- 1 Why do I feel like I have a ball of phlegm in my throat
- 2 Is it normal to have mucus in throat for months
- 3 When should I be worried about a cough that won’t go away
- 4 How do I know if my cough is from GERD
- 5 Is acid reflux cough serious
Why do I feel like I have a ball of phlegm in my throat
Globus is a symptom that can make you feel like you have a lump in your throat. It is also called ‘globus sensation’. Globus can be caused by many things, such as an increased tension of muscles or irritation in the throat. There are various things you can do to manage your globus symptoms at home, without the need to attend your GP.
Is it normal to have mucus in throat for months
Why do I have so much phlegm in my throat all the time? – If someone has phlegm in their throat all the time, it may occur due to a long-term condition, such as acid reflux, postnasal drip, or allergies. Overproduction of mucus also commonly occurs in people that smoke.
Mucus production in the throat is natural and helps protect the tissues and prevent infection. However, certain conditions and factors can lead to an overproduction of mucus, such as infections, allergies, and smoking. Treating the underlying cause of excess mucus helps reduce the production. Additional ways to decrease mucus include drinking plenty of water, taking medications to dry mucus, and using a PEP device to clear mucus out of the throat.
If mucus production of mucus continues to increase, is green or yellow, or is very thick, a person may want to consider contacting a healthcare professional.
Why do I always have phlegm in my throat?
There are a couple of reasons people get chronic phlegm— acid reflux, post-nasal drip, and allergies can all contribute to the problem. Your physician can conduct an exam of your nose and throat area to help determine the cause.
Can you damage your throat from coughing?
Identification and management of cough-induced laryngotracheitis Department of Surgery, Division of Critical Care, St. Luke’s Memorial Hospital, Ponce Health Sciences University, Ponce, PR, USA Find articles by 1 Department of Family Medicine, The Methodist Hospital, Houston, Texas Find articles by Department of Surgery, Division of Critical Care, St.
Department of Surgery, Division of Critical Care, St. Luke’s Memorial Hospital, Ponce Health Sciences University, Ponce, PR, USA 1 Department of Family Medicine, The Methodist Hospital, Houston, Texas 2 Department of Internal Medicine, Division of Pneumology, Memorial Hermann Southwest Hospital, Houston, Texas
Address for correspondence: Dr. Joel E. Rodriguez, The Methodist Hospital, Department of Family Medicine, 424 Hahlo St. Houston, TX 77020, USA. E-mail: Received 2018 Jan 24; Accepted 2018 Feb 14. : © 2018 Annals of Thoracic Medicine This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Chronic cough is associated with repetitive injury to the upper airway and trachea, which can lead to an underdiagnosed pathology known as “cough-induced” laryngotracheitis (CILT). In this report, we describe a case of CILT that responded well to dual therapy. Keywords: Chronic cough, dual therapy, laryngotracheitis, postviral cough Cough is one of the most common symptoms that lead to outpatient visits.
When assessing a cough it is helpful to define the duration, as there are three general time frames on presentation: acute (≤ 3 weeks), subacute (3–8 weeks), and chronic (≥ 8 weeks). The latter presentations may be related to a lingering etiology that is either not treated or partially treated.
- However, complications of chronic/repetitive cough should also be considered, which includes trauma to the upper airway and trachea.
- In this case report we describe a young man who had a persistent cough, which was due to “cough-induced” laryngotracheitis (CILT).
- A 23-year-old man with no medical history presented to the clinic with a persistent cough of 3-month duration.
It was described as a loud vigorous “barking” cough that was exacerbated at night and with colder temperature. The cough had progressively worsened over the past month and was refractory to over-the-counter and narcotic cough suppressants. The only other complaints were mild hoarseness and a constant irritating sensation at the upper airway/trachea.
