Association of Gastroesophageal Reflux Disease Symptoms with Stable Chronic Obstructive Pulmonary Disease

Background  

Patients with various chronic respiratory diseases have a higher incidence of gastroesophageal reflux disease (GERD)-related symptoms, but the mechanisms of the relationship between GERD symptoms and chronic obstructive pulmonary disease (COPD) remain unclear. The aim of the present study was to explore the association of GERD symptoms with impaired pulmonary function and other factors in patients with COPD.     

Cricopharyngeal dysfunction in chronic obstructive pulmonary disease

Dysphagia due to cricopharyngeal dysfunction is well known; however, there have been no previous data indicating an association between cricopharyngeal dysfunction and COPD. After observing marked cricopharyngeal dysfunction with aspiration in three patients who had frequent and severe exacerbations of COPD, we performed pharyngoesophageal examinations with videotaping in another 22 nonrandomized patients. Cineradiography or videofluoroscopic recording with capabilities of slow-motion and freeze-frame playback is mandatory, since the transit time of the bolus through the pharynx is rapid. Severe cricopharyngeal dysfunction was observed in 17 elderly patients with COPD. Deglutition disorders were elicited by careful questioning in 15 of these. In eight subjects, cricopharyngeal myotomy resulted in improvement of swallowing and complete or partial relief of acute exacerbations of respiratory distress. In one subject, myotomy relieved only the swallowing problem. The mechanism of cricopharyngeal dysfunction in elderly patients with COPD is unknown at this time, but may be related to gastroesophageal reflux, therapeutic agents, and/or alterations in pharyngoesophageal anatomic structures. We conclude that investigations for swallowing disorders should be considered in patients with COPD who have frequent acute exacerbations of respiratory distress.     

Physiological Factors Related to Aspiration Risk: A Systematic Review

Penetration–aspiration is considered the most serious component of oropharyngeal dysphagia. Clinicians regularly evaluate the pathophysiology of swallowing and postulate reasons or mechanisms behind penetration–aspiration. In this article we share the results of a two-stage literature review designed to elucidate the association between abnormalities in physiological measures of swallowing function and the occurrence of penetration–aspiration. In the first stage, a broad scoping review was undertaken using search terms for nine different structures involved in oropharyngeal swallowing. In the second stage, based on the results of the initial search, a more focused systematic review was undertaken which explored the association between aspiration and abnormalities in respiratory, tongue, hyoid, and laryngeal function in swallowing. A total of 37 articles underwent detailed quality review and data extraction in the systematic review. The results support measurement of tongue strength, anatomically normalized measures of hyoid movement, bolus dwell time in the pharynx while the larynx remains open, respiratory rate, and respiratory swallow phasing as parameters relevant to aspiration risk.     

Laryngopharyngeal Dysmotility in Multiple Sclerosis

This study investigated the swallowing physiology of 13 patients [age 27-69 years (mean = 45 years)] with multiple sclerosis (MS) who had Kurtzke Extended Disability Status Scale (EDSS) scores ranging from 2 to 9 (mean = 6) and who complained of difficulty swallowing. Videofluoroscopic recordings of the patients' calibrated liquid and paste bolus swallows were analyzed and compared with publi-shed normative data. Results showed that swallowing physiology was disordered in the 13 MS patients with severity level ranging from mild to severe. Eleven patients had primary pharyngeal dysphagia, 1 patient had primary laryngeal dysphagia, and 1 patient had primary oral dysphagia. Laryngeal dysmotility, the predominant anterior pharyngeal segment dysfunction, was evidenced in all 13 patients with MS. They displayed significantly longer-than-normal pharyngeal delay times, shorter-than-normal time intervals from onset of laryngeal excursion to return to rest, and longer-than-normal time intervals between airway closure at the arytenoid to epiglottic base and upper esophageal sphincter opening. Pharyngeal constrictor dysmotility, the predominant posterior pharyngeal segment dysfunction, was observed in 11 of the 13 MS patients. A significant relationship was found between the severity of the MS patients' functional swallowing impairment and posterior pharyngeal segment dysfunction. Material penetrated the supraglottic airway of 9 patients with 1 patient aspirating. A significant relationship was observed between supraglottic penetration and brainstem dysfunction. No significant relationship was found between severity of dysphagia and neurological disability as measured by EDSS scores or neurological impairment as measured by Functional System (FS) scores. Disturbed neuromotor sequencing of laryngeal events and a progression in neuromotor weakening of the pharyngeal constrictors were suggested from the findings.     

