- What Are the Common Acid Reflux Symptoms?
- Hanna Saadah
- Acid Reflux and Asthma
- Why GERD May Trigger Asthma
- Why Asthma May Trigger GERD
- Medical Treatments
- Lifestyle and Home Remedies
- Treating silent reflux disease does not improve poorly controlled asthma
- GERD and Asthma Management
- Gastroesophageal Reflux Disease (GERD) and Asthma
What Are the Common Acid Reflux Symptoms?
Heartburn, regurgitation, and dyspepsia are a few of the most common acid reflux symptoms.
Heartburn. Also called acid indigestion, heartburn is a burning pain or discomfort that can move up from your stomach to the middle of your abdomen and chest. The pain can also move into your throat. Despite its name, heartburn doesn’t affect your heart.
Regurgitation. Another common symptom of acid reflux is regurgitation — or the sensation of acid backing up into your throat or mouth. Regurgitation can produce a sour or bitter taste, and you may experience “wet burps.”
Dyspepsia. Many people with acid reflux disease also have a syndrome called dyspepsia. Dyspepsia is a general term for stomach discomfort. Symptoms of dyspepsia include:
- Nausea after eating
- Stomach fullness or bloating
- Upper abdominal pain and discomfort
Symptoms of acid reflux may be a sign that stomach acid has inflamed your esophagus. When that happens, stomach acid can damage the lining of your esophagus and cause bleeding. Over time, it can also change the cells of esphagus and cause cancer (Barrett’s esophagus).
Although acid reflux is extremely common and rarely serious, don’t ignore your acid reflux symptoms. Making a few lifestyle changes and using over-the-counter antacids are often all you need to control acid reflux symptoms.
Dyspnea, which means shortness of breath, has numerous causes. The five major body systems that can cause dyspnea are the a) lungs, b) heart, c) muscles, d) blood, and e) circulation. Disturbances of these five systems such as: a) lung asthma, b) heart failure, c) muscle weakness, d) blood anemia, e) and circulation dehydration all lead to shortness of breath, especially upon exertion. True shortness of breath, therefore, is worsened by exertion (because exertion increases the demand for oxygen) and improves with rest (because rest reduces the demand for oxygen).
Pseudo-dyspnea, which means false shortness of breath, is the opposite of true dyspnea. It is improved by exertion and worsened by rest. One of the best clinical tools that can differentiate between true and false shortness of breath is exertion. Simply asking the patient who suffers from dyspnea if the shortness of breath is made worse or better by activity will clarify the diagnosis. The three main causes of pseudo-dyspnea or the false shortness of breath are a) esophagitis, b) anxiety, and c) panic.
a) Esophagitis, or inflammation of the esophagus, is mostly caused by acid reflux, which is the backlash of stomach acid into the esophagus. Whereas the stomach is constituted like the mouth, the esophagus is constituted like the eye. A drop of lemon juice in the mouth tastes good but the same drop in the eye causes a red eye. Similarly, acid in the stomach is well tolerated because the stomach has a thick mucous coat whereas acid backlash into the esophagus burns and causes inflammation or esophagitis.
Esophagitis is like an iceberg, silent in the majority but causes symptoms in a small minority. Unaware, all of us backlash acid into the esophagus many times a day but anti-reflux defenses come to our rescue and wash the acid away. When our anti-reflux defenses fail, we develop esophagitis and some of us develop symptoms.
The common and well-known symptoms of esophagitis include heartburn, indigestion, abdominal pain, cough, chest pain, sore throat, and hoarse voice. A less known but more worrisome symptom is the feeling of shortness of breath, which usually occurs without the other, more common symptoms. Undiagnosed, this false shortness of breath or pseudo-dyspnea may lead to frequent heart and lung investigations and inappropriate treatments.
There are sensory nerve endings in the esophagus that can send false messages to the brain. When the esophagus is burned by refluxed acid, these nerve endings fool the brain into feeling short of breath, as though the lungs were not providing enough oxygen. Reacting to this feeling, the individual takes in deep sighs in an attempt to alleviate the perceived shortness of breath. But, the more and the deeper the sighs, the worse the perceived shortness of breath gets, rendering the individual restless and anxious. This restless anxiety leads the individual to pace or exercise, which temporarily relieves the shortness of breath. When motion ceases and the individual sits or lies down, the shortness of breath returns.
