The prevalence of gastroesophageal reflux in asthma patients without reflux symptoms

Effects of esomeprazole 40 mg twice daily on asthma: a randomized placebo-controlled trial

RATIONALE

Gastroesophageal reflux disease (GERD) is common in patients with asthma, suggesting an interaction between the two conditions.

OBJECTIVES

To assess the effect of gastric acid suppression with the proton pump inhibitor esomeprazole on asthma outcomes in subjects with persistent moderate to severe asthma treated with antiinflammatory asthma medication.

METHODS

In this double-blind study, subjects were randomized to receive esomeprazole 40 mg or placebo twice daily for 16 wk. According to nocturnal respiratory symptoms (NOC) and GERD, subjects were divided into three strata: GERD-/NOC+, GERD+/NOC-, and GERD+/NOC+.

MEASUREMENTS AND MAIN RESULTS

A total of 770 subjects were randomized. There was no statistically significant improvement in morning peak expiratory flow (PEF) over placebo in the overall study population: 6.3 L/min (p = 0.061). Over the whole treatment period, in GERD+/NOC+ subjects (n = 350), esomeprazole provided an 8.7-L/min improvement (p = 0.03) in morning PEF, and a 10.2-L/min improvement (p = 0.012) in evening PEF over placebo. Among 307 subjects taking long-acting beta2-agonists, improvements over placebo were observed in morning PEF (12.2 L/min, p = 0.017) and in evening PEF (11.1 L/min, p = 0.024); these improvements were more pronounced in GERD+/NOC+ subjects. Esomeprazole 40 mg twice daily was well tolerated and no safety concerns were noted.

CONCLUSIONS

Esomeprazole improved PEF in subjects with asthma who presented with both GERD and NOC. In subjects without both GERD and NOC, no improvement could be detected.

Gastroesophageal reflux disease in children with asthma: treatment implications

An association between asthma and gastroesophageal reflux disease (GERD) has long been recognized both mechanistically and epidemiologically. The clinical relevance of this interplay continues to be explored, with special interest given to the role of GERD in the worsening of asthma. The effect of GERD is most frequently contemplated in patients with asthma that is difficult to control. Medical and surgical anti-reflux trials attempting to alter asthma symptoms have reported mixed but generally underwhelming results, although asthma symptom scores are generally improved following effective treatment of GERD. Many of the pharmaceutical studies can be criticised for having too short a duration or for likely incomplete acid suppression. Few trials have specifically studied pediatric populations. Because GERD is a common condition, particularly in young children, the role reflux plays in the worsening of asthma symptoms and the potential benefit on asthma of anti-reflux therapy warrants further exploration. Whether or not treating symptomatic GERD reduces the symptoms and severity of asthma in children, GERD coexisting with asthma should be aggressively treated. GERD symptoms in most patients with or without asthma can be controlled medically with continuous use of proton pump inhibitors such as omeprazole and lansoprazole and to a lesser extent by histamine H(2) receptor antagonists such as famotidine and cimetidine.

Outpatient experience of patients with GERD in the United States: analysis of the 1998-2001 National Ambulatory Medical Care Survey

This study documents the number of ambulatory visits associated with gastroesophageal reflux disease (GERD) in the United States. Sample data from nearly 80,000 patients captured by the National Ambulatory Medical Care Survey (NAMCS; 1998-2001) were analyzed. Basic demographics of patients with GERD and factors associated with each visit were assessed. Approximately 38.53 million of 2.653 billion adult outpatient visits made in the United States during the study period were GERD-related. GERD-related visits increased by 46.5% from 1998 to 2001. Most GERD-related visits were by women (54.7%) with an average age of 56.0 years, compared with patients without GERD, who were even more likely to be women (62.2%) and younger (52.6 years). Patients with GERD were more likely to have multiple reasons (50.5%) and multiple diagnoses (79.3%) per medical visit versus non-GERD patients (37.6% and 48.4%, respectively). Utilization of data from the NAMCS reveals that GERD-related visits increased annually during the study period. Patients with GERD are more likely to see a physician if they have concomitant medical conditions, making GERD a condition that is very likely untreated in a high percentage of individuals.

Acid suppression does not change respiratory symptoms in children with asthma and gastro-oesophageal reflux disease

BACKGROUND

Epidemiological studies have shown an association between gastro-oesophageal reflux disease (GORD) and asthma, and oesophageal acid perfusion may cause bronchial constriction. However, no causative relation has been proven.

AIM

To assess whether acid suppression would lead to reduced asthma symptoms in children with concomitant asthma and GORD.

METHODS

Thirty eight children (mean age 10.8 years, range 7.2-16.8; 29 males) with asthma and a reflux index > or =5.0 assessed by 24 hour oesophageal pH monitoring were randomised to 12 weeks of treatment with omeprazole 20 mg daily or placebo. The groups were similar in age, gender, mean reflux index, and asthma severity. Primary endpoints were asthma symptoms (daytime wheeze, symptoms at night, in the morning, and during exercise) and quality of life (PAQLQ). Secondary endpoints were changes in lung function and the use of short acting bronchodilators. At the end of the study a repeated pH study was performed to confirm the efficacy of acid suppression.

