Med 2000 Dec;94(12):1166-70
Effects of anti-reflux surgery on chronic cough and asthma in patients
gastro-oesophageal reflux disease.
Ekstrom T, Johansson KE
Department of Pulmonary Medicine, University Hospital, Linkoping, Sweden.
This two-group prospective study evaluated the effect of anti-reflux
(fundoplication) on 24 patients with severe gastro-oesophageal reflux
(GORD) and concomitant asthma (n=13) or chronic cough (n=11). Twenty-four
oesophageal pH monitoring and lung function tests (FEV1, FVC) were done
and within 1 year after anti-reflux surgery. A diary was kept by the
during the 4-week period prior to surgery and during 4-week periods 6 and
months postoperatively, with daily monitoring of peak expiratory flow
respiratory and reflux symptoms and medication. In non-asthmatic patients,
coughing was reduced by 47% and 80% during the day and night,
months after surgery (P < 0.01). Concomitant hoarseness and
also significantly reduced (P<0.05). No effect on lung function was
patients with asthma, small, non-significant reductions in asthma symptom
and consumption of rescue medication were seen. Twenty-two patients were
completely free from their GORD symptoms after surgery. In conclusion,
anti-reflux surgery in patients with GORD had a more favourable effect on
concomitant cough than concomitant asthma.
Am J Med 2000 Feb;108(2):179
The association of chronic cough with the risk of myocardial infarction:
Framingham Heart Study.
Hahn DL, McBride PE, Pasternak AV
Eur Respir J 2000 Oct;16(4):633-8
Chronic cough and gastro-oesophageal reflux: a double-blind
study with omeprazole.
Kiljander TO, Salomaa ER, Hietanen EK, Terho EO
Dept. of Pulmonary Diseases, Turku University Central Hospital, Finland.
Gastro-oesophageal reflux (GOR) is an important cause of chronic cough.
has been a lack of placebo-controlled trials treating GOR related chronic
with antireflux therapy. The aim of this study was to determine the
omeprazole on GOR related chronic cough. After excluding other common
cough, oesophageal pH monitoring was performed on 48 patients with chronic
cough. Twenty-nine patients found to have GOR were randomized in a
fashion to receive omeprazole 40 mg o.d. or placebo for 8 weeks. After a
washout period, patients were crossed over to the other treatment.
recorded daily in a diary. Twenty-one patients completed both treatment
Cough (p=0.02) and gastric symptoms (p=0.003) improved significantly
omeprazole treatment in twelve patients who received placebo during the
and omeprazole during the second 8-week period. In nine patients who
omeprazole during the first 8-week period, amelioration in cough reached
statistical significance only after cessation of omeprazole. Gastric
also remained minor during placebo in these nine patients. Omeprazole 40
seems to improve chronic cough in patients with gastrooesophageal reflux
effect of omeprazole in ameliorating both cough and reflux symptoms
after treatment ceases.
Am J Gastroenterol 2000 Aug;95(8 Suppl):S9-14
Gastroesophageal reflux and chronic cough.
Irwin RS, Richter JE
Division of Pulmonary, Allergy and Critical Medicine, University of
Massachusetts Medical School, Worcester, USA.
Eur Respir J 2000 Jul;16(1):108-11
Chlamydia pneumoniae infection in adults with chronic cough compared with
healthy blood donors.
Birkebaek NH, Jensen JS, Seefeldt T, Degn J, Huniche B, Andersen PL,
Dept of Pediatrics, Skejby Hospital, Arhus, Denmark.
