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Communications to the Editor |

Gastroesophageal Reflux Common in Patients With Sleep Apnea Rather Than Snorers Without Sleep Apnea FREE TO VIEW

Shinji Teramoto; Hiroshi Yamamoto; Yasuyoshi Ouchi
Author and Funding Information

Affiliations: University of Tokyo Hospital Tokyo, Japan,  Vienna, Austria
 ,  London, UK
 ,  Otto-Wagner-Hospital Middlesex Hospital

Correspondence to: Shinji Teramoto, MD, Department of Geriatric Medicine, The University of Tokyo Hospital, 7-3-1 Hongo Bunkyo-ku, Tokyo 113-8655, Japan; e-mail: shinjit-tky@umin.ac.jp



Chest. 2003;124(2):767-768. doi:10.1378/chest.124.2.767
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Published online

To the Editor:

In a recent issue of CHEST (June 2002) Valipour and coworkers1 reported that symptomatic gastroesophageal reflux (GER) is common in subjects with a breathing sleep disorder, but that there was no difference between those with obstructive sleep apnea (OSA) and subjects who snore.

We agree with the authors that GER is common in subjects with a breathing sleep disorder. However, we do not agree with the second conclusion that the symptoms of GER are not different between a patient with OSA and a snorer without OSA.

First, because a pathologic link between GER and OSA has been suggested by us and others,28 the interrelationship between GER and OSA is not totally due to snoring, but primarily to sleep apneas.

Second, the authors assessed the severity of GER by the degree of GER-related symptoms alone. However, outcomes after the treatment of GERD are usually measured by symptoms, pH monitoring, and health-related quality of life.9 Thus, the current study did not complete the assessment of the severity of GER in both OSA patients and snorers. Furthermore, conventional GER is effectively treated by, but is not cured by, continuous positive airway pressure (CPAP). This suggests that the disease state of GER in OSA patients is not equal to that of GER alone.

Third, we have already reported10 that GER symptoms in OSAS patients were reversed by nasal CPAP treatment. Kerr and coworkers11 also reported that treatment with nasal CPAP at night can correct sleep apnea-related GER in patients with OSA. These results indicate that OSAS is more associated with the symptoms of GER than with snoring alone.

Fourth, Senior and coworkers12 have reported that the treatment of GER with omeprazole improves the apnea index and respiratory disturbance index in patients with obstructive sleep apnea.

Fifth, when snoring patients have a spectrum of symptoms, featuring upper airway resistance syndrome (UARS), the GER symptoms may be similar between snoring patients with UARS and patients with OSA.

Considering the points listed above, GER seems to associate with sleep apnea rather than snoring alone.

This study was supported by a grant from the Japan Arteriosclerosis Fund in Japan.

References

Valipour, A, Makker, HK, Hardy, R, et al (2002) Symptomatic gastroesophageal reflux in subjects with a breathing sleep disorder.Chest121,1748-1753. [PubMed] [CrossRef]
 
Teramoto, S, Kume, H, Ouchi, Y Nocturnal gastroesophageal reflux: symptom of obstructive sleep apnea syndrome in association with impaired swallowing.Chest2002;122,2266-2267. [PubMed]
 
Teramoto, S, Ishii, T, Matsuse, T Chronic cough, sleep apnea, and gastroesophageal reflux disease.Chest2001;120,1036-1037. [PubMed]
 
Teramoto, S, Ouchi, Y A possible pathologic link between chronic cough and sleep apnea syndrome through gastroesophageal reflux disease in older people.Chest2000;117,1215-1216. [PubMed]
 
Teramoto, S, Ohga, E, Matsui, H, et al Obstructive sleep apnea syndrome may be a significant cause of gastroesophageal reflux disease in older people.J Am Geriatr Soc1999;47,1273-1274. [PubMed]
 
Ing, AJ, Ngu, MC, Breslin, AB Obstructive sleep apnea and gastroesophageal reflux.Am J Med2000;108(suppl),120S-125S
 
Palombini, BC, Villanova, CAC, Araujo, E, et al A pathologic triad in chronic cough: asthma, postnasal drip syndrome, and gastroesophageal reflux disease.Chest1999;116,279-284. [PubMed]
 
Wolf, SM, Furman, Y Sleep apnea and gastroesophageal reflux disease.Ann Intern Med2002;136,490-491. [PubMed]
 
Mathias, SD, Colwell, HH, Miller, DP, et al Health-related quality-of-life and quality-days incrementally gained in symptomatic nonerosive GERD patients treated with lansoprazole or ranitidine.Dig Dis Sci2001;46,2416-2423. [PubMed]
 
Okada, S, Ouchi, Y, Teramoto, S Nasal continuous positive airway pressure and weight loss improve swallowing reflex in patients with obstructive sleep apnea syndrome.Respiration2000;67,464-466. [PubMed]
 
