The Hidden Link Between Acid Reflux and Sleep Apnea

What’s Keeping Me Up at Night? Sleep Apnea or Reflux?

Picture this: You’re meeting with Mark, a 52-year-old with a story you’ve heard before. Mark has been struggling with his sleep for years, often waking up gasping for air, which led to a diagnosis of severe obstructive sleep apnea (OSA). He was prescribed a CPAP machine. But he's also been battling persistent heartburn and a chronic cough. He rarely mentions these symptoms to his pulmonologist because they seem like completely separate problems.

Mark's sleep is fragmented, and he's exhausted all the time. He’s tried everything: different pillows, various sleeping positions, even avoiding coffee after dinner. But the symptoms persist, and his frustration is palpable. The more he struggles to breathe at night, the more his chest feels tight and he wakes up with a burning sensation in his throat. At the same time, a late-night dinner seems to guarantee he'll be up all night with trouble breathing, coughing and clearing his throat, leading to a miserable, sleepy day. He’s getting it from all angles and there doesn’t seem to be any light at the end of the tunnel. What could be going on?

A Single Problem with Two Names

Clinicians like yourself are often familiar with the discomfort of acid reflux or the restless nights caused by sleep apnea. Both can be debilitating and impact patients’ lives tremendously. But the truth is, these problems are often one in the same; a single problem with two names. 

The connection between gastroesophageal reflux disease (GERD) and obstructive sleep apnea (OSA) is far from simple, but it’s a connection worth investigating because the research indicates a strong relationship. 

What’s the relationship exactly? GERD can cause OSA. Oh, and OSA can cause GERD. And the severity of one often impacts the severity of the other. We have the perfect climate for a vicious cycle. Incoming! 

As healthcare professionals, we understand the importance of sleep (whether or not we get enough ourselves is a different story). We also understand the importance of maintaining a healthy aerodigestive system. So how do we manage both of these conditions when the factors involved in them are multifaceted and intertwined? First, let’s make sure we understand the problem… 

GERD as a Cause for OSA 

You might be asking, "Can acid reflux actually cause sleep apnea?". One major study found that GERD is associated with a substantially elevated risk of OSA (Wang et al., 2025). The real danger lies in laryngopharyngeal reflux (LPR), which is similar to GERD, but where highly acidic gastric contents erupt beyond the esophagus and turn the pharynx, larynx, and airways into Pompeii. Several factors come into play here:

• Airway Inflammation: When acid and pepsin reflux into the upper airway, they cause inflammation that can directly narrow the airway. This makes the tissues more prone to collapse while you sleep, which is the hallmark of OSA.

• Vagal Nerve Reflexes: The presence of acidic refluxate can stimulate vagal receptors in the larynx, triggering reflexes that constrict the airway. This makes it even harder to breathe during sleep.

• Frequent Arousals: LPR symptoms are directly linked to increased arousals during sleep. The more severe the reflux, the more frequent these disruptions become. This cycle of reflux, exacerbated respiratory events, and subsequent arousal can severely fragment sleep.

OSA as a Cause for GERD 

Let’s look at the other side of the equation now. Sleep apnea creates a perfect storm for reflux. During an apneic episode, your upper airway collapses. Your body, in its effort to take in deep breaths in between apneic episodes, creates an excessive negative intrathoracic pressure—basically, a powerful suction in your chest. Think of your chest cavity as a vacuum cleaner, and during these moments, it's trying to suck air in. This pressure change creates a strong gradient that pulls gastric contents right past the lower esophageal sphincter and into the esophagus and beyond.

“OSA patients report nocturnal reflux nearly 2.5 times more often than the general population”

This "vacuum effect" is especially potent in patients with a high arousal threshold (ArTH). These individuals can tolerate a significant amount of negative pressure before waking up, which means the vacuum can pull even harder and for longer, independently increasing the presence and frequency of nighttime reflux. It's no surprise that untreated moderate-to-severe OSA patients may have nocturnal reflux nearly 2.5 times more often than the general population (Emilsson et al., 2024).  

Is The Link Between OSA and GERD Set in Stone?

We need to keep in mind that the research is still mixed here and so the story is yet to be fully formed. For example, some genetic studies using Mendelian randomization have found no significant evidence that sleep apnea causally increases the risk of developing GERD (Wang et al., 2025). Let’s look at a few variables so we can clear things up for each individual patient and navigate when and how to intervene.

What Are Some Key Variables to Consider?

When you’re trying to connect the dots between reflux and sleep apnea, several variables inevitably stand out:

• Severity: The prevalence of LPR symptoms may significantly increase with the severity of OSA. If a patient is considered high-risk for OSA, they often show a higher prevalence of LPR-related symptoms as well.

• Obesity: Both GERD and OSA share obesity as a major risk factor. Increased abdominal girth and pressure can exacerbate reflux and is one of the ways these two conditions are so closely linked.

• Arousal Threshold (ArTH): As discussed earlier, a higher arousal threshold is independently associated with nocturnal GER in OSA patients. A higher ArTH allows a patient to tolerate more negative pressure in the chest before waking up. This pressure can open the lower esophageal sphincter, leading to more reflux. Understanding your patient’s ArTH can be a key piece of the puzzle in determining the cause of their symptoms and developing a treatment plan.

