Document Type : Research articles


1 Department of Physiotherapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

2 Tehran University of Medical Sciences, Tehran, Iran

3 Department of Biostatistics and Computer, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran


Background: Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal disorders that can disturb pa- tients respiratory indices. Proton pump inhibitors (PPIs) such as omeprazole are currently the most common treatment in the patients. PPI-refractory GERD is a clinical problem constituting around 30% of patients with GERD.
Objectives: The aim of this study was to investigate the effects of diaphragmatic breathing (DB) and omeprazole on respiratory indices (RI) and diaphragmatic excursion (DEX) in patients with GERD.
Methods: This is a clinical trial conducted for eight weeks among 40 patients with severe GERD in Tehran in 2018. The block ran- domization method was designed to randomize 40 patients into two groups (DB and control) that resulted in equal sample sizes. The control group received omeprazole 20 mg once daily, and the DB group, in addition to omeprazole, performed DB. Respiratory indices, including (Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 second (FEV1), Peak Expiratory Flow (PEF)), and DEX were evaluated before, immediately, and six weeks after the end of intervention by spirometry and ultrasonography; respectively. Results: There was no significant difference in the RI and DEX before the intervention between groups. FVC (P = 0.04) and PEF (P = 0.02) significantly changed in the control group, but FEV1 (P = 0.001), FVC (P = 0.002), PEF (P = 0.001) and DEX (0.001) significantly changed after DB. There was a significant difference in terms of RI between before and followed up in DB.
Conclusions: Diaphragmatic breathing with omeprazole had more effects on RI and DEX than omeprazole alone. The positive effects of DB remain at least six weeks after the end of the intervention


