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CHAPTER 1
INTRODUCTION
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1.1INTRODUCTIONChronic obstructive pulmonary disease (COPD) has been defined by the Global
initiative for chronic obstructive pulmonary disease (GOLD) as a disease characterized
by air flow limitation that is not fully reversible. The airflow limitation is usually both
progressive and associated with an abnormal inflammatory response of the lungs to
noxious particles or gases.(www . GOLD COPD .com) 1
The chronic airflow limitation characteristic of COPD is caused by a mixture of
small airway disease and paranchymal destruction, the relative contribution of which
varies from person to person. Chronic inflammation causes remodelling and narrowing
of the small airways. Destruction of the lung parenchyma, also by inflammatory process,
leads to the loss of alveolar attachments to the small airways and decreases lung elastic
recoil, inturn these changes diminish the ability of the airways to remain open during
expiration. Air flow limitation is measured by spirometry, as this is most widely
available, reproducible test of lung function.2
COPD is a global health concern, and is a major cause of chronic morbidity and
mortality worldwide. Many people suffer from this disease for years and die prematurely
from it or its complications. The global burden of COPD is projected to be the fifth
leading cause of death and GOLD estimates and suggests that the COPD will rise from
the sixth to third most common cause of the death world wide by 2020. The burden of
COPD in Asia is currently greater than that in developed Western countries.3
Worldwide cigarette smoking is the most commonly encountered risk factor for
COPD, although in many countries, air pollution resulting from the bumming of wood
and other biomass fuels also been identified as a COPD risk factor .The second most
significant documented risk factor for COPD IS alpha-1 antitrypsin deficiency .Certain
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occupational exposures like dusts and chemicals (vapours, irritants, fumes) and indoor
and outdoor air pollutions are also associated with increased risk of COPD.
The characteristic symptoms of COPD are cough, sputum production and dyspnoea
on exertion. Chronic cough and sputum production often precede the development of
airflow limitation by many years; although not all individuals with cough and sputum
production go on to develop COPD. The natural course of COPD is characterized by
occasional sudden worsening of symptoms called acute exacerbations, most of which are
caused by infections or air pollution. This pattern offers a unique opportunity to identify
those at risk for COPD and intervene when the disease is not yet a health problem. A
major objective of GOLD is to increase awareness among health care providers and the
general public of the significance of these symptoms and decrease morbidity and
mortality from the disease .GOLD aims to improve prevention and management of
COPD through a concerted world wide effort of people involved in all facets of health
care and health care policy, and to encourage an expanded level of research interest in
this highly prevalent disease.5
All population based studies in developed countries showed a markedly greater
prevalence and mortality of COPD among men compared to woman .gender related
differences in exposure to risk factors mostly cigarette smoking probably explain this
pattern. 6
The goals of the global initiative for COPD are to increase awareness of COPD and
decrease morbidity and mortality from the disease. GOLD aims to improve prevention
and management of COPD through a concerted world wide effort of people involved in
all facets of health care and health care policy, and to encourage an expanded level of
research interest in this highly prevalent disease.7
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Dyspnoea limiting physical activity is a common complaint in COPD patients with
moderate to severe airflow obstruction and usually arises during the sixth or seventh
decade of life. The onset of dyspnoea is often insidious and may be attributed incorrectly
to the effects of ageing. Avoidance of activity as a strategy to limit the experience of
dyspnoea leads to a sedentary lifestyle. Accompanying this lifestyle is locomotor muscle
de condition pounds the effects of pulmonary dysfunction on dyspnoea. The reduction of
maximum expiratory flow rate and slow forced emptying of lung are common problems
seen in COPD that leads to dyspnoea and reduction in exercise tolerance. The COPD
patients are reluctant to do exercises because of dyspnoea. In severe cases of COPD
accessory muscles may required for respiration. 8
The four stage classification COPD severity provides an educational tool and a
general indication of the approach to management.
Stage 1: Mild COPD Mild airflow limitation (FEV1/FVC _80%
predicted.), and sometimes, but not always chronic cough and sputum production.
Stage 2: Moderate COPD Worsening airflow limitation (FEV1/FVC
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This conceptual frame work also emphasizes that COPD is usually progressive if
exposure to the noxious agent is continued. The staging is based on airflow limitation as
measured by spirometry which is essential for diagnosis and provides a useful
description of severity of pathological changes in COPD.
The overall approach to managing stable COPD should be characterized by a step
wise increase in treatment, depending on the severity of the disease. The classification of
severity of stable COPD incorporates an individualized assessment of disease severity
and therapeutic response in to the management strategy.11
While disease prevention is the ultimate goal, once COPD has been diagnosed,
effective management should be aimed at the following goals:
-prevent disease progression
-relieve symptoms
-improve exercise tolerance
-improve health status
-prevent and treat complications
-prevent and treat exacerbations
-reduce mortality.