How to Address It: Nighttime Routines for Better Mornings

So, what do we do? Fortunately, treating one factor often helps the others, which is why a comprehensive approach is so important.

1. Optimize OSA Treatment to Improve Reflux:

• CPAP Therapy: CPAP is a highly effective treatment for OSA that can significantly reduce reflux events and symptoms. It works by reducing the airway obstruction and inspiratory force, which in turn reduces reflux events and arousals.

• Upper Airway Surgery: When medically indicated, surgical interventions for OSA can also have a positive impact on patient-reported GERD symptoms, leading to a reduction in the severity of heartburn.

2. Address Acid Reflux to Improve Sleep and OSA:

• Medications: Medications like proton pump inhibitors (PPIs) and H2 receptor antagonists (H2RAs) are effective in reducing reflux symptoms and improving sleep. Newer options like Vonoprazan have been shown to provide rapid relief for nocturnal heartburn as well.

• Routines: Implementing lifestyle modifications for nocturnal GERD can greatly improve sleep quality and reduce symptoms.

• Elevate the Head of Bed: Use gravity to keep stomach contents down.

• Lose Weight: Losing excess weight can significantly reduce reflux symptoms, as obesity is a major contributing factor to both conditions.

• Positional Sleep: Avoid sleeping on your right side; try to sleep on your left due to the anatomical positioning of the stomach and esophagus.

• Mind Your Meal Timing: Don't eat meals within three hours of bedtime.

• Avoid Trigger Foods: Common culprits like coffee, chocolate, carbonated beverages, and greasy foods can make reflux worse, so try to limit them, especially at night.

• Consider Alginate Therapy: RefluxRaft is a natural remedy to mild to moderate reflux. The Midnight Berry PM formula includes 1mg of melatonin per serving to support healthy digestion by strengthening the lower esophageal sphincter and promoting a natural sleep cycle.

By recognizing the intricate, bidirectional link between acid reflux and sleep apnea, healthcare professionals can adopt a more holistic and integrated approach to patient care. Treating one condition often yields significant improvements in the other, offering a powerful pathway to enhanced patient well-being. 

This comprehensive strategy, encompassing both optimized OSA treatments and targeted acid reflux management through medications and lifestyle adjustments, is crucial for breaking the vicious cycle and empowering patients like Mark to achieve better sleep quality and healthier lives. Always remember to consult with a trusted healthcare professional to develop a personalized treatment plan that addresses the unique needs of each individual.

About the Author:
George Barnes, MS, CCC-SLP, BCS-S, is a Board-Certified Specialist in Swallowing and Swallowing Disorders with extensive clinical experience in reflux, dysphagia, and aerodigestive function. Known for his evidence-based, patient-centered approach, George advocates for comprehensive evaluation and targeted care plans that address the full scope of swallowing disorders, especially those that defy easy answers. He’s passionate about educating clinicians and empowering patients to understand the root causes of their symptoms better.

References: 

Bhutada, A. M., Broughton, W. A., Beverly, B. L., Choi, D., Barui, S., & Garand, K. L. (2021). Predictors of patient-reported dysphagia and reflux symptoms in obstructive sleep apnea. Perspectives of the ASHA Special Interest Groups, 13, 21-00171. https://doi.org/10.1044/2021_PERSP-21-00171

El Hage Chehade, N., Fu, Y., Ghoneim, S., Shah, S., Song, G., & Fass, R. (2023). Association between obstructive sleep apnea and gastroesophageal reflux disease: A systematic review and meta-analysis. Journal of Gastroenterology and Hepatology, 38(8), 1244–1251. https://doi.org/10.1111/jgh.16245

Emilsson, Ö. I., Aspelund, T., Janson, C., Benediktsdottir, B., Juliusson, S., Maislin, G., Pack, A. I., Keenan, B. T., & Gislason, T. (2024). Nocturnal gastro-oesophageal reflux and respiratory symptoms are increased in sleep apnoea: comparison with the general population. BMJ Open Respiratory Research, 11(1), e002192. https://doi.org/10.1136/bmjresp-2023-002192

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Feng, Z., Wu, S., Wang, M., Wang, H., Hou, Y., Yi, H., Xiao, F., Xu, L., Dong, X., & Han, F. (2025). A high arousal threshold is associated with nocturnal gastroesophageal reflux in obstructive sleep apnea. Sleep Medicine, 129, 297–305. https://doi.org/10.1016/j.sleep.2025.03.004

Hamdan, A.-L., Lechien, J. R., Ghanem, A., Raji Feghali, P. A., Hosria, J., & Alam, E. (2023). Self-reported symptoms of laryngopharyngeal reflux using the reflux symptom score in patients with obstructive sleep apnea syndrome. Acta Oto-Laryngologica, 143(9), 801–805. https://doi.org/10.1080/00016489.2023.2258160

Jia, P., Shi, L., Xing, D., Qin, J., Zheng, C., Li, S., & Wu, D. (2022). The effect of laryngopharyngeal reflux on arousal in patients with obstructive sleep apnea. Acta Oto-Laryngologica, 142(5), 438–442. https://doi.org/10.1080/00016489.2022.2075033

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Disclaimer: This article is for educational purposes only and is not intended to diagnose or treat any medical condition. Always consult your healthcare provider before making changes to your treatment plan.