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Original Research: Critical Care |

Acid and Weakly Acidic Gastroesophageal Reflux and Pepsin Isoforms (A and C) in Tracheal Secretions of Critically Ill ChildrenGastroesophageal Reflux and Pepsin in ICU Children

Cristiane Hallal, PhD; Veridiana S. Chaves, MD; Gilberto C. Borges, MD; Isabel C. Werlang, PhD; Fernanda U. Fontella, PhD; Ursula Matte, PhD; Marcelo Z. Goldani, PhD; Paulo R. Carvalho, PhD; Eliana A. Trotta, PhD; Jefferson P. Piva, PhD; Sergio G. S. Barros, PhD; Helena A. S. Goldani, MD, PhD
Author and Funding Information

From the Post-Graduate Program Sciences in Gastroenterology and Hepatology (Drs Hallal, Barros, and H. A. S. Goldani); Pediatric Gastroenterology Unit (Drs Hallal, Borges, and H. A. S. Goldani), Pediatric Intensive Care Unit (Drs Chaves, Carvalho, Trotta, and Piva) and Laboratory of Translational Pediatrics (Drs Werlang, Fontella, M. Z. Goldani, and H. A. S. Goldani), Hospital de Clínicas de Porto Alegre; and Post-Graduate Program in Child and Adolescent Health (Drs Matte, M. Z. Goldani, Carvalho, and H. A. S. Goldani), Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil.

CORRESPONDENCE TO: Cristiane Hallal, PhD, Rua Ramiro Barcelos 2350, CEP 90035-903, Porto Alegre-RS, Brazil; e-mail: cris.hallal@yahoo.com


FOR EDITORIAL COMMENT SEE PAGE 300

FUNDING/SUPPORT: This study was conducted using academic funds from the Ministry of Education (Capes), and Fundo de Incentivo à Pesquisa e Eventos do Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(2):333-339. doi:10.1378/chest.14-1967
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BACKGROUND:  Gastroesophageal reflux (GER) and pulmonary aspiration are frequent in patients in the ICU. The presence of pepsin in airways seems to be the link between them. However, pepsin isoforms A (gastric specific) and C (pneumocyte potentially derived) need to be distinguished. This study aimed to evaluate GER patterns and to determine the presence of pepsin A and C in tracheal secretions of critically ill children receiving mechanical ventilation.

METHODS:  All patients underwent combined multichannel intraluminal impedance-pH (MII-pH) monitoring. Tracheal secretion samples were collected to determine the presence of pepsin. Pepsin A and C were evaluated by Western blot. MII-pH parameters analyzed were number of total GER episodes (NGER); acid, weakly acidic, and weakly alkaline GER episodes; and proximal and distal GER episodes.

RESULTS:  Thirty-four patients (median age, 4 months; range, 1-174 months) were included. MII-pH monitoring detected 2,172 GER episodes (77.0% were weakly acidic; 71.7% were proximal). The median NGER episodes per patient was 59.5 (25th-75th percentile, 20.3-85.3). Weakly acidic GER episodes per patient were significantly more frequent than acid GER episodes per patient (median [25th-75th percentile], 43.5 [20.3-68.3] vs 1.0 [0-13.8], respectively; P < .001). Only three patients had an altered acid reflux index (44.9%, 12.7%, and 13.6%) while not taking antacid drugs. Pepsin A was found in 100% of samples and pepsin C in 76.5%.

CONCLUSIONS:  The majority of GER episodes of children in the ICU were proximal and weakly acidic. All patients had aspiration of gastric contents as detected by pepsin A in tracheal fluid. A specific pepsin assay should be performed to establish gastropulmonary aspiration because pepsin C was found in > 70% of samples.

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