RESULTS

The change in total symptom score did not differ significantly between the omeprazole and the placebo group, and decreased by 1.28 (95% CI -0.1 to 2.65) and 1.28 (95% CI -0.72 to 3.27) respectively. The PAQLQ score increased by 0.62 (95% CI 0.29 to 0.95) in the omeprazole group compared to 0.50 (95% CI 0.29 to 0.70) in the placebo group. Change in lung function and use of short acting bronchodilators were similar in the groups. The acid suppression was adequate (reflux index <5.0) under omeprazole treatment.

CONCLUSION

Omeprazole treatment did not improve asthma symptoms or lung function in children with asthma and GORD.

Frequency of gastroesophageal reflux disease in nonatopic children with asthma-like airway disease

Gastroesophageal reflux disease (GERD) is commonly associated with asthma; however, frequency in nonatopic children with asthmatic symptoms is unknown. The aim of this study was to determine the frequency of gastroesophageal reflux (GER) in nonatopic children with asthma-like airway disease that recur despite conventional asthma treatment and to evaluate the clinical response to lansoprazole treatment. Twenty-five nonatopic children aged between 1 and 16 years who have asthma-like airway disease and 25 healthy children were included in the study. All cases underwent 24 h pH monitoring with dual sensor catheters. Additionally, acid suppressor treatment was administered to patients diagnosed as having GERD and clinical response was evaluated. Major symptoms encountered in the patient group included wheezing and cough (88%, and 32%, respectively). Reflux episodes were more common in distal esophagus during the prone position (reflux index (RI) of 11.5+/-10.3 vs. 16.2+/-9.4 during supine vs. prone). All distal esophageal parameters were significantly higher in the patient group except number of reflux episodes lasting longer than 5 min (RI of 13.3+/-13.1 vs. 3.9+/-2.9 in the patient vs. control groups, respectively). There was a significant improvement in symptoms and requirement for medication with treatment (number of systems decreased from 2.3+/-0.6 to 0.4+/-0.6, P=0.00). In conclusion, GERD is significantly more common in nonatopic children with asthma-like airway disease compared to the controls and clinical improvement is significant after acid suppressor treatment. Thus, we suggest that children followed-up with the diagnosis of nonatopic asthma with recurrent exacerbations despite adequate asthma treatment have a high frequency of GER and that lansoprazole treatment may be considered early in management.

Review article: extraoesophageal manifestations of gastro-oesophageal reflux disease

Although recent studies suggest that gastro-oesophageal reflux disease may frequently contribute to ear, nose and throat and respiratory diseases, the cause-and-effect relationship is far from proven. The review will address this controversial topic emphasizing recent literature raising concerns about the credibility of this association and our tests to make this diagnosis. The author believes these extraoesophageal symptoms suspected to be secondary to gastro-oesophageal reflux disease are an unresolved issue, but selective use of aggressive proton-pump inhibitor therapeutic trials may help to resolve this problem in our individual patients.

Gastroesophageal Reflux Disease and Asthma

STUDY OBJECTIVES

Gastroesophageal reflux disease (GERD) and asthma are common causes for consultation in primary care, but the relationship between the two remains unclear. The aim of our study was to investigate the temporal relationship between first diagnoses of GERD and asthma in general practice.

METHODS

We used the UK General Practice Research Database to identify a cohort of patients with a first diagnosis of GERD (n = 5,653) and another cohort of patients with a first diagnosis of asthma (n = 9,712) during 1996, which we compared with age-matched and sex-matched control cohorts drawn from the general population without either diagnosis. We investigated the incidence of a GERD diagnosis among the asthma patients and control subjects, and the incidence of an asthma diagnosis among the GERD patients and control subjects during a mean follow-up period of 3 years. We calculated the relative risk (RR) of these diagnoses using Cox regression analysis and examined the risk associated with medication use using nested case-control analysis.

RESULTS

The incidence rates of GERD and asthma among the control cohorts were 4.4 and 3.8 per 1,000 person-years, respectively. During the follow-up period, the RR of an incident asthma diagnosis in patients with a new diagnosis of GERD was 1.2 (95% confidence interval [CI], 0.9 to 1.6), while the RR of an incident GERD diagnosis among patients with a new diagnosis of asthma was 1.5 (95% CI, 1.2 to 1.8) after adjustment for age, sex, smoking, prior comorbidity, and number of health-care contacts. This increased risk was mainly seen during the first year of follow-up. The prior use of prescription medications for asthma and GERD had no significant effects on the risk of GERD and asthma diagnosis, respectively.

CONCLUSIONS

Patients with asthma are at a significantly increased risk of developing GERD, mainly during the first year following diagnosis. A nonsignificant increase in the risk of developing asthma was evident among GERD patients. The relationship between GERD and asthma warrants further investigation.

Gastric fullness, physical activity, and proximal extent of gastroesophageal reflux

OBJECTIVES

Proximal extent of gastroesophageal reflux (PER) is relevant for symptoms in GERD patients. It has been suggested that PER is determined by the volume of the refluxate that, in turn, might depend on the degree of gastric fullness. Abdominal straining, during ambulation, increases the likelihood of gastroesophageal reflux. We assessed the influence of gastric fullness and ambulation on proximal extent of reflux.

