Reflux And Spontaneous Arousals In Mild Sleep Apnea

Gastro-esophageal reflux and laryngopharyngeal reflux disease are commonly seen in patients with obstructive sleep apnea. Many of you will have the typical throat clearing, post-nasal drip, chronic cough or hoarseness that's seen with laryngopharyngeal reflux disease. Sleep apnea causes your normal stomach juices to leak up into the throat, which not only causes you to wake up, but also causes swelling and inflammation in the throat. 


We know that any form of breathing obstruction (apnea, hypopnea, RERA) can cause you to wake up. But what's not too commonly known is the fact that any degree of acid in the throat can stimulate certain chemical receptors, which causes you to wake up so you can swallow. It's thought that this is needed to prevent aspiration of stomach juices into your lungs. 


A recent Japanese study not only confirmed these concepts, but found an interesting additional observation: While people with severe obstructive sleep apnea have mostly arousals due to  breathing pauses, those with mild to moderate sleep apnea have a higher number of spontaneous arousals. Spontaneous arousals are noted on a sleep study when your brain waves go from deep sleep to light sleep or temporary awakening, without any objective evidence of breathing pauses.


What this study doesn't address is the fact that it's not only acid that comes up into the throat when you stop breathing. Your stomach juices also contain bile, digestive enzymes, and bacteria. An obstruction causes a tremendous vacuum effect that's created in the throat, literally suctioning up your normal stomach juices. This initial obstruction will lead to the typical respiratory arousal, but lingering juices will irritate the throat leading to spontaneous arousals. Think of your stomach juices as a sort of sensory form of stimulation, like a loud noise or a bright light. Your throat has a number of very sensitive chemical and pressure receptors that can cause your brain to wake up, without any physical obstruction.


There are also studies that show that chronic exposure to acid can make pressure sensors less sensitive over time, leading to longer and longer pauses with each obstruction.


Furthermore, there's research showing that some of these arousals don't ever show up on routine brain wave leads during a standard sleep study. This is because these protective reflex signals are so minimal that they stay in the deeper levels of the brain, never reaching the outer cortex.


I've always felt that spontaneous arousals are somehow related to breathing pauses. This study only confirms my suspicion that too many spontaneous arousals may be a sign of upper airway resistance syndrome or early obstructive sleep apnea. 


What's your opinion on this? Do you have laryngopharyngeal reflux disease?






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16 thoughts on “Reflux And Spontaneous Arousals In Mild Sleep Apnea

  1. Since you ask, I suspect I have laryngopharyngeal reflux disease, but  I haven't confirmed that diagnosis with a doctor because I have no intention of taking acid-reducing drugs, and I know that would be recommended. I frequently have a burning sensation in my throat; it usually comes on during my workout in the early evening and lasts until I fall asleep. I've been taking melatonin every night and that has helped me stay asleep all night most nights. I eat a low-carb diet, and that has helped reduce the number of esophageal heartburn episodes, but I don't understand how the acid misses the esophagus but causes burning in the throat. My husband tells me I snore a lot through the night, so there are probably airway issues.

  2. Ethyl,

    You're right in that most doctors will give acid reducing medications. But one thing about these medications is that they don't do anything to prevent reflux into the throat. The esophagus is lined by a squamous layer, link the skin on your arm. The throat is lined with mucous membranes, which are much more sensitive to even small amounts of acid, digestive enzymes, or bile. 

    It does sound like laryngopharyngeal reflux disease along with an underlying sleep-breathing problem. If you snore that much, maybe you should consider undergoing a sleep study to make sure you don't have obstructive sleep apnea.