He referred that 3 months prior, he had flu-like symptoms that included an aggressive cough. The symptoms resolved within days, but the cough lingered and changed in caliber over weeks. He referred that the cough was now negatively impacting all daily activities. He had no other symptoms to suggest an upper airway cough syndrome (postnasal drip), gastroesophageal reflux, or asthma as potential etiologies.
Upper and lower respiratory examinations were within normal limits. Pulse oximetry was normal at rest and walking. Chest X-ray was negative for atelectasis, interstitial disease, pneumatic processes, or a nodule/mass. At this point we suspected an upper airway irritation related to CILT, and a respiratory inhalant combo with powdered salmeterol/fluticasone (/ actuation) every 12 hours for 3 days was prescribed with special instructions to inhale at the trachea and hold for 15–20 seconds (i.e.
tracheal hold technique). Within 48 hours, the patient had complete resolution of the cough and associated complaints. The complications related to a chronic cough are broad (respiratory, musculoskeletal, neurological, psychiatric, etc.) and ultimately reduce quality of life for the patient. During vigorous coughing, intrathoracic pressures may reach 300 mmHg and expiratory velocities approach 500 miles/hour (85% of the speed of sound), which are essential to dislodge and expel secretions or foreign bodies.
However, these same pressures and velocities can become pathologic if not controlled and can lead to complications such as exhaustion, self-consciousness, insomnia, headache, dizziness, musculoskeletal pain, and hoarseness. The latter is related to repetitive insults to the laryngotracheal domain (LT), which takes a downstream insult with each cough.
- Acute inflammation is usually self-limited, particularly during an infectious challenge; however, with extended insult, a chronic inflammatory response may persist that can lead to tissue damage via direct (i.e.
- Mechanical trauma) and/or indirect (i.e.
- Cellular and immune) pathways.
- We believe that the natural history/mechanism of CILT includes the following:(1) an acute airway illness induces an aggressive cough; (2) the patient’s prodrome improves, but a residual cough remains that causes recurrent trauma to the upper airway/trachea, which causes a chronic inflammatory response at the LT domain; (3) the locoregional inflammation induces further propagation of cough in a feedback mechanism; and (4) the patient seeks relief from their cough at a subacute or chronic time frame,
Patients usually respond well to an inhalant combo with counseling on the technique to inhale and hold the medication at the trachea. This technique ensures maximum local effects of the corticosteroid at the LT domain, while avoiding the systemic effects of corticosteroids.
Furthermore, studies have shown that in the setting of reactive airway disease, a dual therapeutic approach has a synergistic anti-inflammatory effect, which improves clinical efficacy. As was observed in this patient, and others we have treated with a similar presentation, the response to therapy is usually rapid with most patients having a complete response within 24–48 hours.
We recommend at least a 3–5-day course of treatment to ensure resolution. If the patient’s symptoms do not resolve, another pathology should be suspected and a bronchoscopic evaluation with biopsy may be considered. In closing, CILT is a benign and relatively common complication of chronic cough that can significantly impact a patient’s quality of life.
- It must be considered in a patient with a subacute or chronic cough, when other common etiologies have been ruled out.
- CILT has a characteristic presentation, which includes coughing bouts with a vigorous barking quality that is refractory to cough suppressants and no other signs of systemic disease.
If suspected, a short-term treatment with respiratory inhalant combo via the tracheal hold technique is an effective treatment and a reasonable step before a more invasive workup is considered. The authors certify that they have obtained all appropriate patient consent forms.
- In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal.
- The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
There are no conflicts of interest.1. Irwin RS. Complications of cough: ACCP evidence-based clinical practice guidelines. Chest.2006; 129 :54S–8S.2. Comroe JH., Jr, Physiology of Respiration: An Introductory Text.2nd ed. Chicago, IL: Yearbook Medical Publishers; 1974.
