ArticlePDF AvailableLiterature Review

Asthma and gastroesophageal reflux disease: A multidisciplinary point of view

  • Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino
  • Azienda Ospedaliero Universitaria Maggiore della Carità Novara
  • Institute of Biostructure and Bioimaging (CNR)
  • Azienda Ospedaliera Città della Salute e della Scienza di Torino (Molinette Hospital) Italy


Asthma and gastro-oesophageal reflux (GORD) are widespread and potentially coexisting diseases. Incidence and prevalence of concomitant asthma and GORD are highly variable among studies. This is mainly due to the heterogeneity of study designs. To explain a potential link, it has been proposed some pathophysiological anomaly such as the altered pressure gradient between thorax and abdomen, the parasympathethic reflex, the hightened bronchial reactivity and chemical effects of microaspired gastric juice. An accurate diagnosis of asthma and GORD are pivotal in order to lead effective treatment and to reach a significant positive outcome, in terms of quality of life and respiratory function amelioration. Gastroenterological evaluation of GORD includes the empiric proton pump-inhibitors (PPIs) trial, the esophageal pH monitoring and endoscopic evaluation. Besides spirometric investigations, pulmonologist have more specific examens such as bronchoalveolar lavage and exhaled breath condensate. Actually, international recommendations regarding the management of asthma, suggest the assessment of potential comorbidities, including the presence of GORD, mostly in children, only in patients with normal pulmonary functional tests with frequent respiratory symptoms, and in case of uncontrolled asthma. Symptomatic gastro-oesophageal reflux patients should be treated, but those with uncontrolled asthma should not be treated with anti-reflux drugs unless they are symptomatic for reflux. This review explores the state of the art about the pathogenesis and the management of relationship between asthma and GORD.
VOLUME 108 . No.4 . AUGUST 2017
350 MINERVA MEDICA August 2017
allergen or irritant exposure, change in weath-
er, or viral respiratory infections.1
Clinical manifestations may be silent for
weeks or months, but sometimes the trend
may be interposed by episodic exacerbations
of asthma, sometimes life-threatening. The
features of asthma usually persist, even when
symptoms are absent or lung function is nor-
mal, but may be responsive to appropriate
Among factors triggering asthma, several
studies have focused on the possible associa-
Asthma is a chronic respiratory disease,
usually associated with airway hyper-re-
sponsiveness to direct or indirect stimuli, and
with chronic airway inammation, affecting
1-18% of the general population. This condi-
tion is characterized by the presence of vari-
able expiratory airow limitation and intermit-
tent symptoms, including wheeze, shortness of
breath, chest tightness and/or cough. Symp-
toms and airow limitation characteristically
vary within and between individuals over time
and are triggered by factors such as exercise,
Asthma and gastroesophageal reux disease:
a multidisciplinary point of view
Paolo SOLIDORO 1, Filippo PATRUCCO 1 *, Sharmila FAGOONEE 2 , Rinaldo PELLICANO 3
1Division of Pulmonology, Cardiothoracic and Vascular Department, AOU Città della Salute e della Scienza
di Torino, Turin, Italy; 2 Institute for Biostructures and Bioimages (CNR) c/o Molecular Biotechnology Center,
University of Turin, Turin, Italy; 3Unit of Gastroenterology, Molinette Hospital, Turin, Italy
*Corresponding author: Filippo Patrucco, Bramante 88/90, Città della Salute e della Scienza, Turin, Italy.
E-mail: 
Anno: 2017
Mese: August
Volume: 108
No: 4
Rivista: Minerva Medica
Cod Rivista: Minerva Med
Lavoro: 5181-MM
primo autore: SOLIDORO
pagine: 350-6
citazione: Minerva Med 2017;108:350-6
Asthma and gastroesophageal reux (GORD) are widespread and potentially coexisting diseases. Incidence and preva-
lence of concomitant asthma and GORD are highly variable among studies. This is mainly due to the heterogeneity of
study designs. To explain a potential link, some pathophysiological anomaly has been proposed such as the altered pres-
sure gradient between thorax and abdomen, the parasympathetic reex, the heightened bronchial reactivity and chemical
effects of microaspired gastric juice. An accurate diagnosis of asthma and GORD is pivotal in order to lead effective
treatment and to reach a signicant positive outcome, in terms of quality of life and respiratory function amelioration.
Gastroenterological evaluation of GORD includes the empiric proton pump-inhibitors (PPIs) trial, the esophageal pH
monitoring and endoscopic evaluation. Besides spirometric investigations, pulmonologist have more specic examens
such as bronchoalveolar lavage and exhaled breath condensate. Actually, international recommendations regarding the
management of asthma suggest the assessment of potential comorbidities, including the presence of GORD, mostly in
children, only in patients with normal pulmonary functional tests with frequent respiratory symptoms, and in case of un-
controlled asthma. Symptomatic gastro-esophageal reux patients should be treated, but those with uncontrolled asthma
should not be treated with anti-reux drugs unless they are symptomatic for reux. This review explores the state of the
art about the pathogenesis and the management of the relationship between asthma and GORD.
(Cite this article as: Solidoro P, Patrucco F, Fagoonee S, Pellicano R. Asthma and gastroesophageal re ux disease: a multidis-Solidoro P, Patrucco F, Fagoonee S, Pellicano R. Asthma and gastroesophageal reux disease: a multidis-
ciplinary point of view. Minerva Med 2017;108:350-6. DOI: 10.23736/S0026-4806.17.05181-3)
Key words: Asthma - Gastroesophageal reux - Esophagitis - Respiration disorders.
