Respiratory Reflux, The Trillion Dollar Misdiagnosis - Revealed: Dr. Jamie Koufman

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[00:00:05][music] >> It is a tremendous honor to be here to introduce Dr. Jamie Koufman for this lecture. It's interesting, I was just in the speaker ready room and somebody said, "I hear there's a real legend here." And yeah, [laughter] I think so.

[00:00:27]So, the rumors are already out.

[00:00:29]Um but yet, you know, Dr. Koufman is truly a pioneer in our field. Uh if you look at her publications dating back to the 1970s, she was really one of the first to introduce CO2 laser into microlaryngoscopy.

[00:00:44]She was studying reflux back in the 1980s, early '80s. She had published in 1985 about subglottic pathology due to gastric acid reflux.

[00:00:55]She has authored over 140 peer-reviewed publications. She has four book chapters.

[00:01:03]She has a New York Times bestseller.

[00:01:06]That's something that not most of us can say. Um she is certainly a global expert in our field, as well.

[00:01:15]Um she's received numerous awards from the American Academy of Otolaryngology, from the ALA, from the ABA. I know when I did a fellowship with her, we had patients fly in from literally all over the world to see her as their voice expert. And she's been featured on all kinds of um TV stations, including CBS, NBC. She's been on Good Morning America.

[00:01:40]She's been on Dr. Oz, NPR.

[00:01:45]Next slide here.

[00:01:48]Sorry. There we go.

[00:01:50]In addition to that, she's just a phenomenal mentor. So, she's mentored many of us in the room here, many who have gone on to form their own voice centers and have their own fellowships.

[00:02:03]She's always taught her mentees how to think outside of the box.

[00:02:08]Um I recall going through fellowship and you know, when we wanted to re-approximate bicossa, we would just get sterile super glue cuz that's what you do. You know, when we needed an endotracheal tube, they didn't have um laser safe endotracheal tubes that fit in a very small airway. So we created the um laser safe endotracheal tube by wrapping it with foil tape. Um I mean this was all these were all Dr. Kaufman's MacGyver, you know, approaches and uh that's just how she thinks outside of the box. She's truly visionary. We had a patient who came in extensive recurrent respiratory papilloma throughout the trachea.

[00:02:47]And we tried to put her to sleep, she obstructed nearly immediately. So we would have had to trach her for sure. Um Dr. Kaufman had heard about guide laser in development. Hadn't even been developed yet. And I mean it hadn't gotten FDA approval yet. She had heard it was being developed and she went to her office, she made some phone calls and by the end of the day, she had the approval for compassionate use um application of this laser for this patient. So within a week, we had that patient back in the clinic, we did an awake uh tracheal ablation, removed all of that extensive papilloma. The patient, you know, obviously we kept the patient alive, but also, you know, with a good quality of life avoiding a trach.

[00:03:32]Um and that and that's just how Dr. Kaufman is. She really um thinks outside of the box and will do what it takes to uh provide patients with the best possible care. In addition to that, she is an active leader. She's been prior president of this organization, the ABA.

[00:03:50]And she did establish this award, the ABA Jamie Koufman Annual Lectureship.

[00:03:57]I specifically wanted her to give this talk today because I was program chair last year and I can't think of a better person to give this lecture. She's literally spent the last 40 years studying reflux, which is now respiratory reflux and I think she's going to give us an outstanding update and above all she really is a legend. So with no further ado, Dr. Koufman.

[00:04:24]>> [applause] >> And I have a new blog, jamiekoufman.com and my email has changed. I'm doing consulting.

[00:04:41]So respiratory reflux is a new term. It was coined in 2014, I guess.

[00:04:49]But I want to ask a question. How many people here were not alive in 1981?

[00:04:55]Most of you, okay. In 1981 I already had a CO2 laser. I had the first CO2 laser in the in the world that was not for research and I got a call that there was a patient having trouble breathing on the floor. I went over with a small scope and a little light source and her airway was terrible and there as I was wheeling her down the hall in her bed, I said get me room five. I want my good anesthesia time. We were doing jet ventilation at the time and that's what she had.

