Gastroesophageal reflux is an important and treatable cause of chronic pulmonary disease. Clinical investigation using continuous intraesophageal pH monitoring has shown that the presence or absence of sleep as a factor in the pathophysiology may modulate upper and/or lower respiratory tract involvement. Knowledge of this pathophysiology is useful when eliciting the history, as is identifying the type of 'refluxer' and noting the site of respiratory involvement. While a simple diagnostic test to document a causal relationship between reflux and its respiratory sequelae is lacking, a positive therapeutic response to empiric therapy for reflux can serve as a practical diagnostic aid. With proper patient selection, both medical therapy and surgical therapy are effective in relieving the esophageal and respiratory consequences of reflux.