Illustration of a woman’s face who cannot burp

Can’t Burp?

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Inability to belch or “burp” (Also known as Retrograde Cricopharyngeus Dysfunction, or R-CPD for short) occurs when the upper esophageal sphincter (cricopharyngeus muscle) loses its ability to relax in order to release the “bubble” of air. 

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What is R-CPD (Inability to burp, no-burp)?

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People who cannot release air upwards are miserable. They can feel the “bubble” sitting at the mid to low neck with nowhere to go. Or they experience gurgling when air comes up the esophagus only to find that the way of escape is blocked by a non-relaxing sphincter. It is as though the muscle of the esophagus continually churns and squeezes without success. Common symptoms include the inability to belch, gurgling noises, chest/abdominal pressure and bloating, and flatulence.

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The Top 4 Symptoms of R-CPD

R-CPD cannot burp illustration

Inability to burp

This is almost always, but not exclusively “lifelong,” often excluding infancy, since many with R-CPD did burp as infants. Most no-burpers can’t remember being conventionally able to burp and can also point to a time when they became aware of this as a “problem” or “difference from others” in childhood or teen years.

Some with R-CPD do burp occasionally but they are micro, random, not harnessable, and they don’t provide relief of the following symptoms.

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Socially awkward gurgling noises

These noises can be mostly quiet and “internal,” but more often are loud enough to be embarrassing. Mouth opening makes them louder. Almost everyone says they are easily heard several feet away; not infrequently “all the way to the door.” They engender social anxiety in most persons with R-CPD, causing some to avoid eating or drinking for hours before social occasions and even during them. Carbonation makes them much worse and is to be avoided at all costs. Some more colorful patient descriptions:
  • Symphony of gurgles
  • Croaking frogs
  • Creaking floorboards
  • Dinosaur sounds
  • Strangled whale
  • The Exorcist

Audio examples of gurgling

R-CPD Bloating icon

Bloating & Pressure

Most common location is high central abdomen. Distention is common, especially later in the day. Using pregnancy as an analogy even in men, the usual degree of distention is described as “3 or 4 months.” “Six months” is not rare, and one slender young man was “full term.” Almost as often as abdominal distress, patients describe chest pressure, and for some that is the worst symptom. Some have pressure in the low neck. While “pressure” is the frequent descriptor, some experience occasional sharp pain in abdomen, back, or between shoulder blades. Some have to lie down after eating to find some relief.
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Common Questions about R-CPD

Dr. Bastian responds to a list of questions submitted through YouTube, Facebook, and Instagram.

R-CPD Flatulence leaf blower icon


Routinely, this is described as “major,” or even “ridiculous.” Flatulence increases as the day progresses, and many experience it into the night. When around others, some scan their surroundings at all times for a place they can go briefly to pass gas. Understandably, the social ramifications of this problem can also be major.
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Less Common Symptoms of R-CPD

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especially after eating larger than normal amounts or drinking carbonated beverages.


when symptoms of bloating are major.

Painful Hiccups

again, more commonly after eating.

Anxiety & social inhibition

This can be MAJOR due to gurgling, flatulence, and discomfort.

Shortness of breath

A person can be so full of air that athletics—or even the ability to climb stairs—are impaired.


(Still under evaluation): Flatulence can’t always be responded to, and the result is descending colon appears to dilate, making stretched muscles in its wall less effective in moving colon contents along.

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Inability to Vomit

A few simply cannot vomit; more often it is possible but only after strenuous retching. Vomiting (spontaneous or self-induced) always begins with a very loud noise and major release of air in a phenomenon we call “air vomiting.” Emetophobia can be major.

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What Causes R-CPD?

Inability to burp or belch occurs when the upper esophageal sphincter (cricopharyngeus muscle) cannot relax in order to release the “bubble” of air. The sphincter is a muscular valve that encircles the upper end of the esophagus just below the lower end of the throat passage. If looking from the front at a person’s neck, it is just below the “Adam’s / Eve’s apple,” directly behind the cricoid cartilage.

If you care to see this on a model, look at the photos to the right. That sphincter muscle relaxes for about a second every time we swallow saliva, food, or drink. All of the rest of the time it is contracted. Whenever a person belches, the same sphincter needs to let go for a split second in order for the excess air to escape upwards. In other words, just as it is necessary that the sphincter “let go” to admit food and drink downwards in the normal act swallowing, it is also necessary that the sphincter be able to “let go” to release air upwards for belching.