  1. Ness-Jensen E, Hveem K, El-Serag H, Lagergren J. Lifestyle intervention in gastroesophageal reflux disease. Clinical gastroenterology and hepatology. 2016;14(2):175-182. e3.
  2. Bisaccioni C, Aun MV, Cajuela E, Kalil J, Agondi RC, Giavina-Bianchi P. Comorbidities in severe asthma: frequency of rhinitis, nasal polyposis, gastroesophageal reflux disease, vocal cord dysfunction and bronchiectasis. Clinics. 2009;64(8):769-73.
  3. Nemzek JA, Kim J. Pulmonary inflammation and airway hyperresponsiveness in a mouse model of asthma complicated by acid aspiration. Comp Med. 2009;59(4):321-30. [PubMed: 19712571]. [PubMed Central: PMC2779206].
  4. Cuttitta G, Cibella F, Visconti A, Scichilone N, Bellia V, Bonsignore G. Spontaneous gastroesophageal reflux and airway patency during the night in adult asthmatics. American journal of respiratory and critical care medicine. 2000;161(1):177-81.
  5. Kanda S, Fujimoto K, Komatsu Y, Yasuo M, Hanaoka M, Kubo K. Evaluation of respiratory impedance in asthma and COPD by an impulse oscillation system. Internal Medicine. 2010;49(1):23-30.
  6. Nielsen R, Johannessen A, Benediktsdottir B, Gislason T, Buist AS, Gulsvik A, et al. Present and future costs of COPD in Iceland and Norway: results from the BOLD study. Eur Respir J. 2009;34(4):850-7. doi: 10.1183/09031936.00166108. [PubMed: 19357148]. [PubMed Central: PMC3334277].
  7. Matyasova Z, Novotna B, Matulova M, Dolina J, Kroupa R, Lanikova Z, et al. The relation of GERD, bronchial asthma and the upper respiratory tract. Vnitrni lekarstvi. 2005;51(12):1341-50.
  8. Katz PO, Castell DO, Chen Y, Andersson T, Sostek MB. Intragastric acid suppression and pharmacokinetics of twice‐daily esomeprazole: a randomized, three‐way crossover study. Alimentary pharmacology & therapeutics. 2004;20(4):399-406.
  9. Ong AM, Chua LT, Khor CJ, Asokkumar R, Wang Y. Diaphragmatic breathing reduces belching and proton pump inhibitor refractory gastroesophageal reflux symptoms. Clinical Gastroenterology and Hepatology. 2018;16(3):407-416. e2.
  10. Sarwal A, Walker FO, Cartwright MS. Neuromuscular ultrasound for evaluation of the diaphragm. Muscle Nerve. 2013;47(3):319-29. doi: 10.1002/mus.23671. [PubMed: 23382111]. [PubMed Central: PMC3581727].
  11. Kassem MM, Wallen JM. Esophageal Perforation, Rupture, And Tears. Treasure Island (FL): StatPearls Publishing; 2019.
  12. Kahrilas PJ. Medical management of gastroesophageal reflux disease in adults. UpToDate. 2013.
  13. Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, et al. Standardisation of spirometry. Eur Respir J. 2005;26(2):319-38. doi: 10.1183/09031936.05.00034805. [PubMed: 16055882].
  14. Moore VC. Spirometry: step by step. Breathe. 2012;8(3):232-40.
  15. Cohen E, Mier A, Heywood P, Murphy K, Boultbee J, Guz A. Excursion-volume relation of the right hemidiaphragm measured by ultrasonography and respiratory airflow measurements. Thorax. 1994;49(9):885-9.
  16. Lee AL, Goldstein RS. Gastroesophageal reflux disease in COPD: links and risks. International journal of chronic obstructive pulmonary disease. 2015;10:1935.
  17. Özdemir P, Erdinç M, Vardar R, Veral A, Akyıldız S, Özdemir Ö, et al. The role of microaspiration in the pathogenesis of gastroesophageal reflux-related chronic cough. Journal of neurogastroenterology and motility. 2017;23(1):41.
  18. Akyüz F, Mutluay Soyer Ö. Which diseases are risk factors for developing gastroesophageal reflux disease. Turk J Gastroenterol. 2017;28(Suppl 1):S44-7.
  19. Sweet MP, Patti MG, Hoopes C, Hays SR, Golden JA. Gastro-oesophageal reflux and aspiration in patients with advanced lung disease. Thorax. 2009;64(2):167-73. doi: 10.1136/thx.2007.082719.
  20. Harding SM, Guzzo MR, Schan CA, Alexander RW, Bradley LA, et al. Asthma and gastroesophageal reflux: Acidsuppressive therapy improves asthma outcome. Am J Med. 1996;(100):395-405.
  21. Giannikoulis C, Karkoulias K, Thomopoulos K, Marangos M, Spiropoulos K, Nikolopoulou V. Patients with gastroesophageal reflux disease and respiratory manifestations do not present lung function disorders during cardiopulmonary exercise test. Dis Esophagus. 2011;24(3):189-93. doi: 10.1111/j.1442-2050.2010.01109.x. [PubMed: 21040148].
  22. Takeuchi T, Oota K, Harada S, Edogawa S, Kojima Y, Sanomura M, et al. Characteristics of refractory gastroesophageal reflux disease (GERD) symptoms -is switching proton pump inhibitors based on the patient's CYP2C19 genotype an effective management strategy? Intern Med. 2015;54(2):97-105. doi: 10.2169/internalmedicine.54.3412. [PubMed: 25742999].
  23. Sakurai K, Suda H, Fujie S, Takeichi T, Okuda A, Murao T, et al. Short-Term Symptomatic Relief in Gastroesophageal Reflux Disease: A Comparative Study of Esomeprazole and Vonoprazan. Dig Dis Sci. 2019;64(3):815-22. doi: 10.1007/s10620-018-5365-0. [PubMed: 30415407]. [PubMed Central: PMC6440932].
  24. Sandur V, Murugesh M, Banait V, Rathi P, Bhatia S, Joshi J, et al. Prevalence of gastro-esophageal reflux disease in patients with difficult to control asthma and effect of proton pump inhibitor therapy on asthma symptoms, reflux symptoms, pulmonary function and requirement for asthma medications. Journal of Postgraduate Medicine. 2014;60(3):282-6. doi: 10.4103/0022-3859.138754.
  25. Ford GA, Prior JS, Butland RJ, Wilkinson SP. Omeprazole in the treatment of asthmatics with nocturnal symptoms and gastro-oesophageal reflux: A placebo-controlled cross-over study. Postgrad Med J. 1994;(70):350-4.
  26. Tahir AH, George RB, Weill H, Adriani J. Effects of abdominal surgery upon diaphragmatic function and regional ventilation. International surgery. 1973;58(5):337.
  27. Alaparthi GK, Augustine AJ, Anand R, Mahale A. Comparison of diaphragmatic breathing exercise, volume and flow incentive spirometry, on diaphragm excursion and pulmonary function in patients undergoing laparoscopic surgery: a randomized controlled trial. Minimally invasive surgery. 2016;2016.
  28. Manzano RM, Carvalho CRFD, Saraiva-Romanholo BM, Vieira JE. Chest physiotherapy during immediate postoperative period among patients undergoing upper abdominal surgery: randomized clinical trial. Sao Paulo Medical Journal. 2008;126(5):269-73.
  29. Eherer AJ, Netolitzky F, Hogenauer C, Puschnig G, Hinterleitner TA, Scheidl S, et al. Positive effect of abdominal breathing exercise on gastroesophageal reflux disease: a randomized, controlled study. Am J Gastroenterol. 2012;107(3):372-8. doi: 10.1038/ajg.2011.420. [PubMed: 22146488].
  30. Chitkara DK, Van Tilburg M, Whitehead WE, Talley NJ. Teaching diaphragmatic breathing for rumination syndrome. The American journal of gastroenterology. 2006;101(11):2449.
  31. Halland M, Parthasarathy G, Bharucha AE, Katzka DA. Diaphragmatic breathing for rumination syndrome: efficacy and mechanisms of action. Neurogastroenterology & Motility. 2016;28(3):384-91.
  32. Roman S, Mion F. Refractory GERD, beyond proton pump inhibitors. Curr Opin Pharmacol. 2018;43:99-103. doi: 10.1016/j.coph.2018.09.001. [PubMed: 30240968].