Chest
Volume 130, Issue 5, November 2006, Pages 1520-1526
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Original Research
Pulmonary Aspiration Shown by Scintigraphy in Gastroesophageal Reflux-Related Respiratory Disease

https://doi.org/10.1378/chest.130.5.1520Get rights and content

Objectives

Gastroesophageal reflux (GER) may underlie respiratory manifestations via vagally mediated airway hyperresponsiveness or microaspiration, and intraesophageal pH monitoring is generally used to identify GER in patients with such manifestations. We aimed to establish the frequency of retrograde pulmonary aspiration in patients with unexplained respiratory manifestations.

Methods

Fifty-one patients with refractory respiratory symptoms (cough, n = 18; pneumonia, n = 14; apnea, n = 8; asthma, n = 7; and laryngitis, n = 4) were prospectively evaluated. They underwent 24-h intraesophageal pH monitoring and gastroesophageal 99Tc scintigraphy with lung scan 18 to 20 h after the test meal.

Results

Thirteen of 51 patients (25.5%) had abnormal intraesophageal pH study results (mean reflux index, 11.3%; range, 6.5 to 50%); and in 25 of 51 patients (49%), overnight scintigraphy showed pulmonary aspiration. Nineteen of these 25 patients had entirely normal pH study results, whereas 6 of 13 patients with abnormal pH study results had aspiration. Pulmonary aspiration was demonstrated in all patients with apnea and 61.5% of patients with recurrent pneumonia. Nine of 25 patients (36%) with aspiration had histologic evidence of esophagitis, whereas histologic esophagitis was present in 5 of 13 patients (38.4%) with pathologic GER as shown by intraesophageal pH monitoring.

Conclusions

Pulmonary aspiration as demonstrated by overnight scintigraphy is common in children with unexplained and refractory respiratory manifestations, suggesting that GER could be the underlying cause of these manifestations. Since only a few children with chronic or recurrent respiratory symptoms have a pathologic gastroesophageal acid reflux, a normal intraesophageal pH study result does not rule out GER in these children.

Section snippets

Aim of the Study

Episodes of GER with aspiration of refluxed material are more likely to occur during the nocturnal period, when the esophagus and stomach are leveled and the swallowing response to reflux and airway protection mechanisms are blunted by sleep. Therefore, we wanted to verify the impact of a gastroesophageal radionuclide study followed by overnight scan on the lung fields on the identification of an underlying GER in children with unexplained or refractory respiratory symptoms. We also wanted to

Patients

Fifty-one neurologically normal children (34 boys and 17 girls) aged 1 month to 11.5 years (median, 6.5 years) who had been referred to our unit were prospectively studied during a 3-year period. They suffered from chronic or recurrent respiratory problems (chronic cough, n = 18; recurrent pneumonia, n = 14; apnea episodes, n = 8; asthma/wheezing, n = 7; posterior laryngitis, n = 4) that were hitherto unexplained and/or had not responded satisfactorily to medical treatment such as antibiotics,

Results

No anatomic abnormality was detected during the contrast study of the upper-GI tract. All 23 children subjected to upper-GI endoscopy had normal macroscopic findings, but 21 of 23 children had histologic evidence of mild (grade 1 or G1) esophageal damage, and all had an eosinophil count < 10/high-power field, so that allergic eosinophilic esophagitis could be excluded. Intraesophageal pH study results were abnormal in 13 of 51 patients (25.5%), showing a mean reflux index of 11.3% (range, 6.5

Discussion

Although GER is regarded as a possible cause of respiratory manifestations such as recurrent pneumonia, apnea, asthma, wheezing, chronic cough, and laryngitis,1, 2 its causal role in lung disease has never been clearly established.3 Indeed, one of the very few controlled pediatric studies15 to date showed that over a 1-year follow-up period, infants with regurgitation do not acquire GERD or respiratory symptoms more often than infants without regurgitation. Furthermore, the precise correlation

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    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

    The authors have no conflicts of interest to disclose.

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