People who cannot release air upwards are miserable. They can feel the “bubble” sitting at the mid to low neck with nowhere to go. Or they experience gurgling when air comes up the esophagus and is blocked by a non-relaxing sphincter. It is as though the muscle of the esophagus continually churns and squeezes without success. The person so wants and needs to burp, but can’t. Sometimes this can even be painful. Such people often experience abdominal bloating as the air must make its way through the intestines before finally being released as flatulence.

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Treatment for R-CPD

Botox Injection at Bastian Voice Institute

For people who experience this problem to the point of discomfort and reduced quality of life, here is one approach: First, a videofluoroscopic swallow study, perhaps with effervescent granules. This establishes that the sphincter works normally in a forward (antegrade) swallowing direction, but not in a reverse (retrograde) burping or regurgitating fashion. Along with the symptoms described above, this establishes the diagnosis of retrograde-only cricopharyngeus dysfunction (non-relaxation).

Second, a treatment trial involving placement of Botox into the malfunctioning sphincter muscle. The desired effect of Botox in muscle is to weaken it for at least several months. The person thus has many weeks to verify that the problem is solved or at least minimized. The Botox injection could potentially be done in an office setting, but we recommend the first time (at least) placing it during a very brief general anesthetic in an outpatient operating room. That’s because the first time, it is important to answer the question definitively, that is, that the sphincter’s inability to relax when presented with a bubble of air from below, is the problem.

Lifting the CPM for a R-CPD Injection

These are intra-operative photos of one of nearly 1500 persons treated for R-CPD as of September 2023. This sequence shows several things:   The dilated, “always open” esophagus distal (below) the muscle; how to identify the cricopharyngeus muscle; and one way of injecting it.

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Above the CPM (1 of 5)

The view here is just inside the uppermost part of the esophagus, immediately behind the larynx. The target muscle is not yet seen, but the dilation of the esophagus is notable in this young, muscular male.

Ridge of the CPM (2 of 5)

The larynx is gently lifted forward, and the “ridge” of the muscle begins to be seen.

Exposed CPM ( 3 of 5)

With further lifting, the muscle becomes obvious and is ready for injection.

CPM Palpated ( 4 of 5)

If desired, the muscle can be palpated—here with the side of a suction cannula—to determine compressibility and “size.”

Botox injection ( 5 of 5)

A 25-gauge butterfly has had one “wing” cut off completely, and the other wing cut to leave only a nubbin for grasping with a straight alligator forceps. Seen here is injection of one of three or four sites, chosen to distribute the botox throughout the entire muscle.

What to Expect Post Botox Procedure?

Review Dr. Bastian’s published Journal entry for a complete explanation, but in a nutshell:

  • There will be no relief of R-CPD symptoms for 1—5 days.
  • Only when micro-burps begin do patients start to notice the beginning of symptom relief. So do not try carbonation for lunch on the day of the injection!
  • Initial Botox side effects can be “weird” for a few days to weeks.
  • If you can manipulate your gurgles prior to Botox treatment, to make them softer or louder, use that technique to see if you can hurry burps along or make them bigger.

For a few months at least, patients should experience dramatic relief of their symptoms. And, early experience suggests that it may be that this single Botox injection allows the system to “reset” and the person may never lose his or her ability to belch. Of course, if the problem returns, the individual could elect to pursue additional Botox treatments, or in a truly severe case, might even elect to undergo endoscopic laser cricopharyngeus myotomy.

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Complications Compared to Expected Effects in Treatment of R-CPD

In this video, Dr. Bastian distinguishes the difference between early EFFECTS that are expected, and COMPLICATIONS patients have experienced in a caseload of approximately 870 people. This informal discussion will likely reassure persons considering this treatment for the severe daily misery caused by R-CPD.

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What Is the Best Botox Dose for R-CPD? 100 units? 50? 200?

Newly diagnosed R-CPD patients often ask: “What is the best dose for the initial injection of Botox?” Dr. Bastian provides an answer that includes context and nuance from his group’s experience with over 1200 patients injected to date.

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Do Shaker Exercises Work in Treating R-CPD?

