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Yang J, Nie D, Chen Y, Liu Z, Li M, Gong C, Liu Q. The role of smoking and alcohol in mediating the effect of gastroesophageal reflux disease on lung cancer: A Mendelian randomization study. Front Genet 2023; 13:1054132. [PMID: 36726719 PMCID: PMC9885128 DOI: 10.3389/fgene.2022.1054132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/07/2022] [Indexed: 01/19/2023] Open
Abstract
Observational studies have suggested a positive association between gastroesophageal reflux disease and lung cancer, but due to the existence of confounders, it remains undetermined whether gastroesophageal reflux disease (GERD) has a causal association with lung cancer. Therefore, Mendelian randomization (MR) analyses were applied to investigate the relationship between the two conditions. Two-sample Mendelian randomization analysis was utilized with summary genetic data from the European Bioinformatics Institute (602,604 individuals) and International Lung Cancer Consortium, which provides information on lung cancer and its histological subgroups. Furthermore, we used two-step Mendelian randomization and multivariable Mendelian randomization to estimate whether smoking initiation (311,629 cases and 321,173 controls) and alcohol intake frequency (n = 462,346) mediate any effect of gastroesophageal reflux disease on lung cancer risk. The Mendelian randomization analyses indicated that gastroesophageal reflux disease was associated with and significantly increased the risk of lung cancer (ORIVW = 1.35, 95% CI = 1.18-1.54; p = 1.36 × 10-5). Smoking initiation and alcohol intake frequency mediated 35% and 3% of the total effect of gastroesophageal reflux disease on lung cancer, respectively. The combined effect of these two factors accounted for 60% of the total effect. In conclusion, gastroesophageal reflux disease is associated with an increased risk of lung cancer, and interventions to reduce smoking and alcohol intake may reduce the incidence of lung cancer.
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Affiliation(s)
- Jing Yang
- The First Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Duorui Nie
- Graduate school of Hunan University of Chinese Medicine, Changsha, China
| | - Yujing Chen
- The First Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zixing Liu
- The First Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Mengzhao Li
- The First Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Chun Gong
- The First Affiliated Hospital, Hunan University of Chinese Medicine, Changsha, Hunan, China,*Correspondence: Chun Gong, ; Qiong Liu,
| | - Qiong Liu
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China,*Correspondence: Chun Gong, ; Qiong Liu,
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Pepsin and the Lung—Exploring the Relationship between Micro-Aspiration and Respiratory Manifestations of Gastroesophageal Reflux Disease. J Pers Med 2022; 12:jpm12081296. [PMID: 36013245 PMCID: PMC9410290 DOI: 10.3390/jpm12081296] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is one of the most commonly encountered disorders in clinical practice nowadays, with an increasing burden on healthcare systems worldwide. GERD-related respiratory symptoms such as unexplained chronic cough, bronchial asthma or chronic obstructive pulmonary disease (COPD) with frequent exacerbations often pose diagnostic and therapeutic challenges and may require a multidisciplinary approach. Moreover, a potential role of GERD as a risk factor has been proposed for chronic rejection in patients who underwent lung transplantation. Pepsin has gained considerable attention from the scientific community in the last few years as a possible surrogate biomarker for GERD. The aim of this narrative review was to provide an overview of the potential utility of pepsin detection as a marker of micro-aspiration in various biological fluids retrieved from patients with suspected GERD-induced respiratory manifestations and in lung transplant patients with allograft dysfunction. Data on the subject remains highly contradictory, and while certain studies support its applicability in investigating atypical GERD manifestations, at the moment, it would be realistic to accept a modest utility at best. A major lack of consensus persists regarding topics such as the optimal timeframe for fluid collection and cut-off values. Further research is warranted in order to address these issues.
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Grandes XA, Talanki Manjunatha R, Habib S, Sangaraju SL, Yepez D. Gastroesophageal Reflux Disease and Asthma: A Narrative Review. Cureus 2022; 14:e24917. [PMID: 35706753 PMCID: PMC9187188 DOI: 10.7759/cureus.24917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2022] [Indexed: 11/05/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is defined by retrograde reflux of gastric contents to the esophagus leading to various signs and symptoms that range from heartburn/regurgitation to the development of extraesophageal respiratory syndromes like asthma. Although a cause-effect relationship has been proposed, evidence suggests that these two entities share a complex mechanism that may be reciprocal to each other. The understanding of the underlying mechanisms is imperial due to the fact that asthmatic patients may benefit from reflux therapy with subsequent improvement in pulmonary function testing and quality of life. This study has revised available literature in order to provide evidence for a nexus between GERD and asthma based on clinical correlation, pathophysiology, and pharmacologic management.
