbid disease associations establishes potential risk factors for developing CRS and helps corroborate current postulates of the various pathophysiologic mechanisms involved with the development and persistence of paranasal sinus inflammation.

RECENT FINDINGS

Recent findings demonstrate that the diagnosis of CRS is associated with a higher premorbid prevalence of upper airway diseases, lower airway diseases, gastroesophageal reflux disease, diseases of epithelial tissues, autoimmune disorders, and psychiatric conditions. Although some of these conditions have long been associated with CRS, improvements in study design and future studies in the general population will more accurately estimate the relative strengths of associations, clinical relevance, and temporal relationship of these various conditions in relation to the development of CRS.

SUMMARY

The predisposing patterns of premorbid illnesses may provide valuable information regarding the underlying causes of CRS and allow for both therapeutic and preventive interventions. There remains conflicting evidence within the literature regarding the association of CRS with some medical conditions, signifying the need for continued research on the subject. Limitations of the current studies include small sample sizes, lack of prospective longitudinal or interventional studies that help establish causality, and variable criteria for diagnosis of CRS in the outpatient setting.

Symptomatic reflux disease: the present, the past and the future

The worldwide incidence of GORD and its complications is increasing along with the exponentially increasing problem of obesity. Of particular concern is the relationship between central adiposity and GORD complications, including oesophageal adenocarcinoma. Driven by progressive insight into the epidemiology and pathophysiology of GORD, the earlier belief that increased gastroesophageal reflux mainly results from one dominant mechanism has been replaced by acceptance that GORD is multifactorial. Instigating factors, such as obesity, age, genetics, pregnancy and trauma may all contribute to mechanical impairment of the oesophagogastric junction resulting in pathological reflux and accompanying syndromes. Progression of the disease by exacerbating and perpetuating factors such as obesity, neuromuscular dysfunction and oesophageal fibrosis ultimately lead to development of an overt hiatal hernia. The latter is now accepted as a central player, impacting on most mechanisms underlying gastroesophageal reflux (low sphincter pressure, transient lower oesophageal sphincter relaxation, oesophageal clearance and acid pocket position), explaining its association with more severe disease and mucosal damage. Since the introduction of proton pump inhibitors (PPI), clinical management of GORD has markedly changed, shifting the therapeutic challenge from mucosal healing to reduction of PPI-resistant symptoms. In parallel, it became clear that reflux symptoms may result from weakly acidic or non-acid reflux, insight that has triggered the search for new compounds or minimally invasive procedures to reduce all types of reflux. In summary, our view on GORD has evolved enormously compared to that of the past, and without doubt will impact on how to deal with GORD in the future.