METHODS

PER was assessed in 37 patients with GERD undergoing ambulatory pH impedance monitoring. In 14 controls and 19 GERD patients, esophageal pH impedance and gastric emptying were also studied simultaneously in stationary conditions. We compared PER during fasting, early postprandial (before half emptying), and late postprandial periods in ambulatory and stationary conditions.

RESULTS

More reflux episodes reached the proximal esophagus in the postprandial period compared to fasting (60%+/-4 vs 29%+/-3, p<0.05). In stationary conditions, early postprandial reflux reached higher proximal extent than late postprandial reflux (15+/-3% vs 8+/-4%, p<0.05). The proportion of reflux events reaching the proximal esophagus was significantly higher in ambulatory than in stationary conditions (29+/-5% vs 15+/-3%, p<0.05).

CONCLUSION

Compared to fasting, reflux episodes occurring after the meals are more likely to reach higher proximal extent, particularly so during the early postprandial period. The highest proportion of postprandial proximal reflux occurred in ambulatory condition. These findings suggest that reducing meal volumes and early postprandial physical activity might contribute to decrease proximal extent of reflux and postprandial GERD symptoms.

Gastroesophageal reflux: a potential asthma trigger

Gastroesophageal reflux (GER) is a potential trigger of asthma. Approximately 77% of asthmatics report heartburn. GER is a risk factor for asthma-related hospitalization and oral steroid burst use. Asthmatics may be predisposed to GER development because of a high prevalence of hiatal hernia and autonomic dysregulation and an increased pressure gradient between the abdominal cavity and the thorax, over-riding the lower esophageal sphincter pressure barrier. Asthma medications may potentiate GER. Potential mechanisms of esophageal acid-induced bronchoconstriction include a vagally mediated reflex, local axonal reflexes, heightened bronchial reactivity, and microaspiration, all resulting in neurogenic inflammation. Anti-reflux therapy improves asthma symptoms in approximately 70% of asthmatics with GER. A 3-month empiric trial of twice-daily proton pump inhibitor given 30 to 60 minutes before breakfast and dinner can identify asthmatics who have GER as a trigger of their asthma.

Clinical presentation, diagnosis, and management of gastroesophageal reflux disease

GERD is ubiquitous throughout the adult population in the United States. It commonly adversely affects quality of life and occasionally causes life-threatening complications. The new and emerging medical and endoscopic therapies for GERD and the new management strategies for BE should dramatically reduce the clinical toll of this disease on society.

Activation of the nociceptin/orphanin FQ receptor reduces bronchoconstriction and microvascular leakage in a rabbit model of gastroesophageal reflux

1. Nociceptin/orphanin FQ (N/OFQ) is the endogenous peptide ligand for a specific G-protein coupled receptor, the N/OFQ peptide receptor (NOP). The N/OFQ-NOP receptor system has been reported to play an important role in pain, anxiety and appetite regulation. In airways, N/OFQ was found to inhibit the release of tachykinins and the bronchoconstriction and cough provoked by capsaicin. 2. Here we evaluated the effects of NOP receptor activation in bronchoconstriction and airway microvascular leakage induced by intraesophageal (i.oe.) hydrochloric acid (HCl) instillation in rabbits. We also tested the effects of NOP receptor activation in SP-induced plasma extravasation and bronchoconstriction. 3. In anesthetized New Zealand rabbits bronchopulmonary function (total lung resistance (R(L)) and dynamic compliance (C(dyn))) and airway microvascular leakage (extravasation of Evans blue dye) were evaluated. 4. Infusion of i.oe. HCl (1 N) led to a significant increase in bronchoconstriction and plasma extravasation in the main bronchi and trachea of rabbits pretreated with propranolol, atropine and phosphoramidon. 5. Bronchoconstriction and airway microvascular leakage were inhibited by N/OFQ (3-30 microg kg(-1) i.v.) in a dose-dependent manner. The NOP receptor agonist [Arg14,Lys15]N/OFQ mimicked the inhibitory effect of N/OFQ, being 10-fold more potent, UFP-101, a peptide selective NOP receptor antagonist, blocked the inhibitory effects of both agonists. 6. Under the same experimental conditions, N/OFQ and [Arg14,Lys15]N/OFQ did not counteract the bronchoconstriction and airway microvascular leakage induced by substance P. 7. These results suggest that bronchoconstriction and airway plasma extravasation induced by i.oe. HCl instillation are inhibited by activation of prejunctional NOP receptors.

The prevalence of gastroesophageal reflux disease in adult asthmatics

BACKGROUND

Asthma and gastroesophageal reflux disease (GERD) often coexist. However, the results of the studies investigating the prevalence of GERD among patients with asthma vary greatly.

STUDY OBJECTIVE

To investigate the prevalence of GERD in adult patients with asthma.

SUBJECTS AND METHODS

The basic study population consisted of 2,225 asthmatic patients who were treated in six specialist-headed hospitals during 1 year. From the common computer-based discharge register, every 14th patient was randomly selected for the study. Ninety of the 149 contacted patients (60%) agreed to participate in the study. Twenty-four-hour esophageal pH monitoring was performed on all patients.

