Definition

Reflux-related asthma is defined as symptoms of asthma (such as cough and wheezing) that manifest in members of the adult population who have no history of allergy, do not smoke, who present with respiratory symptoms that are worse after eating or during the night, and who may show improvement of their symptoms with antacid therapy.

Causes

The esophagus and trachea (windpipe) are in close relationship. Gastroesophageal reflux disease is common in patients with asthma and has been identified as a potential trigger for asthma, and patients with gastroesophageal reflux disease may have asthma-like symptoms.

There is a mutual cause-and-effect relationship between asthma and gastroesophageal reflux disease. In some situations, reflux disease can actually cause the asthma, particularly adult-onset asthma. In other cases the gastroesophageal reflux can potentiate existing asthma, making it difficult to control. In addition, asthma symptoms such as cough and wheezing magnify the difference in pressure between chest (negative pressure) and abdomen (positive pressure), encouraging gastroesophageal reflux.

Gastroesophageal reflux disease can cause asthma-like symptoms via two mechanisms. First, aspiration of acid particles in the trachea can cause coughing, wheezing and pneumonia; and second, the presence of acid in the esophagus causes a reflex phenomenon in the trachea, triggering asthma-like symptoms.

Thus, it is important for physicians to consider the possibility of gastroesophageal reflux disease when treating patients with pulmonary problems.

Symptoms

Patient can present with the typical (common) symptoms of reflux disease, including heartburn, dysphagia (difficulty swallowing) and regurgitation. However, as a result of the close relationship between the esophagus and windpipe, many patients may present with respiratory symptoms referred to as atypical (uncommon) symptoms of reflux including:

• Chronic cough
• Hoarseness (voice change)
• Wheezing
• Pneumonia
• Aspiration: Chronic aspiration of gastric acid and bile (non-acidic fluid), which typically occurs at night when patients are Iying down, can severely damage the lungs and vocal cords. Long-standing aspiration can even cause severe pulmonary disease such as pulmonary fibrosis.

Diagnosis

• Videoesophagram
• Esophageal motility study
• Esophageal pH assessment
• 24-hour pH study. In patients with respiratory symptoms, additional measurement in the upper part of the esophagus is made to identify how much acid refluxes up into the mouth, pharynx and possibly into the windpipe, causing respiratory symptoms and damage to the lungs.
• 48-Hour Esophageal pH testing with the Bravo capsule wireless system
• Pharyngeal pH assessment In patients with respiratory symptoms, additional measurement in the pharynx is made to identify how much acid refluxes up into the mouth, pharynx and possibly into the windpipe, causing respiratory symptoms and damage to the lungs.
• Upper endoscopy

Treatment

Dietary and Lifestyle Changes
By Michel Kafrouni, M.D.

Many patients succeed in relieving most if not all the symptoms of gastroesophageal reflux disease (GERD) by changing the way they eat, what they eat and when they eat. Several foods can decrease the pressure at the lower esophageal sphincter, which works as a gateway preventing the acid from getting to the esophagus. Spicy foods, fatty foods, alcohol, sodas, smoking cigarettes, chocolate, coffee and all caffeinated products, peppermints, tomato-based juices and products, and citrus products are examples of those foods. Avoiding those foods will help control GERD.

Some day-to-day lifestyle modifications should be initiated and continued throughout the course of treatment for reflux disease. These include avoiding tight clothes, elevating the head of the bed, avoiding large meals, fasting for three hours before going to bed, and losing 5 percent of one’s body weight.

Medical Treatment
By Michel Kafrouni, M.D.

Despite dietary and lifestyle changes some patients still require medications to control their reflux symptoms. The medications can be given for a short period of time to help with the acute symptoms and to give time for the lifestyle and habits to change. However, some patients require lifetime treatment. Many medications have been used to control GERD. Proton pump inhibitors (PPIs) are the mainstay of treatment. They are potent acid reducers that block the pumps responsible for supplying the acid to the stomach. PPIs include omeprazole, lansoprazole, pantoprazole, esomeprazole and others. These medications are generally safe and can be taken once or twice per day (half an hour before breakfast or dinner).

Other medications have been used to treat GERD. Antacids neutralize the acidity of the stomach and provide short-term relief. Other medications, such as sucralfate, provide a barrier that lines the esophageal and stomach mucosa and protect it from the gastric juices, thus providing the time needed to heal. Some antihistamines, such as ranitidine and famotidine, also can be used to decrease the secretion of acid into the stomach lumen.

Most commonly, the refluxed gastric contents are acidic, and typical medical therapy for reflux aims to suppress gastric acidity. However, bile (non-acidic fluid) may also be present within the gastric juice that is refluxed up into the esophagus and into the trachea (windpipe), and will cause damage to the lungs. Neutralization of acid does not prevent injury to the lungs from the non-acidic fluid. Therefore, even with suppression of acid production, damage to the lungs may continue despite medical therapy in patients with bile reflux.

Surgical Treatment

Approximately 25 percent of patients with gastroesophageal reflux disease will develop progressive disease and complications such as hiatal hernia and Barrett’s esophagus, and severe respiratory symptoms such as recurrent pneumonia and damage to the lungs. In these patients, surgical treatment should be considered. In addition, surgery should be discussed with patients who continually regurgitate despite the reduction of acidity, have intolerance to medications used for treating gastroesophageal reflux disease, or respond well to these medications but do not want to continue taking them for the rest of their lives.

The aim of surgical treatment is to restore the function of the lower esophageal sphincter (the valve between the esophagus and the stomach) to prevent the reflux of acid and bile (non-acidic fluid) from the stomach into the esophagus. The most common procedure to restore the function of the lower esophageal sphincter is a minimally invasive procedure called laparoscopic Nissen fundoplication and is routinely performed at the Memorial Hermann Southeast Esophageal Disease Center for the treatment of patients with gastroesophageal reflux disease.