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Communications to the Editor |

Chronic Cough, Sleep Apnea, and Gastroesophageal Reflux Disease Chronic Cough, Sleep Apnea, and Gastroesophageal Reflux Disease FREE TO VIEW

Joseph Herr
Author and Funding Information

Affiliations: Alamo, CA,  International University of Health and Welfare Tokyo, Japan

Correspondence to: Joseph Herr, 2109 Granite Dr, Alamo, CA 94507-1602



Chest. 2001;120(3):1036-1037. doi:10.1378/chest.120.3.1036
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In a recent issue of CHEST (April 2000),1Teramoto and Ouchi suggested that a possible pathologic link between chronic cough and sleep apnea syndrome (SAS) through nocturnal gastroesophageal reflux disease (GERD) should be carefully considered in the treatment of asthma in treating elderly patients. Respectfully, perhaps this link should be extended to sleep-related breathing disorders to obviate criticism based on the paper by Penzel et al2 and to children.

Evidence of a pathologic link, actually a mechanical link, between SAS and GERD is found in Stiennon.3The phrenoesophageal ligament (PEL) connects the diaphragm to the lower esophageal sphincter (LES). During SAS4(and upper airway resistance syndrome5), there is increased respiratory effort by the diaphragm. This extra effort is transmitted to the LES by the PEL. Only when the force transmitted to LES exceeds that threshold will the LES open and allow gastric fluids to enter the esophagus. Penzel et al2 reported that reflux does not occur with every apnea. Although that article did not consider upper airway resistance syndrome, in 68 of 69 observed reflux events, reflux was associated with “arousals.”

It is suggested that “sleep-related breathing disorders” should be considered in all cases of GERD because children6 as well as adults are subject to sleep-related breathing disorders.

Teramoto, S, Ouchi, Y (2000) A possible pathologic link between chronic cough and sleep apnea syndrome through gastroesophageal reflux disease in older people [letter]Chest117,1215-1216. [PubMed] [CrossRef]
 
Penzel, T, Becker, H, Brandenburg, U, et al Arousal in patients with gastro-oesophageal reflux and sleep apnoeaEur Respir J1999;14,1266-1270. [PubMed]
 
Stiennon, O. The longitudinal muscle in esophageal disease. 1985; WRS Press. Madison, WI:.
 
Guilleminault, C Obstructive sleep apnea: the clinical syndrome and historical perspective.Med Clin North Am1985;69,1187-1203. [PubMed]
 
Guilleminault, C, Stoohs, R, Clerk, A, et al A cause of excessive daytime sleepiness: the upper airway resistance syndrome.Chest1993;104,781-787. [PubMed]
 
Guilleminault, C, Pelayo, R Sleep-disordered breathing in children.Ann Med1998;30,350-356. [PubMed]
 

Chronic Cough, Sleep Apnea, and Gastroesophageal Reflux Disease

To the Editor:

We appreciated Herr’s comments on our article.1As suggested by Herr, the possible pathologic link between chronic cough and sleep apneas through gastroesophageal reflux disease (GERD) may be extended to children as well as adults. Although the pathologic link between sleep apneas and GERD have reported by several investigators,25 the pathologic link between chronic cough and sleep apneas has not been established. Thus, we have to consider carefully the significant association of chronic cough with sleep apneas. In particular, the fundamental mechanism of sleep-disordered breathing in children may not be the same as that of sleep apneas in adults and the elderly. We do not have enough evidence concerning the chronic cough associated with sleep apneas or GERD in younger subjects and children.