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Talbert S, Bourgault AM, Rathbun KP, Abomoelak B, Deb C, Mehta D, Sole ML. Pepsin A in Tracheal Secretions From Patients Receiving Mechanical Ventilation. Am J Crit Care 2021; 30:443-450. [PMID: 34719715 DOI: 10.4037/ajcc2021528] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND In patients in the intensive care unit (ICU) receiving mechanical ventilation, aspiration of gastric contents may lead to ventilator-associated events and other adverse outcomes. Pepsin in pulmonary secretions is a biomarker of microaspiration of gastric contents. OBJECTIVES To evaluate the association between tracheal pepsin A and clinical outcomes related to ventilator use. METHODS A subset of 297 patients from a larger clinical trial on aspiration of oral secretions in adults receiving mechanical ventilation consented to have pepsin A measured in their tracheal aspirate samples. A concentration ≥6.25 ng/mL indicated a positive result. Abundant microaspiration was defined as pepsin A in ≥30% of samples. Statistical analyses included analysis of variance, analysis of covariance, and χ2 tests. RESULTS Most patients were White men, mean age 59.7 (SD, 18.8) years. Microaspiration was found in 43.8% of patients (n = 130), with abundant microaspiration detected in 17.5% (n = 52). After acuity was controlled for, patients with tracheal pepsin A had a longer mechanical ventilation duration (155 vs 104 hours, P < .001) and ICU stay (9.9 vs 8.2 days, P = .04), but not a longer hospital stay. CONCLUSIONS Microaspiration of gastric contents occurred in nearly half of patients and was associated with a longer duration of mechanical ventilation and a longer stay in the ICU. Additional preventative interventions beyond backrest elevation, oropharyngeal suctioning, and management of endotracheal tube cuff pressure may be needed. Also, the timing of pepsin measurements to capture all microaspiration events requires additional exploration.
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Affiliation(s)
- Steven Talbert
- Steven Talbert is interim director of the nursing PhD program and a clinical assistant professor, University of Central Florida College of Nursing, Orlando, Florida
| | - Annette M. Bourgault
- Annette M. Bourgault is an associate professor, University of Central Florida College of Nursing and a nurse scientist, Orlando Health, Orlando, Florida
| | - Kimberly Paige Rathbun
- Kimberly Paige Rathbun is a graduate research assistant, University of Central Florida College of Nursing
| | - Bassam Abomoelak
- Bassam Abomoelak is a senior research associate, Pediatric Specialty Diagnostic Laboratory, Arnold Palmer Hospital, Orlando, Florida
| | - Chirajyoti Deb
- Chirajyoti Deb is a senior research associate, Pediatric Specialty Diagnostic Laboratory
| | - Devendra Mehta
- Devendra Mehta is a pediatric gastroenterologist, Pediatric Specialty Diagnostic Laboratory
| | - Mary Lou Sole
- Mary Lou Sole is dean, professor, and Orlando Health Endowed Chair in Nursing, University of Central Florida College of Nursing and clinical scientist, Orlando Health
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SARS-CoV-2 and other human coronaviruses: Mapping of protease recognition sites, antigenic variation of spike protein and their grouping through molecular phylogenetics. INFECTION GENETICS AND EVOLUTION 2021; 89:104729. [PMID: 33497837 PMCID: PMC7826164 DOI: 10.1016/j.meegid.2021.104729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/10/2020] [Accepted: 01/20/2021] [Indexed: 11/20/2022]
Abstract
In recent years, a total of seven human pathogenic coronaviruses (HCoVs) strains were identified, i.e., SARS-CoV, SARS-CoV-2, MERS-CoV, HCoV-OC43, HCoV-229E, HCoV-NL63, and HCoV-HKU1. Here, we performed an analysis of the protease recognition sites and antigenic variation of the S-protein of these HCoVs. We showed tissue-specific expression pattern, functions, and a number of recognition sites of proteases in S-proteins from seven strains of HCoVs. In the case of SARS-CoV-2, we found two new protease recognition sites, each of calpain-2, pepsin-A, and caspase-8, and one new protease recognition site each of caspase-6, caspase-3, and furin. Our antigenic mapping study of the S-protein of these HCoVs showed that the SARS-CoV-2 virus strain has the most potent antigenic epitopes (highest antigenicity score with maximum numbers of epitope regions). Additionally, the other six strains of HCoVs show common antigenic epitopes (both B-cell and T-cell), with low antigenicity scores compared to SARS-CoV-2. We suggest that the molecular evolution of structural proteins of human CoV can be classified, such as (i) HCoV-NL63 and HCoV-229E, (ii) SARS-CoV-2, and SARS-CoV and (iii) HCoV-OC43 and HCoV-HKU1. In conclusion, we can presume that our study might help to prepare the interventions for the possible HCoVs outbreaks in the future.
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Talbert S, Detrick CW, Emery K, Middleton A, Abomoelak B, Deb C, Mehta DI, Sole ML. Intubation Setting, Aspiration, and Ventilator-Associated Conditions. Am J Crit Care 2020; 29:371-378. [PMID: 32869069 DOI: 10.4037/ajcc2020129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Patients experience endotracheal intubation in various settings with wide-ranging risks for postintubation complications such as aspiration and ventilator-associated conditions. OBJECTIVES To evaluate associations between intubation setting, presence of aspiration biomarkers, and clinical outcomes. METHODS This study is a subanalysis of data from the NO-ASPIRATE single-blinded randomized clinical trial. Data were prospectively collected for 513 adult patients intubated within 24 hours of enrollment. Patients with documented aspiration events at intubation were excluded. In the NO-ASPIRATE trial, intervention patients received enhanced oropharyngeal suctioning every 4 hours and control patients received sham suctioning. Tracheal specimens for α-amylase and pepsin tests were collected upon enrollment. Primary outcomes were ventilator hours, lengths of stay, and rates of ventilator-associated conditions. RESULTS Of the baseline tracheal specimens, 76.4% were positive for α-amylase and 33.1% were positive for pepsin. Proportions of positive tracheal α-amylase and pepsin tests did not differ significantly between intubation locations (study hospital, transfer from other hospital, or field intubation). No differences were found for ventilator hours or lengths of stay. Patients intubated at another hospital and transferred had significantly higher ventilator-associated condition rates than did those intubated at the study hospital (P = .02). Ventilator-associated condition rates did not differ significantly between patients intubated in the field and patients in other groups. CONCLUSIONS Higher ventilator-associated condition rates associated with interhospital transfer may be related to movement from bed, vehicle loading and unloading, and transport vehicle vibrations. Airway assessment and care may also be suboptimal in the transport environment.
