Is there a vicious cycle between obstructive sleep apnea and laryngopharyngeal reflux disease?

Types of Epiglottic Collapse in Breathing Sleep Disorder and Their Impact in Clinical Practice

Introduction  Obstructive sleep apnea (OSA) is a severe form of sleep-disordered breathing (SDB) that is strongly correlated with comorbidities, in which epiglottic collapse (EC) and other contributing factors are involved. Objectives  To evaluate the occurrence of EC in OSA patients through drug-induced sleep endoscopy (DISE) and to determine the factors contributing to EC. Methods  A retrospective study of 37 adult patients using medical history. Patients were assessed for laryngopharyngeal reflux (LPR) and lingual tonsil hypertrophy (LTH) using reflux symptom index and reflux finding score (RFS); for OSA using polysomnography, and for airway collapse through DISE. An independent t -test was performed to evaluate risk factors, including the involvement of three other airway structures. Results  Most EC patients exhibited trap door epiglottic collapse (TDEC) (56.8%) or pushed epiglottic collapse (PEC) (29.7%). Lingual tonsil hypertrophy, RFS, and respiratory effort-related arousal (RERA) were associated with epiglottic subtypes. Laryngopharyngeal reflux patients confirmed by RFS (t(25) = -1.32, p  = 0.197) tended to suffer PEC; LTH was significantly associated (X2(1) = 2.5, p  = 0.012) with PEC (odds ratio [OR] value = 44) in grades II and III LTH patients; 11 of 16 TDEC patients had grade I LTH. Pushed epiglottic collapse was more prevalent among multilevel airway obstruction patients. A single additional collapse site was found only in TDEC patients. Conclusion  Laryngopharyngeal reflux causes repetitive acid stress toward lingual tonsils causing LTH, resulting in PEC with grade II or III LTH. Trap door epiglottic collapse requires one additional structural collapse, while at least two additional collapse sites were necessary to develop PEC. Respiratory effort-related arousal values may indicate EC.

Association between sleep-disordered breathing and self-reported sinusitis in adults in the United States: NHANES 2005-2006

OBJECTIVES

The association between sleep-disordered breathing (SDB) and sinusitis has been widely studied; however, research on SDB-related sleep problems and sinusitis are limited. This study aims to determine the relationship between SDB-related sleep problems, SDB symptom score, and sinusitis.

METHODS

After the screening, data were analyzed from 3414 individuals (≥20 years) from the 2005-2006 National Health and Nutrition Examination Survey questionnaire. Data on snoring, daytime sleepiness, obstructive sleep apnea (snorting, gasping, or cessation of breathing while sleeping), and sleep duration were analyzed. The SDB symptom score was determined based on a summary of the scores of the above four parameters. Pearson chi-square test and logistic regression analysis were used in statistical analyses.

RESULTS

After adjusting for confounders, self-reported sinusitis was strongly correlated with frequent apneas (OR: 1.950; 95% CI: 1.349-2.219), excessive daytime sleepiness (OR: 1.880; 95% CI: 1.504-2.349), and frequent snoring (OR: 1.481; 95% CI: 1.097-2.000). Compared to an SDB symptom score of 0, the higher the SDB symptom score, the higher the risk of self-reported sinusitis. For the subgroup analyses, this association was significant in females and across ethnic groups.

CONCLUSION

In the United States, SDB is significantly associated with self-reported sinusitis in adults. In addition, our study suggests that patients with SDB should be aware of the risk of developing sinusitis.

Assessment of Laryngopharyngeal Reflux and Obstructive Sleep Apnea: A Population-Based Study

OBJECTIVES/HYPOTHESIS

To evaluate the presence of laryngopharyngeal reflux (LPR) and the potential association between presence of LPR symptoms and obstructive sleep apnea (OSA) in a representative sample from a population-based study.

STUDY DESIGN

Cross-sectional study.

METHODS

Participants of the follow-up of the Epidemiological Sleep Study were evaluated. Sleep was assessed through questionnaires and polysomnography. The presence of LPR was based on the questionnaire Reflux Score Index (RSI), and scores higher than 13 were suggestive of LPR. A general linear model test was used for comparison of continuous data and Pearson's chi-square test was used to compare categorical variables. Predictors of LPR were obtained by regression analysis.

RESULTS

701 were enrolled (54.8% female, 45.2% male; mean age, 50.2 ± 13.3 years). The mean apnea-hypopnea index score was 17 ± 18.3 events/hr, and the mean RSI score was 7.0 ± 8.1. LPR was found in 17% of the volunteers, whereas OSA was present in 38.5% of the sample. Specifically, in those patients with OSA, the prevalence of LPR was 45.4%; however, there was no statistically significant association between LPR and the presence of OSA. The severity of OSA was not associated with RSI score. The presence of LPR was associated with older age, smoking, excessive daytime sleepiness and worse quality of life and sleep scores questionnaires.