[00:05:26]She was obstructing granulomas and of course it took you know a minute or 30 seconds to take them off. Taking them off wasn't a difficult problem. But she alerted me to the fact that she in every way was a refluxer. There was no part of her body and her personality and her diet and everything and I realized that my patients I I took care of patients that other people didn't want. They'd had complications. And they in In common, these people had inflammation.

[00:05:53]Um and so the inflammation was that was the key was the key variable.

[00:05:57]So, let's get rid of the term thing first. So, let me begin. A gastroesophageal reflux has been around for a long time. Um believe it or not, reflux laryngitis was in 1968.

[00:06:09]Um Margulies and and Cherry and Nilsson had used that term. Um and I was writing a paper for uh one of the journals on reflux laryngitis. And I borrowed the technology of reflux testing using the pH probes from the GIs. So, they didn't like that. So, they decided we're going to call what I had reflux laryngitis just atypical gastroesophageal reflux disease.

[00:06:34]So, then in 1987, I said, "Enough with this. My patients don't have uh heartburn. They don't have indigestion.

[00:06:40]They have normal esophageal exams. And they have proven uh reflux in the pharynx. And the reflux in the pharynx often was uh basically the worse the reflux, the worse the findings, and so on."

[00:06:53]And uh so, they didn't like that either.

[00:06:55]So, along came a extraesophageal reflux.

[00:06:58]And so, uh it's it's uh uh these other terms are interesting and they have relevance. Certainly, silent reflux is is the pattern we see today.

[00:07:07]And uh and finally, respiratory reflux.

[00:07:10]So, uh this is sort of pinnacle terms.

[00:07:14]So, laryngopharyngeal reflux is hard to pronounce. It's awkward. It's not intuitive to patients or anyone else.

[00:07:21]So, uh it doesn't stood the test of time in the literature along with gastroesophageal reflux disease. But in my opinion, it's time to change it to respiratory reflux. And here's why.

[00:07:34]When I went to New York and I left academic medicine, and I actually had the greatest learnings that I've had in my career. And I found that the whole respiratory tract could be involved. So, we're talking about ear symptoms and sinus symptoms and certainly respiratory and breathing symptoms. And so, I think respiratory reflux is a pinnacle term.

[00:07:52]And then, that it will give the it will give the the GI gastrointestinal reflux or our esophageal reflux. And I think listening to the papers that have been presented here, please don't say GERD. Okay, our patients don't have GERD. They just don't.

[00:08:08]Time to retire GERD, okay? It's been a wastebasket for all reflux forever for a very long time. A A Google hasn't recognized anything.

[00:08:18]Everything reflux goes into GERD. And all of a sudden, I saw respiratory reflux in a item that it came came through to me from from Google. So, I think it's time to think about retiring this waste basket a term and going to respiratory reflux.

[00:08:34]And And this other one could be I guess esophageal reflux.

[00:08:38]>> [snorts] >> So, that's all I have to say about that, but I I do believe it's a pinnacle term. I do believe we'll use that going forward because it's it's easier.

[00:08:47][clears throat] So, I want to talk about establishing standards. So, without further ado, how many people in the room uh think this is an abnormal larynx?

[00:09:01]Three. Uh how many people think it's a normal larynx?

[00:09:07]10.

[00:09:08]All right, what about the rest [laughter] of What about the rest of you?

[00:09:12]Don't you want to have a little bit of a go?

[00:09:14]So, this woman is a 28-year-old woman who came to see me with um chronic chronic cough. And um that's what she looked like after treatment. Now, um you don't see that.

[00:09:28]I have not seen a larynx that looked like that since I've been coming to these meetings.

[00:09:33]That's normal normal normal. Look at the vocal folds. Look at the bow of the ship. Look at look at all of that. And that woman is the same patient two or three months later. So, understand something. When you see reflux, it's usually edema. Not everything that said, "Oh, the vocal cords were so red." No.

[00:09:52]Erythematous to me is I reflux last night. Um but generally we're talking about edema. So, this mild edema that's diffuse became not so mild and and nice.

