A variety of studies have indicated that somewhere between 45% to 80% of patients with asthma also have gastroesophageal reflux (stomach acid refluxes, or backs up, into the food pipe). These asthmatics frequently present with significant instability of their asthma requiring more and more medication for control. They may demonstrate frequent nocturnal symptoms of cough and/or wheeze. Obvious reflux symptoms, such as heartburn, occurring after meals may not be present.

Mechanism:

Several mechanisms have been suggested as the possible cause for asthma symptoms related to gastroesophageal reflux. These include:

1. Bronchoconstriction stimulated by microaspiration of refluxed stomach contents;
2. Reflex bronchoconstriction via the vagus nerve caused by refluxed stomach contents stimulating receptors in the esophagus;

Theophylline and certain beta-agonists reduce the lower esophageal sphincter (the stomach’s ‘lid’ which prevents stomach contents from reguritating) pressure allowing increased reflux.

SIGNS AND SYMPTOMS:

Patients with chronic cough, steroid-dependent asthma, nighttime asthma, asthma that worsens with theophylline therapy or asthmatics with nighttime cough and upper gastrointestinal complaints should be evaluated for gastroesophageal reflux. While this group of patients obviously require a thorough evaluation, other patients with reflux may present with more subtle symptoms.

One should suspect gastroesophageal reflux in individuals that report:

PATIENT EDUCATION:

Patient education regarding conservative measures for gastroesophageal reflux is often helpful. These include:

OTHER DIAGNOSTIC MEASURES:

If the patient has a good response to conservative anti-reflux measures, Dr. Windom will often reduce or discontinue pharmacological therapy. Poor response to conservative measures may suggest the necessity for further therapy and diagnostic examination. Diagnostic tests may include barium swallow, barium esophagram, esophageal manometry, Bernstein test, endoscopy, or 24-hour esophageal pH monitoring. The 24-hour esophageal pH monitoring is now considered the "gold standard" for the diagnosis of gastroesophageal reflux.

PHARMACOLOGIC THERAPY:

Histamine receptor antagonists are usually the basic initial therapy in all symptomatic patients. These include cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid) and ranitidine (Zantac). If there is an unsatisfactory response to these basic medications, additional medications may be considered including sucralfate (Carafate), metoclopramide (Reglan), lansoprazole (Prevacid) or omeprazole (Prilosec). Uncontrolled symptoms are an indication for surgical intervention which can now be performed in a minimally invasive fashion using a laparoscope. Unfortunately, relief of reflux does not result in a complete cure for asthma symptoms even though they may be improved.

SUMMARY:

There is a significant amount of evidence that suggests that gastroesophageal reflux can cause chronic cough and increase asthma symptoms. Those patients who present with an increase in nocturnal symptoms or who have obvious reflux symptoms are readily identified. Other patients may be more complex or "quiet" in their presentation. Careful observation of symptoms and direct questions to the patient to help elicit subtle symptoms are essential. It is this method of assessment, diagnosis, and education that can effectively empower the patient to control their asthma/cough.