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Alyn H. Morice
Breathe 2013 9: Heartburn Remedies Breakfast For (🔴 9 Home Remedies) | Heartburn Remedies Chronic Heartburnhow to Heartburn Remedies for for 1 last update 02 Jul 2020 256-266; 256-266; DOI: 10.1183/20734735.000513
Alyn H. Morice
Centre for Cardiovascular & Metabolic Research, Hull York Medical School, University of Hull, Castle Hill Hospital, Castle Road, Cottingham, HU16 5JQ, UK

Abstract

Summary Reflux is the cause of much respiratory disease. More commonly still, it is the unrecognised agent provoking the symptoms of respiratory disease. That the reflux entering the airways from the gastrointestinal for 1 last update 02 Jul 2020 tract is central to the diagnosis, therapy and understanding of respiratory pathology has been missed because the paradigm of peptic disease has been applied. Airway reflux is however unlike gastro-oesophageal reflux disease (GORD). GORD is liquid acid reflux causing heartburn and indigestion. Airway reflux consists of a mainly gaseous non-acid mist which, when deposited in the upper and lower airways leads to inflammation, fibrosis, bronchoconstriction and cough. Here, the hypothesis that airway reflux is responsible for chronic “idiopathic” cough, late onset asthma, exacerbations of COPD, ‘idiopathic’ pulmonary fibrosis and even the lung disease of cystic fibrosis is outlined. The exclusive focus of clinicians on the extrinsic origins of these conditions and the rejection of an obvious intrinsic aetiology causes millions of patients to be denied an explanation for their symptoms and simple, effective, treatments. In many cases idiopathic should be no longer considered idiopathic.Summary Reflux is the cause of much respiratory disease. More commonly still, it is the unrecognised agent provoking the symptoms of respiratory disease. That the reflux entering the airways from the gastrointestinal tract is central to the diagnosis, therapy and understanding of respiratory pathology has been missed because the paradigm of peptic disease has been applied. Airway reflux is however unlike gastro-oesophageal reflux disease (GORD). GORD is liquid acid reflux causing heartburn and indigestion. Airway reflux consists of a mainly gaseous non-acid mist which, when deposited in the upper and lower airways leads to inflammation, fibrosis, bronchoconstriction and cough. Here, the hypothesis that airway reflux is responsible for chronic “idiopathic” cough, late onset asthma, exacerbations of COPD, ‘idiopathic’ pulmonary fibrosis and even the lung disease of cystic fibrosis is outlined. The exclusive focus of clinicians on the extrinsic origins of these conditions and the rejection of an obvious intrinsic aetiology causes millions of patients to be denied an explanation for their symptoms and simple, effective, treatments. In many cases idiopathic should be no longer considered idiopathic.

Introduction

Reflux is the cause of all respiratory disease. An exaggeration of course, but I hope to convince you in this article that there is more than a germ of truth in this outrageous statement. There have been two barriers to the revelation that reflux is a major contributor to respiratory pathology. First, we have been labouring under the diagnostic criteria of reflux as gastroesophageal reflux disease (GORD). There is no doubt that GORD exists and the gastroenterologists have defined and characterised the disease which causes heartburn, dyspepsia and oesophagitis; however, they have been very reluctant to accept that this is merely the tip of the reflux iceberg, with extra-oesophageal reflux being out of their home territory. Respiratory professionals, being largely ignorant of reflux, its aetiology and manifestations, have accepted the wisdom of the gastroenterologists, since this is “their” area. So blinkered has this attitude become that, with one or two exceptions, one should not talk to a gastroenterologist about what has been termed airway reflux. You might as well talk to a tree!

Secondly, within the respiratory community there has been marked reluctance to accept reflux as even the potential cause of respiratory disease; although it has not always been so. Indeed, in 1698, Sir John Floyer in his great book, A Treatise on the Asthma (fig. 1), vividly describes what he terms as flatulent asthma [1]. In 1881, Congreve described “a dry or nervous asthma”, which is accompanied by flatulence and he observes that dyspepsia is “an accompanying evil and perhaps the exciting cause” [2]. However, with the discovery of the cellular and molecular basis of allergic disease and its emphasis on allergens, the entire focus of research has been towards external factors which are inhaled. This extrinsic hypothesis is the current, exclusive, paradigm used to explain respiratory disease. The balance needs redressing. Forty years ago, asthma was termed either extrinsic or intrinsic. This is the true pathophysiology of respiratory disease. Extrinsic factors are important but we have lost sight of intrinsic factors in the form of reflux. Thinking in this way opens the door to understanding many of the otherwise inexplicable phenomena described by our patients. It also suggests alternative avenues of therapy to end the intractable suffering of “difficult” patients who steadfastly refuse to respond to conventional respiratory treatments.

Figure 1

Floyer''s reaction to airway reflux depends on the individual patient and ranges from fibrosis of the terminal airways, to both neutrophilic and eosinophilic bronchitis and upper airway pathology.

  • Treating the acid component of airway reflux is ineffective in preventing disease.

  • Reflux should always be considered if there is a failure of conventional the 1 last update 02 Jul 2020 treatment in “other” respiratory disease.Reflux should always be considered if there is a failure of conventional treatment in “other” respiratory disease.

  • Educational questions

    1. Proton pump inhibitors

      1. Are effective treatments of reflux

      2. Should for 1 last update 02 Jul 2020 be used at high dose in troublesome coughShould be used at high dose in troublesome cough

      3. May cause worsen of the 1 last update 02 Jul 2020 airway diseaseMay cause worsen of airway disease

      4. Are useful add-on therapy in severe asthma

      5. Improve oesophageal motility

    2. Characteristic features of the symptoms of airway reflux do not include

      1. Attacks of rapid onset

      2. Heartburn Remedies Heartburn Treatments (☑ Treatment) | Heartburn Remedies 11 Foods That Causehow to Heartburn Remedies for A the 1 last update 02 Jul 2020 worsening at nightA worsening at night

      3. Upper airway involvement such as voice change

      4. An association with food

      5. Throat clearing

    3. Which of these factors do not increase the probability of reflux?

      1. Hyperexpanded lungs

      2. Male sex

      3. Hiatus hernia

      4. Neuropathy

      5. Heartburn Remedies What To Eat (🔴 Foods To Eat And Avoid) | Heartburn Remedies GERD Diethow to Heartburn Remedies for Obesity

    4. Which of the following are consequences of airway reflux

      1. Pulmonary fibrosis

      2. Squamous carcinoma of the bronchus

      3. Heartburn Remedies Simples Steps To (👍 Diet For) | Heartburn Remedies Remedieshow to Heartburn Remedies for Episodic wheeze

      4. Eosinophilic bronchitis

      5. Haemoptysis

    Heartburn Remedies Anti-Reflux Diet (👍 Why) | Heartburn Remedies Treatments Forhow to Heartburn Remedies for Suggested answers

    1. c.

    2. b.

    3. b.

    4. a, c, d.

    Footnotes

    • Heartburn Remedies Heartburn Medicine (🔴 Disease Treatment) | Heartburn Remedies Solutionshow to Heartburn Remedies for Statement of Interest

      None declared.

    • ©ERS 2013

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