Tips for preventing reflux and aspiration
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People living with cystic fibrosis (CF) are at risk of gastroesophageal reflux disease and aspiration, both of which can have negative effects on the lungs and heart.
Gastroesophageal reflux occurs when stomach acid travels upward into the esophagus, and its most common symptom is heartburn. Normally, the lower esophageal sphincter (LES) — a band of muscle where the stomach and esophagus connect — prevents the backflow of stomach contents into the esophagus. Reflux can happen when the LES is relaxed at inappropriate times or distended because the stomach is too full.
Gwen A. Huitt, MD, an infectious disease doctor with a special interest in mycobacteria and cystic fibrosis, spoke with the Cystic Fibrosis News Today team about what aspiration is and how it is dangerous to CF patients, while offering a number of tips for prevention.
What is aspiration and how is it harmful?
Aspiration is the act of inhaling a liquid or a solid into the lungs, and often results in a person coughing and getting a sore throat and hoarse voice.
The term “silent aspiration” is applied when there is no cough reflex after a liquid, such as stomach acid, gets into the lungs. The person is often unaware this has happened, and doesn’t show any outward signs of swallowing difficulty.
“The dangers of aspiration for CF or non-CF patients are that you are sending not only germs such as Pseudomonas or nontuberculous mycobacteria into the airway that contribute to infection, but also that digestive enzymes and acids cause significant inflammation in the airways,” said Huitt.
According to a recent study, gut bacteria entering the lungs during acid reflux and aspiration episodes may promote lung inflammation and poorer lung function in people with CF.
Aspiration also can lead to bronchiectasis, a condition in which the lung airways become widened, leading up to the buildup of excess mucus. This, in turn, can lead to pulmonary exacerbations, events characterized by an increase in respiratory symptoms, and a decline in lung function.
In order to reduce the risk of acid reflux and aspiration, Huitt made a number of suggestions regarding meal size and frequency, foods to reduce reflux, sleep and bed positions, and seeking professional healthcare advice about medications.
Eat small meals and limit liquids
Too much food and liquid can distend the stomach. People living with CF can be affected by gastroparesis, where the stomach empties slowly after eating. A distended, slow-emptying stomach can contribute to acid reflux.
Instead, one should eat small meals more frequently during the day, and avoid a late night meal.
Furthermore, Huitt also suggests that patients should limit liquids to no more than 6 ounces per hour and should not consume liquids within three hours of bedtime. Carbonated liquids should be avoided.
People with CF may also be affected by exocrine pancreatic insufficiency (EPI), a condition in which there is a lack of pancreatic enzymes making it difficult to break down food and absorb nutrients. Pancreatic enzyme replacement therapy (PERT) replaces these missing enzymes through pancreatic enzyme products.
Take bedtime meds with evening meal
According to Huitt, it’s important to move bedtime meds to the evening meal, with the exception of sleeping medication. This applies to CF-specific medications, including CFTR modulators and PERT, as well as vitamins, acid reflux reducers, constipation treatments, and probiotics and prebiotics.
Never take a sleeping pill until all evening activities are complete and it’s bedtime. This can reduce the risk of falls from dizziness and drowsiness, and reduce possible performance problems the next day.
Sleep elevated
Sleeping while elevated — ideally on an adjustable bed where the upper body is elevated between 30 to 45 degrees and the knees are slightly elevated and flexed — can be helpful in reducing reflux and aspiration. Another way to do this is to lift the head of the bed with blocks.
Merely sleeping on two pillows is unlikely to be enough to reduce reflux, according to Huitt.
Sleep on the left side
Avoid sleeping on the right side or stomach as this can increase reflux at night.
When asleep, the body’s gastrointestinal system slows down, including a relaxation of the lower esophageal sphincter, which is the most common cause of gastroesophageal reflux.
But sleeping on the left side makes gravity work in the body’s favor, given the positioning of the stomach and its angle of connection to the esophagus. By laying on the left side of the body, the stomach stays below the esophagus. In contrast, the risk of reflux is increased when one sleeps on their back, right side, or stomach.
Huitt suggests that, if necessary, one should switch sides of the bed in order to sleep on the left side.
