Gastroesophageal reflux disease and asthma: the two are directly related

Predictors of persistent poor control and validation of ASSESS score: Longitudinal 5-year follow-up of severe asthma cohort

Background

Longitudinal predictors of persistent poor asthma control in severe asthma (SA) cohort remain scarce. The predictive value of the asthma severity scoring system (ASSESS) in the SA cohort outside the original study and in the Asian population is unknown.

Objective

We sought to determine the 5-year longitudinal outcome of patients with SA and validate the use of ASSESS score in predicting future outcomes in SA.

Methods

A prospective longitudinal observational study of patients with SA attending the multidisciplinary specialist SA clinic of the Singapore General Hospital from 2011 to 2021 was conducted. The number of exacerbations and asthma control test results were recorded yearly for 5 consecutive years. The ASSESS score was computed at baseline, and the area under the receiver-operating characteristic curve for predicting persistent poor asthma control was generated.

Results

Of the 489 patients recruited into the study, 306 patients with 5-year follow-up data were analyzed. Seventy-three percent had type 2 inflammation with increased overall exacerbations over 5 years (rate ratio, 2.55; 95% CI, 1.31-4.96; P = .006) relative to non-type 2 SA. In the multivariate model, bronchiectasis, gastroesophageal reflux disease, and an asthma control test score of less than 20 were significantly associated with persistent poor asthma control over 5 years. ASSESS scores were good at predicting persistent poor asthma control with an area under the receiver-operating characteristic curve of 0.71 (95% CI, 0.57-0.84).

Conclusions

Bronchiectasis and gastroesophageal reflux disease are predictors for persistent poor asthma control and targeted traits for precision medicine in SA. The ASSESS score has a good prediction for persistent poor asthma control over 5 years.

Gastrointestinal Comorbidities Associated with Atopic Dermatitis-A Narrative Review

The current understanding of atopic dermatitis (AD) seems to be extending beyond a skin-confined condition frequently associated with allergic comorbidities, as in a number of epidemiological studies, the prevalence rate of a range of illnesses has been determined to be greater in patients with AD, or inversely. In most cases, the reasons for this are vague. A subset of these conditions are gastrointestinal disorders, including food sensitization (FS) and food allergy (FA), eosinophilic esophagitis (EoE) (it is of mixed background, both IgE-dependent and independent), food protein-induced enterocolitis syndrome (FPIES) (it exemplifies an IgE-independent food allergy), Crohn's disease (CD), colitis ulcerosa (CU), celiac disease, irritable bowel syndrome (IBS), and gastroesophageal reflux disease (GERD). In this review, we performed a comprehensive search of the literature using the PubMed database. We addressed the epidemiology of the increased co-occurrence of these diseases with AD and discussed potential causes for this subject. Multiple gastroenterological comorbidities appear to be more common in patients with AD, according to our review. The mechanisms that underlie this phenomenon are largely unknown, highlighting the need for further study in this field.

Equine Gastric Ulcer Syndrome affects fitness parameters in poorly performing Standardbred racehorses

Introduction

Equine Gastric Ulcer Syndrome (EGUS) is a highly prevalent disorder in horses, which can be classified, based on the localization of the lesions, as Equine Squamous Gastric Disease (ESGD) or Equine Glandular Gastric Disease (EGGD). Although EGUS is recognized as a common cause of poor performance in racehorses, objective investigations about its relation with athletic capacity are lacking. Therefore, the present retrospective study aims to evaluate the associations between EGUS severity and some fitness parameters measured during an incremental treadmill test in Standardbred racehorses in training.

Methods

With this aim, data from 87 Standard bred racehorses which underwent a complete diagnostic evaluation for poor performance was reviewed. During gastroscopic examination, a 0-4 score was assigned to ESGD, while EGGD was evaluated for absence/presence; a total EGUS score was obtained by adding 1 point to ESGD score in horses showing concomitant EGGD. Fitness parameters obtained during incremental treadmill test included speed at a heart rate of 200 bpm (V200), speed and heart rate at a blood lactate of 4 mmol/L (VLa4, HRLa4), peak lactate, lactate and heart rate at 30 minutes post-exercise, maximum speed, minimum pH and maximum hematocrit. The associations between fitness parameters and EGUS and ESGD scores were evaluated by Spearman correlation, while Mann-Whitney test was used to compare them between horses with or without EGGD. Statistical significance was set at p<0.05.

