Published/Last Reviewed: October 27, 2005
As two of the most common causes of doctor visits in the United States, asthma and gastroesophageal reflux disease (GERD) have both become a major cause of concern. But some doctors suspect that the high occurrence of these diseases isn't a coincidence, and, in some cases, the two may be closely related.
But how can an irritation of the esophagus be linked to a breathing disorder? And should parents of children with asthma be concerned? The Children's Digestive Health and Nutrition Foundation is working with the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, representing pediatric gastroenterologists nationwide, to launch a campaign on pediatric reflux and GERD. Dr. Ben Gold, director of the Division of Pediatric Gastroenterology and Nutrition at Emory University School of Medicine and Dr. John T. Boyle, director of the Division of Pediatric Gastroenterology and Nutrition at the University of Alabama explain how treating acid reflux may sometimes keep asthma under control.
How prevalent is GERD and asthma?
BEN GOLD, MD: There is a knowledge gap with respect to understanding the association, but the problem in terms of looking at cause and effect are that both GERD and asthma are considered to be public health problems. Asthma clearly has been on the rise in the United States, affecting all ages. Recent estimates say that there are close to 4.8 million cases of asthma in children under the age of 16 in the United States.
GERD is also a chronic problem and it is, in fact, the most common GI condition. There are 18.6 million cases of GERD in the United States, and it poses a significant health care burden in terms of patient's needs; there is close to $15 billion spent on the care of patients with GERD every year.
So between GERD and asthma, you have two conditions that both have a significant impact and result in a number of office and emergency room visits. So, it becomes difficult to discern whether they are totally unrelated, or if there is some cause and effect between the two. Clearly, though, minimizing this disease burden would be helpful for both the patient and the general population.
TIM BOYLE, MD: And in adults, up to 40 percent of asthmatics complain of symptoms of GERD.
Does GERD cause asthma?
TIM BOYLE, MD: No. I think it's very important to mention that GERD doesn't cause asthma. GERD is best considered to be a trigger of asthma.
TIM BOYLE, MD: The major reason a patient may have reflux is because of a pressure difference between the abdomen and chest. Asthma is a chronic lung condition that results in increased chest pressure. Since there is positive pressure in the abdomen and negative pressure in the chest, the tendency is for the liquids in the gastrointestinal track to go up. And if you increase that negative pressure, then you increase this tendency. Many of the medications used to treat asthma, like long-acting bronchodilators, reduce the pressure in the lower esophagus, making the pressure difference even worse. So that may be another confounding variable.
Another way the two may be connected is more physical. There is a valve at the lower end of the esophagus that is closed by contractions of the diaphragm, particularly during breathing. This closing prevents reflux. But people with asthma are less able keep the valve closed because of their breathing difficulties.
What other symptoms can GERD cause beyond heartburn?
TIM BOYLE, MD: These symptoms include chronic cough, particularly night cough, chronic laryngitis, chronic hoarse voice, recurrent sore throat, chronic throat clearing, recurrent ear infections, recurrent sinus infections, chronic and recurrent dental erosions and a sensation called "globus" where the patient feels a fullness in their neck or has difficult with swallowing.
Is there any evidence that treating someone for GERD makes a difference in
TIM BOYLE, MD: In patients with both conditions, there are a number cases where an improvement was seen in both asthma symptoms and the need for asthma medication after the patients were given acid reduction therapy. But the overall data on the actual effects of GERD therapy on asthma and lung function are weak. It is clear that there is an association between the two conditions, but the nature of the relationship is still controversial.
BEN GOLD, MD: There have been a number of other small studies where surgical management of GERD has resulted in a reduction in the number of asthma attacks in patients.
And recently, there have been studies where a proton pump inhibitor (PPI), which reduces acid, was studied in children with abnormal acid levels and asthma. In this study, a hundred percent of those children had a reduction in their use of asthma medications and asthma attacks after using PPIs. In fact, pulmonary function, as measured by the amount of air they exhale, actually improved. So, at in least small studies, patients demonstrate a significant improvement is asthma symptoms after reflux treatment.What would you look for if a child has asthma and you suspect GERD may be a factor?
TIM BOYLE, MD: One of the most important questions is to ask the patient about actual symptoms of GERD. A high percentage of patients with asthma have symptoms of GERD, such as heartburn or regurgitation. If a patient had symptoms, then we should also monitor his asthma to see if it was effected by GERD treatment.
There are also patients who have poorly controlled asthma. These are patients who have nocturnal symptoms waking them from sleep or who wake in the morning with wheezing and tightness of their chest. These children need significant lifestyle modifications because of their asthma and are missing a lot of school, have frequent hospitalizations or need to use short-acting bronchodilators more than four times per day. These are definite factors that you can look for in a patient with asthma in which acid reflux might be a factor.
BEN GOLD, MD: If someone has non-allergic asthma or asthma in which there really doesn't seem to be any environmental triggers, one needs to start thinking about something else that may be triggering it. And GERD may be that something else.
Should a child with asthma, but no other symptoms of reflux be looked at
for the possibility of having GERD?
BEN GOLD, MD: I would say, "No, but..." If you take a child that has no GERD- related symptoms and uncontrolled asthma, the first course would be to look at compliance with asthma medications. This is probably the most critical factor in terms of not just acute asthma, but long-term management of asthma. If the family is compliant with the medications and there are still exacerbations, then I would start to think about GERD being a factor.
But if that patient is doing well, then I wouldn't worry as much about looking for something that may not be there.
What is non-acid reflux? And what role does it play in the treatment of
TIM BOYLE, MD: All studies to date have looked at patients where reflux has been defined by monitoring acid levels in the esophagus. However, some patients do not respond to acid reduction therapy, because they have what's called non-acid reflux. So, if you treat someone with reflux, you may be turning off stomach acid, but you're not removing the reflux itself. Non-acidic reflux tends to be higher in the esophagus, making it more likely to spill over into the upper airway and trigger wheezing in a susceptible patient.
And the question then is should these patients try surgery to correct their reflux? Surgery is the only therapy that actually cures GERD by directly treating the mechanism of reflux. In order to make that decision, a doctor should assure the patient that there is a good chance that their asthma is going to improve if they take that step.