Chronic Cough and Reflux

Today's blog augments my social media posts this week on chronic cough.  I mean, now is definitely not the time to be dealing with chronic cough, am I right?  With the coronavirus pandemic having us all just a bit twitchy about every scratchy throat, runny nose and cough, dealing with chronic cough can be even more stressful (which ironically can make your cough worse!).  So today we're going to talk about the role of reflux - and more specifically "silent reflux," in the role of chronic cough.
What is Silent Reflux?
The medical term used is laryngopharyngeal reflux (say that 3 times fast!) or LPR.  It occurs when the stomach contents flow back up in the the larynx and pharynx (so the back of the throat and mouth).  The symptoms are different than traditional GERD (gastroesophageal reflux disease - which is heartburn and regurgitation); LPR symptoms usually involve symptoms in the throat - cough, sore throat, voice issues like hoarseness and difficulty talking loudly and the sensation that something is in the throat (usually lots of throat clearing).
Treating LPR/Silent Reflux
Many patients who come to me for treatment of chronic cough are on, or have been on anti-reflux medications - usually proton-pump inhibitors (PPI's) like Prevacid, Protonix or Dexilant.  However, studies show that PPI's are ineffective at treating LPR, and indeed, are ineffective at treating chronic cough.  PPI's are meant for treating GERD, not LPR which is why they don't seem to have an effect.  And cough is more associated with LPR than GERD.  My first choices in dealing with suspected LPR are diet and diaphragm strengthening.
Diet:  Often it is acidic and spicy foods that will contribute to worsening symptoms of LPR.  I usually give people a list of foods (like this one) that highlight those associated with increased reflux, have them check it and compare it to their usual diet.  If they tend to eat a lot of the "reflux causing" foods, I will ask them to reduce those foods for a couple of weeks.  If their cough symptoms improve, then we can start suspecting diet/LPR as a factor and figure out a plan from there.  If there has been no change in symptoms, then we continue to look for other causes.
Diaphragm:  the Lower Esophageal Sphincter (basically the gate keeper between the stomach and the esophagus) is located within the diaphragm muscle.  Its job is to keep stomach contents from coming back up the esophagus.  Studies have shown that dysfunction of this sphincter can lead to LPR.  Studies have also shown that the diaphragm can directly impact this.  Strengthening the diaphragm via inspiratory muscle training has shown to reduce LPR.  Inspiratory muscle training can also have a positive impact on the muscle function of the upper airway (larynx), which can also be beneficial for chronic cough.
If you want a bit more science on LPR and treatments, I encourage to read this helpful review.  This blog is by no means comprehensive for treating LPR, nor chronic cough, but merely addr

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