Original Contribution

The American Journal of Gastroenterology (2004) 99, 789–796; doi:10.1111/j.1572-0241.2004.04141.x

Asthmatics Have More Nocturnal Gasping and Reflux Symptoms than Nonasthmatics, and They are Related to Bedtime Eating

Stephen J Sontag MD, Susan O'Connell RN, Todd Q Miller PhD, Mitchell Bernsen MD and Jean Seidel

Department of Medicine, Veterans Affairs Hospital, Hines, Illinois and Loyola University Stritch School of Medicine, Maywood, Illinois

Correspondence: Stephen J Sontag, MD, Department of Veterans Affairs Medical Center, Building 1, Room B321, Hines, IL 60141.

Received 2 December 2003; Accepted 12 January 2004.





Certain pulmonary diseases are now recognized as possible complications of gastroesophageal reflux (GER) disease. To further clarify the relationship between GER and asthma, we determined the prevalence, nature, and patterns of reflux symptoms in consecutive asthmatics and a well-defined patient population control group.



Two hundred and sixty-one asthmatic outpatients with well-documented asthma were interviewed in person using an extensive questionnaire. To avoid selection bias, we (a) used no selection criteria other than asthma, (b) interviewed every identified asthmatic from either the outpatient general medical clinic or pulmonary clinic (and excluded the gastroenterology clinic), and (c) excluded asthmatics referred because of gastrointestinal symptoms. A control group comprised 218 consecutive outpatients chosen from the same general medical clinics in which the asthmatics were enrolled. Interviews were conducted by one of two investigators.



The control and asthmatic groups were similar with regard to age, gender, ethnicity, and consumption of tobacco and alcohol. There were major significant differences between the asthmatics and controls with regard to the age of onset of pulmonary and reflux symptoms, prevalence of eating before bedtime, prevalence of reflux symptoms, the quality of reflux symptoms, and the factors that promote and relieve reflux symptoms. Heartburn, regurgitation, and dysphagia were present in 71%, 45%, and 22% of asthmatics compared with 51%, 30%, and 5% of controls (p < 0.001). Three times as many asthmatics as controls had heartburn occurring throughout the day and night (OR; 95% CI: 19.5; 4.5–85.7), and three times as many asthmatics as controls had sudden nocturnal awakening with reflux symptoms and reflux-associated pulmonary symptoms that occurred simultaneously with the reflux symptoms (p < 0.001). Within the asthma group, reflux symptoms were similar in those who required and those who did not require continuous bronchodilator therapy. In these asthmatics, however, those requiring continuous bronchodilator therapy (more severe asthma) developed pulmonary and GER symptoms at a significantly older age. Eating before bedtime was recognized by significantly more asthmatics than controls as a promoter of serious nocturnal GER symptoms (4.5; 2.7–7.7). In terms of patient awareness, one-third of the asthmatics with heartburn had previously considered a relationship between their reflux symptoms and their asthma.



Compared to nonasthmatics, asthmatics have significantly more frequent and more severe day and night GER symptoms and significantly more of the pulmonary symptoms (nocturnal suffocation, cough, or wheezing) so often attributed to GER. The habit of eating before bedtime appears in asthmatics to have serious and life-threatening consequences.