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

Background: Chronic cough is one of the most common symptoms for which a patient seeks medical attention in the U.S.; however, a large number of patients with that symptom fail to receive an accurate diagnosis and effective treatment. Such a “recalcitrant” population represents 20% of the author’s practice. Presented herein are the author’s diagnostic and therapeutic data on a series of chronic cough patients, mostly with reflux-related and neurogenic cough.

Materials and Methods: Retrospective review of 50 consecutive, unselected patients with chronic cough. The mean duration of the chronic cough symptom was 13.5 ± 12.5 years (range 0.5–60 years). There was a 3:1 female preponderance (37F/13M), and the mean age was 55 ± 8.8 years (range 22-90 years).

Most of the study subjects had been previously evaluated by a pulmonary specialist; and at presentation, 60% (30/50) had received a diagnosis of asthma, laryngospasm, paradoxical vocal fold movement, and/or reactive airway disease. The referral sources of the study group were: pulmonologists 16 patients, other internists (including gastroenterologists) 16 patients, and otolaryngologists 10 patients; 8 patients were self-referred. None of the study subjects were active smokers, and fewer than half were ethanol drinkers. Thirty-six percent (18/50) of the subjects dated onset of their cough to a preceding upper respiratory infection.

All of the subjects underwent videostroboscopic laryngeal examination. Forty-three (86%) of the subjects underwent reflux testing using high-definition pharyngeal/UES/esophageal manometry followed by ambulatory, 24-hour, double-probe (simultaneous pharyngeal and esophageal) pH monitoring, and thirty (60%) underwent diagnostic laryngeal electromyography (EMG).

Based upon the clinical diagnosis and the results of the diagnostic testing, patients in the study group were treated with reflux medications for laryngopharyngeal reflux (LPR) and/or other medications for neurogenic cough. Ninety percent (45/50) of the study subjects were treated for LPR: 74% (37/50) with “maximum” antireflux medication (twice-daily proton pump inhibitors with an H2-antagonist at bedtime); 10% (5/50) underwent laparoscopic fundoplication; two were managed by diet alone, and one with H2-antagonists alone.

Sixty-two percent (31/50) of the study subjects were on other medications: amitriptyline 46% (23/50), nortriptyline 4% (2/50), tramadol 10% (5/50), gabapentin 8% (4/50), and clonazepam 4% (2/50). Fourteen percent (7/50) were on two of the above medications. Cough was graded on a 5-point scale by each subject at every visit: 0-None, 1-Infrequent, 2-Mild, 3-Moderate, 4-Severe, 5-Extreme/Disabling.  (Every subject was 4 or 5 for cough at presentation.)

Results: Of the 50 study subjects, the clinical diagnosis was reflux alone in 40% (20/50), neurogenic cough alone 12% (6/50), and both (reflux and neurogenic cough) in 48% (24/50). Seventy-four percent (37/50) had pH-documented LPR; 60% (30/50) had neuropathic findings on laryngeal EMG; and 46% met the diagnostic criteria for both LPR and vocal fold paresis.

The mean number of pH-documented pharyngeal reflux events was very high (122.5 ± 20.2). The single most striking finding was that of the 37 abnormal pH studies, all 37 had pharyngeal reflux, but only 12 (32%) of those had abnormal esophageal pH data. Thus, had these subjects undergone traditional single-probe or impedance reflux studies (with no pharyngeal pH sensors), two-thirds (25/37) of the group with LPR would have had false-negative reflux studies.

Eighty-six percent (43/50) of the study group responded very favorably to treatment. At the time of this report, antireflux surgery was recommended for three of the (medical treatment) failures.