December 06, 2017
Clinical Gastroenterology and Hepatology
TAKE-HOME MESSAGE
Most belches in patients with gastroesophageal reflux disease (GERD) are supragastric and can induce episodes of reflux. The authors hypothesized that diaphragmatic breathing training could reduce supragastric belching and improve GERD symptoms in patients with proton pump inhibitor–refractory GERD.
Diaphragmatic breathing training reduced the belching visual analogue scale score by nearly 50%, significantly reduced belching frequency in 80%, significantly reduced symptoms of GERD, and improved quality-of-life scores.
Primary Care
Written by David Rakel MD, FAAFP
Diaphragmatic Breathing for Belching-Inducing GERD
Many things that we use PPIs for should not be treated with acid suppression therapy. One of these is excessive belching, which is produced by micro-spasms of the diaphragm, resulting in negative airway pressure and excessive air swallowing. The mechanism of belching can then cause disruption of the lower esophageal barrier, leading to reflux symptoms. To address the root of the problem, the wise clinician will improve diaphragm function so treating the reflux will not be necessary.
In this small study of 36 patients with excessive belching and PPI-refractory GERD, 15 were taught diaphragmatic breathing (DB) once weekly for 4 weeks vs a wait-list control. The wait-list control was also taught the DB after their waiting was complete. Out of the whole study group, 73% were able to come off their PPIs. Of the DB group, 80% had improvement in belching and GERD vs 19% in the wait-list control group. The benefits lasted 4 months after the intervention. This was a small study and needs to be replicated. But it is promoting an intervention that is low-cost, low-harm, and always available to the patient. It also helps us reduce the use of a medicine (PPI) that has growing concerns with long-term use.
How to Belly Breathe
While sitting in a chair or lying down, place one hand on the abdomen and one on the chest. Slowly inhale for a count of 3 to 4. With each inhalation, the belly hand should expand more than the chest hand. When the belly expands, the diaphragm is contracting, taking up more room and pushing the abdominal contents outward. This diaphragmatic contraction also stimulates the vagus nerve and the parasympathetic branch of the autonomic nervous system. Some imagine filling up a balloon located in the abdomen. Exhale for a count of 6 to 7. Exhalation is generally twice as long as inhalation. The autonomic nervous system is brought under balance with one in-and-out breath every 10 seconds, or 6 breaths per minute. During these breathing exercises, the mind should focus on one thing, such as the present moment, the in and out flow of the breath, or a calming word.
Encourage 30 belly breaths three times daily. With practice, the body starts to breathe like this normally.
Abstract
BACKGROUND & AIMS
In patients with gastroesophageal reflux disease (GERD) and excessive belching, most belches are supragastric, and can induce reflux episodes and worsen GERD. Supragastric belching (SGB) might be reduced with diaphragmatic breathing exercises. We investigated whether diaphragmatic breathing therapy is effective in reducing belching and proton pump inhibitor (PPI) refractory gastroesophageal reflux symptoms.
METHODS
We performed a prospective study of 36 consecutive patients with GERD refractory to PPI therapy and a belching visual analogue scale (VAS) score of 6 or more, seen at a gastroenterology clinic at a tertiary hospital in Singapore from April 2015 through October 2016. Patients underwent high-resolution manometry and 24 hr pH-impedance studies while they were off PPIs. Fifteen patients were placed on a standardized diaphragmatic breathing exercise protocol (treatment group) and completed questionnaires at baseline, after diaphragmatic breathing therapy, and 4 months after the therapy ended. Twenty-one patients were placed on a waitlist (controls), completed the same questionnaires with an additional questionnaire after their waitlist period, and eventually received diaphragmatic breathing therapy. The primary outcome was reduction in belching VAS by 50% or more after treatment. Secondary outcomes included GERD symptoms (evaluated using the reflux disease questionnaire) and quality of life (QoL) scores, determined from the reflux qual short-form and EuroQoL-VAS (EQ-VAS).
RESULTS
Nine of the 15 patients in the treatment group (60%) and none of the 21 controls achieved the primary outcome (P<.001). In the treatment group, the mean belching VAS score decreased from 7.1 ± 1.5 at baseline to 3.5 ± 2.0 after diaphragmatic breathing therapy; in the control group, the mean VAS score was 7.6 ± 1.1 at baseline and 7.4 ± 1.3 after the waitlist period. Eighty percent of patients in the treatment group significantly reduced belching frequency compared to 19% in controls (P=.001). Treatment significantly reduced symptoms of GERD (the mean reflux disease questionnaire score increased by 12.2 in the treatment group and 3.1 in the control group; P=.01). The treatment significantly increased QoL scores (the mean reflux qual short-form score increased by 15.4 in the treatment group and 5.2 in the control group, P=0.04) and mean EQ-VAS scores (15.7 increase in treatment group and 2.4 decrease in the control group). These changes were sustained at 4 months after treatment. In the end, 20 of the 36 patients who received diaphragmatic breathing therapy (55.6%), all with excessive SGB, achieved the primary outcome.
CONCLUSION
In a prospective study, we found a standardized protocol for diaphragmatic breathing to reduce belching and PPI-refractory gastroesophageal reflux symptoms, and increase QoL in patients with PPI-refractory GERD with belching-especially those with excessive SGB.
Copyright © 2017 Elsevier Inc. All rights reserved.