The connection between Gastro-esophageal reflux disease (GERD) and obstructive sleep apnea (OSA)
Gastro-esophageal reflux disease (GERD) and obstructive sleep apnea (OSA) have long been considered to have an association.They are both common medical conditions reducing the quality of life for thousands of Canadians.
Laryngo-pharyngeal reflux (LPR) is the back-flow of stomach contents up the esophagus and into the upper airway, while GERD includes back-flow only into the esophagus.
The damage resulting from this refluxate (a mixture of activated pepsin) a proteolytic enzyme) and hydrochloric acid can cause extensive symptoms.
These include, altered voice, throat clearing, vocal fatigue, laryngeal tightening and glottic carcinoma.
LPR has been estimated to affect up to 35% of the population over 40 years of age.
There are two main theories regarding this LPR/GERD causation to OSAS. Primarily it is believed that airway obstruction during apnea causes a negative intra-thoracic chest pressure following diaphragmatic activation causing the drawing up of the refluxate.
The resultant inflammation from this causes irritation and swelling, in turn causing direct airway compromise and obstruction in the airway.
Local neural sensation (including innervation that retains airway patency) is also affected.
The other main theory suggests direct laryngospasm leading to further obstruction. Regardless of the theory chosen (and there still remains controversy over this apparently bi-directional relationship), it appears clear how such a pathophysiological relationship may work.
Researchers maintain that for patients with a sleep disorder, investigation into GERD/LPR is indicated. Equally so, for those presenting with or complaining of chronic heartburn or acid reflux, obstructive sleep apnea should be ruled out as a matter of course.
It is well known that Canadians take too many antacid tablets. “Doctors are warning that millions of Canadians are taking a commonly prescribed class of drugs used to treat acid reflux much longer than the recommended two-month period, upping the risk of a number of health-related side-effects.
Proton pump inhibitors, as the class of drugs is known, are found in medicine cabinets across Canada. They reduce the production of stomach acid, which helps break down food but can reflux up the throat and cause a burning sensation or severe discomfort.
The drugs’ efficacy is the reason they are the second-most commonly prescribed medication in Canada.
Product monographs say that doctors should prescribe the lowest dose for the shortest amount of time possible, and no longer than eight weeks.” (CTV News)
“With sleep apnea, people tend to breathe harder because their breathing has stopped, and that could induce reflux to flow into the esophagus,” says gastroenterologist Ken DeVault, MD, of the Mayo Clinic in Jacksonville, Florida, and spokesman for the American College of Gastroenterology. “It’s been thought that this causes reflux to enter the esophagus.”
GERD Statistics
- Gastroesophageal reflux disease (GERD) is characterized by heartburn and acid regurgitation, where there is reflux of stomach contents into the esophagus.
- GERD symptoms are widespread in the community and range from 2.5% to more than 25%. (Savarino et al. 2017)
- The history and prevalence of GERD is difficult to establish because of the lack of a standard and universally accepted definition.
- In North America, it is estimated that the prevalence of GERD is 15%. (Eusebi et al. 2018)
- GERD has detrimental societal consequences, and negatively impacts quality of life and work productivity. (Hunt et al. 2017)
- Proton pump inhibitors are one type of drug that can be used to reduce stomach acid and relieve GERD symptoms.
- Proton pump inhibitors are one of the most common drugs prescribed in Canada. In 2012, there were more than 11 million prescriptions dispensed nationwide. (Farrell et al. 2017)
- In 2017, spending on proton pump inhibitors by public drug programs totaled $198.2 million in Canada, ranking the drug seventh in terms of public drug program spending. (Canadian Institute for Health Information 2017)
- A Canadian study estimated that patients with GERD lose 16% of their work time due to their symptoms. (Fedorak et al. 2010)
- https://www.ncbi.nlm.nih.gov/pubmed/28687968
Associations between obstructive sleep apnea severity and endoscopically proven gastroesophageal reflux disease.
CONCLUSIONS:
Endoscopically proven GERD was associated with more severe OSA. GERD symptoms were also associated with deteriorated sleep quality.
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Dr. Stephen Bray 2019