A Doctor’s Guide to Treatment of Silent Reflux, Respiratory Reflux, and LPR

Understanding Different Types of Reflux

Effective treatment begins with understanding that not all reflux is the same. While GERD (gastroesophageal reflux disease) is the most widely recognized, it is neither the most prevalent nor the most harmful type of reflux. Silent reflux, which is harder to diagnose, often leads to more long-term complications, affecting the throat, voice box, and airways without the typical symptoms of heartburn.

Here’s how they differ:

GERD (Gastroesophageal Reflux Disease) – Occurs when stomach acid backs up into the esophagus, causing heartburn, regurgitation, and esophageal irritation. GERD symptoms are typically felt in the chest and worsen when lying down or after eating acidic foods.

Silent Reflux (Laryngopharyngeal Reflux or LPR, also called Respiratory Reflux) – Unlike GERD, silent reflux does not always cause heartburn. Instead, stomach contents—acid, pepsin, and bile—travel beyond the esophagus, irritating the throat, voice box (larynx), and even the airways. This leads to symptoms like chronic cough, hoarseness, throat clearing, post-nasal drip, sinus issues, and breathing difficulties. Some cases of silent reflux affect only the throat, while others spread deeper into the airways, leading to asthma-like symptoms, wheezing, or lung inflammation.

SNoRR (Silent Nocturnal Respiratory Reflux) – Many cases of LPR/silent reflux occur at night, when stomach contents reach the throat and airways while you sleep. This can cause waking up with a sore throat, excess mucus, nighttime coughing, or breathing difficulties. Because symptoms happen overnight, many people don’t associate them with reflux.

Silent Reflux: A Deep Dive into What It Is and How to Treat It

Silent reflux — also called laryngopharyngeal reflux (LPR) or respiratory reflux — affects millions of people, causing chronic cough, hoarseness, throat clearing, post-nasal drip, and even breathing difficulties.

Unlike traditional acid reflux (GERD), silent reflux often happens without heartburn, making it harder to diagnose. Because of this, many people struggle for years without realizing silent reflux is the cause of their symptoms.

This guide explains the best treatments, including diet changes, lifestyle adjustments, and medications that actually work.

As a pioneering specialist in ENT (ear, nose, and throat) disorders, I have spent my career researching and refining treatment for this condition. Below I share my comprehensive treatment approach that combines diet, lifestyle changes, and targeted treatments based on my clinical experience and research.

I. The Best Diet for Silent Reflux

The foods and drinks you consume can either help or worsen reflux. Because the major culprit in reflux, pepsin, is only active in acidic environments, it’s essential to eliminate acidic foods and instead consume alkaline foods and beverages. For an in-depth look and a practical guide on acid-alkaline balance, my book Dropping Acid: The Reflux Diet Cookbook & Cure provides more insights.

Top Foods to Avoid

A low-acid diet is key to preventing pepsin activation and protecting your throat. Avoid foods and drinks with a pH below 5, including:

• Soda and carbonated beverages (pH 2.7-3.9) – These reactivate pepsin in the throat.

• Citrus fruits and juices – Oranges, lemons, grapefruit, and their juices are highly acidic.
• Tomatoes and tomato-based products – Including sauces, salsa, and ketchup.
• Vinegar-containing foods – Such as pickles, salad dressings, and condiments.
• Wine and alcohol – Alcohol relaxes the lower esophageal sphincter (LES)—the valve between the esophagus and stomach—and many wines, like champagne and red wine, are highly acidic.
• Coffee and tea – Even decaffeinated coffee and tea can trigger reflux by affecting the LES. For most people, caffeine is the main reflux trigger, so it should be limited to 120 mg per day.
• Chocolate – Contains caffeine and theobromine, which relax the LES.
• Mint products – Peppermint and spearmint can worsen reflux symptoms by relaxing the LES.

Best Alkaline Foods to Eat

Instead, focus on foods with a pH above 5, such as:

• Non-citrus fruits – Bananas, melons, apples, pears, figs, and dates.
• Vegetables – Most, except tomatoes and onions.
• Whole grains – Oatmeal, whole grain bread, and brown rice.
• Lean proteins – Chicken, turkey, and fish (grilled or baked, not fried).
• Healthy fats – Avocados, olive oil, fish, and select nuts (pistachios, almonds, and walnuts).
• Alkaline water – Alkaline water with a pH above 8.0 can help neutralize pepsin, but I recommend water that is pH 9.5 or higher. Alkaline water drops can also be effective.

The Two-Phase Dietary Approach

I typically recommend:

• Induction (Healing) Phase – A strict four-week detox that eliminates all foods and drinks with a pH below 5. This allows irritated throat tissues to heal and for pepsin to be cleared from the aerodigestive tract.
• Maintenance Phase – A more flexible approach that allows for occasional moderate-acid foods while maintaining an overall alkaline diet.

