Medical and Surgical Treatment of Nonallergic Asthma Associated with Gastroesophageal Reflux

doi:10.1378/chest.99.6.1330

Chest

Volume 99, Issue 6, June 1991, Pages 1330-1335

https://doi.org/10.1378/chest.99.6.1330 Get rights and content

Patients presenting to a chest clinic because of adult-onset wheezing with no history of allergy had a 90 percent prevalence of gastroesophageal reflux, even though reflux symptoms were mild or absent. Ninety patients were randomly assigned to receive cimetidine or an identical placebo or to undergo antireflux surgery. During a six-month period, all groups improved clinically; the cimetidine and surgical groups improved more than the placebo group. The intake of pulmonary medication decreased significantly in both cimetidine and surgical groups. Pulmonary function test results improved in the cimetidine- and surgically treated patients; improvement was not statistically significant. At long-term follow-up, the surgical group maintained clinical improvement and decreased pulmonary medication intake, whereas the placebo group worsened. We conclude that gastroesophageal reflux can play a significant role in some patients with nonallergic pulmonary disease and that its treatment can improve pulmonary symptoms and objective measurements of pulmonary function.

Section snippets

Patient Selection

From March 1976 through January 1978, all patients presenting to the Hospital del Torax, Santiago, Chile, with symptoms of wheezing and/or shortness of breath were screened for this study. Patients with a family history of asthma, symptoms of chronic bronchitis (a productive cough for more than three months per year), or a correlation between acute attacks and inhaled allergens were excluded from the study. Also excluded were patients under 18 years of age, those with positive immediate skin

Results

After randomization, four of the patients assigned to the surgical arm refused to undergo surgery. One patient assigned to cimetidine also refused to enter the study. During the time of the study, two patients in the placebo group and two more patients in the cimetidine group withdrew. This left a final study population of 28 who received placebo, 27 who received cimetidine, and 26 who underwent surgery. Figure 1 shows the mean line score values obtained during the monthly evaluation of

Discussion

Although the association of reflux and pulmonary symptoms has been recognized for many years, there is still controversy about whether reflux causes pulmonary disease, is caused by pulmonary disease, or both.4, 5, 6, 7, 8 Currently, although a direct relationship between bursts of reflux and attacks of wheezing is not often demonstrated,9, 10, 11 it seems more likely that reflux damage to the esophagus can lead to bronchial hyperreactivity.12, 13, 14, 15, 16 Lung disease can cause reflux either