  3. Hi Dr Park, I have a somewhat complicated situation but I’ll try to simplify things a bit. I’m a fit (runner just like you), athletic healthy female, 46yrs of age, non smoker/drinker. height 5’7, 143lbs. I was diagnosed with moderate OBSA about 7 yrs ago. This was confirmed as well by subsequent PSGs the following years for CPAP titration/problems. I have tried every mask on the market(fullface, nasal, nasal pillows..and chin strap(even taping my mouth shut), only to have the air pushing back out of my nose, or causing excessive burping.(this was worse on my right side by the way). Also my eyes would be swollen even after using Mirage Lite Nasal pillows(no pressure on face). I resigned to using the CPAP a couple of hours per night. Well earlier this year, I noticed that I couldn’t tolerate the CPAP at all, the burping was constant, every few seconds, so I abandoned the whole thing. I started noticing that at sleep onset my throat would collapse, close, or tighten, making it very difficult to fall asleep. Suspecting, my OBSA had worsened, I had another PSG done. To everyone’s surprise I no longer had sleep apnea. All PSGs were done at the same facility, my weight was consistent, the only differences were this time around I was no longer taking Paxil, and used lorazepam to help me sleep. How does sleep apnea disappear without significant weight loss? Sorry for the book here, but can you explain my results and cause of arousals if apnea is absent? Do you think I might have asymptomatic GERD, or laryngoesaphageal reflux? No burning, or discomfort whatsoever.
    RESULTS : Sleep eff: 71.3% Stage3 12%,Stage4 19.5% REM 25%. 22.7arousals/hr, 3.4 awakenings/hr. mean sat 99% 1.8 PLM/hr(absent from other all other PSGs) What is causing the arousals? Why does my throat shut at sleep onset? oh, and cardiac rhythm sinus throughout. Any insight would be appreciated. I was told I had significant fragmented sleep, but no explanation as to why. Would like your respected opinion. thank you, Roxy

  4. Roxy,

    Without looking at your full sleep study it’s difficult to say, but here are a few thoughts that I had as I read through your response:

    1. Lorazepam is a benzodiazepine, which can suppress REM sleep. Stage REM is when you’re most likely to have apneas, due to muscle relaxation. Certain antidepressants that have this effect can significantly lower your apneas. One study using mirtazipine showed that it lowered the AHI by 50%.

    2. Apneas and hypopneas by definition are total or partial obstructions that last for 10 seconds or longer. If most your your previous study’s apneas lasted on average 11 to 14 seconds, and your most recent study’s apnea durations lasted 8-9 seconds (or shorter), then most of your apneas will disappear and move into RERAs or even spontaneous arousals. I can’t tell if your study reported RERAs (respiratory event related arousals). However, you still had almost 27 arousals per hour. I’m willing to bet that many of these arousals are due to short breathing pauses, whereas others can be reflux arousals (from short breathing pauses), TMJ, or leg movements.

    3. Laryngopharyngeal reflux disease, by definition, can be silent. Having acid in your throat stimulates chemical receptors that causes you to wake up so you can swallow. This prevents aspiration of acid into your lungs. One recent study showed that the presence of laryngopharyngeal reflux disease significantly increases your chances of aerophagia (swallowing air) since you have to swallow so much to rid of the acid, but in the process, you’re also swallowing the air.

    4. You’re in the pre-menopause years, where by definition, your progesterone levels are slowly dropping. This causes more tongue relaxation (due to progesterone’s muscle tensing effects), leading to more frequent obstructions and arousals.

    Your sleep is probably fragmented to mainly from breathing pauses, but not long enough to be called mostly apneas or hypopneas. Since you had so many problems with CPAP, another option would be a mandibular advancement device. If you nose is stuffy, then addressing this definitively can sometimes help people begin to tolerate and benefit from CPAP.

    Hope this answers your question.

  5. Dr. Park, From personal experience I believe there is a lot of truth that reflux, spontaneous arrousals, and poor quality sleep go together. Some quick background on myself, I broke my nose in 2006 and ever since then I have had terrible sleep – I feel like I am in a light dreamy sleep all night long and briefly wake up many, many (sometimes dozens) times throughout the night. I have many symptoms that come from this poor sleep quality – headaches, cold hands, dizziness, extreme fatigue. Also I can’t sleep on my back without waking up within minutes. I’ve had three sleep studies, all of which show mild-to-no sleep apnea but a very high spontaneous arousal (most recent = 147 spontaneous arousals over 4.5 hours).

    I used CPAP, at various pressures, for over a year and had no improvement – the machine filled my stomach with air even at the lowest pressures. I tried high end dental appliances but for some reason positioning my lower jaw forward caused me to to take in air and belch. Personnally I believe my esophagus sphincter(s?) is weak and that is the main problem.

    I am 36 years old but have had reflux for many years. Last year I started taking a PPI (e.g.Protonix) two times a day and I started seeing improvement in sleep – longer stretches of sleep w/o all the wake ups and dreaminess. Additionally the symptoms (e.g. fatigue, dizziness) have gone away – most days partially and somedays fully away. The more PPI I take the better I sleep and feel, however I am leary about taking more than two but sometimes I do as it is the only thing that seems to help. Whats interesting is, although I had reflux when eating certain foods, I rarely if ever felt reflux at night, so I never really considered reflux as a contributor to my poor sleep quality.