[00:10:01]And I'll just say that as a laryngologist seeing a pristine larynx is quite un- quite uncommon.

[00:10:08]So, let's talk about reflux. How big is the problem?

[00:10:12]Um it's the American way.

[00:10:14]The evening meal is the big refueling meal of the day. It's often with alcohol for people who drink.

[00:10:20]Um it's too close to dinner. American diet I you know, a third of us are obese, a third of us eat fast food every day. And so, you can if you look at all the things that could be related to reflux from uh sleep apnea and COPD and and and and and asthma. Um it's cultural.

[00:10:41]And I'll give I'm going to give you a a sign that you can use that I find very very useful.

[00:10:46]But um I'll give you an example.

[00:10:48]On my intake form I've always had asthma. And when that little circle is ticked off that little circle, I I've been saying this now for 45 years. Say, "When you have an asthma attack, do you have more trouble getting in air air air in out or both?" And they go, "In."

[00:11:08]I said, "How's that asthma medicine working for you?" "Not so much."

[00:11:12]So, trouble breathing in is never asthma.

[00:11:15]It's reflux, okay? Four to five people in America, in my opinion, with a diagnosis of asthma don't have it. It's been steady on 80% for at least the last 20 years. So, what about these other diseases?

[00:11:31]Respiratory reflux can affect any of these problems that we see. I thought we proved that subglottic stenosis was caused by reflux. I thought we proved that laryngomalacia was related to reflux. And the problem is literature searches no longer go back to the pioneering articles. They somehow think everything happens in the last three or five years.

[00:11:53]But we study these things and we have good data. And so I think it's important to recognize that this is an inflammatory problem and if you have a granuloma or if you take off a carcinoma and you get another granuloma, you take out another carcinoma three years later non-smoker a little thing on the vocal cord get another granuloma.

[00:12:12]These are patients who have reflux and this silent reflux.

[00:12:16]So here's something I've done ambulatory double probe pH monitor since 1987. I have my own lab. We had custom-made catheters with the two different probes.

[00:12:28]Isfet it was the best a possible pH probe chip we could find.

[00:12:34]And this patient has supine nocturnal reflux all night long.

[00:12:39]The question is I mean which of these events gave rise to that? That doesn't make any sense. Here's another one to think about. We see people with inlet patches. Inlet patches like Barrett's.

[00:12:51]How much reflux do you have to have just below the LES to get inlet patch? Maybe it sits there all night and in some people it bubbles up and you have a reflux all night long. So what I'm going to say to you one of the things I I don't do this anymore is that there's absolutely no pattern that we understand about respiratory reflux. I've had patients I said oh you have respiratory reflux with this cancer. I test them it's normal. I test them again it's abnormal. So we don't know and the gastroenterologists are absolutely out of their minds. They say oh you must have a reflux episode in your esophagus followed by one in your pharynx. Never seen that, okay? Just not like that very often.

[00:13:31]But this is the pattern we see today, um supine nocturnal reflux.

[00:13:36]And it's quiet.

[00:13:41]So, we don't know how many millions of people have silent nocturnal respiratory reflux, a new term, snore. But I will tell you that it's in the tens of millions and I'm betting at least half the people in this room have it.

[00:13:56]So, the gastroenterologists, I want to say something, they don't even know about reflux. Forget about respiratory reflux.

[00:14:02]I'm going to prove it to you. They zilch, zero, next, all the words you can think of.

[00:14:07]Um I don't know if you saw if anyone saw this paper. It's the most regressive paper ever published in our in our field or related to our field. This is the San Diego consensus for laryngopharyngeal reflux symptoms and laryngopharyngeal reflux disease. They don't even know what the symptoms are.

[00:14:23]Okay? And they're what what they're doing is unbelievable.

[00:14:27]These are 28 self-appointed experts. I sure hope none of the six total laryngologists or whatever it is are in this room.