Rigid Spine Syndrome: A Radiologic and Manometric Study of the Pharynx and Esophagus

The rigid spine syndrome (RSS) is not a recognized cause of dysphagia. The "vacuolar variant" of RSS causes mild, generalized, and slowly progressive weakness. Respiratory evaluation detected severe restrictive chest wall defect and significant respiratory muscle weakness. We identified nine patients at our Neuromuscular Clinic over a period of years. The aim of this evaluation was to ascertain whether pharyngoesophageal dysfunction caused cough (2/9), intermittent oropharyngeal dysphagia (4/9), and aspiration pneumonia (3/9). Pharyngeal and esophageal functions were evaluated separately by conventional cineradiography and intraluminal esophageal manometry over a one-year study period. An age- and gender-matched volunteer group without swallowing complaints partook in the manometric component of the study. There were seven male and two female patients. The mean age of patients was 19.1 years (17.8 years for controls), and the age range was 11-36 years (13-32 years for controls). The mean disease duration was 17.2 years (range=8-31 years). Patients were commonly underweight (7/9). Cineradiology detected abnormal swallow physiology of pharyngeal striated muscle (1/9) and of esophageal smooth muscle (2/9). Mean manometric pressures in patients were not significantly different from control data. Manometry detected "nonspecific" contractility abnormalities (3/9) that were not reflected in the mean data. The relative lack of instrumental findings suggested minor upper alimentary tract dysmotility in patients with the RSS. The myopathy that underlies this syndrome likely caused dysfunction of the striated muscle of the pharyngeal constrictors and upper esophageal sphincter. The documented abnormalities of esophageal smooth muscle motility were nonspecific and tenuously associated with the muscle disorder. The incongruity between complaints of intermittent dysphagia and study results was perhaps due to transient pharyngoesophageal dysmotility, altered swallowing mechanics of limited cervical spine mobility, altered swallowing perception after previous intubation/tracheostomy, or a "functional" upper intestinal complaint.     

Gastroesophageal Reflux Disease (GERD) and Irritable Bowel Syndrome (IBS)—Is It One Disease or an Overlap of Two Disorders?

Up to 79% of IBS patients report gastroesophageal reflux disease (GERD) symptoms, and up to 71% of GERD patients report irritable bowel syndrome (IBS) symptoms. There are two principal hypotheses for the common presence of IBS symptoms in GERD patients. The first theory suggests that GERD and IBS overlap in a significant number of patients. The second theory suggests that IBS-like symptoms are part of the spectrum of GERD manifestation. The first theory is supported by genetic studies and similarities in gastrointestinal sensory-motor abnormalities potentially due to general gastrointestinal disorder of smooth muscle or sensory afferents. The other theory is primarily supported by studies demonstrating improvement of IBS-like symptoms in GERD patients receiving anti-reflux treatment. The close relationship between GERD and IBS could be explained by either GERD affecting different levels of the GI tract or a high overlap rate between GERD and IBS due to similar underlying GI dysfunction.     

Increased gastro-oesophageal reflux disease in patients with severe COPD.

