成人胃食管反流性慢性咳嗽：CHEST指南和专家小组报告
2017/08/08
摘要
背景：我们更新了2006年ACCP临床实践指南，用于治疗反流咳嗽综合征。
材料与方法：使用系统综述的办法试图解决两个有关人群，干预，比较，结局（PICO）的问题：（1）治疗胃食管反流可以改善或消除成人慢性咳嗽吗？（2）在确定慢性咳嗽可能对胃食管反流治疗有反应的指南中是否有最低的临床标准？
结果:我们没有发现与这两个问题有关的高质量研究。根据可查到的针对问题1的随机对照试验（RCT），我们得出结论：（1）咳嗽的治疗具有很强的安慰剂作用；（2）包括饮食改变和体重减轻的研究有较好的治疗结局；（3）生活方式的改变和体重减轻可能对疑诊反流性咳嗽的病人有益，单独使用质子泵抑制剂（PPI）时没有受益；（4）由于潜在的遗传效应，应避免使用PPI进行交叉研究。对于问题2，我们从现有的观察性试验中得出 结论：（1）系统的治疗方案可以解决82％〜100％的慢性咳嗽；（2）咳嗽变异型哮喘和上呼吸道咳嗽综合征（UACS）（以前称为鼻后滴注综合征）是最常见的病因；（3）先前报道的反流性咳嗽患病率差异很大。
结论：（1）建议使用诊断性治疗方法来解决包括症状性反流在内的常见病因的咳嗽；（2）虽然生活方式的改变和体重减轻可能对疑诊反流性咳嗽的病人有益，单独使用质子泵抑制剂（PPI）时没有受益；（3）建议对考虑反流手术治疗的难治性患者或临床高度疑诊患者进行生理检查。
Chronic Cough Due to Gastroesophageal Reflux in Adults: CHEST Guideline and Expert Panel Report
Peter J. Kahrilas, MD; Kenneth W. Altman, MD, PhD; Anne B. Chang, PhD; Stephen K. Field, MD, FCCP;
Susan M. Harding, MD, FCCP; Andrew P. Lane, MD; Kaiser Lim, MD, FCCP; Lorcan McGarvey, MD; Jaclyn Smith, PhD;
and Richard S. Irwin, MD, Master FCCP; on behalf of the CHEST Expert Cough Panel
Abstract
BACKGROUND: We updated the 2006 ACCP clinical practice guidelines for management of reflux-cough syndrome.
METHODS: Two population, intervention, comparison, outcome (PICO) questions were addressed by systematic review: (1) Can therapy for gastroesophageal reflux improve or eliminate cough in adults with chronic and persistently troublesome cough? and (2) Are there minimal clinical criteria to guide practice in determining that chronic cough is likely to respond to therapy for gastroesophageal reflux?
RESULTS: We found no high-quality studies pertinent to either question. From available randomized controlled trials (RCTs) addressing question #1, we concluded that (1) there was a strong placebo effect for cough improvement; (2) studies including diet modification and weight loss had better cough outcomes; (3) although lifestyle modifications and weight reduction may be beneficial in suspected reflux-cough syndrome, proton pump inhibitors (PPIs) demonstrated no benefit when used in isolation; and (4) because of potential carryover effect, crossover studies using PPIs should be avoided. For question #2, we concluded from the available observational trials that (1) an algorithmic approach to management resolved chronic cough in 82% to 100% of instances; (2) cough variant asthma and upper airway cough syndrome (UACS) (previously referred to as postnasal drip syndrome) from rhinosinus conditions were the most commonly reported causes; and (3) the reported prevalence of reflux-cough syndrome varied widely.
CONCLUSIONS: The panelists (1) endorsed the use of a diagnostic/therapeutic algorithm addressing causes of common cough, including symptomatic reflux; (2) advised that although lifestyle modifications and weight reduction may be beneficial in suspected reflux-cough syndrome, PPIs demonstrated no benefit when used in isolation; and (3) suggested that physiological testing be reserved for refractory patients being considered for antireflux surgery or for those in whom there is strong clinical suspicion warranting diagnostic testing.
