Inspiratory muscle training improves antireflux barrier in GERD patients

Abstract

Nobre e Souza MÂ, Lima MJ, Martins GB, Nobre RA, Souza MH, de Oliveira RB, dos Santos AA. Inspiratory muscle training improves antireflux barrier in GERD patients. Am J Physiol Gastrointest Liver Physiol 305: G862-G867, 2013. First published October 10, 2013 doi:10.1152/ajpgi.00054.2013.-The crural diaphragm (CD) is an essential component of the esophagogastric junction (EGJ), and inspiratory exercises may modify its function. This study's goal is to verify if inspiratory muscle training (IMT) improves EGJ motility and gastroesophageal reflux (GER). Twelve GER disease [GERD; 7 males, 20 -47 yr, 9 esophagitis, and 3 nonerosive reflex disease (NERD)] and 7 healthy volunteers (3 males, 20 -41 yr) performed esophageal pH monitoring, manometry, and heart rate variability (HRV) studies. A 6-cm sleeve catheter measured average EGJ pressure during resting, peak inspiratory EGJ pressures during sinus arrhythmia maneuver (SAM) and inhalations under 17-, 35-, and 70-cmH2O loads (TH maneuvers), and along 1 h after a meal. GERD patients entered a 5-days-a-week IMT program. One author scored heartburn and regurgitation before and after IMT. IMT increased average EGJ pressure (19.7 Ϯ 2.4 vs. 29.5 Ϯ 2.1 mmHg; P Ͻ 0.001) and inspiratory EGJ pressure during SAM (89.6 Ϯ 7.6 vs. 125.6 Ϯ 13.3 mmHg; P ϭ 0.001) and during TH maneuvers. The EGJ-pressure gain across 35-and 70-cmH2O loads was lower for GERD volunteers. The number and cumulative duration of the transient lower esophageal sphincter relaxations decreased after IMT. Proximal progression of GER decreased after IMT but not the distal acid exposure. Low-frequency power increased after IMT and the higher its increment the lower the increment of supine acid exposure. IMT decreased heartburn and regurgitation scores. In conclusion, IMT improved EGJ pressure, reduced GER proximal progression, and reduced GERD symptoms. Some GERD patients have a CD failure, and IMT may prove beneficial as a GERD add-on treatment. crural diaphragm; GERD; lower esophageal sphincter; muscle training

The Chicago Classification of esophageal motility disorders, v3.0

“…The emphasis on inspiratory as opposed to expiratory EGJ pressure is also supported by preliminary work with 3D‐HRM, demonstrating that the hiatus and CD dominate over the intrinsic LES in defining EGJ barrier function . Preliminary data utilizing inspiratory muscle training as an effective therapeutic intervention in GERD also support this contention …”

Anatomical and functional deficiencies of the crural diaphragm in patients with esophagitis

“…We recently showed that esophagitis patients failed to achieve a high EGJ pressure during inspiratory maneuvers by conventional manometry. Furthermore, EGJ pressures and GERD symptoms improved after inspiratory muscle training . Two other groups have showed that respiratory exercises may improve GERD .…”

“…Firstly, without airflow resistance, the volunteers carried out six cycles of 5‐second deep inhalation and 5‐second exhalation (sinus arrhythmia maneuver [SAM]). Secondly, with airflow resistance, they did a fast and forced inhalation through a device that incorporated a flow‐independent one‐way spring‐loaded valve that provided an adjustable airflow resistance (Threshold IMT; Philips Respironics, Andover, MA, USA) . Each subject trained the maneuvers during few minutes before the study and accomplished inhalations under increasing, resistance loads of 12‐, 24‐, and 48‐cmH 2 O (threshold maneuver [TH]).…”

Diaphragmatic breathing for rumination syndrome: efficacy and mechanisms of action

“…Other studies have demonstrated the beneficial effects of DB on esophageal functions. Thus, DB decreased swings in the gastroesophageal pressure gradient when compared to rib breathing, and reduced reflux in patients with upright gastroesophageal reflux disease while inspiratory muscle training significantly increased EGJ pressure …”