Special acts involving breathing.3. Gabay C. Interleukin-6 and chronic inflammation. Arthritis Res Ther.2006; 8 (Suppl 2):S3.4. Tabas I, Glass CK. Anti-inflammatory therapy in chronic disease: Challenges and opportunities. Science.2013; 339 :166–72.5. Nelson HS, Chapman KR, Pyke SD, Johnson M, Pritchard JN.
Enhanced synergy between fluticasone propionate and salmeterol inhaled from a single inhaler versus separate inhalers. J Allergy Clin Immunol.2003; 112 :29–36.6. Barnes NC, Qiu YS, Pavord ID, Parker D, Davis PA, Zhu J, et al. Antiinflammatory effects of salmeterol/fluticasone propionate in chronic obstructive lung disease.
When should I be worried about a cough that won’t go away
Call your doctor if your cough (or your child’s cough) doesn’t go away after a few weeks or if it also involves any one of these:
- Coughing up thick, greenish-yellow phlegm
- Experiencing a fever
- Experiencing shortness of breath
- Experiencing fainting
- Experiencing ankle swelling or weight loss
Seek emergency care if you or your child is:
- Choking or vomiting
- Having difficulty breathing or swallowing
- Coughing up bloody or pink-tinged phlegm
- Experiencing chest pain
What if I have a dry cough but no other symptoms?
WHAT CAUSES A DRY COUGH? – Dry cough causes vary; most are the result of a recent cold or flu, which is often called a post-viral cough. However, they may also be caused by an allergy, asthma or chronic acid reflux. Less common dry cough causes include environmental factors like a dry atmosphere, air pollution or a sudden change in temperature.
How do I know if my cough is from GERD
Journal List Gastroenterol Hepatol (N Y) v.12(1); 2016 Jan PMC4865789
As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Gastroenterol Hepatol (N Y).2016 Jan; 12(1): 64–66. G&H What is the most common cause of chronic cough? DF Acute episodes of cough, often referred to as acute bronchitis, are among the most common conditions seen in medicine and are usually self-limited and related to upper respiratory tract infections. However, a distinction must be made between acute and chronic cough. The latter is significantly more complicated to treat, and its cause is often unknown. In many cases, chronic cough begins as one of several symptoms in an upper respiratory infection and persists. Patients experiencing chronic cough are often referred to pulmonologists; allergists; ear, nose, and throat doctors; and gastroenterologists, who each try to uncover the source, but a large portion of chronic cough remains unexplained, or idiopathic. There are pulmonary causes, particularly in patients who smoke or who have asthma or chronic obstructive pulmonary disease. Lately, there has been a push to try to advance gastroesophageal reflux disease (GERD) as the major cause, although the large majority of patients who are presumed to have GERD are found not to have clinical reflux on pH testing. While GERD has been shown to play a role in chronic cough, it is likely just a cofactor and not the main culprit in idiopathic chronic cough. G&H Is there an association between chronic cough and nonacid or weakly acidic reflux? DF There is possibly an association. It is very difficult to prove; therefore, many physicians recommend and use combined pH-impedance testing to try to determine whether nonacid reflux is involved. Presumably, any irregular substance (eg, particulate or refluxate) that gets into the throat can act as an irritant and initiate coughing. G&H Should treatment consist of therapies that control reflux instead of those that control acid? DF The data on treatment are still not very clear. Reflux medication does help a subset of patients who have chronic cough; however, many patients with cough are given reflux medication empirically and do not improve, so it is hard to know if treating acid reflux that way is helpful. My colleagues and I conducted a study evaluating definitive treatment of reflux for cough, in which patients with a primary symptom of chronic cough underwent gastric fundoplication. Abnormal preoperative impedance was not associated with postoperative improvement of cough symptoms. Instead, predictors of improvement were concomitant typical GERD symptoms of heartburn and regurgitation, and a positive capsule pH test. Patients with chronic cough combined with one or both cofactors tended to improve with the gastric fundoplication. These findings indicate that irregular impedance testing by itself is not very predictive of extraesophageal reflux and that patients who have cough without traditional GERD symptoms often do not improve with reflux medication or surgical treatment. G&H How is GERD-related chronic cough differentiated from non-GERD-related chronic