[00:14:36]Uh >> [laughter] >> Yeah, I I actually have a 12-gauge 12-gauge shotgun. So, we'll see we'll see you later. So, but anyway, there's a very important thing. This is a very very important concept.

[00:14:51]Therapeutic twice-a-day PPIs for 3 months. If they don't get better, they don't have reflux, okay? I want to say something you didn't know.

[00:15:01]PPIs cure 0% of people.

[00:15:05]An acid suppressor is an acid suppressor and not even all that good. So, you say you put them on PPIs, you put them on people people like that was a therapeutic test for reflux. It isn't for you, it isn't for me, it isn't for anybody.

[00:15:17]Uh they they said there are no specific findings of LPR, really?

[00:15:22]Uh they said uh abnormal EGD means they might have a Not true. 80% of people with LPR have normal esophageal exams.

[00:15:30]And they get to pay behavioral therapy. You don't know what's wrong with the person. You say it's in their head. And the chronic coughers and the chronic throat clearers are ending up in psychologist's office and they're getting tricyclics and SSRIs. I mean, this is really sort of the malpractice area.

[00:15:48]And they still insist that to prove LPR you must have a GI test and you must show an association between esophageal and pharyngeal reflux events. So, none of this is true.

[00:16:00]It's made up.

[00:16:02]It's a bunch of assumptions that cannot be validated. I can tell you from my experience, we certainly invalidated them.

[00:16:12]It's all about pepsin. I've been interested in pepsin uh my whole career.

[00:16:16]Um this is a patient who was coming in for some procedure, not a laryngeal procedure.

[00:16:21]Um he had reflux laryngitis and we had a protocol then. This was taken uh from the uh back of the larynx. And uh on the left you see H&E stain and on the right you see we had immunohistochemistry for pepsin. You made it out. So, there you're seeing pepsin. It's uh on the surface. It's deep. It's intracellular. It's extracellular.

[00:16:41]Which uh which which which PPI is going to take care of that?

[00:16:45]Which diet for 6 weeks is going to take care of that?

[00:16:50]So, why is this such a conundrum?

[00:16:55]The aerodigestive tract is one system.

[00:16:58]You can't divide it into otolaryngology and pulmonology and and and and GI.

[00:17:04]That mistake is global.

[00:17:07]Okay? Unless you understand how this whole thing works together, um you don't understand none of it.

[00:17:13]And you, my colleagues, um have the biggest area cover. The pharynx is Grand Central Station. Nothing goes up or down except through the pharynx.

[00:17:26]And I've yet to see anything near a normal larynx in this meeting.

[00:17:32]Um reflux-wise.

[00:17:34]So, we [snorts] need to think about uh you know, who Everyone deals with the airway. You got the got the got the anesthesiologist and the critical care people and and so we need to think about how we evaluate the airway and how we specifically I evaluate um for I'm going to tell you what I think it's going to be the the for the time being um is spitting in a cup and getting pepsin. I developed that. I patented it.

[00:17:58]Nobody brought it to market.

[00:18:00]One little test from random don't mean anything.

[00:18:04]You're going to have the patient go ah with your with your tongue blade. You're going to take the smallest cup forcep known to man. You're going to grab a little tiny piece of the of the posterior pharynx and you're going to put it in some stuff and if it turns brown, he's got pepsin or you can send it for for for analysis. But this is what we're fighting. It's pepsin that's tissue-bound, causes inflammation uh anywhere.

[00:18:28]Integrated digestive medicine is a new concept meaning uh I am part otolaryngologist, gastroenterologist, and um uh uh uh pulmonologist and ENT. So, what what what what happens we're going to we're going to treat people. We're we're going to treat train people. So, one doctor can treat postnasal drip, reflux, right?

[00:18:50]Asthma, and all of these common things.

[00:18:52]Instead, they're going from specialist to specialist to specialist. In my chronic cough index, we had average patients had been 10 years with coughing. They'd been seen at major medical centers and the average had spent oh well over a quarter million dollars and seen 19 specialists for reflux.

[00:19:13]So, integrated digestive medicine is a new idea and the question is, you know, who's going to be behind that and what's the agenda and the curriculum going to look like?

