A prospective evaluation of esophageal testing and a double-blind, randomized study of omeprazole in a diagnostic and therapeutic algorithm for chronic cough

Objective:Recent studies suggest an association between chronic cough and gastroesophageal reflux. Our study aims were 1) to define the prevalence of acid reflux induced cough in the general community, 2) to examine the ability of esophageal testing to identify gastroesophageal reflux related cough, and 3) to assess the utility of omeprazole in a chronic cough algorithm.Methods:Patients with chronic cough of unknown etiology, who were mostly from the community, were evaluated. Subjects underwent a chest x-ray, methacholine challenge test, and empiric trial of postnasal drip therapy, and completed daily cough symptom diaries subjectively evaluating cough frequency and severity on a graded scale of 0–4 (combined maximum 8). After excluding other causes of cough, the remaining patients underwent esophageal and pH testing. Those testing positive were randomized to omeprazole 40 mg b.i.d. or placebo for 12 weeks. Follow-up was 1 yr.Results:A total of 71 patients were screened; 48 were excluded. Twenty-three patients were evaluated for gastroesophageal reflux disease; six (26%) were eventually determined to have an acid-related cough. Of these patients, 17 had a positive pH test, six (35%) of whom showed a striking improvement or resolution of their cough during omeprazole treatment which was sustained for up to 1 yr. Six had a negative pH test, none of whom responded to omeprazole therapy. No significant differences were seen between responders (n = 6) and nonresponders (n = 11) for demographic factors, baseline symptom frequency and duration, or physiological parameters (motility/pH).Conclusions:Acid-related chronic cough was present in 26% (six of 23) of patients evaluated for gastroesophageal reflux disease. Esophageal testing does not reliably identify patients with acid induced chronic cough responsive to proton pump inhibitor therapy. We suggest that the best diagnostic and therapeutic approach, after excluding asthma and postnasal drip syndrome, is empiric treatment for 2 wk with a high dose proton pump inhibitor.

[1]  C. T. French,et al.  Chronic cough due to gastroesophageal reflux disease , 2002, Surgical Endoscopy.

[2]  L. Boulet,et al.  Managing cough as a defense mechanism and as a symptom. A consensus panel report of the American College of Chest Physicians. , 1998, Chest.

[3]  R. Sampliner,et al.  The clinical and economic value of a short course of omeprazole in patients with noncardiac chest pain. , 1998, Gastroenterology.

[4]  R. Irwin,et al.  From a prospective study of chronic cough: diagnostic and therapeutic aspects in older adults. , 1998, Archives of internal medicine.

[5]  D. Castell,et al.  Nocturnal recovery of gastric acid secretion with twice-daily dosing of proton pump inhibitors , 1998, American Journal of Gastroenterology.

[6]  A R Zinsmeister,et al.  Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. , 1997, Gastroenterology.

[7]  J. Richter,et al.  Twenty-four-Hour Ambulatory Esophageal pH Monitoring in the Diagnosis of Acid Reflux-Related Chronic Cough , 1997, Southern medical journal.

[8]  D. Castell,et al.  Pulmonary symptoms associated with gastroesophageal reflux: use of ambulatory pH monitoring to diagnose and to direct therapy. , 1996, The American journal of gastroenterology.

[9]  D. Castell,et al.  Persistent acid secretion during omeprazole therapy: a study of gastric acid profiles in patients demonstrating failure of omeprazole therapy. , 1996, The American journal of gastroenterology.

[10]  D. Castell,et al.  Optimal dosing of omeprazole 40 mg daily: effects on gastric and esophageal pH and serum gastrin in healthy controls. , 1996, The American journal of gastroenterology.

[11]  J. Richter,et al.  Asthma and gastroesophageal reflux: acid suppressive therapy improves asthma outcome. , 1996, The American journal of medicine.

[12]  D. Castell,et al.  Omeprazole for the treatment of posterior laryngitis. , 1995, American Journal of Medicine.

[13]  M. Pratter,et al.  An Algorithmic Approach to Chronic Cough , 1993, Annals of Internal Medicine.

[14]  R. Irwin,et al.  Chronic cough due to gastroesophageal reflux. Clinical, diagnostic, and pathogenetic aspects. , 1993, Chest.

[15]  Richter Je,et al.  The use of esophageal function tests. , 1993 .

[16]  S. Schappert.  National Ambulatory Medical Care Survey: 1991 summary. , 1993, Advance data.

[17]  A. Ing,et al.  Chronic persistent cough and clearance of esophageal acid. , 1992, Chest.

[18]  Schappert Sm.  National Ambulatory Medical Care Survey: 1992 summary. , 1994, Advance data.

[19]  G. Viegi,et al.  Respiratory symptoms and risk factors in an Arizona population sample of Anglo and Mexican-American whites. , 1991, Chest.

[20]  J. Richter,et al.  Prolonged ambulatory esophageal pH monitoring in the evaluation of gastroesophageal reflux disease. , 1990, American Journal of Medicine.

[21]  R. Irwin,et al.  Chronic cough. The spectrum and frequency of causes, key components of the diagnostic evaluation, and outcome of specific therapy. , 1990, The American review of respiratory disease.

[22]  R. Irwin,et al.  Chronic cough as the sole presenting manifestation of gastroesophageal reflux. , 1989, The American review of respiratory disease.

[23]  R. Irwin,et al.  Chronic persistent cough in the adult: the spectrum and frequency of causes and successful outcome of specific therapy. , 2015, The American review of respiratory disease.

[24]  T R DeMeester,et al.  Technique, indications, and clinical use of 24 hour esophageal pH monitoring. , 1980, The Journal of thoracic and cardiovascular surgery.

[25]  S. Spector,et al.  Standardization of bronchial inhalation challenge procedures. , 1975, The Journal of allergy and clinical immunology.

[26]  N. Mantel,et al.  [Epidemiology of persistent cough]. , 2015, Folia clinica internacional.