In this video, Dr. Bastian explains his thinking about “Shaker Exercises” as a means of learning to burp in persons with R-CPD (no-burp). A recent Reddit thread was created in response to his July 2022 Webinar comments on this subject, and it appeared to him that he had not conveyed his thinking clearly enough. Here is his more detailed and nuanced discussion…

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Where Our R-CPD Patients Come From

NO-BURPERS turned burpers!
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Photo Essays from our R-CPD Patients

Abdominal Distention of R-CPD

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Gastric Air Bubble (1 of 3)

This abdominal xray of an individual with R-CPD shows a remarkably large gastric air bubble (dotted line), and also excessive air in transverse (T) and descending (D) colon. All of this extra air can cause abdominal distention that increases as the day progresses.

Bloated Abdomen (2 of 3)

Flatulence in the evening and even into the night returns the abdomen to normal, but the cycle repeats the next day. To ask patients their degree of abdominal distention, we use pregnancy as an analogy in both men and women. Not everyone describes this problem. Most, however, say that late in the day they appear to be “at least 3 months pregnant.” Some say “6 months” or even “full term.” In a different patient with untreated R-CPD, here is what her abdomen looked like late in every day. Her abdomen bulges due to all of the air in her GI tract, just as shown in Photo 1.

Non-bloated Abdomen (3 of 3)

The same patient, a few weeks after Botox injection. She is now able to burp. Bloating and flatulence are remarkably diminished, and her abdomen no longer balloons towards the end of every day.

The Daily Inflation-Deflation Cycle for R-CPD

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Abdominal distention (1 of 4)

Lateral (side) view of abdomen of a person with R-CPD in the morning, before eating or drinking anything. Flatulence late evening and through the night has “deflated” the abdomen.

Deflated abdomen (2 of 4)

Frontal view again in the morning with abdomen “deflated.”

Bloating (3 of 4)

Side view of the same person, in the afternoon: bloating and abdominal distention by air has occurred. Compare with photo 1.

R-CPD distention (4 of 4)

Frontal view in the afternoon, showing distention by air. Compare with photo 2.

Progression of Bloating and Abdominal Distention – a Daily Cycle for Many with R-CPD

This young woman has classic R-CPD symptoms—the can’t burp syndrome. Early in the day, her symptoms are least, and abdomen at “baseline” because she has “deflated” via flatulence through the night.  In this series you see the difference in her abdominal distention between early and late in the day.  The xray images show the remarkable amount of air retained that explains her bloating and distention.  Her progression is quite typical; some with R-CPD distend even more than shown here especially after eating a large meal or consuming anything carbonated.

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Side view of a bloated abdomen (1 of 6)

Early in the day, side view of the abdomen shows mild distention. The patient’s discomfort is minimal at this time of day as compared with later.

Front view (2 of 6)

Also early in the day, a front view, showing again mild distention.

Greater Distention (3 of 6)

Late in the same day, another side view to compare with photo 1. Accumulation of air in stomach and intestines is distending the abdominal wall.

Front view of bloating stomach (4 of 6)

Also late in the day, the front view to compare with photo 2, showing considerably more distention. The patient is quite uncomfortable, bloated, and feels ready to “pop.” Flatulence becomes more intense this time of day, and will continue through the night.

X-ray of trapped air (5 of 6)

Antero-posterior xray of the chest shows a very large stomach air bubble (at *) and the descending colon is filled with air (arrow).

Side view (6 of 6)

A lateral view chest xray shows again the large amount of excess air in the stomach and intestines that the patient must rid herself of via flatulence, typically including through the night, in order to begin the cycle again the next day.

Abdominal Distention Caused by R-CPD

This sixty-something man has endured the misery of R-CPD all of his life. His symptoms of inability to burp, gurgling, bloating, flatulence (and more) are dramatically relieved after botulinum toxin into his cricopharyngeus muscle (upper esophageal sphincter). Here, we see the before and after difference in his abdominal distension as well.

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Bloating and abdominal distention before botox injection for inability to burp (1 of 2)

Late-day abdominal distension caused by inability to burp. The discomfort of R-CPD may cause hypersalivation and extra reflexive swallowing, which only adds to the air in his GI tract. He is athletic; the distension represents air in stomach and intestines that could not be burped—not excess weight.

Resolved, one month after botox, with burping restored (2 of 2)

Within the first month after botulinum toxin injection, he no longer feels bloated and his stomach does not distend at the end of the day. Body weight is the same in both photos.

A Rare “abdominal crisis” Due to R-CPD (inability to burp)

This young man had an abdominal crisis related to R-CPD. He has had lifelong symptoms of classic R-CPD: inability to burp, gurgling, bloating, and flatulence. During a time of particular discomfort, he unfortunately took a “remedy” that was carbonated. Here you see a massive stomach air bubble. A lot of his intestines are air-filled and pressed up and to his right (left of photo, at arrow). The internal pressure within his abdomen also shut off his ability to pass gas.