    I’ve had a lot of tests (brain MRI, barium swallow, endoscopes, sleep studies) and seen a lot of specialists (GI, ENT, Sleep Doctors) to try and figure out what is wrong. It has been extrodinarily frustrating beyond explanation.

    I hope the article above is right. I hope maybe someone has finally figured out how to label what is causing my poor quality sleep. The PPI has helped a lot, but hasn’t solved the problem. I’m looking for the next step to give this problem a good kick so I can move on with my life.

    I have thought about coming to visit your office as you seem to be the only one thats on top of this stuff. I may do that yet. Right now I am scheduled to go the Mayo Clinic for a third/fourth opinion.

    Thanks for the information that you provide in your postings and website, it has been one of the few hopes that has kept me going. I have three beautiful little girls who need their Dad to get better just as much as I need it.

  6. You have truly confirmed what I already new about myself, but have a sleep specialist who doesnt see my spontaineous arousals & occasional wake up gasping for air,as anything to worry about. After only one study, you think the man would inform me that I may need a few studies to make a full diagnosis, NO, I had to red that on the web somewhere…

    My Symptoms and ailments:
    Hx/diagnosed w/:
    -Gastro-esophageal reflux (Rx-Nexium)
    -Laryngopharyngeal reflux disease
    -Enviro. Allergies 12/12mths (Rx-Reactine 20mg)
    -Post nasal Drip (Cryo therapy was helpful-Can now breath through nose)(Rx-Omnaris)
    -Asthma (Symbicort OD)
    -Spontaineous Arousl (Rx)-Clonasapam 0.5mg at bed time)

    -Presented with (CC) – Feel tired after full night sleep
    -Often wake-up gasping for air
    -Throat clearing ++++ every day!

    Your comment below,
    “I’ve always felt that spontaneous arousals are somehow related to breathing pauses. Too many spontaneous arousals may be a sign of upper airway resistance syndrome or early obstructive sleep apnea”.

    In my humble, non-medical opinion, this conclusion is – ACCURATE!

    There should be more Specialists like yourself keeping up-to-date with new research, as patients like myself feel unheard when we KNOW something is wrong, but the dinasaure MD who thinks he’s seen it all just shrug you off!

  7. I have Hashimotos and laryngeal reflux ESP when I eat certain foods- when I do it can go nonstop for days. I am being treated with T3T4 med and hormonal cream
    To normalize hormone levels. Levels are better but estrogen is still higher than progesterone. is it helpful to do a sleep apnea study…which one comes first really
    LPR or sleep apnea? I am thinking about getting a TNE to scope larynx since I’ve
    Been dealing with the reflux for 6 years. I ‘ m looking to see someone in the Richmond ,VA area any ideas on thoughts for what is causing the loose sphincter
    I have a theory it’s the slowed down metabolism due to thyroid issue. I remember one time feeling an extreme tightening in my upper stomach and on hindsight wonder if that ‘s when the reflux began? I originally saw Dr. Bolte in NYC at the beginning of this dilemma . ..
    Thank you for your time.
    Stephanie Kitts

  8. Ms. Kitts,

    It’s not a bad idea to get a baseline sleep study, to show if you have any significant arousals, whether or not they are due to breathing pauses. You can try treating the sleep-breathing problem and see if it improves your reflux. Good luck.

  9. Thank goodness for your article. I suffer from depression and severe sleep apnea. I take 200 mg of imipramine and also 7.5 mg of zopiclone (related to ambien).

    Over the past several months, I became aware that I was having a terrible post nasal drip. Occasionally, I felt asthma-like lung congestion. More recently, I began to develop pain and discomfort that was more like classical reflux, and my doctor placed me on medication that reduced acid levels. However, as you pointed out, this has not stopped my “post nasal drip.”

    I suspected that my difficulties were related to my apnea, but my gp was not aware of any information about the relationship between the two.

    My last sleep study was 2 years ago, and was not accurate because i was unable to sleep during the study (menopause related?). More recently, I was given a trial with a CPAP with self adjusting pressure settings, but I feel that the results were inconclusive because i had so many arousals. From your information, I suspect that my CPAP pressure is not high enough.

    I am due to see my sleep specialist within the next two weeks, but would welcome any suggestion you might have. I am making sure I don’t eat for at least 3 hours before sleep, but i certainly used to be a late night snacker.!

  10. I have been suffering from regurgitation and belching for the past 3 weeks regardless of what i eat. I have been though quite stressed could the stress be causing my LES to weaken or slow the digestion of foods.

