Reflux aspiration in children with neurodisability—a significant problem, but can we measure it?

Trinick, Ruth; Johnston, Nikki; Dalzell, A M; McNamara, Paul

doi:10.1016/j.jpedsurg.2011.11.019

Cited by 29 publications

(21 citation statements)

References 79 publications

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“…There are technical challenges in accurately measuring pepsin and bile acids in airway samples [47]. To date, three studies have investigated biochemical markers of refluxate in samples from patients with chronic cough and compared them to healthy controls [21,48,49].…”

Section: Jaclyn a Smith Against The Motionmentioning

confidence: 99%

A Causal Relationship Between Cough and Gastroesophageal Reflux Disease (GERD) has been Established: A Pro/Con Debate

Kahrilas

Smith

Dicpinigaitis

2013

Lung

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Along with upper airway cough syndrome (formerly, postnasal drip syndrome) and eosinophilic airway inflammation (asthma, non-asthmatic eosinophilic bronchitis), gastroesophageal reflux disease (GERD) is generally considered among the most common etiologies of chronic cough. Indeed, cough management guidelines published by numerous respiratory societies worldwide recommend evaluation and treatment of GERD as an integral component of the diagnostic/therapeutic algorithm for the management of chronic cough. However, a significant number of patients with chronic cough presumed due to GERD do not report improvement despite aggressive acid-suppressive therapy. Some of these refractory cases may be due to the recently appreciated entity of non-acid or weakly acidic reflux. Further contributing to the controversy are recent studies demonstrating that patients with chronic cough do not have excessive reflux events relative to healthy volunteers. Although a temporal relationship between cough and reflux events has been suggested by studies utilizing impedance-pH monitoring of reflux events and objective cough recording, consensus is lacking in terms of whether this temporal relationship proves a causal link between reflux and cough. The 4th American Cough Conference, held in New York in June, 2013, provided an ideal forum for the debate of this issue between two internationally recognized experts in the field of reflux and chronic cough.

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Section: Jaclyn a Smith Against The Motionmentioning

confidence: 99%

A Causal Relationship Between Cough and Gastroesophageal Reflux Disease (GERD) has been Established: A Pro/Con Debate

Kahrilas

Smith

Dicpinigaitis

2013

Lung

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“…1,2 Distinguishing between these two types of aspiration is important in guiding treatment recommendations. However, the diagnosis of aspiration associated extra-esophageal reflux disease (AERD) continues to be difficult, as well as defining its role in patients with chronic pulmonary symptoms.…”

Section: Introductionmentioning

confidence: 99%

“…5 Stovold et al used pepsin as a biomarker of gastric aspiration and reported elevated levels of pepsin in BAL of lung allografts, the highest levels found in patients with acute rejection. 1 Fisichella et al also used pepsin as a biomarker for aspiration and reported that laparoscopic anti-reflux surgery is an effective means to present aspiration as defined by the presence of pepsin in the BAL. 12 While the literature continues to have more studies demonstrate the effective use of pepsin as a biomarker of aspiration, this technique has not been fully translated to the clinical setting and often pathology labs are not fully equipped to perform this testing.…”