Treatment of this false shortness of breath relies on suppressing stomach acid and coating the esophagus with acid protecting agents. A combination of Omeprazole (or other acid suppressing medicines) plus Simethicone (or other acid protecting medicines) will give prompt relief and reassurance that there is nothing wrong with the heart or lungs.
Esophageal pseudo-dyspnea cannot be diagnosed with tests, examinations, or procedures. This diagnosis is entirely clinical, based on the history alone, and can only be confirmed with a therapeutic trial. Obtaining relief with acid suppressing and acid neutralizing agents confirms the diagnosis and cures the condition.
b) Anxiety or worry often lead to feelings of shortness of breath, and exercise is again helpful because it temporarily alleviates anxiety. Specific anti-anxiety medicines given by experienced physicians or specific anti-anxiety psychological therapies are both effective in controlling these false symptoms.
c) Panic attacks come on unexpectedly, cause sudden air hunger with feelings of choking or strangulation, and prompt the patient to run away into the open air. Unlike esophageal pseudo-dyspnea and anxiety pseudo-dyspnea, they are self-limited, last no more than an hour, and leave the patient drained and dreading. Like anxiety, treatment depends on both medications and psychological therapies.
To conclude, in all varieties of pseudo-dyspnea, the feeling of shortness of breath leads to hyperventilation. Hyperventilation leads to low carbon dioxide. Low carbon dioxide leads to dizziness, numbness, worry, and restlessness. The diagnoses are entirely clinical, tests and procedures are of little value, successful therapeutic trials confirm the diagnoses, and the prognoses are good. A great deal of suffering occurs because, unlike true dyspnea, pseudo dyspnea is less known and often misdiagnosed and mistreated.
This information is not intended to replace the personal physician, who should always be consulted before any treatment or action are taken.
Acid Reflux and Asthma
People with asthma are twice as likely as those without asthma to develop the chronic form of acid reflux known as gastroesophageal reflux disease (GERD) at one time or another. In fact, research has shown that more than 75 percent of adults with asthma also have GERD. The exact connection between GERD and asthma isn’t entirely clear. However, researchers have a few theories as to why the two conditions may coincide.
Why GERD May Trigger Asthma
One possibility is that the repeated flow of stomach acid into the esophagus damages the lining of the throat and the airways to the lungs. This can lead to breathing difficulties as well as a persistent cough. The frequent exposure to acid may also make the lungs more sensitive to irritants, such as dust and pollen, which are all known to trigger asthma.
Another possibility is that acid reflux may trigger a protective nerve reflex. This nerve reflex causes the airways to tighten in order to prevent the stomach acid from entering the lungs. The narrowing of the airways can result in asthmatic symptoms, such as shortness of breath.
Why Asthma May Trigger GERD
Just as GERD can make asthma symptoms worse, asthma can exacerbate and trigger symptoms of acid reflux. Pressure changes that occur inside the chest and abdomen during an asthma attack, for example, are believed to aggravate GERD. As the lungs swell, the increased pressure on the stomach may cause the muscles that usually prevent acid reflux to become lax. This allows stomach acid to flow back up into the esophagus.
Heartburn is the main GERD symptom that adults face. In some people, however, GERD can occur without causing heartburn. Instead, symptoms may be more asthmatic in nature, such as a chronic dry cough or difficulty swallowing.
Your asthma may be connected to GERD if:
- asthma symptoms begin in adulthood
- asthma symptoms get worse following a large meal or exercise
- asthma symptoms occur while drinking alcoholic beverages
- asthma symptoms happen at night or while lying down
- asthma medications are less effective than usual
It can be difficult to identify symptoms of GERD in children, especially if they’re very young. Infants under age 1 will often experience symptoms of acid reflux, such as frequent spitting up or vomiting, with no harmful effects.
