Can gastro‑oesophageal reflux disease cause shortness of breath?

Can GERD Cause Shortness of Breath?

Yes, GERD can cause shortness of breath through multiple mechanisms, though the relationship is complex and not all patients with both conditions have a causal connection. 1

Established Mechanisms Linking GERD to Respiratory Symptoms

GERD produces respiratory symptoms including shortness of breath through two distinct pathways 1:

Direct Airway Contact Mechanism

• Gastric acid refluxes through the lower esophageal sphincter into the distal esophagus, then continues proximally through the upper esophageal sphincter into the pharynx and potentially the airways 1
• This can cause direct irritation of the larynx and lower respiratory tract through microaspiration or macroaspiration, leading to bronchospasm and dyspnea 1
• Aspiration syndromes associated with GERD include chemical pneumonitis, recurrent bacterial pneumonias, chronic interstitial fibrosis, and bronchiectasis—all of which can cause shortness of breath 1

Esophageal-Bronchial Reflex Mechanism

• Refluxate in the distal esophagus alone can trigger a vagally-mediated esophageal-bronchial cough reflex that causes bronchospasm and respiratory symptoms without requiring direct airway contact 1
• Acid challenges to the esophagus markedly reduce the threshold for respiratory symptoms and can directly result in dyspnea 1
• This reflex can be prevented by atropine inhalation, confirming a CNS-dependent reflex pathway that results in bronchospasm and/or mucous secretion 1

Critical Clinical Context

Prevalence and Presentation

• GERD can be "silent" from a gastrointestinal standpoint in up to 75% of patients presenting with extraesophageal manifestations like shortness of breath 1, 2
• When GERD causes chronic respiratory symptoms, typical heartburn and regurgitation may be completely absent 1
• There is nothing about the character or timing of respiratory symptoms that distinguishes GERD-related dyspnea from other causes 1

Important Diagnostic Pitfalls

• Most studies have demonstrated no significant correlations between GERD and exercise-induced bronchoconstriction (EIB), and many patients with exercise-related respiratory symptoms receive a misdiagnosis of asthma when they truly have exercise-onset GERD 1
• One study showed that patients with GERD and respiratory manifestations with normal spirometry present no pulmonary dysfunction during cardiopulmonary exercise testing, despite having respiratory symptoms 3
• Merely observing laryngoscopic or bronchoscopic signs of inflammation is not specific for GERD, as these changes may be due to the act of coughing itself from other diseases 1

When to Suspect GERD as the Cause

GERD should be strongly considered when patients present with shortness of breath and the following clinical profile 1:

• Not exposed to environmental irritants nor a current smoker 1
• Not taking an angiotensin-converting enzyme inhibitor 1
• Chest radiograph is normal or shows only stable, inconsequential scarring 1
• Symptomatic asthma has been ruled out (negative methacholine challenge or no improvement with asthma therapy) 1
• Upper airway cough syndrome has been ruled out (no improvement with first-generation H1-antagonist and "silent" sinusitis excluded) 1
• Nonasthmatic eosinophilic bronchitis has been ruled out (negative sputum studies or no improvement with corticosteroids) 1

This clinical profile has approximately 91% predictive value that respiratory symptoms will respond to antireflux treatment 1

Diagnostic Approach

Initial Evaluation

• Actively inquire about heartburn, regurgitation, dysphagia, or relief with antacids, though absence does not rule out GERD 1, 2
• Look for aspiration syndromes on chest imaging or bronchoscopy (subglottic stenosis, hemorrhagic tracheobronchitis, erythema of subsegmental bronchi, parenchymal abnormalities) 1
• Consider laryngoscopy to evaluate for reflux laryngitis (posterior laryngitis with red arytenoids and piled-up interarytenoid mucosa) 1, 4

Treatment Trial

• Initiate a PPI trial for 8-12 weeks minimum, as extraesophageal manifestations require longer treatment than typical GERD 2
• If one PPI trial fails (up to 12 weeks), pursue objective testing with pH-impedance monitoring off PPI rather than trying additional empiric PPI trials, as further empiric therapy is low yield 5, 2

Objective Testing

• Consider objective testing before initiating PPI therapy in patients lacking typical GERD symptoms, as 50-60% will not have GERD as the underlying cause 2
• Prolonged wireless pH monitoring off medication (96-hour preferred) is required to confirm pathologic reflux and establish causation 6, 5
• No single diagnostic tool conclusively identifies reflux as the cause; diagnosis requires integrating symptoms, endoscopy findings, reflux monitoring results, and treatment response 5

Key Caveats

• Do not continue empiric PPI therapy beyond 12 weeks without objective testing 5
• A multidisciplinary approach with gastroenterology, pulmonology, and ENT evaluation produces the best outcomes 6, 5
• Some controversies exist: one study showed proton pump inhibitors relieved acid reflux symptoms related to running but not the respiratory symptoms of EIB, while other investigators reported improvements in exercise-related breathing symptoms with PPI treatment 1
• The term "acid reflux disease" should be replaced by "reflux disease" unless definitively shown to apply, as not all patients with GERD-related respiratory symptoms improve with acid-suppression therapy alone 1