Minerva Medica 2017 August;108(4):350-6
DOI: 10.23736/S0026-4806.17.05181-3
Online version at
Vol. 108 - No. 4 MINERVA MEDICA 351
ly involved in the pathogenesis of esophageal
acid-induced bronchoconstriction: vagally me-
diated reex, heightened bronchial reactivity,
and microaspiration of gastric juice.
For the demonstration of the rst mecha-
nism, authors provided the infusion of acid in
esophagi of normal control patients, asthmatics
with GORD and asthmatics without GORD;
esophageal acid caused a decrease in peak ex-
piratory ow rate and an increase in specic
airway resistance in asthmatics with GORD,
which did not improve after acid clearance;11
asthmatics patients had also a partial response
after infusion of vagolytics, suggesting a role
of parasympathetic system.
The bronchial reactivity was studied com-
paring results of methacholine tests of asth-
matics with GORD and normal control sub-
jects. Authors found that the dose for induce
a response was lower when esophageal acid
was infused versus normal saline solution,
and this response was abolished when atro-
pine pre-medication was performed. This sug-
gested that GORD could aggravate asthma by
increasing bronchomotor responsiveness to
other stimuli.12
Microaspiration role has been investigated
performing simultaneous tracheal and esopha-
geal pH testing in patients with severe asthma.
Authors found that peak expiratory ow rate
had higher decrease when a concomitant drop
of pH was present. Episodes of tracheal mi-
croaspiration were associated with signicant
deterioration in pulmonary function.13
In summary, there is a parasympathetic va-
gally mediated reex present so that the acid
in the esophagus causes bronchoconstriction;
however, if microaspiration is present, there is
further augmentation of this bronchoconstric-
tor response.
A critical aspect is that the studies about the
effects of acid perfusion of the esophagus in
case of asthma were designed to maximize the
likelihood that the effects on pulmonary func-
tion would be identied. The wide majority of
studies described small changes in one or two
of the more sensitive and less specic ow-
volume loop or resistance parameters,14 with a
probably low clinical signicance.
tion between this pulmonary disease and gas-
troesophageal reux disease (GORD), with
conicting conclusions and failing to clarify a
potential cause-effect interaction generally due
to their heterogeneity.2-4
Asthma and GORD: basic principles
Both asthma and GORD are listed among
the most prevalent diagnosed chronic condi-
tions in Western Countries.5
The belief that GORD could trigger or
worsen asthma (in a context of several extra-
esophageal manifestations) originated from
the observation that asthmatic patients often
have GORD and that esophageal acidication
promotes increasing of airway resistances.6, 7
However a lot of critical issues persist and im-
pede to clarify this relationship.
There are 4 points of discussion in investi-
gating the relationship between asthma and
gastroesophageal reux: 1) frequently, studies
did not characterize asthma, both in terms of
spirometric diagnosis and classication of its
severity; 2) inaccurate denitions of GORD; 3)
inability of current methods to identify not only
the different types of GORD (acid, slightly acid,
and alkaline) but also their magnitude; 4) lack
of well-established criteria for determining the
value of a diagnosis of asymptomatic GORD.8
Actually, international recommendations
regarding the management of asthma, suggest
the assessment of comorbidities, including the
presence of GORD, mostly in children, in pa-
tients with normal pulmonary functional tests
with frequent respiratory symptoms, and in
case of uncontrolled asthma.1, 3
There is a pathophysiological bidirectional
link between asthma and GORD.9 On one side
the altered respiratory physiology, in asthma
patients, may predispose to a pathological pat-
tern of gastro-esophageal reux. In this con-
text, there is an increased pressure gradient
between the thorax and abdominal cavity and
this promotes gastro-esophageal reux.10 On
the other side three mechanisms are potential-
352 MINERVA MEDICA August 2017
GORD in nocturnal asthma. For this reason
International guidelines recommend that pa-
tients who present a difcult to control asthma
should be investigated for GORD.3, 20, 21 Ad-
ditionally, a cross-sectional study assessing
over 2600 persons concluded that those with
GORD had signicantly more nocturnal asth-
ma symptoms than those without.22 However, a
randomized, placebo-controlled, double-blind
trial, demonstrated that even in those patients
with a esophageal pH monitoring positive for
GORD, a trial with PPIs did not improve asth-
ma control.23
Prevalence and incidence
The prevalence of both concomitant condi-
tions, reported in literature, is extremely vari-
able and depends on the criteria used to dene
GORD and the population studied.24, 25 A sys-
tematic review on GORD symptom assessment
in asthmatics provided a realistic estimate of
the strength and direction of the association
between GORD and asthma in adults. In pa-
tients with asthma, the prevalence of abnormal
esophageal pH, esophagitis and hiatal hernia
were 50.9%, 37.3% and 51.2% respectively.
