DISCUSSION: The patient had several episodes of repeated aspirations, leading to chronic inflammation of the bronchioles. Diffuse aspiration bronchiolitis (DAB) has been proposed to define a clinical entity that is characterized by a chronic inflammation of bronchioles caused by recurrent aspiration of foreign bodies.1 DAB was originally recognized in the elderly, but can occur in younger patients with achalasia or GERD with similar manifestations. In this condition, the sphincter does not close completely, after food enters the stomach. In absence of concomitant peristalsis, the acid goes back up from the stomach into the esophagus and trachea. In primary/idiopathic esophageal aperistalsis there is failed esophageal contractility and a hypotensive lower esophageal sphincter without a known systemic cause as with our patient. The word secondary is applied to esophageal disorders in systemic disorders such as connective tissue disease, diabetes, dermatomyositis, amyloidosis, and Chagas’ disease.3 Endoscopy may not be the best test to evaluate LES especially in connective tissue disease.3 Esophageal manometry was the diagnostic test in our case. Patient received antibiotics, bronchodilators, and bethanecol, which stimulates parasympathetic receptors to increase muscle tone, and leads to contraction of the sphincter. Lower esophageal sphincter and the crural diaphragm represent the major antireflux barrier, hence a specific inspiratory muscle training2 was started. At follow up she continued to show improvement.