In a small uncontrolled study, persistent cough has recently been found to
associated with serological evidence of acute Chlamydia pneumoniae
order to assess whether C. pneumoniae plays a role in chronic cough, the
prevalence of C. pneumoniae infection in 201 adult patients with chronic
was compared with the prevalence in 106 healthy blood donors without
tract symptoms in the preceding 3 months. A microimmunofluorescence
test was used to determine C. pneumoniae antibodies in the immunoglobulin
IgG and IgA fractions. Further, nasopharyngeal aspirates from the 201
were examined for C. pneumoniae deoxyribonucleic acid by polymerase chain
reaction (PCR). As judged by serology, nine patients (4%) and one control
had acute C. pneumoniae infection, and 92 patients (46%) and 42 controls
had previous or chronic C. pneumoniae infection. Of the nine patients with
infection, three were C. pneumoniae PCR positive, and they all had an IgM
antibody titre response. The remaining six patients had either an IgG
titre of > or =512 (five patients) or an IgA antibody titre of > or
patient). None of these six patients had detectable IgM antibodies. The
cough period for the five IgG positive patients (10.8 weeks) was
longer than the mean cough period for the remaining patient population
weeks; p=0.004). It is concluded that Chlamydia pneumoniae infection was
statistically significantly more prevalent in patients with chronic cough
in healthy blood donors, and that Chlamydia pneumoniae appears to have a
role in patients with chronic cough. Direct detection of Chlamydia
polymerase chain reaction on nasopharyngeal aspirates is highly correlated
detectable immunoglobulin M antibodies, but in the late stages of
cough serological testing of immunoglobulin G and immunoglobulin A may be
beneficial for obtaining a microbiological diagnosis.
Chest 2000 Jul;118(1):278-9
Chronic cough revisited.
Arch Bronconeumol 2000 Apr;36(4):208-20
[Study and diagnosis of chronic cough in adults].
[Article in Spanish]
de Diego Damia A, Perpina Tordera M
Servicio de Neumologia, Hospital Universitario La Fe, Valencia.
Chest 2000 Apr;117(4):1215-6
A possible pathologic link between chronic cough and sleep apnea syndrome
through gastroesophageal reflux disease in older people.
Teramoto S, Ouchi Y
Am J Med 2000 Mar 6;108 Suppl 4a:126S-130S
Anatomical diagnostic protocol in evaluating chronic cough with specific
reference to gastroesophageal reflux disease.
Irwin RS, Madison JM
Department of Medicine, University of Massachusetts Medical School,
Using the anatomic, diagnostic protocol, the cause of chronic cough can be
determined 88% to 100% of the time, leading to specific therapy with
rates of 84% to 98%. Gastroesophageal reflux disease (GERD), along with
postnasal drip syndrome (PNDS) and asthma, is one of the three most common
causes of chronic cough in all age groups. When GERD is the cause of
cough, there may be no gastrointestinal (GI) symptoms up to 75% of the
and, in these cases, the term "silent GERD" is used. The most
specific test for GERD is 24-hour esophageal pH monitoring. In
test, it is essential not only to evaluate the duration and frequency of
reflux episodes but also to determine the temporal relationship between
and cough events. Patients with normal standard reflux parameters still
reflux diagnosed as the likely cause of cough if a temporal relationship
The definitive diagnosis of cough resulting from GERD can only be made if
goes away with antireflux therapy. When 24-hour esophageal pH monitoring
be done, an empiric trial of antireflux medical therapy is appropriate
is a likely cause of chronic cough. It is likely in the following
patients with prominent GI symptoms consistent with GERD and/or those with
complaints and normal chest x-rays, who are not taking
enzyme inhibitors and who are not smoking, and in whom asthma and PNDS
excluded. However, if empiric treatment fails, it cannot be assumed that
has been ruled out as a cause of chronic cough; rather, objective
for GERD is recommended, because the empiric therapy may not have been
enough or it may have failed. In treating patients with chronic cough
from GERD, cough has been reported to resolve with medical therapy 70% to
of the time. Mean time to recovery may take as long as 161 to 179 days,
patients may not start to get better for 2 to 3 months. In patients who
respond to maximal medical therapy, antireflux surgery can be successful.
Am J Gastroenterol 1999 Nov;94(11):3131-8
A prospective evaluation of esophageal testing and a double-blind,
study of omeprazole in a diagnostic and therapeutic algorithm for chronic
Ours TM, Kavuru MS, Schilz RJ, Richter JE
Center for Swallowing and Esophageal Disorders, Department of
The Cleveland Clinic Foundation, Ohio 44195, USA.
OBJECTIVE: Recent studies suggest an association between chronic cough and
gastroesophageal reflux. Our study aims were 1) to define the prevalence
reflux induced cough in the general community, 2) to examine the ability
esophageal testing to identify gastroesophageal reflux related cough, and
assess the utility of omeprazole in a chronic cough algorithm. METHODS:
with chronic cough of unknown etiology, who were mostly from the
evaluated. Subjects underwent a chest x-ray, methacholine challenge test,
empiric trial of postnasal drip therapy, and completed daily cough symptom
diaries subjectively evaluating cough frequency and severity on a graded
of 0-4 (combined maximum 8). After excluding other causes of cough, the
remaining patients underwent esophageal and pH testing. Those testing
were randomized to omeprazole 40 mg b.i.d. or placebo for 12 weeks.
was 1 yr. RESULTS: A total of 71 patients were screened; 48 were excluded.
