Message from Dr. Jamie Koufman (Director, Voice Institute of New York)

I am referred many patients with non-pulmonary, chronic cough (CC) because I have extensive experience diagnosing and treating both reflux-related and neurogenic cough. This expertise evolved over a period of 25 years, because I have special diagnostic technology, airway reflux testing and electromyography. These tests allow me to precisely diagnose reflux-related and neurogenic cough. Interestingly, of 50 CC patients recently studied, 12% had neurogenic cough alone, 40% had reflux-related cough alone, and 48% had both; see the abstract of the paper here.

I also see many patients with pulmonary disease (e.g., bronchitis, COPD, asthma) that may or may not be related to airway reflux, as well as patients with reactive airway disease (laryngospasm, paradoxical vocal fold movement, and pseudo-asthma). In most cases, these patients have acid reflux as well.  In other words, chronic airway reflux can cause other airway diseases.

Airway Diseases That May be Caused By Reflux
COPD (chronic obstructive pulmonary disease)
Chronic or acute bronchitis
Paradoxical vocal fold movement
Paroxysmal laryngospasm
Asthma / Pseudo-asthma
Reactive airway disease
Vocal cord dysfunction
Vasomotor rhinitis
“Allergic” rhinitis
Chronic cough
Sinusitis

Reflux-Related vs. Neurogenic Cough

The back flow of material from the stomach/esophagus into the throat, that is, into the airway, is a very common cause of chronic, non-pulmonary, cough. By the way, the term “non-pulmonary” provides an important distinction here; it implies that the cough is NOT due to primary pulmonary (lung) disease. In other words, “non-pulmonary” implies a pulmonary specialist has declared the lungs to be okay and/or that the patient has a normal chest x-ray.

Over the past 25 years, my clinical history taking in CC patients has evolved to the point that ten key questions usually distinguish neurogenic from reflux-related cough. Awaking in the middle of the night from a sound sleep coughing and gasping for air like a fish out of water is virtually always REFLUX.  Conversely, coughing when exposed to perfume or ambient temperature change is NEUROGENIC.  See also the other posts on this blog.

Here are the ten questions, and the PDF version of the Koufman Chronic Cough Index (KCCI) may be seen by clicking here.

KOUFMAN CHRONIC COUGH INDEX (KCCI)

Please circle “Yes” or “No” for every question (R= Reflux, N= Neurogenic)

Do you awaken from a sound sleep coughing                              YES     NO
violently? With trouble breathing?

Do you have choking episodes when you cannot                         YES     NO
get enough air, gasping for air?

Do you usually cough when you lie down into                               YES     NO
the bed, or when you just lie down to rest?

Do you usually cough after meals or eating?                                 YES     NO

Do you cough when (or after) you bend over?                                YES     NO

Do you more-or-less cough all day long?                                        NO      YES

Does change of temperature make you cough?                            NO      YES

Does laughing or chuckling cause you to cough?                         NO      YES

Do fumes (perfume, automobile fumes, burned                            NO      YES
toast, etc.) cause you to cough?

Does speaking, singing, or talking on the phone                           NO      YES
cause you to cough?

R_____│_____N

Add up the total R and N. More Ns suggest neurogenic cough and vice versa. While the author’s treatment paradigm is beyond the limits of this post, here are three key points:

1. Neurogenic cough is usually treated with medications such as amitriptyline (Elavil), gabapentin (Neurontin), and/or tramadol (Ultram).  Usually, these three drugs are used in very small doses alone or in combination. Yes, there is often a lot of trial and error involved in finding the right combination.
2. Initially, reflux treatment must be intense and individualized for people with reflux-related chronic cough. This includes twice-daily (before breakfast and before dinner) proton pump inhibitors (e.g., Prilosec, Prevacid, Protonix, Nexium), an H2-antagonist at bedtime,  as well as the Induction Reflux Diet.
3. Many people have both airway reflux and a neurogenic component to their cough and to get optimum results, both must be identified and treated.

PDF version of the Koufman Chronic Cough Index

ABSTRACT

Background: Chronic cough is the most common symptom for which a patient seeks medical attention; however, many patients with chronic cough fail to obtain an accurate diagnosis and effective treatment. Chronic cough patients are especially enigmatic for the otolaryngologist.

Materials and Methods: Retrospective review of 50 consecutive chronic cough patients. None of the subjects had primary pulmonary disease; although 54% (26/50) had been previously diagnosed with asthma. All subjects underwent laryngeal examination, 92% had reflux testing, 72% had esophagoscopy, and 60% had laryngeal electromyography.

Results: The clinical diagnosis for chronic cough was reflux alone in 40% (20/50), neurogenic (cough) alone in 14% (7/50), and both (reflux-related and neurogenic cough) in 46% (23/50). Eighty-six percent (43/50) had pH-documented reflux; 56% had neuropathic findings on laryngeal EMG; and 46% met criteria for both reflux and vocal fold paresis. The mean number of pH-documented pharyngeal reflux events pH <5 was 146. Of the 43 abnormal pH studies, 93% (43/46) had pharyngeal reflux, but only 37% (16/43) had abnormal esophageal pH data (pH <4). Thus, had those subjects undergone traditional esophageal or impedance reflux testing, 63% (27/43) would have been falsely considered negative. In addition, 36 subjects underwent esophagoscopy and 64% (23/36) had significant pathology. Eighty-eight percent (44/50) responded favorably to treatment.

Conclusions: Although other causes must be excluded, chronic cough in otolaryngologic practice is usually related to airway reflux and/or a neurogenic cause. Airway reflux testing for chronic cough requires specific pharyngeal pH-monitoring technology that is not yet widely available; however, accurate diagnosis is essential to provide effective, patient-specific treatment. In addition, the alarmingly high rate of esophageal pathology in this series of chronic cough patients underscores the need for esophageal screening in patients with airway reflux.