GERD and sleep apnea are often associated with each other with approximately 60 percent of patients who have obstructive sleep apnea (OSA) also having GERD.

If you have GERD then you know it often feels like burning chest pain that moves upward to the neck and throat. If you’re experiencing GERD at night, your symptoms are often worse and more destructive. 

Untreated acid reflux impairs sleep. One top complaint is constant sleep disruptions and nighttime wakings. If you’ve never been tested for sleep apnea, these sleep problems may be dismissed as merely a side effect of nighttime GERD when they may also be a symptom of undiagnosed sleep apnea. 

Fortunately, treating either sleep apnea or GERD improves both conditions with numerous studies reporting that when sleep apnea is treated, GERD symptoms go away – without medication. 

We’re sharing everything you need to know about nocturnal GERD, how sleep apnea may be causing your GERD and nighttime GERD symptoms, and what treatment options are available. 

What is GERD?

GERD, otherwise known as Gastroesophageal Reflux Disease, is a chronic condition where stomach acid flows out of the stomach and into the esophagus. GERD is caused by numerous factors including:

  • Improper diet
  • Being overweight or obese
  • Pregnancy
  • Certain types of bacteria
  • Hiatal hernias

Your stomach and esophagus are separated by a muscle known as the lower esophageal sphincter, or LES. The LES is intended to serve as an entrance to the stomach from the esophagus, opening to allow food into the stomach to digest.

In individuals with reflux, however, this sphincter doesn’t close properly or close enough, which allows stomach acid to flow back into the esophagus, creating the unpleasant taste and discomfort familiar to those who have ever experienced it.

Other GERD symptoms include pain or difficulty swallowing, chest pain, nausea and a chronic cough, or a hoarse voice. It’s also linked to respiratory symptoms including chronic persistent coughing, wheezing, and shortness of breath. These symptoms are often worse at night. 

It may come as a surprise to many, but nighttime heartburn relief may come from an unexpected place, a sleep center, if you have obstructive sleep apnea syndrome. But first, let’s talk about the difference between GERD and acid reflux and why you should be more concerned about your nocturnal GERD symptoms. 

The Difference between GERD and Acid Reflux

Surprisingly, up to 20% of US adults report having heartburn, the most common symptom of acid reflux, at least once a week. 

Although acid reflux and GERD are often used interchangeably, GERD is more severe than acid reflux and is considered chronic acid reflux.  GERD is also known as gastroesophageal reflux, or GER. 

It’s common to experience heartburn occasionally from acid reflux after a big meal or overindulging on hard to digest foods, but if it’s frequent you probably have GERD.

Left untreated, GERD can cause erosion of the esophageal lining, and contribute to more serious health conditions such as Barrett’s Esophagus and even esophageal cancer.

Nighttime GERD Symptoms

If you’re experiencing GERD, you’re likely experiencing it both during the day and at night. Rarely does someone experience reflux during the day and not at night with a reported 70-75% of individuals with GERD reporting nighttime heartburn.

Regurgitation and heartburn are the most common GERD symptoms, although you can have GERD without heartburn. Pain in the chest, trouble swallowing, and hoarseness in the morning are also symptoms.  

According to gastroenterologists, if you have nighttime heartburn you’re definitely experiencing gastroesophageal reflux (GER) or nocturnal reflux. 

Why Nighttime GERD is Worse Than Daytime GERD

Nighttime heartburn is considered more dangerous than daytime heartburn because acid is left in the esophagus longer, thereby causing more damage.

Nighttime GERD is also considered a more aggressive form of the disease. According to studies, nighttime heartburn sufferers experience more severe symptoms. Symptoms may include higher levels of regurgitation than during the day and waking often with an acid or sour taste in your mouth. Waking up choking and coughing are also common. 

Fortunately, PPI therapy can relieve nighttime heartburn and sleep disturbance symptoms according to one study published in the  American Journal of Gastroenterology, but what if nighttime heartburn isn’t a symptom?  There are many people with nighttime GERD who are “asymptomatic” or have “silent reflux” at night. This means they have nighttime reflux but without obvious symptoms, like heartburn, alerting them to the issue. Without telltale signs like heartburn, GERD is often overlooked and goes undiagnosed. 