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Affiliation(s)
- Steven Talbert
- Steven Talbert is an assistant clinical professor, Christine Wargo Detrick is a doctoral student, and Kimberly Emery is a doctoral candidate, University of Central Florida College of Nursing, Orlando, Florida
| | - Christine Wargo Detrick
- Steven Talbert is an assistant clinical professor, Christine Wargo Detrick is a doctoral student, and Kimberly Emery is a doctoral candidate, University of Central Florida College of Nursing, Orlando, Florida
| | - Kimberly Emery
- Steven Talbert is an assistant clinical professor, Christine Wargo Detrick is a doctoral student, and Kimberly Emery is a doctoral candidate, University of Central Florida College of Nursing, Orlando, Florida
| | - Aurea Middleton
- Aurea Middleton is a clinical research coordinator, Orlando Regional Medical Center, Orlando, Florida
| | - Bassam Abomoelak
- Bassam Abomoelak is a senior research associate and Chirajyoti Deb is a senior research scientist, Gastrointestinal Translational Laboratory, Arnold Palmer Hospital, Orlando Health, Orlando
| | - Chirajyoti Deb
- Chirajyoti Deb is a senior research scientist, Gastrointestinal Translational Laboratory, Arnold Palmer Hospital, Orlando Health, Orlando
| | - Devendra I. Mehta
- Devendra I. Mehta is an associate professor at Florida State University and director of the Gastrointestinal Translational Laboratory, Arnold Palmer Hospital for Children, Orlando Health
| | - Mary Lou Sole
- Mary Lou Sole is dean, Orlando Health Endowed Chair in Nursing, and University of Central Florida Pegasus Professor, University of Central Florida College of Nursing
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Choi YS, Na HG, Bae CH, Song SY, Kim YD. Pepsin exposure in a non-acidic environment upregulates mucin 5AC (MUC5AC) expression via matrix metalloproteinase 9 (MMP9)/nuclear factor κB (NF-κB) in human airway epithelial cells. Int Forum Allergy Rhinol 2020; 11:894-901. [PMID: 32846027 DOI: 10.1002/alr.22685] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 08/03/2020] [Accepted: 08/13/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Gastric reflux (GR) is a backflow of gastric content to the aerodigestive tract. GR was previously found to be associated with inflammatory airway diseases and a potential cause of airway remodeling. Chronic exposure to gastric content may induce damage from nose to lung, because digestive enzymes and acidity are toxic to airway epithelial cells. Recently, the toxicity of pepsin in a non-acidic environment was found to increase proinflammatory cytokines and receptors in the epithelium of the aerodigestive tract. However, the effect of pepsin in non-acidic conditions on mucin expression has not been investigated in human airway epithelial cells. The purpose of this study was to evaluate the effect of pepsin on mucin 5AC (MUC5AC) expression in upper and lower airway epithelial cells as an important potential factor of non-acidic GR-related airway inflammation. METHODS In NCI-H292 cells and human nasal epithelial cells (HNEpCs), the effects and signaling pathways of pepsin on MUC5AC expression were examined using reverse-transcription polymerase chain reaction (RT-PCR), real-time PCR, enzyme immunoassay, zymography, Western blot, and immunofluorescence staining. RESULTS Pepsin increased MUC5AC expression in non-acidic condition of NCI-H292 cells and HNEpCs. Further, pepsin activated matrix metalloproteinase 9 (MMP9) and phosphorylated nuclear factor κB (NF-κB). Moreover, inhibitors of MMP9 and NF-κB significantly attenuated pepsin-induced MUC5AC expression, and the knockdown of NF-κB by small interfering RNA (siRNA) significantly blocked pepsin-induced MUC5AC expression in human airway epithelial cells. CONCLUSION These findings suggest that pepsin increased MUC5AC expression in non-acidic conditions via the activation of MMP9 and NF-κB in human airway epithelial cells.