Results

EGUS grade was inversely correlated with V200 (p = 0.0025) and minimum pH (p = 0.0469); ESGD grade was inversely correlated with V200 (p = 0.0025) and VLa4 (p = 0.0363). Although a trend was observed, no significant differences in V200 were observed between horses with or without EGGD (p = 0.073); horses with EGGD reached a lower minimum pH (p = 0.0087).

Discussion

These results show a negative association between aerobic capacity and EGUS, in particular ESGD. Although different hypotheses have been proposed, including abdominal pain and decreased appetite due to lactate accumulation, the underlying mechanisms are still unknown, and it is not clear whether EGUS represents a cause or a consequence of an early lactate accumulation and post-exercise acidosis.

Contribution of comorbidities to obesity-related asthma in children

Children with obesity are at increased risk for developing asthma that is difficult to control. A complicating factor to asthma management among these children is likely the commonplace co-morbidities that also result from obesity. We discuss three common obesity-related comorbidities which appear to complicate the effective management of asthma, including hypovitaminosis D, obstructive sleep apnea and gastro-esophageal reflux. Each conditions requires more research to understand their effects on asthma management.

Extra-esophageal symptoms in individuals with and without erosive esophagitis: a case-control study in Albania

INTRODUCTION

Erosive reflux esophagitis caused a large clinical spectrum of symptoms. Our aim was to assess the prevalence of extra-esophageal symptoms in individuals with and those without erosive esophagitis in Albania.

METHODS

A case-control study was conducted at the Regional Hospital of Durres, the second main district in Albania, a transitional country in South Eastern Europe, including 248 patients with erosive esophagitis (aged 46.5 ± 16.3 years) and 273 controls (aged 46.4 ± 16.0 years; response rate: 70%) enrolled during the period January 2013-June 2014. Both cases and controls underwent upper endoscopy. Information on socio-demographic characteristics and lifestyle factors was also collected. Binary logistic regression was used to assess the association of erosive esophagitis and extra-esophageal symptoms.

RESULTS

Patients with erosive esophagitis had a higher prevalence of excessive alcohol consumption, smoking, sedentarity, non-Mediterranean diet and obesity compared to their control counterparts (9% vs. 5%, 70% vs. 49%, 31% vs. 17%, 61% vs. 49% and 22% vs. 9%, respectively). Upon adjustment for all socio-demographic characteristics and lifestyle/behavioral factors, there was evidence of a strong association of erosive esophagitis with chronic cough (OR = 3.2, 95% CI = 1.7-5.8), and even more so with laryngeal disorders (OR = 4.4, 95% CI = 2.6-7.5). In all models, the association of erosive esophagitis with any extra-esophageal symptoms was strong and mainly consistent with each of the symptoms separately (fully-adjusted model: OR = 4.6, 95% CI = 2.9-7.3).

CONCLUSION

Our findings indicate that the prevalence of extra-esophageal symptoms is higher among patients with erosive esophagitis in a transitional country characterized conventionally by employment of a Mediterranean diet.

Review article: gastro-oesophageal reflux disease in asthma and chronic obstructive pulmonary disease

BACKGROUND

When gastro-oesophageal reflux is causing symptoms or lesions in the oesophagus, this is referred to as gastro-oesophageal reflux disease (GERD). GERD can manifest itself through typical symptoms (heartburn, regurgitation) or may lead to extra-oesophageal symptoms. Extra-oesophageal manifestations of GERD gained increasing attention over the last decade, especially respiratory disorders, because of the prevalent co-occurrence with GERD. The role of GERD in the pathogenesis of respiratory disorders has become a topic of intense discussion.

AIM

To provide an overview of the current knowledge on the role of GERD in asthma and chronic obstructive pulmonary disease (COPD).

METHODS

PubMed was searched for relevant articles using the keywords: GERD, asthma, COPD, prevalence, treatment. Case reports were excluded, only English language articles were considered.

RESULTS

Estimates for the prevalence of GERD in asthma range from 30% to 90%, compared to an average of 24% in controls. In COPD patients, the prevalence of GERD ranges from 19% to 78% compared to an average of 18% in controls. These data indicate an increased prevalence of GERD in patients with asthma and COPD, although causality is not established and GERD treatment yielded inconsistent effects. Literature supports GERD as a risk factor for COPD-exacerbations and a predictor of the 'frequent-exacerbator'-phenotype.

