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Gastroesophageal Related Aspiration and Frequent COPD Exacerbations and Recurrent Pneumonia
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A7510 - Gastroesophageal Related Aspiration and Frequent COPD Exacerbations and Recurrent Pneumonia
Author Block: R. C. Balkissoon; Medicine, National Jewish Health, Denver, CO, United States.
Rationale: Despite use of inhaled corticosteroids and long acting bronchodilators, there remains a subset of COPD patients that appear to have recurrent COPD exacerbations. These exacerbations are often presumed to be lower respiratory tract infections. The COPD GENE study has demonstrated that the presence of a hiatal hernia is associated with increased risk of exacerbations. It remains unclear what the exact relationship is between the association of hiatal hernia and recurrent exacerbations. It is hypothesized that gastro-esophageal reflux disease (GERD) associated aspiration may be a plausible mechanism for this observed association.
Objectives: To examine the frequency and nature of associations between High Resolution Computed Tomography (HRCT) findings, barium esophagram, tailored barium, impedance probe, rhinolaryngoscopy and bronchoscopy with bronchoalveolar lavage and endobronchial biopsy findings suggestive of reflux associated aspiration in patients with recurrent COPD exacerbations and/or pneumonia.
Methods: COPD patients (n=94) referred for evaluation with at least 2 exacerbations and/or episodes of pneumonia in past 12 months underwent a battery of tests to assess evidence for aspiration. Patients had to have refrained from smoking for at least 2 years. Evaluation included: High Resolution CT scan, barium esophagram, tailored barium esophagram, sputum and complete blood count absolute eosinophils, exhaled nitric oxide levels, Pulmonary function tests (PFT’S), methacholine challenge, rhinolaryngoscopy, impedance probe, and bronchoscopy with BAL and endobronchial biopsies. We examined the frequency of association between squamous metaplasia on endobronchial biopsy and BAL lymphocytosis/neutrophilia (indirect evidence of possible aspiration) with other clinical assessments.
Findings: There was a high frequency of association between squamous metaplasia and/or lymphocytosis on BAL with evidence of laryngopharyngeal reflux, proximal reflux on impedance probe and barium esophogram, and CT signs of basilar atelectasis and/or bronchiectasis, ground glass and reticular changes. BAL lymphocytosis was also strongly associated with proximal non-acid and acid reflux. Patients with significant neutrophilia demonstrated a polymicrobial flora on cultures suggestive of possible dysbiosis.
Conclusions: Many patients with reports of frequent exacerbations and/or lower respiratory tract infections demonstrate features suggestive of high (proximal) gastroesophageal reflux and aspiration. Aspiration may be a contributing factor to the development of dysbiosis. In such patients emphasis on GERD lifestyle and dietary measures and possible prokinetic agents may be as important or more important than acid suppression therapy. Further prospective intervention studies are necessary to fully elucidate these relationships.
Author Block: R. C. Balkissoon; Medicine, National Jewish Health, Denver, CO, United States.
Rationale: Despite use of inhaled corticosteroids and long acting bronchodilators, there remains a subset of COPD patients that appear to have recurrent COPD exacerbations. These exacerbations are often presumed to be lower respiratory tract infections. The COPD GENE study has demonstrated that the presence of a hiatal hernia is associated with increased risk of exacerbations. It remains unclear what the exact relationship is between the association of hiatal hernia and recurrent exacerbations. It is hypothesized that gastro-esophageal reflux disease (GERD) associated aspiration may be a plausible mechanism for this observed association.
Objectives: To examine the frequency and nature of associations between High Resolution Computed Tomography (HRCT) findings, barium esophagram, tailored barium, impedance probe, rhinolaryngoscopy and bronchoscopy with bronchoalveolar lavage and endobronchial biopsy findings suggestive of reflux associated aspiration in patients with recurrent COPD exacerbations and/or pneumonia.
Methods: COPD patients (n=94) referred for evaluation with at least 2 exacerbations and/or episodes of pneumonia in past 12 months underwent a battery of tests to assess evidence for aspiration. Patients had to have refrained from smoking for at least 2 years. Evaluation included: High Resolution CT scan, barium esophagram, tailored barium esophagram, sputum and complete blood count absolute eosinophils, exhaled nitric oxide levels, Pulmonary function tests (PFT’S), methacholine challenge, rhinolaryngoscopy, impedance probe, and bronchoscopy with BAL and endobronchial biopsies. We examined the frequency of association between squamous metaplasia on endobronchial biopsy and BAL lymphocytosis/neutrophilia (indirect evidence of possible aspiration) with other clinical assessments.
Findings: There was a high frequency of association between squamous metaplasia and/or lymphocytosis on BAL with evidence of laryngopharyngeal reflux, proximal reflux on impedance probe and barium esophogram, and CT signs of basilar atelectasis and/or bronchiectasis, ground glass and reticular changes. BAL lymphocytosis was also strongly associated with proximal non-acid and acid reflux. Patients with significant neutrophilia demonstrated a polymicrobial flora on cultures suggestive of possible dysbiosis.
Conclusions: Many patients with reports of frequent exacerbations and/or lower respiratory tract infections demonstrate features suggestive of high (proximal) gastroesophageal reflux and aspiration. Aspiration may be a contributing factor to the development of dysbiosis. In such patients emphasis on GERD lifestyle and dietary measures and possible prokinetic agents may be as important or more important than acid suppression therapy. Further prospective intervention studies are necessary to fully elucidate these relationships.
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