The prevalence of asthmatics with GORD was
4.6% but this increases to 12.3% when weekly
heartburn and/or acid regurgitation were in-
cluded in evaluation. The nal odds ratio was
2.27 (95% CI: 1.8-2.8).26
The incidence was evaluated in two large
retrospective studies. The rst demonstrated
that incidence rate of hospitalization for asth-
ma in patients who had a previous hospitaliza-
tion for hernia or esophagitis was 2.6 cases per
1000 person/year.27 The second described an
incidence rate of new asthma diagnosis among
patients suffering from GORD of 6.0 cases per
1000 person/years.28
These studies suggest a signicant associa-
tion between GORD and asthma. The preva-
lence of GORD symptoms in asthmatics and
the prevalence of asthmatics in patients with
GORD is generally higher than controls. How-
ever, the majority of studies performed in
this eld are cross-sectional or case-control
and they could not give us a clear indication
Rather than promoting asthma, GORD
might facilitate the triggering of asthma in-
volving other irritant factors. One of these
could be cough and increased respiratory ef-
fort accompanying asthma; this could facilitate
GORD increasing pressure gradient across the
lower esophageal sphincter (LES).15 Pulmo-
nary hyperination could affect the relation-
ship between the low resistance portion of
diaphragm and the gastroesophageal junction
compromising LES function too.16
Another potential factor inuencing the ap-
parent strict relationship between bronchial
tree and LES is the role played by relaxing ef-
fect of β2-agonists on bronchial smooth muscle
for asthma treatment. The effects of inhaled β2-
agonists on LES function are not so clear. One
study demonstrated that oral β2-agonist therapy
decreases LES tone. This mechanism could be
signicant with inhalers’ devices because part
of the drug dose is swallowed. Authors have
shown that inhaled albuterol therapy reduced
LES basal tone and contractile amplitudes in
the smooth muscle of esophageal body in a
dose-dependent manner, increasing esopha-
geal acidication in susceptible patients. This
could lead to further bronchoconstriction and
persistence of asthmatic symptoms triggering
a vicious cycle.17
Bronchial hyper-responsiveness (BHR) is
the relative ease of bronchi to constrict in re-
sponse of physical or chemical stimuli such as
methacholine. It is assumed that patients with
BHR, without respiratory symptoms, may be
in a latent phase of asthma that may become
clinically evident over the course of life.18 The
association between reux and asymptomatic
BHR (hyper-responsiveness without asthma
symptoms) has been sparked off, promoting
discussions about the cause-and-effect relation-
ship between asthma and GORD.19 Bagnato et
al. found that 36% of patients with GORD and
without respiratory symptoms had BHR sug-
gesting that GORD was associated with the in-
crease in asymptomatic BHR.18 Similar results
were found by Lapa et al. with a prevalence of
BHR of 50% in adults with GORD, compared
with 27% in the control group.8
Some study suggested a role played by
Vol. 108 - No. 4 MINERVA MEDICA 353
antisecretory therapy. In this latter case it has
been suggested that symptoms may be due to
reux having pH≥4.0 (i.e. non-acid reux), a
type of reux that is difcult to identify with
conventional pH-metry. Hence, it has been
introduced a new technique named intralumi-
nal impedance depending on changes in resis-
tance to alternating current (i.e. impedance)
between two metal electrodes (i.e. impedance
measuring segment) produced by the presence
of bolus inside the esophageal lumen. Elec-
tric conductivity (the opposite of resistance
or impedance) is directly related to the ionic
concentration of the intraluminal content. En-
doscopy is superior to radiology to identify
erosive esophagitis and allows the grading of
the severity of lesions.
Laryngopharynx examination provides di-
agnostic information about symptoms and may
reveal signs of reux. It is performed with a
exible laryngoscope and the most common
ndings of reux being erythema, posterior
commissure hypertrophy, granulomas, vocal
cord dysfunction, pseudosulcus, edema, ven-
tricular obliteration, erythematous mucosa in
the nasopharynx and red mucosa of the lingual
Bronchoalveolar lavage (BAL) is an inva-
sive bronchoscopic technique for the sampling
of lung epithelial lining uid. It is performed
inserting a bronchoscope through the bron-
chial tree, where it is wedged to occlude the
airway. Saline is introduced through the op-
erating channel of the bronchoscope and re-
covered for the examination. Direct proof of
aspiration requires the recovery of substances
from the lungs that are produced in the gas-
trointestinal tract, such as pepsin and bile
acids.32 However, the detection of pepsin on
BAL may not necessarily be an abnormal nd-
ing because also healthy individuals aspirate
nasopharyngeal secretions during sleep due to
drop of the upper esophageal sphincter tone.
Nevertheless, in case of bronchial asthma the
nding of pepsin in the brocholaveolar uid
has been shown in 100% of cases in a recent
study.33 The microaspiration of bile acids from
duodenal gastroesophageal reux and their
pathogenic potential to induce severe lung
of the temporal sequence of these conditions.
The severity-response relation for the evalu-
ation of casual association was inconsistent
among studies but tended to a positive corre-
lation when the increased severity of GORD
was associated with an increased prevalence
of asthma (considering increased frequency of
symptoms and severity of esophagitis).26
In patients with conrmed asthma, GORD
should be considered as a possible cause of a
dry cough. Guidelines suggest an assessment
of comorbidities in patients with uncontrolled
asthma for GORD, however there is no value
in screening (evidence A).1 A prompt diagno-
sis of GORD in patients with asthma is crucial
for the management of lung disease, improv-
ing quality of life and lung function.
The main strategies involved in the inves-
tigation of this potential relationship are de-
scribed below. From a gastroenterological
point of view the 3 potential approaches are
the empiric proton pump-inhibitors (PPIs) tri-
al, the esophageal pH monitoring and endos-
copy.29, 30
A rapid symptomatic response to PPIs,
in patients with a presumptive diagnosis of
GORD, is commonly considered to validate
the diagnosis (the so-called “PPIs test”). How-
ever, the accuracy of a symptomatic response
to PPIs compared with objective measures of
GORD (such as ambulatory pH monitoring)
is unclear. Studies addressing this issue have
produced variable estimates of test accuracy.