CONCLUSIONS

Despite the high prevalence of GERD in asthma and COPD, a causal link is lacking. The results of anti-reflux therapy on pulmonary outcome are inconsistent and contradictory. Future studies will need to identify subgroups of asthmatics and COPD patients that may benefit from anti-reflux therapy (nocturnal or silent reflux).

Observational study of omeprazole for gastroesophageal reflux on pulmonary function in adult asthmatics

Background

Asthma is a chronic inflammatory disease of airways. Gastroesophageal reflux disease (GERD) is known to be associated with worsening asthma. We hypothesized that treatment of GERD in asthmatics will improve asthma control and quality of life. We reviewed our experience of treatment of GERD in asthmatics in Thailand.

Objectives

To study the effects of omeprazole for treatment of GERD in patients with poorly controlled asthma on pulmonary function tests and asthma control test (ACT) scores.

Methods

This study was conducted at King Chulalongkorn Memorial Hospital between August 2009 and December 2010. Patients with partly controlled and uncontrolled asthma who were found to have GERD by 24 hour esophageal pH monitoring were administered omeprazole 40 mg per day for 8 weeks. Pulmonary function tests and ACT scores before and after treatment were compared at 4-weeks and 8-weeks follow up.

Results

Twenty four patients were included in this study. None of them had asthmatic attacks during the study. After 4 and 8 weeks of omeprazole treatment, the mean FEV1 (2.20 ± 0.64 L, 2.36 ± 0.58 L, respectively) and the mean ACT score (20.82 ± 3.30, 23.00 ± 1.69, respectively) were significantly higher than the pretreatment values (mean FEV1 1.99 ± 0.56 L and ACT score 16.36 ± 3.97) (P < 0.05).

Conclusion

High-dose omeprazole may improve pulmonary function and the level of asthma control in Thai patients with partly controlled or uncontrolled asthma and coexisting GERD.

Extra-esophageal gastroesophageal reflux disease and asthma: understanding this interplay

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.

Overweight children report qualitatively distinct asthma symptoms: analysis of validated symptom measures

BACKGROUND

Past studies of asthma in overweight/obese children have been inconsistent. The reason overweight/obese children commonly report worse asthma control remains unclear.

OBJECTIVE

To determine qualitative differences in symptoms between lean and overweight/obese children with early-onset, atopic asthma.

METHODS

We conducted a cross-sectional analytic study of lean (20% to 65% body mass index) and overweight/obese (≥85% body mass index) 10- to 17-year-old children with persistent, early-onset asthma. Participants completed 2 to 3 visits to provide a complete history, qualitative and quantitative asthma symptom characterization, and lung function testing. We determined associations between weight status and symptoms using multivariable linear and logistic regression methods.

RESULTS

Overweight/obese and lean asthmatic children displayed similar lung function. Despite lower fraction of exhaled nitric oxide (30.0 vs 62.6 ppb; P = .037) and reduced methacholine responsiveness (PC20FEV1 1.87 vs 0.45 mg/mL; P < .012), overweight/obese children reported more than thrice frequent rescue treatments (3.7 vs 1.1 treatments/wk; P = .0002) than did lean children. Weight status affected the child's primary symptom reported with loss of asthma control (Fisher exact test; P = .003); overweight/obese children more often reported shortness of breath (odds ratio = 11.8; 95% CI, 1.41-98.7) and less often reported cough (odds ratio = 0.26; 95% CI, 0.08-0.82). Gastroesophageal reflux scores were higher in overweight/obese children (9.6 vs 23.2; P = .003) and appear to mediate overweight/obesity-related asthma symptoms.

CONCLUSIONS

Overweight/obese children with early-onset asthma display poorer asthma control and a distinct pattern of symptoms. Greater shortness of breath and β-agonist use appears to be partially mediated via esophageal reflux symptoms. Overweight children with asthma may falsely attribute exertional dyspnea and esophageal reflux to asthma, leading to excess rescue medication use.

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.

