1. V. V. Lupu, M. Burlea, M. Moscalu, A. Ignat
Relationship between gastroesophageal reflux disease and recurrent respiratory tract infections in children
V. V. Lupu, M. Burlea, M. Moscalu, A. Ignat
Pediatrics Department, “Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania

2. Introduction
The gastroesophageal reflux disease is the intermittent or permanent passing of the stomach content into the esophagus, which triggers a whole set of digestive, respiratory and/or neurobehavioral symptoms or the absence of any symptoms.

3. Introduction Respiratory Manifestations
chronic cough
episodes of obstructive apnea
wheezing
chronic or recurrent pneumonia
simple chronic hoarseness
episodes of cyanosis accompanied by stridor, hiccups, dysphonia
aspiration pneumonia obstructive recurrent bronchitis
episodes of bronchial asthma,
recurrent otitis media
Gaude GS. Pulmonary manifestations of gastroesophageal reflux disease. Annals of Thoracic Medicine. 2009;4(3):

4. Introduction Respiratory Manifestations
Pathological GERD → can be found in 30% to 80% of patients with asthma.
A systematic review of 28 epidemiological studies → a 59.2% weighted average prevalence of GERD symptoms in asthmatic patients, compared to 38.1% in controls.
Based on continuous ambulatory esophageal pH-monitoring → at least 50% of adults and children have evidence of GERD.
The prevalence of GERD-associated cough ranges from 10% to 40%.
In children, the prevalence of GERD as a cause of chronic cough → is reported to be 4% to 15%.
Richter JE. Gastroesophageal reflux disease and asthma: The two are directly related. Am J Med. 2000;108:153S–8S.

5. Purpose
The purpose of our study → to investigate the relationship between GERD and recurrent respiratory tract infections, epidemiology and the effectiveness of treatments for GERD (proton pumps inhibitors).

6. Material and methods
The study group consists of 53 children who were referred to a pediatric gastroenterology regional center in northeast Romania for evaluation of GERD as a cause of recurrent respiratory tract infections by 24 hours pH monitoring.
The results of 24 hours esophageal pH monitoring were interpreted using the Boix Ochoa score.
All children with positive score received treatment with proton pump inhibitors and they were reevaluated after 2 months.

7. Results
GERD proved by a positive Boix Ochoa score was detected in 41 (77.36%) of these children.
12 children (22.64%) had a negative score.
Study group
RRTI
Control group
No. Cases %
GERD + 41
77.36%
131
72.38% - 12
22.64% 50
27.62%
Total 53
181

8. Correlation coefficient
Chi-square 2 p
95% confidence interval
Pearson Chi-square - 2
Correlation coefficient
(Spearman Rank R)
Results
After a 2 months treatment with proton pump inhibitors, reflux remained present in 8 patients (19.51%), and disappeared after another 2 months cure of PPI.
The study of association of recurrent respiratory infections demonstrates the absence of a significant correlation between them and the presence of reflux (χ2 = 1.63, p = , 95% CI).
Anyway, improvement was observed in respiratory symptoms after anti- reflux therapy was started.

9. Discussions
The patient's history → an extremely important part of the diagnosis of GERD- associated asthma.
The diagnosis is important to consider → significant improvement in symptoms and in asthma control occurs with appropriately treated GERD.
Patients' symptoms suggesting reflux → nocturnal cough, worsening of asthma symptoms after eating large meal, drinking alcohol, or being in the supine position.
GERD should be considered in asthmatics → in those without an intrinsic component and in those not responding to bronchodilator or steroid therapy.
Richter JE. Gastroesophageal reflux disease and asthma: The two are directly related. Am J Med. 2000;108:153S–8S.

10. Discussions
Patients with chronic cough should have a history taken and physical examination carried out to evaluate common causes of cough (asthma, sinusitis, GERD), as well as chest radiograph.
GERD should be considered if there are typical gastrointestinal symptoms or if cough remains unexplained after standard investigations.
The diagnosis of GERD as the cause of cough can only be made with certainty when cough subsides with specific anti-reflux therapy.

11. Discussions
Esophageal tests that may be helpful in diagnosis → the barium esophagogram, gastroesophageal scintigraphy, and prolonged esophageal pH–monitoring.
Esophageal pH- monitoring → was considered the gold standard for the diagnosis of GERD and is the only esophageal test that can directly correlate acid reflux episodes with wheezing or other symptoms of bronchospasm.
Sensitivity is improved by using impedance - pH-monitoring, but this technology has not yet been standardized to a level which would satisfy the definition of a test suitable for routine clinical practice. 
Ahmed T, Vaezi MF. The role of pH monitoring in extraesophageal gastro-esophageal reflux disease. Gastrointest Endosc Clin N Am. 2005;15:319–31. 

12. Discussions
Treatment for GERD → reducing the abnormal backflow, or reflux of acid, into the esophagus; preventing injury to the esophagus or helping it to heal if injury has already occurred.
General measures
Proclive position at degrees

13. Discussions Lifestyle modifications
small and frequent meals, at regular hours;
avoid food and beverages 2 to 3 hours before going to the bed;
avoid sleeping immediately after a meal;
avoidance of food and beverages with a pH of < 5 and/or capability of relaxing the lower esophageal sphincter → alcohol, chocolate, mint, onions, tea, cola, citrus fruits
no active or passive smoking;
be careful → there are drugs decreasing LES pressure.

14. Discussions
PPIs
the most effective acid-suppression medications available
are the cornerstone of therapy for GERD and other acid-mediated conditions.
Once-a-day PPIs therapy → improves chronic cough in patients with GERD, and the effect of PPI in ameliorating both cough and reflux symptoms continues after treatment ceases.
There is evidence that 2 months with PPIs is sufficient to reduce cough in patients with GERD.

15. Conclusions
Our results suggest that recurrent respiratory tract infections should be a solid reason for evaluating the presence of a gastroesophageal reflux by 24 hour pH-monitoring.
Early diagnosis and anti-reflux therapy in cases with GERD associated with recurrent respiratory complaints can result in significant improvement in symptoms.

16. Thank you!