Twenty-three patients were evaluated for gastroesophageal reflux disease;
(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
sustained for up to 1 yr. Six had a negative pH test, none of whom
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).
Acid-related chronic cough was present in 26% (six of 23) of patients
for gastroesophageal reflux disease. Esophageal testing does not reliably
identify patients with acid induced chronic cough responsive to proton
inhibitor therapy. We suggest that the best diagnostic and therapeutic
after excluding asthma and postnasal drip syndrome, is empiric treatment
wk with a high dose proton pump inhibitor.
Randomized controlled trial
Chest 1999 Nov;116(5):1287-91
The role of sinus imaging in the treatment of chronic cough in adults.
Pratter MR, Bartter T, Lotano R
Division of Pulmonary and Critical Care Medicine, Cooper
Medical Center, University of Medicine and Dentistry of New Jersey/Robert
Johnson Medical School at Camden, NJ, USA.
PRIMARY STUDY OBJECTIVE: To determine the appropriate role and timing of
imaging studies in the evaluation and treatment of chronic cough. DESIGN:
Prospective study of chronic cough. All patients underwent sinus imaging,
results of which identified prospectively the following: (1) fluid in
with or without opacification, and (2) mucosal thickening. Patients then
treated using an algorithm that sequentially addresses the etiologies of
cough. Patients whose sinus imaging studies had demonstrated fluid were
initially for sinusitis, but mucosal abnormalities alone were not
indication to change the algorithm. After workup, relationships between
abnormalities on sinus imaging studies and diagnoses were determined.
University hospital pulmonary outpatient clinic. PATIENTS: Thirty-six
(31 women, 5 men; mean age, 58.4 years). Cough duration averaged 5.2 years
(range, 4 weeks to 30 years). RESULTS: Diagnoses were made in 100% of
and cough resolved in 86%. Mucosal thickening correlated with sinusitis as
cause of cough in only 29% of cases. CONCLUSIONS: Mucosal thickening is
diagnostic of sinusitis as a cause of chronic cough; in most patients,
will resolve without treatment for sinusitis. Given this lack of
is reasonable to delay sinus imaging until after efforts at treating
have failed and, in the absence of complaint or findings of postnasal
until after completion of evaluation for asthma. The principles of
treatment of chronic cough remain simple: go sequentially from the most
to the least common cause; use tools that begin with the most available
least expensive and invasive modality; then move as needed to tools that
more expensive and invasive.
Clin Infect Dis 1999 Nov;29(5):1239-42
Bordetella pertussis and chronic cough in adults.
Birkebaek NH, Kristiansen M, Seefeldt T, Degn J, Moller A, Heron I,
Moller JK, Ostergard L
Department of Pediatrics, Skejby Hospital, University of Arhus,
Brendstrupgardsvej, Denmark. Niels_Birkebaek@dadlnet.dk
To evaluate Bordetella pertussis as a cause of persistent cough in adults,
examined 201 patients who had a cough for 2-12 weeks and no pulmonary
We obtained the following at presentation: medical history, chest
respiratory function measurement, nasopharyngeal aspirate for polymerase
reaction (PCR), nasopharyngeal swab specimen for culture, and a blood sample
(acute serum). Four weeks later a second blood sample (convalescent serum)
obtained. Control sera were obtained from 164 age-matched healthy blood
with no history of cough during the previous 12 weeks. Four patients were
pertussis culture-positive; 11 (including the culture-positive patients)
pertussis PCR-positive; and 33, including 10 of the 11 PCR-positive
had serological evidence of recent B. pertussis infection.
and -negative patients could not be discriminated by a history of cough.
conclude that B. pertussis infection is a common cause of persistent cough
adults. This is of concern, because these patients may be B. pertussis
reservoirs from which transmission may occur to infants, in whom the
Can Respir J 1999 Jul-Aug;6(4):323-30
Nonasthmatic chronic cough: No effect of treatment with an inhaled
corticosteroid in patients without sputum eosinophilia.
