Gastroesophageal Reflux and Asthma
Section snippets
Coexistence of GER and Asthma
In a review on pulmonary complications of esophageal disease, Belsey[8]reported that patients with GER were liable to severe, progressive, and disabling pulmonary damage. Of 636 patients referred for surgical correction of severely symptomatic GER, more than 60% had symptoms of pulmonary disease coexisting with the GER.[9]Table 1 shows the published reports of asthma coexisting with GER in both children and adults.
Prevalence of GER in Patients With Asthma
The prevalence of GER in patients with asthma has been described in studies of both children and adults.3, 12, 15, 18, 22, 24, 29, 35
The true prevalence, however, is difficult to determine from these published studies. Most of the studies comprise highly selected referred populations that may not reflect the overall population with pulmonary disease. Despite these limitations, the studies that did attempt to determine prevalence rates reported remarkably similar results. The prevalence of GER
Mechanisms
The mechanisms by which GER might induce asthma have been a subject of debate. Two different mechanisms for GER-induced symptoms have been postulated: (1) activation of a GER-induced vagal reflex arc (vagal mediation) from the esophagus to the lung, resulting in bronchoconstriction,[29]and (2) microaspiration of gastric contents into the lung resulting in an exudative mucosal reaction.[8]
Reflux Abnormalities in Pulmonary Patients
Two retrospective radiographic studies reported on the prevalence of hiatal hernia and barium reflux in patients with pulmonary disease.14, 28Friedland and associates,[28]in a retrospective radiographic review of 54 children with unremitting asthma reported a 48% prevalence rate of hiatal hernia. Using barium x-ray studies and a control group, Mays[14]reported on 28 patients with severe asthma, 64% of whom had hiatus hernia and 46% of whom had barium reflux. These studies were criticized by
Prospective Epidemiologic Data
Recently, investigators have prospectively assessed the epidemiology and the prevalence of GER factors in consecutively studied asthmatic patients. Such epidemiological and cross-sectional studies clearly demonstrated that GER is highly prevalent in asthmatic patients. Recent studies show that about 75% of patients with asthma, independent of the use of bronchodilators,16, 20, 45, 53have heartburn,[16]pathologic acid GER,[20]and increased frequency of reflux episodes.[20]In addition, almost 60%
Effect of Medical Antireflux Treatment on Asthma
The effects on asthma of medical therapy of GER are shown in Table 2. Although improvement in pulmonary symptoms was reported in these studies, there are major problems with data interpretation. The duration of antireflux treatment (up to 8 weeks) is far too short to judge efficacy, and the prescribed dosage of H2-receptor antagonist is much too low to adequately prevent reflux. In addition, the definition of abnormal acid reflux (pH <4 for more than 1% of the time) may be too lenient, and a
Uncontrolled Studies
Early reports of an association between GER and asthma described a reduction or even a disappearance of the asthmatic state after antireflux surgery9, 12, 17, 22, 24, 61, 63, 64, 65, 66, 67, 68In most of these studies, however, pulmonary function tests were not performed before or after surgical repair. Despite the lack of objective data, the dramatic subjective improvement reported in some of the studies (e.g., complete elimination of asthma after 20 years) cannot be ignored. Fig. 1 shows the
Conclusions
The evidence is strong that GER plays an important role in some patients with asthma. Despite sophisticated study methods and technologically advanced diagnostic tests, the results of published studies on mechanisms failed to provide a diagnostic test with a degree of certainty great enough to identify which patients have GER-induced or GER-exacerbated asthma and which patients will respond to antireflux therapy. The difficulties involved in establishing a definite cause-and-effect relationship
References (68)
“Silent” gastroesophageal reflux: an important but little known cause of pulmonary complications
Dis Chest.
(1962)The pulmonary complications of oesophageal disease
Br J Dis Chest.
(1960)- et al.
Gastroesophageal reflux and hiatal hernia: Complications and therapy
J Thorac Cardiovasc Surg.
(1967) - et al.
Esophageal reflux as a trigger in asthma
Dis Chest.
(1966) - et al.
Most asthmatics have gastroesophageal reflux with or without bronchodilator therapy
Gastroenterology.
(1990) Quantitative gastroesophageal reflux and pulmonary function in asthmatic children and normal adults receiving placebo, theophylline, and metaproterenol sulfate therapy
J Allergy Clin Immunol.
(1984)- et al.
Respiratory response to intraesophageal acid infusion in asthmatic children during sleep
J Allergy Clin Immunol.
(1983) - et al.
Frequency and site of gastroesophageal reflux in patients with chest symptoms
Chest.
(1994) - et al.
Chronic persistent cough and clearance of esophageal acid
Chest.
(1992) - et al.
Gastroesophageal reflux causing respiratory distress and apnea in newborn infants
J Pediatr.
(1979)
Comparison of airway responses following tracheal or oesophageal acidification in the cat
Gastroenterology.
Association of lipid-laden alveolar macrophages and gastroesophageal reflux in children
J Pediatr.