Since its introduction ambulatory, esophageal
pH monitoring is the current “gold standard”
for GORD testing, a method based on detec-
tion of changes in content in the esophageal
lumen. Monitoring of esophageal pH allows
not only the detection of acid exposure but
also the assessment of the relationship between
acid reuxate and symptoms. It is useful to test
patients with typical or atypical reux symp-
toms who did not respond to empirical therapy
with a PPI, and for assessment of the level
of acid suppression in patients with refractory
symptoms or esophagitis despite appropriate
354 MINERVA MEDICA August 2017
asthma (most of whom with GORD), but no
effect on asthma outcomes.47 Benets of PPIs
in asthmatics seem to be limited to those pa-
tients affected by symptomatic reux and night
respiratory symptoms.48
Severe asthma is dened as asthma that re-
quires treatment with high dose ICS plus a sec-
ond controller and/or systemic corticosteroids
to prevent it from becoming ‘‘uncontrolled’’ or
that remains ‘‘uncontrolled’’ despite this ther-
apy.49, 50 Symptoms originating from GORD
may mask those due to asthma. The role of
GORD treatment in patients with severe asth-
ma is not clear but International guidelines
suggest that GORD should be treated in order
to minimize its potential effects. In a recent
study, Yii et al. have shown in 177 problematic
asthma patients, that gastro-esophageal reux
was a risk of severe exacerbation. Hence, it
was included in a clinical risk score to accu-
rately identify patients at risk for future fre-
quent severe exacerbations.51
One of the potential effects of severe asth-
ma treatment on GORD symptoms may be
played by oral corticosteroids. Strickland et
al. noted in healthy subjects that 1 month of
treatment with 20 mg/day of prednisolone had
an increased stimulation of gastric acid secre-
tion that could promote GORD.52 Lazenby et
al. evaluated the role of oral prednisone in pa-
tients with stable moderate persistent asthma:
they found an increased esophageal acid con-
tact times at pH esophageal testing, not cor-
related with respiratory functional parameters,
nor with LES or upper esophageal sphincter
(UES) pressure, peristaltic contractions, trans-
diaphragmatic pressure gradient, or diaphrag-
matic pinch pressure. Thus, the mechanism for
the increase of esophageal acid contact times
remains unclear.53
In addition to the strength of evidence
on relationship between gastroesophageal
acid reux and asthma, the spectrum of un-
certainty encompasses other aspects of the
problem. The paradoxical observations that
asthma symptoms but not pulmonary function
damage was suggested in animal studies and
some clinical studies of rare diseases.34, 35
Exhaled breath condensate (EBC) is the
breath water vapor that has been condensed,
typically via cooling using a collection de-
vice (commonly to 4 °C or sub-zero tempera-
tures).31, 36 Pepsin has been found in EBC of
patients with clinical suspect of GORD associ-
ated with cough.37 EBC pH decreases in case
of active inammation of airways such as in
asthmatic exacerbations.38
Treatment of asthmatic patients with
GORD: pulmonologist point of view
The cornerstones of asthma treatment are
inhaled corticosteroids (ICS) and β2-agonists.
The treatment with regular daily dose of ICS
is associated to a reduction of asthma symp-
toms, asthma-related exacerbations, hospi-
talization and death.39-44 International recom-
mendations suggested their usage in STEP 1
asthma treatment as alternative to short acting
β2-agonists, and alone or in association with
short and long acting β2-agonists (respectively
SABA and LABA) in STEP 2, 3, 4 and 5.1 The
fraction of ICS that is deposited in the mouth
during inhalation will be swallowed, and oral
bioavailability is determined by its absorption
from the gastrointestinal tract and the degree
of rst-pass metabolism in the liver.45
Due to their rapid effect SABA are used
in all steps of asthma treatment, to reduce
symptoms.1 Adding LABA to ICS provides
additional improvements in symptoms and
lung function with a reduced risk of exacerba-
tions.46 Potential effects of inhaled short and
long acting β2-agonists have been previously
In literature there are no studies that inves-
tigate the effect of swallowed ICS on develop-
ment or worsen of GORD.
International recommendations suggest that
symptomatic gastroesophageal reux should
be treated, but patients with uncontrolled
asthma should not be treated with anti-reux
drugs unless they are symptomatic for reux.1
A review showed a small signicant benet of
PPIs on peak expiratory ow of patient with
Vol. 108 - No. 4 MINERVA MEDICA 355
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Hind CR, et al. Simultaneous tracheal and oesophageal
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antireux therapy has a benecial effect on
the former but not on the latter should lead
the therapeutic management. Actually, the in-
vestigation or the treatment of asymptomatic
reux are not justied whether they do not af-
fect pulmonary function or involves patients
with refractory asthma.54 Patients suffering
from asthma and moderate or severe GORD
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ics with reux-associated respiratory symp-
toms require more profound acid inhibition to
achieve treatment goals than would be nec-
essary for patients with GORD but without
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discussed in the manuscript.