[Comparison between conventional ph measurement and multichannel intraluminal esophageal impedance in children with respiratory disorders]

INTRODUCTION

Gastroesophageal reflux (GER) is associated with respiratory symptoms. The link between non-acid GER and the pathogenesis of respiratory disease has been demonstrated. Esophageal multichannel intraluminal impedance (MII) is able to detect non-acid and alkaline GER, as well as reflux height. The objective of the study was to compare the diagnostic effectiveness of dual-channel pH-meter and MII.

PATIENTS AND METHODS

A prospective study was conducted on patients diagnosed with uncontrolled asthma, persistent cough, or chronic laryngitis. Patients were monitored continuously for 24 hours using a combination of MII and a dual-channel pH-meter. A descriptive and comparative analysis of the techniques was performed using the t test for comparison between groups and McNemar test for non-parametric data.

RESULTS

A total of 49 patients with respiratory disease between September 2008 and April 2010 (79.6% uncontrolled asthma, 10.2% persistent cough, and 10.2% chronic laryngitis) were included in the study. The mean number of refluxes detected was 18.3 (range 0-93) using the pH-meter and 39.2 (11-119) using MII (P<.001). Acid GER was detected using pH in 7 children and using MII in 25 children (8 acid, 10 alkaline and 7 mixed). A mean of 21 proximal refluxes were detected using MII.

CONCLUSIONS

MII makes it possible to diagnose a greater number of refluxes, whether acid or alkaline, than conventional pH measurement in children with respiratory disease that is poorly controlled with their usual treatment. MII can also detect proximal refluxes.

Long-term respiratory symptoms following oesophageal atresia

Background

Oesophageal atresia (OA) is a congenital malformation that can lead to persistent respiratory symptoms in adulthood.

Aim

To describe the prevalence of respiratory symptoms in adulthood in a population-based study of patients with repaired OA and to compare this with the prevalence in the general population.

Methods

Of 80 patients operated for OA in Gothenburg in 1968–1983, 79 were located. The patients received a questionnaire on respiratory symptoms. Controls were 4979 gender- and age-matched subjects who answered the same questions.

Results

The questionnaire was answered by 73 of 79 (92%) patients. Physician-diagnosed asthma was reported by 30% in the OA group vs 10% in the control group (OR 4.1; 95% CI 2.4–6.8), and recurrent wheeze in 29% vs 5.5% (OR 6.9; 4.1–11.6). Also wheeze during the last year, asthma medication, a long-standing cough, cough with sputum production and chronic bronchitis were significantly more common among the patients with OA. In contrast, there was no significant difference regarding risk factors for asthma. The prevalence of respiratory symptoms did not appear to decrease with age.

Conclusion

A high prevalence of respiratory symptoms remains among adult patients with repaired OA. Many of the patients had an asthma diagnosis. However, asthma heredity or allergic rhinitis was not overrepresented.

Mechanisms of esophago-pharyngeal acid regurgitation in human subjects

Esophago-pharyngeal regurgitation is implicated in various otolaryngologic and respiratory disorders. The pathophysiological mechanisms causing regurgitation are still largely unknown.

Obesity and poor asthma control in patients with severe asthma

BACKGROUND

Asthma is a public health problem as it leads to hospitalization and eventual death, particularly in its severe forms. Many studies have demonstrated an association between obesity and asthma.

OBJECTIVE

The aim of this study was to investigate the relationship between obesity and asthma control in a group of patients at a reference center for severe asthma in Brazil.

METHODS

This cross-sectional study was conducted in the outpatient central reference clinic of the Program for Control of Asthma in the State of Bahia. It included 508 subjects with severe asthma of both genders and above 18 years of age. All the participants answered a sociodemographic and a clinical questionnaire to collect information on their asthma and comorbidities, such as rhinitis and gastro-esophageal reflux disease (GERD). Participants also completed the Asthma Control Questionnaire, performed a spirometry test, and had their weight, height, and waist and hip circumferences registered.

RESULTS

Logistic regression analysis demonstrated a positive association between body mass index (BMI) and uncontrolled asthma [odds ratio (OR) 1.5; 95% confidence interval (CI) 1.02-2.20]. Symptoms of chronic rhinitis and GERD were also significantly associated with uncontrolled asthma (OR 3.68, 95% CI 1.50-9.01; and OR 2.78, 95% CI 1.91-4.03, respectively). There was no correlation between waist-to-hip ratios and asthma control.