CONCLUSIONS

Age, smoking, but not body mass index, were associated with LPR. There was not statistically significant association of LPR with OSA. Individuals with symptoms of LPR had greater drowsiness and worse quality of life and sleep.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:1877-1882, 2022.

The effect of laryngopharyngeal reflux on arousal in patients with obstructive sleep apnea

BACKGROUND

Laryngopharyngeal reflux (LPR) may be associated with the severity of obstructive sleep apnea (OSA). However, it is unknown whether LPR may be associated with arousal.

OBJECTIVE

To clarify the effect of LPR on arousal in OSA.

METHODS

This study included 120 OSA patients. The correlations between LPR scores and arousal index (ArI) were analyzed. Finally, to further clarify the effect of LPR on ArI, we analyzed the correlations between respiratory event-related arousal index (BERAI), leg-movement-related arousal index (LMRAI), snore-related arousal index (SRAI), spontaneous arousal index (SAI), and RSI score.

RESULTS

Partial correlation analysis showed that the RSI score was positively correlated with ArI (p = .000), mainly correlated with BERAI and SAI (r = 0.422, p = .000; r = 0.212, p = .020). While controlling for apnea-hypopnea index (AHI), the RSI score was still positively correlated with ArI (p = .002), mainly correlated with BERAI and SAI (r = 0.252, p = .006; r = 0.200, p = .029).

CONCLUSIONS AND SIGNIFICANCE

The effect of LPR symptoms on arousal in OSA exists. The more severe the LPR was, the more frequent the arousal in OSA patients was. Thereinto, respiratory event-related arousal and spontaneous arousal were the most obvious.

Changes in laryngopharyngeal reflux after uvulopalatopharyngoplasty for obstructive sleep apnea: An observational study

PURPOSE

To estimate laryngopharyngeal reflux (LPR) changes after uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea (OSA) using the reflux symptom index (RSI) and reflux finding score (RFS) questionnaires.

METHODS

A total of 91 participants were recruited and divided into three groups: control (n = 27), OSA mild to moderate (n = 29), and OSA severe (n = 35) groups according to polysomnography. All participants completed the preoperative RSI, and underwent blinded evaluation on videolaryngoscopy using the RFS questionnaire. Thirty-four OSA patients who underwent UPPP surgery completed postoperative polysomnography and questionnaires again after a 6-month follow-up.

RESULTS

The RSI score and RFS were higher in patients with OSA than in those without OSA. Patients with severe OSA also had a higher RSI score and RFS than those with mild to moderate OSA. Apnea and hypopnea index degree and percentage of recording time for <90% oxygen saturation showed positive correlation with LPR symptoms. But the lowest blood oxygen saturation during the recording time was negatively correlated with LPR symptoms. The mean RSI score and RFS before UPPP surgery were 15.88 ± 4.85 and 13.18 ± 4.80, after surgery decreasing to 9.53 ± 4.16 and 8.65 ± 4.87, respectively (P <.05). In 25 patients where surgery was successful, RSI scores, RFSs and individual RSI variables decreased after surgery.

CONCLUSIONS

LPR symptoms are common among OSA patients, and the coexistence of OSA and LPR cannot be ignored. Successful UPPP surgery potentially reduces LPR symptoms and improves laryngoscopic signs by alleviating sleep respiratory disorders. Level of Evidence: 3.

Using RSI and RFS scores to differentiate between reflux-related and other causes of chronic laryngitis

OBJECTIVE

To establish if the Reflux Symptom Index (RFI) and the Reflux Finding Score (RFC) can help establish the differential diagnosis in patients with distinct causes of chronic laryngopharyngitis.

METHODS

A group of 102 adult patients with chronic laryngopharyngitis (Group A - 37 patients with allergic rhinitis; Group B - 22 patients with Obstructive Sleep Apnea (OSA); Group C - 43 patients with Laryngopharyngeal Reflux (LPR)) were prospectively studied. Chronic laryngitis was diagnosed based on suggestive symptoms and videolaryngoscopic signs (RSI ≥ 13 and RFS ≥ 7). Allergies were confirmed by a positive serum RAST, OSA was diagnosed with a positive polysomnography, and LPR with a positive impedance-PH study. Discriminant function analysis was used to determine if the combination of RSI and RFS scores could differentiate between groups.