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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.
Anti-reflux surgery for controlling respiratory symptoms of gastro-esophageal reflux disease: A systematic review and meta-analysis
2021, Asian Journal of Surgery
Gastro-esophageal reflux disease (GERD) patients have a higher prevalence of airway symptoms, such as chronic cough, wheezing, and hoarseness. The therapeutic management of patients with these symptoms is controversial. Therefore, this study aims to perform a systematic review and meta-analysis evaluating the efficacy of anti-reflux surgery for controlling respiratory symptoms related to GERD. A systematic review and meta-analysis was performed. Extraction of the data concerning proportions of participants who were not free of respiratory symptoms related to GERD (cough, wheezing, hoarseness) or not substantially improved at follow-ups (failure to cure) was performed. Of the 3,424 initially screened articles, 68 studies were included for systematic review and 61 were included for meta-analysis, with a cumulative sample size of 3,869 patients. Of all the included patients, after anti-reflux surgery, the general symptoms improvement was 80% (95% CI 75.2–84%). The numbers needed to harm (NNH) and the numbers needed to treat (NNT) were 15.21 and 1.23, respectively. Of the included patients, 83.4% (95% CI 78.3–87.5%) patients reported improvement in cough symptoms after surgery. For the wheezing symptom, 71.5% (95% CI 62.9–78.8%) reported improvement after surgery. Moreover, surgery presented better results in improving respiratory symptoms than medical therapy (risk difference: −0.46; 95% CI -0.77, −0.16). Physicians should strongly consider surgical anti-reflux procedures for controlling respiratory symptoms in GERD patients after proper patient selection. Anti-reflux surgery has shown high efficacy in improving respiratory symptoms related to GERD, even when compared to medical therapy.
Genotype tailored treatment of mild symptomatic acid reflux in children with uncontrolled asthma (GenARA): Rationale and methods
2019, Contemporary Clinical Trials
Asthma causes enormous suffering and cost for children in the US and around the world [[1], [2], [3]]. Co-morbid gastroesophageal reflux disease (GERD) makes asthma management more difficult due to increased symptoms. Proton pump inhibitor (PPI) drugs are effective at improving to GERD symptoms, however they have demonstrated only modest and variable effects on asthma control in the setting of co-morbid GERD. Importantly, PPI metabolism and efficacy depend on CYP2C19 genotype. The Genotype Tailored Treatment of Symptomatic Acid Reflux in Children with Uncontrolled Asthma (GenARA) study is a randomized, double-blind, placebo-controlled trial to determine if genotype-tailored PPI dosing improves asthma symptoms among children with inadequately controlled asthma and GERD symptoms. This study has an innovative design to both assess the efficacy of genotype-tailored PPI dosing and perform pharmacokinetic modeling of the oral PPI Lansoprazole. Children ages 6–17 years old with clinician-diagnosed asthma and mild GERD symptoms will submit a saliva sample for CYP2C19 genotyping. Participants will undergo a two-step randomization to: (1) genotype-tailored versus conventional dosing of open-label oral lansoprazole for pharmacokinetic modeling, and (2) genotype-tailored lansoprazole daily versus placebo for 24 weeks to determine the effect of genotype-tailored PPI dosing on asthma control. Measures of asthma control, spirometry, and nasal washes during acute illnesses will be collected at 8-week intervals throughout the study. GenARA will better define the effects of CYP2C19 genotype on the dose response of lansoprazole in children and adolescents and assess if a novel dosing regimen improves GERD and asthma control.
Nonallergic Triggers and Comorbidities in Asthma Exacerbations and Disease Severity
2019, Clinics in Chest Medicine
Extraesophageal Symptoms and Diseases Attributed to GERD: Where is the Pendulum Swinging Now?
2018, Clinical Gastroenterology and Hepatology
The purpose of this review is to outline the recent developments in the field of extraesophageal reflux disease and provide clinically relevant recommendations.
The recommendations outlined in this review are based on expert opinion and on relevant publications from PubMed and EMbase. The Clinical Practice Updates Committee of the American Gastroenterological Association proposes the following recommendations:
Best Practice Advice 1: The role of a gastroenterologist in patients referred for evaluation of suspected extra esophageal symptom is to assess for gastroesophageal etiologies that could contribute to the presenting symptoms.
Best Practice Advice 2: Non-GI evaluations by ENT, pulmonary and/or allergy are essential and often should be performed initially in most patients as the cause of the extraesophageal symptom is commonly multifactorial or not esophageal in origin.
Best Practice Advice 3: Empiric therapy with aggressive acid suppression for 6-8 weeks with special focus on response of the extraesophageal symptoms can help in assessing association between reflux and extraesophageal symptoms.
Best Practice Advice 4: No single testing methodology exists to definitively identify reflux as the etiology for the suspected extra esophageal symptoms.
Best Practice Advice 5: Constellation of patient presentation, diagnostic test results and response to therapy should be employed in the determination of reflux as a possible etiology in extra esophageal symptoms.
Best Practice Advice 6: Testing may need to be off or on proton pump inhibitor (PPI) therapy depending on patients’ presenting demographics and symptoms in assessing the likelihood of abnormal gastroesophageal reflux.
A. On therapy testing may be considered in those with high probability of baseline reflux (those with previous esophagitis, Barrett’s esophagus or abnormal pH).
B. Off therapy testing may be considered in those with low probability of baseline reflux with the goal of identifying moderate to severe reflux at baseline.
Best Practice Advice 7: Lack of response to aggressive acid suppressive therapy combined with normal pH testing off therapy or impedance-pH testing on therapy significantly reduces the likelihood that reflux is a contributing etiology in presenting extraesophageal symptoms.
Best Practice Advice 8: Surgical fundoplication is discouraged in those with extra esophageal reflux symptoms unresponsive to aggressive PPI therapy.
Best Practice Advice 9: Fundoplication should only be considered in those with a mechanical defect (e.g., hiatal hernia), moderate to severe reflux at baseline off PPI therapy who have continued reflux despite PPI therapy and have failed more conservative non-GI treatments.
Surgical management of gastroesophageal reflux disease (GERD) in children: A systematic review
2017, Journal of Pediatric Surgery
The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to derive recommendations from the medical literature regarding the surgical treatment of pediatric gastroesophageal reflux disease (GERD).
Five questions were addressed by searching the MEDLINE, Cochrane, Embase, Central, and National Guideline Clearinghouse databases using relevant search terms. Consensus recommendations were derived for each question based on the best available evidence.
There was insufficient evidence to formulate recommendations for all questions. Fundoplication does not affect the rate of hospitalization for aspiration pneumonia, apnea, or reflux-related symptoms. Fundoplication is effective in reducing all parameters of esophageal acid exposure without altering esophageal motility. Laparoscopic fundoplication may be comparable to open fundoplication with regard to short-term clinical outcomes. Partial fundoplication and complete fundoplication are comparable in effectiveness for subjective control of GERD. Fundoplication may benefit GERD patients with asthma, but may not improve outcomes in patients with neurologic impairment or esophageal atresia. Overall GERD recurrence rates are likely below 20%.
High-quality evidence is lacking regarding the surgical management of GERD in the pediatric population. Definitive conclusions regarding the effectiveness of fundoplication are limited by patient heterogeneity and lack of a standardized outcomes reporting framework.
Systematic review of level 1–4 studies.
Level 1–4 (mainly level 3–4)

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The authors acknowledge financial and technical support from Smith Kline & French Laboratories.

Manuscript received June 4; revision accepted October 1.

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Chest

Clinical InvestigationsClinical TrialMedical and Surgical Treatment of Nonallergic Asthma Associated with Gastroesophageal Reflux

Section snippets

Patient Selection

Results

Discussion

Gastroenterology

Chest

J Pediatr

Chest

J Allergy Clin Immunol

J Pediatr

J Pediatr

Ann Thorac Surg

Chest

Technical considerations in posterior gastropexy

Surg Gynecol Obstet

Spirometric standards for healthy nonsmoking adults

Am Rev Respir Dis

Gastroesophageal reflux and chronic respiratory disease

Am Rev Respir Dis

Mechanisms for the association of gastroesophageal reflux and bronchospasm

Am Rev Respir Dis

Respiratory complications of gastroesophageal reflux

Arch Intern Med

Gastroesophageal reflux and asthma

Postgrad Med

Gastro-oesophageal reflux and triggering of bronchial asthma: a negative report

Eur J Respir Dis

Gastro-oesophageal reflux and nocturnal asthma

Eur Respir J

Clinical Investigations
Clinical Trial
Medical and Surgical Treatment of Nonallergic Asthma Associated with Gastroesophageal Reflux