The prevalence and clinical consequences of gastro-oesophageal reflux disease (GERD) in chronic obstructive pulmonary disease (COPD) are not well characterised. The present study prospectively studied 42 males with COPD (forced expiratory volume in one second % predicted: 35%, range 20-49) and 16 healthy volunteers of similar age without respiratory or gastro-oesophageal symptoms. The diagnosis of GERD was confirmed using oesophageal 24 h pH monitoring. In the current study group, reflux symptoms were measured using the Vigneri score, cough and dyspnoea with the modified Medical Research Council questionnaire, and pulmonary function with bronchodilator response and health status using St George's Respiratory Questionnaire. Pathological reflux was documented in 26 out of 42 patients (62%) and in three volunteers (19%). In patients with GERD, 15 patients (58%) did not report any reflux symptoms. There were no differences in symptoms, health status, bronchodilator treatment and pulmonary function test between patients with and without GERD. Oxygen desaturation coincided with episodes of increased oesophageal acidity in 40% of patients with GERD. Patients with severe chronic obstructive pulmonary disease have a high prevalence of asymptomatic gastro-oesophageal reflux. The association between this reflux and oxygen desaturation deserves further attention.     

Swallowing and Esophageal Function in Parkinson's Disease

Dysphagia and drooling of saliva are frequent symptoms in Parkinson's disease (PD), occurring in one-half and three-quarters of all patients, respectively. Aspiration related to swallowing is a major cause of morbidity and mortality in PD. Defects in oral, pharyngeal, and esophageal phases of swallowing have been documented in patients with PD, and these defects precede symptoms. This paper reviews the current knowledge concerning swallowing abnormalities in PD.
The pathogenesis of dysphagia and drooling of saliva is multifactorial, involving cognitive and psychological changes in addition to abnormalities of the extra-pyramidal and autonomic nervous systems. Videofluoro-scopic imaging of the upper esophageal sphincter and pharynx during mastication and swallowing has been the basis of our understanding of the mechanical malfunction present in patients with PD. Manometric abnormalities of the esophageal body and lower esophageal sphincter have also been documented. The use of combined manofluoroscopy to examine the upper esophageal sphincter and pharynx in PD offers great promise both in understanding the defects and directing therapy. Voluntary airway protection techniques may reduce aspiration, but they need to be tested in a clinical study. Such maneuvers may reduce the morbidity seen in PD.     

Relationship between chronic nasal and respiratory symptoms in patients with COPD

The relationship between the upper and lower airways in chronic obstructive pulmonary disease (COPD) is unknown. We examined the prevalence of chronic nasal symptoms and the correlation with lower respiratory symptoms and parameters of severity of COPD such as exacerbation frequency and spirometry. 61 COPD patients from the East London COPD cohort were studied. [Mean (SD) age 70 (6.96) years, FEV1 0.98 (0.38) l, FVC 2.45 (0.72) l, FEV1%Pred 37.0 (12.3), and 47.6 (31.8) smoking pack years, 14 current smokers, 36 males]. COPD patients had a high prevalence of nasal symptoms (75%), more than half reporting nasal discharge (52.5%) and sneezing (45.9%). Associations were found between nasal score and daily sputum production (P = 0.005) and post-nasal drip and sputum production (P = 0.046) with a trend to increased nasal symptoms in frequent exacerbators compared to infrequent exacerbators. No significant relationship was found between nasal symptoms and FEV1 or any other lower respiratory airway symptom. Associations between nasal and respiratory symptoms were found suggesting that there is a relationship between the upper and lower airway in COPD.     

