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

Does omeprazole improve asthma-control in poorly-controlled asthmatic children with gastro-esophageal reflux

OBJECTIVES

The role of gastro-esophageal reflux disease (GERD) in poorly controlled asthma is often mentioned, but published studies have presented discordant results. Our main objective was to assess the effectiveness of GERD treatment in controlling asthma in children.

METHODS

We conducted a prospective study including poorly controlled asthmatic children aged 4 to 16 years. We checked the presence of acid reflux using pH monitoring. Patients with GERD were randomized into two groups; one received omeprazole for 6 months and the control group was not treated. The outcome was the score of the children asthma control test at the end of 6 months. The acid suppression was checked at the end of treatment with pH monitoring. After treatment, children with persistent acid reflux received high PPI doses and therefore were reevaluated 6 months later.

RESULTS

We included 102 children with poorly controlled asthma among which 59 (57.8%) had acid reflux. Gastroesophageal reflux (GER) was significantly more common in boys (p = 0.04). Treatment with omeprazole in sufficient doses improved the control of asthma in 5 children out of 6 (84.8 vs 11.5; p<.0001). Three factors appeared to be statistically associated with asthma control improvement after PPI therapy: male sex (p=.04), normal birth weight (p=.05) and a positive Prick-test (p=.05). These factors were not confirmed or were not sufficiently precise in multivariate analysis. The likelihood of a causal relationship between acid reflux and asthma, difficult to highlight with pH monitoring, was poor.

CONCLUSIONS

This study confirmed the high prevalence of GER in poorly controlled asthmatic children and showed the possible benefit of an efficient GER treatment in improving asthma control.

Preschool Wheezing and Gastro-Esophageal Reflux: --Causal or Casual Coincidence? Update from Literature

Gastroesophageal reflux (GER) and wheeze are two common conditions in children. GER has been advocated as a causative factor for explaining recurrent to persistent respiratory symptoms at any age. This association very often means that many children with cough, wheezing, or recurrent respiratory infections receive empirical anti-reflux medications. The causal relationship is still largely discussed. Compared to the large number of studies in infants and adolescents, literature on the relationship between GER and wheeze in preschool children is scarce and inconclusive. The aim of the present narrative review was to summarize what is known so far, and what the literature has proposed in the last 20 years, on the relationship between preschool wheezing and GER. In preschool children with respiratory symptoms there is a high rate of positivity of reflux testing, for this reason pH-MII testing and endoscopy are recommended. Flexible bronchoscopy may be useful to exclude anatomical abnormalities as the cause of wheezing in infancy and preschool years. Several biomarkers, as well as empirical anti-reflux therapy, have been proposed for the diagnosis of GER-related airway diseases, but the conclusions of these studies are controversial or even conflicting. There is a great need for future clinical trials to confirm or rule out the association.

Genotype tailored treatment of mild symptomatic acid reflux in children with uncontrolled asthma (GenARA): Rationale and methods

Asthma causes enormous suffering and cost for children in the US and around the world [1-3]. Co-morbid gastroesophageal reflux disease (GERD) makes asthma management more difficult due to increased symptoms. Proton pump inhibitor (PPI) drugs are effective at improving to GERD symptoms, however they have demonstrated only modest and variable effects on asthma control in the setting of co-morbid GERD. Importantly, PPI metabolism and efficacy depend on CYP2C19 genotype. The Genotype Tailored Treatment of Symptomatic Acid Reflux in Children with Uncontrolled Asthma (GenARA) study is a randomized, double-blind, placebo-controlled trial to determine if genotype-tailored PPI dosing improves asthma symptoms among children with inadequately controlled asthma and GERD symptoms. This study has an innovative design to both assess the efficacy of genotype-tailored PPI dosing and perform pharmacokinetic modeling of the oral PPI Lansoprazole. Children ages 6-17 years old with clinician-diagnosed asthma and mild GERD symptoms will submit a saliva sample for CYP2C19 genotyping. Participants will undergo a two-step randomization to: (1) genotype-tailored versus conventional dosing of open-label oral lansoprazole for pharmacokinetic modeling, and (2) genotype-tailored lansoprazole daily versus placebo for 24 weeks to determine the effect of genotype-tailored PPI dosing on asthma control. Measures of asthma control, spirometry, and nasal washes during acute illnesses will be collected at 8-week intervals throughout the study. GenARA will better define the effects of CYP2C19 genotype on the dose response of lansoprazole in children and adolescents and assess if a novel dosing regimen improves GERD and asthma control.

