BACKGROUND: Gastroesophageal reflux disease (GERD) may be associated with episodes of bronchoaspiration, sometimes leading to life-threatening respiratory complications. GERD is frequently observed in the setting of type 1 (sliding type) hiatal hernia, but only infrequently complicates the course of type 2 (paraesophageal) hernia. METHODS OF STUDY: We performed a retrospective analysis of 50 patients operated for type 2 hiatal hernia in our hospital, to determine the prevalence of respiratory complaints related to GERD in this setting. RESULTS: We found 7 cases (14%) of type 2 hiatal hernia complicated by pulmonary manifestations as the only symptoms of GERD. These ranged from dyspnea to severe bronchoconstriction and acute respiratory failure. The series is illustrated by the report of 1 patient who experienced acute bronchospasm and cardiopulmonary arrest as a complication of GERD. In all patients, surgical repair of the hiatal hernia, together with an antireflux procedure, resulted in complete resolution of the respiratory complaints for follow-up periods up to 160 months. CONCLUSIONS: Our data emphasize the particular prevalence of respiratory involvement in the case of GERD complicating type 2 hiatal hernia, and also the excellent symptomatic results obtained by surgical therapy for this condition.