RESULTS

GERD was found in 32 of the patients (36%). Eight of these patients (25%) were free from classical reflux symptoms. Forty-seven of the 90 patients (52%) presented with typical reflux symptoms. Twenty-four of these patients (51%) were found to have abnormal acidic reflux.

CONCLUSIONS

According to the current study, one third of adult patients with asthma have GERD. These patients often do not have typical reflux symptoms. However, the presence of typical reflux symptoms in an asthmatic patient does not seem to guarantee the presence of abnormal acidic reflux.

Reflujo gastroesofágico proximal y síndrome de la apnea obstructiva del sueño

INTRODUCTION

Patients with mild or moderate Sleep Apnea Syndrome (SAS) need wider therapeutic scope options according to their disease severity.

AIM

To consider including proton pump inhibitors (PPI) to the therapeutical alternatives of these patients.

MATERIAL AND METHODS

A prospective study was designed, among patients with SAS. Nocturnal polysomnography and double channel pHmetry were performed simultaneously.

RESULTS

From the 18 patients included in this preliminary phase, in three (16.7%) nocturnal proximal ph monitoring was positive. These 3 patients were treated with PPI during at least 3 months with a very satisfactory outcome in two of them.

CONCLUSIONS

Treatment with PPI may be a useful therapeutical alternative in patients with mild to moderate SAS.

Review article: diagnosis and management of night-time reflux

Symptoms of gastro-oesophageal reflux disease (GERD) range from mild to severe and, when they occur during night-time hours, can interfere with sleep patterns and reduce overall quality of life. The clinical presentation of GERD is characterized by oesophageal as well as supra-oesophageal symptoms, including otolaryngologic and pulmonary complications. However, GERD may be overlooked as the cause of a patient's supra-oesophageal symptoms because these complaints can occur in the absence of oesophageal symptoms or endoscopic changes. The role of available tools used for GERD diagnosis, including endoscopy, oesophageal pH monitoring and an empirical course of proton pump inhibitor therapy, is discussed. Interventions available to achieve the therapeutic goals of symptom relief and prevention include specific lifestyle modifications and over-the-counter as well as prescription pharmacological agents. Patient-initiated, as-needed treatment may not be the best choice for managing persistent night-time reflux because it requires patient arousal from sleep. Proton pump inhibitor therapy remains the treatment of choice for patients with more severe symptoms and those with erosive oesophagitis. Few studies have specifically evaluated the role of pharmacological agents in the management of night-time reflux and comparisons are difficult due to the variability in study design and endpoints assessed.

Review article: supra-oesophageal manifestations of gastro-oesophageal reflux disease and the role of night-time gastro-oesophageal reflux

Gastro-oesophageal reflux disease (GERD) has been associated with a variety of supra-oesophageal symptoms, including asthma, laryngitis, hoarseness, chronic cough, frequent throat clearing and globus pharyngeus. GERD may be overlooked as the underlying mechanism for these symptoms because typical GERD symptoms may be absent, despite abnormal oesophageal acid exposure. Two basic mechanisms linking GERD with laryngeal symptoms have been proposed: direct contact of gastric acid with the upper airway, in some cases due to micro-aspiration, and a vagovagal reflex triggered by acidification of the distal portion of the oesophagus. Gastro-oesophageal reflux (GER) during sleep is believed to be an important mechanism for the development of supra-oesophageal complications of GERD, such as asthma and idiopathic pulmonary fibrosis (IPF). Several physiological changes during sleep, including prolonged oesophageal acid contact time, decreased upper oesophageal sphincter pressure, increased gastric acid secretion, decreased salivation, decreased swallowing and a decrease in conscious perception of acid, render an individual more susceptible to reflux-induced injury. Supra-oesophageal symptoms often improve in response to aggressive acid-suppressive therapy. However, many unanswered questions remain regarding the appropriate approach to diagnosis and treatment of patients with GERD-related supra-oesophageal symptoms. In this article we review the relationship between supra-oesophageal symptoms and GERD and, where possible, highlight the evidence supporting the role of night-time reflux as a contributing factor to these symptoms.

Extraesophageal symptoms: what role for the proton pump inhibitors?

The esophageal complications of gastroesophageal reflux disease (GERD) are well described and include erosive esophagitis, stricture, Barrett esophagus, and adenocarcinoma. Primary care physicians often encounter patients with "extraesophageal" manifestations of GERD in the absence of heartburn. Patients may present with symptoms involving the pulmonary system, noncardiac chest pain, and ear, nose, and throat disorders. The diagnosis of reflux disease in these individuals may be challenging because, in addition to the absence of heartburn, endoscopy is often negative. Laryngoscopy and 24-hour dual-channel intraesophageal pH-metry may have greater diagnostic yields, but they are costly, invasive, and time-consuming. A trial of proton pump inhibitor (PPI) therapy is increasingly being considered a first-line diagnostic test in those with suspected reflux-related extraesophageal symptoms. The duration as well as dose of PPI should be based on the presenting symptoms, with patients having pulmonary manifestations often requiring twice-daily therapy for 2 to 3 months. In contrast, symptoms of reflux-related noncardiac chest pain may be relieved with a 1-week, standard-dose treatment trial. Patients who fail to experience symptom resolution or improvement should undergo further diagnostic evaluations including 24-hour esophageal pH studies while continuing their PPI therapy to establish persistent versus absent acid reflux. The role of fundoplication or other surgical/laparoscopic procedures in these patients has yet to be determined.