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... Although there are milder symptoms in older patients, the high rate of esophagitis may be related to this condition. Studies showing that lung and heart diseases and drugs used for these diseases trigger GERD support our idea (24,25). However, although polypharmacy commonly used in the elderly population have been associated with GERD, unfortunately it was not possible to reach the medications of patients because of the study's retrospective design. ...
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Objective: To determine and compare the clinical features and endoscopic findings of gastro-esophageal reflux disease (GERD) in elderly and younger age groups. Materials and Methods: The clinical and endoscopic features were evaluated for all patients with GERD between January 2017 and September 2020. The criteria for inclusion were being aged over 65 and under 50 years and having an upper gastrointestinal endoscopy with reflux symptoms resistant to ppi theraphy. The exclusion criteria included prior surgery, age under 18 years, and pregnancy. The diagnosis of GERD was made according to the patients' symptoms. The SPSS 11.0 for Windows pocket program was used for statistical analysis. Results: Two hundred eighty-six patients aged over 65 years and 261 patients aged below 50 years were enrolled in this study. The mean age of the older group was 68.2 ± 4.5 years and the mean age of the young group was 38 ± 7.2 years. The male/female ratio was 5/3 and 2/1 in the young and older groups, respectively. The older patients had less severe and rare typical symptoms than the young patients. However, significantly more serious endoscopic findings were noted in the older patients compared with the younger patients. Conclusion: The older and young patients with GERD were predominantly male and typical reflux problems were less common in older patients with GERD. Older patients had more important endoscopic findings such as hernia, esophagitis, and cancer.
... In our study, we selected the fifth visit from the asthma index as the prediction date (testing set A) according to the average number of visits (5.78, SD 6.04) between asthma index and exacerbation among the patients. The detailed steps for the cohort selection are listed in Multimedia Appendix 1 [4,25,[40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55]. In next-visit prediction, we simply set the penultimate visit as the prediction date (testing set B). ...
Background Asthma exacerbation is an acute or subacute episode of progressive worsening of asthma symptoms and can have a significant impact on patients’ quality of life. However, efficient methods that can help identify personalized risk factors and make early predictions are lacking. Objective This study aims to use advanced deep learning models to better predict the risk of asthma exacerbations and to explore potential risk factors involved in progressive asthma. Methods We proposed a novel time-sensitive, attentive neural network to predict asthma exacerbation using clinical variables from large electronic health records. The clinical variables were collected from the Cerner Health Facts database between 1992 and 2015, including 31,433 adult patients with asthma. Interpretations on both patient and cohort levels were investigated based on the model parameters. Results The proposed model obtained an area under the curve value of 0.7003 through a five-fold cross-validation, which outperformed the baseline methods. The results also demonstrated that the addition of elapsed time embeddings considerably improved the prediction performance. Further analysis observed diverse distributions of contributing factors across patients as well as some possible cohort-level risk factors, which could be found supporting evidence from peer-reviewed literature such as respiratory diseases and esophageal reflux. Conclusions The proposed neural network model performed better than previous methods for the prediction of asthma exacerbation. We believe that personalized risk scores and analyses of contributing factors can help clinicians better assess the individual’s level of disease progression and afford the opportunity to adjust treatment, prevent exacerbation, and improve outcomes.
... Neutrophilic airway inflammation is the predominant phenotype in severe coPD; 5 neutrophils, which are resistant to ICS anti-inflammatory effects, in combination with bacteria and icS, may result in harm. [6][7][8] This is due to the effects of icS on neutrophils, disabling their antimicrobial response, bringing to a growth of bacterial load and potential increased risk of exacerbations or pneumonia. [9][10][11] on the other side, it has been demonstrated that icS are effective on exacerbation reduction, and their withdrawal exposes some patients to an increased and unacceptable risk of exacerbations; moreover, icS withdrawal could determine an adrenal insufficiency due to ICS' effects on adrenocortical axis suppression. ...
The purpose of the review: to analyze the evolution of the views of clinicians and researchers on the relationship between gastroesophageal reflux and is extraesophageal bronchial manifestations, and the stages of the formation of the diagnosis of microaspiration of the lower respiratory tract in children. Materials and methods. Sarch in electronic databases: Elibrary, Federal Electronic Medical Library of the Ministry of Health of the Russian Federation, bibliographic database of articles on medical sciences, created by the US National Library of Medicine MEDLINE. Main statements. Diagnostics and treatment of gastroesophageal reflux and its extraesophageal manifestations both in the 20th century and at the beginning of the 21-st century present certain difficulties for pediatricians and pulmonologists. Currently, there are numerous domestic and foreign clinical guidelines created with the aim f improving diagnostics and approaches to the treatment of gastroesophageal reflux and "silent" microaspiration of the lower respiratory tract of the respiratory tract. However, the evidence base for the problem under discussion is rather limited, due to the lack of specificity of the symptoms of the disease and the absence of a "gold standard" diagnostics. Conclusion. The presented review gives information about non-invasive diagnosis of microaspiration in children with bronchial asthma and chronic cough what will help us decide on treatment, taking into account the concomitant gastroesophageal reflux. A non-invasive method for detecting lactose in the induced sputum of the respiratory tract and also an additional determination of the average cytochemical coefficient of macrophages can serve as an effective alternative to the verification of "silent" microaspiration in children with bronchial asthma and chronic cough.
