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What Is Respiratory Reflux & Why Doesn't My Doctor Know About This?

What Is Respiratory Reflux & Why Doesn't My Doctor Know About This?

At-A-Glance

  • Respiratory Reflux, formally known as LPR, is acid reflux that comes up into the throat and respiratory tract, which can cause, complicate, worsen or accelerate any and all respiratory symptoms and diseases.
  • Respiratory Reflux may affect the ears, nose, sinuses, throat, voice box, trachea, bronchial tubes, and lungs; and unfortunately, most doctors do not know much about this.
  • Respiratory Reflux (RR) is ubiquitous and four times (4X) more common that GERD (gastroesophageal reflux disease), symptoms of the latter being heartburn and indigestion. RR may affect as many as 100 million Americans.
  • Why The New Term? I coined the term Respiratory Reflux as a more accurate, pronounceable, and intuitive term for LPR (laryngopharyngeal reflux). In 1987, I coined the term LPR as a way to differentiate the symptoms and patterns of reflux in my ENT patients from those of GI patients with GERD. Typically, people with RR do not have heartburn, indigestion, or esophageal disease
  • It's Silent. RR is usually “silent,” because the reflux occurs mostly at night during sleep without awakening the sufferer and because most people with RR don’t have GERD. RR is almost always Silent Nocturnal Respiratory Reflux; and because it is silent, people with RR are often unaware that they have it.
  • Why Doesn’t My Doctor Know About This? The go-to doctor for acid reflux, the gastroenterologist, gastrointestinal (GI) specialist, knows almost nothing about RR; it’s just not in their curriculum. Thus, other medical specialists who consult GIs for help with their patients are handicapped because GI doctors do not have the tools or knowhow to diagnose and treat RR.

What Is Respiratory Reflux?

The throat (pharynx) is like Grand Central Station where the respiratory and digestive tracts converge. The pharynx is an integral part of both systems. And when acid reflux reaches the throat, LPR, it can then go north up to the ears and nose, or south down to the bronchial tubes and lungs … and anywhere between; it can affect any part of the respiratory system. 

I coined the term, Respiratory Reflux (RR) in 2017 as a new, more accurate, pronounceable, and intuitive term for LPR (laryngopharyngeal reflux. In 1987, I coined the term LPR as a way of differentiating reflux disease in my ENT patients with respiratory symptoms from GI patients with symptoms such as heartburn and indigestion, so-called GERD (gastroesophageal reflux disease).

Throughout most of my career, I performed reflux testing that is/was superior to anything that other doctors had/have ... in doing 24-hour pH monitoring, I used the best, pH (ISFET) chips, in both the esophagus and pharynx. In three decades of testing in tens-of-thousands of patients, I found that ~75% had pH-documented RR in patients with:

Allergies and asthma

Snoring and sleep apnea

COPD (chronic obstructive lung disease)

Bronchitis, bronchiolitis, and bronchiectasis

Vocal cord polyps, nodules, and granulomas

Oral, vocal cord, throat, esophageal, and lung cancer

I would stake my life on the fact that those findings prove causality. And it’s not just the diagnostic data that make that case. I have effectively treated thousands of patients in above groups with “cure,” that is, with complete resolution of their conditions. See, for example, the blogs on Bronchitis, Choking, COPD, and Asthma. The reflux-testing data also reveal that most people with RR have the Silent Nighttime RR, again, with no heartburn, indigestion, or esophageal disease.

A more complete list of symptoms and diseases caused by RR is shown at the bottom of this blog. Make no mistake about it, RR can cause,  complicate, worsen or accelerate any and all respiratory diseases.

What Is the Cost of Misdiagnosing Respiratory Reflux?

My data have staggering implications for U.S. healthcare system, since in most RR cases, neither the patient nor their doctor(s) are aware that the underlying problem is reflux. Take asthma for example: in my practice three-out-of-four (75%) of patients with “asthma” are misdiagnosed; they have trouble breathing IN not OUT; they have RR-caused “pseudo-asthma,” not true asthma. 

Annually, “asthma” costs the U.S. healthcare system $80 billion; so if I am right, we waste $60 billion a year on asthma misdiagnosis alone. If you add just allergies, chronic cough, COPD, snoring, and sleep apnea, I estimate that correct diagnosis could save almost $200 billion per year and patients would receive better care as well!

Hopefully, this post is a wake up call for the public, the medical community, and Google as well as other search engines. With regard to the latter, search engines have failed to recognize the term LPR for three decades. The default for all “reflux” on the internet is “acid reflux.” Thus, the search engines help prevent proliferation of new information and ideas about RR/LPR, which may affect so many millions of Americans. Attention Google!  Just because gastroenterologists don’t, Google should recognize GERD, LPR, RR, and Silent Reflux as being distinct entities/diseases that may all fall under the big acid reflux tent.

Why Doesn’t My Doctor Know About This?

Over a period of decades, by far the most common question that my patients have asked is, “Why doesn’t my doctor know about this?”

There are the three reasons why doctors remain uninformed about RR: (1) RR being silent, is east to miss, (2) GIs (gastroenterologists) hijacked reflux decades ago, and (3) over-specialized medical specialists can't see the RR forest for the trees.