cough? DF Differentiation, in my opinion, is more related to a thorough patient history and listening to the patient than to any technologic device that is being used. Patients who present with classic GERD symptoms and cough tend to have GERD-related cough. Nighttime coughs or coughing after meals are signs associated with reflux-induced cough. Similarly, it is easier to point to GERD as a potential etiology when patients display a history of GERD, heartburn, or regurgitation. When patients deny having GERD, regurgitation, belching, or any other symptoms, the likelihood of them actually having acid reflux as a primary cause of their cough is small. G&H What is the relationship between cough, GERD, and phonation? DF This is an interesting question and one that I believe needs further attention. In my practice, patients often relate talking as a trigger for their chronic cough. The hypothesized mechanism for this is laryngeal, specifically vocal fold, hypersensitivity. To further evaluate this phenomenon, my colleagues and I conducted a blinded, cross-sectional study of 27 nonsmoking patients with chronic cough (>8 weeks refractory to maximum antireflux medication) to determine whether GERD was the cause of chronic cough. All patients underwent 24-hour acoustic recording synchronized with ambulatory pH- impedance monitoring, and cough, phonation, and pH- impedance events were recorded. We then evaluated the temporal relationship between cough, GERD, and phonation using several statistical techniques and found that the actual trauma from coughing caused further coughs. We also found that de novo coughs would occur after patients spoke or experienced a minor reflux event, as defined by the pH-impedance testing. These findings are interesting because even minor reflux events were triggers for cough. More interesting, however, is that phonation or talking was a trigger for cough in a majority of the patients. Both findings implicate the larynx as a potential source for the sensitivity of the airway. The stimulation of the vocal folds by phonation and the minor irritation from GERD are both triggers for chronic cough patients. G&H What treatment options are currently available to manage chronic cough? DF If the cough is GERD-related, then treating the GERD with proton pump inhibitors (PPIs) is the most common approach. A 3-month empiric trial with either once- or twice-daily PPIs is generally advocated. Pulmonary etiologies should be excluded to ensure that malignancy or intrinsic lung diseases are not the source of the cough. Evaluation for a contribution from GERD is also often performed. If these conditions are ruled out and no other obvious cause is identified, an etiology that should be considered is laryngeal sensory neuropathy. The mechanism for this condition is upregulation of sensory nerves at the level of the larynx caused by repeated vocal fold trauma from the cough. To illustrate this further, the sound produced by the cough derives from the vocal folds striking each other. This repeated trauma results in sensitivity at the level of the vocal folds, which can be stimulated by changes in heat, talking, smells, and other usually benign physiologic tasks and exposures. There are at least 3 treatment options available for laryngeal sensory neuropathy. The first and most conservative is improving the vocal hygiene by increasing water intake and reducing the viscosity of the upper airway mucus, which can act as a trigger. Patients also need to use sips of water to quench the foreign body—trigger sensation before the cough paroxysm starts. In essence, this breaks the cycle of cough begetting more cough. It is also helpful for these patients to use a humidifier or vaporizer to hydrate the upper and lower pulmonary tracts. Similarly, some patients assume they have postnasal drainage and are treated with drying medications such as decongestants and antihistamines, which can worsen symptoms. In fact, anything drying such as caffeine, alcohol, or even snoring at night can exacerbate the dryness of the throat and cough. Another simple consideration is avoidance of menthol cough drops, which are considered an obvious treatment for cough, but actually do not work for patients with chronic cough. Those cough suppressants contain a small amount of alcohol that create a drying effect in the throat, and the need to cough returns as soon as that drying effect disappears. A second treatment option is pharmacologic intervention. The medications used to treat laryngeal sensory neuropathy or airway hypersensitivity syndrome are similar to those used to treat neuropathy in other parts of the body. For instance, gabapentin, amitriptyline, pre- gabalin (Lyrica, Pfizer), and tramadol are often used and work fairly well. The correct medication for a particular person’s condition needs to be considered carefully. It is often necessary to titrate doses until an effect is achieved. A third less commonly discussed, although effective, approach is behavioral modification that involves working with speech language pathologists who are trained in cough suppression therapy. They are able to teach various techniques for managing that tickle in the throat that makes people want to cough. Other common treatment approaches exist, but are beyond the scope of this column. G&H What role does surgery play in managing chronic cough? DF Surgery should be considered a last resort for treatment. Circumstances in which surgery is helpful in chronic cough are rare. The most discussed treatment for presumed GERD-related chronic cough that has been refractory to pharmacologic intervention is gastric fundoplication. I do not recommend this surgery to my patients, even in extreme cases, unless I am absolutely convinced that GERD is the culprit, which is difficult to prove. Patients whose cough readily responds to PPIs with objective evidence of GERD on pH-impedance testing could be considered candidates. Without objective evidence of GERD and/or concomitant symptoms of heartburn or regurgitation, the likelihood of a durable improvement from surgery is relatively small. I would argue that in the majority of cases, GERD is not the cause of chronic cough. G&H Which diagnostic tests or cough monitoring systems are used to assess cough? DF It must be emphasized that the most important diagnostic test is a careful patient history. Triggers for a patient’s cough can be illuminating and can help direct diagnostic and treatment decisions. Clinicians must also recognize whether patients have pneumonia, asthma, or chronic obstructive pulmonary disease that could be causing the cough. Patients should undergo pulmonary function tests and further pulmonary evaluation as needed. All patients with refractory chronic cough should undergo flexible laryngoscopy to confirm that there are no lesions in their upper airway (eg, pharynx, larynx) that could be triggering their cough. If GERD is a suspected source, patients can either be placed on a PPI for 3 months or undergo an upper endoscopy with pH-impedance testing and considerations made for esophageal manometry. In general, cough monitoring systems are usually not used in clinical practice. They are, however, extremely useful in the research realm because they provide objectivity and a good measure for improvement. These systems do have some limitations, though, including the issue of temporality. Some devices do not record every sound, and it can be challenging to digitally differentiate a throat clear from a cough or phonation. In the absence of this technology, this differentiation is often performed manually, which is time-consuming and tedious. G&H What are the next steps of research in this area? DF One of the most important steps is to use interdisciplinary partnerships to share new approaches to management, develop new hypotheses regarding mechanisms, and cross-pollinate across specialties. Sharing of ideas and opening a dialogue will advance research at a faster rate. Chronic cough is a condition that affects so many patients and is cared for by so many specialties that it is incumbent on clinicians to entertain and investigate new ideas regarding etiology and management. There have been several long-term studies to examine the efficacy of acoustic cough monitoring devices; however, we need more studies evaluating other etiologies besides GERD. Most cough monitoring devices enumerate the number of coughs, but to investigate the cause of the cough, these devices need to have the ability to synchronize with objective diagnostic tests, such as impedance and pH testing, in order to examine the temporality of other physiologic aspects.
How do you diagnose GERD cough?
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Market. This recommendation was made because unacceptable levels of NDMA, a probable carcinogen (cancer-causing chemical), were found in some ranitidine products. If you’re prescribed ranitidine, talk with your doctor about safe alternative options before stopping the drug. If you’re taking OTC ranitidine, stop taking the drug and talk with your healthcare provider about alternative options.
Instead of taking unused ranitidine products to a drug take-back site, dispose of them according to the product’s instructions or by following the FDA’s guidance, Ranitidine, brand name Zantac, is now marketed as Zantac 360, which contains a different active ingredient (famotidine).