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II. Sleep & Lifestyle Tips to Stop Silent Reflux

Diet alone is not enough—lifestyle changes are equally critical in managing reflux. Here’s what I recommend:

Sleep Position and Timing

• Elevate the head of your bed – Raising it 45 degrees helps prevent nighttime reflux with the help of gravity keeping stomach contents from going up. Recliners or adjustable beds work best, as typical reflux wedges are not high enough.
• Avoid eating close to bedtime – Stop eating at least 4 hours before lying down to minimize reflux episodes. If the stomach contains food when lying down, the helpful effects of gravity are no longer there, making reflux more likely.

Eating Habits

• Eat smaller meals – Large meals stretch the stomach and increase pressure on the LES, increasing the risk of reflux.
• Eat slowly and chew thoroughly – This aids digestion and reduces reflux risk.
• Stay upright after eating – Wait at least three hours before lying down.

Weight Management & Stress Reduction

• Lose excess weight – Extra abdominal fat increases pressure on the stomach, worsening reflux. Even modest reduction in weight can significantly reduce reflux symptoms.
• Manage stress – Chronic stress contributes to reflux. I recommend meditation, breathwork, and mindfulness techniques.
• Choose the right exercise – Avoid high-impact activities that put excessive pressure on the LES.

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III. Medication and Surgery Options for Silent Reflux: What Works and What Doesn’t

Traditional GERD treatments often fail to address silent reflux because they focus solely on reducing acid. Here’s what I recommend instead:

Avoid Proton Pump Inhibitors (PPIs)

PPIs only reduce stomach acid production; they do not prevent stomach contents from moving up into the esophagus and throat. This is why they are not effective for respiratory reflux. Worse, they are linked to an increased risk of esophageal cancer and other severe side effects. For respiratory reflux PPIs are not the best option.

H2 Receptor Antagonists (H2 Blockers)

Unlike proton pump inhibitors (PPIs), H2 receptor antagonists (H2 blockers) lower stomach acid without completely shutting down acid production. This makes them a safer and more effective choice for respiratory reflux, as they help reduce acid exposure without interfering with digestion or increasing long-term health risks.

The most effective H2 blocker for reflux is famotidine (Pepcid), which has been shown to:

• Reduce acid levels safely without the rebound effect seen with PPIs
• Minimize reflux-related inflammation in the throat and esophagus
• Have fewer side effects and lower long-term risks compared to PPIs

For those with significant acid reflux, I recommend 80 mg per day—20 mg first thing in the morning, 20 mg 30 minutes before dinner, and 40 mg before bed.

Alginate-Based Therapy

Algienates create a protective barrier, preventing reflux from reaching the throat. Some formulations contain sodium alginate, which can bind to pepsin, further reducing its harmful effects.

Surgical Intervention

For patients with severe, medication-resistant respiratory reflux who have already followed strict dietary and lifestyle modifications for at least 6-12 months, surgery may be an option.

The most effective surgical procedure for respiratory reflux is laparoscopic Nissen fundoplication, a minimally invasive operation where the top of the stomach is wrapped around the lower esophagus. This strengthens the LES, preventing stomach contents from traveling upward.

For respiratory reflux, a full 360° Nissen wrap is preferred over partial wraps like Toupet fundoplication, which do not provide a strong enough barrier against reflux.

Some newer endoscopic procedures, such as Transoral Incisionless Fundoplication (TIF) and the LINX procedure, have gained popularity, but they are generally less effective for respiratory reflux.

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Putting it All Together: A Doctor’s Integrated Treatment Approach to Silent Reflux

I believe an integrated, stepwise approach to reflux treatment is most effective.

First-Line Treatment (4-6 weeks)

• Strict adherence to the anti-reflux diet
• Implementation of all lifestyle modifications
• Appropriate medication (famotidine and alginates taken properly)

Second-Line Treatment (additional 2-3 months)

• Continued dietary and lifestyle compliance
• Medication adjustments as needed

Maintenance Phase

• Less restrictive but still careful diet
• Continued lifestyle modifications
• Reduced medication or as-needed use

Refractory Cases

• Reevaluation of diagnosis
• Consideration of the surgical option

Conclusion: A Personalized Approach to Treating Silent Reflux

Through decades of research, I’ve found that a comprehensive, personalized approach is key to treating respiratory reflux and silent reflux. Unlike traditional GERD, silent reflux doesn’t respond well to medication alone.

The most effective treatments combine dietary changes, lifestyle modifications, and appropriate medications. By following this integrated approach, most patients experience significant symptom relief and improved quality of life.

If you’re struggling with silent reflux or respiratory reflux and need a personalized treatment plan, you can schedule a virtual consultation with me. Book It Online.

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For more information about diagnosis and treatment of acid reflux, see two companion books on Amazon: Dr. Koufman’s Acid Reflux Diet and Dropping Acid: The Reflux Diet Cookbook & Cure. If you would like to receive personalized guidance and strategies for lasting relief, consider scheduling an online consultation.