EFFECTIVENESS OF PURSED LIPS BREATHING EXERCISE AND

DIAPHRAGMATIC BREATHING EXERCISE AMONG ASTHMATICS -

A COMPARATIVE STUDY

L.ANAND.M.Sc(N)

LECTURER,COLLEGE OF NURSING,

NEIGRIHMS,SHILLONG

INTRODUCTION

Asthma is one of the most common chronic diseases in the world. It is estimated that asthma accounts for about 1 in every 250 deaths worldwide.

Mortality is not only issue when considering the impact of chronic lung disease, morbidity is an even greater issue. Patients with chronic lung disease suffer from reduced functional capacity, mainly from exertional dyspnoea, and accordingly this leads to decrease a quality of life.

Although respiratory rehabilitation has been shown to be beneficial in improving health related quality of life, reducing dyspnoea and length of hospitalization, the contribution of the components of the rehabilitation programs has been less well defined.

Breathing exercises have been taught for hundreds of years in both Eastern and Western societies for numerous conditions including asthma. But the profound role of breathing exercises is not sufficiently acknowledged as a therapeutic option.

INTRODUCTION

NEED FOR THE STUDY

Since from the inception, the effectiveness of breathing exercises in improving lung function and breathing pattern is controversial.

Despite many studies on the topic, the role of breathing exercises such as pursed lips breathing (PLB) and diaphragmatic breathing (DB) in the rehabilitation of people with asthma and COPD remains unclear.

NEED FOR THE STUDY

• Researchers often examine a combination of retraining techniques, which makes it impossible to attribute outcomes to any single technique.

• Hence, it is aimed to determine the effectiveness of PLB and DB as a sole intervention and to compare the effectiveness of these interventions.

OBJECTIVES

To assess the perceived severity of dyspnoea, degree of airway obstruction as determined by PEFR (% Pred.), and RR of the selected asthma patients.

To determine the effectiveness of PLBE and DBE.

To compare the effectiveness of the PLBE and DBE.

HYPOTHESES

H1 - The mean of difference in the modified Borg dyspnoea score of the experimental group-1 will be higher than the mean of difference of the control group.

H2 - The mean of difference in the PEFR (% Pred.) value of the experimental group-1 will be higher than the mean of difference of the control group.

H3 - The mean of difference in the RR of the experimental group-1 will be higher than the mean of difference of the control group.

HYPOTHESES

H4 - The mean of difference in the modified Borg dyspnoea score will be higher than the mean of difference of the control group.

H5 - The mean of difference in the PEFR (% Pred.) value of the experimental group-2 will be higher than the mean of difference of the control group.

H6 - The mean of difference in the RR of the experimental group-2 will be higher than the mean of difference of the control group.

HYPOTHESES

H7 - The mean of difference in the modified Borg dyspnoea score of experimental group-1 will be different from experimental group-2

H8 - The mean of difference in the PEFR (% Pred.) value of the experimental group-1 will be different from the experimental group-2

H9 - The mean of difference in the RR of the

experimental group-1 will be different from the experimental group-2.

OPERATIONAL DEFINITIONS

Effectiveness It refers to determining the extent to which breathing exercise intervention has achieved the desired result intended, and is measured in terms of significant gain in the post test.

Pursed Lips Breathing It refers to inhaling through the nose with mouth closed, taking normal breath and exhaling through mouth slowly, with lips pursed.

OPERATIONAL DEFINITIONS

Diaphragmatic Breathing

It refers to inhaling slowly and deeply through the nose, letting the abdomen protrude as far as it will and breath out slowly through the slightly opened mouth, while tightening the abdominal muscles.

Peak Expiratory Flow Rate

It is the maximum amount of air expelled forcefully into the mouth piece of a peak flow meter. It is measured in litres/min.

Modified Borg Score It refers to a 10 point category with extremes of ‘nothing at all’ and ‘maximal’. It is used to measure the intensity of dyspnoea sensation perceived by asthmatic subjects. It includes verbal descriptors (e.g “slight” , “severe”) to assist in rating the symptom of dyspnoea.

Respiratory Rate It refers to number of breaths (both inspiration and expiration) per minute. It is assessed by observing and palpating the abdominal movements and thoracic movements while breathing.

OPERATIONAL DEFINITIONS

CONCEPTUAL FRAMEWORK

The conceptual framework for this study was based on Dorothea E.Orem’s self – care theory.

A prospective, quasi-experimental pre test, post test design with two treatment groups and a control group.

