Asthma and Gastroesophageal Reflux Disease
People with gastroesophageal reflux disease (GERD) often suffer recurrent chest distress and commonly experience asthma symptoms.
This fact sheet provides useful information about the relationship between asthma and GERD. We hope that this material helps you better understand the nature of asthma symptoms, especially as they may relate to GERD. Please keep in mind that this information is not meant to take the place of medical advice from your physician.
After 51-year-old Percy feasted on his wife’s Thanksgiving
dinner, he popped a couple of antacid tablets to ward off the usual heartburn. But the feeling that he couldn’t quite catch his breath just wouldn’t go away. Throughout the holiday season, the frequent parties and irregular eating schedule only seemed to make his heartburn feel worse than ever before plus he developed a wheezing cough that plagued him late at night. When he visited his internist in January, the physician told him he probably had asthma- related GERD — and together they developed a plan of treatment to help Percy feel better.
What is asthma?
Asthma is a disease of increased responsiveness of the airways to various stimuli including allergens and irritants that cause obstruction of the airways. Constriction of muscles around the airway and inflammation result in swelling of the lining and increased secretion of mucous. The most common causes of an asthma flare up are infection, exercise, allergens, and air pollution (an irritant). Allergens and irritants are substances found in our everyday environment. People who have asthma may experience wheezing, cough, shortness of breath, and chest tightness. Asthma can begin at any age but with proper management and education, people with asthma can lead normal, active lives.
What is gastroesophageal reflux disease?
GERD is a digestive disorder that affects the circular band of “sphincter” muscle of the lower esophagus. The esophagus is the “food tube” that carries swallowed food to the stomach.
Normally, the lower esophageal sphincter muscle opens (relaxes) to allow food to pass into the stomach and then closes tightly (contracts) to keep stomach contents from backing up into the esophagus. Gastroesophageal reflux occurs when the lower esophageal sphincter does not close completely, allowing some semi-digested food and gastric acid to be pushed back up into the esophagus. This pushing back is known as reflux. The sensation caused by the refluxed food and acid gastric juice usually creates a burning sensation felt as “heartburn.”
People with GERD may experience reflux periodically or on a very regular basis — both upright and when lying down.
Statistical fact: According to the American College of Gastroenterology, at least 60 million Americans experience heartburn at least once a month; of these, more than 15 million experience daily heartburn symptoms. Symptoms of heartburn, popularly known as “acid indigestion,” are more common among elderly and obese persons and pregnant women; however, GERD can occur in all body types and even in infants.
What is the link between asthma and gastroesophageal reflux disease?
Researchers have discovered that GERD can trigger asthma symptoms. In addition, GERD is more common in people with asthma than in the general population. Individuals whose asthma is especially hard to treat appear to be more prone to GERD than other affected persons.
Generally speaking, reflux may cause asthma symptoms in two ways.
1) The stomach acid that leaks back into the esophagus creates a chain reaction leading to asthma symptoms. The refluxed gastric acid irritates the nerve endings in the esophagus generating signals to the brain. Subsequently, the brain responds with impulses to the lungs that stimulate the muscle and mucus production in the airways. The small airways of the lungs then constrict, resulting in asthma symptoms.
2) In many cases, physicians believe that the refluxed stomach contents enter the lungs directly. This situation is called aspiration. The foreign material is a potent irritant for the airways, creating wheezing, coughing, chest tightness, and other symptoms of asthma.
Some experts believe that asthma also may trigger GERD, when breathing difficulties or certain asthma medications cause the esophageal sphincter muscle to relax and allow stomach contents to reflux — completing a troublesome, potential vicious cycle.
Who develops GERD-related asthma?
Anyone — including infants, children, and teens — can develop gastroesophageal reflux. Keep in mind that people may experience GERD symptoms periodically or chronically. GERD symptoms also may be related to eating specific foods or, rarely, even to food allergies.
GERD, asthma, and children
The National Institutes of Health (NIH) reports that GERD often may be overlooked in babies and young children. Recent studies strongly suggest that GERD aggravates or may be the predominant cause of asthma symptoms in the very young.
Since small children have underdeveloped digestive systems, they are more likely to experience GERD and its consequences. Not only does GERD cause repeated regurgitation and reflux in very young children, but it also may be the cause of chronic cough or other respiratory problems. Regular burping during feedings and an upright position for at least 30 minutes after feedings can reduce reflux. Newborns and infants usually outgrow regular bouts of reflux by one year of age. Older children with reflux may benefit from dietary adjustments.
Stat fact: GERD affects as many as 89% of all patients with asthma, regardless of their age, sex, or ethnic background. (American Academy of Allergy, Asthma and Immunology)
What causes GERD?
The precise causes of gastroesophageal reflux disease are often unknown; however, physicians do know that a variety of factors can increase your risk for developing this problem. These factors include:
• Excessive use of alcohol
• Hiatal hernia (in which part of the stomach rises into the chest)
In addition, some foods are known to make symptoms of reflux more likely if you already have a problem with it. These foods include:
• Spicy foods
• Fatty foods
• Fried food
• Garlic, onions
• Citrus fruits
• Tomato-based foods, such as pasta sauces
Asthma medications and GERD
Recent studies indicate that some asthma medications may promote gastric reflux. For example, prednisone and albuterol can possibly decrease the contracting abilities of the esophageal sphincter, thus allowing reflux. Certain other bronchodilators, which relax the smooth muscles of the esophagus, can increase the possibility for gastric reflux. Still, many patients who use those asthma medications regularly will not necessarily develop GERD or experience worsened symptoms.
