What is the relationship between Asthma and GERD?

• ASTHMA is defined as chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction and bronchospasm. Symptoms include wheezing, coughing, chest tightness and shortness of breath.
• GERD = Gastro esophageal reflux disease /( Heartburn) also referred to as acid reflux disease, occur when the lower esophageal sphincter (LES) does not close properly and stomach contents reflux back up into the esophagus. It is a digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the esophagus.
• People with asthma are at higher risk of developing GERD. Asthma flare-ups can cause the lower esophageal sphincter to relax, allowing stomach contents to flow back, or reflux, into the esophagus.
• On the other hand, acid reflux can make asthma symptoms worse by irritating the airways and lungs.  The refluxed acid from the stomach can be aspirated into the airways and lung, making breathing difficult and causing the patient to cough. A triggered nerve reflex causes   the airways to narrow. This will then cause shortness of breath.

Symptoms/Signs

1. GERD maybe the cause of asthma when :
   •  Asthma begins in adulthood, called adult-onset asthma
   • Asthma  symptoms get worse after a meal, after exercise, at night or after lying down
   • Asthma doesn’t respond to the standard asthma treatment.
2. Asthma symptoms such as shortness of breath (dyspnea), chest tightness and cough.  Wheezing, nocturnal awakening with respiratory symptoms.
3. May have heartburn (burning sensation at epigastric region), regurgitation or worsening cough. Sometime associated with difficulty in swallowing (dysphagia).Other symptoms including sore throat and hoarseness of voice.
4. Gastro esophageal reflux- triggered asthma does not have specific physical examination findings.
5. Patients may be obese with high BMI ( body mass index).
6. Look for cushingoid appearance (puffiness of face, buffalo hump) from oral corticosteroid therapy.
7. Signs /physical finding of acute asthma attack such as : increased respiratory rate with accessory muscle use. Wheezing on inspiration and expiration.

Complication

1. Some asthma medications can increase heartburn and other symptoms of GERD. Theophylline has been most closely tied to worsening GERD symptoms.
2. Undiagnosed GERD can worse asthma symptoms.
3. Look for other differential diagnosis of asthma if not improved.
   •  Laryngospasm (‘Laryngeal Asthma’ or ‘Factitious Asthma’).
   • Left ventricular dysfunction with pulmonary edema (‘Cardiac Asthma’).
   • Chronic obstructive pulmonary disease ( COPD)
   • Bronchiectasis
   • Pulmonary embolism
   • Foreign body in the airway
   • Endo-bronchial or tracheal tumours.

Treatment

1. If asthma is not well controlled with the standard medication, please see your doctor for further assessment.
2. Investigations (required when asthma is not well controlled) :
   • Lung function test-à spirometry (to diagnose COPD).
   • Esophageal pH testingà   to document GERD (monitors the amount of acid in the esophagus).
   • Upper endoscopy is useful in detecting esophageal mucosa injury.
   • Barium esophagram.
   • Bronchoscopy (to look for foreign body or tumour in the airway).
   • Computed tomography (CT) scanning with high-resolution of the lungs (to look for chronic lung diseases which may mimic asthma, e.g. bronchiectasis)
3. An empiric GER treatment trial using a proton pump inhibitor (PPI) -à useful test to examine GER –triggered asthma. A minimum 3 month empiric trial should be used to assess asthma symptom improvement. Monitor the asthma symptoms, PEFR and lung function tests during this empiric PPI trial.

Preventative steps to control GERD symptoms includes :

1. Sleep with your head and shoulder on an incline
   • Lying down flat presses the stomach’s contents against the LES (Lower Esophageal Sphincter). With the head higher than the stomach, gravity helps reduce this pressure and keeps stomach contents in the stomach.
   • You can elevate your head in a couple of ways, example can place bricks, blocks or anything that’s sturdy securely under the legs at the head of your bed. You can also use a wedge-shaped pillow to elevate your head.
2. Sleep on your left side
   • This position aids digestion and helps with the removal of stomach acid.
   • Sleeping on the right side has been shown to worsen heartburn.
3. Eat at least  two to three hours before lying down
   • If you take naps, try sleeping in a chair.
   • Lying down with a full stomach can cause stomach contents to press harder against the LES, increasing the chances of refluxed food.
4. Avoid foods that are known to lead to heartburn
   • These include foods that can trigger your heartburn, either by increasing acid production and gastric pressure or by loosening the lower sphincter muscle.
   • Avoid foods that can irritate the lining of the esophagus, such as spicy foods, coffee, citrus fruit and juices.
   • If you eat any of these foods at dinner times, you will increase your chances of having night time heartburn.
   • If you aren’t sure what foods trigger your heartburn symptoms, try keeping a heartburn record for a week.
5. Eliminate  late- night snacking
   • Have your last snack no later than two hours before bedtime.
6. Stop smoking
   • Nicotine can weaken the lower esophageal sphincter, which can lead to stomach contents entering the esophagus, with heartburn as the result.
   • Smoking can stimulates the production of stomach acid.
   • Stop smoking if possible.
7. Avoid alcohol
   • Alcohol increases the production of stomach acid.
   • Alcohol also relaxes the lower esophageal sphincter (LES), allowing stomach contents to reflux back up into the esophagus.
8. Other  measurements : lose weight , avoid theophylline ( if possible)

Rehabilitation

• In severe and medication intolerant cases, surgery maybe indicated
• Long term management of GER-triggered asthma includes regular evaluation of both pulmonary and GER symptoms while on GER therapy.