RESEARCH DESIGN

RESEARCH DESIGN

GroupMeasurement of

dependent variables

Manipulation of independent variables

Measurement of dependent variables

Control group Pre test

No specific Intervention

Post Test

Experimental Group – 1

Pre test

PLBE Post Test

Experimental Group – 2

Pre test

DBE Post Test

POPULATIONBronchial Asthma Patients.

SAMPLING DESIGN

Convenience sampling.

SAMPLING TECHNIQUE

Cluster randomization technique

CRITERIA FOR SAMPLE SELECTION

Inclusion Criteria

1. Diagnosed and known asthmatic patients on regular allopathic treatment.

2. Age between 20 – 70 years.

3. Available for 10 days from the onset of intervention.

4. Non-smokers (Patients who were not having history of smoking atleast for the 30 days)

Exclusion Criteria

– Acute breathing difficulty and acute asthma.

– Asthmatic patients associated with generalized edema.andCardiac Asthma.

– Recent abdominal surgeries.

– Status Asthmaticus

– Those who is performing regular breathing exercise or yoga.

– Those who participated in the pulmonary rehabilitation program within 6 months.

– Those who is taking alternative medicines like Siddha, Unani, Ayurveda etc.

DESCRIPTION OF THE DATA COLLECTION INSTRUMENT

The data collection tool consisted of four sections

Section A

Demographic data.

Section B

Clinical and treatment data.

SECTION – C

Modified Borg dyspnoea category scale. It was a 10 point category scale with extremes of ‘nothing at all’ and maximal. It has good reproducibility and reliability.

DESCRIPTION OF THE DATA COLLECTION INSTRUMENT

Section – DIt consists of PEFR (% Pred.).

It is measured by peak expiratory flow meter. It is recorded in litre/min. PEFR (% Pred.) is converted into % of predicted value by the following formula.

PEFR (% Pred.) = Patient’s Best Value

Predicted Value (i,.e. Normal value of particular

individual)

This section also consists of RR.

Section E

It consists of observation check list to monitor the skill of the participant while performing the intervention.

VALIDITY

Content validity of the intervention and tool was obtained from the experts belonging to various fields.

SAMPLE SIZE DETERMINATION AND POWER ANALYSIS

Power analysis was done to solve for the sample size needed in a study to increase the likelihood of demonstrating significant results and to determine the power of a statistical test. The power of the study was fixed at 80%, the sample size was estimated as 21 for each group.

DATA COLLECTION PROCEDURE

The data were collected for the entire study from 15.12.04 to 31.01.05. The entire data collection procedure was done between 8.00 A.M. to 11.30 A.M and four hours after the bronchodilator therapy or anti asthmatic therapy.

Then the subject was asked to describe his perceived severity of dyspnoea by using modified Borg scale ranges from 0 to 10.

DATA COLLECTION PROCEDURE

After assessing dyspnoea score, PEFR (% Pred.) was measured by using Pulmono peak flow meter (Fyne Dynamics Ltd, England Design No. 21000423) ranges from 60 to 800 litres / minute (Wright’s Scale).

It was measured three times with an intervals of two minutes. The best measure was recorded.

DATA COLLECTION PROCEDURE

After 5 minutes of rest, participant was asked to assume semi-lying position. RR was measured for one minute.

It was measured for three times with the interval of one minute. Stop watch was used to count the time interval. The highest score was recorded.

All the data were collected and recorded only by the same researcher.

DESCRIPTION OF THE INTERVENTIONS

During the first contact, after the pre test the participants of the experimental group -1 received individualized training and instruction of PLBE from the researcher.

The experimental group – 2 participants received the DBE training and instruction.

Then the participants were asked to perform and practice the exercise for 30 minutes, 2 times/day, for ten days.

DESCRIPTION OF THE INTERVENTIONS

Observation checklist was used.

Self instruction manual and diary were supplied.

During O.P.D visits, supervised training was given and mastery level was recorded. Diary was reviewed.

A standard and uniform verbal encouragement was given to participants belonging to all three groups, to appear for the post test.

The medical officer, physicians, staff nurses, and other health care professionals were requested not to give any specific type of health education or training regarding breathing exercises, physical exercises, and yoga.

ATTRITION

Five of the 63 participants withdrew from the study :(three from the control group and two from the experimental group – 2). Thus, 58 participant’s data were included for analysis.

DATA ANALYSIS

The Analysis of Variance (ANOVA), Analysis of Co-variance (ANOVA) and post hoc Scheffe multiple comparison tests were used to test the hypotheses.

