Ong AML, et al. - This study was performed to examine whether diaphragmatic breathing therapy was effective in reducing belching and proton pump inhibitor (PPI) refractory gastroesophageal reflux symptoms. The researchers found a standardized protocol for diaphragmatic breathing to reduce belching and PPI-refractory gastroesophageal reflux symptoms and increased quality of life (QoL) among patients with PPI-refractory gastroesophageal reflux disease (GERD) with belching, particularly those with excessive supragastric belching (SGB).

• From April 2015 through October 2016, the researchers 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.
• While patients were off PPIs, high-resolution manometry and 24 hr pH-impedance studies were performed.
• They placed 15 patients 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 (controls) who completed the same questionnaires with an additional questionnaire after their waitlist period eventually received diaphragmatic breathing therapy.
• Reduction in belching VAS by 50% or more after treatment was the primary outcome.
• 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) were included as secondary outcomes.

• In the treatment group, 9 of the 15 patients (60%) and none of the 21 controls achieved the primary outcome (P < .001).
• The mean belching VAS score decreased from 7.1 ± 1.5 at baseline to 3.5 ± 2.0 after diaphragmatic breathing therapy in the treatment group.
• The mean VAS score was 7.6 ± 1.1 at baseline and 7.4 ± 1.3 after the waitlist period in the control group.
• In the treatment group, 80% of patients 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).
• At 4 months after treatment, these changes were sustained.
• Twenty of the 36 patients who received diaphragmatic breathing therapy (55.6%), all with excessive SGB, achieved the primary outcome in the end.