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About 10 to 30 of patients with depression use CAM sometimes without provider knowledge because of their preference for selfdirected therapy, favorable adverse effect profiles, lower cost, or perceived superior efficacy.

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The crura of the diaphragm partially compensate by creating a bend in the lower oesophagus, but using a mobile structure to accomplish this has drawbacks; reflux on phonation is common, particularly with laughing as the intra-abdominal pressure oscillates.

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Clinical Trials: In a 12 week, randomized, double-blind, positive-control, crossover study of albuterol sulfate, ipratropium bromide, and Ipratropium Bromide and Albuterol Sulfate Inhalation Solution, 863 COPD patients were evaluated for bronchodilator efficacy comparing Ipratropium Bromide and Albuterol Sulfate Inhalation Solution with albuterol sulfate and ipratropium bromide alone.

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Because this effect is blocked by inhaled lidocaine, vagal irritant receptors may be involved.

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