[00:19:22]So, um this is another Sorry about this.

[00:19:26]Um in my experience, both otolaryngology and GI are going backwards. Uh when I was very active, I felt as though we were moving somewhere. I thought I could get double probe pH testing like I was doing to be more popular. Of course, I've already told you just recently that these patterns seem to have changed, especially 2008, we started to see a nocturnal refluxes.

[00:19:47]Now, and here's another another one.

[00:19:50]A guy very funny guy. He was a He was an undercover cop. First time I met him, he comes in my office and he starts taking out two guns going on my uh coffee table and all that and he he's explaining I don't look like my my psychic cop. So, he he gets on a on a program, it's terrible reflux, and he comes back a month later and he looks worse.

[00:20:09]And he says, "I'm doing the program."

[00:20:11]And the answer was he was doing the program except Saturday nights. Saturday night, he didn't have to do the program.

[00:20:18]So, understand that we're going to talk about programs and treatment, but there's cure and then there's treatment of symptoms. Let's talk about heartburn, okay? You got heartburn, you're going on PPI. It's 20 years later. I stopped using PPIs in 2014 with publication of the Danish study.

[00:20:38]10,000 people national study of esophageal disease, long-term use of PPIs associated with increased incidence of esophageal cancer. Increases risk of cancer. And I said, "Duh." Takes care of the symptom, but the disease goes on unabated. And it does.

[00:21:00]>> [laughter] >> They're not even defended differently.

[00:21:02]You know, you can have 60 reflux episodes a day and uh GI I say that's normal.

[00:21:09]Um if you have one reflux episode in the lung, you can have complete slough of all the epithelium. And if if it's bigger, you'll have pneumonia.

[00:21:17]Um I always joke about this that there's a law that's been misinterpreted that people in nursing homes have to be offered a snack.

[00:21:24]So, before they go to bed, they have ginger ale and chocolate pudding. And 2:00 in the morning, they have ginger ale and chocolate pudding in their lungs. And then they go and it's a uh a ginger ale chocolate pudding pneumonia that kills them.

[00:21:40]So, I want to estimate No, I want to ask how would we better figure out the patterns of respiratory reflux. And it's not going to be on based on acid. We're going to need new tools. We're going to need people like Nikki um who's done some a lot of this work uh to come with new ideas how we evaluate this problem. But it's absolutely ubiquitous.

[00:22:05]Forget about the GIs.

[00:22:09]So, let me make an assumption to you.

[00:22:12]Let's say I'm right.

[00:22:14]And now, a mere 70% of your patients have reflux and it's contributing to their their disease. Have you not seated our specialty to gastroenterologists already because they're reflux doctors?

[00:22:26]So, there's going to have to be some rethinking about who does what and who's responsible. But let me tell you right now, I tell my patients when I'm doing consult, they go, "Oh, I'm scheduled to have a a a Bravo next week."

[00:22:38]And I say, to every every single one of them, "For you to see a gastroenterologist, you would be better off better off talking to a tree."

[00:22:54]So, you know, it's interesting with with with with with with uh heartburn, there's reflux. Reflux is heartburn. That's easy. Symptom to diagnosis.

[00:23:04]But what about our people? Huh? You wake up in the middle of the night coughing and can't breathe. You have a laryngospasm. You cough after lying down, after eating.

[00:23:13]You have globus. You have hoarseness.

[00:23:16]Sometimes it's worse after you've gone out for a night. You start adding the symptoms together. They have asthma that isn't asthma. And you start seeing that most of these people have have 10 symptoms and and and thick mucus and chronic throat clearing.

[00:23:30]It gets on the vocal folds the poor newscaster who's stuck with someone his vocal cords trying to finish his work for all the world to see.

[00:23:39]It's a lot to get that off of there. So understand that this is what I do when I go to work.

[00:23:46]That's what I've been doing now for better part of three decades.

[00:23:51]All of that. By the way, COPD.

[00:23:56]Guy comes to see me. Quit smoking 25 years ago. He's dragging the oxygen.