    I belch/regurgitate as soon as i awaken and can still taste what i ate the night prior.

  11. I was diagnosed with LPRD several years ago (2005). I had persistent dysphasia. I had multiple tests run because no one would tell me what was going on. I constantly felt like something was stuck in my throat. I had a barium swallow and UGI, 2 types of video swallow studies (one under radiology and one with food dyes performed under speech), an esophageal monometry study, EGDs, colonoscopies and finally trips to the ENT and them looking at my larynx. I found out how quickly ENT and Gastroenterology butt heads a lot on diagnosing. Which is unfortunate for the patient.

    As it all turned out. I had a cyst on my larynx which was pushing against my esophagus and forcing foods to be squished around the area and mostly down one side of my throat. In doctors terms, “Primary passage through the left valleculae and effacement of the right pyriform sinus”. (Sorry for spelling errors). So at least I knew I wasn’t crazy in my head, which one doctor basically suggested. I had low LES pressure which typically means reflux. The cyst was caused by reflux coming all the way up and irritating my vocal cords. I constantly had post nasal drip, clearing my throat and my voice was a little hoarse and would crack. All in all they tried several medications and I finally found Prilosec to be most helpful for me.

    Fast forward to last year. At some point in time the cyst ruptured and the “lump” in my throat disappeared. I stayed on the medication for most of the last 10 years. I went off a short time only to have worsening reflux symptoms when I was pregnant, so I went back on and stayed on the Prilosec. During pregnancy was the only time I ever felt the classic heartburn symptoms. Otherwise it was just post-nasal drip, constant “junk” in my throat, and clearing my throat. I had another EGD done with the same “reflux” diagnosis, polyps that they biopsied and were normal. But I had a new issue. Fatigue.

    Not just fatigue. But to the point I couldn’t function fatigue. I heard it all. You work, you have 2 small children, you’re just tired. No amount of “rest” helped. I would wake up with headaches, nap when my kids napped, sleep 8+ hours every night, pass out when my head hit the pillow, but never be refreshed. Finally a doctor took me seriously and ordered a sleep study. Low and behold I was diagnosed with mild sleep apnea and severe fragmented sleep pattern. On average my body was waking
    me up 56.4 times per hour and only 5.2 of those were from true apnea. It kinda boggled their minds a little when they got the results. I got a CPAP machine and it instantly made a difference!

    I really think the force of the CPAP helps keep the LPRD under control and forces the acid to stay further toward my stomach. Before the CPAP, even on medications I would wake up coughing, gagging and choking in the middle of the night, bust mostly just a restless sleep, tossing and turning. Once starting the CPAP all of that stopped and most of my reflux symptoms stopped too. I still stay on the Prilosec for the reflux, but I can tell a huge difference when I don’t use my CPAP. Being pregnant again, now, the reflux symptoms are worse because of the added baby pressure on my stomach, and they upped my dosage for Prilosec. I at least don’t have the dreaded “heartburn” symptoms this go around. But I’ve had some issues with getting comfortable with my CPAP while pregnant and I can tell the nights I don’t use it. I will cough, gag and choke in my sleep again, with constant clearing of my throat. I really think the number of times your body kicks you out of the deep sleep is equivalent to you clearing your throat and swallowing while sleeping because of the reflux. I think those are directly related.

    Let me know if this in any way sounds familiar to you? Or makes sense. Thanks.

  12. My husband lived on OTC acid reducers until he got his CPAP, his reflux was gone the next day. That was 10 years ago. This is the first article I’ve seen making a connection.

  13. I use CPAP for mild apnea but still have spontaneous arousals not associated with any apnea event. When this happens I also feel the burning sensation of acidity in the stomach. Should I take an antacid before bed to help?

  14. Very interesting Dr. Park.

    2 questions:

    1) Why don’t people with higher AHI develop these ‘spontaneous’ arousals from laryngopharyngeal reflux disease? It seems that it only happens to people with mild OSA. Myself I have low OSA, but very high arousal index.

    2) How is it possible to treat laryngopharyngeal reflux disease? Or is the obstructions what would have to be treated in order to avoid acid reaching the throat?

  15. Hi Dr. Park,

    Is there a definitive way to see/test if LPR and reflux arousals are a result of gastric pressures pushing gastric contents up from below OR as a result of the vacuum effect (caused by obstructed breathing passages) sucking / suctioning gastric contents up (as described above)?