Respiratory Reflux is so big that it’s almost invisible. Many people with RR are unaware that they have it, because they don't have heartburn or indigestion, and that is understandable. But the problem with "ignorance" of medical community may have more to do with doctors protecting their precious “turf” and with MONEY.

How could it be that medical specialists who deal with the airway (respiratory tract) know so little about it? A big problem, at least in the United States, is hyper-specialization. Indeed, when it comes to respiratory reflux, the specialist model of American medicine has failed. That’s because the idea of dividing the body up into small, non-overlapping, anatomic areas makes no sense. The respiratory and digestive systems are intimately connected and specialists don’t seem to know that. The “turf” of each specialty, each sovereign domain, is defended with nothing short of dirty academic and economic warfare.

I know this because as I have encroached on the GI reflux world, I have been personally and professionally attacked as a quack. In truth, the ducks out of water here are GI opinion-leaders, many of whom actually deny the existence of RR/LPR … that because it threatens the “heartburn business model.” What Is the heartburn business model?  "Reflux is heartburn; heartburn is reflux; it's esophageal, and we own it!"

How did this happen? In the 1970s, the Olympus Corporation began to market high-quality endoscopes to GIs, and the sedated endoscopy market — now a multi-billion-dollar-a-year business — was born. GIs look into the esophagus and then prescribe purple pills … that’s pretty much it … even though none of it works.

The other specialists that share the airway (e.g., allergists, otolaryngologists, pulmonologists) are left in the dark, because GIs worse than just being ignorant about RR/LPR, often attack it. I believe that they do so because if RR is so much bigger and more important than GERD, then the heartburn business model falls apart.

Unfortunately, most physicians still mistakenly subscribe to the GI (gastroenterology) model of reflux disease, but it's wrong, all wrong:  (1) Reflux is not about heartburn and indigestion; far more common is reflux without GI symptoms, Silent Respiratory Reflux is more common than GERD; (2) Endoscopy (looking in the esophagus) is not a useful test to determine if you have reflux; (3) By themselves, acid-suppressive purple pills (PPIs) are ineffective anti-reflux treatment; (4) Reflux is not necessarily a chronic disease; it can be reversed, cured; and (5) Successful anti-reflux treatment depends healthy diet and lifestyle with the goal of eradicating pepsin where it shouldn't ought to be; the reflux problem isn’t about acid. For more about this, see What Is Pepsin?

RR just isn’t yet in medical schools, residency training programs, etc.; if interested about more on the topic of inept medical specialists, see my New York Times Op-Ed, The Specialists’ Stranglehold on Medicine

So, one might ask who might be the “other” audience for this blog? The answer is physicians, especially those who deal with respiratory conditions, including pulmonologists (lung doctors), otolaryngologists (ear, nose, and throat doctors), allergists, pediatricians, critical care specialists, and “generalists.” i.e. primary care physicians and family physicians.

THE BIGGER RESPIRATORY REFLUX LISTS (Note: Even These are NOT exhaustive)

What Symptom Can Respiratory Reflux Cause?

Aspiration (food/drink going into lungs)

Choking episodes

Chronic cough

Chronic throat-clearing                                              

Coughing up blood (bronchitis with hemoptysis)

Dysphagia (difficulty swallowing)                                                    

Ear pain, stuffiness, pressure, fluid

Food getting stuck in throat

Globus (a sensation of a lump in the throat)                          

Halitosis (bath breath)

Inability to breathe in

Inability to breathe out                      

Inability to take a full breath in                                 

Laryngitis       

Loss of vocal range (singers)                         

Nasal obstruction

Runny and stuffy nose                      

Shortness of breath                                                    

Sleep apnea                            

Snoring

Sour taste in the mouth

Tinnitus (ringing in the ears)                          

Vocal fatigue 

Voice change, hoarseness

Voice-use pain

What Diseases Can Respiratory Reflux Cause or Complicate (Worsen)?

Aspiration

Asthma

Bronchiectasis

Bronchiolitis

Bronchitis

COPD (chronic obstructive lung disease)

Cystic fibrosis

Esophageal cancer

Eustachian tube dysfunction

Hemoptysis (Coughing up blood)

Idiopathic pulmonary fibrosis*

Laryngeal cancer

Laryngeal webbing and stenosis (scarring)

Laryngospasm (cannot get air in, choking)

Lung cancer

MAC lung disease (Mycobacterium avium)

Oral (mouth) cancer

Paradoxical vocal cord movement

Pneumonia

Pseudo-asthma

Recurrent pneumonia

Serous Otitis media (fluid in the ears)

Sinus pressure and sinusitis

Subglottic stenosis (scarring)

Throat cancer

VCD, vocal cord dysfunction (inability to get air in)

Vocal cord cancer

Vocal cord granulomas

Vocal cord nodule

Vocal cord polyps

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When Jamie Koufman gives advice, you should listen.

Dr. Koufman has been a world-renowned pioneer in acid reflux for decades. Through her medical practice and scientific research, Dr. Koufman almost single-handedly advanced our understanding of the interaction between digestive and respiratory disease. She has won prestigious awards and is a New York Times best-selling author for her books on reflux and chronic cough.

Dr. Koufman’s Books on Reflux

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Copyright 2020 | Dr. Jamie Koufman | Privacy Policy + Disclaimer
Copyright 2020 Dr. Jamie Koufman
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The Voice & Reflux Institute of New York
Transnasal Esophagoscopy
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