Famotidine is in the same class as ranitidine and works the same way but has not been found to contain unacceptable levels of NDMA. You may experience a chronic cough if you have gastroesophageal reflux disease. Treating the cough typically involves treating the acid reflux. While most people experience occasional acid reflux, some people may develop a more serious form of acid problems.
This is known as gastroesophageal reflux disease (GERD). People with GERD experience chronic, persistent reflux that occurs at least twice a week. Many people with GERD have daily symptoms that can lead to more serious health problems over time. The most common symptom of acid reflux is heartburn, a burning sensation in the lower chest and middle abdomen.
- Some adults may experience GERD without heartburn as well as additional symptoms.
- These can include belching, wheezing, difficulty swallowing, or a chronic cough.
- GERD is one of the most common causes of a persistent cough.
- In fact, researchers at the University of North Carolina School of Medicine estimate that GERD is responsible for over 25 percent of all cases of chronic cough,
The majority of people with a GERD-induced cough don’t have classic symptoms of the disease such as heartburn. Chronic cough can be caused by acid reflux or the reflux of nonacidic stomach contents. Some clues as to whether a chronic cough is caused by GERD include:
coughing mostly at night or after a mealcoughing that occurs while you’re lying downpersistent coughing that occurs even when common causes are absent, such as smoking or taking medications (including ACE inhibitors) in which coughing is a side effectcoughing without asthma or postnasal drip, or when chest X-rays are normal
GERD can be difficult to diagnose in people who have a chronic cough but no heartburn symptoms. This is because common conditions such as postnasal drip and asthma are even more likely to cause a chronic cough. The upper endoscopy, or EGD, is the test used most often in a complete evaluation of symptoms.
- The 24-hour pH probe, which monitors esophageal pH, is also an effective test for people with chronic cough.
- Another test, known as MII-pH, can detect nonacid reflux as well.
- The barium swallow, once the most common test for GERD, is no longer recommended,
- There are other ways to find out whether a cough is related to GERD.
Your doctor may try putting you on proton pump inhibitors (PPIs), a type of medication for GERD, for a period of time to see if symptoms resolve. PPIs include brand name medications such as Nexium, Prevacid, and Prilosec, among others. If your symptoms resolve with PPI therapy, it is likely you have GERD.
PPI medications are available over the counter, though you should see a doctor if you have any symptoms that aren’t going away. There may be other factors causing them, and a doctor will be able to suggest the best treatment options for you. Many infants experience some symptoms of acid reflux, such as spitting up or vomiting, during their first year of life.
These symptoms can occur in infants who are otherwise happy and healthy. However, infants who experience acid reflux after 1 year of age may indeed have GERD. Frequent coughing is one of the main symptoms in children with GERD. Additional symptoms may include:
heartburnrepeated vomiting laryngitis (hoarse voice)asthmawheezing pneumonia
Infants and young children with GERD may:
refuse to eatact colickybecome irritableexperience poor growtharch their backs during or immediately following feedings
You’re at greater risk for developing GERD if you smoke, are obese, or are pregnant, These conditions weaken or relax the lower esophageal sphincter, a group of muscles at the end of the esophagus. When the lower esophageal sphincter is weakened, it allows the contents of the stomach to come up into the esophagus. Certain foods and drinks can also make GERD worse. They include:
alcoholic beveragescaffeinated beverageschocolatecitrus fruitsfried and fatty foodsgarlicmint and mint-flavored things (especially peppermint and spearmint)onionsspicy foodstomato-based foods including pizza, salsa, and spaghetti sauce
Lifestyle changes will often be enough to reduce or even eliminate a chronic cough and other symptoms of GERD. These changes include:
avoiding foods that make symptoms worseavoiding lying down for at least 2.5 hours after mealseating frequent, smaller meals losing excessive weight quitting smoking raising the head of the bed between 6 and 8 inches (extra pillows don’t work)wearing loose-fitting clothing to relieve pressure around the abdomen
Medications, especially PPIs, are generally effective in treating symptoms of GERD. Others that may help include:
antacids such as Alka-Seltzer, Mylanta, Rolaids, or Tums foaming agents such as Gaviscon, which reduce stomach acid by delivering an antacid with a foaming agent H2 blockers such as Pepcid, which decrease acid production
You should contact your doctor if medications, lifestyle changes, and diet changes do not relieve your symptoms. At that point, you should discuss other treatment options with them. Surgery can be an effective treatment for those who don’t respond well to either lifestyle changes or medications.