Official American Thoracic Society Clinical Practice Guidelines: Diagnostic Evaluation of Infants with Recurrent or Persistent Wheezing

BACKGROUND

Infantile wheezing is a common problem, but there are no guidelines for the evaluation of infants with recurrent or persistent wheezing that is not relieved or prevented by standard therapies.

METHODS

An American Thoracic Society-sanctioned guideline development committee selected clinical questions related to uncertainties or controversies in the diagnostic evaluation of wheezing infants. Members of the committee conducted pragmatic evidence syntheses, which followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The evidence syntheses were used to inform the formulation and grading of recommendations.

RESULTS

The pragmatic evidence syntheses identified few studies that addressed the clinical questions. The studies that were identified constituted very low-quality evidence, consisting almost exclusively of case series with risk of selection bias, indirect patient populations, and imprecise estimates. The committee made conditional recommendations to perform bronchoscopic airway survey, bronchoalveolar lavage, esophageal pH monitoring, and a swallowing study. It also made conditional recommendations against empiric food avoidance, upper gastrointestinal radiography, and gastrointestinal scintigraphy. Finally, the committee recommended additional research about the roles of infant pulmonary function testing and food avoidance or dietary changes, based on allergy testing.

CONCLUSIONS

Although infantile wheezing is common, there is a paucity of evidence to guide clinicians in selecting diagnostic tests for recurrent or persistent wheezing. Our committee made several conditional recommendations to guide clinicians; however, additional research that measures clinical outcomes is needed to improve our confidence in the effects of various diagnostic interventions and to allow advice to be provided with greater confidence.

Evaluation of gastro-oesophageal reflux disease in wheezy infants using 24-h oesophageal combined impedance and pH monitoring

BACKGROUND AND STUDY AIMS

Gastro-oesophageal reflux disease (GERD) is incriminated as a cause of non-asthmatic infantile wheeze. To date, no diagnostic test is considered standard for GERD-related airway reflux diagnosis. Oesophageal combined multiple channel intraluminal impedance and pH (MII-pH) monitoring is proposed to be a sensitive tool for evaluation of all GERD including infantile wheeze. We aimed to determine the GERD prevalence amongst wheezy infants in the first year of life using combined MII-pH versus pH monitoring alone and evaluate the sensitivity and specificity of objective MII-pH monitoring parameters in GERD-associated infantile wheeze diagnosis compared to those of lipid-laden macrophage index (LLMI).

PATIENTS AND METHODS

Thirty-eight wheezy infants below 1year of age were evaluated for GERD using oesophageal combined MII-pH monitoring and LLMI.

RESULTS

Totally, 60.5% of cases had abnormal MII-pH; only 7.9% of them had abnormal pH monitoring. LLMI was significantly higher in wheezy infants with abnormal MII-pH than infants with normal MII-pH monitoring (112±88 versus 70±48; P=0.036). The current definitions of abnormal MII-pH study, reflux index≥10% and distal reflux episodes≥100, had low sensitivity (23%) but high specificity (100% and 96%, respectively) in GERD-related aspiration diagnosis defined by LLMI≥100. Using ROC curves, bolus contact time≥2.4% and proximal reflux episodes≥46 had 61% and 54% sensitivity and 64% and 76% specificity, respectively, in GERD-related aspiration diagnosis.

CONCLUSION

Combined MII-pH is superior to pH monitoring in reflux-associated infantile wheeze diagnosis. Objective data including proximal reflux episodes and bolus contact time should be combined with the current parameters used in reflux-associated infantile wheeze diagnosis.