The level of significance was fixed at 0.005 for accepting or rejecting the hypothesis.

DISTRIBUTION OF PARTICIPANTS ACCORDING TO SEX IN THE EXPERIMENTAL GROUP – 1, EXPERIMENTAL GROUP – 2, AND

CONTROL GROUP

8

13

7

12

6

12

0

2

4

6

8

10

12

14

Experimental Group - 1 Experimental Group - 2 Control Group

Male

Female

DISTRIBUTION OF PARTICIPANTS ACCORDING TO THEIR PLACE OF RESIDENCE IN THE EXPERIMENTAL GROUP – 1,

EXPERIMENTAL GROUP – 2, AND CONTROL GROUP

10

11

10

9 9 9

0

2

4

6

8

10

12

Experimental Group - 1 Experimental Group - 2 Control Group

Urban

Rural

MEAN AND STANDARD DEVIATION OF THE AGE OF THE PARTICIPANTS IN THE EXPERIMENTAL GROUP – 1, EXPERIMENTAL GROUP – 2, AND CONTROL GROUP

46.38

13.84

44.05

14.42

42.94

12.78

0

5

10

15

20

25

30

35

40

45

50

Experimental Group -1

Experimental Group -2

Control Group

Mean

SD

MEAN, STANDARD DEVIATION AND TEST OF DIFFERENCES OF THE MODIFIED BORG SCORE

Group

Pre test Post test Mean of difference

Estimated Post test Score

ANCOVA

Mean S.D. Mean S.D. Mean S.D. ‘F’ value ‘P’ value

Exp. Group – 1N = 21

7.24 0.15 3.86 0.85 3.38 0.8 3.71

47.72 0.001Exp. Group – 2 N = 19 7.32 0.20 4.79 0.92 2.53 0.7 4.59

Control Group N = 18

6.33 0.29 5.72 0.89 0.72 0.96 6.09

ANOVA

‘F’ value 6.098 21.434 Adjusted R2 = 0.400

‘P’ value 0.004 0.001

Post hoc Scheffe Test E1 E2 C E1 E2 C

MEAN, STANDARD DEVIATION AND TEST OF DIFFERENCES OF THE PEAK EXPIRATORY

FLOW RATE [PEFR (% Pred.)]

GroupPre test Post test

Mean of difference Estimated

Post test Score

ANCOVA

Mean S.D. Mean S.D. Mean S.D. ‘F’ value ‘P’ value

Exp. Group – 1

N = 2151.32 5.25 59.29 5.73 7.99 2.5 57.98

30.09 0.001Exp.

Group – 2 N = 19

50.72 4.98 55.25 4.99 4.53 2.4 54.54

Control Group N = 18

47.67 3.97 48.06 5.81 0.39 3.5 50.34

ANOVA

‘F’ value 31.134 20.272

Adjusted R2 = 0.400‘P’ value 0.051 0.001

Post hoc Scheffe Test

E1 E2 C E1 = E2 C

MEAN, STANDARD DEVIATION AND TEST OF DIFFERENCES OF THE RESPIRATORY RATE (RR)

GroupPre test Post test

Mean of Difference

Estimated Post test Score

ANCOVA

Mean S.D. Mean S.D. Mean S.D. ‘F’ value ‘P’ value

Exp. Group – 1

N = 2122.38 1.86 19.9 1.61 2.48 1.25 19.98

8.009 0.001Exp.

Group – 2 N = 19

22.42 1.84 20.53 1.98 1.89 1.05 20.58

Control Group N = 18

22.78 1.96 22.33 2.50 1.22 1.96 22.18

ANOVA

‘F’ value

0.253 7.262 Adjusted R2 = 0.400

‘P’ value

0.778 0.002

Post hoc Scheffe Test

E1 E2 C E1 = E2 C

MAJOR FINDINGS OF THE STUDY

The PLBE group showed significant effectiveness in reducing the modified Borg score than the control group.

The DBE group showed significant effectiveness in reducing the modified Borg score than the control group.

The PLBE group showed greater degree of effectiveness than the DBE group in reducing modified Borg score.

The PLBE group showed significant effectiveness in improving PEFR (% Pred.) than the control group.

MAJOR FINDINGS OF THE STUDY

The DBE group showed significant effectiveness in improving PEFR (% Pred.) than the control group.

The PLBE and DBE groups showed comparable degree of effectiveness in improving PEFR (% Pred.).

There was no significant difference existed between the PLBE, DBE, and control groups in respect of RR.