Reviewer’s report
Title: 
May chronic cough in chronic obstructive pulmonary disease be a
contraindication of Percutaneous Endoscopic Gastrostomy placement: a case
report
Version: 
4 
Date: 
08 Jun 2020
Reviewer's report:
This is a case report illustrating recurrent buried bumper syndrome in a patient
with COPD. The point is made that chronic cough can predispose to PEG tube
displacement and should be considered a contraindication.
The manuscript reads reasonably well, and needs a modest amount syntax
editing.
It does contain an important message, which is nicely illustrated by the
thoughtful photographs.
However to improve the clinical usefulness, the paper needs to include
recommendations on tube choice and tube aftercare for these patients, rather than
just saying they cannot have a PEG.
General comments:
1. The identification of severe chronic cough as a risk factor for buried bumper
(BB) is valid, but over-interpreted as a contraindication. The implication is for
setting the tube correctly and the proper daily tube care.
2. There is lack of detail on the tube used in this patient, this should be added.
3. The benefits of using a traction-removable tube, which completely bypasses
all problems with BBs are not mentioned and need adding.
4. Minimally invasive radiologic techniques for dealing with a BB need
mentioning in order to highlight the need for a multi-disciplinary approach.
Specific comments (Page numbers are missing and could not be given, Line
numbers are given; suggested changes in CAPITALS):
Background
5. 31: The earliest sign is usually increasing feeding pressures, as well as leak.
The key clinical sign is that the tube can no longer be pushed into the stomach
during daily tube care.
6. Please add that it is essential for all patients, but particularly in those who
have a chronic cough, that during the daily tube cleaning the PEG is not only
rotated, but advanced in and out of the stomach and then set to the correct
length. In these patients the tubes need to be set longer to accommodate the
excursion of the abdominal wall during forced expiration while coughing. His
may precipitate leakage.
Case presentation
7. 58: Please identify the PEG type and size used
8. 14: An image from the CT scan for education would be very valuable
9. 15: Please identify what measures were taken to remove the tube (needle
knife, balloon etc.) 
Discussion
10. 45: Please add comments the daily care routine and on how tubes should be
set in patients with COPD. These are valuable points for the community nurses.
11. Please identify how this institution has changed their practice on the basis of
this experience: Are PEGs no longer undertaken in COPD patients? Are these
referred for radiological gastrostomy with a balloon tube or surgical
jejunostomy?
12. Please add a comment on traction-removable PEG tubes, which can be
simply extracted in case of a buried bumper
References
13. The median age of the papers cited is 6 years (2014). The literature search
should be updated and include ESGE guidelines
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the
authors.
Unable to assess
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
No
Are you able to assess any statistics in the manuscript or would you
recommend an additional statistical review?
If an additional statistical review is recommended, please specify what aspects
require further assessment in your comments to the editors.
Not relevant to this manuscript
Quality of written English
Please indicate the quality of language in the manuscript:
Needs some language corrections before being published
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
I declare that I have no competing interests.H-U Laasch
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please publish my name with my
report.
Reviewer’s report
Title: 
May chronic cough in chronic obstructive pulmonary disease be a
contraindication of Percutaneous Endoscopic Gastrostomy placement: a case
report
Version: 
4 
Date: 
08 Jun 2020
Reviewer's report:
This is a case report illustrating recurrent buried bumper syndrome in a patient
with COPD. The point is made that chronic cough can predispose to PEG tube
displacement and should be considered a contraindication.
The manuscript reads reasonably well, and needs a modest amount syntax
editing.
It does contain an important message, which is nicely illustrated by the
thoughtful photographs.
However to improve the clinical usefulness, the paper needs to include
recommendations on tube choice and tube aftercare for these patients, rather than
just saying they cannot have a PEG.
General comments:
1. The identification of severe chronic cough as a risk factor for buried bumper
(BB) is valid, but over-interpreted as a contraindication. The implication is for
setting the tube correctly and the proper daily tube care.
2. There is lack of detail on the tube used in this patient, this should be added.
3. The benefits of using a traction-removable tube, which completely bypasses
all problems with BBs are not mentioned and need adding.
4. Minimally invasive radiologic techniques for dealing with a BB need
mentioning in order to highlight the need for a multi-disciplinary approach.
Specific comments (Page numbers are missing and could not be given, Line
numbers are given; suggested changes in CAPITALS):
Background
5. 31: The earliest sign is usually increasing feeding pressures, as well as leak.
The key clinical sign is that the tube can no longer be pushed into the stomach
during daily tube care.