RESULTS

Patients with respiratory allergies and those with LPR showed similar and significantly higher RSI scores when compared to that of patients with OSA (p < 0.001); Patients with OSA and those with LPR showed similar and significantly higher RFS scores when compared to that of patients with Respiratory Allergies (OSA vs. Allergies p < 0.001; LPR vs. Allergies p < 0.002). The combination of both scores held a higher probability of diagnosing OSA (72.73%) and Allergies (64.86%) than diagnosing LPR (51.16%).

CONCLUSIONS

RSI and RFS are not specific for reflux laryngitis and are more likely to induce a false diagnosis if not used with diligence.

Cough, an unresolved problem in interstitial lung diseases

PURPOSE OF REVIEW

Many patients with interstitial lung diseases (ILDs), especially fibrotic ILDs, experience chronic cough. Cough has a major impact on wellbeing, affecting both physical and psychological aspects of life. The pathophysiology of cough in ILDs is poorly understood and currently no good antitussive therapy exists.

RECENT FINDINGS

Research on cough in ILDs is increasing. A recent proof-of-concept study with nebulized sodium cromoglycate for patients with idiopathic pulmonary fibrosis (IPF)-related cough showed a promising effect on cough. Observational data suggest that antifibrotic pirfenidone might reduce cough in IPF. Studies on the effect of acid inhibition on cough in ILDs show contradicting results.

SUMMARY

The first steps in analyzing new treatment options for chronic cough in patients with ILDs, especially in IPF, have been taken, but an effective treatment is still lacking.

Temporal Association Between Respiratory Events and Reflux in Patients With Obstructive Sleep Apnea and Laryngopharyngeal Reflux

STUDY OBJECTIVES

The aim of the current study was to test the hypothesis that there is a temporal correlation between reflux episodes and respiratory events in patients with laryngopharyngeal reflux and obstructive sleep apnea.

METHODS

Adults with clinically diagnosed laryngopharyngeal reflux confirmed by two validated instruments (reflux symptom index ≥ 13 and reflux finding score ≥ 7) and obstructive sleep apnea (OSA) underwent full polysomnography with concomitant and synchronized multichannel intraluminal impedance-pH esophageal monitoring. The apnea-hypopnea and arousal indexes that occurred 15, 30, and 45 minutes before and after each reflux episode were recorded and compared to full-night apnea and hypopnea and arousal index.

RESULTS

We studied 27 patients (14 males, age 51.7 ± 9.1 years, body mass index 32.4 ± 4.2 kg/m²) with laryngopharyngeal reflux (reflux symptom index 16 ± 2 and reflux finding score 12 ± 3) and OSA (apnea-hypopnea index = 32.3 ± 28.4 events/h). We evaluated 102 reflux episodes. Almost half of the reflux episodes occurred while awake (43.1%) and only five reflux episodes (4.9%) occurred during an obstructive respiratory event. The apnea and hypopnea and arousal indexes 15, 30, and 45 minutes before and after reflux episodes were lower than full-night apnea and hypopnea and arousal indexes, respectively.

CONCLUSIONS

Among patients with well-established laryngopharyngeal reflux and OSA, there is no temporal association between reflux and obstructive respiratory events. Even though the data comprised a small sample size, it seems that a more complex mechanism is involved with these two highly prevalent diseases.

Clinical and polysomnographic predictors of laryngopharyngeal reflux in obstructive sleep apnea syndrome

Introduction

Obstructive sleep apnea syndrome and laryngopharyngeal reflux are diseases with a high prevalence in the overall population; however, it remains unclear whether they are diseases with the same risk factors present in the same populations or if there is any association between them.

Objectives

To evaluate and determine the prevalence of laryngopharyngeal reflux in patients with moderate and severe obstructive apnea syndrome and also to determine its predictive factors.

Methods

Historical cohort, cross-sectional study of patients aged 18–70 years, referred to a tertiary service Otorhinolaryngology outpatient clinic with a polysomnographic diagnosis of moderate or severe obstructive sleep apnea syndrome. The reflux symptom index questionnaire and the reflux finding score at indirect videolaryngoscopy were applied to the assessed population, considering the inclusion and exclusion criteria.

Results

Fifty-six patients were evaluated, of which 64.3% had a positive laryngopharyngeal reflux (positive reflux symptom index and/or positive endolaryngeal reflux finding score). Body mass index was a predictor of reflux presence in this group of patients with moderate to severe obstructive sleep apnea syndrome. In patients with positive score for endoscopic findings and reflux symptom index (12.3%), there was a trend toward significance for a higher mean apnea–hypopnea index and a higher percentage of sleep time with oxyhemoglobin saturation below 90% (p = 0.05).

