Gastro-oesophageal reflux disease and non-asthma lung disease
However, a significant number of asthma patients have silent GERD (ie, GERD only detected by pH probes). In the previously mentioned ACRC study, none of the 38% of patients who had a positive pH probe had classic symptoms of GERD. But in a subset of people with severe asthma, GERD treatments could actually worsen their breathing troubles.
Numerous methods have been utilized to support the diagnosis of GERD-related pulmonary disease. These methods (Table 1) include (1) inspection of sputum for lipid-laden alveolar macrophages, (2) scintigraphic monitoring to document pulmonary aspiration of gastric contents, (3) ambulatory esophageal pH monitoring and acid infusion of the esophagus to provoke vagally mediated bronchoconstriction, and (4) surveys on the prevalence of GER symptoms. Unfortunately, none of these techniques has been proved reliable to predict which patients may have GER-triggered or GER-associated pulmonary disease.
The EPR-3 guidelines provide the framework for assessing the patient, gathering diagnostic and disease monitoring information to establish the diagnosis and follow its course, treatment options and strategies, patient and family education, and it addresses comorbid conditions. Treatment is based on severity and includes medications (classified as rescue or control), education, self-management, strategies to prevent exposure to triggers, and reduce problems caused by comorbid conditions.
Treatment today is not much different, and involves elevating the head of your bed, weight loss, and a diet that eliminates alcohol, caffeine, smoking, and carbonated beverages. It is also recommended to eat small meals, and to eat 2-3 hours before lying down to sleep.
Treatment may also involve over the counter or prescribed medicine to reduce stomach acid and prevent reflux. This makes airways hypersensitive (twitchy) in response to asthma triggers (one of which may be the acid reflux itself), resulting in airway narrowing and airflow limitation that is reversible and controlled with asthma rescue medicine and inhaled corticosteroids (often high doses).
Of note, patients needing more than one type of drug for asthma control had a lower rate of asthma exacerbations. JGM It is not entirely clear why GERD is more common in asthma patients. Several theories have been advanced, with the most common one being that pressure swings in the thorax of asthmatics allow more acid to reflux into the esophagus. There are animal studies that suggest that instillation of acid in the esophagus stimulates vagal tone and may increase respiratory resistance and â€œprimeâ€ the airways for bronchoconstriction. These and other animal studies suggest that chronic microaspiration from GERD may trigger bronchoconstriction and also possibly increase inflammation in the airways.
The LES is a muscle at the bottom of the food pipe (esophagus). The LES opens to let food into the stomach. It closes to keep food in the stomach. When the LES relaxes too often or for too long, stomach acid flows back into the esophagus.
When aspiration is unaccompanied by symptoms, it can result in a slow, progressive scarring of the lungs (pulmonary fibrosis) that can be seen on chest X-rays. Aspiration is more likely to occur at night because that is when the processes (mechanisms) that protect against reflux are not active and the coughing reflex that protects the lungs also is not active.
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On the other hand, some studies have shown that treatment of reflux (by either medical or surgical means) resulted in improvement in asthma symptoms. Current guidelines, based on data from older studies with significant limitations, recommend considering treatment for reflux disease, even without the classic symptoms, in patients with uncontrolled asthma. evaluated tachykinin levels and reflux parameters in a group of patients with chronic cough and mild asthma and in patients with no asthma. Their results showed increased tachykinin levels in those with reflux and a significant correlation between distal esophageal acid exposure and bronchial levels of substance P and neurokinin A, suggesting vagus-induced activation of airway sensory nerves. There are multiple mechanisms by which asthma and GERD can interact.
MECHANISMS OF A POSSIBLE RELATIONSHIP BETWEEN GOR AND BRONCHIAL ASTHMA
Who should consider surgery or, perhaps, an endoscopic treatment trial for GERD? (As mentioned previously, the effectiveness of the recently developed endoscopic treatments remains to be determined.) Patients should consider surgery if they have regurgitation that cannot be controlled with drugs.
GERD and Asthma Management
It can also be caused by obesity or hiatal hernias. The general goal of patient selection is to enroll patients for whom asthma physicians might prescribe GERD treatment, but where there is uncertainty whether it might be effective. Laryngopharyngeal reflux and high esophageal reflux events, collectively referred to as proximal reflux, were found to be rare in healthy subjects. On the basis of the normative data for HMII, abnormal proximal reflux was considered present when patients had LPR at least once per day and/or high esophageal reflux at least 5 times per day, and we introduced these criteria into our practice. The objective of this study was to determine the pattern and proximity of reflux events in patients with AOA using HMII.
Of those people with asthma, those who have a severe, chronic form that is resistant to treatment are most likely to also have GERD. If GERD makes asthma symptoms worse, and asthma medication makes GERD worse, how do you break the cycle?