Kerr, P, Shoenut, JP, Miller, T, et al Nasal CPAP reduces gastroesophageal reflux in obstructive sleep apnea syndrome.Chest1992;101,1539-1544. [PubMed]
 
Senior, BA, Khan, M, Schwimmer, C, et al Gastroesophageal reflux and obstructive sleep apnea.Laryngoscope2001;111,2144-2146. [PubMed]
 

To the Editor:

We acknowledge the comments by Teramoto et al regarding our recent article in CHEST (June 2002).1 We agree that there might be an interrelationship between gastroesophageal reflux (GER) and sleep-disordered breathing. Lifestyle features associated with sleep apnea, including obesity and alcohol ingestion, are also risk factors for GER, and apnea-induced transdiaphragmatic pressure swings might promote the reflux of gastric contents. However, it remains less clear whether hypoxia is related to GER episodes. While some have suggested that hypoxia induces a protective mechanism against reflux by increasing the lower esophageal sphincter tone,2 others observed increased GER episodes during hypoxia due to an impaired swallowing function.3 In our report, we did not observe a relationship between nocturnal oxygenation and the occurrence of symptomatic GER in patients with sleep apnea.

In their correspondence, Teramoto and colleagues suggested that GER is less common in patients who snore than in those who have obstructive sleep apnea. While this might be true for asymptomatic “silent” reflux episodes, it seems not be true for symptomatic GER, as our data show.1 However, this also might be due to the approach used in the diagnosis of GER. In our report, a validated questionnaire developed by the Mayo Clinic and designed to identify symptomatic GER, was used.4 We decided to use this diagnostic tool based on the following reasons: (1) pH monitoring is an invasive procedure that is reserved for atypical symptoms of GER56 ; (2) in daily practice, the diagnosis of GER is based on the recognition of symptoms, and a response of reflux symptoms to empirical treatment is considered diagnostic, with a sensitivity for and specificity comparable with pH monitoring7 ; and (3) pH recordings have some considerable limitations with poor reproducibility data.8

However, from our findings we cannot rule out that asymptomatic GER was more prevalent in patients with sleep apnea compared to patients who only snore. Only 5 of 15 patients with sleep apnea and GER, which were documented by abnormal findings of pH monitoring studies, had symptomatic GER in the study by Penzel and colleagues.9 It also might be considered that patients with a respiratory condition have a different perception of sensing reflux events compared to healthy subjects.10 If this is the case, do patients with sleep apnea and asymptomatic GER require separate GER treatment? Furthermore, if therapy with continuous positive airway pressure improves nocturnal GER in the absence of sleep apnea,11 is GER then necessarily related to apneas? Since these questions are as yet unanswered, new studies are necessary in order to investigate the link between sleep-disordered breathing and GER more thoroughly.

References
Valipour, A, Makker, HK, Hardy, R, et al Symptomatic gastroesophageal reflux in subjects with a breathing sleep disorder.Chest2002;121,1748-1753. [PubMed] [CrossRef]
 
Kiatchoosakun, P, Dreshaj, IA, Abu-Shaweesh, JM, et al Effects of hypoxia on respiratory neural output and lower esophageal sphincter pressure in piglets.Pediatr Res2002;52,50-55. [PubMed]
 
Teramoto, S, Sudo, E, Ohga, E, et al Impaired swallowing reflex in patients with obstructive sleep apnea syndrome.Chest1999;116,17-21. [PubMed]
 
Locke, GR, Talley, NJ, Weaver, AL, et al A new questionnaire for gastroesophageal reflux disease.Mayo Clin Proc1994;69,539-547. [PubMed]
 
de Castecker, JS, Blackwell, JN, Brown, J, et al The oesophagus as a cause of recurrent chest pain: which patients should be investigated and which tests should be used.Lancet1985;126,1143-1146
 
Brzana, RJ, Koch, KL Gastroesophageal reflux disease presenting with intractable nausea.Ann Intern Med1997;126,704-707. [PubMed]
 
Schenk, BE, Kuipers, EJ, Klinkenberg-Knol, EC, et al Omeprazole as a diagnostic tool in gastro-oesophageal reflux disease.Am J Gastroenterol1997;92,1997-2000. [PubMed]
 
Mela, GS, Savarino, V, Vigneri, S, et al Limitations of continuous 24-h intragastric pH monitoring in the diagnosis of duodenogastric reflux.Am J Gastroenterol1995;90,933-937. [PubMed]
 
Penzel, T, Becker, HF, Brandenburg, U, et al Arousal in patients with gastro-esophageal reflux and sleep apnoea.Eur Respir J1999;14,12166-1270
 
Mokhlesi, B, Morris, AL, Huang, CF, et al Increased gastroesophageal reflux symptoms in patients with COPD.Chest2001;119,1043-1048. [PubMed]
 
Kerr, P, Shoenut, JP, Steens, RD, et al Nasal continuous positive airway pressure: a new treatment for nocturnal gastroesophageal reflux?J Clin Gastroenterol1993;17,276-280. [PubMed]
 