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X-Ray of Abdominal Bloating (1 of 2)

Note arrow pointing to lack of gas in the descending colon/rectum. NG decompression of his stomach allowed him to resume passing gas, returning him to his baseline “daily misery” of R-CPD.

Original X-Ray (2 of 2)

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R-CPD in X-ray Pictures: Misery vs. Crisis from Inability to Burp
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Shortness of Breath Caused by No-Burp

Persons who can’t burp and have the full-blown R-CPD syndrome often say that when the bloating and distention are particularly bad—and especially when they have a sense of chest pressure, they also have a feeling of shortness of breath. They’ll say, for example, “I’m a [singer, or runner, or cyclist or _____], but my ability is so diminished by R-CPD.  If I’m competing or performing I can’t eat or drink for 6 hours beforehand.”  Some even say that they can’t complete a yawn when symptoms are particularly bad.  The xrays below explain how inability to burp can cause shortness of breath.

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X-ray of trapped air (1 of 2)

In this antero-posterior xray, one can see that there is so much air in the abdomen, that the diaphragm especially on the left (right of xray) is lifted up, effectively diminishing the volume of the chest cavity and with it, the size of a breath a person can take.

Side view (2 of 2)

The lateral view again shows the line of the thin diaphragmatic muscle above the enormous amount of air in the stomach. The diaphragm inserts on itself so that when it contracts it flattens. That action sucks air into the lungs and simultaneously pushes abdominal contents downward. But how can the diaphragm press down all the extra air? It can’t fully, and the inspiratory volume is thereby diminished. The person says “I can’t get a deep breath.”

Esophageal Findings

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Aortic shelf (1 of 3)

A view of the mid-esophagus in a young person (early 30’s). The esophagus is kept open by the patient’s un-burped air. Note the “aortic shelf” at A, delineated by dotted lines.

Bony spur emerges due to stretched esophagus (2 of 3)

A moment later, additional air is pushed upwards from the stomach to dilate the mid-esophagus even more. A bony “spur” in the spine is thrown into high relief by the stretched esophagus.

Stretched esophagus due to unburpable air (3 of 3)

A view of the upper esophagus (from just below the cricopharyngeus muscle sphincter) shows what appears to be remarkable lateral dilation (arrows) caused over time by the patient’s unburpable air. Dilation can only occur laterally due to confinement of the esophagus by trachea (anteriorly) and spine (posteriorly), as marked.

Esophageal Stretching by Unburpable Air in R-CPD

This young man has had the classic syndrome of R-CPD lifelong. His esophageal findings at the end of a videoendoscopic swallow study are classic. The esophagus is mostly a collapsed muscular tube in young people, yet his esophagus is widely open on a continuous basis due swallowed air that he cannot burp up.

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Typical view of an esophagus (1 of 4)

Typical view of the esophagus using an ENT scope without insufflated air. Esophageal walls are collapsed and therefore too close to the lens of the scope to allow visualization of the esophageal wall.

Lower esophagus (2 of 4)

Using ENT (not GI) scope in this young man with R-CPD to view the lower esophagus, which is continuously “open” due to un-burped air. H = heart; Ao = aorta. Blue water previously administered, moves up and down between stomach and lower esophagus due to lower esophageal sphincter incompetence from years of bloating.

Stretched mid-esophagus (3 of 4)

A view in the mid esophagus: Ao = aorta; S = spine; T = trachea. The esophagus remains open continuously due to unburped air. Insufflated air is routinely not necessary in persons with R-CPD.

Esophagus stretches laterally (4 of 4)

At a moment of upward surge of air that cannot escape the upper esophageal sphincter as a burp, the esophagus stretches laterally, almost trying to get around (arrows) the non-compressible trachea (T), accentuating the “tracheal mound.” Note as well the widened lumen as compared with photo 3.

More Interesting Esophageal Findings of R-CPD (Inability to Burp)

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Stretched Esophagus (1 of 4)

Using a 3.7mm ENT scope with no insufflated air, note the marked dilation of the esophagus by swallowed air the patient is unable to belch. T = trachea; A = aortic shelf; S = spine

Tracheal Wall (2 of 4)

The posterior wall of the trachea (T) is better seen here from a little higher in the esophagus. A = aorta

Over-dilation (3 of 4)

The photo is rotated clockwise at a moment when air from below is pushed upward so as to transiently over-dilate the esophagus. Note that the esophagus is almost stretching around the left side of the trachea in the direction of the arrow.

