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Chronic cough in Swiss bagpipe player

Case studies can reveal interesting considerations for both the diagnosis and management of seemingly common conditions. Chronic cough can be a symptom of many conditions: chronic bronchitis, asthma, allergy, bronchiectasis, postnasal drip or GORD. It can also be a side effect associated with prescribed medicines, such as ACE inhibitors. In some cases, a persistent cough may be a symptom of a more serious condition, such as lung cancer, heart failure, PE or tuberculosis.

In this unusual case report, published earlier this year, a 34-year-old man presented to the GI clinic with chronic cough. These coughing episodes were exacerbated during periods in which he played bagpipes, as well as the morning after playing. In reviewing the patient’s history, airway hyperreactivity was noted. Previous assessments excluded allergic bronchopulmonary aspergillosis, and identified no pathological findings on CT. Bronchoscopy with BAL and mucosal biopsy showed no pulmonary aetiology, although BAL showed elevated macrophage and bacteria representative of the oral flora. The patient was previously prescribed budesonide and formoterol followed by 8 weeks of PPI therapy, both of which failed to reduce symptoms. After these tests, the patient was referred to the GI clinic, who, after an unremarkable endoscopy, performed a high-resolution oesophageal manometry and 24-hour multichannel intraluminal impedance-pH test.

The results of these tests demonstrated GORD. Interestingly, testing was also performed during bagpipe playing, and two reflux episodes were noticed, which were followed by elevated distal oesophageal acid exposure. It was noted that during bagpipe playing, abdominal/oesophageal pressure increased to 80–90 mmHg. The patient, rather than choosing pharmacologic intervention, modified his instrument to lower its resistance, and potentially the abdominal/oesophageal pressure. At a 7-month follow-up, the patient reported resolution of his cough, and repeat testing showed a 30% reduction in abdominal/oesophageal pressure with the new bagpipe modifications. No reflux episodes occurred during bagpipe playing, and the patient’s acid exposure was reduced to below the criteria for GORD.

Authors concluded that in patients who play wind instruments and have an inconclusive pulmonary work-up for cough, GI causes should be considered. This case demonstrates both the need to think more broadly about the potential causes for unexplained patient symptoms, as well as potential strategies for their resolution.

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