The most common and effective surgery for long-term relief from GERD is called fundoplication, It is minimally invasive and connects the upper part of the stomach to the esophagus. This will reduce reflux. Most patients return to their normal activities in a couple of weeks, after a brief, one to three day hospital stay.
This surgery usually costs between $12,000 and $20,000. It may also be covered by your insurance. If you suffer from a persistent cough, talk to your doctor about your risk for GERD. If you’re diagnosed with GERD, be sure to follow your medication regime and keep your scheduled doctor’s appointments.
Is acid reflux cough serious
Acid reflux can cause coughing when stomach acid irritates the throat or is breathed in. Studies show that a long-term cough can be a sign of gastroesophageal reflux disease (GERD), When you have GERD, acid from your stomach backs up into your esophagus,
Does drinking water help GERD cough?
3. Discussion – Heartburn and acid regurgitation, frequent manifestations of GERD, are the most common symptoms managed by gastroenterologists, Symptom resolution following initial management with proton pump inhibitor (PPI) can conclude the diagnosis,
However, it is deemed to have a low specificity of 54%, The extraesophageal manifestations of GERD include asthma, chronic cough, and laryngitis. There is ample evidence to show strong association of GERD with respiratory and laryngeal symptoms, Nevertheless, as suggested in Montreal consensus, it is imperative to conduct thorough evaluation to rule out non-GERD causes for such extraesophageal symptoms,
They also opined that extraesophageal symptoms are rare in the absence of typical symptoms of GERD. Individual with chronic cough, even with typical GERD symptoms, should have pulmonary evaluation with imaging studies and bronchoscopy to rule out any pulmonary lesion.
- Patients with refractory GERD should have optimization of medical management.
- For those with refractory symptoms despite optimization, endoscopy and ambulatory pH monitoring is performed for further evaluation.
- The parameters assessed include presence of hiatal hernia, acid exposure time (AET), and responsiveness to therapy with proton pump inhibitors.
Surgical modality can be considered for those with elevated AET (above 6%) and good symptom correlation, However, management is unclear for patients with multiple GERD manifestations like heartburn and cough, where one of the symptoms responds and other does not following therapies targeted against acid control.
- In our case scenario, heartburn had an appropriate response to PPI, but improvement in cough was minimal.
- Evaluation for surgical intervention in such a patient needs to be done on a case-to-case basis with a clear understanding of failure to respond with surgical intervention.
- It is prudent to understand the advantages as well as shortcomings of different modalities for ambulatory pH testing in the evaluation and management of extraesophageal symptoms like cough.
The wireless Bravo® Capsule involves transnasal or peroral route of insertion and suction assisted distal esophageal capsule deployment. The ambulatory catheter-based pH testing includes transnasal pH probe placement with manometry-assisted identification of the lower esophageal sphincter (LES).
- The catheter is kept for a duration of 24 to 48 hours depending on the protocol,
- The patient tolerability, multiesophageal site evaluation (distal, proximal, and hypopharyngeal), and the inclusion of the multichannel intraluminal impedance (MII) monitoring are the key features to consider while selecting the modality.
The MII-pH system has the multiesophageal sites (distal, proximal, and hypopharyngeal), and the site of the reflux can better assist in understanding the pathogenesis of cough, The impedance monitoring with the MII-pH protocol certainly has advantages of evaluating nonacid reflux; it also assists in assessing correlation of extraesophageal symptoms especially in patients on PPI,
- In our scenario, the catheter-based MII-pH was not performed; hence, the possibility of the nonacid reflux remains undiagnosed and remains a shortcoming in our case.
