In patients with chronic cough due to GERD that has failed to improve with the most maximal medical therapy, which includes an intensive antireflux diet and lifestyle modification, maximum acid suppression, and prokinetic therapy, and the rest of the spectrum of treatment options in Table 3, cough may only improve or be eliminated with antireflux surgery.
Level of evidence, low; benefit, substantial; grade of recommendation, B in detail
In patients who meet the following criteria, antireflux surgery is the recommended treatment: (a) findings of a 24-h esophageal pH-monitoring study before treatment is positive, as defined above; (b) patients fit the clinical profile suggesting that GERD is the likely cause of their cough (Table 1); (c) cough has not improved after a minimum of 3 months of intensive therapy (Table 3), and serial esophageal pH-monitoring studies or other objective studies (eg, barium esophagography, esopha-goscopy, and gastric-emptying study with solids) performed while the patient receives therapy show that intensive medical therapy has failed to control the reflux disease and that GERD is still the likely cause of cough; and (d) patients express the opinion that their persisting cough does not allow them a satisfactory quality of life. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A
In patients with chronic cough due to GERD, the term acid reflux disease, unless it can be definitively shown to apply, should be replaced by the more general term reflux disease so as not to mislead the clinicians into thinking that all patients with cough due to GERD should improve with acidsuppression therapy. Level of evidence, expert opinion; benefit, substantial; grade of recommendation. In patients with chronic cough who also complain of typical and frequent GI complaints such as daily heartburn and regurgitation, especially when the findings of chest-imaging studies and/or clinical syndrome are consistent with an aspiration syndrome, the diagnostic evaluation should always include GERD as a possible cause.
Level of evidence, low; benefit, substantial; grade of recommendation, B
Patients with chronic cough who have GI symptoms that are consistent with GERD or who fit the clinical profile described in Table 1, should be considered to have a high likelihood of having GERD and should be prescribed antireflux treatment even when they have no GI symptoms. Level of evidence, low; benefit, substantial; grade of recommendation, B