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Affiliation(s)
- Yoon Seok Choi
- Department of Otorhinolaryngology-Head and Neck surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Hyung Gyun Na
- Department of Otorhinolaryngology-Head and Neck surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Chang Hoon Bae
- Department of Otorhinolaryngology-Head and Neck surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Si-Youn Song
- Department of Otorhinolaryngology-Head and Neck surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Yong-Dae Kim
- Department of Otorhinolaryngology-Head and Neck surgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea.,Regional Center for Respiratory Diseases, Yeungnam University Medical Center, Daegu, Republic of Korea
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8
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Wang Z, Bonella F, Li W, Boerner EB, Guo Q, Kong X, Zhang X, Costabel U, Kreuter M. Gastroesophageal Reflux Disease in Idiopathic Pulmonary Fibrosis: Uncertainties and Controversies. Respiration 2018; 96:571-587. [PMID: 30308515 DOI: 10.1159/000492336] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/23/2018] [Indexed: 11/19/2022] Open
Abstract
The mechanisms of idiopathic pulmonary fibrosis (IPF), a rare, devastating disease with a median survival of 3-5 years, are not fully understood. Gastroesophageal reflux disease (GERD) is a frequent comorbidity encountered in IPF. Hypothetically, GERD-associated microaspiration may lead to persistent inflammation impairing lung infrastructure, thereby possibly accelerating the progression of IPF. IPF may increase intrathoracic pressure, which can aggravate GERD and vice versa. On the basis of the possible beneficial effects of antireflux or antacid therapy on lung function, acute exacerbation, and survival, the recent international IPF guideline recommends antacid therapies for patients with IPF, regardless of symptomatic GERD. However, due to newer conflicting data, several national guidelines do not support this recommendation. Elucidation of these questions by further clinical and bench-to-bedside research may provide us with rational clinical diagnostic and therapeutic approaches concerning GERD in IPF. The present review aims to discuss the latest data on the controversial association of IPF and GERD.
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Affiliation(s)
- Zheng Wang
- Department of Respiratory and Critical Medicine, Zhengzhou University People's Hospital, The Provincial People's Hospital Affiliated to Henan University, Zhengzhou,
| | - Francesco Bonella
- Interstitial and Rare Lung Disease Unit, Ruhrlandklinik, University Hospital, Duisburg-Essen University, Essen, Germany
| | - Wenting Li
- Third Liver Unit, Department of Infectious Diseases and Hepatology, Anhui Provincial Hospital, the First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Eda B Boerner
- Interstitial and Rare Lung Disease Unit, Ruhrlandklinik, University Hospital, Duisburg-Essen University, Essen, Germany
| | - Qiongya Guo
- Department of Digestive Diseases, Zhengzhou University People's Hospital, The Provincial People's Hospital Affiliated to Henan University, Zhengzhou, China
| | - Xianglong Kong
- Department of Respiratory Medicine, The First Hospital of Changsha, Changsha, China
| | - Xiaoju Zhang
- Department of Respiratory and Critical Medicine, Zhengzhou University People's Hospital, The Provincial People's Hospital Affiliated to Henan University, Zhengzhou, China
| | - Ulrich Costabel
- Interstitial and Rare Lung Disease Unit, Ruhrlandklinik, University Hospital, Duisburg-Essen University, Essen, Germany
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik, University of Heidelberg and Translational Lung Research Center Heidelberg, member of the German Center for Lung Research, Heidelberg, Germany
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9
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Imam SS, Shinkar DM, Mohamed NA, Mansour HE. Effect of right lateral position with head elevation on tracheal aspirate pepsin in ventilated preterm neonates: randomized controlled trial. J Matern Fetal Neonatal Med 2018; 32:3741-3746. [PMID: 29768111 DOI: 10.1080/14767058.2018.1471674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Objective: To evaluate the effect of right lateral positioning in comparison with supine positioning on tracheal aspirate pepsin levels as a marker of aspiration of gastric contents in ventilated preterm neonates. Study design: This randomized controlled trial was conducted on 60 ventilated preterm neonates <35 weeks; 30 neonates were nursed in right lateral position for 6 hours while the other 30 neonates were nursed in supine position for 6 hours. Tracheal aspirate sample was obtained from each neonate in both the groups just after the end of 6 hours and pepsin level was measured. Results: Neonates in right lateral position group had significantly lower tracheal pepsin level than neonates in supine position group (6 ng/ml) interquartile range [IQR] (3-20) versus 15 ng/ml [IQR] (5.5-90) (p = .024). There is positive correlation between tracheal aspirate pepsin level and fraction of inspired oxygen (FiO2) needed during the intervention (r = 0.383, p = .040). There is no correlation between tracheal pepsin level and gestational age, birth weight, or duration of mechanical ventilation and other ventilatory settings. Conclusion: Nursing ventilated premature infants in right lateral position is associated with decreased aspiration of gastric contents.