[00:24:01]Hardly makes it into my exam room. Exam is reflux is terrible. And we treat him.

[00:24:06]He's as highly motivated as they get.

[00:24:08]And three months later without oxygen, he's in his car on his way to Florida to see Mets spring training. He still uses it sometime, but he was dependent. He was going to die at progression of his COPD.

[00:24:23]Integrated air digestive medicine might apply.

[00:24:26]So I want to tell you this is a sort of interesting that there's two pieces I want to give you that I think are useful as clinical pearls.

[00:24:35]I just took a hundred consecutive consults that I did. This is what the symptoms look like. I do want to say that I think I mentioned to somebody before. We've done pharyngeal UES, esophageal manometry. After we finish the esophageal manometry, we pull up that that we see with with with uh uh with globus low pressures, high pressures, or even uh pressures that look normal but rebound to 200 to 300 mm.

[00:25:01]It's a little unreliable. But, the you can not all these phases are the same.

[00:25:07]They don't need a big workup. You say, "Is it right here?" Yeah.

[00:25:10]"Is your swallowing loud?" Yeah. I mean, okay. They point right there. Okay?

[00:25:16]It's a synchrony. You everywhere.

[00:25:19]The valve is closing in the middle of a swallow.

[00:25:23]And fix the reflux, and it goes away.

[00:25:26]The valve is closing in the middle of a swallow. That's the synchrony. It's right here. You can just differentiate that from something more worrisome. If you need, get a barium swallow esophagram.

[00:25:37]Well, I talked about shortness of breath because I have something I'd like to share with you. So, remember, these are people who are not normal. They're already self-selecting as respiratory reflux consulting me because they're not getting what they want. And so, half of them have shortness of breath. And of those, 2/3 it's a chief complaint, about 32 patients, I think.

[00:25:58]And so, I what I do when I get that, I say to the patient, "Listen, there are at least three types of shortness of breath. And I'm going to tell them to you, and then you tell me which of those you have, or maybe something different."

[00:26:07]And the first type is difficulty to go up two flights of stairs, and you're huffing and you're puffing. Um that's with exertion.

[00:26:15]The second type is air movement, like you see when you have laryngospasm or asthma. It's a It's an airway obstruction kind of symptom. And the third is highly specific. [laughter] Difficulty or discomfort taking a full breath in.

[00:26:31]And not only is it pathognomonic for respiratory reflux, as the person gets better, they'll feel it. Um it's easier for me to get a full breath in now. And they will characterize this as shortness of breath.

[00:26:45]So, I think that the forms that we take, you know, reflux symptom index, that's that's gone away. We need more. We need to ask about these things in our in our patients.

[00:26:54]And that's where there's the third. Look at that, 71%. And of course, some of them had multiple. They had two or three types of shortness of breath.

[00:27:03]>> [snorts] >> So, I thought I'd throw in some pictures.

[00:27:07]These aren't subtle.

[00:27:08]Um I I had this patient come in, I don't know, 30 years ago, and I took this picture, and I sent it to, you know, all my fancy friends, you know, one in Philadelphia and one in New York, and so on. I said, "What is this?" And I never got a response.

[00:27:23]Um that's cobblestoning in the nasopharynx, and that's reflux.

[00:27:28]I mean, here's a normal.

[00:27:29]Look at all these. Do you think Do you think that's not a primary inflammatory disease? Is there another alternative? Is there another diagnosis?

[00:27:38]Um is this autoimmune disease? No.

[00:27:42]The pharynx is interesting. It's always granular. You usually see mucus. When you see a narrow one like this, even though you're looking at the palate area, these patients almost always have a sleep apnea.

[00:27:54]Look at it. The This granular uvula is getting longer and longer and longer. If you get one of these and the patient's miserable with the uvula that's, you know, in the larynx, please don't operate on it. Get them on 3 weeks reflux treatment, and this thing's back where it belongs.

[00:28:07]Um but again, the granularity, and by the way, see, this is actually the most typical type of this uh thick mucus.

