Many cases of asthma do not present with the typical recognizable symptoms. So you may not initially think asthma. You might think you have allergies or some other exposure to a substance or product in the environment, at home or in the work place, that’s instigating symptoms. You may also not think it’s asthma because the symptoms present at peculiar times and you don’t respond to traditional asthma therapy when it’s dispensed. You or your doctor, in that case, may even decide to increase dosages or add medications, and yet, you still don’t respond. What gives?
The more you look at external causes, the farther you may get from diagnosing the real inner cause: gastric reflux. It’s probably hard to imagine that acid produced by the stomach can cause shortness of breath. The fact is that gastric reflux is one of the most common causes of chronic cough.
How Acid Reflux worksThe stomach produces acid in order to digest proteins and kill the bacteria that commonly enter the GI tract. The stomach is equipped with a thick lining called the** gastric mucosa** that helps it to resist the burning effect of the acidity. The** esophagus** is the pathway that connects the mouth to the stomach, and it is not equipped with such a thick (protective) mucosal layer. After swallowing, the food contents go through the esophagus and enter the stomach. A sphincter valve between the two opens to allow the passage of the food. The sphincter then closes to keep the food there and allows the mixing of food and acidic gastric juices.
In certain situations, the process of digestion does not run smoothly. Obese people, especially those with central obesity, have their stomach pouch pushed up to the chest area, a condition known as hiatal hernia, which can interfere with the sphincter action. Individuals who consume large amounts of alcohol or caffeine have a situation where the sphincter to the stomach does not fully close. In both cases, this allows the gastric juices to back track into the esophagus (meaning they flow in the exact opposite direction) causing inflammation and erosion in the esophageal mucosa. This is what is known as Gastro Esophageal Reflux Disease (GERD). The condition is commonly treated with antacid medications, such as omeprazole or ranitidine. This may reduce the acid content but does not address the main issue, which is the incompetence of the sphincter, so the condition often persists.
How does this condition cause respiratory symptoms?
The same nerve that goes to the terminal esophagus the vagus nerve, which infiltrates many parts of the body is also very active in the bronchi of the lungs. So irritation of the esophagus has implications in the lungs. In some cases there’s a resulting cough, while at other times the person suffers with wheezing. Very frequently, I have patients who have gone to an Ears Nose and Throat (ENT) specialist complaining of throat soreness and the patient is diagnosed with erosion in the vocal cords, attributed to GERD.
Most important is that in this case of asthma, the symptoms occur at night. Asthma during sleep has very serious consequences, because a person’s breaths are quite shallow, and one is less sensitive to resulting changes in levels of oxygen and carbon dioxide. This situation is made even worse when people go to sleep with a full stomach. Muscles routinely become flaccid during sleep, so the sphincter that contains the stomach juices is open. If the stomach is full, it stimulates more acid production, which then flows back and causes even more erosion because of the horizontal position during sleep. This allows the acidic fluids to go up the throat and sometimes even fall into the lungs, throughout the night. A person will only realize this in the morning, when experiencing a bitter taste in the mouth.
What can you do to avoid asthma caused by GERD?
- Avoid eating late at night
- Limit alcohol
- Make dinner portions smaller
- Avoid caffeinated drinks late in the day
- Raise the head of the bed by at least six inches
- Do not lie down within two to three hours of eating
- Avoid carbonated beverages
- Lose weight, stop smoking
- Consider taking medications that reduce stomach acid
Unfortunately, if you increase the dose of asthma medications, or add additional asthma medications, you may experience palpitations and/or shaking. If you are prescribed more steroids, you may experience weight gain. You will then probably have poor sleep and still have the symptoms of asthma caused by GERD. A proper diagnosis is key to addressing asthma caused by GERD. If you start to exhibit GERD symptoms, speak with your doctor.
Eli Hendel, M.D., is a board-certified internist/pulmonary specialist with board certification in Sleep Medicine. An Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, and Qualified Medical Examiner for the State of California Department of Industrial Relations, his areas include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases. Favorite hobby? Playing jazz music. Find him on Twitter @Lung_doctor.