Pizzichini MM, Pizzichini E, Parameswaran K, Clelland L, Efthimiadis A,
J, Hargreave FE
University of Santa Catarina (UFSC), Florianopolis, Brazil.
BACKGROUND: Inhaled corticosteroids are effective in suppressing a chronic
without asthma associated with sputum eosinophilia. OBJECTIVE: To
the inflammatory characteristics in the induced sputum of patients with a
chronic cough without asthma or known cause and the effects of budesonide
treatment on chronic cough in those patients. PATIENTS AND METHODS:
adults (mean [minimu, maximum] age of 45 years [20,75], 28 women, 17
subjects and 32 nonsmokers], with a daily bothersome cough for at least
and who had no evidence of asthma or other known cause for the cough, were
consecutively enrolled. The trial was a randomized, double-blind,
parallel group trial of budesonide 400 mg twice daily for two weeks versus
placebo. Patients then received open administration of the same dose of
budesonide for a further two weeks. Sputum was induced before and at the
each treatment period. Cough severity was documented by a visual analogue
RESULTS: Thirty-nine (89%) patients produced mucoid sputum after induction
least one study visit. At baseline, the majority (59%) had a mild
the median proportion of neutrophils (65%). All had elevated fluid phase
of fibrinogen (3200 mg/L) and albumin (880 mg/L), and high levels of
interleukin-8 and substance P. Interleukin-8 correlated with neutrophils
(rho=0.72, P<0.001), fibrinogen (rho=0.65, P<0.001), albumin
001) and eosinophil cationic protein (rho=0.60, P=0.001). Substance P
with albumin (rho=0.60, P=0.006). No subject had an increase in
Treatment with budesonide did not affect cough or sputum measurements.
CONCLUSIONS: Patients with nonasthmatic chronic cough enrolled in this
evidence of a mild neutrophilia and/or microvascular leakage. Chronic
not respond to treatment with budesonide, perhaps because the cause was
associated with sputum eosinophilia.
Randomized controlled trial
Am J Respir Crit Care Med 1999 Aug;160(2):406-10 [Texto
Eosinophilic bronchitis is an important cause of chronic cough.
Brightling CE, Ward R, Goh KL, Wardlaw AJ, Pavord ID
Department of Respiratory Medicine, Glenfield Hospital, Leicester, United
Eosinophilic bronchitis presents with chronic cough and sputum
without the abnormalities of airway function seen in asthma. It is
know how commonly eosinophilic bronchitis causes cough, since in contrast
cough in patients without sputum eosinophilia, the cough responds to
corticosteroids. We investigated patients referred over a 2-yr period with
chronic cough, using a well-established protocol with the addition of
sputum in selected cases. Eosinophilic bronchitis was diagnosed if
no symptoms suggesting variable airflow obstruction, and had normal
values, normal peak expiratory flow variability, no airway
(provocative concentration of methacholine producing a 20% decrease in
([PC(20)] > 8 mg/ml), and sputum eosinophilia (> 3%). Ninety-one
chronic cough were identified among 856 referrals. The primary diagnosis
eosinophilic bronchitis in 12 patients, rhinitis in 20, asthma in 16,
post-viral-infection status in 12, and gastroesophageal reflux in seven.
further 18 patients a diagnosis was established. The cause of chronic
remained unexplained in six patients. In all 12 patients with eosinophilic
bronchitis, the cough improved after treatment with inhaled budesonide 400
micrograms twice daily, and in eight of these patients who had a follow-up
sputum analysis, the eosinophil count decreased significantly, from 16.8%
1.6%. We conclude that eosinophilic bronchitis is a common cause of
cough, and that sputum induction is important in the investigation of
Am J Respir Crit Care Med 1999 Jun;159(6):1810-3 [Texto
Exhaled nitric oxide as a noninvasive assessment of chronic cough.
Chatkin JM, Ansarin K, Silkoff PE, McClean P, Gutierrez C, Zamel N,
Divisions of Respiratory Medicine, University of Toronto, Toronto, Canada.