Ear, nose and throat and respiratory manifestations of gastro-esophageal reflux disease: an increasing conundrum

Although recent studies suggest that gastro-oesophageal reflux disease (GORD) may contribute frequently to ear, nose and throat (ENT) and respiratory diseases, the cause-and-effect relationship is far from proven. This article addresses this controversial topic, emphasising recent literature that raises concerns about the credibility of this association and our tests to make this diagnosis. The author believes that these extra-oesophageal symptoms suspected to be secondary to GORD are a conundrum, but selective use of aggressive proton-pump-inhibitor therapeutic trials may help to resolve this issue in our patients.

Variables affecting the occurrence of gastroesophageal reflux in obstructive sleep apnea patients

A number of recent studies have suggested that apnea and/or hypopnea episodes may be in a causal relationship with nocturnal gastroesophageal reflux (GER) episodes in obstructive sleep apnea (OSA) patients. In this study, we addressed the possible factors that may affect the occurrence of reflux events in OSA patients. For this reason, we investigated respiratory and sleep parameters in OSA patients with or without nocturnal GER episodes. Nineteen patients who were referred to the sleep laboratory for suspected sleep apnea were included in the study. All subjects underwent polysomnographic evaluation simultaneously with distal and proximal esophageal pH monitoring. During the recording period, a total of 134 reflux events, 134 from distal probes and none from proximal probes, were recorded. We divided patients into two groups: (1) nocturnal GER-positive patients ( n=8; age: 41.9+/-11.9) and (2) nocturnal GER-negative patients ( n=11; age: 45.4+/-3.3). We compared demographic, respiratory and sleep parameters between the two groups. Then we analysed the time relation between GER episodes and obstructive respiratory events. The two groups were matched by age and body mass index. Sleep and respiratory parameters were not different between the two groups. In conclusion, we suggested that age, body mass index and the severity of disease in obstructive sleep apnea patients are not effective determinants of gastroesophageal reflux. There is no sufficient evidence to accept arousals and obstructive apneas as primary causes of gastroesophageal reflux and vice versa. And finally, sleep macroorganisation has no impact on the occurrence of GER in OSAS.

Review article: supra-oesophageal manifestations of gastro-oesophageal reflux disease

Supra-oesophageal manifestations of gastro-oesophageal reflux disease (GERD) are common and often under-appreciated, in part due to the absence of classic symptoms of heartburn and regurgitation. Patients with supra-oesophageal manifestations of GERD may report symptoms involving the pulmonary, otolaryngologic or pharyngeal systems. Endoscopy is often negative and therefore of limited diagnostic value in these patients, and while laryngoscopy and 24 h dual-channel intra-oesophageal pH-metry may have greater yields they are costly, invasive and time-consuming. Therefore, a trial of proton pump inhibitor therapy is now widely considered a first-line diagnostic test in those with suspected GERD-induced supra-oesophageal symptoms. The dose as well as duration of the proton pump inhibitor trial is dependent upon a patient's presenting symptoms. For example, GERD-related non-cardiac chest pain may be relieved with a short-term (e.g. 1 week) treatment with standard doses of a proton pump inhibitor. The use of high-dose twice daily proton pump inhibitor therapy for an extended period (e.g. 2-3 months) may be required before any discernible improvement in pulmonary symptoms or pharyngo-laryngitis is noted. Patients who do not experience symptom improvement following a proton pump inhibitor trial may require further diagnostic evaluations including 24 h oesophageal pH studies, while on acid anti-secretory therapy, to establish the absence of persistent acid reflux. The role of anti-reflux surgical or endoscopic interventions in those with supra-oesophageal manifestations of GERD remains to be established.

Causative and contributive factors to asthma severity and patterns of medication use in patients seeking specialized asthma care

STUDY OBJECTIVES

(1) To assess the prevalence of specific factors considered causative or contributive to asthma in a population of patients seen in a specialized asthma clinic, and to determine whether any of these factors were associated with more severe disease; and (2) to assess the utilization of inhaled steroids by asthma severity in this population and compare it with published guidelines of the National Heart, Lung, and Blood Institute (NHLBI). DESIGN, SETTING, AND PATIENT POPULATION: We conducted a retrospective chart review of new patients seen in a specialized asthma treatment center over a 2.5-year period and recorded the prevalence of 14 causative or contributive factors, the severity of asthma, and the intensity of treatment with inhaled corticosteroids in each patient. Patients were grouped as mild asthma vs moderate/severe asthma and compared by chi(2) analysis and stepwise logistic regression to determine whether certain factors were associated with more severe asthma.

MEASUREMENTS AND RESULTS

The average number of factors recorded was 2.9 +/- 1.8 in the mild group (+/- SD) and 3.5 +/- 1.6 in the moderate/severe asthma group. This difference was statistically significant (p = 0.014). Increasing age, male gender, symptomatic gastroesophageal reflux disease (GERD), and chronic sinusitis were independently associated with more severe asthma. Suboptimal use of inhaled corticosteroids was more common in patients with mild persistent asthma, but suboptimal dosing of inhaled corticosteroids was equally common in mild and moderate/severe asthma. No relationship was found between allergen sensitization combined with exposure to cats, dogs, dust mite, or molds and more severe asthma.