Conclusion

The prevalence of laryngopharyngeal reflux was higher in this group of patients with moderate to severe obstructive sleep apnea syndrome, and the body mass index was a predictor of laryngopharyngeal reflux in these patients. There was a trend toward greater oxyhemoglobin desaturation in patients with a positive score for reflux symptoms index (RSI) and reflux finding score (RFS).

Laryngopharyngeal Reflux Diagnosis in Obstructive Sleep Apnea Patients Using the Pepsin Salivary Test

Background: To investigate the presence of laryngopharyngeal reflux in patients with obstructive sleep apnea (OSA) employing the salivary pepsin concentration method. To compare the results of pepsin concentration with the severity of the pathology. Methods: Seventy-five OSA patients (44 males, 31 females) were enrolled in the study. For each patient, the AHI (apnea–hypopnea index) and the BMI (body mass index) were initially evaluated. All the patients enrolled were assessed using the reflux symptom index (RSI) and the reflux finding score (RFS) in order to perform a clinical diagnosis of laryngopharyngeal reflux. In all patients a salivary sample was taken to estimate the presence of pepsin and its concentration. Results: The incidence of LPR (laryngopharyngeal reflux) in OSA patients, evaluated using the salivary pepsin concentration test (PEP-test), was found to be 32% of cases. Linear regression testing did not show any correlation between AHI and pepsin concentration in salivary samples (p = 0.1). Conclusion: A high number of patients with OSA seem to show positivity for salivary pepsin, correlated to an LPR. There does not appear to be a correlation between the severity of apnea and the grade of salivary pepsin reflux. On the other hand, direct correlation between BMI and the value of pepsin in salivary specimens was observed.

Laryngopharyngeal reflux and dysphagia in patients with obstructive sleep apnea: is there an association?

INTRODUCTION

There is evidence that patients with obstructive sleep apnea (OSA) tend to have a high prevalence of laryngopharyngeal reflux (LPR) and dysphagia. These diseases are known to share the same risk factors and may be interrelated, but there is a lack of studies evaluating their co-occurrence.

OBJECTIVES

To evaluate whether the presence of signs and symptoms suggestive of LPR may be associated with the presence of dysphagia in patients with moderate and severe obstructive sleep apnea (OSA), as well as assess the additional impact of these diseases on quality of life in patients with OSA.

METHODS

Seventy adult patients with moderate or severe OSA were included in the study. The RSI (Reflux Symptom Index) and Swallowing Quality of Life (SWAL-QOL) in dysphagia questionnaires were administered, laryngoscopy was performed to calculate the Reflux Finding Score (RFS), and fiber-optic endoscopic evaluation of swallowing (FEES) was conducted.

RESULTS

The prevalence of LPR was 59.7%, and the prevalence of dysphagia was 27.3%. The association between LPR and dysphagia was present in 17.9% of patients, but with no statistically significant difference. Lower SWAL-QOL scores were observed in several domains in patients with LPR and in only one domain in patients with evidence of dysphagia on FEES.

CONCLUSIONS

Although 17.9% of patients presented with findings suggestive of concomitant LPR and dysphagia, there was no statistically significant association between these two conditions. Patients with LPR had worse scores in several domains of dysphagia-related quality of life, while FEES evidence of dysphagia was associated with worse quality of life in only one domain.

Clinical outcomes of laryngopharyngeal reflux treatment: A systematic review and meta-analysis

OBJECTIVES

To investigate the therapeutic benefit of proton pump inhibitors (PPIs) over placebo in patients with laryngopharyngeal reflux (LPR) and to analyze the epidemiological factors of heterogeneity in the literature.

METHODS

An electronic literature search was conducted to identify articles published between 1990 and 2018 about clinical trials describing the efficiency of medical treatment(s) on LPR. First, a meta-analysis of placebo randomized controlled trials (RCTs) comparing PPIs versus placebo was conducted according to diet. The heterogeneity, response to PPIs, and evolution of clinical scores were analyzed for aggregate results. Second, a systematic review of diagnosis methods, clinical outcome of treatment, and therapeutic regimens was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

RESULTS

The search identified 1,140 relevant publications, of which 72 studies met the inclusion criteria for a total of 5,781 patients. Ten RCTs were included in the meta-analysis. The combined relative risk was 1.31 in favor of PPIs and increased to 1.42 when patients did not receive diet recommendations. Randomized controlled trials were characterized by a significant heterogeneity due to discrepancies in clinical therapeutic outcomes, diagnosis methods (lack of gold standard diagnostic tools), and therapeutic scheme. The epidemiological analysis of all articles supports the existence of these discrepancies in the entire literature. In particular, many symptoms and signs commonly encountered in LPR are not assessed in the treatment effectiveness. The lack of diagnosis precision and variability of inclusion criteria particularly create bias in all reported and included articles.

