COMMENTARY

Simple, Free Breathing Technique Reduces GERD-Related Belching

David A. Johnson, MD

Disclosures

December 22, 2017

Common but Overlooked Symptom

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

A proton pump inhibitor (PPI) is an extremely effective treatment in most of our patients with gastroesophageal reflux disease (GERD). However, there's a sizeable minority of people with GERD or associated symptoms who are deemed PPI resistant.

Belching, although not considered a traditional symptom like heartburn and regurgitation, is very common in patients with GERD. It may actually be the predominant symptom, reportedly occurring in 40%-50% of patients with reflux symptoms.[1]

Belching was previously ascribed to air swallowing, which we now know is really not the case. In particular, reflux-related belching is due to a supragastric belch. This occurs when there's an involuntary contraction of the diaphragm, a negative intrathoracic pressure, air rushes into the esophagus, and there's then an expulsion that results in the belch.

Patients receiving a PPI for GERD may have supragastric belches associated with their condition; however, their medication doesn't really address this but instead deals with acid. This may explain why many of these patients still have refractory symptoms.

Promising New Data

There was a very interesting study from Singapore that I discussed briefly in an earlier presentation on highlights from Digestive Disease Week 2017. This has now been published in a final manuscript,[2] whose online version includes a video of the protocol they used. I would encourage you to view this, as I believe it has some take-home value.

The authors studied diaphragmatic breathing as a treatment in 36 patients with GERD who were PPI refractory and had supragastric belching as a primary symptom. All patients underwent 24-hour impedance-pH monitoring while off PPIs. Patients had a median frequency of 46 belches per 24 hours, so it was a considerable amount of belching. Researchers [placed] 15 patients into the [treatment group], where they met with a therapist trained in teaching diaphragmatic breathing. The remaining 21 patients were placed on a waitlist, which served as the control group. Patients were followed for 4 months.

The primary outcome of a 50% reduction in belching was seen, as early as 1 month and persisting for 4 months, in 60% of the patients who had the active diaphragmatic breathing exercise and in none of the control population. The endpoint of "any reduction in belching" was noted in 80% of the diaphragmatic breathing population and in around 20% of the controls. This represents another highly significant reduction in belching.

Beyond the primary endpoint of belching, the authors also looked at GERD symptoms using a validated reflux disease questionnaire. This also showed significant improvement in the diaphragmatic breathing group. However, dissecting this out for the domain of benefit for diaphragmatic breathing particularly was all with regurgitation and not with heartburn. Clearly, acid-suppressive therapies do not do as well with predominant regurgitation response.

A Successful Treatment That's Also Free

This study shows that diaphragmatic breathing was effective early, at 1 month, but its effect was also persistent and durable, with no attenuation over time.

Why does it work? We're not quite sure whether diaphragmatic breathing changes the crural diaphragm through relaxation. Potentially, this technique may relax the patient better, although the demographics between the two study groups were well balanced for anxiety, depression, and all of those other things that may comitigate toward why patients may be more anxious. We don't know exactly why this works, but it does work.

Diaphragmatic breathing is something that's very simple and seems to be very effective. I have found this particularly effective in patients with rumination. I am now going to expand it to the patients with belching, in particular the patients with GERD who are PPI refractory. I found it very successful, though not quite as successful as the data reported here today, in the refractory hiccup (singultus) patients. I've found that patients who have experience with yoga will latch onto this immediately and that they understand this.

To show you how it's done. I invite you to go back and look at a Computer Consult I did on diaphragmatic breathing. It's very simple. You tell patients to put their hand on their chest and take a deep breath; the chest wall rises. Then, I ask them to keep their hand on their chest and put the other on their abdomen. The hand [on their chest] shouldn't rise as they take a deep breath; instead, they're taking a deep breath and are belly breathing. Their abdomen is expanding. They breathe out slowly to promote relaxation, again with the hand not moving on their chest but moving on their abdomen. I offer repetitive training on this.

Think about it for your patients with PPI-refractory belching. Learn the technique. It's simple, easy, and effective, and you don't have to spend time negotiating this with an insurance company—the best of all aspects. Try it and learn about it, because it works.

I'm Dr David Johnson. Thanks again for listening.

Suggested Reading

Chitkara DK, Van Tilburg M, Whitehead WE, Talley NJ. Teaching diaphragmatic breathing for rumination syndrome. Am J Gastroenterol. 2006;101:2449-2452.

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