WAO-ARIA consensus on chronic cough - Part III: Management strategies in primary and cough-specialty care. Updates in COVID-19.

Background: Chronic cough management necessitates a clear integrated care pathway approach. Primary care physicians initially encounter the majority of chronic cough patients, yet their role in proper management can prove challenging due to limited access to advanced diagnostic testing. A multidisciplinary approach involving otolaryngologists and chest physicians, allergists, and gastroenterologists, among others, is central to the optimal diagnosis and treatment of conditions which underly or worsen cough. These include infectious and inflammatory, upper and lower airway pathologies, or gastro-esophageal reflux. Despite the wide armamentarium of ancillary testing conducted in cough multidisciplinary care, such management can improve cough but seldom resolves it completely. This can be due partly to the limited data on the role of tests (eg, spirometry, exhaled nitric oxide), as well as classical pharmacotherapy conducted in multidisciplinary specialties for chronic cough. Other important factors include presence of multiple concomitant cough trigger mechanisms and the central neuronal complexity of chronic cough. Subsequent management conducted by cough specialists aims at control of cough refractory to prior interventions and includes cough-specific behavioral counseling and pharmacotherapy with neuromodulators, among others. Preliminary data on the role of neuromodulators in a proof-of-concept manner are encouraging but lack strong evidence on efficacy and safety. Objectives: The World Allergy Organization (WAO)/Allergic Rhinitis and its Impact on Asthma (ARIA) Joint Committee on Chronic Cough reviewed the recent literature on management of chronic cough in primary, multidisciplinary, and cough-specialty care. Knowledge gaps in diagnostic testing, classical and neuromodulator pharmacotherapy, in addition to behavioral therapy of chronic cough were also analyzed. Outcomes: This third part of the WAO/ARIA consensus on chronic cough suggests a management algorithm of chronic cough in an integrated care pathway approach. Insights into the inherent limitations of multidisciplinary cough diagnostic testing, efficacy and safety of currently available antitussive pharmacotherapy, or the recently recognized behavioral therapy, can significantly improve the standards of care in patients with chronic cough.

WAO-ARIA consensus on chronic cough - Part II: Phenotypes and mechanisms of abnormal cough presentation - Updates in COVID-19.

BACKGROUND: Chronic cough can be triggered by respiratory and non-respiratory tract illnesses originating mainly from the upper and lower airways, and the GI tract (ie, reflux). Recent findings suggest it can also be a prominent feature in obstructive sleep apnea (OSA), laryngeal hyperresponsiveness, and COVID-19. The classification of chronic cough is constantly updated but lacks clear definition. Epidemiological data on the prevalence of chronic cough are informative but highly variable. The underlying mechanism of chronic cough is a neurogenic inflammation of the cough reflex which becomes hypersensitive, thus the term hypersensitive cough reflex (HCR). A current challenge is to decipher how various infectious and inflammatory airway diseases and esophageal reflux, among others, modulate HCR. OBJECTIVES: The World Allergy Organization/Allergic Rhinitis and its Impact on Asthma (WAO/ARIA) Joint Committee on Chronic Cough reviewed the current literature on classification, epidemiology, presenting features, and mechanistic pathways of chronic cough in airway- and reflux-related cough phenotypes, OSA, and COVID-19. The interplay of cough reflex sensitivity with other pathogenic mechanisms inherent to airway and reflux-related inflammatory conditions was also analyzed. OUTCOMES: Currently, it is difficult to clearly ascertain true prevalence rates in epidemiological studies of chronic cough phenotypes. This is likely due to lack of standardized objective measures needed for cough classification and frequent coexistence of multi-organ cough origins. Notwithstanding, we emphasize the important role of HCR as a mechanistic trigger in airway- and reflux-related cough phenotypes. Other concomitant mechanisms can also modulate HCR, including type2/Th1/Th2 inflammation, presence or absence of deep inspiration-bronchoprotective reflex (lower airways), tissue remodeling, and likely cough plasticity, among others.