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Danling Liu,1,* Tingting Qian,1,* Shan Sun,1 Jack J Jiang1,2 1Otorhinolaryngology Department, ENT Institute, Eye & ENT Hospital, State Key Laboratory of Medical Neurobiology, NHC Key Laboratory of Hearing Medicine Research, Fudan University, Shanghai 200032, People’s Republic of China; 2Department of Surgery, Division of Otolaryngology Head and Neck Surgery, University of Wisconsin Medical School, Madison, WI 53792-7375, USA*These authors contributed equally to this workCorrespondence: Shan Sun Email J Jiang Email The upper aerodigestive tract (UAT) is the first line of defense against environmental stresses such as antigens, microbes, inhalants, foods, etc., and mucins, intracellular junctions, epithelial cells, and immune cells are the major constituents of this defensive mucosal barrier. Laryngopharyngeal reflux (LPR) is recognized as an independent risk factor for UAT mucosal disorders, and in this review, we describe the components and functions of the mucosal barrier and the results of LPR-induced mucosal inflammation in the UAT. We discuss the interactions between the refluxate and the mucosal components and the mechanisms through which these damaging events disrupt and alter the mucosal barriers. In addition, we discuss the dynamic alterations in the mucosal barrier that might be potential therapeutic targets for LPR-induced disorders.Keywords: laryngopharyngeal reflux, LPR, upper aerodigestive tract, UAT, inflammatory response, mucosal barrier dysfunction
Idiopathic pulmonary fibrosis (IPF) is a rare and progressive chronic respiratory disease. Although interconnections between gastroesophageal reflux disease (GERD) and IPF are numerous, their relationship is still controversial. Pathogenetic hypotheses involve micro-aspiration of gastric acid causing inflammation and then remodeling of lung structure until fibrosis, even to acute accelerating exacerbations of IPF. Moreover, IPF may itself aggravate GERD increasing intrathoracic pressure. Several studies have evaluated the possible beneficial effects of antacid and antireflux therapies on patients' outcomes and pulmonary function, but results are still conflicting. This narrative review explores many aspects of the relationship between IPF and GERD, including pathogenesis, clinical implications, medical and surgical GERD therapies, summarizing the results of most important studies conducted in this specific field.
Rib fractures represent one of the most common chest injuries and they may be associated with immediate or potentially life-threatening consequences. in the emergency department setting it is crucial to identify the presence of rib injuries and trauma related complications requiring specialistic evaluation. Most frequent complications are represented by pneumothorax, hemothorax and pulmonary contusion even if vascular injuries are frequent. The mainstay of rib fractures management includes pain control, the treatment of complications and stabilization of chest wall deformities. in this narrative review we analyzed the role of radiological investigations in chest wall trauma with rib injuries, rib fractures patterns and their possible complications; finally, we included a section focused on the management of rib fractures, with general and non-surgical as well as surgical indications.
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Background Assessing future risk of exacerbations is an important component of asthma management. Existing studies have investigated short-, but not long-term risk. Problematic asthma patients with unfavorable long-term disease trajectory and persistently frequent severe exacerbations need to be identified early to guide treatment. Methods Severe exacerbation rates over five years for 177 “problematic asthma” patients presenting to a specialist asthma clinic were tracked. Distinct trajectories of severe exacerbation rates were identified using group-based trajectory modeling. Baseline predictors of trajectory were identified and used to develop a clinical risk score for predicting the most unfavorable trajectory. Results Three distinct trajectories were found: 58.5% had rare intermittent severe exacerbations (“infrequent”), 32.0% had frequent severe exacerbations at baseline but improved subsequently (“non-persistently frequent”), and 9.5% exhibited persistently frequent severe exacerbations, with the highest incidence of near-fatal asthma (“persistently frequent”). A clinical risk score composed of ≥2 severe exacerbations in the past year (+2 points), history of near-fatal asthma (+1 point), body mass index≥25kg/m2 (+1 point), obstructive sleep apnea (+1 point), gastroesophageal reflux (+1 point) and depression (+1 point) was predictive of the “persistently frequent” trajectory (area under the receiver operating characteristic curve: 0.84; sensitivity 72.2%, specificity 81.1% using cut-off ≥3 points). The trajectories and clinical risk score had excellent performance in an independent validation cohort. Conclusions Patients with problematic asthma follow distinct illness trajectories over a period of five years. We have derived and validated a clinical risk score that accurately identifies patients who will have persistently frequent severe exacerbations in the future.
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Objectives To estimate the prevalence of common chronic conditions and multimorbidity among patients at GP encounters and among people in the Australian population. To assess the extent to which use of each individual patient?s GP attendance over the previous year, instead of the average for their age-sex group, affects the precision of national population prevalence estimates of diagnosed chronic conditions. Design, setting and participants A sub-study (between November 2012 and March 2016) of the Bettering the Evaluation and Care of Health program, a continuous national study of GP activity. Each of 1,449 GPs provided data for about 30 consecutive patients (total 43,501) indicating for each, number of GP attendances in previous year and all diagnosed chronic conditions, using their knowledge of the patient, patient self-report, and patient's health record. Results Hypertension (26.5%) was the most prevalent diagnosed chronic condition among patients surveyed, followed by osteoarthritis (22.7%), hyperlipidaemia (16.6%), depression (16.3%), anxiety (11.9%), gastroesophageal reflux disease (GORD) (11.3%), chronic back pain (9.7%) and Type 2 diabetes (9.6%). After adjustment, we estimated population prevalence of hypertension as 12.4%, 9.5% osteoarthritis, 8.2% hyperlipidaemia, 8.0% depression, 5.8% anxiety and 5.2% asthma. Estimates were significantly lower than those derived using the previous method. About half (51.6%) the patients at GP encounters had two or more diagnosed chronic conditions and over one third (37.4%) had three or more. Population estimates were: 25.7% had two or more diagnosed chronic conditions and 15.8% had three or more. Conclusions Of the three approaches we have tested to date, this study provides the most accurate method for estimation of population prevalence of chronic conditions using the GP as an expert interviewer, by adjusting for each patient?s reported attendance.