CONCLUSION

In our sample of patients with severe asthma, those who were obese were more likely to have uncontrolled asthma than patients with a normal BMI. Nevertheless, this is not conclusive evidence for a direct causal association between obesity and poor asthma control. Future studies are necessary to dissect the relationship between obesity and asthma outcomes.

Pulmonary manifestations of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) may cause, trigger or exacerbate many pulmonary diseases. The physiological link between GERD and pulmonary disease has been extensively studied in chronic cough and asthma. A primary care physician often encounters patients with extra esophageal manifestations of GERD in the absence of heartburn. Patients may present with symptoms involving the pulmonary system; noncardiac chest pain; and ear, nose and throat disorders. Local irritation in the esophagus can cause symptoms that vary from indigestion, like chest discomfort and abdominal pain, to coughing and wheezing. If the gastric acid reaches the back of the throat, it may cause a bitter taste in the mouth and/or aspiration of the gastric acid into the lungs. The acid can cause throat irritation, postnasal drip and hoarseness, as well as recurrent cough, chest congestion and lung inflammation leading to asthma and/or bronchitis/ pneumonia. This clinical review examines the potential pathophysiological mechanisms of pulmonary manifestations of GERD. It also reviews relevant clinical information concerning GERD-related chronic cough and asthma. Finally, a potential management strategy for GERD in pulmonary patients is discussed.

Rabeprazole: a pharmacologic and clinical review for acid-related disorders

Rabeprazole is a proton pump inhibitor that can be used in the treatment of acid-peptic-related disorders (gastroesophageal reflux disease [GERD], duodenal ulcer, gastric ulcer, gastric acid hypersecretory syndromes) and Helicobacter pylori. Pharmacodynamic data has demonstrated that rabeprazole, with a high pKa of approximately 5.0, can be activated at a higher pH than other proton pump inhibitors. This possibly results in faster onset of action. Owing to its non-enzymatic pathway of metabolism, rabeprazole is also less influenced by genetic polymorphisms of the CYP2C19, which others proton pump inhibitors are dependent on. In a 2-week, placebo-controlled trial, rabeprazole was both rapid and effective in relieving heartburn on day 1 of therapy and improved other GERD-related symptoms including regurgitation, belching, bloating, early satiety and nausea. For oesophageal reflux disease without erosions both 10 and 20 mg of rabeprazole are equivalent and better than placebo at 2 and 4 weeks. An on-demand approach to non-erosive reflux disease with 10 mg of rabeprazole has also been documented as superior to placebo. Some success in the treatment of extra-oesophageal manifestations of GERD, such as asthma and chronic laryngitis, has also been achieved with rabeprazole. Overall, rabeprazole with very few side effects is a safe and efficacious medication for acid suppression therapy.

Limited diagnostic value of laryngopharyngeal lesions in patients with gastroesophageal reflux during routine upper gastrointestinal endoscopy

BACKGROUND AND AIMS

There is growing evidence that gastroesophageal reflux disease (GERD) may cause typical laryngeal/pharyngeal lesions secondary to tissue irritation. The prevalence of those lesions in GERD patients is not well established. The aim of this study was to evaluate the prevalence of GERD signs in the laryngopharyngeal area during routine upper gastrointestinal endoscopy.

METHODS

Between July 2000 and July 2001, 1,209 patients underwent 1,311 upper gastrointestinal endoscopies and were enrolled in this study. The structured examination of the laryngopharyngeal area during upper gastrointestinal endoscopy was videotaped for review by three gastroenterologists and one otorhinolaryngologist, blinded to the endoscopic esophageal findings. From the 1,209 patients enrolled in this prospective study, all patients (group I, N = 132) with typical endoscopical esophageal findings of GERD (Savary-Miller I-IV) were selected. The sex- and age-matched control group II (N = 132) underwent upper gastrointestinal endoscopy for different reasons, had no reflux symptoms, and had normal esophagoscopy.

RESULTS

In the two groups of patients, we found no difference in the prevalence of abnormal interarytenoid bar findings (32%vs 32%), arytenoid medial wall erythema (47%vs 43%), posterior commissure changes (36%vs 34%), or posterior cricoid wall edema (1%vs 3%). The only difference was noted in the posterior pharyngeal wall cobblestoning (66%vs 50%, P= 0.004).