The role of ambulatory 24-hour esophageal manometry in clinical practice.

High-resolution manometry revolutionized the assessment of esophageal motility disorders and upgraded the classification through the Chicago Classification. A known disadvantage of standard HRM, however, is the inability to record esophageal motility function for an extended time interval; therefore, it represents only a more snapshot view of esophageal motor function. In contrast, ambulatory esophageal manometry measures esophageal motility over a prolonged period and detects motor activity during the entire circadian cycle. Furthermore, ambulatory manometry has the ability to measure temporal correlations between symptoms and motor events. This article aimed to review the clinical implications of ambulatory esophageal manometry for various symptoms, covering literature on the manometry catheter, interpretation of findings, and relevance in clinical practice specific to the evaluation of non-cardiac chest pain, chronic cough, and rumination syndrome.

[Clinical trial of acupuncture treatment of gastroesophageal reflux cough by needling dorsal segment of the Governor Vessel].

OBJECTIVE: To observe the curative effect of acupuncture stimulation of the back segment (10 spots below the spinous processes from T3 to T12) of the Governor Vessel in the treatment of gastroesophageal reflux cough (GERC). METHODS: A total of 60 cases of GERC patients were randomly divided into acupuncture and medication groups (n＝30 in each). For patients of the acupuncture group, the depression spots below the spinous processes from T3 to T12, including acupoints Shenzhu (GV12), Shendao (GV11), Lingtai (GV10), Zhiyang (GV9), Jinsuo (GV8) and non-acupoints (T4, T8, T12) were punctured with filiform needles, once every other day for 8 weeks. Patients of the medication group were ordered to take omeprazole capsules (20 mg/time), twice a day for 8 weeks. The therapeutic effect was assessed by using "Reflux Diagnostic Questionnaire"(RDQ, scores of symptoms of heartburn, retrosternal pain, acid regurgitation and food regurgitation, 0－40 points), cough symptom score (0－3 points) and "Leicester Cough Questionnaire" (LCQ, scores of physiological, psychological and social functions, 0－21 points), respectively. RESULTS: Following the treatment, RDQ score and cough symptom scores during both daytime and night were significantly decreased in both groups (P<0.05)，and the scores of physiological status, psychological health and social function of LCQ were significantly increased in both acupuncture and medication groups in comparison with their own pre-treatment (P<0.05). The therapeutic effect of acupuncture was markedly superior to that of medication in lowering RDQ score and cough symptom scores of daytime and night, and in raising LCQ scores of the physiological status, psychological health and social function (P<0.05). CONCLUSION: Acupuncture stimulation of the dorsal segment of the Governor Vessel is effective in improving clinical symptoms and living quality of GERC patients.

Reflux characteristics in patients with gastroesophageal reflux-related chronic cough complicated by laryngopharyngeal reflux.

BACKGROUND: This study aimed to investigate the reflux characteristics in patients with gastroesophageal reflux-related chronic cough (GERC) complicated by laryngopharyngeal reflux (LPR). METHODS: Patients with chronic cough were recruited. Reflux symptom index (RSI) scoring, cough symptom scoring, assessment of capsaicin cough sensitivity, and multichannel intraluminal impedance and pH monitoring (MII-pH) were performed. RESULTS: RSI score in GERC patients was significantly higher than that in patients with atopic cough (AC), cough variant asthma, eosinophilic bronchitis (EB), and upper airway cough syndrome (UACS) (P<0.05). The RSI score in non-acid GERC patients was significantly higher than that in acid GERC patients (P=0.003). The cut-off value of the RSI score was defined as 19 during diagnosis of non-acid GERC. In the RSI ≥19 group, there was more proximal reflux and more significant gas and non-acid reflux, and the efficacy of a combined use of baclofen or gabapentin was better than that of the RSI <19 group (P<0.05). The efficacy of proton pump inhibitor (PPI) at a routine dosage together with prokinetic agents in the RSI <19 group was better than that in the RSI ≥19 group (P=0.009). CONCLUSIONS: LPR overlaps with GERC in part. GERC patients with higher RSI scores may present more proximal reflux, non-acid reflux, and gas reflux, and get better efficacy with neuromodulators (gabapentin or baclofen) used as an add-on therapy.