Gastroesophageal reflux during sleep in asthmatic patients
J Pediatr.
Is 24-hour ambulatory oesophageal pH monitoring useful in a district general hospital?
Lancet
Esophageal pH monitoring during sleep identifies children with respiratory symptoms from gastroesophageal reflux
Gastroenterology
Prevalence of gastroesophageal reflux symptoms in asthma
Chest.
Hiatus hernia and the respiratory tract
Ann Thorac Surg.
Clinical observations regarding sliding hiatal hernia
Dis Chest.
Long-term results of surgical treatment for gastroesophageal reflux in asthmatic patients
Chest.
Recent advances in the treatment of asthma and hay fever
Practitioner.
GE reflux and asthma
West J Med.
Relationship between pulmonary disease, hiatal hernia, and gastroesophageal reflux
NY State J Med.
Reflux gastro-oesophagien et manifestations respiratoires: attitute diagnostique, indications therapeutiques et resultats
Ann Chir.
Medical and surgical treatment of non-allergic asthma associated with gastroesophageal reflux
Chest.
Intrinsic asthma in adults, association with gastroesophageal reflux
JAMA.
Ambulatory pH monitoring of gastro-oesophageal reflux in “morning dipper” asthmatics
Br Med J.
Asthmatics have a high prevalence of reflux symptoms regardless of the use of bronchodilators
Gastroenterology.
Asthma and gastroesophageal reflux. Results of a survey of over 150 cases
Poumon Coeur.
Reflujo gastroesofagico asociado a asma bronquial
Bol Med Hosp Infant Mex.
Cited by (69)
Laryngopharyngeal reflux - Own experience in diagnosis and treatment
2013, Otolaryngologia PolskaSurgical Therapy for Gastroesophageal Reflux Disease: Indications, Evaluation, and Procedures
2009, Gastrointestinal Endoscopy Clinics of North AmericaCitation Excerpt :Recently it has been appreciated that chest pain, asthma, laryngitis, recurrent pulmonary infections, chronic cough, and hoarseness may be associated with reflux, and this association is leading to increasing numbers of patients with these atypical GERD symptoms to be evaluated for reflux. As many as 80% of patients with asthma have endoscopic evidence of GERD,11 and 50% of patients in whom a cardiac cause of chest pain has been excluded have acid reflux as a cause of their pain. Otolaryngologists are beginning to make primary referrals for the treatment of GERD based on chronic laryngitis and evidence of acid-induced vocal cord damage, and dentists are identifying dental damage from chronic acid reflux.
Antireflux Surgery
2008, Surgical Clinics of North AmericaCitation Excerpt :That being said, it has recently been appreciated that chest pain, asthma, laryngitis, recurrent pulmonary infections, chronic cough, and hoarseness may be associated with reflux, and this association is leading to increasing numbers of patients with these atypical GERD symptoms to be evaluated for reflux. As many as 80% of patients who have asthma have endoscopic evidence of GERD [11], and 50% of patients in whom a cardiac cause of chest pain has been excluded have acid reflux as a cause of their pain. Otolaryngologists are beginning to make primary referrals for the treatment of GERD based on chronic laryngitis and evidence of acid-induced vocal cord damage, and dentists are identifying dental damage from chronic acid reflux.
Cost analysis of GER-induced asthma: A controlled study vs. atopic asthma of comparable severity
2007, Respiratory MedicineCitation Excerpt :In contrast, the role of the aetiological determinants of the disease received much less attention from this point of view, although it is well known that assessment of the precise origin of asthma can become difficult in some circumstances (i.e. when the atopic cause is excluded), independently of the therapeutic approach. Increasing attention has been paid to bronchial asthma when related to the occurrence of acid gastro-oesophageal reflux (GER), and the causative (or triggering) role of GER was emphasised in the last decade, particularly in non-atopic subjects.12–17 GER-related asthma represents a peculiar form of bronchial asthma which falls in the domain of both gastroenterologists and pneumologists.
Gastro-pharyngeal reflux and total laryngectomy. Increasing knowledge about its management
2018, American Journal of Otolaryngology - Head and Neck Medicine and SurgeryCitation Excerpt :Our multivariate analysis showed no significant association among clinical characteristics of the study population and the onset of reflux symptoms after the operation of total laryngectomy, but the finding of a high incidence of reflux after total laryngectomy indicates that, in accordance with literature, reflux should be investigated and scored in order to better manage complications that might occur after surgery, during radiotherapy, and in voice rehabilitation. For example, there are some reports in literature that declare a significant correlation between the occurrence of thacheo-esophageal fistula complications, together with pulmonary distress, and the severity of supra-esophageal reflux in laryngectomised patients [33,38–42]. In this scenario, pathological gastro-pharyngeal reflux appears among the possible causes of speech fistula enlargement together with local inflammatory responses in the region of the fistula, atrophy of the tissue around the fistula as a result of adjuvant radiotherapy, micro-movements of the prosthesis and trauma in the region of the fistula during prosthesis replacement procedures [43].