Bronchus (4 of 4)

Now deeper in the esophagus (with it inflated throughout the entire examination by the patient’s own air), it even appears that the left mainstem bronchus (B) is made visible by esophageal dilation stretching around it.

R-CPD and Esophageal Dilation

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Posterior pharyngeal wall (1 of 3)

Here, in the panoramic view of the “bottom of the throat,” between posterior pharyngeal wall (marked PPW) and arytenoid eminences (A). The airway is indicated by the short arrow, and the dotted line shows the waiting “entrance” to the upper esophagus just above the CPM. The “entrance” opens for a second to permit passage of food or liquid through the sphincter and into the upper esophagus. The * is for reference with photo 2.

Is it R-CPD? (2 of 3)

At the entrance to the esophagus, at closer range. Notice that the mucosa is redundant, a common but not universal finding in R-CPD.

Stretched esophagus indicates R-CPD (3 of 3)

Now the view is within the upper esophagus. It almost appears that the lumen is dilated, especially in a lateral direction (arrows). Purely speculatively, one wonders if constant forcing of air upwards again a barrier ( the non-relaxing cricopharynxgeus muscle, aka upper esophageal sphincter), dilates the esophagus over time. Certainly, many with R-CPD experience not only gurgling, but also chest pressure and even pain that may be from “stretching” of the esophagus.

What the Esophagus Can Look Like “Below A Burp”

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Baseline (1 of 3)

Mid-esophagus of a person with R-CPD who is now burping well after Botox injection into the cricopharyngeus muscle many months earlier. The esophagus remains somewhat open likely due to esophageal stretching from the years of being unable to burp and also a “coming burp.”

Pre-burp (2 of 3)

A split-second before a successful burp the esophagus dilates abruptly from baseline (photo 1) as the excess air briefly enlarges the esophagus. An audible burp occurs at this point.

Post-burp (3 of 3)

The burp having just happened, the esophagus collapses to partially closed as the air that was “inflating it” has been released.
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Additional R-CPD Resources

Dr. Bastian’s Published Articles


Dr. Bastian’s Initial Article about R-CPD

Inability to Belch and Associated Symptoms Due to Retrograde Cricopharyngeus Dysfunction: Diagnosis and Treatment

Read more →

March 15, 2019


Partial Cricopharyngeal Myotomy for Treatment of Retrograde Cricopharyngeal Dysfunction

Read more →

April 16, 2020


The Long-term Efficacy of Botulinum Toxin Injection to Treat Retrograde Cricopharyngeus Dysfunction

Read more →

June 29, 2020


Efficacy and Safety of Electromyography-Guided Injection of Botulinum Toxin to Treat Retrograde Cricopharyngeus Dysfunction

Read more →

February 2, 2021


Retrograde Cricopharyngeus Dysfunction: An Orphan Disease?

Read more →

September 2022

More R-CPD Videos

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R-CPD Webinar

A live R-CPD (no-burp) Webinar hosted by Dr. Bastian on July 26, 2022 at 6 p.m. CST

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Q&A—Part I

Dr. Bastian answers a list of questions submitted by our R-CPD Webinar attendees.

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Q&A—Part II

In Part 2 of the R-CPD Q&A, Dr. Bastian answers more questions submitted by our webinar attendees.

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R-CPD Panel

A panel of expert discussion on R-CPD (aka “No-Burp Syndrome”) featuring questions and answers from leaders in the field.

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What Surprises No-burpers about People who Can Burp

Here are a few things that surprise people who can’t burp, about people who can! (This is especially for those with R-CPD aka no-burp).
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RCPD Workup – Do You Need Testing for a Diagnosis?

What is necessary to diagnose R-CPD? What is sufficient? Do we need to spend thousands of dollars for x-rays, manometry, upper GI scopes, gastric emptying studies? 

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entrance to the esophagus

What to Expect After Botox Injection for R-CPD

Robert W. Bastian, M.D. — Published: January 26, 2023 Background of R-CPD R-CPD causes 4 primary symptoms: inability to belch, gurgling noises, bloating, and flatulence. Less universal symptoms include painful hiccups, nausea after large meals, shortness of breath when very

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