In general, infants and young children with GERD will:
- become irritable
- arch their backs often (usually during or immediately following feedings)
- refuse to eat
- experience poor growth (both in terms of height and weight)
In older toddlers and children, GERD may cause:
- repeated regurgitation
- symptoms of asthma, such as coughing, shortness of breath, and wheezing
Until recently, it was believed that controlling “silent” acid reflux with proton pump inhibitors (PPIs), such as esomeprazole (Nexium) and omeprazole (Prilosec), would help relieve asthmatic symptoms as well. However, a 2009 study published in the New England Journal of Medicine questioned the drugs’ effectiveness in treating severe asthma attacks. During the nearly six-month-long study, there was no difference in the rate of severe attacks between people taking medication and those taking a placebo.
Before the study, researchers estimated that between 15 and 65 percent of people with asthma took PPIs to manage GERD symptoms and control severe asthma attacks. Due to the suspected ineffectiveness of these drugs, however, those with asthma may want to consider other medications to treat their condition.
Make sure you talk to your doctor before changing or abandoning your asthma medications. Some medicines that are commonly used to treat asthma, such as theophylline and beta-adrenergic bronchodilators, may aggravate acid reflux.
Lifestyle and Home Remedies
Since certain medications can be ineffective in treating GERD and asthma simultaneously, the best treatment for these conditions may consist of lifestyle and home remedies.
Controlling GERD Symptoms
To help control or prevent GERD symptoms, you can try:
- losing excess weight
- quitting smoking
- avoiding foods or drinks that contribute to acid reflux, such as:
- alcoholic or caffeinated beverages
- citrus fruits
- fried foods
- spicy foods
- high-fat foods
- tomato-based foods, such as pizza, salsa, and spaghetti sauce
- eating smaller meals more often instead of eating larger meals three times a day
- eating meals at least three to four hours before bedtime
- using a wedge pillow or raising the head of the bed 6 to 8 inches by placing blocks underneath bedposts
- wearing loose clothing and belts
When these strategies and treatments don’t work, surgery is usually an effective last resort in treating GERD.
Controlling Acid Reflux in Children
A few easy strategies for avoiding acid reflux in children include:
- burping infants several times during feeding
- keeping infants in an upright position for 30 minutes after feeding
- feeding children smaller, more frequent meals
- not feeding children foods that can trigger acid reflux (noted above)
Controlling Asthma Symptoms
To relieve asthma symptoms, you may want to consider trying:
- ginkgo extract
- natural herbs, such as butterbur and dried ivy
- fish oil supplements
- deep breathing exercises
Make sure to consult with your doctor before you try any herbs, supplements, or alternative treatments. Your doctor may be able to recommend an effective treatment plan that can help prevent your asthma and GERD symptoms.
Treating silent reflux disease does not improve poorly controlled asthma
Should patients with poorly controlled asthma be treated empirically for gastroesphageal reflux disease (GERD)?
Current guidelines1 indicate that trying a proton pump inhibitor may be worthwhile. However, the results of a recent multicenter trial2 indicate that this does not help control asthma symptoms and that we need to reevaluate the guidelines and focus on other factors that can worsen asthma control.
REFLUX DISEASE IS LINKED TO ASTHMA
GERD’s association with asthma has long been recognized. Asthma patients have a higher prevalence of GERD than the general population, with reported rates of 20% to 80%.3–8
GERD may worsen asthma via several mechanisms. If stomach acid gets into the airway, it can induce bronchoconstriction, vagal reflexes, and chronic airway inflammation, all of which can increase airway reactivity.9–16 Chronic reflux can also cause inflammation of the esophagus, which can exacerbate cough and possibly bronchospasm via neurogenic mechanisms.17
In turn, asthma may worsen GERD. Airway restriction can lead to hyperinflation and increased negative inspiratory pleural pressure, both of which may reduce the effectiveness of the lower esophageal sphincter.18 In addition, the beta-agonists and methylxanthines used to treat asthma may impair function of the lower esophageal sphincter and exacerbate reflux.18–20
CURRENT GUIDELINES ARE BASED ON LIMITED INFORMATION
The symptoms of GERD and asthma are nonspecific and can be similar (chest tightness, chest discomfort), which can make it challenging for clinicians or patients to distinguish asthma from GERD.2 Moreover, in asthma patients, GERD often presents without classic symptoms such as heartburn, and thus has been labeled “silent” GERD.
