The Link Between Asthma, Reflux, and Mood Disorders

January 6, 2014

About one in 12 people in the US (about 25 million, or 8% of the population) had asthma in 2009. More than 1/2 of all adults and children with asthma had an attack in 2008. 185 children and 3,262 adults died from an asthma attack in 2007. These numbers are likely to be higher in 2014 (source: CDC).

Asthma is thought to be a chronic inflammatory disorder of the lungs. Symptoms include chronic cough, wheezing, chest tightness and shortness of breath. 

A recent study out of Taiwan reported that teenagers with asthma had a significantly higher chance of developing depression or bipolar disease 10 years later. After adjusting for other conditions such as allergic rhinitis, atopic dermatitis, and other confounders, patients with asthma were 1.81 times more likely to develop major depression, 1.74 times more likely to develop any depressive disorder, and 2.27 times more likely to develop bipolar disorder than patients without asthma. This was the first prospective study linking asthma with mood disorders.

Not too coincidentally, another study came out that showed that pepsin, a stomach enzyme, was found in 71% of  bronchial washings in children with chronic lung diseases. In contrast, healthy children had no cases of pepsin in bronchial washings. 

Obstructive sleep apnea is found in up to 10% of chidden and about 25% of adults. During an apnea, tremendous vacuum forces are created in the chest cavity, leading to a suctioning effect of normal stomach juices into the throat. These juices can then go into the lungs or the nose and ears. Stomach juices not only contain acid, but also bile, digestive enzymes, and bacteria. Even microscopic amounts of these materials can wreak havoc inside your lungs or nose.

Here’s a review of the link between asthma and obstructive sleep apnea. Not too surprisingly, the peak time for the highest levels of restricted breathing in asthmatics is during 3 to 5 AM. This is also the same time that REM sleep peaks, when apneas are most common. There are countless studies showing strong associations between obstructive sleep apnea and mood disorders. 

This is another great example of  how everything comes together when you start to connect the dots.


Reflux, Sleep Apnea and Increased Survival in Lung Disease

May 29, 2013

This blog post’s topic may sound completely unrelated to obstructive sleep apnea, but here’s a study showing that in people with idiopathic pulmonary fibrosis (IPF), being placed on an acid reflux medication (proton pump blocker) boosted survival significantly by about 2 years (3.4 vs. 1.4 years). The author’s explanation is somewhat complicated:

“DDAH and inducible nitric oxide synthetase are increased in lung epithelium and fibroblastic foci in IPF, and we found that proton pump inhibitors inhibit DDAH.”

In other words, Proton pump inhibitors, such as Prilosec, Nexium, or Aciphex have properties that prevent a complex pathway that leads to inflammation in the lungs. This phenomenon was also seen in subjects that had no reflux symptoms, leading the authors to postulate that a non-reflux mechanism could explain the survival benefit.

Here’s a simpler possible explanation: Many people with obstructive sleep apnea have silent reflux, due to vacuum forces that are created in the chest and throat during an apnea. Stomach juices (which include acid, bile, digestive enzymes, and bacteria) travel up into the throat, and then down into the lungs, causing chronic long-term inflammation. Treating with acid reducers may lower the acidity of the juices going into the lungs, thus possibly increasing survival.

The problem with using reflux medications is that they don’t really do anything for reflux. They only lower acid levels in the stomach, but what comes up into the throat is just less acidic. However, you still have bile, enzymes and bacteria, which can be very caustic to the lungs (or ears or sinuses).

It would be interesting to do a similar study, but instead, screen for and treat obstructive sleep apnea in patients with IPF, and see what the results show.

Why Your Heartburn Medications Don’t Work

November 14, 2012

Here’s an article from the Wall Street Journal that explains why many people who have heartburn don’t respond to acid reflux medications. In addition to what’s explained in the article (non-erosive reflux disease, or NERD), another explanation is that acid reflux medications don’t do anything to treat reflux. What they are designed to do is to lower acid production in the stomach. However, they don’t do anything to prevent reflux of normal stomach contents into the esophagus or throat. This is a common condition in obstructive sleep apnea, where acid, bile, stomach enzymes, and even bacteria can irritate the throat, lungs, and nose.