Symptom priority ranking in the care of gastroesophageal reflux: a review of 1,850 cases

BACKGROUND: Clinical history remains an important part of the medical evaluation of patients with gastroesophageal reflux disease (GERD). Heartburn, regurgitation, and dysphagia are considered typical symptoms of GERD. Priority rankings of these symptoms can be determined with a standardized questionnaire. OBJECTIVE: To determine whether symptom priority ranking and symptom severity grading can provide useful information in the evaluation of patients with GERD. METHODS: From 1,850 patients that were analyzed retrospectively, patients with dysphagia unrelated to GERD were excluded. A standardized questionnaire was applied before each patient underwent any esophageal diagnostic study. Priority of symptoms was determined to be primary, secondary, tertiary, or none based on the patient response to the questionnaire. Presence of a stricture was determined either by endoscopy, esophagraphy, or both studies. Stationary esophageal manometry and 24-hour pH monitoring were performed on all patients. Through bivariate and multivariate analysis, the relationships among typical GERD symptoms, esophageal reflux-related stenosis, lower esophageal sphincter pressure, and composite score were established. RESULTS: High priority ranking of the symptom dysphagia is predictive of the presence of an esophageal stricture, but has a negative association with abnormal manometric and pH studies. In contrast, high priority ranking of the symptom heartburn and regurgitation are positively associated with abnormal manometric and pH results. CONCLUSIONS: Priority ranking can be a valuable adjunct to objective testing in the evaluation of GERD. In certain clinical situations it can obviate the need for 24-hour pH monitoring.     

Manometric study in Kearns–Sayre syndrome

Although swallowing difficulties have been described in patients with Kearns-Sayre syndrome (KSS), the spectrum of manometric characteristics of dysphagia is not yet well known. Moreover, it is conceivable that a combination of various degrees of swallowing difficulties with different patterns in manometric studies exist, each playing a major role in the prognosis, natural history, and quality of life of KSS patients. An 18-year-old girl diagnosed at the age of 5 years with KSS (muscle biopsy) was admitted to our department with an upper respiratory tract infection and dysphagia. Clinical examination revealed growth retardation, external ophthalmoplegia, pigmentary retinopathy, impaired hearing, and ataxia. An electrocardiogram revealed cardiac conduction defects (long Q-T), and brain magnetic resonance imaging showed abnormalities in the cerebellar hemispheres. A manometric and motility study for dysphagia was conducted and the pharynx and upper esophageal sphincter (UES) resting pressures were similar to control group values, but the swallowing peak contraction pressure of the pharynx and the closing pressure of the UES were very low and could not promote effective peristaltic waves. Relaxation and coordination of the UES were not affected although pharyngeal and upper esophagus peristaltic waves proved to be very low and, consequently, were practically ineffective. The patient was started on treatment comprising a diet rich in potassium, magnesium, and calcium, and oral administration of vitamin D and co-enzyme Q10 100 mg daily; she was discharged 6 days later with apparent clinical improvement.     

Objective Measures of Swallowing Function Applied to the Dysphagia Population: A One Year Experience

Quantitative, reliable measures of swallowing physiology can be made from an modified barium swallowing study. These quantitative measures have not been previously employed to study large dysphagic patient populations. The present retrospective study of 139 consecutive patients with dysphagia seen in a university tertiary voice and swallowing clinic sought to use objective measures of swallowing physiology to (1) quantify the most prevalent deficits seen in the patient population, (2) identify commonly associated diagnoses and describe the most prevalent swallowing deficits, and (3) determine any correlation between objective deficits and Eating Assessment Tool (EAT-10) scores and body mass index. Poor pharyngeal constriction (34.5 %) and airway protection deficits (65.5 %) were the most common swallowing abnormalities. Reflux-related dysphagia (36 %), nonspecific pharyngeal dysphagia (24 %), Parkinson disease (16 %), esophageal abnormality (13 %), and brain insult (10 %) were the most common diagnoses. Poor pharyngeal constriction was significantly associated with an esophageal motility abnormality (p < 0.001) and central neurologic insult. In general, dysphagia symptoms as determined by the EAT-10 did not correlate with swallowing function abnormalities. This preliminary study indicates that reflux disease is common in patients with dysphagia and that associated esophageal abnormalities are common in dysphagic populations and may be associated with specific pharyngeal swallowing abnormalities. However, symptom scores from the EAT-10 did not correspond to swallowing pathophysiology.     