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Affiliation(s)
- Safaa Shafik Imam
- a Pediatrics Department, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Dina Mohamed Shinkar
- a Pediatrics Department, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Nevine Ahmed Mohamed
- b Clinical Pathology Department, Faculty of Medicine , Ain Shams University , Cairo , Egypt
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10
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Hunt EB, Sullivan A, Galvin J, MacSharry J, Murphy DM. Gastric Aspiration and Its Role in Airway Inflammation. Open Respir Med J 2018; 12:1-10. [PMID: 29456774 PMCID: PMC5806178 DOI: 10.2174/1874306401812010001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 12/22/2017] [Accepted: 01/01/2018] [Indexed: 12/15/2022] Open
Abstract
Gastro-Oesophageal Reflux (GOR) has been associated with chronic airway diseases while the passage of foreign matter into airways and lungs through aspiration has the potential to initiate a wide spectrum of pulmonary disorders. The clinical syndrome resulting from such aspiration will depend both on the quantity and nature of the aspirate as well as the individual host response. Aspiration of gastric fluids may cause damage to airway epithelium, not only because acidity is toxic to bronchial epithelial cells but also due to the effect of digestive enzymes such as pepsin and bile salts. Experimental models have shown that direct instillation of these factors to airways epithelia cause damage with a consequential inflammatory response. The pathophysiology of these responses is gradually being dissected, with better understanding of acute gastric aspiration injury, a major cause of acute lung injury, providing opportunities for therapeutic intervention and potentially, ultimately, improved understanding of the chronic airway response to aspiration. Ultimately, clarification of the inflammatory pathways which are related to micro-aspiration via pepsin and bile acid salts may eventually progress to pharmacological intervention and surgical studies to assess the clinical benefits of such therapies in driving symptom improvement or reducing disease progression.
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Affiliation(s)
- E B Hunt
- The Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland.,The Health Research Board Clinical Research Facility, University College Cork, Cork, Ireland
| | - A Sullivan
- The APC Microbiome Institute, Schools of Medicine and Microbiology, University College Cork, Ireland
| | - J Galvin
- The APC Microbiome Institute, Schools of Medicine and Microbiology, University College Cork, Ireland
| | - J MacSharry
- The APC Microbiome Institute, Schools of Medicine and Microbiology, University College Cork, Ireland
| | - D M Murphy
- The Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland.,The Health Research Board Clinical Research Facility, University College Cork, Cork, Ireland
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11
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Ghebre YT, Raghu G. Idiopathic Pulmonary Fibrosis: Novel Concepts of Proton Pump Inhibitors as Antifibrotic Drugs. Am J Respir Crit Care Med 2017; 193:1345-52. [PMID: 27110898 DOI: 10.1164/rccm.201512-2316pp] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The prevalence of abnormal acid gastroesophageal reflux (GER) is higher in patients with idiopathic pulmonary fibrosis (IPF) than in matched control subjects. Several studies demonstrated that more than one-third of patients with IPF have abnormal esophageal acid exposures. In addition, many of these studies indicate that the majority of patients with IPF have silent reflux with no symptoms of GER. Findings of abnormal reflux persist in a large proportion of patients with IPF placed on antacid therapy such as proton pump inhibitors (PPIs). This seemingly paradoxical observation suggests that either patients with IPF are somehow resistant to PPI-based intervention or PPIs are inherently unable to suppress acid GER. By contrast, patients with IPF who undergo Nissen fundoplication surgery are effectively relieved from the complications of GER, and retrospective studies suggest improved lung function. Retrospective, anecdotal data suggest a beneficial role of PPIs in IPF including stabilization of lung function, reduction in episodes of acute exacerbation, and enhanced longevity. The recent evidence-based guidelines for treatment of IPF approved conditional recommendation of PPIs for all patients with IPF regardless of their GER status. Recently, we have reported that PPIs possess antiinflammatory and antifibrotic activities by directly suppressing proinflammatory cytokines, profibrotic proteins, and proliferation of lung fibroblasts. Our study provides an alternative explanation for the beneficial effect of PPIs in IPF. In this Perspective, we reviewed emerging progress on antifibrotic effect of PPIs using IPF as a disease model. In addition, we summarized surgical and pharmacological interventions for GER and their downstream effect on lung physiology.
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Affiliation(s)
- Yohannes T Ghebre
- 1 Department of Radiation Oncology, Baylor College of Medicine, Houston, Texas; and
| | - Ganesh Raghu
- 2 Division of Pulmonary and Critical Care Medicine, Center for Interstitial Lung Disease, University of Washington, Seattle, Washington
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12
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Emilsson ÖI, Benediktsdóttir B, Ólafsson Í, Cook E, Júlíusson S, Berg S, Nordang L, Björnsson ES, Guðlaugsdóttir S, Guðmundsdóttir AS, Janson C, Gislason T. Definition of nocturnal gastroesophageal reflux for studies on respiratory diseases. Scand J Gastroenterol 2016; 51:524-30. [PMID: 26825677 DOI: 10.3109/00365521.2015.1124284] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Nocturnal gastroesophageal reflux (nGER) has been associated with respiratory diseases. Our aim was to study a questionnaire method to identify nGER subjects with respiratory involvement in a general population. MATERIAL AND METHODS A subgroup of Icelandic participants in the European Community Respiratory Health Survey III (ECRHS III) reporting symptoms of nGER (n = 48) as well as age and gender paired controls (n = 42) were studied further by a structured interview, questionnaires, laryngeal fibrescopy, and exhaled breath condensate. A subgroup underwent 24-h oesophageal pH impedance (24-h MII-pH) measurements. Symptoms of nGER were assessed with a modified version of the reflux disease questionnaire (RDQ), where symptoms were divided into daytime and nocturnal. A report of nGER both at baseline and at follow-up was defined as persistent nGER. RESULTS Participants reporting persistent nGER had significantly more signs of laryngopharyngeal reflux according to the reflux finding score than those without nGER (Mean ± SD: 5.1 ± 2.3 vs. 3.9 ± 2.2, p = 0.02). Of the 16 persistent nGER subjects that underwent 24-h MII-pH, 11 had abnormal gastroesophageal reflux, but none of three control subjects (69% vs. 0%). Pepsin was more commonly found in exhaled breath condensate in the nGER group (67% vs. 45%, p = 0.04). CONCLUSIONS Participants with nGER symptoms at least once a month, reported on two occasions, had a high level of positive 24-h MII-pH measurements, laryngeal inflammation and pepsin in exhaled breath condensate. This nGER definition identified a representable group for studies on nGER and respiratory diseases in a general population.