Exhaled nitric oxide (ENO) has been suggested as a marker of airway
inflammation. This study aimed to evaluate the role of ENO in the
of chronic cough. We measured ENO in 38 adult patients reporting chronic
in 23 healthy control subjects, and in 44 asthmatics. In addition to the
investigation, ENO was measured by a chemiluminescent analyzer using the
restricted breath technique. In the chronic cough group, 30 were
nonasthmatic, whereas asthma was diagnosed in eight by a positive
challenge. ENO values were significantly higher in patients with chronic
attributable to asthma as compared with those with chronic cough not
attributable to asthma and to healthy volunteers (75.0 ppb; 16.7 ppb; and
ppb, respectively). The sensitivity and specificity of ENO for detecting
using 30 ppb as the ENO cutoff point, were 75 and 87%, respectively. The
positive and negative predictive values were 60 and 93%, and the positive
negative likelihood ratios were 5.8 and 0.3, respectively. We conclude
may have a role in the evaluation of chronic cough. In this group of
low ENO suggested little likelihood of asthma. The patients with chronic
not attributable to asthma showed a low ENO value as compared with healthy
volunteers and asthmatics.
Hosp Pract (Off Ed) 1999 Apr 15;34(4):62-3
Diagnosing chronic cough.
Hoag S, Wentworth M
Am J Respir Crit Care Med 1999 May;159(5 Pt 1):1533-40 [Texto
Bronchoalveolar cell profiles in children with asthma, infantile wheeze,
cough, or cystic fibrosis.
Marguet C, Jouen-Boedes F, Dean TP, Warner JO
Paediatric Respiratory Disease Unit, Hopital Ch. Nicolle, Rouen, France.
Differential cell counts of bronchoalveolar lavage (BAL) have been
normal children but few data on cellular profiles in bronchial diseases in
childhood are available. We determined the BAL cell profiles of 72
divided into 5 groups: asthma (n = 14), chronic cough (n = 12), infantile
(n = 26), cystic fibrosis (n = 10), and control (n = 10). The highest
cell, eosinophil, and neutrophil counts were found in children with cystic
fibrosis. The cell profile of children with chronic cough was similar to
control children. Asthma and infantile wheeze were characterized by a high
median ratio of eosinophils (3%) and neutrophils (12%), respectively. In
diseases, epithelial shedding was suggested by an elevated epithelial cell
count, 13.5 and 12%, respectively. Lymphocyte subset analysis showed a
proportion of CD8 cells (58 versus 40%) and therefore a lower CD4/CD8
(0.266 versus 0. 455) in children with asthma compared with infantile
(p = 0. 02). Irrespective of the presence or absence of radiological
abnormalities, a proportion of neutrophils > 10%, was found in
one-third of the
children with asthma and in half of the infantile wheezers, and was
symptom severity. We suggest that neutrophil-mediated inflammation, with
without bacterial infection, may contribute to symptoms of asthma in
Chronic cough, however, is not associated with the cell profiles
asthma and in isolation should not be treated with prophylactic antiasthma
Hosp Pract (Off Ed) 1999 Jan 15;34(1):53-60; quiz 129-30 [Texto
Silencing chronic cough.
University of Massachusetts, Worcester, USA.
The cause can almost always be identified. Postnasal drip syndrome,
gastroesophageal reflux disease account for most cases. The differential
diagnosis also includes ACE inhibitor therapy, pertussis, and, in up to
patients, multiple causes. Response to treatment may offer diagnostic
confirmation but can be slow in coming.
Am Fam Physician 1998 Dec;58(9):2015-22 [Texto
An office approach to the diagnosis of chronic cough.
University of Texas Health Science Center, San Antonio, USA.
Chronic cough is a common problem in patients who visit family physicians.
three most common causes of chronic cough in those who are referred to
specialists are postnasal drip, asthma and gastroesophageal reflux. The
treatment of patients with cough is often empiric and may involve a trial
decongestants, bronchodilators or histamine H2 antagonists, as monotherapy
combination. If a therapeutic trial is not successful, sequential
testing including chest radiograph, purified protein derivative test for
tuberculosis, computed tomography of the sinuses, methacholine challenge
barium swallow may be indicated. By using a standard protocol for
treatment, 90 percent of patients with chronic cough can be managed
in the family physician's office. However, in some cases it may take three
five months to determine a diagnosis and effective treatment. For the
of patients in whom this diagnostic approach is unsuccessful, consultation
a pulmonary specialist is appropriate.
Scand J Infect Dis 1998;30(3):227-9
Chronic cough in patients with HIV infection.
Wong KH, Cooper DA, Pigott P, Marriott DJ
AIDS Unit, Department of Health, Hong Kong.
