Chest
Volume 116, Issue 2, August 1999, Pages 279-284
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Clinical Investigations
Asthma
A Pathogenic Triad in Chronic Cough: Asthma, Postnasal Drip Syndrome, and Gastroesophageal Reflux Disease

https://doi.org/10.1378/chest.116.2.279Get rights and content

Background

Coughing may be produced by a number of different disorders in distinct anatomic sites. Chronic cough causes major functional limitation in a considerable patient population and requires careful evaluation.

Methods

Seventy-eight nonsmoking patients of both genders who complained of cough for≥ 3 weeks and had normal findings on plain chest radiographs were studied prospectively. Their histories were obtained, and physical examinations were performed. The diagnostic workup included pulmonary function tests, CT of the paranasal sinuses and chest, carbachol provocation test, fiberoptic rhinoscopy, fiberoptic bronchoscopy, and 24-h esophageal pH monitoring. The final diagnosis depended on clinical, radiologic, and laboratory findings; a successful response to therapy was required for confirmation.

Results

The causes of chronic cough were determined in all patients. Coughing was due to a single cause in 30 patients (38.5%) and multiple causes in 48 patients (61.5%). The five most important causative factors were asthma (46 patients; 58.9%), postnasal drip syndrome (PNDS; 45 patients; 57.6%), gastroesophageal reflux disease (GERD; 32 patients; 41.1%), bronchiectasis (14 patients; 17.9%), and tracheobronchial collapse (11 patients; 14.1%).

Interpretation

Asthma, PNDS, and GERD, alone or in combination, were responsible for 93.6% of the cases of chronic cough. The presence of these three conditions was so frequent that the expression “pathogenic triad of chronic cough” should be acknowledged in specialized literature. It is essential to consider pulmonary and extrapulmonary causes in order to prescribe a successful specific therapy for chronic cough.

Section snippets

Materials and Methods

The protocol for this study was approved by the Hospital Ethics Committee, and all patients gave their informed consent. This was a prospective, descriptive study of consecutive, unselected, immunocompetent patients who were referred to our university outpatient clinic for the evaluation of chronic cough. All patients were evaluated using a previously published diagnostic protocol.45678

Results

Seventy-eight patients were studied: 27 were male (36%) and 51 were female (64%). The mean ± SD age was 57 ± 16.7 years (range, 15 to 81 years). The mean ± SD history of cough was 72 ± 96.4 months (range, 1 to 480 months). The mean ± SD number of physicians previously seen was 7.4 ± 8.8 per patient. A total of 666 diagnostic tests were performed (mean, 8.5 tests per patient). A diagnosis was established in all 78 patients. The therapeutic success rate was 93.6%, ie, 73 of the patients who

Discussion

Several published studies of the differential diagnosis of chronic cough have employed similar protocols.456782425262728 These studies included chest radiography, sinus radiography, pulmonary function tests, methacholine inhalational challenge, biochemical laboratory tests, BRONCH, and esophageal pH monitoring. In the present study, we added RHINOS, sinus HRCT, and chest HRCT. We believe that RHINOS should be included routinely, as recent articles in the literature have quoted the presence of

Conclusion

Several conclusions regarding the study of chronic cough appear to be important based on our findings.

The concept of an anatomic protocol focused on evaluating the location of receptors and afferent pathways of coughing is still valid. The five most important causal factors of chronic cough were asthma, PNDS, GERD, BRO, and TRCOL. These conditions were responsible for 96.2% of cases of chronic cough. Single causes of coughing were present in 38.5% of cases in the series, and we were surprised

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    Presented in part at the annual meeting of the American Thoracic Society, New Orleans, LA, May 10, 1996.

    Supported in part by Fundação de Amparo à Pesquisa do Rio Grande do Sul, Brazil.

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