The most common complaint for someone with “silent reflux” is sleep disturbance. Frequent nighttime arousals and constant awakenings at night are the only indication there is a health concern. Studies have also found that PPI therapy to prevent acid reflux isn’t always enough to prevent nighttime arousals. This is because nonacid reflux, which PPI therapy doesn’t prevent, triggers the same protective measures in the esophagus.

Sadly, If you’re experiencing frequent nighttime arousals and sleep disturbance but no other obvious GERD symptoms, your doctor is unlikely to identify silent reflux as an issue.However, if you notice that you wake with a sour taste in your mouth, or coughing and choking, or with a sore throat or hoarse voice, even if you don’t have heartburn, it’s worth talking to your doctor.   

There also could be a more serious sleep disorder contributing to the nighttime arousals and causing your nighttime GERD. 

Does GERD Cause Sleep Apnea?

Put simply, no— GERD does not cause sleep apnea, but it can occur secondary to obstructive sleep apnea (OSA). Although there are few studies examining the relationship between the two conditions there’s a high prevalence, with 58-62% of OSA patients with GERD. 

With untreated obstructive sleep apnea (OSA), GERD symptoms are more severe than for someone who doesn’t have OSA. This is because sleep apnea can make acid reflux symptoms worse. 

If you have untreated or undiagnosed OSA a “vacuum effect”, or negative pressure, is created in the thorax during apneic events. This draws the stomach acid or contents up the esophagus to the back of the throat. This is in part because you have to create large negative pressures to bring air in through a narrow aperture. When there is negative pressure in the chest, it creates positive pressure in the belly resulting in reflux. 

Over time, exposure of the esophagus to stomach acid causes erosion of the esophageal lining, and the end result is gastroesophageal reflux.

Does CPAP Therapy Help with GERD?

Yes, numerous studies have demonstrated that a CPAP machine effectively reduces the symptoms and severity of GERD at night. GERD and sleep apnea can also have a cyclical effect on each other, so it’s important to treat both at the same time.

CPAP therapy prevents apneas and hypopneas (partial obstructions of the airway). By preventing these obstructions, it helps eliminate or reduce many obstructive sleep apnea symptoms – including GERD. CPAP also increases pressure in the chest. That pressure is transmitted onto the esophagus which prevents acid from coming back up. The higher the force of air into the airways, the greater the improvement in symptoms. 

One study reported how CPAP therapy reduces acid reflux and claimed that patients who consistently used CPAP therapy had their heartburn scores decrease by over 60 percent. The study also showed that continued use of CPAP therapy lowered heartburn scores further.

CPAP therapy is a popular and effective sleep apnea treatment.  If you suffer from nighttime GERD it’s encouraging to see that one treatment can be beneficial for both conditions.

Related: CPAP Treatment for Sleep Apnea: All You Need to Know

Treating GERD and Sleep Apnea 

Sleep apnea and GERD are conditions people often have for years without being diagnosed. Understanding what symptoms to look out for makes it easier to know when to seek diagnosis and possible treatment. 

Thankfully, if you experience both GERD and sleep apnea, it’s possible to treat them together and CPAP is an effective treatment option. 

Positive lifestyle changes are also beneficial. Tip number one is recommended for anyone dealing with both GERD and OSA. If your sleep study or sleep apnea test indicates OSA isn’t to blame for nighttime GERD try tips two and three in addition to your doctor’s treatment recommendations.   

1. Maintain Healthy Weight to Reduce Sleep Apnea and GERD symptoms

Your chances of having sleep apnea and GERD are much higher if you are overweight or obese. Losing weight can remove excess pressure from your stomach and diaphragm, which can reduce symptoms of GERD or sleep apnea.