CONCLUSION

The results of this large systematic investigation challenge the diagnostic specificity of laryngopharyngeal findings attributed to gastroesophageal reflux.

Effect of omeprazole and domperidone on adult asthmatics with gastroesophageal reflux

AIM: To study the effect of combined omeprazole (Ome) and domperidone (Dom) therapy on asthma symptoms and pulmonary function in asthmatics with gastroesophageal reflux.

METHODS: We selected 198 asthmatics with gastroesophageal reflux diagnosed by 24-h esophageal pH monitoring to receive Ome 20 mg twice daily and Dom 10 mg three times daily or placebo for 16 wk (1:1 double-blind randomization). Spirometry was done at baseline and after 16 wk of treatment. The primary outcome measures were: mean daily daytime and nighttime asthma symptom scores. Mean daily reflux symptom scores, albuterol use as rescue medication (number of puffs), daytime and nighttime peak expiratory flow rate (PEFR), postbronchodilator forced expiratory volume in 1 second (FEV₁) and postbronchodilator forced vital capacity (FVC) were secondary outcome measures.

RESULTS: Comparison of mean change from baseline between antireflux therapy and placebo groups revealed significant reduction in daytime asthma symptom score (17.4% vs 8.9%), nighttime asthma symptom score (19.6% vs 5.4%), reflux symptom score (8.7% vs 1.6%) and rescue medication use (23.2% vs 3.1%) after antireflux therapy compared to mean change in placebo group (P < 0.001). There was significant improvement in morning PEFR (7.9% vs 0.2%), evening PEFR (9.8% vs 0.5%), FEV₁ (11.1% vs 3.78%) and FVC (9.3% vs 1.52%) in the antireflux therapy group compared to placebo on comparing the mean change from baseline after 16 wk (P < 0.01).

CONCLUSION: Combined therapy with Ome and Dom in adult asthmatics with gastroesophageal reflux may be beneficial by reducing asthma symptoms, rescuing medication use, and improving pulmonary function.

Associations between respiratory symptoms, lung function and gastro-oesophageal reflux symptoms in a population-based birth cohort

BACKGROUND

Several studies have reported an association between asthma and gastro-oesophageal reflux, but it is unclear which condition develops first. The role of obesity in mediating this association is also unclear. We explored the associations between respiratory symptoms, lung function, and gastro-oesophageal reflux symptoms in a birth cohort of approximately 1000 individuals.

METHODS

Information on respiratory symptoms, asthma, atopy, lung function and airway responsiveness was obtained at multiple assessments from childhood to adulthood in an unselected birth cohort of 1037 individuals followed to age 26. Symptoms of gastro-oesophageal reflux and irritable bowel syndrome were recorded at age 26.

RESULTS

Heartburn and acid regurgitation symptoms that were at least "moderately bothersome" at age 26 were significantly associated with asthma (odds ratio = 3.2; 95% confidence interval = 1.6-6.4), wheeze (OR = 3.5; 95% CI = 1.7-7.2), and nocturnal cough (OR = 4.3; 95% CI = 2.1-8.7) independently of body mass index. In women reflux symptoms were also associated with airflow obstruction and a bronchodilator response to salbutamol. Persistent wheezing since childhood, persistence of asthma since teenage years, and airway hyperresponsiveness since age 11 were associated with a significantly increased risk of heartburn and acid regurgitation at age 26. There was no association between irritable bowel syndrome and respiratory symptoms.

CONCLUSION

Reflux symptoms are associated with respiratory symptoms in young adults independently of body mass index. The mechanism of these associations remains unclear.

The influence of gastroesophageal reflux disease and its treatment on asthmatic cough

Gastroesophageal reflux is known to cause chronic cough and is also implicated in worsening of asthma. We conducted a prospective study to examine the clinical significance of gastroesophageal reflux disease (GERD) in asthmatic patients with chronic cough to analyze the temporal relationship between reflux events and coughing and to assess the effect of esomeprazole treatment on respiratory symptoms and lung function in these patients. Asthmatic patients (126) with chronic dry cough were studied. Diagnosis of GERD was based on typical symptoms and the effectiveness of therapeutic test or on pH monitoring. Patients without GERD (negative pH results) consisted of the control group. The results of pH monitoring showed that 64% of cough episodes were related to acid reflux and in 91% of reflux events preceded coughing. Esomeprazole treatment (40 mg/day for 3 months) not only diminished GERD symptoms but also improved asthma outcome Baseline FEV(1) and PEF values increased significantly together with a decrease in symptom scores and the use of rescue medication. In most patients included in the extended part of the study for another 3 months, the dose of inhaled steroids could be reduced with sustained GERD therapy. Our data showing that reflux events preceded coughing in most cases and that treatment of GERD resulted in an improvement in different outcome measures of asthma suggest that GERD worsens asthma, and its treatment is of clinical importance to effectively manage these patients.