Earlier studies21–29 (Table 1) suggested that treating GERD may improve asthma control. Based on this information, the most recent asthma guidelines from the National Institutes of Health (NIH) recommend trying GERD treatment in patients with poorly controlled asthma, even if they do not have classic GERD symptoms.1
However, these studies all had significant limitations, such as small sample size. Also, the definitions of asthma and GERD differed from study to study. In some cases, the definition of GERD included self-reported GERD, which often fails to correlate with GERD documented with esophageal pH monitoring in asthma patients.1 These limitations were highlighted in a Cochrane review,30 which found that asthma patients with GERD showed no overall improvement in asthma after treatment of reflux. It concluded that small groups of patients may benefit, but that predicting who will respond is difficult.
Larger randomized controlled trials28,29 attempted to address some of these limitations, with varying results.
Littner et al29 gave lansoprazole (Prevacid) 30 mg twice daily or placebo to 207 patients with moderate to severe asthma and symptomatic GERD and saw no improvement in daily asthma symptoms, ie, asthma control in the active-treatment group. While these patients had an improvement in symptoms of severe reflux, their overall quality-of-life scores were similar to those of the placebo group. Of note, patients needing more than one type of drug for asthma control had a lower rate of asthma exacerbations.
Kiljander et al28 gave esomeprazole (Nexium) 40 mg twice daily or placebo to 770 patients who had mild to moderate asthma and symptoms of nocturnal asthma with or without symptoms of GERD. The only benefit was a slight improvement in peak expiratory flow in those with symptoms of both GERD and nocturnal asthma, and this was most significant in patients taking long-acting beta-agonists. Other measures—eg, the forced expiratory volume in the first second (FEV1), use of a beta-agonist, symptom scores, and nocturnal awakenings—did not improve.
In both of these studies,28,29 patients reported symptoms of GERD, so they did not have silent GERD.
THE DESIGN OF SARA
To address the limitations of the studies discussed above and evaluate the effect on asthma control of treating silent GERD, the American Lung Association and the National Heart, Lung, and Blood Institute funded the multicenter Study of Acid Reflux in Asthma (SARA) (Table 2).2
In SARA, 412 patients age 18 and older with inadequately controlled asthma were randomized to receive esomeprazole 40 mg twice a day or placebo for 24 weeks. Inadequate control was defined as a score of 1.5 or higher on the Juniper Asthma Control Questionnaire31 despite treatment with inhaled corticosteroids. Patients had no symptoms of GERD. The 40-mg twice-daily dosage of esomeprazole was chosen because it is known to suppress more than 90% of acid reflux.24,32
All patients completed a baseline asthma diary, recording peak expiratory flow rates, asthma symptoms, nighttime symptoms, and beta-agonist use. This information was collected every 4 weeks throughout the trial.
All participants also underwent esophageal pH monitoring for an objective confirmation of GERD. Patients were randomized independently of the results of the pH probe; in fact, investigators and patients were blinded to these results.
The primary outcome measure was the rate of episodes of poor asthma control, with poor control defined as any of the following:
- A decrease of 30% or more in the morning peak expiratory flow rate on 2 consecutive days, compared with the patient’s best rate during the run-in period
- An urgent visit, defined as an unscheduled health care visit, for asthma symptoms
- The need for a course of oral prednisone for treatment of asthma.
Asthma was defined as doctor-diagnosed, plus either a positive methacholine challenge test (a concentration of methacholine causing a 20% reduction in FEV1 < 16 mg/mL) or a positive bronchodilator response (a 12% increase in FEV1) to an inhaled beta-agonist. Participants had no other indication for acid suppression, including symptoms of GERD or previously diagnosed erosive esophageal or gastric disease.