Infant wheeze, comorbidities and school age asthma

BACKGROUND

Factors associated with early onset of wheeze have been described, but there is limited knowledge on which of these infant wheezers who will have developed asthma in school age. The aim was to identify clinical risk factors for asthma in the 8-yr-old children that wheezed during infancy in a population-based setting.

METHODS

Three thousand two hundred and fifty-one children from a population-based birth cohort followed prospectively from infancy until age 8 yr were included in the study. Data were analyzed using multivariate logistic regression analysis.

RESULTS

Parents reported any wheeze episode before age 2 yr in 823 subjects (25%). Infant wheezers had an almost fourfold risk of asthma at age 8 [adjusted odds ratio (aOR) 3.68, 95% CI 2.74-4.96], equivalent to an asthma prevalence of 14% compared with 4% among non-wheezers (p < 0.001). After adjustments for sex, exposure to tobacco smoke and indoor dampness/mould, allergic heredity (aOR 1.53, 95% CI 1.02-2.30), increased frequency of wheeze (aOR 3.41, 95% CI 2.09-5.56 for children with ≥3 episodes compared with ≤2 episodes during the first 2 yr of life), infant eczema (aOR 2.31, 95% CI 1.52-3.49), and recurrent abdominal pain (aOR 2.33, 95% CI 1.30-4.16) remained risk factors for school age asthma in the infant wheezing group.

CONCLUSIONS

Among infant wheezers, allergic heredity, increased severity of wheeze, infant eczema, and recurrent abdominal pain were independent risk factors for asthma at age 8 yr. Among children with three or four of these risk factors, 38% had asthma at school age.

Lung diffusion capacity in children with respiratory symptoms and untreated GERD

BACKGROUND

Gastroesophageal reflux disease (GERD) is associated with many respiratory disorders, among which, chronic cough, laryngitis, and asthma are among the most common. We investigated lung function, including gas diffusion capacity, in children with poor asthma control or chronic laryngitis with untreated GERD.

MATERIAL AND METHODS

A total of 71 children, aged 6-17 years, with chronic respiratory and other symptoms suggestive for GERD, were enrolled and divided into 2 groups: chronic laryngitis and asthma. Participants underwent 24-hour pH monitoring and lung function assessment, measurement of single-breath diffusing capacity of the lung for carbon monoxide (DLCO), and fraction of exhaled nitric oxide (FENO) measurement.

RESULTS

24-hour pH monitoring was positive for GERD in 92.1% of preselected children with asthma and 90.1% of children with chronic recurrent laryngitis. All flows (PEF, MEF75, MEF50, and MEF25) were significantly lower in the asthma group, while FENO and DLCO were significantly lower in the laryngitis group. A significant inverse relationship was found between DLCO and all reflux indexes in the laryngitis group. Each unit change of Johnson-DeMeester score and Boix-Ochoa score increased the odds for significantly lower DLCO in laryngitis patients by 3.9% and 5.5%, respectively.

CONCLUSIONS

In children with uncontrolled asthma and chronic laryngitis, the regurgitation of gastric contents due to GERD contributes to poor asthma control and aggravation of chronic laryngitis. Despite having normal lung function, the gas diffusion capacity should be controlled in patients with GERD and chronic laryngitis, and it might be the very first abnormality in distal airways.

The relationship between gastro-oesophageal reflux disease and asthma during childhood

BACKGROUND

The relationship between GERD and asthma is complex. It is not yet clear whether GERD is an accompanying finding or a cause of asthma, or even if it is an aggravating factor. The aim of this study was to determine the frequency of asthma and allergic diseases in patients who underwent 24-h pH monitoring for a suspicion of GERD, including a comparison between subjects with and without GERD.

METHOD

Subjects who were evaluated by 24h ambulatory intraoesophageal pH monitoring were investigated for the presence of asthma and allergic disorders. All participants were subjected to a skin prick test and a complete blood count and serum levels of specific IgE.