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AIM: The aim of this study was to study the clinical characteristic of patient with refractory asthma (RA) from Saudi Arabia. METHODS: This paper prospectively studied in a university hospital factors leading to RA in a cohort of patients who have inadequately controlled asthma or with frequent exacerbations despite optimum controller therapy. It also studied patients with asthma that requires extended periods of oral steroids to control. RESULTS: The mean age was 45.1 years (±9.1) where 74 patients were enrolled in this study with the age group (37-48 years) is having the highest percentage (64.8%). Female patients represented 62.2%. The two major comorbid conditions were allergic rhinitis (54.1%) and gastroesophageal reflux (33.8%). The vast majority (72 patients) had at least one trigger factor for asthma (97.3%). The asthma control test showed that 86.4% had an uncontrolled status. Spirometry showed mild disease in 9.5%, moderate in 47.3%, and severe in 43.2%. Eosinophilia was seen in only 16.2%. Immunoglobulin E level between 70 and 700 μg/L was found in 58.1% of patients. CONCLUSION: RA has certain clinical characteristics and associated comorbid conditions as well as precipitating factors that facilitate the identifications of these cases.
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Background: Pepsin plays a role in gastroesophageal reflux (GER). Aims of this study were to verify if pepsin could be the cause of frequent bronchial exacerbations and to check if the persistence of chronic respiratory symptoms were correlated with pre-existing respiratory diseases. Methods: From January to May 2016, 42 patients underwent a diagnostic bronchoscopy. All patients had a history of at least one bronchial exacerbation during the previous year. Bronchial lavage fluid specimens were obtained. A semiquantitative assessment of pepsin in the samples was carried out based on the intensity of the test sample. Results: Pepsin was present in 37 patients (88%), but in patients with bronchial asthma and chronic obstructive pulmonary disease (COPD), the finding of pepsin in the bronchoalveolar fluid was 100%. There was a strong positive statistical correlation between pepsin detection and radiological signs of GER (ρ=0.662), and between pepsin detection and diagnosis (ρ=0.682). No correlation was found between the bacteriology and the presence of pepsin in the airways (ρ=0.006). Conclusions: The presence of pepsin in the airways shows the occurrence of reflux. The persistence of respiratory symptoms by at least 2 months suggest an endoscopic bronchial examination. This straightforward test confirms the cause possible irritation of the airways and may prevent further diagnostic tests, such as an EGD or pH monitoring esophageal.
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Background . There is no gold standard test for diagnosis of gastroesophageal reflux disease (GERD) associated infantile wheezing. Objectives . To evaluate the value of bronchoalveolar lavage (BAL) pepsin assay in diagnosis of GERD in wheezy infants. Methods . Fifty-two wheezy infants were evaluated for GERD using esophageal combined impedance-pH (MII-pH) monitoring, esophagogastroduodenoscopy with esophageal biopsies, and BAL pepsin. Tracheobronchial aspirates from 10 healthy infants planned for surgery without history of respiratory problems were examined for pepsin. Results . Wheezy infants with silent reflux and wheezy infants with typical GERD symptoms but normal MII-pH had significantly higher BAL pepsin compared to healthy control (45.3 ± 8.6 and 42.8 ± 8 versus 29 ± 2.6, P < 0.0001 and P = 0.011 , resp.). BAL pepsin had sensitivity (61.7%, 72 %, and 70%) and specificity (55.5%, 52.9%, and 53%) to diagnose GERD associated infantile wheeze compared to abnormal MII-pH, reflux esophagitis, and lipid laden macrophage index, respectively. Conclusion . A stepwise approach for assessment of GERD in wheezy infants is advised. In those with silent reflux, a trial of antireflux therapy is warranted with no need for further pepsin assay. But when combined MII-pH is negative despite the presence of typical GERD symptoms, pepsin assay will be needed to rule out GERD related aspiration.
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Asthma is a complex inflammatory disorder of the airways characterized by airway hyper-responsiveness and variable, reversible, airflow obstruction. Bronchial thermoplasty (BT) is a new modality for treating asthma. It targets airway smooth muscles (ASM) by delivering a controlled specific amount of thermal energy (radiofrequency ablation) to the airway wall through a dedicated catheter. The use of bronchial thermoplasty has been widely discussed for its potential in the treatment of asthma, since it seems to be able to reduce the symptoms of asthma. The definitive study for BT (AIR2 trial) employed a randomized, double-blind, sham-controlled design and enrolled 288 subjects with severe persistent asthma from 30 US and international centers. The results of the AIR2 trial demonstrated clinically significant benefits of BT compared with the sham group at one year post-treatment, including an improvement in asthma-related quality of life, 32% reduction in severe exacerbations, 84% reduction in emergency department visits for asthma symptoms, and a 66% reduction in time lost from work/school/other daily activities because of asthma symptoms. Preclinical work showed that ASM is reduced after BT by at least 3 years after treatment. The recent article from the ARI2 trial study group analyses the long-term safety and effectiveness of BT in patients with severe persistent asthma and demonstrates the 5-year durability of the benefits of BT in the control of symptoms and safety. It supports the evidence that reduction in asthma attacks, ER visits, and hospitalizations for respiratory symptoms are maintained for at least 5 years. There is a pressing need to understand the underlying mechanism(s) of BT and how the delivered heat is translated into clinical benefit. This necessitates additional investigation to identify disease and patient characteristics that would enable accurate phenotyping of positive responders to avoid unnecessary procedures and risks.