Acid reflux was evaluated by ambulatory pH monitoring, which had to last at least 16 hours and span one meal and 2 hours in the recumbent position. Reflux was present if the pH was less than 4.0 for more than 5.8% of total time, 8.2% of time upright, or 3.5% of time lying down.33 Episodes and severity were measured by the Gastroesophageal Reflux Disease Symptom Assessment Scale.34
GERD and Asthma Management
GERD, or Gastro-Esophageal Reflux Disease, triggers or worsens respiratory symptoms in a number of people with asthma. Once the GERD is controlled, asthma often improves – leading to a reduction in medication required and allowing easier breathing. GERD is a common condition in which the acid from the stomach flows up the esophagus causing irritation and inflammation. This is often felt as a burning sensation in the upper abdomen and can lead to a bad taste in the mouth and a sense of burning in the chest if the fluid rises high enough. Since the nerves in the lower esophagus are connected to the nerves in the lungs, it is common for acid reflux to trigger asthma symptoms so it is important to control the reflux as much as possible. The most important way to control reflux is to first see a doctor to make sure that reflux is the correct diagnosis, as other conditions can mimic it. The treatment for GERD itself is the same as if one did not have asthma. In many cases a simple trial of an acid reducer such as ranitidine, which is available over the counter, might control the symptoms. Stronger medications called proton pump inhibitors also can reduce acid secretion. From a dietary standpoint, it helps to avoid eating meals for several hours before bedtime (avoiding large evening meals) and to reduce fat intake. Alcohol consumption in excess and caffeine can also predispose to acid reflux. Sleeping on several pillows with the upper body propped up to let gravity keep the fluid down may help. Weight loss for those who are overweight is recommended, as weight gain can worsen reflux. It is also important to assess whether certain asthma medications may be worsening GERD. Asthma medications that could increase reflux include theophyllines and oral steroids, and should be used only if there are no other alternatives. For most who suffer from both conditions, asthma can be controlled with the usual asthma therapies along with treatment of GERD. If these simple measures don’t work, then more extensive evaluation and treatment may be needed. Sometimes, medical therapy is not adequate and GERD will require a surgical repair. Further evaluation should be done under the supervision of a qualified physician.
Gastroesophageal Reflux Disease (GERD) and Asthma
Gastroesophageal reflux disease, known as GERD, is the pathological reflux of stomach contents, including stomach acid, into the esophagus. The unpleasant symptoms of this disease are known as “heartburn,” and they have been associated with a cough.
Heartburn and gastroesophageal reflux disease (GERD) can also trigger asthma symptoms. Try the following to reduce reflux symptoms:
- Eat smaller meals.
- Do not lie down for two to three hours after eating.
- Avoid foods that can trigger your heartburn or GERD symptoms.
- Talk to your health care provider about medicine that may help your GERD.
Asthma patients who report frequent heartburn should stop eating two to three hours before they go to bed, should raise the head of the bed 6 to 8 inches and may be prescribed antacid proton pump inhibitor medications for GERD by their provider. Diet modifications such as avoiding fatty foods, fried foods, spicy foods, chocolate, caffeine, peppermint or large meals may help control GERD symptoms.
Knowing how to manage asthma is important for better health and quality of life. We offer an online course called ASTHMA Care for Adults. This comprehensive program covers a full range of topics everyone with asthma needs to know. This self-paced online course is presented in different formats, such as videos, animations, handouts and more.
Medical Review June 2019.
Asthma is treated by drugs that relax the muscle of the breathing passages. Drugs also reduce swelling and/or stop the breathing passages from responding to irritation.
Asthma caused or made worse by laryngopharyngeal reflux is assessed in the same way as the latter condition.
Ways that patients may help relieve the condition include:
- Elevating the head of the bed four to six inches
- Avoiding alcohol, chocolate and caffeine
- Avoiding overeating
- Eating or drinking nothing two to three hours before bed
- Avoiding greasy, fatty foods
- Losing weight
- Maintaining a healthy weight
- Abstaining from smoking
The doctor may suggest one or more of the following treatments:
- Antacids to offset having too much stomach acid
- Anti-secretory drugs that lower acid production by the stomach. These include two types of drugs: histamine 2 receptor blockers and proton pump inhibitors.
- Surgery to tighten the junction between the stomach and esophagus. The most common surgery is done by wrapping the top part of the stomach around the junction between the stomach and esophagus. It is then sewn in place.