Section: Introductionmentioning

confidence: 99%

Prevalence of Pediatric Aspiration-Associated Extraesophageal Reflux Disease

Kelly

Parakininkas

Werlin

et al. 2013

JAMA Otolaryngol Head Neck Surg

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Importance The role of aspiration associated extra-esophageal reflux disease (AERD) in patients with chronic respiratory symptoms is not well defined. Identifying the frequency of AERD in these patients may provide us with further guidance in treatment and management of these patients. Objective The purpose of this study is to determine the prevalence of AERD in patients with chronic respiratory symptoms compared to controls and, secondly, to assess the utility of pepsin as a new marker for AERD. Design Case-control study performed from 2008-2012. Setting Tertiary referral center. Participants Patients (4.5 months-24 years) with chronic pulmonary disease, both with and without tracheostomy, were compared to controls with no prior history of pulmonary disease undergoing elective surgery. Interventions: Lavage fluid specimen was obtained from each participant. Main Outcome Measures Western blot analysis for pepsin and oil red O staining for lipid-laden macrophages (LLM) was performed on lavage fluid specimens to assess for AERD. Results Seventy-six total patients were enrolled: 65 study patients, of which, 34 patients underwent bronchoscopy, 31 patients had tracheostomy for sampling, and 11 controls. Pepsin positive lavage fluid specimens were identified in 25 (74%) bronchoscopy patients and 22 (71%) tracheostomy patients. All control specimens were negative for pepsin. Presence of LLM was identified in 91% of bronchoscopy group, 52% of tracheostomy patients, and 64% of controls, with a similar distribution of the quantity of LLM in each lavage fluid specimen amongst the groups. Conclusions and Relevance Patients with chronic pulmonary disease have a high prevalence of AERD, which may have important treatment implications. The presence of pepsin was a better predictor of AERD in patients with respiratory symptoms compared to controls than LLM. Detection of pepsin in BAL can serve as a biomarker for AERD and is potentially superior to the current method of measuring LLM. While there is a significant association among patients with AERD and those patients with chronic respiratory symptoms, this study does not verify causation. Additional study investigating the mechanism of pepsin on the respiratory epithelium may provide further understanding of the pathophysiology of this association and provide additional management options for these patients.

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“…It should also be kept in mind that pepsin measurement is also not validated as a marker of aspiration because of some significant methodological issues, like cross reaction of the immunologic assay with pepsinogen. 31 For aspiration to occur, the refluxate should traverse the length of the esophagus and reach the larynx and pharynx. Although pharyngeal reflux is not prominent in chronic cough patients, our findings indicate that it may occur more often in these patients.…”

Section: Discussionmentioning

confidence: 99%

The Role of Microaspiration in the Pathogenesis of Gastroesophageal Reflux-related Chronic Cough

Özdemir

Erdinç

Vardar

et al. 2017

J Neurogastroenterol Motil

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Background/AimsGastroesophageal reflux disease (GERD) is one of the main causes of chronic cough. We evaluated the role of microaspiration in the pathogenesis of reflux-related cough by determining the amount of lipid-laden macrophages (LLMs) in bronchoalveolar lavage (BAL) specimens. MethodsA total of 161 cases of chronic cough were evaluated, and 36 patients (average age 48.2 years) were recruited for this single center prospective study. Patients with a history of smoking, angiotensin converting enzyme inhibitor usage, any abnormality on pulmonary function tests, abnormal chest X-rays, occupational or environmental exposures, or upper airway cough syndrome were excluded. GERD was evaluated by 24-hour esophageal impedance-pH monitoring. BAL specimens for LLM determination were obtained from 34 patients by flexible bronchoscopy. ResultsPatients with pathological intra-esophageal reflux according to multichannel intraluminal impedance and pH monitoring had higher LLM positivity in BAL specimens than patients without pathological reflux (8/14 in reflux positive group vs 1/22 in reflux negative group; P = 0.004). The BAL cell distribution was not different between the 2 groups (P = 0.574 for macrophages, P = 0.348 for lymphocytes, P = 0.873 for neutrophils and P = 0.450 for eosinophils). ConclusionsOur results confirm the role of the microaspiration of refluxate in the pathogenetic mechanism of chronic cough. While bronchoscopy is indicated in patients with chronic cough, in addition to the routine airway evaluation, BAL and LLM detection should be performed. LLM can be used to diagnose aspiration in reflux-related chronic cough. Future studies are needed to evaluate the response to antireflux medications or surgery in patients with LLM positivity.

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Reflux aspiration in children with neurodisability—a significant problem, but can we measure it?

Cited by 29 publications

References 79 publications

A Causal Relationship Between Cough and Gastroesophageal Reflux Disease (GERD) has been Established: A Pro/Con Debate

A Causal Relationship Between Cough and Gastroesophageal Reflux Disease (GERD) has been Established: A Pro/Con Debate

Prevalence of Pediatric Aspiration-Associated Extraesophageal Reflux Disease

The Role of Microaspiration in the Pathogenesis of Gastroesophageal Reflux-related Chronic Cough

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