However, it is interesting to know the swallowing function in child patients and older patients with sleep apneas or GERD. Because the swallowing function is impaired in patients with sleep apnea syndrome (SAS),6 and because the swallowing function is associated with cough reflex thorough substance P, the abnormality in swallowing function in SAS may be associated with chronic cough in children and adults. Although many patients with adults SAS complain of sleep-related heartburn and regurgitation of gastric contents into the pharynx,25 the complaint was rarely heard in children with apneas. Therefore, the similarities and differences in swallowing function, cough reflex, and gastroesophageal reflux between children and adult patients with SAS may lead to further knowledge regarding the coupling mechanism between respiration and deglutition. However, as GERD manifests a spectrum of conditions, including asthma, posterior laryngitis, and chronic coughing, the pathologic link among chronic cough, SAS, and GERD is not simply determined in children.

References
Teramoto, S, Ouchi, Y A possible pathologic link between chronic cough and sleep apnea syndrome through gastroesophageal reflux disease in older people [letter]Chest2000;117,1215-1216. [PubMed] [CrossRef]
 
Samelson, CF Gastroesophageal reflux and obstructive sleep apnea.Sleep1989;12,475-476. [PubMed]
 
Diaz, S, Esteban, E, Piro, JM, et al Utility of CPAP in gastroesophageal reflux [letter]. Chest. 1990;;97 ,.:1275
 
Kerr, P, Shoenut, JP, Miller, T, et al Nasal CPAP reduces gastroesophageal reflux in obstructive sleep apnea syndrome.Chest1992;101,1539-1544. [PubMed]
 
Teramoto, S, Ohga, E, Matsui, H, et al Obstructive sleep apnea syndrome may be a significant cause of gastroesophageal reflux disease in the elderly.J Am Geriatr Soc1999;47,1273-1274. [PubMed]
 
Teramoto, S, Sudo, E, Ohga, E, et al Impaired swallowing reflex in patients with obstructive sleep apnea syndrome.Chest1999;116,17-21. [PubMed]
 

Figures

Tables

References

Teramoto, S, Ouchi, Y (2000) A possible pathologic link between chronic cough and sleep apnea syndrome through gastroesophageal reflux disease in older people [letter]Chest117,1215-1216. [PubMed] [CrossRef]
 
Penzel, T, Becker, H, Brandenburg, U, et al Arousal in patients with gastro-oesophageal reflux and sleep apnoeaEur Respir J1999;14,1266-1270. [PubMed]
 
Stiennon, O. The longitudinal muscle in esophageal disease. 1985; WRS Press. Madison, WI:.
 
Guilleminault, C Obstructive sleep apnea: the clinical syndrome and historical perspective.Med Clin North Am1985;69,1187-1203. [PubMed]
 
Guilleminault, C, Stoohs, R, Clerk, A, et al A cause of excessive daytime sleepiness: the upper airway resistance syndrome.Chest1993;104,781-787. [PubMed]
 
Guilleminault, C, Pelayo, R Sleep-disordered breathing in children.Ann Med1998;30,350-356. [PubMed]
 
Teramoto, S, Ouchi, Y A possible pathologic link between chronic cough and sleep apnea syndrome through gastroesophageal reflux disease in older people [letter]Chest2000;117,1215-1216. [PubMed] [CrossRef]
 
Samelson, CF Gastroesophageal reflux and obstructive sleep apnea.Sleep1989;12,475-476. [PubMed]
 
Diaz, S, Esteban, E, Piro, JM, et al Utility of CPAP in gastroesophageal reflux [letter]. Chest. 1990;;97 ,.:1275
 
Kerr, P, Shoenut, JP, Miller, T, et al Nasal CPAP reduces gastroesophageal reflux in obstructive sleep apnea syndrome.Chest1992;101,1539-1544. [PubMed]
 
Teramoto, S, Ohga, E, Matsui, H, et al Obstructive sleep apnea syndrome may be a significant cause of gastroesophageal reflux disease in the elderly.J Am Geriatr Soc1999;47,1273-1274. [PubMed]
 
Teramoto, S, Sudo, E, Ohga, E, et al Impaired swallowing reflex in patients with obstructive sleep apnea syndrome.Chest1999;116,17-21. [PubMed]
 
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