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Affiliation(s)
- Össur Ingi Emilsson
- a Faculty of Medicine, University of Iceland , Reykjavik , Iceland ;,b Department of Respiratory Medicine and Sleep , Landspitali University Hospital , Reykjavik , Iceland ;,c Department of Respiratory , Allergy and Sleep Research, Uppsala University , Uppsala , Sweden
| | - Bryndís Benediktsdóttir
- a Faculty of Medicine, University of Iceland , Reykjavik , Iceland ;,b Department of Respiratory Medicine and Sleep , Landspitali University Hospital , Reykjavik , Iceland
| | - Ísleifur Ólafsson
- d Department of Clinical Biochemistry , Landspitali University Hospital , Reykjavik , Iceland
| | - Elizabeth Cook
- d Department of Clinical Biochemistry , Landspitali University Hospital , Reykjavik , Iceland
| | - Sigurður Júlíusson
- a Faculty of Medicine, University of Iceland , Reykjavik , Iceland ;,e Department of Ear, Nose and Throat , Landspitali University Hospital , Reykjavik , Iceland
| | - Sören Berg
- f Department of Otolaryngology and Head and Neck Surgery , Lund University , Lund , Sweden
| | - Leif Nordang
- g Department of Surgical Sciences , Otorhinolaryngology and Head and Neck Surgery, Uppsala University , Uppsala , Sweden
| | - Einar Stefán Björnsson
- a Faculty of Medicine, University of Iceland , Reykjavik , Iceland ;,h Department of Gastroenterology , Landspitali University Hospital , Reykjavik , Iceland
| | - Sunna Guðlaugsdóttir
- h Department of Gastroenterology , Landspitali University Hospital , Reykjavik , Iceland
| | | | - Christer Janson
- c Department of Respiratory , Allergy and Sleep Research, Uppsala University , Uppsala , Sweden
| | - Thorarinn Gislason
- a Faculty of Medicine, University of Iceland , Reykjavik , Iceland ;,b Department of Respiratory Medicine and Sleep , Landspitali University Hospital , Reykjavik , Iceland
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Ghebre Y, Raghu G. Proton pump inhibitors in IPF: beyond mere suppression of gastric acidity. QJM 2016; 109:577-579. [PMID: 27647940 PMCID: PMC5943831 DOI: 10.1093/qjmed/hcw115] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Indexed: 02/06/2023] Open
Abstract
Proton pump inhibitors (PPIs) are structurally composed of benzimidazole core; a pharmacologically common scaffold that makes up nearly one quarter of the hundred most selling drugs including anticancer, opioid, antihistaminic and antihelmintic drugs. In medicinal chemistry, benzimidazoles are coined as privileged scaffolds due to their ability to recognize and bind diverse biological targets. In this regard, PPIs have been linked to other extra-intestinal functions including direct modulation of airway epithelial, vascular endothelial and immune cells. PPIs have been reported to improve outcomes in idiopathic pulmonary fibrosis (IPF) including slowing the decline in measures of lung function, reducing episodes of acute exacerbations and prolonging transplant-free survival. Recently, the evidence-based guidelines for IPF treatment conditionally recommended the use of PPIs in IPF. However, no prospective clinical trial has been conducted to empirically evaluate the safety and efficacy of PPIs in IPF. Here, we discuss emerging anti-inflammatory and antifibrotic activity of PPIs in the context of IPF. We also discuss possible molecular mechanisms by which PPIs may unleash their beneficial effect in IPF.