RESULTS

A total of 204 subjects (49.5% male) with a mean age of 7.8±4.3 years were enrolled. A diagnosis of GERD was made in 78 (38.2%) subjects after 24h pH monitoring. The frequency of asthma in subjects with GERD was 20.5% compared to 25.4% in subjects without GERD (p=0.424). Subjects with GERD presenting with respiratory symptoms have higher incidence of asthma compared to subjects with GERD presenting with gastrointestinal symptoms (35.3% and 5.3% respectively; p=0.001).

CONCLUSION

Although, patients with and without GERD had comparable frequencies of asthma, our findings suggest that subjects who present with respiratory symptoms suggestive of GERD should also be evaluated for the presence of an underlying asthma.

Gastroesophageal reflux disease and childhood asthma

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) is common in children with asthma and may be present with or without symptoms. Clinicians, influenced by position statements in national guidelines, have routinely treated children with poorly controlled asthma with various anti-GERD medications. This practice is based on the pervasive but unproven belief that GERD is an important determinant of poor asthma control.

RECENT FINDINGS

Clinical studies show that GERD is highly prevalent in children with asthma, with estimates as high as 80%, but nearly half of the children are asymptomatic. However, there is no conclusive evidence per se that asymptomatic GERD informs asthma control, and treatment of GERD in the few controlled trials available for review does not substantively improve asthma outcomes. In a recent large controlled clinical trial, treatment with a proton-pump inhibitor (PPI) was not only ineffective, but adverse effects were common, including an increased prevalence of symptomatic respiratory infections.

SUMMARY

Current evidence does not support the routine use of anti-GERD medications in the treatment of poorly controlled asthma of childhood. However large controlled trials of children symptomatic of both GERD and asthma have not been conducted, and in this case the benefits of treatment, although unproven, might outweigh the risks.

Extra-esophageal manifestations of gastroesophageal reflux disease: controversies between epidemiology and clicnic

Gastroesophageal reflux disease (GERD) is widely associated with asthma, chronic cough, and laryngitis. Many studies have focused on acidic reflux; however, acid is just one of many factors that can cause pulmonary injury. The discrepancy between the high frequency of GERD in asthmatic patients and the ineffective reflux therapy outcomes in these patients suggests that GERD may cause injury through other mechanisms, such as pepsinogen, pepsin, bile salts, or other components of reflux materials, instead of the acid. Research using appropriate and innovative methodologies to investigate these potential inflammatory agents in patients with GERD is required to determine the underlying factors associated with pulmonary disorders in these patients.

Role of adipokines and hormones of obesity in childhood asthma

PURPOSE

The aim of this study was to evaluate serum levels of leptin, ghrelin, and adiponectin in obese and non-obese children with asthma and in healthy non-asthmatic children, and analyze their relationships with clinical outcomes.

METHODS

This study enrolled 40 obese and 51 non-obese children with asthma and 20 healthy children. Body mass index and serum leptin, ghrelin, and adiponectin levels were determined in all children. Asthma symptom scores and lung function test results were recorded for subjects with asthma.

RESULTS

Serum leptin levels (11.8±7.9, 5.3±6.8, and 2.1±2.4 ng/mL in the obese asthmatic, non-obese asthmatic, and control groups, respectively) and adiponectin levels (12,586.2±3,724.1; 18,089.3±6,452.3; and 20,297.5±3,680.7 ng/mL, respectively) differed significantly among the groups (P<0.001 for all). Mean ghrelin levels were 196.1±96.8 and 311.9±352.8 pg/mL in the obese and non-obese asthmatic groups, respectively, and 348.8±146.4 pg/mL in the control group (P=0.001). The asthma symptom score was significantly higher in the obese children with asthma than in the non-obese children with asthma (P<0.001). Leptin and adiponectin levels were correlated with the asthma symptom score in non-obese children with asthma (r=0.34 and r=-0.62, respectively).

CONCLUSIONS

Obesity leads to more severe asthma symptoms in children. Moreover, leptin, adiponectin, and ghrelin may play important roles in the inflammatory pathogenesis of asthma and obesity co-morbidity.