Eat foods that help reduce reflux
According to Johns Hopkins Medicine researchers, foods that are high in fiber, alkaline in nature, and that are watery can help reduce acid reflux in the general population.
Carbohydrates, grains, and starches absorb stomach liquids enough that they will not easily reflux into the esophagus and be aspirated into the lungs, according to Huitt.
High fiber foods include:
- whole grains such as oatmeal, couscous, and brown rice
- root vegetables such as carrots, sweet potatoes, and beets
- green vegetables such as broccoli, asparagus, and green beans.
Foods that are alkaline include: fruits like banana and melon, vegetables such as cauliflower, and nuts. Because they are alkaline, they can potentially counteract the acids found in the stomach.
Watery foods are those with a high percentage of water in their composition, and it is believed they can dilute stomach acid. Examples of watery foods include watermelon, and vegetables such as cucumber, celery, and lettuce.
Reduce foods that increase reflux
Diet plays a part in aggravating heartburn.
In general, people experiencing gastroesophageal reflux should avoid citrus/acidic foods, fried and/or fatty foods, chocolate, peppermint, caffeinated beverages, and alcohol. Spicy foods also should be avoided.
Foods that may aggravate reflux include:
- fast food
- fried food
- potato chips
- cheese
- bacon and sausage
- pizza
- chili powder and other peppers
- chocolate
- peppermint
- citrus fruits
- carbonated beverages.
Alcohol and smoking also adversely affect LES pressure.
As for CF patients in particular, Huitt emphasized alcohol, caffeine, carbonated beverages, fatty foods, tomato sauces, and chocolate can make silent reflux worse for several hours.
No medication stops reflux
While there are no medications that stop the physical reflux action, there are drugs that lower the acid content in the stomach juices, including proton pump inhibitors (PPI) and H2 blockers.
“Medications such as PPI (i.e., Nexium) or H2 blocker (i.e., Zantac) medications suppress acid production, which certainly can help with heartburn or cough, but they do not stop the physical action of reflux,” Huitt said.
Proton pump inhibitors include:
- Omeprazole (Prilosec)
- Lansoprazole (Prevacid)
- Esomeprazole (Nexium).
H2 blockers include:
- Ranitidine (Zantac)
- Famotidine (Pepcid)
- Nizatidine (Axid)
- over-the-counter antacids, such as simethicone (Maalox or Mylanta).
However, some studies have suggested that the prolonged use of proton pump inhibitors can put people with CF at a higher risk for lung infections with Pseudomonas aeruginosa, and may be linked to an increased hospitalization risk.
“Part of the action of acid in digestive juices is to kill some proportion of germs that we swallow. If you are still refluxing (while taking PPIs) and you then aspirate some of this digestive soup, you are actually aspirating more germs,” Huitt said.
Some studies have also shown that certain CFTR modulators, such as Kalydeco and Trikafta (sold as Kaftrio in Europe), may ease acid reflux in people with CF.
Always seek advice from a healthcare professional about medications to help lower the risk of gastroesophageal reflux.
Cystic Fibrosis News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.
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FAQs about 7 Tips for preventing reflux and aspiration
Medication cannot stop aspiration in people with cystic fibrosis. However, there are medications which can reduce gastroesophageal reflux, which in turn can lower the risk of aspiration.
Aspiration cannot be completely prevented. But the risk of gastroesophageal reflux and aspiration in people with cystic fibrosis can be reduced by changes to meal size and frequency, eating foods to reduce reflux, changes to sleep and bed positions, and seeking professional healthcare advice about medications.
Gastroesophageal reflux is one of the main factors that can contribute to aspiration in cystic fibrosis patients. It occurs when stomach acids travel upward into the esophagus.
Unlike regular aspiration, where a person reacts to a liquid or solid entering their lungs by coughing, or having difficulty swallowing, during silent aspiration there are no symptoms and the person is unaware it is happening.
Gut bacteria can enter the lungs during acid reflux and aspiration — when a liquid or a solid is inhaled into the lungs by accident — and this can ultimately contribute to lung inflammation, a higher risk of infections, and poorer lung function in people with cystic fibrosis.
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