Elsevier

Sleep Medicine Reviews

Volume 9, Issue 6, December 2005, Pages 453-458
Sleep Medicine Reviews

Clinical Review
The relationship between extraesophageal reflux (EER) and obstructive sleep apnea (OSA)

https://doi.org/10.1016/j.smrv.2005.05.003Get rights and content

Summary

Obstructive sleep apnea (OSA) and extraesophageal reflux (EER) are common chronic diseases and share several similar risk factors. The prevalence of gastroesophogeal (GERD) in OSA patients is significantly higher than the general population; however, no temporal or causal relationship has ever been demonstrated between the two. The purpose of this review is to understand the association between obstructive sleep apnea (OSA) and extraesophageal reflux disease (EER) in the adult population. We conclude that CPAP treatment of OSA significantly reduces GERD symptoms and acidic pH exposure in the esophagus and this improvement with CPAP physiologically occurs in the presence or absence of OSA; and treatment of GERD in OSA patients improves the number of arousals during sleep, but only one study showed a significant difference in apnea.

Section snippets

Purpose

The purpose of this review is to understand the association between obstructive sleep apnea (OSA) and extraesophageal reflux disease (EER) in the adult population. We will attempt to answer three main questions:

  • 1.

    What is the association between OSA and EER, and is there any evidence for a cause and effect relationship?

  • 2.

    Does the treatment of OSA by positive airway pressure improve EER symptoms?

  • 3.

    Does the treatment of EER by acid inhibition improve OSA symptoms?

What is the association between OSA and EER?

In a large national survey evaluating the presence of nocturnal GERD (nGER) and its effect on quality of life, 10% of respondents reported symptoms of nGER.7 This is in sharp contrast to the prevalence of nGER in OSA patients. The frequency of nGER in OSA patients ranges from 54 to 76% (reviewed in16). In a recent prospective study of 331 OSA patients, nGER was present in 62% before the start of continuous positive airway pressure (CPAP) treatment.16 Also, a small study of OSA and control

Does the treatment of OSA by positive airway pressure improve EER symptoms?

While it is not obvious why the treatment of OSA by positive pressure would improve EER, there is one prevailing hypothesis of why this may be true. As negative intrathoracic pressure is generated through inspiration, these negative pressures are transmitted to the intrathoracic esophagus. In OSA, the obstruction events cause higher negative pressure gradients to develop than normal physiology. This may allow for lower esophageal resistance to EER and it may allow for increased lower esophageal

Does treatment of EER improve OSA severity?

Given the high prevalence of GERD in OSA patients, it is hypothesized that acid exposure has a significant impact on the mucosa of the upper airway. Lower pH exposure in the upper airway may cause significant edema and tissue inflammation; this may in turn worsen the obstructive physiology of the upper airway. It makes biologic sense that treatment of EER could reduce OSA severity. A few small trials have attempted to evaluate this (Table 2); however, all of these should be considered

Acknowledgements

Special thanks to Farhad Ardeshirpour, UNC medical student, for help in preparation of this manuscript.

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