How do Proton Pump Inhibitors (PPIs) help with laryngospasm?

How PPIs Help with Laryngospasm

PPIs do not directly treat laryngospasm itself, but rather address the underlying laryngeal inflammation and irritation caused by gastroesophageal reflux that may predispose to laryngeal hyperreactivity and spasm. The mechanism involves reducing gastric acid production, which decreases acid exposure to the laryngeal tissues, allowing healing of chronic laryngitis that can trigger laryngospasm episodes.

Mechanism of Action in Laryngeal Protection

PPIs suppress gastric acid secretion for up to 36 hours, reducing the acidic refluxate that reaches the laryngopharynx and causes mucosal injury. 1 When gastric contents reflux into the laryngopharynx, they cause:

• Erythema, edema, and surface irregularities of the vocal folds and arytenoid mucosa 1
• Chronic inflammation that increases laryngeal sensitivity and reactivity 1
• Mucosal damage that can predispose to laryngospasm episodes 1

By healing these inflammatory changes, PPIs may reduce the laryngeal hyperreactivity that leads to laryngospasm.

Evidence for PPI Efficacy in Laryngeal Symptoms

When PPIs May Be Beneficial

PPIs should be considered when laryngoscopy demonstrates objective signs of chronic laryngitis (erythema, edema, redundant tissue, or surface irregularities of the interarytenoid mucosa, arytenoid mucosa, posterior laryngeal mucosa, and/or vocal folds). 1

• Twice-daily PPI dosing is superior to once-daily dosing for laryngopharyngeal symptoms, with response rates of 50% at 2 months versus 28% for once-daily dosing 2
• Treatment duration of 8-12 weeks is optimal for extraesophageal reflux symptoms 1
• At 4 months, overall response rates reach 70-72% with aggressive twice-daily PPI therapy 2

When PPIs Are NOT Recommended

PPIs should NOT be prescribed empirically for laryngeal symptoms without either typical GERD symptoms (heartburn/regurgitation) or laryngoscopic evidence of laryngitis. 1 The evidence shows:

• A randomized trial of 145 patients with chronic laryngeal symptoms and laryngoscopic laryngitis found no benefit of esomeprazole 40mg twice daily versus placebo for symptom scores or quality of life 1
• Meta-analyses show no advantage for PPIs over placebo for GERD-related chronic laryngitis (relative risk 1.28; 95% CI 0.94-1.74) 1
• Six out of nine systematic reviews concluded PPIs are not superior to placebo for laryngopharyngeal reflux 3

Clinical Algorithm for PPI Use

Step 1: Perform Laryngoscopy

Direct visualization is essential to identify objective signs of laryngeal inflammation before initiating PPI therapy. 1

Step 2: Assess for Concomitant GERD Symptoms

PPIs are most appropriate when patients have both laryngeal symptoms AND typical esophageal reflux symptoms (heartburn/regurgitation). 1

Step 3: Dosing Strategy if Treatment Indicated

• Start with twice-daily PPI dosing (e.g., lansoprazole 30mg BID or omeprazole 40mg BID) 2
• Continue for minimum 8-12 weeks before assessing response 1
• If no response at 2 months, continue for full 4 months as additional 22% response occurs between months 2-4 2

Step 4: Combine with Lifestyle Modifications

• Avoid food intake 2-3 hours before recumbency 1
• Elevate head of bed 1
• Weight loss if overweight/obese 1
• Avoid trigger foods on individualized basis 1

Important Caveats and Pitfalls

Diagnostic Limitations

Laryngoscopic findings have poor inter-rater reliability and can be present in healthy individuals without reflux. 1 Findings like posterior commissure hypertrophy and pseudosulcus were noted in healthy volunteers without GERD symptoms. 1

PPI Risks to Consider

Long-term PPI use carries risks including:

• Hip fractures in older adults 1
• Vitamin B12 deficiency 1
• Iron deficiency anemia 1
• Increased pancreatitis risk 1

Predictors of Response

Pretherapy abnormalities of the interarytenoid mucosa and true vocal folds are associated with twofold increased likelihood of symptom response to PPIs (odds ratio 1.99 and 1.96 respectively). 2

Bottom Line for Laryngospasm

PPIs do not acutely treat laryngospasm episodes but may reduce their frequency by healing underlying laryngeal inflammation from reflux. However, the evidence for this indication is weak and conflicting. Only use PPIs when objective laryngoscopic evidence of chronic laryngitis exists, preferably with concomitant typical GERD symptoms, and always weigh the risks of long-term PPI therapy against uncertain benefits. 1