Effect of Bed Head Elevation During Sleep in Symptomatic Patients of Nocturnal Gastroesophageal Reflux

Bashir Ahmad Khan; Jaswinder Singh Sodhi; Showkat Ali Zargar; Gul Javid; Ghulam Nabi Yattoo; Altaf Shah; Ghulam Mohamad Gulzar; Mushtaq Ahmad Khan


J Gastroenterol Hepatol. 2012;27(6):1078-1082. 

In This Article


Patient Population

Inclusion criteria: Patients of GERD who had the following features were included in the study.

1 Symptoms of heartburn of greater than 6 months' duration, with an average of ≥ 2 episodes of night-time heartburn per week, with an associated GERD-related sleep disturbance of ≥ 1 month's duration.[11,12]

2 Abnormal 24 h esophageal pH test. Patients who had supine reflux (nocturnal) during 24 h esophageal pH test.

Exclusion criteria included patients who had peptic ulcer, biliary tract surgery, systemic diseases, pregnancy and children below 18 years of age. All subjects gave informed consent for the study. The study was approved by the ethics committee of our institute.

Study Variables and Efficacy Assessments

Heartburn Symptoms. Patients who met the initial inclusion criteria entered a screening period for a period of 1 week. During this period patients recorded on diary cards the severity of heartburn and were graded as mild (nuisance value only), moderate (spoils enjoyment of life), marked (interferes with living a normal life) and severe (worst thing ever).[11] "Heartburn" was defined as a burning feeling arising from the stomach or lower part of the chest towards the neck. "Night-time (22.00 hours to 05.00 hours)" was defined as the time between when the patient went to bed to try and go to sleep and when the patient got up in the morning to start daily activities. "Complete resolution of symptoms" was defined as a response of "none" on 7 consecutive days. "Symptom improvement" was defined as any decrease in weekly symptom grade from baseline compared to the last (7th) day.

Resolution of Sleep Disturbance. "Complete resolution of sleep disturbance" was defined as a no response on 7 consecutive days and "relief of sleep disturbance" was defined as a yes response on no more than 2 of 7 consecutive days.[12]

Patients were subjected to upper gastrointestinal endoscopy to look for esophagitis, peptic ulcer or hiatus hernia. Esophagitis was graded as per the Los Angeles system of classification.[13]

24-h Ambulatory Esophageal pH Test

Intraesophageal pH was used to evaluate gastroesophageal reflux. A glass pH electrode (In gold messtechnik AGE industrie Nord ch-8902, Urdorf, Switzerland) was calibrated with pH 9, 7 and 4 buffer solutions (col Parmer instrument Co., Chicago, IL, USA) and then placed transnasally 5 cm above the upper margin of the lower esophageal sphincter, its location determined manometrically prior to placement of the pH probe. An ambulatory recorder (Proxima light 2; Proxima Electronicus, Montova, Italy) was used to obtain continuous pH data. pH measurement was stored every 6 s (14 400 readings). The stored data was transferred to a computer for analysis.

Expression of Abnormal Esophageal Acid Exposure

Acid exposure was measured as the time the pH in the esophagus was less than 4. Twenty-four-hour esophageal acid exposure was measured by using: (i) % time pH < 4 for total, supine and upright time; (ii) number of refluxes 5 min longer (R5L); and (iii) acid clearance time (ACT) during the supine period, which was measured by dividing total supine reflux time by number of reflux episodes during the supine period.

Abnormal 24-h Esophageal pH Test. Abnormal 24-h esophageal pH was considered if the values of reflux time percent were two standard deviations above the mean values obtained in the healthy subjects.[14]

Types of Refluxers. Patients of reflux were categorized into the following groups: (i) upright refluxers (patients who refluxed in an upright position); (ii) supine refluxers (patients who refluxed in a supine position); and (iii) combined refluxers (patients who refluxed in both supine and upright positions).

Study Protocol

Patients of nocturnal reflux symptoms were admitted and on day 1 were subjected to an esophageal pH test to confirm GERD. During the night these patients slept on a bed with a single pillow (without bed head elevation). Patients who had predominant supine reflux on esophageal pH test continued to stay in hospital on the 2nd day and were subjected to bed head elevation during sleep (supine period). From day 3 to day 7 the same method of bed head elevation was practiced at home. Patients who had an upright or combined reflux were excluded from the study. In order to determine the effect of bed head elevation during the supine period, various factors that could provoke reflux were prohibited, as follows.

Diet. Four meals were given during 24 h, and outside meals the patient could take water only. Gaseous drinks, alcohol, coffee and smoking were prohibited. Patients remained off drugs 1 week before the study and also during the 7-day study period.

Activity. The patients remained upright during the daytime from 05.00 hours to 22.00 hours. During this period, the patient could sit, stand or walk, and would not bend, stoop or lie down. The patient would retire to sleep and would remain in a lying down position from 22.00 hours to 05.00 hours (night-time).

Bed Head Elevation. Bed head elevation was done by raising the entire bed frame on a wooden block of 20 cm height, at the head end. Prior to this, the wheels on the bed where locked to keep the bed in one position only. Our staff and patients attendant ensured that the patients were sleeping in the appropriate position. Patients used a single pillow. Patients were discharged from the hospital on day 3 and were asked to follow the instructions at home as were taught in hospital till day 7. On day 7 patients came back to hospital for a 24-h esophageal pH test. Supine RT%, ACT, number of R5L, symptom grade and sleep disturbance were compared between day 1 (without bed head elevation) and day 7 (with bed head elevation). Each patient therefore acted as his own control.

Statistical Analysis

Statistical analysis was done by using spss for Windows release 11.5 (spss, Chicago, IL, USA). Data are expressed as means and percentages. Appropriate tests were used for comparing data, which included the Student's paired t-test, the χ2-test, and Wilcoxon's signed rank test. Contingency tables were made to compare the grades of symptoms between day 1 and day 7. Differences with P < 0.05 were accepted as statistically significant.


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