A healthy, balanced diet is an excellent way to keep yourself at a healthy weight, and keep your symptoms under control. Make sure to avoid large meals too soon before bed. It’s helpful to stop eating around 2-3 hours before going to bed. Also avoid foods that can potentially trigger heartburn, like:

  • Greasy, fatty, or fried foods
  • Alcohol or caffeine
  • Spicy food
  • Acidic food, including citrus and tomatoes

2. Elevate Your Upper Body for Nighttime GERD Relief

Laying flat on your back can exacerbate your reflux symptoms, making it easier for acid to wash into your esophagus and throat. This could give you a sore throat in the morning, an unpleasant acidic taste in your mouth, or even wake you during the night with a choking or gagging sensation.

If you’re most comfortable sleeping on your back, elevating your upper body places yourself at a comfortable incline that helps relieve nighttime GERD symptoms. This is because your esophagus is now higher than your stomach— this makes it more difficult for stomach acid to reach your esophagus, because gravity will be working against it.

You’ll want to use a special wedge-shaped pillow for this, however. Normal pillows will only elevate your head, and not your upper body. Be sure to use a wedge pillow that is thick at the top for ideal results.

3. Sleep on Your Left Side to Relieve Nighttime GERD 

As mentioned above, laying flat on your back is bad news for your GERD symptoms. If elevating your upper body is uncomfortable try sleeping on your left side instead. 

Similar to elevating your upper body, this positions your esophagus higher than your stomach, making it easier for gravity to keep the contents of your stomach where they belong. Sleeping on your side is very helpful for snoring as well.

That being said, it’s important to note that sleeping on your right side does not have the same benefits as sleeping on your left. In fact, it can be quite the opposite. Like sleeping flat on your back, sleeping on your right side can make reflux more likely, which is unhelpful in treating your nighttime symptoms. If you’re not a back sleeper using a wedge pillow, sleeping on your left side will be most helpful here.

Healthy lifestyle changes can make a big difference in dealing with GERD, but if you have untreated or undiagnosed obstructive sleep apnea OSA treatment improves GERD. The most common OSA treatment, continuous positive airway pressure (CPAP), has been shown to reduce the total 24 hour esophageal acid contact time.

When to Consult an Expert

If you suspect your gastroesophageal reflux is related to obstructive sleep apnea or another sleep disorder, it’s very important to reach out for a consultation and evaluation. If you’re interested in finding out if you have other risk factors for sleep apnea (also known as sleep-disordered breathing), in addition to GERD, take our sleep apnea quiz.

You can also contact Sleep Centers of Middle Tennessee today to schedule a consultation and sleep test. With GERD and sleep apnea being so closely connected, an easy and brief sleep evaluation could be the difference between another night of poor sleep, and the rest you deserve.  

References

Jung, Hye-Kyung, et al. “Gastroesophageal Reflux Disease and Sleep Disorders: Evidence for a Causal Link and Therapeutic Implications.” Journal of Neurogastroenterology and Motility, Korean Society of Neurogastroenterology and Motility, Jan. 2010, www.ncbi.nlm.nih.gov/pmc/articles/pmc2879818/.

“Definition & Facts for GER & GERD.” National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Department of Health and Human Services, www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/definition-facts.

“Symptoms & Causes of GER & GERD.” National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Department of Health and Human Services, www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/symptoms-causes.

Orr, William C. “Management of Nighttime Gastroesophageal Reflux Disease.” Gastroenterology & Hepatology, Millennium Medical Publishing, Aug. 2007, www.ncbi.nlm.nih.gov/pmc/articles/pmc3099296.

“How to Sleep Better with GERD & Acid Reflux.” Sleep Foundation, 14 Aug. 2020, www.sleepfoundation.org/physical-health/gerd-and-sleep.

“Study Finds That CPAP Therapy Reduces Acid Reflux in People with Sleep Apnea.” American Academy of Sleep Medicine – Association for Sleep Clinicians and Researchers, 3 Oct. 2016, aasm.org/study-finds-that-cpap-therapy-reduces-acid-reflux-in-people-with-sleep-apnea/.