Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Managing Chronic Cough When Reflux Treatment Falls Short

  Chronic cough is usually defined as a cough lasting more than eight weeks. Gastro-oesophageal reflux disease (GORD), also called GERD in much of the international literature, can contribute through acid exposure, non-acid reflux, microaspiration, or irritation of cough-sensitive nerves. Yet a persistent cough after acid suppression does not automatically prove that reflux remains the cause.

  For Australian patients, the practical task is to assess reflux alongside asthma, upper-airway cough syndrome, smoking, medication effects and other respiratory disease. A careful history, appropriate testing and realistic treatment goals can prevent months of escalating therapy without a clear benefit.

  Why Reflux Can Sustain A Cough

  Reflux may trigger coughing when gastric contents reach the oesophagus or throat, but the relationship is often indirect. Acid can inflame the oesophagus, while weakly acidic or non-acid material may stimulate sensory pathways. Repeated coughing can then increase abdominal pressure and promote further reflux, creating a self-reinforcing cycle.

  Some patients have laryngeal symptoms such as throat clearing, hoarseness, globus, or a sensation of mucus. These features can occur with reflux, but they are not specific. Laryngeal irritation, rhinitis, postnasal drainage and cough hypersensitivity can produce a similar pattern.

  The term “refractory” should be used carefully. It may describe ongoing symptoms despite an adequate proton pump inhibitor (PPI) trial, but it does not establish that reflux is the active driver. In Australia, a patient may have already tried several medicines purchased through a pharmacy, changed brands, or taken a PPI only when symptoms flare, making the true treatment exposure difficult to judge.

  Establishing The Diagnosis

  Assessment begins with the cough itself: onset, timing, triggers, sputum, nocturnal symptoms, meals, lying flat, voice use, exercise and workplace exposures. Ask about wheeze, breathlessness, heartburn, regurgitation and swallowing difficulty. Red flags include haemoptysis, weight loss, recurrent chest infections, fever, progressive dysphagia and abnormal chest findings.

  A chest X-ray and spirometry are often useful starting points, with bronchodilator testing or bronchial provocation considered when asthma remains possible. Review ACE inhibitor use, smoking or vaping, obstructive sleep apnoea, chronic rhinosinusitis and environmental irritants. Bushfire smoke, dusty work sites and dry inland conditions can aggravate cough in communities from Perth to regional New South Wales, even when reflux is also present.

  Reflux testing should match the clinical question. Upper endoscopy can identify erosive disease, stricture or other pathology, but a normal result does not exclude reflux-related cough. Ambulatory pH or impedance-pH monitoring can measure acid and non-acid reflux, while oesophageal manometry may be needed before selected interventions. Referral to a respiratory physician or gastroenterologist is sensible when the diagnosis remains uncertain or symptoms are disabling.

  Making Treatment More Precise

  Check how the PPI is being used before calling treatment unsuccessful. Many PPIs work best when taken before food, commonly before breakfast, although the exact regimen should follow the prescriber’s advice. If symptoms persist, a clinician may consider dose adjustment or a time-limited trial, but indefinite escalation should have a reason and review date.

  Lifestyle measures should be tailored rather than presented as a long list of restrictions. Helpful options can include smaller evening meals, avoiding food close to bedtime, raising the head of the bed for nocturnal symptoms, reducing alcohol, stopping smoking and identifying personal triggers. Weight reduction may improve reflux for people who are above a healthy weight, while overly restrictive diets can create unnecessary burden.

  Alginate preparations may provide a mechanical barrier after meals or at bedtime for selected patients. H2-receptor antagonists can sometimes help short-term nocturnal acid breakthrough, although tolerance and individual response vary. Australian prescribing, Pharmaceutical Benefits Scheme rules and non-prescription pharmacy products can affect access, so the medication list should include everything the patient takes.

  Recognising When Cough Needs A Different Path

  A cough that continues after reflux control warrants a search for coexisting causes. Cough-variant asthma, eosinophilic airway disease, bronchiectasis, chronic obstructive pulmonary disease and upper-airway disease may require their own investigations and treatments. In a smoker or former smoker, chronic bronchitis and malignancy must not be overlooked simply because reflux symptoms are present.

  Cough hypersensitivity is another important possibility. Patients may cough in response to perfume, cold air, talking, laughing or minor throat sensations. Speech pathology-led cough control therapy can teach relaxed throat breathing, swallow techniques and strategies to interrupt the cough reflex. This approach is available through some Australian hospital services and private clinics, although waiting times and out-of-pocket costs vary between metropolitan and regional areas.

  Medication review should include inhalers, sedatives and drugs that dry or irritate the upper airway. Consider sleep quality, anxiety around coughing and the social impact of symptoms, particularly for people working in schools, healthcare, hospitality or public-facing roles. For Aboriginal and Torres Strait Islander patients, care should be culturally safe and accessible, with attention to transport, continuity and the patient’s preferred health service.

  Practical Points For Shared Care

  A written plan helps the GP, respiratory team, gastroenterologist and patient work from the same evidence. It should state why reflux is suspected, what has been tested, how medicines should be taken, when benefit will be assessed and which symptoms require urgent review. This is particularly useful when care moves between a local GP in regional Queensland and a tertiary service in Brisbane or Sydney.

  Useful features to document include:

  • Cough triggers, timing and impact on sleep or work
  • PPI dose, timing, duration and non-prescription treatments
  • Chest imaging, spirometry and reflux test results
  • Red flags, smoking history and relevant occupational exposures

  Treatment goals should be specific. A reduction in coughing bouts, improved sleep and fewer throat-clearing episodes may be meaningful even if the cough does not disappear immediately. Avoid promising that reflux surgery or stronger acid suppression will resolve a cough unless objective reflux evidence and specialist assessment support that pathway.

  Follow-up can also identify harm from unnecessary treatment, including medication costs, interactions and anxiety about food. Patients should know to seek prompt medical review for vomiting blood, black stools, progressive swallowing difficulty, unexplained weight loss, severe chest pain or breathing deterioration.

  For chronic cough linked with suspected reflux, the central lesson is to treat proven reflux while investigating other causes. Persistent symptoms after an adequate trial are a reason to reassess the diagnosis, not simply to add another medicine. The reader should remember that effective care depends on objective evidence, coordinated Australian healthcare support and a plan that addresses both reflux and cough hypersensitivity.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)