[Clinical observation of acupuncture at Zhiyang (GV 9) Bazhen points combined with pantoprazole for gastroesophageal reflux cough with damp-heat type].

OBJECTIVE: On the basic treatment, to observed the effect difference between acupuncture at Zhiyang (GV 9) Bazhen points combined with pantoprazole and simple pantoprazole for gastroesophageal reflux cough with damp-heat type. METHODS: A total of 102 patients were randomly assigned into an observation group and a control group, 51 cases in each group. The patients in the two groups were given domperidone tablets (10 mg each time, 3 times a day). The patients in the control group were treated with pantoprazole capsule (40 mg each time, once a day). On the basis of the control group, the patients in the observation group were treated with Zhiyang (GV 9) Bazhen points, once a day, 5 times a week. All the treatment was given for 8 weeks. The indexes were observed before and after treatment, including cough symptom at daytime and nighttime scores, TCM symptom (heartburn, acid regurgitation, chest pain, epigastric pain, throat discomfort) scores and quality of life scores of cough questionnaire in Leicester (physiological, psychological and social aspects). The clinical effects were compared. RESULTS: After treatment, the daytime and nighttime cough scores, TCM symptom (heartburn, acid regurgitation, chest pain, epigastric pain, throat discomfort) scores were lower, and the quality of life scores of cough questionnaire in Leicester (physiological, psychological and social aspects) were higher than those before treatment in the two groups (all P<0.05), with better results in the observation group (all P<0.05). The total effective rate of the observation group was 94.1% (48/51), which was better than 80.4% (41/51) of the control group (P<0.05). CONCLUSION: On the basic treatment, acupuncture at Zhiyang (GV 9) Bazhen points combined with pantoprazole can improve TCM symptoms, such as cough, of the patients with gastroesophageal reflux cough with damp-heat type, and improve their quality of life.

Clinical trial of acupuncture treatment of gastroesophageal reflux cough by needling dorsal segment of the Governor Vessel / 针刺研究

OBJECTIVE: To observe the curative effect of acupuncture stimulation of the back segment (10 spots below the spinous processes from T3 to T12) of the Governor Vessel in the treatment of gastroesophageal reflux cough (GERC). METHODS: A total of 60 cases of GERC patients were randomly divided into acupuncture and medication groups (n＝30 in each). For patients of the acupuncture group, the depression spots below the spinous processes from T3 to T12, including acupoints Shenzhu (GV12), Shendao (GV11), Lingtai (GV10), Zhiyang (GV9), Jinsuo (GV8) and non-acupoints (T4, T8, T12) were punctured with filiform needles, once every other day for 8 weeks. Patients of the medication group were ordered to take omeprazole capsules (20 mg/time), twice a day for 8 weeks. The therapeutic effect was assessed by using "Reflux Diagnostic Questionnaire"(RDQ, scores of symptoms of heartburn, retrosternal pain, acid regurgitation and food regurgitation, 0－40 points), cough symptom score (0－3 points) and "Leicester Cough Questionnaire" (LCQ, scores of physiological, psychological and social functions, 0－21 points), respectively. RESULTS: Following the treatment, RDQ score and cough symptom scores during both daytime and night were significantly decreased in both groups (P<0.05)，and the scores of physiological status, psychological health and social function of LCQ were significantly increased in both acupuncture and medication groups in comparison with their own pre-treatment (P<0.05). The therapeutic effect of acupuncture was markedly superior to that of medication in lowering RDQ score and cough symptom scores of daytime and night, and in raising LCQ scores of the physiological status, psychological health and social function (P<0.05). CONCLUSION: Acupuncture stimulation of the dorsal segment of the Governor Vessel is effective in improving clinical symptoms and living quality of GERC patients.