CONCLUSIONS

This study confirms earlier studies showing that symptomatic GERD and chronic sinusitis are important comorbid conditions in patients with asthma, both being associated with greater asthma severity. This study further shows that the doses of inhaled corticosteroids used for treatment of asthma fall short of NHLBI guidelines in the majority of patients regardless of asthma severity.

Extraesophageal manifestations of GERD

The association between gastroesophageal reflux disease (GERD) and extraesophageal disease is often referred to as extraesophageal reflux (EER). This article reviews EER, discussing epidemiology, pathogenesis, diagnosis, and treatment with a focus on the most studied and convincing EER disorders-asthma, cough, and laryngitis. Although EER comprises a heterogeneous group of disorders, some general characterizations can be made, as follows. First, although GERD's association with extraesophageal diseases is well-established, definitive evidence of causation has been more elusive, rendering epidemiological data scarce. Secondly, regarding the pathogenesis of EER, 2 basic models have been proposed: direct injury to extraesophageal tissue by acid and pepsin exposure or injury mediated through an esophageal reflex mechanism. Third, because heartburn and regurgitation are often absent in patients with EER, GERD may not be suspected. Even when GERD is suspected, the diagnosis may be difficult to confirm. Although endoscopy and barium esophagram remain important tools for detecting esophageal complications, they may fail to establish the presence of GERD. Even when GERD is diagnosed by endoscopy or barium esophagram, causation between GERD and extraesophageal symptoms cannot be determined. Esophageal pH is the most sensitive tool for detecting GERD, and it plays an important role in EER. However, even pH testing cannot establish GERD's causative relationship to extraesophageal symptoms. In this regard, effective treatment of GERD resulting in significant improvement or remission of the extraesophageal symptoms provides the best evidence for GERD's pathogenic role. Finally, EER generally requires more prolonged and aggressive antisecretory therapy than typical GERD requires.

Laparoscopic Nissen Fundoplication Improves Quality of Life in Patients with Atypical Symptoms of Gastroesophageal Reflux

Laparoscopic Nissen fundoplication has been shown to improve overall quality of life (QOL) in patients with gastroesophageal reflux, but most studies have not addressed patients with atypical symptoms. We investigated the effect of laparoscopic Nissen fundoplication on QOL using the Gastrointestinal Quality of Life Index (GIQLI) survey modified to address both typical (heartburn, regurgitation, dysphagia) and atypical (hoarse voice, chronic cough, adult-onset asthma, vocal cord polyps) symptoms. One-hundred forty-eight patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease (GERD) at UCLA Medical Center from January 1, 1995 to May 1, 2002. Surveys evaluating pre- and postoperative QOL were administered after surgery: 55 per cent of patients responded (82/148). Forty-eight per cent of all patients (72/148) had atypical symptoms. Perioperative morbidity and mortality were 8.8 per cent and 0.7 per cent, respectively. Mean length of postoperative stay was 2.96 ± 1.5 days. Mean follow-up for the entire cohort was 18.5 months. Postoperative dysphagia not present before surgery occurred in 4.7 per cent of patients. Eighty per cent of patients were medication-free following surgery. QOL scores for all participants increased significantly from 52.5 ± 15.3 preoperatively to 72.0 ± 14.9 postoperatively ( P < 0.0001). Patients with atypical symptoms or typical symptoms alone showed significant mean QOL score increases from 48.3 ± 17.6 preoperatively to 71 ± 15.7 postoperatively ( P < 0.0001) and from 55.7 ± 12.6 to 72.8 ± 14.4 ( P < 0.0001), respectively. Laparoscopic Nissen fundoplication can effectively improve overall QOL for patients with GERD. Patients with atypical GERD symptoms can experience increases in QOL similar to those with only typical gastrointestinal symptoms.

Recent clinical investigations examining the association of asthma and gastroesophageal reflux

For more than a decade, investigations have examined the association between asthma and gastroesophageal reflux (GER), and have demonstrated that the presence of esophageal acid events is associated with respiratory symptoms. The most current research shows that GER is prevalent in patients with asthma, that esophageal acid may alter bronchial hyperresponsiveness, and that medical or surgical GER therapy may improve asthma outcome in selected asthma patients. Further research will build on our current knowledge base and, hopefully, enable us to better identify those patients with asthma who will most benefit from reflux therapy.

The role of proton pump inhibitors in the management of gastroesophageal reflux disease-related asthma and chronic cough

Gastroesophageal reflux disease (GERD) occurs in at least one third of patients with asthma and is recognized as a potential trigger for asthma symptoms. The results of studies conducted in patients with both asthma and GERD, in which proton pump inhibitor (PPI) therapy is used to evaluate its effect on asthma outcome, are inconsistent, and many of these studies suffer from different design flaws. However, it does appear that PPI treatment may improve nocturnal asthma symptoms in patients who also have GERD. Moreover, both daytime asthmatic symptoms and pulmonary function seem to improve in some patients with PPI treatment. There is evidence that more severe GERD might predict a more favorable asthma outcome with PPI therapy. For effective management of GERD-related asthma, PPIs should be used at a dose double that of the standard dose for a minimum of 2 to 3 months. Although GERD is also known to be an important cause of chronic cough, there have been only 2 placebo-controlled trials investigating the efficacy of PPI on GERD-related chronic cough. Results of both of these trials suggest that PPI treatment relieves GERD-related chronic cough. As with GERD-related asthma, it would seem reasonable to use a double-standard dose of a PPI for a minimum of 2 to 3 months in the management of GERD-related chronic cough. However, larger, adequately planned studies are needed to confirm the role of PPIs in the management of GERD-related asthma and chronic cough.

