When should Gastroesophageal Reflux Disease (GERD) be considered in patients with chronic cough?

When to Consider GERD in Patients with Chronic Cough

GERD should be considered as a cause in all patients with chronic cough, particularly when they fit a specific clinical profile or have typical GI symptoms, even when GI symptoms are completely absent. 1

Always Consider GERD When:

Patients with Typical GI Symptoms

• Daily heartburn and regurgitation should always prompt evaluation for GERD as a cause of chronic cough, especially when chest imaging shows aspiration-related findings 1
• However, recognize that up to 75% of patients with GERD-related cough have NO GI symptoms whatsoever (so-called "silent GERD") 1, 2

Patients Fitting the High-Probability Clinical Profile

Consider GERD highly likely when ALL of the following criteria are met: 1

• Chronic cough present AND
• Not exposed to environmental irritants nor currently smoking AND
• Not taking an ACE inhibitor AND
• Chest radiograph is normal or shows only stable, inconsequential scarring AND
• Symptomatic asthma has been ruled out (either cough failed to improve with asthma therapy OR methacholine challenge is negative) AND
• Upper airway cough syndrome ruled out (first-generation H1-antagonist failed to improve cough AND "silent" sinusitis excluded) AND
• Nonasthmatic eosinophilic bronchitis ruled out (sputum studies negative OR cough failed to improve with inhaled/systemic corticosteroids) 1

This clinical profile predicts approximately 91% likelihood that the cough will respond to antireflux treatment 1

Additional Clinical Clues Suggesting GERD:

Timing and Positional Patterns

• Cough exacerbated by meals 2, 3
• Positional worsening, particularly at night when lying down 2, 3
• Complete resolution of cough during travel (suggesting dietary or environmental factors) 3

Associated Aspiration Syndromes

GERD should be strongly suspected when imaging or clinical findings suggest aspiration, including: 1

• Mendelson syndrome
• Bacterial pneumonia and lung abscess
• Chemical pneumonitis
• Recurrent bacterial pneumonias
• Chronic interstitial fibrosis
• Bronchiectasis
• Diffuse aspiration bronchiolitis
• Tracheobronchitis

Bronchoscopic Findings

• Hemorrhagic tracheobronchitis 1, 2
• Erythema of subsegmental bronchi 1, 2
• Subglottic stenosis 1

Important caveat: Laryngoscopic and bronchoscopic signs of inflammation may also result from the act of coughing itself from other diseases, not just GERD 1

Critical Clinical Pearls:

Character of Cough is NOT Diagnostic

• There is nothing about the character or timing of GERD-related cough that distinguishes it from other causes 1
• Can present as productive cough (cough-phlegm syndrome) similar to chronic bronchitis 1, 2
• Can present as dry cough 1, 2
• Occurs nocturnally in only a minority of patients 1

When to Initiate Empiric Treatment

For patients fitting the clinical profile or having GI symptoms consistent with GERD, prescribe antireflux treatment immediately without waiting for diagnostic testing 1

The American College of Chest Physicians recommends starting treatment in lieu of testing for patients fitting the clinical profile, as this approach is both diagnostic and therapeutic 1

Epidemiological Context

• GERD accounts for 5-41% of chronic cough cases in specialty clinic populations 2
• Patients newly diagnosed with GERD have 1.7 times increased likelihood of developing cough within 12 months 2
• Regurgitation is a strong predictor of cough (OR 1.71) 2

Common Pitfall to Avoid:

Never assume GERD has been ruled out simply because:

• The patient lacks heartburn or regurgitation 1
• Esophagoscopy is normal 1
• Initial empiric therapy fails 1 (therapy may not have been intensive enough, or medical therapy may have failed requiring surgical intervention)