Some of the clinical severity of chronic obstructive pulmonary disease (COPD) is determined by also having other medical conditions. One common medical condition is acid reflux, technically called gastroesophageal reflux disease (GERD). People with COPD who also have reflux have a higher risk of suffering with acute exacerbations.

GERD is one of the most common digestive disorders worldwide. It’s defined by having acidic stomach juices or foods back up from the stomach into the esophagus. The esophagus is the tube that carries food or liquid down the throat to the stomach. The two most common symptoms are heartburn and regurgitation – when food comes back into the mouth from the esophagus or stomach. Other less common symptoms are bad breath, nausea, pain in your chest or the upper part of the abdomen, painful swallowing, vomiting, and tooth erosion caused by stomach acid.

However, many people do not know that GERD can also cause respiratory problems. Research shows that up to 50% of those with COPD also have GERD, making it more common in people with COPD than it is in the general population. If GERD is severe, stomach acid can enter the lungs. The stomach acid can then irritate the throat and lungs, causing respiratory problems such as laryngitis and pneumonia, particularly while sleeping. Irritation of the esophagus by stomach acid can also make the nerves of the esophagus inflamed. These are the same nerves that go to the airways in the lung and can cause one to cough. In this situation, a cough can be misdiagnosed as asthma since the airways appear twitchy like they are in asthma.

Individuals with GERD usually experience more coughing. This coughing worsens reflux creating a vicious cycle. Many people use more albuterol, which also loosens the muscle tone in the lower esophagus and promotes more reflux. The problem is that about half of people with GERD have no heartburn; so, a persistent cough is often the only manifestation of reflux. In these cases, the words “silent reflux” are often used.

GERD can develop if the lower esophageal sphincter, a muscle that separates the esophagus and the stomach, becomes weak or relaxes when it shouldn’t. This usually happens with aging. The esophagus can become dilated, and the top of the stomach can rise to be higher in the chest. This condition is called a hiatal hernia. Other risk factors for GERD are eating too late in the evening, obesity, pregnancy, and smoking.
There are also some foods and medications that relax the lower esophageal sphincter. These include alcohol, foods containing citric acid like oranges and tomatoes, and unfortunately, chocolate. The medications include calcium channel blockers, beta-agonists like albuterol, and some antidepressants, antihistamines, painkillers, and sedatives.

Generally, a primary care specialist diagnoses GERD by evaluating one’s health history. Treatment trials that are successful confirm the diagnosis. Rarely, patients require a gastroenterologist to make a diagnosis using endoscopy (a camera to see the esophagus), or an ambulatory acid probe (a thin tube placed down the nose and into the throat to measure the amount of acid present over 24 hours).

The first step in treatment is to avoid food for 3-4 hours before bedtime. Avoiding alcohol, citrus, and chocolate in the evening is often helpful. Sleeping with the head of the bed raised by 30 degrees is also recommended. Medication trials with antacids, histamine receptor antagonists such as famotidine (e.g., pepcid), and proton pump inhibitors (e.g., omeprazole, esomeprazole, pantoprazole) usually fix the problem.

If medication provides little relief, surgery can be a last resort. The surgery is called a fundoplication because it tightens the top of the stomach which is known as the fundus. Options to fix the problem using scopes have been developed. One method of operation involves placing a ring of titanium beads around the outside of the lower esophagus which compresses the area while still allowing food to pass through. A newer therapy, called Transoral Incisionless Fundoplication (TIF), does not require surgery. In this procedure, the doctor feeds the endoscope through a special TIF device which allows them to repair or recreate the body’s natural barrier to reflux.

Controlling exacerbations in Alpha-1 patients is important. Frequent flare-ups or exacerbations of disease could be related to GERD. Understanding the relationship between GERD and COPD may help Alphas and healthcare providers improve cough, use medications wisely, and prevent COPD exacerbations to stay healthy.

As always, consult your physician before making any changes to your medication regimen or diet.