The effect of acid suppression on upper airway anatomy and obstruction in patients with sleep apnea and gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) and obstructive sleep apnea syndrome (OSAS) are often comorbid disorders.1–3 OSAS is a condition marked by pharyngeal narrowing, resulting in upper airway obstruction during sleep, which, in turn, produces repeated episodes of decreased oxygen saturation and brief arousals from sleep. It is well recognized clinically that patients with OSAS often complain of heartburn, and they clearly share a major overlapping risk factor, which is obesity. In one investigation, of the patients referred for overnight sleep studies, 74% reported GERD-related symptoms, including heartburn, acid regurgitation, or both.2 Other studies have also shown a significant increase in reflux symptoms in patients with demonstrated OSAS.1,4 The incidence of significant reflux symptoms in these studies ranges from 62% to 74%. In another study, patients whose OSAS was successfully treated with continuous positive airway pressure (CPAP) had a marked improvement in nighttime reflux, compared with those patients who were noncompliant or did not use CPAP.1 In a study that utilized polysomnography concurrent with distal esophageal pH monitoring, Ing and colleagues5 found that patients with OSAS exhibited more frequent nocturnal reflux than did similar patients with very mild OSAS. In this same study,5 esophageal acid clearance was also prolonged in patients with OSAS with a significantly greater proportion of time at an esophageal pH < 4.0. Similar results were found in a study by Berg et al.,6 who concluded that reflux events and obstructive apnea are not causally linked but may be the consequence of a coexisting pathology. It is also of interest that CPAP treatment itself will significantly lower the percentage of nighttime acid contact.7 Another study has shown that powerful acid inhibition with a proton pump inhibitor (pantoprazole) will markedly improve symptoms of sleepiness and reflux symptoms in patients with documented OSAS.8 Senior et al.3 have shown that a similar treatment in patients with documented OSAS and GERD via 24- hour pH monitoring will significantly reduce the apnea-hypopnea index (AHI). However, it should be noted that this study consisted of only 10 patients, and only 3 actually responded to treatment. The authors did conclude that further investigation is necessary to establish whether reducing gastroesophageal reflux (GER) may alter the upper airway, resulting in a reduction of upper airway obstruction. Thus, it appears that GERD is a common comorbid condition with OSAS and that symptoms are substantially improved by treating obstructive events. It remains to be determined definitely whether suppressing GER improves upper airway anatomy, physiology, or both anatomy and physiology in a way that could result in a reduction in upper airway obstructive events. In the present study, we have undertaken an evaluation of patients with OSAS selected via both polysomnography and 24-hour pH recording to have both mild OSAS and documented GERD. We hypothesized that the treatment of GERD in patients with mild OSAS and objective evidence of significant reflux would reduce the number of obstructive events and that this would be accompanied by improvements in upper airway anatomy and sleep quality. Patients were subjected to powerful acid suppression (ie, rabeprazole 20 mg, twice a day) for 2 months. Patients were assessed with laryngoscopy, as well as full polysomnography and 24-hour esophageal pH monitoring, before and after treatment with powerful acid suppression.