September 21, 2021

9/11: Ground Zero, Reflux, and Chronic Cough


  • First responders and those who lived and/or worked in lower Manhatten in the weeks-to-months after 9/11 have been a part of the majority who have experienced severe and often undiagnosed, acid reflux, asthma, chronic cough, and lung disease.
  • While the mechanism of damage to exposure and inhalation of residual toxic dust has not yet been precisely clear, in my practice (using state-of-the-art reflux testing) virtually every one of my “ground-zero” patients had/has respiratory reflux (aka LPR).
  • It is important to note that gastroenterologists may not have the tools necessary to diagnose this type of respiratory reflux. But, if you were exposed, you still may have it and should take it seriously.
  • Thankfully, the antireflux treatment appears to help prevent the progression of pulmonary diseases and improve most people’s reflux symptoms. Note: The focus of treatment is a healthy diet and lifestyle, and for some recalcitrant cases, antireflux surgery (i.e., laparoscopic fundoplication).
  • I recommend that all “Ground-Zero” exposed individuals routinely take rigorous, long-term anti-reflux precautions (shown below).

In the 20 years since 9/11, it has become clear that asthma and progressive respiratory diseases are ubiquitous among survivors who lived and worked in lower Manhattan and that acid reflux is a significant co-factor.[1,2,3,4,5,6] Often discussed in the medical literature LPR, aka “respiratory reflux,” is too uncommonly credited as the cause of respiratory disease and respiratory disease progression; however, in my experience, it is. To more clearly understand the relationship between reflux and lung disease, see the COPD blog. Silent respiratory reflux is also the most common cause of chronic cough; see The Chronic Cough Enigma.

Even if half of the American population have reflux, virtually 100% of first responders had/have pH-documented reflux in my practice. Over time, I have managed approximately hundreds of such patients, with most seeing real improvement due to antireflux treatment and/or antireflux surgery. The purpose of this post is to emphasize that respiratory reflux acts as an accelerant to all forms of respiratory disease and that it is often “silent,” occurring at night during sleep — but that it can be corrected.

Silent reflux is reflux that occurs without the telltale symptoms of heartburn and indigestion. Silent refluxers usually have a constellation of symptoms that includes: post-nasal drip, too much throat mucus, chronic throat clearing, hoarseness (especially in the morning), a sensation of a lump in the throat, difficulty swallowing, sinus symptoms, shortness of breath, asthma, and COPD (chronic obstructive lung disease). 

Preemptive Treatment For Silent Respiratory Reflux

  • Have your last meal of the day early, and do not make it your principal refueling meal of the day. The idea here is for you to go to sleep with an empty and quiet stomach. It takes five hours for the stomach to empty completely in people who have long-standing reflux. So if you go to bed at 11pm, you should close the kitchen at 6pm, and try to get most of your calories for the day before 5pm. And no late-night snacks.
  • Sleep on an incline of 45° or more, and gravity helps keep the reflux out of your respiratory tract. Unfortunately, standard GERD wedges are not high enough to be of great assistance to you.
  • Eat a diet that is lean, green, clean, and alkaline. Avoid high-fat and deep-fried food, especially in the evening.[5,6,7] Drink nothing out of the bottle except still water, preferably alkaline water. That means no soda or other soft drinks, energy drinks, fruit juices, and the like.
  • Avoid all high-risk, reflux-trigger foods, including alcohol (especially white wine), chocolate, onions, peppers, and garlic. Avoid mint, apple cider vinegar, citrus of any kind, and more than 2 cups of coffee a day.


Silent, nighttime, respiratory reflux is ubiquitous among people who were exposed (anywhere around Ground Zero) in lower Manhattan after 9/11.

Silent reflux, LPR occurring at night during sleep, is pernicious and is tied to asthma, sleep apnea, and lung disease. Remember, respiratory reflux can exacerbate and accelerate all other respiratory conditions — and it should be preemptively and vigorously treated.

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