Association between gastroesophageal reflux and endobronchial carcinoid: a case report

Children with neurological disorders may suffer from gastroesophageal reflux disease (GERD). Typical symptoms are vomiting, regurgitation and hematemesis. Patients present with respiratory symptoms only in cases with swallowing disorders causing chronic airway aspiration. We report the case of a patient affected by chromosome 8 p deletion syndrome with mental retardation, referred to our unit for suspected GERD. Chest X-ray, performed at admission for coexisting respiratory complaints, showed left lower lobe pneumonia; esophageal pH monitoring and upper endoscopy were normal for GERD. To rule out chronic airway aspiration, gastroesophageal 99 mTc scintigraphy with lung scan 18 to 24 h after a test meal and video fluoroscopy swallowing study were performed, both negative. Two months later, a second episode of left lower lobe pneumonia occurred. A chest CT scan was performed and showed an endobronchial mass; the biopsy taken during the broncoscopy was not conclusive. Surgical excision resulted in a diagnosis of pulmonary carcinoid. Bronchial carcinoids, although rare, should be taken into consideration as a potential cause of recurrent pneumonia even in the presence of demonstrated GERD where severe respiratory infections only occur with coexisting chronic pulmonary aspiration, even in neurologically impaired people.     

Oral aspiration,type 1 laryngeal cleft,and respiratory tract infections in canadian inuit children

Canadian Inuit infants suffer the highest rate of lower respiratory tract infections (LRTI's) in the world. The causes of this are incompletely understood. The primary objective of this study was to determine whether there exists an association between respiratory morbidity and oral aspiration in Inuit children. A retrospective chart review was conducted including children from Nunavut who underwent Video Fluoroscopic Swallowing Study between the years of 2001 to 2015. The primary outcome was hospitalization for LRTI. We hypothesized that infants found to have aspiration would experience a higher rate of admissions for LRTI than those with normal swallowing studies. One‐hundred and twenty‐seven patients were identified, of whom 94 were included. Fifty‐six percent of patients had an abnormal swallowing study. Compared with patients with normal swallowing, the incidence rate of LRTI was higher in patients with aspiration (incidence rate ratio [IRR] = 1.51; 95% confidence interval [CI] = 1.23‐1.87) and in patients with penetration (IRR = 1.40; 95% CI = 1.11‐1.76). Fourteen percent of patients had confirmed laryngeal cleft; patients with confirmed presence of this also had a higher incidence rate of LRTI (IRR = 1.66; 95% CI = 1.32‐2.07). The incidence of abnormal swallowing study showed an 11‐fold variation across the five regions in Nunavut, with the highest prevalence in west Qikiqtani Region (Baffin Island). We conclude that swallowing dysfunction is not only prevalent amongst Canadian Inuit but clinically significant. This is the first study to demonstrate an association between swallowing dysfunction and respiratory morbidity in this population. Geographic distribution patterns and high rates of laryngeal cleft may point to a potential genetic etiology for what remains at this point, idiopathic swallowing dysfunction.     

The association of gastroesophageal reflux disease with asthma and chronic cough in the adult

Gastroesophageal reflux disease (GERD) is a common condition which is particularly prevalent in patients with asthma and chronic cough. Physiologic changes caused by asthma and chronic cough promote acid reflux. GERD is also considered by many investigators as a factor contributing to airway inflammation. An etiological relationship between GERD and asthma/chronic cough and vice versa has been supported by a large number of experimental and clinical findings and refuted by others. Although further controlled studies are needed to clarify this relationship, GERD and asthma/chronic cough appear to be linked to each other. The association of GERD with asthma and chronic cough involves nerve reflexes, cytokines, inflammatory and neuroendocrine cells and, in some patients, tracheal aspiration of refluxing gastric fluids. GERD may present with typical symptoms but can also be asymptomatic. Sensitive methods for diagnosing GERD are available, which include esophageal pH monitoring, acid provocative tests, modified barium swallow and endoscopy. Consideration of the association of GERD with asthma and chronic cough is of practical value in the management of chronic cough or asthma resistant to treatment. Treatment of GERD in patients with asthma has been consistently shown to improve respiratory symptoms but not necessarily pulmonary function tests. Surgical treatment can be a useful and cost-effective approach in selected patients with asthma and GERD.     