The Missing Link Between Gum Disease and Heart Disease

April 19, 2012

It’s medical dogma that having gum disease can cause heart disease. The most common explanation is that bacteria from your mouth can spread through the bloodstream and infect your heart valves (called endocarditis). The problem with this explanation is that endocarditis is a tiny fraction of people who have heart disease. Just because there’s an association, it doesn’t mean that one causes the other.

The American Heart Association recently reviewed 537 articles on this subject and published a review, stating that there’s no scientific evidence that gum disease causes heart disease, heart attacks, or stroke. Past studies were mainly observational, and not based on prospective studies. They also state that there’s no evidence that treating periodontal disease can prevent heart disease.

What’s the missing link? You guessed it: Obstructive sleep apnea. We know that obstructive sleep apnea can cause reflux and inflammation in the mouth. Mouth breathing due to craniofacial narrowing and inflammation also dries out saliva, which helps to protect your mouth from pathogens. If you’re missing teeth, then your mouth gets smaller, narrowing your airway even further. We also know that obstructive sleep apnea significant increases your risk of heart disease, heart attack, stroke, and death.

So it makes sense that if you treat sleep apnea, you’ll have less gum disease, and less heart disease. Obviously a prospective, randomized, placebo-controlled, double-blinded study is needed to prove this point.

Can Reflux Medications Help Asthma Symptoms?

January 27, 2012

Here’s a classic example of a study with negative results which is not surprising. Researchers gave acid reducing medications (lansoprazole) to children with steroid dependent asthma. About 300 children were randomized to receive either the medication or a placebo. They found no significant differences between the two groups in terms of asthma symptoms. If you look at all the studies that link asthma to obstructive sleep apnea, and reflux to obstructive sleep apnea, it makes more sense that the two (asthma and reflux) are connected by obstructive sleep apnea. 

It’s been shown that apneas create conditions in the esophagus and throat which can cause your stomach juices to reach your throat. Furthermore, pepsin and bile have been found in lung and sinus washings. What this means is that your stomach juices are still coming up into your throat, especially if you have obstructive sleep apnea. However, what’s coming up is just less acidic juices, but still includes bile, digestive enzymes, and bacteria. We know that proton pump inhibitors and H2 blockers such as cimetidine don’t really do anything to prevent reflux into the throat. 

My hypothesis is supported by studies that show that pro-motility agents such as domperidone and clarithromycin can help lower asthma symptoms. There are also numerous studies showing that treating obstructive sleep apnea can help with symptoms of asthma and reflux. 


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How Azithromycin Can Help COPD

August 28, 2011

Here’s a study showing that taking azithromycin can help to cut the rate of acute exacerbations in people with COPD. The anti-inflammatory properties of the macrolide antibiotics are well described. However, one thing that’s usually not addressed is the fact that the macrolides have anti-reflux properties. In general surgery, we used to give intravenous erythromycin to help speed gastric emptying after abdominal surgery. So by helping to empty the stomach faster, less juices are around to reflux up into the throat and then to the lungs. It’s important to realize that what comes up not only includes acid, but also stomach enzymes, bacteria and sometimes bile. Imagine even small amounts of these substances in your lungs. 

Even if you don’t have significant obstructive sleep apnea, juices from your stomach can come up with any of the smaller obstructive events that aren’t classified as apneas or hypopneas. Not only do these same juices go into your lungs, it can also reach your nose and sinuses. 

Is Nocturnal Asthma Really Sleep Apnea?

August 21, 2011

Having an asthma attack in the middle of the night can be a frightening and terrifying experience. Typically, these attacks happen in the early morning hours, just before awakening. 

Now there’s research showing that poorly controlled asthma during pregnancy can increase a woman’s chances of developing preeclampsia (50%) and premature births (25%). Furthermore, infants born to mothers with poorly controlled asthma delivered babies that were about 0.2 pounds less than those born to mothers without asthma.