[00:28:16]Here's your larynx. Now, no one in a in a million years would say those two on the right are normal, all right? I mean, you don't have no ventricle.

[00:28:24]I mean, and and and and and you know, some of these are really funny. I mean, these These look like door columns.

[00:28:30]Um and and and yet yet I want to show So, here we go. This This guy's a left vocal fold paresis as well, you can see. But look at this one.

[00:28:40]Front of larynx looks pretty darn good.

[00:28:41]Back of larynx looks pretty bad. Maybe she refluxes once a week. Um maybe she has just enough wine. Uh maybe she sleeps on her back or inclined.

[00:28:52]But as long as the postcricoid area is touching the posterior pharyngeal wall, you can say to yourself, "Supine nocturnal respiratory reflux." Please don't get CT cans scans of these people anymore.

[00:29:06]Okay? You will never see you'll you'll never see one of these with a positive it's not a positive study. And by the way, um I've been saying for a long time that you can get cancer without smoking but not without reflux. Same thing. 20% of COPD, 20% of all these not smokers.

[00:29:23]Look at Look at these.

[00:29:25]These are huge refluxy looking looking larynges. And the one on the right, what's the one on the bottom right? That one's in trouble. That one had radiation and will have a tracheotomy soon unless something is done.

[00:29:37]>> [snorts] >> So, I'm going to show you this. This is uptake of uh pepsin in cellular laryngeal tissue culture and pepsin alone and it's in the in the cell membrane and it then gets distributed in the cell. So, we know that this stuff goes in there and we don't know yet what it does.

[00:29:55]Pepsin activity, peak activity at two, reactivation at six. And so, it's sitting there and you drink a Coca-Cola and back it goes.

[00:30:04]Um and here's the key. Uh it's deactivated at pH eight, which is why we have people particularly all of the singers in Broadway are walking around with these little blue bottles. You open your mouth and you spray.

[00:30:14]pH 8.5, okay? Pepsin dies at 9.5 dies at eight. So, the only thing you can do to help uh get this problem rectified faster.

[00:30:26]People ask me, "How long does it take to And if those of you want to know how I treat people, take out your camera cuz when I did this slide, I knew I wasn't going to have time to talk about But it depends upon what you want. Do you want to get somebody's symptoms better who's miserable?

[00:30:42]Um or do you want to cure them? They don't want to be cured. You tell them I had one, I did a consult, it was lovely, everything was fine until the end when she said, "Well, I'm still going to have chocolate every night before I go to bed."

[00:30:54]So, understand that cure is quite possible.

[00:30:59]And that's what it takes. I wish it was simpler.

[00:31:02]Do a reverse uh intermittent fast, 45° low-fat low-acid diet, no alcohol, nothing out of a bottle or a can, alkaline water pH 9.5, uh coffee tea less than 120 mg per monitoring, alginate and gum chewing by the way, quite good. And so, um if this program is continued for 4 weeks, it's not really, isn't it? It's going to take longer than that. Because at the end of 4 weeks, you say, "Um by the way, the thing you hate the most you can change, but leave everything else alone." So, they put their bed down and they leave everything else alone for several days. They say, "I want to add some fruit." But they leave everything else alone. So, with trial and error that comes with this kind of a program, there's another month or two essentially.

[00:31:46]And these people need it. These are people who have Two people have died in their family of esophageal cancer. These are people who have had cancers and and non-smokers. These people want it.

[00:31:57]So, [snorts] that's all I have to say.

[00:31:59]Um I will I will add um uh if you see a posterior larynx like that, uh think reflux and nothing else.

[00:32:08]And finally, I say to my patients, "Reflux is not a medical disease. It can cause medical problems, okay? There's not a better doctor, there's not a better pill, um there's not a better procedure.

[00:32:20]It is diet and lifestyle. And the uh trillion-dollar elephant in the room is the American diet."

[00:32:27]Thank you very much.

[00:32:29]>> [applause] [music] >> It's time for questions.

[00:32:39]>> [applause and music] [music] >> Stacy, do we have time for a couple of questions or not?