Long-term follow-up of oropharyngeal dysphagia in children without apparent risk factors

BACKGROUND: The presence of swallowing dysfunction in children without obvious risk factors remains under appreciated. Early identification and prompt initiation of appropriate treatments are critical for reduction of morbidities associated with dysphagia. OBJECTIVE.: To describe the clinical presentations, radiologic characteristics, and long-term outcomes in children with oropharyngeal dysphagia presenting as unexplained respiratory problems. We completed a retrospective chart review of all children without known dysphagic risk factors upon presentation to Speech-Language Pathology (December 1991-April 1995) for feeding/swallowing evaluations because of refractory respiratory problems and dysphagic concerns, and who subsequently were diagnosed with dysphagia on Videofluoroscopic Swallow Study (VFSS). In August 2002, follow-up telephone interviews were conducted with caregivers of 14 children. RESULTS.: We identified 19 children (mean age 1.14 years; range 0.9-5.75) with dysphagia presenting as unexplained respiratory problems. On VFSS, delayed pharyngeal swallow onset was the most common abnormal radiologic finding and always preceded penetration or tracheal aspiration. Eleven (57.9%) children aspirated. Aspiration occurred only with liquids and 100% of aspiration events were silent (i.e., no cough). Dysphagia was not a concern in 11 children at a mean age 3.2 years (range 0.7-10) and persisted in three children who were 9 years or older. CONCLUSIONS.: Oropharyngeal dysphagia should be considered in the differential diagnosis of young children without known risk factors associated with swallowing dysfunction when they present with unexplained respiratory problems. Although the prognosis for resolution of dysphagic concerns is very good, it may take several years.     

Oropharyngeal and esophageal interrelationships in patients with nonobstructive dysphagia

Normal swallowing requires the close functional coordination of the mouth, pharynx, and esophagus, and if one of these components becomes functionally impaired, it is likely that the others may be affected. Using videofluoroscopy and manometry in this study, we examined the esophageal phase of swallowing in 12 patients with oropharyngeal dysphagia (group A) and the oropharyngeal components of swallowing in 29 patients with esophageal motor dysfunction and nonobstructive dysphagia (group B). A wide range of esophageal function abnormalities was seen in the first group, including delayed esophageal body peristalsis, spontaneous or simultaneous (tertiary) contractions, esophageal body dilation, proximal bolus redirection, and poor lower esophageal sphincter relaxation. Manometrically, 92% of group A patients were classified as having nonspecific esophageal motility disorder (NSEMD). In a similar fashion, group B patients exhibited many oropharyngeal function abnormalities on videofluorography including disturbed lingual peristalsis, slowed pharyngeal transit time with poor constriction of pharyngeal muscles, and laryngeal vestibular and tracheal bolus penetration. Manometrically, group B patients were classified as having NSEMD, achalasia, diffuse esophageal spasm, nutcracker esophagus, scleroderma, and chronic intestinal pseudoobstruction. In conclusion, oropharyngeal function is significantly altered in patients with esophageal motility disorders and dysphagia, and esophageal motor dysfunction occurs in patients with oropharyngeal dysphagia. These changes may represent either a compensatory mechanism or concomitant involvement of the oropharynx or the esophagus by the underlying neuromotor disorder. We suggest that assessment by esophageal motility and videofluoroscopy of both the oropharyngeal and esophageal phases of swallowing may improve diagnosis and therapy in patients with nonobstructive dysphagia.     