We retrospectively studied the clinical spectrum, course and outcome of 26
patients with HIV infection and chronic cough. All except 2 were
males. 22 (85%) had AIDS. They had cough for a mean of 75 d with sputum
production (88%) and dyspnoea (77%) being the commonest associated
Sputum examination and chest X-ray were useful initial investigations. CT
of the chest and sinuses had a high rate of abnormal results for selected
patients (89-100%). Cause of cough was found in 21 patients (81%):
bronchopulmonary infections (17), Kaposi's sarcoma (5) and sinus
Patients with sinopulmonary infections tended to have longer duration of
Overall, 4 patients (15%) had significant improvement in the illness with
during the study period. Four patients with bronchopulmonary infections
concluded that chronic cough is a heterogeneous clinical problem in
HIV-infected patients, most commonly caused by an infective process.
Extrapulmonary disease, such as sinusitis, has to be considered and
investigated. The clinical course and outcome is unfavourable for most of
Arch Intern Med 1998 Jun 8;158(11):1222-8
From a prospective study of chronic cough: diagnostic and therapeutic
Smyrnios NA, Irwin RS, Curley FJ, French CL
Department of Medicine, University of Massachusetts Medical School,
BACKGROUND: Cough is the most common complaint for which adults see a
in the ambulatory setting in the United States. An anatomical diagnostic
protocol has been used since 1981 to evaluate patients with chronic cough.
has been shown to be effective in diagnosing the cause of cough and
specific treatment in a variety of adult populations but has never been
evaluated specifically in a population of older adults. OBJECTIVES: To
whether the spectrum and frequency of causes of chronic cough and the
to therapy would be different in older adults. METHODS: Thirty patients at
64 years of age with a history of cough lasting at least 3 weeks were
prospectively evaluated with a protocol designed to detect diseases that stimulate the afferent limb of the cough reflex. The final diagnosis of
cause of chronic cough required fulfillment of pretreatment criteria and
cough disappear with specific therapy. When more than one disease
pretreatment diagnostic criteria, therapy was instituted in the order that
were fulfilled. Probability statistics were used to describe the testing
characteristics of individual components of the diagnostic protocol in
sensitivity, specificity, positive predictive value, and negative
value as they applied to chronic cough. RESULTS: Forty causes of chronic
were identified in all 30 patients. Postnasal drip syndrome,
reflux disease, and asthma were the most common causes of chronic cough,
accounting for 85% of all causes found. Among patients with normal chest
radiograph findings who were not cigarette smokers and not taking an
angiotensin-converting enzyme inhibitor, postnasal drip syndrome,
gastroesophageal reflux disease, and asthma accounted for 100% of all
found. Specific therapy was successful in eliminating chronic cough in
the patients studied. Except for barium esophagography, all laboratory
which information was available had sensitivities and negative predictive
of 100%. CONCLUSIONS: Postnasal drip syndrome, gastroesophageal reflux
and asthma accounted for 85% of all causes of chronic cough in older
Chronic cough caused substantial physical and emotional morbidity among
patients. The major value of performing objective testing in evaluating
cough is its ability to rule out specific diseases as a diagnostic
The following clinical profile consistently predicts patients with cough
attributable to gastroesophageal reflux disease: the patient has cough
been persistently troublesome for at least 3 weeks; does not smoke
does not take an angiotensin-converting enzyme inhibitor; does not have or
not responded to therapy for postnasal drip syndrome and asthma; and has
or nearly normal findings and stable chest radiograph. The differences
what we observed regarding chronic cough in older adults and observations
ourselves and others regarding chronic cough in general are minor.
Mayo Clin Proc 1997 Oct;72(10):957-9
Assessment of the patient with chronic cough.
Yu ML, Ryu JH
Division of Pulmonary and Critical Care Medicine and Internal Medicine,
Clinic Rochester, Minnesota 55905, USA.
Chronic cough, defined as cough that persists for 3 weeks or longer, is
the most common symptoms evaluated by a primary-care physician. With the
exclusion of cigarette smoking, postnasal drip, asthma, and
reflux are responsible for more than 80% of the causes of chronic cough.
Elicitation of a thorough history and performance of a physical
usually provide clues about the cause of chronic cough. The use of
tests including methacholine challenge, gastroesophageal reflux studies,
sinus imaging is based on clinical suspicion. Treatment of chronic cough
aimed at the underlying cause.