The prevalence of gastroesophageal reflux disease in adult asthmatics

BACKGROUND

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

STUDY OBJECTIVE

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

SUBJECTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Predictors of outcome in an open label, therapeutic trial of high-dose omeprazole in laryngitis

BACKGROUND

Gastroesophageal reflux is implicated in some cases of laryngitis. There are no established predictors of response to acid suppression therapy in suspected reflux laryngitis.

AIM

In a population with laryngitis, the aim is to determine whether (a) omeprazole 20 mg tds (3 months) improves symptoms and laryngitis, and (b) the outcome in response to potent acid suppression can be predicted by esophageal and/or pharyngeal parameters during ambulatory pH monitoring or by other pretreatment variables.

METHODS

From the 70 consecutive patients with laryngitis screened, 20 patients met the inclusion criteria (dysphonia >3 months; laryngoscopically demonstrated laryngitis); and 50 patients were excluded because of one or more criteria indicating alternative causes for laryngeal injury. The primary outcome measure was improvement of at least one level in a 4-point laryngitis grading at 3 months. Twenty-four-hour dual, pharyngo-esophageal pH monitoring was performed at baseline. Secondary outcomes (symptom questionnaire; computerized voice analysis) were measured at baseline, and at 6 and 12 wk.

RESULTS

Response rates at 6 and 12 wk were 47% and 63%, respectively. GERD symptoms (heartburn (p= 0.03) and regurgitation (p= 0.0001)) improved. However, neither baseline GERD symptoms nor endoscopic findings predicted laryngoscopic or symptomatic response. Neither baseline laryngitis grade (p= 0.46) nor esophageal acid exposure on pH testing (p= 0.3) predicted outcome. Four of 20 patients demonstrated pharyngeal regurgitation on pH testing, all four of whom responded to potent acid suppression (p= 0.2). Computerized voice measures were not predictive of outcome, although fundamental frequency (Fo) was inversely related to baseline laryngoscopic grade.

CONCLUSION

In a carefully defined population of patients with laryngitis (a) 63% have a laryngoscopic response to 3 months of potent acid suppression without significant improvement in laryngeal symptoms; (b) neither voice measures, esophageal acid exposure time, symptoms nor severity of laryngitis predict outcome; and (c) although numbers were small, all patients with a positive pharyngeal pH study responded to therapy and pharyngeal pH-metry may prove useful; (4) available evidence supports an empiric trial of high-dose proton pump inhibitors (PPI), for at least 12 wk, as the initial diagnostic step for suspected reflux laryngitis.

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

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

The prevalence of hypopharynx findings associated with gastroesophageal reflux in normal volunteers

Routine laryngeal examination of patients with otolaryngologic complaints often reveals findings thought to result from gastroesophageal reflux. The direct association between these mucosal findings and uncontrolled reflux is not well established. To begin exploring the specificity of tissue signs, 105 normal, healthy, adult volunteers were examined by routine video fiber-optic endoscopy for the presence of findings attributed to reflux disease. Medical conditions, lifestyle factors, and ENT complaints were surveyed to reveal potential airway irritants, while the study design attempted to eliminate silent reflux. The majority of subjects (86%) had findings associated with reflux and certain signs reached a prevalence of 70%. Prevalence was not affected by ENT complaint, smoking, alcohol, or asthma. Intraexaminer and interexaminer agreement information is provided. The traditional attribution of hypopharynx irritation signs to reflux is challenged; the need for improved diagnostic specificity is highlighted.

Managing gastroesophageal reflux disease

A common condition, gastroesophageal reflux disease (GERD) involves the reflux of gastric contents into the esophagus. GERD may contribute to asthma, noncardiac chest pain, and other problems. This article presents trends in GERD management, including pathophysiology, diagnosis, and treatment. The authors also explore lifestyle modifications, pharmacologic therapy, and gastroenterology referral.