We typically think of asthma being a separate, distinct condition from obstructive sleep apnea, and it’s treated in completely different ways. However, it’s not just coincidence that nocturnal awakenings from asthma and the most intense periods of apnea occur at the same time in the middle of the night—the early morning hours. The early morning hours are when REM sleep is most prominent, and this is the time when throat muscles are most relaxed. Having an apnea also is known to cause reflex, which is known to reach the throat as well as the nose and the lungs. In one small study in people with sleep apnea and asthma, treating sleep apnea with CPAP significantly improved nocturnal asthma symptoms. 

We know that any degree of stress on the mother’s body can lead to a higher rate of pregnancy-related complications and low birth rates. Even snoring by the mother alone was found to result in lower Apgar scores in newborn infants. Apneas are also known to raise blood pressure and promote insulin resistance. Stress hormones are also known to increase when you have apneas.

In light of all these findings, it’s not surprising that pregnant women with poorly controlled asthma have higher complications rates. This is another great example of “connecting the dots” between two seemingly unrelated conditions, which only adds to support my sleep-breathing paradigm.



The Single Most Important Advice I Give

May 7, 2011

As physicians and surgeons, we like to think that offering medications or surgery is what makes the most impact, but I’ve learned over the years that it’s the simple lifestyle changes that make more of a difference in almost every chronic medical condition we have. It’s a humbling realization.

With every patient, I give a handful of conservative recommendations to being with. This applies to most routine ENT visits such as for sinusitis, ear problems, nasal congestion, throat pain, or hoarseness. In about 75% of my patients, I don’t give prescription medications at all on the first visit.

Of all the recommendations I make, the single most important tip I give to just about everyone is not to eat within 3-4 hours of bedtime. You may have heard this before from your doctor or from magazines or articles, but the reason why this is so important is not for the reasons that you may be thinking. I also stress that it’s not a recommendation—it has to be done, or your throat pain, sinus or ear problems won’t get better.

Traditionally, it’s thought that eating late slows down your metabolism. Another is that food doesn’t digest well since your bowels shut down while sleeping, thus converting the nutrients into fat. There are dozens of other explanations. Here’s an article on the benefits of eating early.

Here’s one that that makes sense: All modern humans have narrowed upper airway anatomy due to the fact that we can talk. Over the past 100 years or so, due to a radical change in our diets and eating habits, our jaws are not widening like they used to. This is why most people in Western countries need braces, since there isn’t enough space for the teeth.

This predisposes people to breathing pauses at night due to the tongue falling back (due to gravity when on our backs) and due to muscle relaxation in deep sleep. You can stop breathing multiple times every hour and not have obstructive sleep apnea. Every time you stop breathing, you’ll literally vacuum up your stomach juices into your throat, causing you to wake up into a lighter stage of sleep, and causing more inflammation and swelling, which causes more obstructions. Your stomach juices (acid, bile, enzymes and bacteria) can then go into your lungs and your nose, causing even more inflammation.

So the later you eat, the more juices you’ll have in your stomach, and the more it’ll come up into your throat. This leads to more frequent obstructions and arousals, leading to less efficient sleep. We know that poor sleep causes weight gain, hormonally, neurologically and biochemically.

Unfortunately, some people are very resistant to this recommendation since it disrupts their lifestyles or they have job schedules that make it very difficult. These are the people who keep coming back over and over again for more medications, and in the long term, many years later, being diagnosed with obstructive sleep apnea.

How many of you notice that you sleep much better when you eat early?

How Reflux Aggravates Sleep Apnea

April 19, 2011

One of the central tenets of my sleep-breathing paradigm is the connection between breathing obstruction and reflux: One can cause the other, and vice versa. I happened to be reading an article on gastrointestinal function while sleeping, and found some interesting facts about your stomach and how it behaves when you’re sleeping:

1. Gastric acid secretion is significantly increased just after bedtime, around 12 AM.

2. Stomach emptying is delayed.

3. Esophageal clearance is delayed.

4. Upper esophageal pressure is decreased.

5. Nighttime reflux is more difficult to control using medications.

Any kind of breathing obstruction can create tremendous vacuum effects in the throat, which can actively suction up your stomach juices. However, this is also actively being promoted by steps 1 through 4 above. Once acid reaches your throat, it can cause swelling in your throat. If you still have your tonsils, they can get very large, which obstructs your breathing even more. Acid also is known to desensitize your protective chemo-receptors that help to wake you up from deep to light sleep when it senses acid in your throat, so that you can swallow your stomach juices and prevent aspiration into your lungs.