Am Fam Physician 1997 Oct 1;56(5):1395-404 [Texto
Department of Family Medicine, University of Alabama School of Medicine,
Tuscaloosa 35401, USA.
Chronic cough is defined as a cough that lasts for more than three weeks.
than 90 percent of cases of chronic cough result from five common causes:
smoking, post-nasal drip, asthma, gastroesophageal reflux and chronic
bronchitis. Although in most patients chronic cough has a single cause, in
one fourth of patients, multiple disorders contribute to the cough. A
evaluation in patients with chronic cough can minimize the invasiveness
expense of the work-up. Initial screening of patients with chronic cough
search for smoking, occupational exposure to an airway irritant,
medications, airway hyperresponsiveness following upper respiratory
chronic bronchitis or any systemic symptoms suspicious for serious
Patients who are not diagnosed after an initial screening are evaluated or
empirically treated in a stepwise fashion for postnasal drip, asthma and
Bronchoscopy is reserved for use in the few patients still without a
after the previous steps have been completed.
Am J Respir Crit Care Med 1997 Jul;156(1):211-6 [Texto
A systematic evaluation of mechanisms in chronic cough.
Carney IK, Gibson PG, Murree-Allen K, Saltos N, Olson LG, Hensley MJ
Airway Research Centre, John Hunter Hospital, New South Wales, Australia.
We tested the hypothesis that hyperresponsiveness of the upper airway
present in patients with chronic cough of diverse etiology. We determined
frequency of bronchial hyperresponsiveness (BHR), hyperresponsiveness of
upper airway, sputum eosinophilia, pulmonary aspiration, and psychological
symptoms in adults with chronic cough. Consecutive adults (n = 30)
a tertiary referral clinic with chronic cough were compared with a group
asymptomatic adults. Measurements included histamine provocation testing
measurement of flow volume curves to determine inspiratory and expiratory
airflow obstruction; hypertonic saline induced sputum for analysis of
eosinophils, mast cells and lipid-laden macrophages; and a validated
psychological symptom questionnaire. Symptomatic rhinitis and
reflux were common causes of chronic cough. BHR occurred in seven patients
and in no control subjects (p < 0.05). UAHR occurred in 40% of patients
cough and in four (20%) control subjects (p > 0.05). Eosinophils were
the sputum of more patients with cough than control subjects (50% versus
< 0.05). High degrees of eosinophilia were present in six patients with
including three without BHR. No subject had significant lipid-laden
There was greater somatization in patients with chronic cough; ten
scored in the clinically significant range (p < 0.05). Abnormalities in
more of these tests were 7.67-fold (95% CI 1.83-34.52) more likely to
cough patients than control subjects. We conclude that chronic cough is a
nonspecific symptom that is associated with several apparently unrelated
mechanisms. These include UAHR, somatization, BHR, and eosinophilic
UAHR cannot be implicated as a single unifying mechanism. These findings
emphasize the need to systematically evaluate several different causes of
in patients who present with chronic cough.
South Med J 1997 Mar;90(3):305-11 [Texto
Twenty-four-hour ambulatory esophageal pH monitoring in the diagnosis of
reflux-related chronic cough.
Vaezi MF, Richter JE
Division of Gastroenterology, University of Alabama at Birmingham, USA.
To define the role of ambulatory pH monitoring in evaluating chronic
studied esophageal pH values of patients referred to a gastroenterology
laboratory. Chronic cough was evaluated in 31 patients, who were grouped
on response to treatments; 11 patients (35.5%) had gastroesophageal reflux
(GER)-related cough, 11 (35.5%) had pulmonary/otorhinolaryngologic-related
(1 bronchitis, 6 asthma, 2 postnasal drip, 1 pneumonia), and 9 patients
had cough of unknown etiology. Esophageal pH values of groups were
Excessive acid reflux distally (upright and supine) and proximally
cough symptom frequency related to acid reflux were significantly higher
patients with GER. Esophageal pH monitoring had good sensitivity (91%),
specificity (82%), and positive (83%) and negative (90%) predictive values
identifying GER-related cough. In summary, ambulatory pH monitoring is an
excellent test for identifying patients with GER-related cough.
Rev Clin Esp 1996 Jul;196(7):461-8
[Chronic cough in adults].
[Article in Spanish]
Cordero PJ, Benlloch E
Servicio de Neumologia, Hospital Universitario La Fe, Valencia.