CONCLUSION

This meta-analysis supports a mild superiority of PPIs over placebo and the importance of diet as additional treatment but demonstrates the heterogeneity between studies, limiting the elaboration of clear conclusions. International recommendations are proposed for the development of future trials. Laryngoscope, 129:1174-1187, 2019.

A possible association between dysphonia and sleep duration: A cross-sectional study based on the Korean National Health and nutrition examination surveys from 2010 to 2012

BACKGROUND

Sleep is important in terms of good general health and appropriate sleep duration has been linked to quality-of-life. Dysphonia may impair communication and social relationships, and is thus also closely related to quality-of-life. No large-scale, cross-sectional epidemiological study of a sample representative of the population of an entire country has yet assessed the possible existence of a relationship between sleep duration and dysphonia.

METHODS

We investigated a possible association between subjective voice problems and self-reported sleep duration in South Korean subjects using 2010-2012 data from the Korean National Health and Nutrition Examination Survey (KNHANES). Cross-sectional data on 17,806 adults (7,578 males and 10,228 females) over the age of 19 years who completed the KNHANES were analyzed. All participants reported voice problems (if present) and their daily average sleep duration using a self-reporting questionnaire. Sleep duration was classified into five categories as follows: ≤5, 6, 7, 8, and ≥9 h/day.

RESULTS

The overall prevalence of dysphonia was 6.8%; 5.7% in males and 7.7% in females. The prevalence for dysphonia by sleep duration exhibited a U-shape, with the lowest point being at sleep duration of 7-8h. After adjustment for covariates (age, sex, smoking status, alcohol consumption, regular exercise, low income, high-level education), a sleep duration of ≤5 h (OR = 1.454; 95% CI, 1.153-1.832) and a sleep duration of ≥9 h (OR = 1.365; 95% CI, 1.017-1.832) were significantly associated with dysphonia, compared to a sleep duration of 7 h. In terms of gender, males who slept for ≥9 h were at a 2-fold (OR = 2.028; 95% CI, 1.22-3.35) higher odds for dysphonia (p<0.05) compared to those who slept for 7 h. A sleep duration ≤5 h was associated with a 1.6-fold (OR = 1.574; 95% CI, 1.203-2.247) higher odds of dysphonia ≥3 weeks in duration (long-term dysphonia).

CONCLUSIONS

This is the first study to show that both short and long sleep duration were significantly associated with the development of dysphonia. The association between sleep duration and dysphonia was more marked in males than females. A sleep duration ≤5 h had a significant impact on the prevalence of long-term dysphonia.

Changes in the Reflux Symptom Index After Multilevel Surgery for Obstructive Sleep Apnea

Objectives

This study evaluated whether the symptoms of laryngopharyngeal reflux (LPR) change after multilevel surgery for obstructive sleep apnea (OSA).

Methods

Patients who underwent multilevel surgery for OSA between April 2009 and September 2014 were enrolled in this study. All patients underwent preoperative polysomnography prior to surgery and were asked to complete the reflux symptom index (RSI) questionnaire before and after surgery.

Results

Of 73 enrolled patients, 24 (33%) reported an RSI score >13 and were thus classified as having reflux. The mean RSI score before surgery was 11.48±7.95; this number decreased to 4.95±6.19 after surgery (P<0.001). The rate of positive RSI responses was 33% before surgery and 9% after surgery. Each variable that comprised the RSI improved significantly after surgery, except for difficulty with swallowing. Regarding the degree of RSI improvement after surgery, there were no significant differences between subgroups according to sex, age, body mass index, OSA severity, or surgical outcome.

Conclusion

LPR symptoms are prevalent in OSA patients. Treatment for OSA using multilevel surgery potentially reduces the symptoms of LPR.

Cough in idiopathic pulmonary fibrosis

Many patients with idiopathic pulmonary fibrosis (IPF) complain of chronic refractory cough. Chronic cough is a distressing and disabling symptom with a major impact on quality of life. During recent years, progress has been made in gaining insight into the pathogenesis of cough in IPF, which is most probably "multifactorial" and influenced by mechanical, biochemical and neurosensory changes, with an important role for comorbidities as well. Clinical trials of cough treatment in IPF are emerging, and cough is increasingly included as a secondary end-point in trials assessing new compounds for IPF. It is important that such studies include adequate end-points to assess cough both objectively and subjectively. This article summarises the latest insights into chronic cough in IPF. It describes the different theories regarding the pathophysiology of cough, reviews the different methods to assess cough and deals with recent and future developments in the treatment of cough in IPF.