Figures

Tables

References

Valipour, A, Makker, HK, Hardy, R, et al (2002) Symptomatic gastroesophageal reflux in subjects with a breathing sleep disorder.Chest121,1748-1753. [PubMed] [CrossRef]
 
Teramoto, S, Kume, H, Ouchi, Y Nocturnal gastroesophageal reflux: symptom of obstructive sleep apnea syndrome in association with impaired swallowing.Chest2002;122,2266-2267. [PubMed]
 
Teramoto, S, Ishii, T, Matsuse, T Chronic cough, sleep apnea, and gastroesophageal reflux disease.Chest2001;120,1036-1037. [PubMed]
 
Teramoto, S, Ouchi, Y A possible pathologic link between chronic cough and sleep apnea syndrome through gastroesophageal reflux disease in older people.Chest2000;117,1215-1216. [PubMed]
 
Teramoto, S, Ohga, E, Matsui, H, et al Obstructive sleep apnea syndrome may be a significant cause of gastroesophageal reflux disease in older people.J Am Geriatr Soc1999;47,1273-1274. [PubMed]
 
Ing, AJ, Ngu, MC, Breslin, AB Obstructive sleep apnea and gastroesophageal reflux.Am J Med2000;108(suppl),120S-125S
 
Palombini, BC, Villanova, CAC, Araujo, E, et al A pathologic triad in chronic cough: asthma, postnasal drip syndrome, and gastroesophageal reflux disease.Chest1999;116,279-284. [PubMed]
 
Wolf, SM, Furman, Y Sleep apnea and gastroesophageal reflux disease.Ann Intern Med2002;136,490-491. [PubMed]
 
Mathias, SD, Colwell, HH, Miller, DP, et al Health-related quality-of-life and quality-days incrementally gained in symptomatic nonerosive GERD patients treated with lansoprazole or ranitidine.Dig Dis Sci2001;46,2416-2423. [PubMed]
 
Okada, S, Ouchi, Y, Teramoto, S Nasal continuous positive airway pressure and weight loss improve swallowing reflex in patients with obstructive sleep apnea syndrome.Respiration2000;67,464-466. [PubMed]
 
Kerr, P, Shoenut, JP, Miller, T, et al Nasal CPAP reduces gastroesophageal reflux in obstructive sleep apnea syndrome.Chest1992;101,1539-1544. [PubMed]
 
Senior, BA, Khan, M, Schwimmer, C, et al Gastroesophageal reflux and obstructive sleep apnea.Laryngoscope2001;111,2144-2146. [PubMed]
 
Valipour, A, Makker, HK, Hardy, R, et al Symptomatic gastroesophageal reflux in subjects with a breathing sleep disorder.Chest2002;121,1748-1753. [PubMed] [CrossRef]
 
Kiatchoosakun, P, Dreshaj, IA, Abu-Shaweesh, JM, et al Effects of hypoxia on respiratory neural output and lower esophageal sphincter pressure in piglets.Pediatr Res2002;52,50-55. [PubMed]
 
Teramoto, S, Sudo, E, Ohga, E, et al Impaired swallowing reflex in patients with obstructive sleep apnea syndrome.Chest1999;116,17-21. [PubMed]
 
Locke, GR, Talley, NJ, Weaver, AL, et al A new questionnaire for gastroesophageal reflux disease.Mayo Clin Proc1994;69,539-547. [PubMed]
 
de Castecker, JS, Blackwell, JN, Brown, J, et al The oesophagus as a cause of recurrent chest pain: which patients should be investigated and which tests should be used.Lancet1985;126,1143-1146
 
Brzana, RJ, Koch, KL Gastroesophageal reflux disease presenting with intractable nausea.Ann Intern Med1997;126,704-707. [PubMed]
 
Schenk, BE, Kuipers, EJ, Klinkenberg-Knol, EC, et al Omeprazole as a diagnostic tool in gastro-oesophageal reflux disease.Am J Gastroenterol1997;92,1997-2000. [PubMed]
 
Mela, GS, Savarino, V, Vigneri, S, et al Limitations of continuous 24-h intragastric pH monitoring in the diagnosis of duodenogastric reflux.Am J Gastroenterol1995;90,933-937. [PubMed]
 
Penzel, T, Becker, HF, Brandenburg, U, et al Arousal in patients with gastro-esophageal reflux and sleep apnoea.Eur Respir J1999;14,12166-1270
 
Mokhlesi, B, Morris, AL, Huang, CF, et al Increased gastroesophageal reflux symptoms in patients with COPD.Chest2001;119,1043-1048. [PubMed]
 
Kerr, P, Shoenut, JP, Steens, RD, et al Nasal continuous positive airway pressure: a new treatment for nocturnal gastroesophageal reflux?J Clin Gastroenterol1993;17,276-280. [PubMed]
 
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