Risk factors for hospitalization among adults with asthma: the influence of sociodemographic factors and asthma severity

BACKGROUND

The morbidity and mortality from asthma have markedly increased since the late 1970s. The hospitalization rate, an important marker of asthma severity, remains substantial.

METHODS

In adults with health care access, we prospectively studied 242 with asthma, aged 18-50 years, recruited from a random sample of allergy and pulmonary physician practices in Northern California to identify risk factors for subsequent hospitalization.

RESULTS

Thirty-nine subjects (16%) reported hospitalization for asthma during the 18-month follow-up period. On controlling for asthma severity in multiple logistic regression analysis, non-white race (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.1-8.8) and lower income (OR, 1.1 per $10,000 decrement; 95% CI, 0.9-1.3) were associated with a higher risk of asthma hospitalization. The severity-of-asthma score (OR, 3.4 per 5 points; 95%, CI 1.7-6.8) and recent asthma hospitalization (OR, 8.3; 95%, CI, 2.1-33.4) were also related to higher risk, after adjusting for demographic characteristics. Reliance on emergency department services for urgent asthma care was also associated with a greater likelihood of hospitalization (OR, 3.2; 95% CI, 1.0-9.8). In multivariate analysis not controlling for asthma severity, low income was even more strongly related to hospitalization (OR, 1.2 per $10,000 decrement; 95% CI, 1.02-1.4).

CONCLUSION

In adult asthmatics with access to health care, non-white race, low income, and greater asthma severity were associated with a higher risk of hospitalization. Targeted interventions applied to high-risk asthma patients may reduce asthma morbidity and mortality.

Asthma

Asthma is an important and increasingly prevalent respiratory disease. Its proper diagnosis and treatment lie at the heart of improving asthma outcome. Unfortunately, asthma has many faces and is affected by many variables, many of them difficult to control. Like many chronic illnesses, asthma tends to affect the poor and less advantaged individuals in society. Heightened awareness among patients and physicians of the serious nature of the disease is needed to reduce the morbidity and mortality of asthma. Treatment clearly requires a multifaceted approach, including behavioral, environmental, social, and medical interventions, in which the National Asthma Education and Prevention Program guidelines provide a logical, step-wise, and effective approach.

Increased prevalence of gastroesophageal reflux symptoms in patients with COPD

STUDY OBJECTIVES

To determine the prevalence of gastroesophageal reflux (GER) symptoms in patients with COPD and the association of GER symptoms with the severity of airways obstruction as assessed by pulmonary function tests (PFTs).

DESIGN

Prospective questionnaire-based, cross-sectional analytic survey.

SETTING

Outpatient pulmonary and general medicine clinics at a Veterans Administration hospital.

PATIENTS

Patients with mild-to-severe COPD (n = 100) were defined based on American Thoracic Society criteria. The control group (n = 51) consisted of patients in the general medicine clinic without respiratory complaints or prior diagnosis of asthma or COPD.

INTERVENTION

Both groups completed a modified version of the Mayo Clinic GER questionnaire.

RESULTS

Compared to control subjects, a greater proportion of COPD patients had significant GER symptoms defined as heartburn and/or regurgitation once or more per week (19% vs 0%, respectively; p < 0.001), chronic cough (32% vs 16%; p = 0.03), and dysphagia (17% vs 4%; p = 0.02). Among patients with COPD and significant GER symptoms, 26% reported respiratory symptoms associated with reflux events, whereas control subjects denied an association. Significant GER symptoms were more prevalent in COPD patients with FEV(1) < or %, as compared with patients with FEV(1) > 50% of predicted (23% vs 9%, respectively; p = 0.08). In contrast, PFT results were similar among COPD patients with and without GER symptoms. An increased number of patients with COPD utilized antireflux medications, compared to control subjects (50% vs 27%, respectively; p = 0.008).

CONCLUSIONS

The questionnaire demonstrated a higher prevalence of weekly GER symptoms in patients with COPD, as compared to control subjects. There was a trend toward higher prevalence of GER symptoms in patients with severe COPD; however, this difference did not reach statistical significance. We speculate that although GER may not worsen pulmonary function, greater expiratory airflow limitation may worsen GER symptoms in patients with COPD.