Obstructive Sleep Apnea and Gastroesophageal Reflux: A Multivariate Population-Level Analysis

OBJECTIVES

Previous studies investigating the relationship between gastroesophageal reflux (GER) and obstructive sleep apnea (OSA) demonstrate mixed results and have had limited capacity to control for concurrent confounders. Our objectives were to (1) determine if GER is significantly associated with OSA when simultaneously adjusting for the presence of other potentially confounding conditions and (2) quantify the magnitude of any such association that exists.

STUDY DESIGN

Cross-sectional analysis of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 2005-2010.

SETTING

Ambulatory visits in the United States.

SUBJECTS AND METHODS

Adults with a diagnosis of OSA or GER and potentially confounding conditions were identified. Univariate and multivariate logistic regression analyses were performed, as well as sensitivity analyses based on increasingly narrow diagnostic definitions.

RESULTS

A significant positive association between GER and OSA was observed, which persisted after adjustment for age, sex, race/ethnicity, sinonasal obstructive and inflammatory disorders, laryngopharyngeal obstructive and inflammatory disorders, obesity, asthma, and lung disorders. This positive association remained significant regardless of diagnostic criteria, whether broad (odds ratio: 1.94, 95% confidence interval: 1.07-3.54, P = .030) or narrow (odds ratio: 2.13, 95% confidence interval: 1.17-3.88, P = .014).

CONCLUSION

In this analysis of a national database defining the 3 most prioritized diagnoses, GER is independently associated with OSA, with double the odds of concurrent occurrence, even while controlling for potentially related conditions.

Under-recognised co-morbidities in idiopathic pulmonary fibrosis: A review

Co-morbidities in idiopathic pulmonary fibrosis are common. These co-morbidities include obstructive sleep apnoea, gastro-oesophageal reflux disease, pulmonary hypertension and depression. The presence of co-morbidities among patients with idiopathic pulmonary fibrosis contributes to worse quality of life, morbidity and mortality. Despite the high prevalence of certain co-morbidities in idiopathic pulmonary fibrosis, the optimal screening and management of many of these conditions remains unclear. The impact of co-morbidities on this patient population is becoming more apparent. Their relevance will only increase as significant effort is being made to develop novel therapeutics that will alter the disease trajectory of patients with idiopathic pulmonary fibrosis. The purpose of this review is to focus on the epidemiology, pathophysiology, diagnosis and management of select co-morbidities, including obstructive sleep apnoea, gastro-oesophageal reflux disease, pulmonary hypertension and depression, in idiopathic pulmonary fibrosis.

Effects of Proton Pump Inhibitor Therapy for Laryngopharyngeal Reflux on Posttreatment Symptoms and Hypopharyngeal pH

OBJECTIVE

To determine the effect of twice-daily proton pump inhibitor (PPI) treatment on the relationship between laryngopharyngeal pH environment and symptoms in patients with laryngopharyngeal reflux (LPR).

STUDY DESIGN AND SETTING

Retrospective analysis of records from consecutive patients seen at a single clinical site between 2009 and 2012.

SUBJECTS AND METHODS

Forty-three records of patients diagnosed with LPR who underwent pre- and posttreatment pH studies were included. Prior to treatment, all had a Reflux Symptom Index (RSI) > 13 and an abnormal pH study. Patients were treated for ≥ 4 weeks with twice-daily PPIs. Following treatment, patients completed a second RSI and pH study.

RESULTS

Most patients (67.4%) had symptom normalization; however, most patients (60.5%) did not have pH normalization. For all patients whose symptoms did not normalize, pH scores also did not normalize; 32.6% of patients showed no subjective or objective treatment response. For individuals whose symptoms normalized but whose pH scores did not normalize, there was a significant decrease in upright pH score. For the entire group, pretreatment symptom and upright pH scores were strongly positively correlated. Improvements in symptom and upright pH scores following treatment were moderately positively correlated.

CONCLUSION

Laryngopharyngeal pH failed to normalize for most individuals after PPI treatment; only pH improvement was necessary for symptom normalization. Many patients had no treatment response. Laryngopharyngeal reflux patients may make up a heterogeneous group, and PPI responsivity may help explain conflicting results from previous studies. Posttreatment pH monitoring is recommended in studies investigating the efficacy of PPI therapy for LPR.