Gastro-esophageal reflux in early childhood wheezers

Wheezing is common among infants and young children due to peculiar anatomical and physiological properties of their lungs. Gastro-oesophageal reflux (GER) has been incriminated as one of the cause of non-asthmatic wheezing in this age group. The present study evaluates the magnitude of GER and its causal relationship with wheezing in early childhood. All recurrent and persistent wheezers (under two years) were investigated for GER and treated medically where tests were positive. The subjects were further profiled to identify any predictors for GER. Sixty-seven children of less than 2 years age with recurrent or persistent wheezing were evaluated for GER. Mean age of the study subjects at enrolment was 10.8 months and at onset of wheezing was 7.1 (± 3.8 S.D) months. Asthma and wheeze associated lower respiratory tract infection (WALRI) was diagnosed in about 1/3 each of the patients studied. GER studies were positive in over one-third (25/67) of cases. Forty-two percent of children who wheezed by 1 year of age had a positive GER study. Interestingly, nearly half (12/25) of the patients with an abnormal study did not have any clinical suggestion of regurgitation ("silent" GERs). The severity of wheezing was higher among those who had GER versus those who did not (p ≤ 0.048; OR: 3.2). However, only 32% patients showed significant response to anti reflux treatment alone while others had partial response. GER, therefore, is an important cause for recurrent wheezing among children less than 2 years of age, either singularly or as a co-morbidity. The study findings justify investigations for GER among early wheezers; particularly for those who have onset of symptoms by 12 months of age or those who have severe disease.

Induced Sputum Substance P in Children with Difficult-to-Treat Bronchial Asthma and Gastroesophageal Reflux: Effect of Esomeprazole Therapy

Objectives. To assess the induced sputum substance P (ISSP) levels in children having difficult-to-treat asthma (DA) with and without gastroesophageal reflux (GER). We aimed also to evaluate the association of GER with childhood DA, relationship of GER severity with childhood asthma control test (C-ACT), FEV(1), peak expiratory flow (PEF) variability, and ISSP. Finally, we tried to evaluate esomeprazole treatment effect on C-ACT and FEV(1) in children with DA. Methods. Spirometry, C-ACT, upper gastrointestinal endoscopy, and ISSP measurement were done for children with DA compared to healthy controls. Results. ISSP was high in DA with higher levels in the group having associated GER. In the latter group, ISSP and C-ACT improved significantly after esomeprazole treatment while FEV(1) and PEF variability did not improve. Reflux severity was positively correlated with ISSP and negatively correlated with FEV(1). Conclusions. GER was found in 49% of our patients with childhood DA. Very high ISSP levels in children with DA may be used as a marker for presence of GERD. Esomeprazole therapy improved asthma symptoms but did not improve lung function.

Relationship between silent gastroesophageal reflux and food sensitization in infants and young children with recurrent wheezing

It is known that early childhood wheezing associated with sensitization to allergens, including food, has an increased risk of developing asthma later during school age. Gastroesophageal reflux (GER) is well known to be associated with asthma. The purpose of this study was to determine whether there is an association between silent GER and food sensitization in infants and young children with recurrent wheezing. Eighty-five infants or young children with recurrent wheezing, and no gastrointestinal symptoms, underwent 24 hr esophageal pH monitoring, as well as total serum IgE and specific IgE testing for eggs and milk. Among the 85 subjects, 48.2% had significant GER. There was no significant difference in the GER between atopic and non-atopic recurrent wheezers (41.7% and 50.8%, respectively). The sensitization rate to food (eggs or milk) was 12.2% and 20.5% in the GER and non-GER groups, respectively and showed no statistically significant difference between the two groups (P=0.34). In conclusion, about half of infants and young children with recurrent wheezing and no gastrointestinal symptoms have silent GER. The silent GER may not contribute to food sensitization in infants and young children with recurrent wheezing.