Childhood gastroesophageal reflux symptoms in adult patients

OBJECTIVES

Gastroesophageal reflux (GER) and its esophageal (esophagitis, Barrett's esophagus) and extraesophageal (asthma, laryngeal disease) disease manifestations (GERD) are increasing common problems in children and adults. There are virtually no published longitudinal outcome studies that describe the natural history of childhood-onset GER throughout a person's lifetime. The aim of this study was to compare the frequency of recalled childhood reflux symptoms in adult patients currently with and without GER symptoms.

METHODS

Four hundred adult patients were classified as refluxers (225 patients; 57%), nonrefluxers (154 patients; 38%), and those who claimed to not know if they had reflux (21 patients; 5%; excluded from analysis). Subjects were given a questionnaire asking them to recall childhood symptoms attributed to GER. Of the 225 refluxers, 141 (63%) recalled at least one childhood symptom, compared with 54 of the 154 nonrefluxers (35%) ( < 0.001).

CONCLUSIONS

Adult refluxers were more likely to recall having developed GER symptoms at an earlier age, beginning at infancy and developing statistically significant GER compared with nonrefluxers after age 11. Adults suffering from GER were far more likely than nonrefluxers to recall having experienced GER symptoms during childhood. Well-designed, population-based epidemiologic studies are needed to more accurately assess the extent of GER in the overall population and the extent of its impact on health care in the United States.

Symptomatic gastroesophageal reflux in subjects with a breathing sleep disorder

STUDY OBJECTIVES

A link between gastroesophageal reflux (GER) and obstructive sleep apnea (OSA) has been suggested; however, the prevalence and frequency of symptomatic GER and the influence of OSA severity on GER are not known.

DESIGN AND PATIENTS

Two hundred seventy-one subjects referred for overnight sleep studies were investigated for subjects with a breathing sleep disorder, occurrence of symptomatic GER, potential risk factors for both conditions, and comorbidity using a validated questionnaire.

RESULTS

Overall, 160 of the 228 respondents (73%; 135 subjects with OSA and 93 subjects who snore) reported GER-related symptoms, with heartburn and/or acid regurgitation being the leading symptoms. No evidence of a difference in the occurrence of symptomatic GER between subjects who snore and subjects with OSA was observed (odds ratio [OR], 1.21; 95% confidence interval [CI], 0.7 to 2.1). Furthermore, the occurrence of reflux symptoms was not influenced by the severity of OSA (OR per 10 4% arterial oxygen saturation [SaO(2)] dips per hour, 0.98; 95% CI, 0.8 to 1.1). Self-reported comorbidity was higher in subjects with OSA compared with subjects who snore (p = 0.02), but none of the potential risks produced an association with the presence of reflux symptoms in this sample of patients with a breathing sleep disorder.

CONCLUSION

We conclude that symptomatic GER is common in subjects with a breathing sleep disorder, but there was no difference between those with OSA and subjects who snore.

Nocturnal worsening of asthma and sleep-disordered breathing

Asthma has a tendency, to destabilize and get worse at night, probably due to a nocturnal increase in airiway inflammation and bronchial responsiveness. Nocturnal airway narrowing in asthma is often associated with sleep disorders, such as episodes of nocturnal and early morning awakening, difficulty in maintaining sleep, and day time sleepiness. On the other hand, an association has been documented between nocturnal sleep-disordered breathing and asthma. This review highlights the causes of nocturnal worsening of asthma and examines the evidence pointing toward a causal relationship between nocturnal asthma and sleep-disordered breathing.

Oral corticosteroids increase esophageal acid contact times in patients with stable asthma

STUDY OBJECTIVES

The prevalence of gastroesophageal reflux disease (GERD) is higher in people with asthma than in control populations. Predisposing factors for GERD development may include asthma medications such as prednisone. The objective of this study was to determine whether prednisone alters GERD parameters in people with asthma.

DESIGN

Prospective, single-blinded, placebo-controlled, crossover study.

SETTING

University medical center clinic.

PARTICIPANTS

Twenty adults with stable, moderate persistent asthma with minimal esophageal reflux symptoms (less than three times a week) who were not receiving antireflux therapy.

INTERVENTION

Prednisone, 60 mg/d, for 7 days.