We also know that it’s not only acid that’s coming up into the throat, but also bile, digestive enzymes, and even bacteria, which can all travel up into your nose, ears and sinuses, or down into your lungs, causing major inflammation. Inflammation causes more swelling, and even further obstruction to breathing.

One major reason why the standard reflux medications don’t work all the time is because they’re not designed to prevent reflux. Instead, these medicines help to lower your stomach juice pH or production, so that it’s less irritating to your throat. This is also why not eating within 3-4 hours of bedtime is so critical if you have sleep apnea.

How many of you with sleep apnea also have reflux issues. Your symptoms don’t have to be heartburn or indigestion. It can be throat clearing, post-nasal drip, coughing, hoarseness, a lump sensation, throat pain, and even tightening.

Who Taught Me Most About Sleep Apnea?

November 19, 2010

Whenever I get asked by patients who are my best teachers, my answer usually surprises them. I tell them my best teachers are my patients. Over the years, I’ve learned more from listening to patients than from anything I’ll ever learn in medical journals or textbooks.

Here’s one great example: One of the most common problems that I see in my practice is when patients complain of a lump in the throat or difficulty swallowing. In most cases, after seeing inflammation in the voice box, I diagnose silent reflux. I usually go one step further and treat the actual cause of the reflux (obstructed breathing), rather than just cover it up with medications. Oftentimes, however, the voice box looks completely normal, but they still have the symptoms. Usually, I’ll blame it on microscopic amounts of stomach juices that you can’t see.

Just this week I saw a young woman who complained of a lump sensation and a tightness in her throat, with difficulty swallowing. She had classic laryngopharyngeal reflux disease. I recommended the usual conservative measures, such as not eating late, avoiding alcohol close to bedtime, proper nasal breathing, and sleep position..

However, in passing, she commented that whenever she swims, the lump sensation goes away temporarily. I didn’t even think about the significance of this statement until a few hours later when I was seeing another patient with similar complaints. Of course! Not only is swimming a good form of exercise, it’s also a type of rhythmic, controlled breathing exercises. By taking regular, deep breaths, she’s doing the same thing that you’d normally do in yoga as you perform the relaxing breath.

Deep breathing has a calming effect on your involuntary nervous system, especially activities that promote prolonged exhalation. This also includes singing, whistling, humming, wind instruments, and even talking. The longer time you spend breathing out, the longer time you stimulate the parasympathetic nervous system. Since the vagus nerve is your main parasympathetic nerve that innervates the voice box as well as your digestive system, this makes absolute sense. Maybe this is why good conversation with friends or family during a slow-paced meal helps you to digest better.

One possible explanation for a lump in your throat is excessive tension and stress in your cricipharyngeal muscle, which is a sphincter-type muscle that closes off the top of your esophagus just behind your voice box. If you’re not sleeping well, then your body will have more physiologic stress, causing tension and spasms in various parts of your body, including the cricopharyngeus muscle. Plus, if there’s direct irritation by stomach juices in the immediate area, then it’s even more likely to go into spasm. (If this tension happens to occur in your muscles of mastication, then you’re likely to have TMJ.)

As a result of the above patient’s passing comment, I reaffirmed that complementary ways of stress reduction and relaxation are just as important as any medical recommendation that I recommend for better sleep. I experience numerous other similar “eureka” moments almost every day, mainly by listening for my patients’ pearls of wisdom.

What’s your opinion on this subject?

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The material on this website is for educational and informational purposes only and is not and should not be relied upon or construed as medical, surgical, psychological, or nutritional advice. Please consult your doctor before making any changes to your medical regimen, exercise or diet program.

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