Relationships between sleep disturbances and gastroesophageal reflux disease in Asian sleep clinic referrals

OBJECTIVE

Studies on the association between gastroesophageal reflux disease (GERD) and sleep apnea syndrome (SAS) have reported conflicting results, and attention has not been paid to the relationship between GERD and other sleep disorders. The aim of the study was to evaluate the relationship between GERD and various aspects of sleep disturbances.

METHODS

A total of 564 subjects who were referred to a sleep laboratory were enrolled in the study. They underwent nocturnal polysomnography (NPSG), and they were asked to complete a GERD questionnaire. The questionnaire consisted of 14 items, and included questions on seven reflux symptoms, namely, heartburn, acid regurgitation, chest pain, hoarseness, globus sensation, coughing and epigastric soreness. Subjects reporting heartburn or acid regurgitation at least once a week were classified as having GERD.

RESULTS

Among 564 participants, 51 subjects (9.0%) were diagnosed as having GERD. GERD patients had higher scores in Beck depression inventory (p<.01), Epworth sleepiness scale (p=.03), Pittsburg sleep quality index (p<.01), more spontaneous arousals in NPSG, and more alcohol consumption than non-GERD patients. There was no association between presence of GERD, SAS-related variables, and body mass index (BMI). GERD was significantly associated with poor sleep quality (adjusted OR, 3.5; 95% CI, 1.3-9.3) and depressed mood (adjusted OR, 2.8; 95% CI, 1.5-5.3).

CONCLUSION

Poor subjective sleep and depressive symptoms are associated with the presence of GERD with no association between SAS, BMI and GERD. In managing patients with GERD, psychiatric and sleep symptoms need to be evaluated and appropriately treated.

Prevalence of signs and symptoms of laryngopharyngeal reflux in snorers with suspected obstructive sleep apnea

Obstructive sleep apnea (OSA) is believed to be correlated with laryngopharyngeal reflux (LPR).

Objective

To study the prevalence of signs and symptoms of reflux in snorers with suspected OSA.

Method

This cross-sectional study enrolled 74 patients assessed positive for OSA with the Berlin questionnaire. The subjects were followed up at the sleep disorder ward of a university center. Studied variables included the BMI, the Epworth sleepiness scale, the reflux symptom index (RSI), the reflux finding score (RFS), and their subdomains related to increased inflammation. The correlations between sleep questionnaires, reflux scales, and their subdomains were deemed statistically significant when p < 0.05.

Results

Ninety-eight percent of the subjects had symptoms and signs suggestive of LPR; prevalence was significantly higher among obese individuals (p = 0.002).

Conclusion

The significant difference seen in the prevalence of signs of inflammation suggestive of LPR when obese and non-obese subjects with suspected OSA were compared indicates that obesity may affect inflammatory findings of the pharynx and larynx. The high prevalence of symptoms and signs of reflux in patients with suspected OSA calls for more studies on the matter.

Hypersensitivity of lung vagal C fibers induced by acute intermittent hypoxia in rats: role of reactive oxygen species and TRPA1

Obstructive sleep apnea, manifested by intermittent hypoxia and excess production of reactive oxygen species (ROS) in airways, is associated with hyperreactive airway diseases, but the mechanism remains unclear. Sensitization of lung vagal C fibers (LVCFs) contributes to the airway hypersensitivity. We investigated the mechanisms underlying the sensitization of LVCFs with acute intermittent hypoxia (AIH), by 10 episodes of exposure to 30 s of hypoxic air (0%, 5%, or 10% O(2)) followed by 30 s of room air in anesthetized, open-chest, and artificially ventilated rats. Reflex apneic response to intravenous capsaicin (an LVCF stimulant), as measured by phrenic nerve activity, was concentration dependently augmented by AIH. Similarly, reflex apneic response to intravenous α,β-methylene-ATP (another LVCF stimulant) was augmented by AIH (0% O(2)). The reflex apnea evoked by these two stimulants was abolished by bilateral vagotomy, which suggests the involvement of lung vagal afferents. The AIH-augmented apneic response to these two stimulants was prevented by pretreatment with dimethylthiourea (a hydroxyl radical scavenger), N-acetyl-l-cysteine (an antioxidant) and HC-030031 [a transient receptor potential ankyrin 1 (TRPA1) receptor antagonist]. Consistently, electrophysiological study revealed the afferent responses of LVCFs to capsaicin or α,β-methylene-ATP were augmented by AIH, and this sensitization of LVCFs was prevented by dimethylthiourea, N-acetyl-l-cysteine, and HC-030031. In contrast, AIH did not alter the afferent response of LVCFs to mechanical stimulation by lung hyperinflation. We concluded that AIH sensitizes LVCFs in rats, thus resulting in exaggerated airway reflexogenic responses to chemical stimulants, possibly by ROS action and activation of TRPA1 receptors.