Gastroesophageal reflux disease and graft failure after lung transplantation

In spite of advances in lung transplantation, the median survival after lung transplant remains less than 5 years, an outcome that is significantly worse than other solid organ transplants. Efforts to understand the unique hurdles faced in lung transplant have revealed gastroesophageal reflux disease (GERD) as a risk factor for ultimate graft failure. The link between GERD and chronic lung rejection parallels the association between GERD and other forms of lung disease such as idiopathic pulmonary fibrosis. Understanding how GERD predisposes to graft failure is an important issue as it may lead to therapies such as surgical correction that aim to lessen the exposure of the pulmonary epithelium to gastric contents. Here, we review the link between GERD and lung disease and discuss the preclinical and clinical studies that are starting to elucidate a mechanism for this association.

Bronchial hyperreactivity in non-atopic children with asthma and reflux: effect of anti-reflux treatment

INTRODUCTION

The prevalence of bronchial hyperreactivity (BHR) or the effect of anti-reflux treatment on BHR in children with asthma and gastroesophageal reflux disease (GERD) is not known.

METHODS

Thirty non-atopic children with persistent asthma were studied. Extended esophageal pH monitoring was used to diagnose GERD and methacholine challenge test (MCT) was used as a marker of BHR and performed before and 2 years after anti-GERD treatment.

RESULTS

Of the 21 patients positive for GERD (group A), 15 had positive MCT suggesting BHR. Of the 9 patients negative for GERD (group B), 5 had positive MCT. On repeat testing 2 years later, 11/15 group A patients and 3/5 group B patients tested negative for BHR. Group A patients were receiving fewer asthma medications and experienced fewer exacerbations than Group B patients.

CONCLUSIONS

BHR is prevalent in children with asthma and GERD and improves with anti-GERD treatment.

Proton pump inhibitor utilization patterns in infants

OBJECTIVE

Practice patterns regarding pediatric gastroesophageal reflux disease include acid suppression for infants meeting certain clinical criteria. This study aimed to examine the use of proton pump inhibitors (PPI) in infants and neonates.

PATIENTS AND METHODS

This retrospective observational study used data from 1999 to 2004 from 4 health care plans in the United States. Infants age <12 months with at least 1 pharmacy claim for a PPI were identified. Demographic information and PPI utilization patterns were assessed. Medical charts were reviewed in a subset of patients to gather dosing information.

RESULTS

Identified infants (N = 2469) were 58% male. PPI use rose 4-fold from 2000 to 2003; lansoprazole and omeprazole were almost exclusively used. Treatment for almost half of the patients was initiated by their fourth month of life. The most common diagnoses identified through medical claims included gastroesophageal reflux (59%), problems feeding (23%), upper respiratory infections (23%), esophagitis (21%), and pain from gas (20%). Preindex H2 blockade was evident in 58% of the patients; preindex metoclopramide was used in 38% of the patients. Longer duration of PPI therapy was associated with patients who had more comorbidities. Through chart review of 388 patients, a subset of 272 patients with dosing information revealed that a median daily dosage in patients receiving lansoprazole was 1.74 mg . kg . day compared with 1.21 mg . kg . day for omeprazole.

CONCLUSIONS

PPI use in the study population increased steadily from 1999 to 2004. These data offer valuable information on current PPI dosing patterns that may be used to design future clinical trials for assessment of gastroesophageal reflux disease regimens and clinical outcomes in the infant population.

Acid and non-acid gastro-esophageal refluxes in children with chronic pulmonary diseases

OBJECTIVES

Acid gastro-esophageal reflux has been shown associated with chronic pulmonary diseases. The role of non-acid refluxes in these children is still unknown. Therefore we investigated the prevalence of acid and non-acid refluxes, and their association with desaturations, in children with chronic pulmonary symptoms.

METHODS

In 25 children aged 6 months to 15 years with unexplained chronic cough, wheeze or sputum production, refluxes were assessed by 24h-multiple intra-esophageal impedance measurements, simultaneous pH metry and continuous recording of oxygen saturation.