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Affiliation(s)
- Y. Ghebre
- Radiation Oncology, Baylor College of Medicine, Houston, TX, USA
| | - G. Raghu
- Center for Interstitial Lung Disease, University of Washington School of Medicine, Seattle, WA, USA
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Hallal C, Chaves VS, Borges GC, Werlang IC, Fontella FU, Matte U, Goldani MZ, Carvalho PR, Trotta EA, Piva JP, Barros SGS, Goldani HAS. Acid and Weakly Acidic Gastroesophageal Reflux and Pepsin Isoforms (A and C) in Tracheal Secretions of Critically Ill Children. Chest 2015; 148:333-339. [PMID: 25654241 DOI: 10.1378/chest.14-1967] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Gastroesophageal reflux (GER) and pulmonary aspiration are frequent in patients in the ICU. The presence of pepsin in airways seems to be the link between them. However, pepsin isoforms A (gastric specific) and C (pneumocyte potentially derived) need to be distinguished. This study aimed to evaluate GER patterns and to determine the presence of pepsin A and C in tracheal secretions of critically ill children receiving mechanical ventilation. METHODS All patients underwent combined multichannel intraluminal impedance-pH (MII-pH) monitoring. Tracheal secretion samples were collected to determine the presence of pepsin. Pepsin A and C were evaluated by Western blot. MII-pH parameters analyzed were number of total GER episodes (NGER); acid, weakly acidic, and weakly alkaline GER episodes; and proximal and distal GER episodes. RESULTS Thirty-four patients (median age, 4 months; range, 1-174 months) were included. MII-pH monitoring detected 2,172 GER episodes (77.0% were weakly acidic; 71.7% were proximal). The median NGER episodes per patient was 59.5 (25th-75th percentile, 20.3-85.3). Weakly acidic GER episodes per patient were significantly more frequent than acid GER episodes per patient (median [25th-75th percentile], 43.5 [20.3-68.3] vs 1.0 [0-13.8], respectively; P < .001). Only three patients had an altered acid reflux index (44.9%, 12.7%, and 13.6%) while not taking antacid drugs. Pepsin A was found in 100% of samples and pepsin C in 76.5%. CONCLUSIONS The majority of GER episodes of children in the ICU were proximal and weakly acidic. All patients had aspiration of gastric contents as detected by pepsin A in tracheal fluid. A specific pepsin assay should be performed to establish gastropulmonary aspiration because pepsin C was found in > 70% of samples.
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Affiliation(s)
- Cristiane Hallal
- Post-Graduate Program Sciences in Gastroenterology and Hepatology, Porto Alegre-RS, Brazil; Pediatric Gastroenterology Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil.
| | - Veridiana S Chaves
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Gilberto C Borges
- Pediatric Gastroenterology Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Isabel C Werlang
- Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Fernanda U Fontella
- Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Ursula Matte
- Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
| | - Marcelo Z Goldani
- Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
| | - Paulo R Carvalho
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
| | - Eliana A Trotta
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Jefferson P Piva
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil
| | - Sergio G S Barros
- Post-Graduate Program Sciences in Gastroenterology and Hepatology, Porto Alegre-RS, Brazil
| | - Helena A S Goldani
- Post-Graduate Program Sciences in Gastroenterology and Hepatology, Porto Alegre-RS, Brazil; Pediatric Gastroenterology Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Laboratory of Translational Pediatrics, Hospital de Clínicas de Porto Alegre, Porto Alegre-RS, Brazil; Post-Graduate Program in Child and Adolescent Health, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil
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15
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16
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Naik RD, Vaezi MF. Extra-esophageal gastroesophageal reflux disease and asthma: understanding this interplay. Expert Rev Gastroenterol Hepatol 2015; 9:969-82. [PMID: 26067887 DOI: 10.1586/17474124.2015.1042861] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a condition that develops when there is reflux of stomach contents, which typically manifests as heartburn and regurgitation. These esophageal symptoms are well recognized; however, there are extra-esophageal manifestations of GERD, which include asthma, chronic cough, laryngitis and sinusitis. With the rising incidence of asthma, there is increasing interest in identifying how GERD impacts asthma development and therapy. Due to the poor sensitivity of endoscopy and pH monitoring, empiric therapy with proton pump inhibitors (PPIs) is now considered the initial diagnostic step in patients suspected of having GERD-related symptoms. If unresponsive, diagnostic testing with pH monitoring off therapy and/or impedance/pH monitoring on therapy, may be reasonable in order to assess for baseline presence of reflux with the former and exclude continued acid or weakly acid reflux with the latter tests. PPI-unresponsive asthmatics, without overt regurgitation, usually have either no reflux or causes other than GERD. In this group, PPI therapy should be discontinued. In those with GERD as a contributing factor acid suppressive therapy should be continued as well as optimally treating other etiologies requiring concomitant treatment. Surgical fundoplication is rarely needed but in those with a large hiatal hernia, moderate-to-severe reflux by pH monitoring surgery might be helpful in eliminating the need for high-dose acid suppressive therapy.
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Affiliation(s)
- Rishi D Naik
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Digestive Disease Center, Vanderbilt University Medical Center, 1660 TVC, Nashville, TN 37232-5280, USA
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17
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Cheng YM, Cao AL, Zheng JP, Wang HW, Sun YS, Liu CF, Zhang BB, Wang Y, Zhu SL, Wu DZ. Airway hyperresponsiveness induced by repeated esophageal infusion of HCl in guinea pigs. Am J Respir Cell Mol Biol 2015; 51:701-8. [PMID: 24828018 DOI: 10.1165/rcmb.2013-0484oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Gastroesophageal reflux is a common disorder closely related to chronic airway diseases, such as chronic cough, asthma, chronic bronchitis, and chronic obstructive disease. Indeed, gastroesophageal acid reflux into the respiratory tract causes bronchoconstriction, but the underlying mechanisms have still not been clarified. This study aimed to elucidate functional changes of bronchial smooth muscles (BSMs) isolated from guinea pigs in an animal model of gastroesophageal reflux. The marked airway inflammation, hyperresponsiveness and remodeling were observed after guinea pigs were exposed to intraesophageal HCl infusion for 14 days. In addition, contractile responses to acetylcholine (ACh), KCl, electrical field stimulation, and extracellular Ca(2+) were greater in guinea pigs infused with HCl compared with control groups. The L-type voltage-dependent Ca(2+) channels (L-VDCC) blocker, nicardipine, significantly inhibited ACh- and Ca(2+)-enhanced BSM contractions in guinea pigs infused with HCl. The Rho-kinase inhibitor, Y27632, attenuated ACh-enhanced BSM contractions in guinea pigs infused with HCl. Moreover, mRNA and protein expressions for muscarinic M2 and M3 receptors, RhoA, and L-VDCC in BSM were detected by real-time PCR and Western blot. Expressions of mRNA and protein for muscarinic M3 receptors, RhoA, and L-VDCC were greater than in BSM of HCl-infused guinea pigs, whereas levels of muscarinic M2 receptors were unchanged. We demonstrate that acid infusion to the lower esophagus and, subsequently, microaspiration into the respiratory tract in guinea pigs leads to airway hyperresponsiveness and overactive BSM. Functional and molecular results indicate that overactive BSM is the reason for enhancement of extracellular Ca(2+) influx via L-VDCC and Ca(2+) sensitization through Rho-kinase signaling.