Obstructive sleep apnea does not promote esophageal reflux in fibrosing interstitial lung disease

BACKGROUND

In patients with fibrosing interstitial lung disease (fILD), gastroesophageal reflux (GER) is highly prevalent, perhaps because of the effects of lung fibrosis on altering intrathoracic pressure, diaphragm morphology and lower esophageal sphincter (LES) function. For unclear reasons, obstructive sleep apnea (OSA) is also highly prevalent among patients with fILD. We conducted this study to test our hypothesis that, in patients with fILD, OSA would exacerbate diaphragm/LES dysfunction and increase the propensity for-and severity of - GER.

METHODS

We identified patients with fILD who underwent screening polysomnogram and pH or pH/impedence probe at our center during the same week. We examined the association between OSA and GER and used logistic regression to determine independent predictors of OSA or GER.

RESULTS

In 54 included subjects, neither OSA (dichotomous) nor apnea hypopnea index (continuous) predicted the presence of GER. Regardless of body position (upright, recumbent), GER was no more frequent or severe among subjects with OSA vs. those without OSA. Subjects with idiopathic pulmonary fibrosis (IPF) had an odds of GER nearly seven-fold greater than subjects with other forms of fILD (odds ratio = 6.84, 95% confidence interval 1.36-34.43, p = 0.02). For the entire cohort and the subgroup with IPF, there was no correlation between pulmonary physiology and GER.

CONCLUSIONS

In fILD, OSA does not appear to promote GER. Research is needed to determine if compensatory mechanisms emanating from the crural diaphragm prevent GER in fILD patients with OSA and to sort out whether GER has a role in the pathogenesis of certain forms of fILD.

Laryngopharyngeal Reflux : Larynx on Fire

Laryngopharyngeal Reflux (LPR) is a commonly occurring and recently described clinical entity due to the retrograde flow of gastric contents into the pharynx. It accounts for many symptoms of upper airway including hoarseness, chronic throat irritation and globus sensation. The sensitive laryngeal mucosa is prone to damage by the combination of acid and pepsin. The inflammatory changes that follow are presumed to cause the symptoms and predispose the individual to laryngeal disorders. Diagnosis can usually be made clinically based on symptoms and laryngeal signs but a 24 hour pH metry is essential to establish diagnosis. Treatment centres on lifestyle modifications, vocal hygiene measures and long term use of proton pump inhibitors. Recent research in this field may lead to a better understanding of the pathophysiology of the disease and change the way LPR is managed.

Prevalence and incidence of high risk for obstructive sleep apnea in World Trade Center-exposed rescue/recovery workers

PURPOSE

World Trade Center (WTC)-exposed rescue/recovery workers continue to have high rates of gastroesophageal reflux disease (GERD), chronic rhinosinusitis, and posttraumatic stress disorder (PTSD) symptoms. This study examines the relationship between these WTC-related conditions and being at high risk for obstructive sleep apnea (OSA).

MATERIALS AND METHODS

The Fire Department of the City of New York (FDNY) performs periodic health evaluations on FDNY members every 12 to 18 months. Evaluations consist of physician examinations and self-administered health questionnaires, which, since 2005, have incorporated questions about sleep problems that were adapted from the Berlin Questionnaire. The study population consisted of 11,701 male firefighters and emergency medical service personnel. Incidence analyses were limited to a cohort (n = 4,576) who did not meet the criterion for being at high risk for OSA at baseline (between September 12, 2005 and September 8, 2006) and had at least one follow-up assessment, on average, 1.4 (±0.5) years later.

RESULTS

The baseline prevalence of high risk for OSA was 36.5%. By follow-up, 16.9% of those not at high risk initially became at high risk for OSA. In multivariable logistic regression models predicting incident high risk for OSA, independent predictors included: earlier time of arrival at the WTC site, GERD, chronic rhinosinusitis, PTSD symptoms, self-assessed fair/poor health, low body mass index (BMI < 18.5 kg/m(2)), and, as expected, BMI > 30 kg/m(2) and weight gain of ≥10 lb (4.5 kg).

CONCLUSIONS

We found significant associations between being at high risk for OSA and common WTC-related conditions, although the responsible causative mechanisms remain unknown. Since the etiology of OSA is likely multifactorial, improvement may require successful treatment of both OSA and its comorbid conditions.