OBJECTIVE: The association of gastroesophageal reflux disease (GERD) and respiratory symptoms is well known. The coexistence of ineffective esophageal motility (IEM, low-amplitude [< 30 mm Hg] or nontransmitted contractions in > or = 30% of 10 wet swallows in the distal esophagus) in patients with GERD has recently been demonstrated. Our aim was to determine the prevalence of IEM in patients with GERD-associated respiratory symptoms. METHODS: Manometry and pH studies of 98 consecutive patients with respiratory symptoms and abnormal reflux shown by pH-metry were reviewed. Symptoms were chronic cough (n = 43), asthma (n = 13), and laryngitis (n = 42). Sixty-six patients with heartburn with no extraesophageal manifestations were used as a control group. Total esophageal acid clearance (EAC) time was calculated for each patient. RESULTS: IEM was the most common motility abnormality seen in all groups of GERD patients. It was seen significantly more often in patients with chronic cough (41%) (p = 0.003) or asthma (53%) (p = 0.01), and numerically more often in patients with laryngitis (31%) than in patients with heartburn (19%). Diffuse esophageal spasm and nutcracker esophagus were rarely seen. Incidence of hypertensive or hypotensive lower esophageal sphincter was similar across all groups. The total EAC time was longer (median: 1.51 min/episode) (p = 0.01) in patients with GERD-associated respiratory symptoms than in patients with heartburn (median: 0.72 min/episode). CONCLUSIONS: IEM is the most prevalent motility abnormality in patients with GERD-associated respiratory symptoms. Coexistence of IEM with GER may place patients at high risk for respiratory symptoms due to the associated delayed esophageal acid clearance seen with this motility abnormality.