Gastroesophageal reflux disease, acid suppression, and Mycobacterium avium complex pulmonary disease

BACKGROUND: Weekly symptoms of gastroesophageal reflux disease (GERD) occur in 20% of the population, and GERD has been implicated in the pathophysiology of many respiratory diseases. Microaspiration of contaminated water is a potential portal of entry for Mycobacterium avium complex (MAC) organisms into the respiratory tract, and acid-suppression therapy may enhance the survival of mycobacteria in the stomach. This study aimed to assess the prevalence of GERD, swallowing disorders, reflux symptoms, and acid-suppression therapy in patients with MAC lung disease (MAC positive [MAC+]), and to compare these patients to control subjects without MAC lung disease (MAC negative [MAC-]). METHODS: Clinical information was collected on 58 MAC+ patients and 58 age- and sex-matched MAC- patients who were asked to complete a DeMeester questionnaire of reflux symptoms and to identify any acid-suppressive medication consumed. RESULTS: A clinical diagnosis of GERD was documented in 23 of 52 MAC+ patients (44.2%), compared to 16 MAC- patients (27.6%) [p = 0.019]. MAC+ patients consumed significantly more histamine type 2 receptor antagonists and prokinetic agents, and MAC- patients consumed more antacids. The mean DeMeester questionnaire score (+/- SD) for MAC+ patients was 1.39 +/- 1.8, and for MAC- patients was 0.88 +/- 1.4. (p = 0.098). Aspiration was suspected in nine MAC+ patients (15.5%), compared to three MAC- patients (5.2%) [p = 0.032]. There was no association between GERD and radiologic presentation of MAC disease. Consolidation and nodules > 5 mm were more common in those receiving acid suppression than those who were not. CONCLUSIONS: GERD, acid suppression, and clinically suspected aspiration are more common in patients with MAC lung disease than in similar patients without MAC disease.     

Pediatric otolaryngologic manifestations of gastroesophageal reflux disease

In adults, an estimated 4% to 10% of chronic, nonspecific laryngeal disease seen in otolaryngologic clinics is associated with gastroesophageal reflux disease (GERD). Although no such estimates exist in children, many investigators have reported extraesophageal manifestations of GERD, of which the most common is the association of GERD with asthma and chronic cough. A variety of signs and symptoms of otolaryngologic disease also have been attributed to GERD, including hoarseness, laryngitis, chronic rhinitis, sinusitis, globus pharyngeus, recurrent croup, laryngomalacia, stridor, subglottic stenosis, otalgia, vocal cord granulomas, and oropharyngeal dysphagia. However, proof of the association between these manifestations of otolaryngologic disease and GERD is sparse. Furthermore, the manifestations of otolaryngologic disease often occur in the absence of such classic systems of GERD as heartburn or chest pain. This review explores the role of GERD in otolaryngologic disease in children.     

Autonomic dysfunction in patients with chronic obstructive pulmonary disease (COPD)

It has been recognized that chronic obstructive pulmonary disease (COPD) is a systemic disease which has been shown to negatively affect the cardiovascular and autonomic nerve system. The complexity of the physiologic basis by which autonomic dysfunction occurs in patients with COPD is considerable and the knowledge in this field remains elementary. The purpose of this review is to provide an overview of important potential mechanisms which might affect the autonomic nervous system in patients with COPD. This review aims to summarize the basic research in the field of autonomic dysfunction in patients with COPD. In COPD patients the activity of sympathetic nerves may be affected by recurrent hypoxemia, hypercapnia, increased intrathoracic pressure swings due to airway obstruction, increased respiratory effort, systemic inflammation and the use of betasympathomimetics. Furthermore, experimental findings suggest that autonomic dysfunction characterized by a predominance of sympathetic activity can significantly modulate further inflammatory reactions. The exact relationship between autonomic dysfunction and health status in COPD remains to be elucidated. Treatment aimed to restore the sympathovagal balance towards a reduction of resting sympathetic activity may modulate the inflammatory state, and possibly contributes to improved health status in COPD.