Low back pain and gastroesophageal reflux in patients with COPD: the disease in the breath
GORD is liquid acid reflux causing heartburn and indigestion. Airway reflux consists of a mainly gaseous non-acid mist which, when deposited in the upper and lower airways leads to inflammation, fibrosis, bronchoconstriction and cough. Here, the hypothesis that airway reflux is responsible for chronic “idiopathic” cough, late onset asthma, exacerbations of COPD, ‘idiopathic’ pulmonary fibrosis and even the lung disease of cystic fibrosis is outlined.
It also suggests alternative avenues of therapy to end the intractable suffering of “difficult” patients who steadfastly refuse to respond to conventional respiratory treatments. COPD and GERD (Gastro-Esophageal Reflux Disorder) often occur together. Research shows that people with COPD are at far greater risk of developing GERD, and almost half of those with severe COPD also have GERD. If lifestyle changes alone don’t improve reflux-related breathing problems, your doctor may also recommend drug treatments for GERD symptoms. Drugs that your doctor may recommend include antacids, H2 receptor blockers, and proton pump inhibitors.
People with COPD may experience shortness of breath resulting in reduced energy levels. This can make everyday activities difficult.
This is confirmed by scintigraphic demonstration of aspiration of radio-labeled isotope into the airway in some patients with GERD and respiratory symptoms. Another theory suggests that distal esophageal acidification results in vagal stimulation and consequent broncho-constriction, independent of airway micro-aspiration. This theory gains support from the observation that not all patients who develop bronchospasm have demonstrable proximal esophageal acidification. Further, even among those who show abnormal proximal esophageal pH, there is improvement in respiratory symptoms with control of distal gastroesophageal reflux alone. It is also possible that physiological changes in asthma, including increased lower esophageal pressure, the mechanical influence of a depressed diaphragm caused by hyperinflation, and cough mediated by increased abdominal pressure, may contribute to gastroesophageal reflux to some degree. In addition, some of the medications used for treatment can aggravate gastroesophageal reflux; thus, there is a perception that gastroesophageal reflux may be an effect rather than cause of chronic respiratory conditions.
Indeed, a higher prevalence of diaphragmatic defects and hiatal hernias was documented in patients with emphysema [14 ]. In addition, it has been postulated that restrictive lung disease can affect the pressure in the intra-thoracic space, reducing the overall lung volume, which can disrupt the diaphragm and potentially increase reflux. In this study, use of inhaled anticholinergics seemed to decrease the risk of RE. A previous study reported that relative risk of GERD increased with use of inhaled anticholinergics .
However, this is NOT the disease which is causing respiratory symptoms. The reflux which causes respiratory consequences is a gaseous mist which is partially or even wholly non-acid. This mist can travel up the oesophagus without a peristaltic wave since the oesophagus, as is usually seen on thoracic computed tomography, is patent; a so-called common cavity. This retrograde transit of gas is a normal phenomenon.
Mixed patterns of reflux are evident, with distal reflux only, proximal reflux only, and a mix of both demonstrated.11,49,56,62 In those with COPD, the prevalence is five times greater than the non-COPD population for proximal and distal reflux.7,67 GERD can affect patients with moderate to very severe COPD.41,42,49,56,62,68 Although a detailed clinical history of symptom presentation is recommended,69 this method of diagnosis is reliant upon the provocation of symptoms by reflux events, which in the event of asymptomatic (clinically silent) reflux is not a reliable indicator. The presence of asymptomatic reflux (20%-74%) in COPD11,41,49,56,62 emphasizes the importance of objective confirmation of GERD in some individuals.
This may be particularly true for patients with IPF [4 ]. Therefore, diagnostic studies are often necessary to adequately assess for aspiration.
- Resolution of GER symptoms and chronic cough in 2% of patients, without change in PFTs.
- Below is information about conditions that have similar symptoms to COPD.
- Discuss with your doctor if there are any medications that can also help.
- In this study, gas diffusion impairment in subjects with increased severity of GERD in the absence of significant spirometric abnormalities with respect to FEV 1 %, FVC%, or FEV 1 /FVC, but with significant negative affection of central airways as detected by IOS with increased severity of GERD, suggests that we may be looking at the earliest measurable dysfunction in a progressive pathway in the evolution of progressive pulmonary fibrosis detected by DLCO.
- Such airway damage can affect breathing by causing coughing or wheezing.
With GERD, however, the sphincter relaxes between swallows, allowing stomach contents and corrosive acid to regurgitate up and damage the mucosa of the esophagus. GERD affects nearly one third of the adult population to some degree, at least once a month. Almost 10% of adults experience GERD weekly or daily.
What are the
Although the results from these studies suggest an association between GER and ILD, causality remains to be proved. Gilson et al., in their prospective evaluation, were not able to establish that esophageal dysfunction was a significant predictor of PFT decline [36 •]. In short, although several studies suggest an association between esophageal dysfunction and ILD in scleroderma, varying methods have lead to conflicting reports, and further study is needed. GER is believed to occur as a result of the failure of normal protective physiological mechanisms. These protective mechanisms include the combined action of the lower esophageal sphincter (LES), a segment of smooth muscle that contracts to a pressure greater than that of the stomach, and the crural diaphragm, which provides extrinsic pressure and a barrier separating the esophageal and gastric compartments [9 ].
Figure 2 summarizes the current concepts of theories that explain a link between asthma and GERD. The reflux theory suggests that symptoms of asthma are due to reflux of acid into the esophagus followed by aspiration into the proximal airways. Animal studies have proven that once trachea is acidified, there is a demonstrable increase in airway resistance.
Can my doctor give me medicine to make my cough go away?
Asymptomatic aspiration of oropharyngeal secretion or gastric fluid into the lungs is called silent microaspiration. It has been demonstrated that approximately half of normal adults experience mild silent microaspiration during sleep at night [19 ]. Normally, natural defenses, including coughing and epiglottic closure, are protective against microaspiration. Depending on the individual, sometimes these defenses become impaired and cause wheezing and coughing [20 ]. Heartburn and gastroesophageal reflux disease (GERD).
This increased GER may lead to increased repetitive microaspiration events, and may be predictive of potential repetitive injury for IPF patients. There is increasing recognition that gastric refluxate, either acidic or nonacidic, can be a risk factor for many respiratory symptoms, including chronic cough [21 , 22 ] and hoarseness [23 ].
admin May 9, 2010