MEASUREMENTS AND RESULTS

Asthma, esophageal reflux symptoms, and spirometry were measured during baseline, placebo, and prednisone phases, each 7 days in duration. Dual-probe esophageal pH monitoring, esophageal and respiratory manometrics (20 subjects), and basal and stimulated gastric acid secretion (4 subjects) were measured after placebo and prednisone phases. There were significant increases in esophageal acid contact times at the distal and proximal pH probes during the prednisone phase. Total percentage of time that pH was < 4.0 at the distal probe was 2.5 +/- 0.4% for placebo compared with 5.9 +/- 0.9% for prednisone (p < 0.002). Total percentage of time that pH was < 4.0 at the proximal probe was 0.3 +/- 0.1% for placebo and 0.8 +/- 0.2% for prednisone (p < 0.0007). There were no significant changes in subject weight, spirometry, asthma or esophageal reflux symptoms, manometrics, or basal or stimulated gastric acid secretion.

CONCLUSION

Prednisone, 60 mg/d for 7 days, increased esophageal acid contact times in this small population of people with stable asthma; however, the mechanism for this finding is unclear.

Respiratory symptoms and nocturnal gastroesophageal reflux: a population-based study of young adults in three European countries

STUDY OBJECTIVE

To estimate the possible association between reported symptoms of gastroesophageal reflux (GER) after bedtime, sleep-disordered breathing, respiratory symptoms, and asthma.

DESIGN

Cross-sectional international population survey.

PARTICIPANTS

Participants consisted of 2,661 subjects (age range, 20 to 48 years) from three countries (Iceland, Belgium, and Sweden), of whom 2,202 were randomly selected from the general population and 459 were added because of reported asthma.

MEASUREMENTS

The investigation included a structured interview, spirometry, methacholine challenge, peak flow diary, skin-prick tests, and a questionnaire on sleep disturbances.

RESULTS

In the random population sample, 101 subjects (4.6%) reported GER, which was defined as the occurrence of heartburn or belching after going to bed at least once per week. Subjects with nocturnal GER more often were overweight and had symptoms of sleep-disordered breathing than participants not reporting GER. Participants with GER were more likely to report wheezing (adjusted odds ratio [OR], 2.5), breathlessness at rest (adjusted OR, 2.8), and nocturnal breathlessness (adjusted OR, 2.9), and they had increased peak flow variability compared to the subjects without GER. Physician-diagnosed current asthma was reported by 9% of subjects with GER compared to 4% of those not reporting GER (p < 0.05). Subjects with the combination of asthma and GER had a higher prevalence of nocturnal cough, morning phlegm, sleep-related symptoms, and higher peak flow variability than subjects with asthma alone.

CONCLUSION

The occurrence of GER after bedtime is strongly associated with both asthma and respiratory symptoms, as well as symptoms of obstructive sleep apnea syndrome. The partial narrowing or occlusion of the upper airway during sleep, followed by an increase in intrathoracic pressure, might predispose the patient to nocturnal GER and, consequently, to respiratory symptoms.

Underlying mechanisms of respiratory symptoms with esophageal acid when there is no evidence of airway response

Although a strong association exists between gastroesophageal reflux (GER) and asthma, results of studies designed to maximize the likelihood of identifying that GER worsens pulmonary function in patients with asthma have been negative or inconclusive. Asthma symptoms worsen during symptomatic reflux episodes, and asthma symptom severity correlates with the severity of symptomatic reflux. Various reasons have been proposed to explain these findings. Discomfort associated with GER can cause reflux-associated respiratory symptoms even when pulmonary function is normal. New findings suggest that increases in minute ventilation rather than inhibition of diaphragm activity are responsible for the changes in respiratory sensation during acid perfusion of the esophagus in nonasthmatic subjects. These results may also pertain to asthmatic patients, because increasing minute ventilation can cause dyspnea and bronchospasm in this population. Treating GER, either medically or surgically, may improve asthma symptoms by preventing GER-induced changes in minute ventilation.

Management Considerations for Chronic Asthma

Asthma is a common chronic disease affecting millions of individuals in the United States. Appropriate management and prevention of asthma symptoms is essential in order to maintain quality of life and reduce healthcare costs. Published consensus guidelines provide recommendations for asthma management and emphasize pharmacologic and nonpharmacologic components for long-term management. Major components of asthma management include environmental control measures, patient education and self-management, pharmacotherapy and periodic assessment. Since publication of the guidelines in 1997, there has been additional research and advances in our knowledge and understanding of asthma. Ongoing research focuses on issues such as regular versus as needed use of short-acting bronchodilators, early initiation of inhaled corticosteroids, safety of inhaled corticosteroids in children with asthma, combination therapy with inhaled corticosteroids and other long-term control agents, and reduction of inhaled corticosteroid doses. Advances in therapy and new knowledge about appropriate management strategies should be incorporated into clinical management strategies.

Chronic cough, asthma, and gastroesophageal reflux

Gastroesophageal reflux disease (GERD) causes chronic cough and triggers asthma. Mechanisms of reflux-associated chronic cough include micro- and macroaspiration, laryngeal injury, and a vagally mediated reflex. An empiric trial of a proton pump inhibitor in patients without other etiologies of cough found through diagnostic testing may be an effective diagnostic strategy for GERD-associated cough. In GERD-associated asthma, there is evidence of neurogenic inflammation. Medical or surgical therapy of GERD results in asthma symptom improvement in about 70% of patients. A 3-month empiric trial of omeprazole, 20 mg daily, followed by esophageal pH testing in drug nonresponders, is the most cost-effective way of diagnosing asthma triggered by GERD.