RESULTS

pH in the proximal and distal esophagus as well as six impedance channels were evaluated in all subjects. A mean of 129.4 refluxes per day per patient was detected. Complete and technically usable readings of oxygen saturation were obtained in 14 children. In this group the subjects had a mean of 112.6 refluxes and 92.6 desaturations per day per patient. The symptom index and symptom sensitivity index for acid refluxes were 34.7% and 24.6%, respectively, for non-acid refluxes 3.0% and 66.7%, respectively.

CONCLUSIONS

We found a high prevalence of acid reflux and a very low number of non-acid refluxes in this population. The symptom index was negative for all types of reflux, whereas the symptom sensitivity index was positive for both acid and non-acid reflux. Our data support a relation between acid gastro-esophageal refluxes and chronic pulmonary symptoms; however, this study does not support a role of non-acid reflux in children with respiratory symptoms, which are not on antacid medication.

The characteristics of different diagnostic tests in adult mild asthmatic patients: comparison with patients with asthma-like symptoms by gastro-oesophageal reflux

BACKGROUND

Diagnosing asthma cannot be always easy. It is important to consider the validity of the diagnostic tests, and/or how much more commonly they are positive in patients with asthma compared to healthy subjects and, particularly, to patients with asthma-like symptoms.

OBJECTIVE

To evaluate the validity of diagnostic tests for asthma, in terms of sensitivity, specificity, positive and negative predictive values, in patients with bronchial asthma compared to patients affected by gastro-oesophageal reflux disease (GERD) with asthma-like symptoms, and healthy control subjects without asthma and gastro-oesophageal reflux (GER).

DESIGN

Single-center, cross-sectional, observational study.

PATIENTS

We studied 60 patients with mild asthma, 30 patients with GERD and asthma-like symptoms and 25 healthy control subjects.

MEASUREMENTS

We measured provocative concentration of methacholine causing a 20% fall in the forced expiratory volume in 1s (MCh PC(20)/FEV(1)), the amplitude percent mean of peak expiratory flow (A%M of PEF), derived from twice-daily readings for >2 weeks, the FEV(1)/forced vital capacity (FEV(1)/FVC) ratio, the eosinophil count in blood and in induced sputum and the serum eosinophil cationic protein (ECP) levels.

RESULTS

FEV(1)/FVC ratio, A%M of PEF, blood eosinophils counts and serum ECP levels were less sensitive and specific when the reference population was composed of patients with asthma-like symptoms by GER. While, MCh PC(20)/FEV(1) and induced sputum eosinophils count were the most sensitive (both 90%) and specific (89% and 92%, respectively) tests.

CONCLUSION

Our findings demonstrate that MCh PC(20)/FEV(1) and the induced sputum eosinophil count are the most useful objective tests in patients with mild asthma. All patients with asthma presented both an MCh PC(20)/FEV(1) <1500 microg and eosinophils count in the induced sputum >1%.

Effect of antireflux treatment on asthma exacerbations in nonatopic children

OBJECTIVE

To evaluate the asthma outcome of treatment with ranitidine or esomeprazole plus metoclopramide in older children with moderate-persistent asthma and gastroesophageal reflux disease (GERD).

PATIENTS AND METHODS

The study patients included 44 patients with asthma and GERD who had received 1 year of treatment with a proton pump inhibitor/prokinetic combination and had shown significant clinical improvement in asthma symptoms and no exacerbations for more than 3 months. For further treatment, 30 of the 44 patients continued treatment with esomeprazole/metoclopramide (group A), and 14 switched to ranitidine (group B). Nine patients with GERD and asthma who had previously undergone fundoplication were used as control individuals (group C). All patients were followed up closely for exacerbation of asthma symptoms and treated according to a standardized protocol.

RESULTS

During the 6-month follow-up, group B patients experienced significantly more exacerbations per patient (2.2) than did those in group A (0.33) or group C (0.77) (P < 0.05).

CONCLUSIONS

Fundoplication or continued treatment with esomeprazole and metoclopramide is associated with significantly fewer exacerbations of asthma symptoms in children with moderate-persistent asthma and concomitant GERD in comparison with treatment with ranitidine.