6. Please add that it is essential for all patients, but particularly in those who
have a chronic cough, that during the daily tube cleaning the PEG is not only
rotated, but advanced in and out of the stomach and then set to the correct
length. In these patients the tubes need to be set longer to accommodate the
excursion of the abdominal wall during forced expiration while coughing. His
may precipitate leakage.
Case presentation
7. 58: Please identify the PEG type and size used
8. 14: An image from the CT scan for education would be very valuable
9. 15: Please identify what measures were taken to remove the tube (needle
knife, balloon etc.) 
Discussion
10. 45: Please add comments the daily care routine and on how tubes should be
set in patients with COPD. These are valuable points for the community nurses.
11. Please identify how this institution has changed their practice on the basis of
this experience: Are PEGs no longer undertaken in COPD patients? Are these
referred for radiological gastrostomy with a balloon tube or surgical
jejunostomy?
12. Please add a comment on traction-removable PEG tubes, which can be
simply extracted in case of a buried bumper
References
13. The median age of the papers cited is 6 years (2014). The literature search
should be updated and include ESGE guidelines
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the
authors.
Unable to assess
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
No
Are you able to assess any statistics in the manuscript or would you
recommend an additional statistical review?
If an additional statistical review is recommended, please specify what aspects
require further assessment in your comments to the editors.
Not relevant to this manuscript
Quality of written English
Please indicate the quality of language in the manuscript:
Needs some language corrections before being published
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
I declare that I have no competing interests.H-U Laasch
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please publish my name with my
report.
Please review this paper.
user
Reviewer’s report
Title: 
May chronic cough in chronic obstructive pulmonary disease be a
contraindication of Percutaneous Endoscopic Gastrostomy placement: a case
report
Version: 
4 
Date: 
08 Jun 2020
Reviewer's report:
This is a case report illustrating recurrent buried bumper syndrome in a patient
with COPD. The point is made that chronic cough can predispose to PEG tube
displacement and should be considered a contraindication.
The manuscript reads reasonably well, and needs a modest amount syntax
editing.
It does contain an important message, which is nicely illustrated by the
thoughtful photographs.
However to improve the clinical usefulness, the paper needs to include
recommendations on tube choice and tube aftercare for these patients, rather than
just saying they cannot have a PEG.
General comments:
1. The identification of severe chronic cough as a risk factor for buried bumper
(BB) is valid, but over-interpreted as a contraindication. The implication is for
setting the tube correctly and the proper daily tube care.
2. There is lack of detail on the tube used in this patient, this should be added.
3. The benefits of using a traction-removable tube, which completely bypasses
all problems with BBs are not mentioned and need adding.
4. Minimally invasive radiologic techniques for dealing with a BB need
mentioning in order to highlight the need for a multi-disciplinary approach.
Specific comments (Page numbers are missing and could not be given, Line
numbers are given; suggested changes in CAPITALS):
Background
5. 31: The earliest sign is usually increasing feeding pressures, as well as leak.
The key clinical sign is that the tube can no longer be pushed into the stomach
during daily tube care.
6. Please add that it is essential for all patients, but particularly in those who
have a chronic cough, that during the daily tube cleaning the PEG is not only
rotated, but advanced in and out of the stomach and then set to the correct
length. In these patients the tubes need to be set longer to accommodate the
excursion of the abdominal wall during forced expiration while coughing. His
may precipitate leakage.
Case presentation
7. 58: Please identify the PEG type and size used
8. 14: An image from the CT scan for education would be very valuable
9. 15: Please identify what measures were taken to remove the tube (needle
knife, balloon etc.) 
Discussion
10. 45: Please add comments the daily care routine and on how tubes should be
set in patients with COPD. These are valuable points for the community nurses.
11. Please identify how this institution has changed their practice on the basis of
this experience: Are PEGs no longer undertaken in COPD patients? Are these
referred for radiological gastrostomy with a balloon tube or surgical
jejunostomy?
12. Please add a comment on traction-removable PEG tubes, which can be
simply extracted in case of a buried bumper
References
13. The median age of the papers cited is 6 years (2014). The literature search
should be updated and include ESGE guidelines
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the
authors.
Unable to assess
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
No
Are you able to assess any statistics in the manuscript or would you
recommend an additional statistical review?
If an additional statistical review is recommended, please specify what aspects
require further assessment in your comments to the editors.
Not relevant to this manuscript
Quality of written English
Please indicate the quality of language in the manuscript:
Needs some language corrections before being published
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
I declare that I have no competing interests.H-U Laasch
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please publish my name with my
report.
assistant