背景：我们更新了2006年ACCP临床实践指南，用于治疗反流咳嗽综合征。
材料与方法：使用系统综述的办法试图解决两个有关人群，干预，比较，结局（PICO）的问题：（1）治疗胃食管反流可以改善或消除成人慢性咳嗽吗？（2）在确定慢性咳嗽可能对胃食管反流治疗有反应的指南中是否有最低的临床标准？
结果:我们没有发现与这两个问题有关的高质量研究。根据可查到的针对问题1的随机对照试验（RCT），我们得出结论：（1）咳嗽的治疗具有很强的安慰剂作用；（2）包括饮食改变和体重减轻的研究有较好的治疗结局；（3）生活方式的改变和体重减轻可能对疑诊反流性咳嗽的病人有益，单独使用质子泵抑制剂（PPI）时没有受益；（4）由于潜在的遗传效应，应避免使用PPI进行交叉研究。对于问题2，我们从现有的观察性试验中得出 结论：（1）系统的治疗方案可以解决82％〜100％的慢性咳嗽；（2）咳嗽变异型哮喘和上呼吸道咳嗽综合征（UACS）（以前称为鼻后滴注综合征）是最常见的病因；（3）先前报道的反流性咳嗽患病率差异很大。
结论：（1）建议使用诊断性治疗方法来解决包括症状性反流在内的常见病因的咳嗽；（2）虽然生活方式的改变和体重减轻可能对疑诊反流性咳嗽的病人有益，单独使用质子泵抑制剂（PPI）时没有受益；（3）建议对考虑反流手术治疗的难治性患者或临床高度疑诊患者进行生理检查。
(中日友好医院呼吸与危重症医学科 王圆方 摘译 林江涛 审校)
(Kahrilas P J, Altman K W, Chang A B, et al. Chronic Cough Due to Gastroesophageal Reflux in Adults: CHEST Guideline and Expert Panel Report[J]. Chest, 2016, 150(6):1341.)
(Kahrilas P J, Altman K W, Chang A B, et al. Chronic Cough Due to Gastroesophageal Reflux in Adults: CHEST Guideline and Expert Panel Report[J]. Chest, 2016, 150(6):1341.)
Chronic Cough Due to Gastroesophageal Reflux in Adults: CHEST Guideline and Expert Panel Report
Peter J. Kahrilas, MD; Kenneth W. Altman, MD, PhD; Anne B. Chang, PhD; Stephen K. Field, MD, FCCP;
Susan M. Harding, MD, FCCP; Andrew P. Lane, MD; Kaiser Lim, MD, FCCP; Lorcan McGarvey, MD; Jaclyn Smith, PhD;
and Richard S. Irwin, MD, Master FCCP; on behalf of the CHEST Expert Cough Panel
Abstract
BACKGROUND: We updated the 2006 ACCP clinical practice guidelines for management of reflux-cough syndrome.
METHODS: Two population, intervention, comparison, outcome (PICO) questions were addressed by systematic review: (1) Can therapy for gastroesophageal reflux improve or eliminate cough in adults with chronic and persistently troublesome cough? and (2) Are there minimal clinical criteria to guide practice in determining that chronic cough is likely to respond to therapy for gastroesophageal reflux?
RESULTS: We found no high-quality studies pertinent to either question. From available randomized controlled trials (RCTs) addressing question #1, we concluded that (1) there was a strong placebo effect for cough improvement; (2) studies including diet modification and weight loss had better cough outcomes; (3) although lifestyle modifications and weight reduction may be beneficial in suspected reflux-cough syndrome, proton pump inhibitors (PPIs) demonstrated no benefit when used in isolation; and (4) because of potential carryover effect, crossover studies using PPIs should be avoided. For question #2, we concluded from the available observational trials that (1) an algorithmic approach to management resolved chronic cough in 82% to 100% of instances; (2) cough variant asthma and upper airway cough syndrome (UACS) (previously referred to as postnasal drip syndrome) from rhinosinus conditions were the most commonly reported causes; and (3) the reported prevalence of reflux-cough syndrome varied widely.
CONCLUSIONS: The panelists (1) endorsed the use of a diagnostic/therapeutic algorithm addressing causes of common cough, including symptomatic reflux; (2) advised that although lifestyle modifications and weight reduction may be beneficial in suspected reflux-cough syndrome, PPIs demonstrated no benefit when used in isolation; and (3) suggested that physiological testing be reserved for refractory patients being considered for antireflux surgery or for those in whom there is strong clinical suspicion warranting diagnostic testing.
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有或不伴慢性阻塞性肺疾病的吸烟人群的急性加重和肺功能丧失
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阿奇霉素对持续未控制哮喘成人患者病情加重及生活质量的作用：一项随机双盲安慰剂对照研究