Clinical observation of acupuncture at Zhiyang (GV 9) points combined with pantoprazole for gastroesophageal reflux cough with damp-heat type / 中国针灸

<p><b>OBJECTIVE</b>On the basic treatment, to observed the effect difference between acupuncture at Zhiyang (GV 9) points combined with pantoprazole and simple pantoprazole for gastroesophageal reflux cough with damp-heat type.</p><p><b>METHODS</b>A total of 102 patients were randomly assigned into an observation group and a control group, 51 cases in each group. The patients in the two groups were given domperidone tablets (10 mg each time, 3 times a day). The patients in the control group were treated with pantoprazole capsule (40 mg each time, once a day). On the basis of the control group, the patients in the observation group were treated with Zhiyang (GV 9) points, once a day, 5 times a week. All the treatment was given for 8 weeks. The indexes were observed before and after treatment, including cough symptom at daytime and nighttime scores, TCM symptom (heartburn, acid regurgitation, chest pain, epigastric pain, throat discomfort) scores and quality of life scores of cough questionnaire in Leicester (physiological, psychological and social aspects). The clinical effects were compared.</p><p><b>RESULTS</b>After treatment, the daytime and nighttime cough scores, TCM symptom (heartburn, acid regurgitation, chest pain, epigastric pain, throat discomfort) scores were lower, and the quality of life scores of cough questionnaire in Leicester (physiological, psychological and social aspects) were higher than those before treatment in the two groups (all <0.05), with better results in the observation group (all <0.05). The total effective rate of the observation group was 94.1% (48/51), which was better than 80.4% (41/51) of the control group (<0.05).</p><p><b>CONCLUSION</b>On the basic treatment, acupuncture at Zhiyang (GV 9) points combined with pantoprazole can improve TCM symptoms, such as cough, of the patients with gastroesophageal reflux cough with damp-heat type, and improve their quality of life.</p>

Clinical efficacy of Sini decoction adjustment combined rabeprazole enteric capsules in gastroesophageal reflux cough and its effect on IL-8, SP, MCT levels / 中国生化药物杂志

Objective To research the clinical efficacy of Sini decoction adjustment combined rabeprazole enteric capsules in treatment of gastroesophageal reflux cough and its effect on interleukin 8 (IL-8) and substance P (SP), the mast cell tryptase (MCT) levels.Methods 92 cases of gastroesophageal reflux cough were divided into control group and experimental group by drawing method , each had 46 cases.Control group were treated by rabeprazole enteric capsules, experimental group were treated with rabeprazole enteric capsules based on the control group.The curative effect, cough symptoms integral, IL-8, SP, MCT, gastric dynamic element (MOT) and the gastrin-releasing (GAS), pulmonary function and safety were compared between two groups.Results The total effective rate of experimental group(93.47%) was higher than the control group(76.08%), the difference was statistically significant (P<0.05).After treatment, the symptoms of experimental group(1.53 ±0.19) points was higher than the control groupthe difference was statistically significant(1.96 ±0.24)points,P<0.05.The IL-8, SP, MCT levels of experimental group were all lower than the control group ( P<0.05 ) .The MOT, GAS, and lung function of experimental group improved more significantly than the control group ( P <0.05 ) .The security between two groups has no significant difference .Conclusion The curative effect of Sini decoction adjustment combined Rabeprazole enteric capsules in treatment gastroesophageal reflux cough is obvious, can decrease IL-8, SP, MCT levels.

Clinical observation on the method of clearing lung and descending stomach for the treatment of gastroesophageal reflux induced cough / 中华中医药杂志

Objective:To observe the therapeutic effect of the method of clearing lung and descending stomach and its mechanism on gastroesophageal reflux cough(GERC).Method:125 cases of GERC were divided randomly into the treatment group(n=65) treated by the therapy of clearing lung and descending stomach(with a self-designed decoction) and the control group(n=60) treated with Omeprazole and Domperidone,and they were all treated for 12 weeks.Results:The total effective rate was 92.3% in the treatment group and 78.3% in the control group,with a significant difference between the two groups(P