EpistemisAcute tracheobronchial pain due to acid reflux
Specialty: Respiratory.
Why it occurs
- Chronic microaspiration of gastric acid and pepsin hydroxide into the trachea and main bronchi in patients with severe gastroesophageal reflux disease (GERD) or sliding hiatal hernia (contact of the highly acidic material pH <3 with the respiratory mucosa causes corrosive chemical tracheitis, clinically manifested by burning retrosternal pain that worsens with deep inspiration, cough and recumbency supine)
- Chronic subclinical Mendelson syndrome (microaspiration of gastric contents during sleep)
- Laryngeal spasm induced by acid irritation of the inferior laryngeal vagal receptors.
Initial workup
esophageal pH-metry with 24-hour ambulatory impedanciometry (gold standard to correlate reflux episodes with pain and cough); Upper gastrointestinal endoscopy (evaluate esophagitis, hiatal hernia or Barrett's esophagus); Flexible bronchoscopy with bronchoalveolar lavage measuring levels of pepsins or lipid-laden macrophages (to confirm acid aspiration); Forced spirometry.
red flags
Tracheobronchial pain accompanied by severe generalized wheezing or inspiratory stridor (severe acid-reactive bronchospasm), recurrent right basal pneumonias on chest x-ray, progressive dysphagia, or mild hemoptysis due to ulceration of the tracheal mucosa.
Standard management
- Esomeprazole — proton pump inhibitor, 40 mg orally every 12 hours given 30 minutes before breakfast and dinner for 8-12 weeks
- Domperidone — prokinetic, 10 mg orally every 8 hours before meals to accelerate gastric emptying
- Sucralfate (oral suspension, 1 g every 8 hours to cover the inflamed esophageal and pharyngeal mucosa).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Respiratory
- Listed causes
- 3
- Treatment options
- 3