What are signs and symptoms of GERD-related asthma?
You may have symptoms of both GERD and asthma, or you may only note asthma symptoms, but not both. Your physician will help you determine if your asthma may be related to gastroesophageal reflux by discussing your symptoms and possibly performing one or more useful tests. The following are of special importance:
• You get a burning sensation — heartburn — in your lower mid-chest after eating a meal, especially a large meal that leaves you feeling really full. The burning sensation is worse when you lie down after the meal.
• Using antacid medications often relieves your heartburn feeling.
• You experience regurgitation after meals or awaken from sleep with sour liquid in your mouth.
• You have bad breath regularly.
• You have frequent hiccupping or burping.
Some people have GERD with no symptoms of heartburn. These individuals may feel chest pain, difficulty swallowing, or have the feeling that something is stuck in their throat or swallowing becomes blocked.
When asthma symptoms are related to a problem with gastroesophageal reflux, one or more of the following are common:
• Your asthma symptoms often follow a large meal
• Your asthma seems to get worse during sleep
• Your asthma symptoms worsen in mid-life and do not appear to be related to allergy or seasonal infections
• You are hoarse on a regular basis
• You have frequent coughing
• Your asthma does not respond well to the usual asthma medications
How is GERD-related asthma diagnosed?
A diagnosis of GERD-related asthma is not always easily made. To weigh this possibility, your physician may ask you to monitor and record your asthma symptoms in detail over a period of time.
In addition, you may be asked to undergo a 24-hour study of your esophagus with an acid-sensing indicator to determine the presence or amount of reflux. A “proton pump inhibitor” also can be used to markedly reduce stomach acid production for one or two months. If you have GERD-related asthma, this therapy should help reduce your asthma symptoms.
What is the treatment for GERD- related asthma?
The key to treating asthma symptoms related to GERD is to treat the gastroesophageal reflux and reduce the potential for damaging the lining of the esophagus from reflux. Many patients who have GERD-related asthma symptoms improve once they successfully address the gastric reflux problem.
Treating and managing GERD may be done in several ways.
1. Medications. Several medications are available to help reduce the secretion of gastric acid. Talk with your physician about using over-the-counter-medications (such as Zantac-75®, Pepcid-AC®) before doing so.
If over-the-counter medications do not help you after two weeks, be sure to tell your physician. Prescription medications to reduce stomach acid are often necessary.
2. Diet. Studies show that reducing your consumption of specific foods can help with GERD. Individuals vary in what foods they can tolerate, so you may have to do a little experimenting. Physicians recommend that people with reflux problems avoid fatty and fried foods; caffeinated drinks; onions; garlic; tomato-based products; citrus fruits; pepper; chocolate; peppermint; and alcoholic beverages.
3. Eat smaller meals. Less food in your stomach may minimize the possibility of reflux. Try eating five to six “mini-meals” spaced throughout the day and early evening, instead of three larger meals.
4. Eliminate tobacco use. Nicotine may be a factor in causing the esophageal sphincter to relax. When this happens, reflux can occur.
5. Lose weight. Unhealthy excess body weight can increase the pressure on your stomach and esophagus, causing reflux.
6. Avoid lying down after meals. You feel sleepy after a full meal, but lying down within three hours of eating can increase the possibility of reflux. Try keeping the head of your bed elevated, as well, to help reduce the role of gravity in causing reflux.
7. Eat dinner early. If you eat at least three hours before going to bed, it will allow your stomach to empty more completely, and reduce the amount of acid in your stomach.
8. Loosen your belt. You may get some relief by wearing looser clothing around your waist and lower abdomen.
Who should treat GERD-related asthma?
If you already have diagnosed asthma, talk with your asthma physician (often an allergist/immunologist or a pulmonologist) about your symptoms. Your physician may refer you to a gastroenterologist for treatment of GERD if your symptoms are severe. Those who have completed training in these specialties are usually called either board- certified or board-eligible.
If you have never been diagnosed with asthma, seek treatment first with your internist or family physician. Your internist or family physician may refer you to an asthma specialist or a physician who treats gastrointestinal disorders, depending on the nature of your symptoms.
Does health insurance cover asthma treatment?
Most health insurance plans provide some level of coverage for asthma patients. Check with your insurance carrier for details. Some things you may want to find out might include:
• Do you need a referral to a specialist from your internist, family physician, or pediatrician?
• Does the insurance carrier offer any patient education or specialized services related to asthma? To GERD? To asthma-related GERD?
• What medications are not covered by your plan? (There can sometimes be a delay in approving newly released medications. Your physician may know about them, but your insurance may not cover them yet.)
What does the future hold for GERD?
The National Institutes of Health report that research is underway to explore the root causes of gastroesophageal reflux disease. Key studies are focusing on the role of hiatal hernia in GERD and the impact of the bacterium, Helicobacter pylori (H.pylori), in causing or preventing various stomach diseases. Scientists expect that application of their research results will improve treatment for GERD and related conditions.
The information provided in this fact sheet should not be a substitute for seeking responsible, professional medical care.
Reprinted with permission from “Asthma and Allergy Answers,” the patient education library developed by the Asthma and Allergy Foundation of America.