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Affiliation(s)
- Yan-Mei Cheng
- 1 Department of Gastroenterology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China; and
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Fodor GH, Peták F, Erces D, Balogh AL, Babik B. Lung mechanical changes following bronchoaspiration in a porcine model: differentiation of direct and indirect mechanisms. Respir Physiol Neurobiol 2014; 199:41-9. [PMID: 24814560 DOI: 10.1016/j.resp.2014.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 04/01/2014] [Accepted: 05/02/2014] [Indexed: 01/13/2023]
Abstract
Bronchoaspiration results in local deterioration of lung function through direct damage and/or indirect systemic effects related to neurohumoral pathways. We distinguished these effects by selectively intubating the two main bronchi in pigs while a PEEP of 4 or 10cm H2O was maintained. Gastric juice was instilled only into the right lung. Lung mechanical and ventilation defects were assessed by measuring unilateral pulmonary input impedance (ZL,s) and the third phase slope of the capnogram (SIII) for each lung side separately before the aspiration and for 120min thereafter. Marked transient elevations in ZL,s parameters and SIII were observed in the affected lung after aspiration. Elevating PEEP did not affect these responses in the ZL,s parameters, whereas it prevented the SIII increases. None of these indices changed in the intact left lung. These findings furnish evidence of the predominance of the local direct damage over the indirect systemic effects in the development of the deterioration of lung function, and demonstrate the benefit of an initially elevated PEEP following aspiration.
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Affiliation(s)
- Gergely H Fodor
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Ferenc Peták
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary.
| | - Dániel Erces
- Institute of Surgical Research, University of Szeged, Szeged, Hungary
| | - Adám L Balogh
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Barna Babik
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
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Bohman JK, Kor DJ, Kashyap R, Gajic O, Festic E, He Z, Lee AS. Airway pepsin levels in otherwise healthy surgical patients receiving general anesthesia with endotracheal intubation. Chest 2013; 143:1407-1413. [PMID: 23117366 DOI: 10.1378/chest.12-1860] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Airway pepsin has been increasingly used as a potentially sensitive and quantifiable biomarker for gastric-to-pulmonary aspiration, despite lack of validation in normal control subjects. This study attempts to define normal levels of airway pepsin in adults and distinguish between pepsin A (exclusive to stomach) and pepsin C (which can be expressed by pneumocytes). METHODS We performed a prospective study of 51 otherwise healthy adult patients undergoing elective extremity orthopedic surgery at a single tertiary-care academic medical center. Lower airway samples were obtained immediately following endotracheal intubation and just prior to extubation. Total pepsin and pepsin A concentrations were directly measured by an enzymatic activity assay, and pepsin C was subsequently derived. Pepsinogen/pepsin C was confirmed by Western blot analyses. Baseline characteristics were secondarily compared. RESULTS In all, 11 (22%; 95% CI = 9.9%-33%) had detectable airway pepsin concentrations. All 11 positive specimens had pepsin C, without any detectable pepsin A. Pepsinogen/pepsin C was confirmed by Western blot analyses. In a multivariate logistic regression, men were more likely to have airway pepsin (OR, 12.71, P = .029). CONCLUSIONS Enzymatically active pepsin C, but not the gastric-specific pepsin A, is frequently detected in the lower airways of patients who otherwise have no risk for aspiration. This suggests that nonspecific pepsin assays should be used and interpreted with caution as a biomarker of gastropulmonary aspiration, as pepsinogen C potentially expressed from pneumocytes may be detected in airway samples.
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Affiliation(s)
- J Kyle Bohman
- Department of Anesthesia, Mayo Clinic College of Medicine, Rochester, MN
| | - Daryl J Kor
- Department of Anesthesia, Mayo Clinic College of Medicine, Rochester, MN; Multidisciplinary Epidemiology and Translational Research in Intensive Care Study Group, Division of Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Rahul Kashyap
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Study Group, Division of Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Study Group, Division of Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Emir Festic
- Department of Critical Care Medicine, Division of Pulmonary Medicine, Mayo Clinic College of Medicine, Jacksonville, FL
| | - Zhaoping He
- Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Augustine S Lee
- Department of Critical Care Medicine, Division of Pulmonary Medicine, Mayo Clinic College of Medicine, Jacksonville, FL.
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