Asthma is a chronic inflammatory pulmonary disorder that is characterized by reversible obstruction of the airways. Underlying cause of the increasing prevalence of asthma is unknown. Important aspects of asthma include airways hyperresponsiveness and bronchoconstriction. Airways hyperresponsiveness refers to an increased tendency of the asthmatic airways to react to a variety of stimuli that would not cause a response in a normal airway. These asthma triggers can cause an asthma attack in an inflamed airway. One of the prominent trigger factor is the acid reflux which is considered to be a nightmare for the asthmatics.

Gastro-oesophageal reflux disease often called “reflux”, “reflux oesophagitis” or sometimes inaccurately referred to as “hiatus hernia”. Gastro-oesophageal reflux is the term used to describe a backflow of acid from the stomach into the oesophagus. Almost everyone experiences GI reflux at sometime. The usual symptom is heart burn, an uncomfortable burning sensation behind the breastbone commonly occurs after a meal. In some individuals reflux is frequent or severe enough to cause more significant problems as trigger aggravate certain other conditions like an episode of asthma in known asthmatics. The role of H. pylori in the pathogenesis of GORD is controversial. Some studies have indicated a protective role1-5 whereas others fail to show different H. pylori infection rates in patients with and without Gastro-oesophageal reflux.6-8 There are also studies which indicate worsening or development of GORD after eradication of H. pylori in duodenal ulcer patients,9 although others reported improvement of reflux symptoms after cure of infection.10 Our aim was to study the improvement in asthma and GORD symptoms after eradication of H. pylori.

Patients presenting to our outpatient department of the tertiary care centre with moderate to severe persistent asthma were screened out of which twenty-five patients were enrolled.

Asthma and severity were defined as per the guidelines issued by the National Heart, Lung and Blood Institute (NHLBI) USA. They were randomly allotted to two groups. In group I, standard treatment based on the same guidelines were given using inhaled salmeterol, inhaled fluticasone, with spacer. Patients with allergic rhinitis were treated with nasal steroids and anti histamines. In group II, in addition to standard treatment patients were treated with a 2-week course against H. pylori consisting of 4 drug regime of Omeprazole, Metronidazole, BismuthSubcitrate and Doxycycline at therapeutic dose for 10 days. Pulmonary function test was done prior to initiating the therapy and predicted values for FVC, FEV1 and FEV1/FVC were derived followed by Wrights peakflow meter reading every 2nd, 4th, 6th and 8th week intervals.

Wrights peakflow meter reading measurements were done blinded to the group the patients belonged to. Predicted values for PEFR were calculated based on age and height of the patient.

The patients were surveyed about their reflux symptoms with specific questionnaire and response categories were provided.

The questions were designed to assess the severity of asthma symptoms, the severity of GOR symptoms both heartburn and regurgitation as well as complaints of cough, its duration, frequency, etc and to determine whether asthma symptoms worsened and patients had to use the b-agents inhaled during symptomatic reflux.
All subjects were questioned to determine whether they suffered from heartburn. Heartburn was described to them as a burning sensation or pain and discomfort in the chest after meals or when lying down.

They were asked whether their cough worsened or had shortness of breath, wheeze, nocturnal symptoms and dyspnoea either during the day or at night.

Question regarding regurgitation were asked like return of stomach contents or acid to the mouth or choking like sensation. Current asthma medication were recorded along with prior treatment for asthma as well as for any other illnesses. Subjects were also asked past history of any diseases, family history and history of smoking or tobacco consumption in any form.

Demographic data have been shown in Table 1. Average age of control group was 49 ± 14 years and 39 ± 12 years. Both groups were well matched in terms of baseline PEFR (Group 1 - 60% ± 10 vs. 52% ± 11 Group 2; p = 0.06). Per cent improvement in PEFR was significant from 2nd to 8th week after treatment in the group 2 (H pylori) compared to the group 1 (standard asthma) as shown in Table 2 and Fig. 1

	Fig. 1 : Percentage improvement in PEFR from baseline.

Gastro-oesophageal reflux (GOR) is a potential trigger of asthma. The oesophagus and lung interacts through a variety of mechanisms. Oesophageal acid induced broncho constriction can be provoked by a vagally mediated reflux, whereby acid in the distal oesophagus produces airway responses, by natural enhancement of bronchial reactivity, whereby oesophageal acid augments airway infection may be common in asthmatics, and worsen airway disease. Treatment for H. pylori may result in improved early asthma control.