Understanding Gastroesophageal reflux disease (GERD) and breathing exercises to help GERD

Gastroesophageal reflux disease(GERD), also known as acid reflux, is a long term digestive disorder in which stomach contents rise into the esophagus leading to inflammation or irritation. The esophagus is a tube that connects the throat to the stomach. Gastroesophageal refers to the stomach and esophagus. Common symptoms of GERD include heartburn(burning pain caused by stimulation of nerve fibers in the esophagus), bad breath, chest pain, acid regurgitation, cavities, and breathing problems. Risk factors of this condition are smoking, obesity, pregnancy, hiatal hernia, stress, and certain medications. Normally, the lower esophageal sphincter prevents acid reflux. However, when a person has GERD, the sphincter muscle becomes weak and fails to contract tightly, allowing stomach acid to back up into the esophagus. (1)

The regurgitated liquid contains acid and pepsin that are produced by the stomach. Acid is known to be the most injurious component of the refluxed liquid. The acid can inflame and damage the lining of the esophagus. Gerd can limit daily activities, but it’s rarely life-threatening. The most effective treatment for GERD is lifestyle modification, diet, over the counter and prescription drugs. GERD if not taken seriously, lead to many complications which include:

  • Cough and asthma
  • Barret’s esophagus
  • Esophagitis
  • Throat and laryngeal inflammation
  • Strictures of the esophagus 

Pulmonary manifestations of GERD

Pulmonary manifestations are considered as a complication of GERD. It is seen that a significant number of patients with asthma or chronic cough have gastroesophageal reflux as a trigger. Even without lung problems, GERD can cause difficulty breathing and shortness of breath. GERD can cause several pulmonary manifestations, such as asthma, chronic cough, bronchitis, pneumonia, and interstitial fibrosis. Chronic cough and asthma are the most common manifestations. (2)

Cough and asthma

Many nerves in the esophagus get stimulated as a result of acid regurgitation, provoking heartburn and coughing. Esophageal acids stimulate vagally mediated tracheobronchial responses, and this ultimately increases the bronchial hyperresponsiveness to other stimuli contributing to exacerbation of cough and asthma. Esophageal acid also stimulates vagus nerve endings, causing bronchoconstriction and leading to bronchial asthma. 

Breathing exercise to help GERD

What if solace from GERD was as simple as taking a few deep breaths?

Many people who have GERD had belching as a primary symptom. Belching, gas, and bloating can be embarrassing and uncomfortable. Usually, it is supra gastric belching, which means air is sucked into the esophagus and then rapidly expelled through the mouth. Many patients use proton pump inhibitors(PPIs) for symptom relief. Although PPIs have had an encouraging safety profile, their long term use has been associated with an increased risk of certain health issues. Many patients are suffering from PPI refractory GERD. There are other ways of treating the symptoms and that includes breathing exercises. It is researched, if you have mild GERD symptoms, breathing can play a phenomenal role in your overall treatment plan. Breathing techniques strengthen the diaphragm, and overtime decreases the acid reflux. 

The connection between breathing and acid reflux is very simple. In people with GERD, the LES fails to function as a barrier between the stomach and the esophagus, preventing acid reflux. Breathing exercises strengthen the diaphragm ( a major respiratory muscle that surrounds the lower esophagus) and can help support the weekend lower esophageal sphincter(LES). LES is an involuntary muscle and can not be exercised directly. However, the diaphragm that surrounds the LES is a voluntary muscle and can be exercised. (3)

Deep breathing or belly breathing

Strengthening the diaphragm through exercise does lessen the acid reflux. All it takes is a comfortable place to sit, and some focus and consistency. This technique focuses on the use of diaphragm muscle to breathe rather than the chest muscles. When the diaphragm is used for breathing through this technique, it becomes stronger and assists the LES do its job. Diaphragmatic breathing is an excellent tool for relaxation and relieving of GERD symptoms, but it requires practice. Here’s how to do it: (4)

  • Get into a comfortable position with your back straight.
  • Breathe in through the nose. Inhale slowly and deeply by counting to four as you hold the breath. 
  • Exhale all of the air through your mouth. 
  • Place one hand on your stomach and the other on your chest. As you breathe in and out, feel the rise and fall of breathing more in the belly than in the chest. You have to make the hand that rests over the stomach move more than the one on the chest. 
  • Take three more slow and deep breaths. 

Benefits of diaphragmatic breathing

  • Reduces symptoms of GERD
  • Reduces belching
  • Activates the relaxation response, or “rest and digest” state. 
  • Strengthens the diaphragm
  • Improves stability in core muscles
  • Lowers heart rate and blood pressure
  • Reduces stress and improves concentration 

Lifestyle changes and breathing guidelines for GERD

  • Quit smoking and alcoholism
  • Eat small meals throughout the day 
  • Stay upright after eating
  • Drink more water
  • Sleep with your head and shoulders popped up
  • Avoid lying down for at least 3 hours after a meal
  • Breathe more slowly and deeply
  • Regular exercise
  • Learn diaphragmatic breathing exercise

Breathing exercises are not something that would work immediately. It all takes time and effort with a healthy routine and lifestyle modification as prescribed by the healthcare provider. 

REFERENCES:

  1. Malfertheiner P, Hallerbäck B. Clinical manifestations and complications of gastroesophageal reflux disease (GERD). International journal of clinical practice. 2005 Mar;59(3):346-55.
  2. Gaude GS. Pulmonary manifestations of gastroesophageal reflux disease. Annals of Thoracic Medicine. 2009 Jul;4(3):115.
  3. Casale M, Sabatino L, Moffa A, Capuano F, Luccarelli V, Vitali M, Ribolsi M, Cicala M, Salvinelli F. Breathing training on lower esophageal sphincter as a complementary treatment of gastroesophageal reflux disease (GERD): a systematic review. Eur Rev Med Pharmacol Sci. 2016 Nov 1;20(21):4547-52.
  4. Ong AM, Chua LT, Khor CJ, Asokkumar R, Wang YT. Diaphragmatic breathing reduces belching and proton pump inhibitor refractory gastroesophageal reflux symptoms. Clinical Gastroenterology and Hepatology. 2018 Mar 1;16(3):407-16.