Shortness of Breath

Shortness of breath (dyspnoea) is a symptom often described by patients with GERD. Some describe this worsening on exertion or simply discomfort behind the breast bone (sternum) on breathing. There may be some specific identifiable causes but often the direct relationship is not clear. Of note, there are multiple causes of dyspnoea apart from GERD and these may co-exist. These include serous lung disorders such as COPD, pneumonia and malignancy, heart problems such as cardiac failure and arrhythmias and pulmonary embolism (lung clots). Occasionally very large hiatus hernias in which the lung press on the lungs may cause shortness of breath.

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An elderly woman consoled by a middle-aged man as she experiences shortness of breath

What causes shortness of breath in GERD?

It is thought that there may be several links between GERD and shortness of breath. Usually, the valve at the bottom of the oesophagus (Lower Oesophageal Sphincter, LOS) ensures that acid and other substances such as Pepsin and Bile in the stomach do not reflux up into the oesophagus. In GERD this valve fails, and reflux of these substances can irritate the oesophagus but may also reach the throat and lungs.

Asthma Reflux firstly may trigger asthma, in which the small airways decrease in size. Asthma is more common in patients with GERD than the general population. Studies suggest that 30%-80% of asthmatics have GERD although most are unaware. This may be caused by direct chemical irritation by acid and other sbstances such as Pepsin from the stomach of the airways themselves. Alternatively, reflux may sensitise the lungs to other causes of asthma such as pollen. Finally, reflux into the oesophagus may trigger a nervous reflux closing the airways.

There are also conditions affecting the lungs that can cause shortness of breath and are thought to be associated with GERD. These include;

Bronchiectasis GERD may occur in up to nearly three quarters of patients and usually without typical heartburn symptoms.
Idiopathic Pulmonary Fibrosis (IPF) Up to 90% of patients will have GERD when formally tested although many have no symptoms.
COPD There is a probably a two-way relationship between GERD and COPD. They co-exist in 17% to 78% of patients. While patients with COPD are more likely to develop GERD, reflux itself can cause acute infective exacerbations of COPD.

My LPR symptoms are vastly improved. I never wake up in the middle of the night with coughing and throat clearing

Nick

How is GERD diagnosed in shortness of breath?

As with all diagnostic pathways, the first steps are for a clinician to listen to the symptoms and background (the history) and perform an examination. Reaching the right diagnosis is critical to achieving the right treatment plan. Even when GERD is suspected tests are often necessary both to exclude some conditions and confirm that reflux is responsible. The first step in patients with shortness of breath is usually to exclude and treat any non-GERD related conditions. This is usually under the care of a respiratory consultant specialist. If its thought that GERD may be responsible investigations may include;

Gastroscopy: Otherwise known as upper GI endoscopy this involves inserting an endoscope through the mouth or nose into the oesophagus and then through the stomach and duodenum (together known as the “foregut”). The endoscope has a high-definition camera enabling the operator to look for structural abnormalities such as hiatus hernias. They will also evaluate the lining of the foregut, for instance identifying oesophagitis, Barrett’s oesophagus and ulcers. If necessary, samples of tissue (biopsies) can be taken for analysis. The examination can be performed with local anaesthetic spray, intra-venous sedation or under general anaesthetic.
24-hour catheter reflux monitoring. A small tube (catheter) is inserted through the nose to the bottom of the oesophagus and measures reflux events usually over 24 hours at the bottom as well as the top of the oesophagus. It will also include a pH sensor in the stomach to ensure normal acid production. The catheter is attached to a recorder about the size of a mobile phone and patients can record when they experience symptoms allowing correlation between the two. These are known as “symptom associations”. pH testing assesses acidic/non acidic reflux events. Modern testing includes impedance which offers the advantage that it also distinguishes between liquid, solid and gas reflux events. So, for instance impedance can identify belching and its relationship with reflux.
Oesophageal pH capsule reflux test. The Bravo test involves attaching a tiny capsule during a gastroscopy onto the lining of the oesophagus just above the stomach. This records acid reflux over a period of 48-96 hours. Instead of a catheter it sends the data wirelessly to a recorder and falls off after the test is complete. The procedure is usually performed under conscious sedation.

What are the treatments for GERD causing shortness of breath?

Reaching the right diagnosis is key to planning treatment. Treating shortness of breath can be challenging and it should not be assumed that reflux when diagnosed is responsible. When caused by GERD an escalating strategy depending on effectiveness is usually recommended.

Lifestyle changes;

Dietary changes such as eating smaller meals, avoiding trigger foods, eating earlier in the day
Losing weight
Stopping smoking
Elevating the head of the bed at night