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Gastroesophageal reflux as an asthma trigger: acid stress Page 1
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Gastroesophageal reflux as an asthma trigger: acid stress

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CHEST,  Nov, 2004  by Susan M. Harding 

Since Sir William Osier recognized that gastroesophageal reflux (GER) is a potential asthma trigger more than a century ago, multiple investigations have shown a potential interaction between the esophagus and the lung. Despite this, there are still many unanswered questions as to how these two organs interact. To substantiate this interaction and to begin to examine causality, three criteria should be met. First, GER prevalence should be higher in asthmatic patients than in control subjects. Second, GER should alter airway reactivity and inflammatory markers. And third, GER therapy should improve asthma outcomes. So where do we stand concerning acid stress? (1,2)

GER symptom prevalence is higher in asthmatic patients compared to control subjects. Field et al (3) examined 109 asthmatic patients and 135 control subjects in two control groups, finding that heartburn was present in 77% of asthmatic patients compared to 48% of control subjects. Furthermore, 41% of asthmatic patients noted reflux-associated respiratory symptoms, and 28% of them utilized inhalers while experiencing GER symptoms. So, not only do asthmatic patients have a higher prevalence of GER symptoms than control subjects, they also associate GER symptoms with asthma symptoms. Our laboratory noted (4) that of 151 respiratory symptoms reported in 199 asthmatic patients during 24-h esophageal pH testing, 79% of respiratory symptoms were temporally related to esophageal acid.

In this issue of CHEST (see page 1490), Kiljander and Laitinen provide further insight into GER prevalence in asthmatic patients. In randomly selected asthmatic patients undergoing 24-h esophageal pH testing, 36% of asthmatic patients had abnormal esophageal acid contact times and 25% of asthmatic patients with abnormal esophageal acid contact times were flee of typical GER symptoms including heartburn. Furthermore, heartburn was not always associated with abnormal esophageal acid contact times. So, should esophageal pH testing be performed in asthmatic patients to identify GER in clinical practice? My answer is, no! Although esophageal pH testing is considered to be the "gold standard" for identifying GER, it has a sensitivity and specificity of approximately 90% and is not a perfect test. (5) Day-to-day esophageal acid contact times vary with activity and diet. Recently, a wireless esophageal pH system has been developed that allows monitoring up to 48 h without the use of an intranasal catheter, so that patients are less likely to alter their daily activities and/or diet. (6) Also, a non-acid refluxate, undetectable with pH monitoring, may have an impact. Currently, minimal data exist on nonacid reflux and its effect on the lung. Nonacid GER can be measured by esophageal impedance monitoring, which was not performed in this study. (7) Despite these issues, Drs. Kiljander and Laitinen verify for us again that the prevalence of GER is indeed high in asthmatic patients.

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