- Nissen’s fundoplication has shown the optimal outcome for gastroesophageal reflux-related heartburn and cough,
- The postfundoplication recurrence of symptoms requires further evaluation.
The fundoplication failure pattern is defined based on the altered surgical anatomy, Essentially, it can lead to the malfunctioning gastroesophageal barrier leading to esophageal acid reflux. The postfundoplication ambulatory pH testing can be performed to assess physiologic characteristics of the gastroesophageal junction,
- In our case, the optimal acid control was achieved after fundoplication, as evaluated by ambulatory pH monitoring.
- Postfundoplication persistence of cough with adequate acid control despite resolution of the other symptoms should prompt evaluation for an alternate etiology.
- A thorough evaluation with the imaging studies, bronchoscopy, and laryngopharyngoscopy was performed in the presented case.
Abnormal esophageal motility has been associated with chronic cough, Gastroesophageal reflux-related respiratory symptoms are also more common in patients with ineffective esophageal motility, It is unclear if the ineffective esophageal motility is the result or the cause of the gastroesophageal reflux,
- Abnormal motility induced decreased acid clearance can be the likely etiology of chronic cough,
- The esophageal dysmotility can be a result of fundoplication and requires no further intervention.
- In our case, cough was optimally controlled for few months after fundoplication.
- Recurrence of symptoms requires investigation into an alternative explanation.
Ineffective esophageal motility resulting from fundoplication could be one of the plausible explanations. It is important to understand the pathophysiology of cough in a patient with gastroesophageal reflux. In refractory cases, evaluation for an underlying etiology of cough is the essence of its treatment.
- The prokinetic agents can be utilized in the management of GERD induced cough.
- The facilitation of the gastric emptying imparts its antitussive action,
- Their effectiveness in the patients with fundoplication is not clear.
- Buspirone may also be used for symptomatic management of patients with ineffective esophageal motility.
The effectiveness has been demonstrated in management of dysphagia, heartburn, and regurgitation, Buspirone’s efficacy, though not proven for cough, can be utilized in a refractory case like ours. The esophageal-bronchial stimulation can induce GERD related chronic cough,
- This reflex can be triggered from aspiration related stimulation of upper or lower esophagus without any laryngeal aspiration.
- Irwin et al.
- Studied the distal and proximal esophageal acid exposure in patients with chronic cough due to GERD and demonstrated that distal esophageal stimulation is the likely etiology of chronic cough,
Shaker et al. demonstrated excess of pharyngeal acid exposure in patients with respiratory or laryngeal symptoms, GERD induced reflux laryngitis can also be one of the plausible causes for chronic cough, Aspiration of gastric acid into respiratory tract can be further investigated with bronchoscopy and chest imaging studies,
- Though not reviewed in literature, patients with fundoplication and esophageal dysmotility may have altered esophageal salivary clearance.
- The catheter-based MII-pH study along with the laryngoscopy findings can assist in evaluating the direction of the refluxed material and further differentiating the etiology.
Taking frequent sips of the water can increase the esophageal clearance and hence can be a remedy to cough by preventing the esophageal-bronchial stimulation. In our presented scenario, cough may have resulted either from nonacid gastroesophageal reflux or esophageal ineffective motility induced altered pharyngeal secretion clearance.
- The sips of the water create the foreign body sensation and inhibit the cough reflex,
- It breaks the paroxysm of the cough begetting cough and hence decreases gastroesophageal reflux resulting from recurrent cough.
- It increases the clearance of lower esophageal acid and nonacid refluxed contents and hence inhibits the lower esophageal stimulation induced cough.
- The esophageal ineffective motility related decreased clearance of thick viscous salivary and pharyngeal secretions is assisted with sips of water.