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OBJETIVO: O intuito deste trabalho foi evidenciar a existência desse reflexo vagal, através de uma broncoprovocação, em pacientes portadores de refluxo gastroesofágico. MÉTODOS: Onze pacientes com endoscopia sem evidências de refluxo gastroesofágico ou hérnia hiatal (grupo controle) e dez pacientes com hérnia hiatal ou refluxo gastroesofágico foram submetidos à broncoprovocação com carbacol. RESULTADOS: O teste foi positivo em 5 dos pacientes com hérnia hiatal ou refluxo gastroesofágico (50%), e em 3 do grupo controle (27%) (p = 0,64). CONCLUSÃO: A hipótese de que as vias aéreas de pacientes com refluxo gastroesofágico sem sintomas asmatiformes anteriores possam ser mais responsivas do que as de pacientes sem refluxo gastroesofágico permanece não comprovada.
Asthma is a serious global health problem affecting all age groups, with global prevalence. Although controller medications are usually highly-effective asthma treatments, patient adherence remains poor, and under-use is associated with greater health resource use, morbidity, and mortality. Up to 70-80% of patients cannot use their inhaler correctly, and similar proportions of health professionals are unable to demonstrate its correct use. A recent paper by Foster et al. explored the effectiveness of two briefs GPs' delivered intervention in improving adherence to asthma treatment and diseases control in patients with uncontrolled moderate/severe persistent asthma, in real-community setting. The results suggested that inhaler reminders may represent an effective strategy for improving adherence in primary care compared with a behavioral intervention or usual care, although this may not be reflected in differences in levels of asthma control. Studies in larger population are needed in order to test the efficacy of available technology on asthma outcomes in all age stages.
Background: We updated the 2006 ACCP clinical practice guidelines for management of reflux-cough syndrome. Methods: Two PICO questions were addressed by systematic review: 1) can therapy for gastroesophageal reflux improve or eliminate cough in adults with chronic and persistently troublesome cough? and 2) are there minimal clinical criteria to guide practice in determining that chronic cough is likely to respond to therapy for gastroesophageal reflux? Results: We found no high quality studies pertinent to either question. From available RCTs addressing question #1, we concluded that: 1) there was a strong placebo effect for cough improvement; 2) studies including diet modification and weight loss had better cough outcomes; 3) while lifestyle modifications and weight reduction may be beneficial in suspected reflux-cough syndrome, PPIs demonstrated no benefit when used in isolation; and 4) because of potential carryover effect, crossover studies using PPIs should be avoided. For question #2, we concluded from the available observational trials that: 1) an algorithmic approach to management resolved chronic cough in 82-100% of instances; 2) cough variant asthma and upper airway cough syndrome (UACS) from rhinosinus conditions were the most commonly reported etiologies; and 3) the reported prevalence of reflux-cough syndrome varied widely. Conclusions: The panelists: 1) endorsed use of a diagnostic/therapeutic algorithm addressing common cough etiologies including symptomatic reflux, 2) advised that while lifestyle modifications and weight reduction may be beneficial in suspected reflux-cough syndrome, PPIs demonstrated no benefit when used in isolation, and 3) suggested that physiological testing be reserved for refractory patients being considered for anti-reflux surgery or in whom there is strong clinical suspicion warranting diagnostic testing.
Study objectives The prevalence of gastroesophageal reflux disease (GERD) is higher in people with asthma than in control populations. Predisposing factors for GERD development may include asthma medications such as prednisone. The objective of this study was to determine whether prednisone alters GERD parameters in people with asthma. Design Prospective, single-blinded, placebo-controlled, crossover study. Setting University medical center clinic. Participants Twenty adults with stable, moderate persistent asthma with minimal esophageal reflux symptoms (less than three times a week) who were not receiving antireflux therapy. Intervention Prednisone, 60 mg/d, for 7 days. Measurements and results Asthma, esophageal reflux symptoms, and spirometry were measured during baseline, placebo, and prednisone phases, each 7 days in duration. Dual-probe esophageal pH monitoring, esophageal and respiratory manometrics (20 subjects), and basal and stimulated gastric acid secretion (4 subjects) were measured after placebo and prednisone phases. There were significant increases in esophageal acid contact times at the distal and proximal pH probes during the prednisone phase. Total percentage of time that pH was < 4.0 at the distal probe was 2.5 ± 0.4% for placebo compared with 5.9 ± 0.9% for prednisone (p < 0.002). Total percentage of time that pH was < 4.0 at the proximal probe was 0.3 ± 0.1% for placebo and 0.8 ± 0.2% for prednisone (p < 0.0007). There were no significant changes in subject weight, spirometry, asthma or esophageal reflux symptoms, manometrics, or basal or stimulated gastric acid secretion. Conclusion Prednisone, 60 mg/d for 7 days, increased esophageal acid contact times in this small population of people with stable asthma; however, the mechanism for this finding is unclear.