The benefits of pulmonary rehabilitation program include improved exercise
capacity, an enhanced sense of wellbeing and a reduced need for hospitalization.
Pulmonary rehabilitation has been demonstrated to improve the health related quality of
life, dyspnoea, and exercise tolerancecapacity.12
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The goal of pulmonary rehabilitation program are to reduce symptoms, improve
activity and daily function, and restore the highest level of independent function in
patient with respiratory disease.
Diaphragmatic breathing is an exercise to better use and to strengthen the
diaphragm, the major and most efficient muscle of breathing. Regular practice of
diaphragmatic breathing can help restore function of diaphragm and return to a more
efficient breathing pattern. Practicing a deeper diaphragmatic style of breathing can help
ease of work of breathing and expect more stale air. 14
Pursed lip breathing is performed as expiratory blowing against pursed lips, is a
pulmonary rehabilitation strategy instinctively or voluntarily employed in patients with
COPD to relieve or control dyspnoea.
Six minute walk test is simple, easy reproducible and requires no apparatus. It is
a self paced exercise that patients could perform this test alone. It can be carried out at
same time of the day at any time.
Management of stable COPD involves the avoidance of risk factors to prevent
disease progression and pharmacotherapy as needed to control symptoms. In addition to
patient education, health advise and pharmacotherapy, these patients require specific
counselling about smoking cessation, instruction in physical exercise, nutritional advise
and continued nursing support. Not all approaches are needed for every patient and
assessing the potential benefit of each approach at each stage of the illness is a crucial
aspect of effective disease management. An effective COPD management plan includes
four components .assess and monitors the disease, reduce risk factors, manage stable
COPD and manage exacerbations.
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The treatment programme includes preventive and general care management. It
includes pharmacological and non pharmacological treatment. Pharmacological
treatment includes medications like B-2 agonists, ancholinergics, methylxanthines, and
bronchodilators. Other pharmacological treatment includes vaccines, antibiotics,
mucolytic agents, antioxidant agents, immuno regulators, antitussives, vasodilators, and
narcotics. non pharmacological treatment includes rehabilitation, education, oxygen
therapy.
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1.2NEED FOR THE STUDY.Reduction of maximum expiratory rate, slow forced emptying of lung and
breathlessness are common problems seen in COPD. In severe cases of COPD, the use of
accessory muscles was increased. Diaphragmatic breathing exercise and PLB are
effective to relieve the symptoms.
In other studies functional performance of the COPD patients are not evaluated.
Hence the need of this study is to improve exercise tolerance along with the flow rates
and rate of perceived exertion.
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CHAPTER 2
REVIEW OF LITERATURE
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REVIEW OF LITERATURE
American thoracic society has defined COPD as`` a disease state characterized by
the presence of airflow limitation due to Chronic Bronchitis or Emphysema; the airflow
obstruction is generally progressive, may be accompanied by airway hyper reactivity,
and may be partially reversible. 13
Hyper inflation of lungs affects not only the bony components of the chest wall,
but also the muscles of the thorax .the resting position of the diaphragm changes to a
more flattened configuration .The angle of pull of diaphragm fibers becomes more
horizontal with a decreased zone of apposition and decreased strength and range of
contraction. In severe cases of hyperinflation the fibers of diaphragm will be aligned
horizontally. Contraction of this much flattened diaphragm will pull the lower ribcage
inward actually working against lung inflation.14
Dyspnoea is a subjective experience of breathing discomfort that consists of
qualitatively distinct sensations that vary in intensity. The experience derives from
interactions among multiple physiological, psychological, social and environmental
factors and may induce secondary physiological and behavioural responses. (American
thoracic society 1999)15
A scale such as the MRC breathlessness scale suggests five different grades of
dyspnoea based on the circumstances in which it arises.
Grade 1 - no dyspnoea except with strenuous exercise.
Grade 2 - dyspnoea when walking up an incline or hurrying on the level.
Grade 3 -walks slower than most on the level, or stops after 15 minutes of walking on
the level.
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Grade 4 -stops after a few minutes of walking on the level.
Grade 5 - dyspnoea with minimal activity such as getting dressed, too dyspnoea to leave
the house.16
COPD patients frequently develop nocturnal oxygen destruction because of
alveolar hypoventilation, worsening of ventilation-perfusion mismatch, and sometimes
obstructive sleep apneas. In contrast, little is known about their oxygen status during the
various activities of daily life.17
The diagnosis of COPD confirmed by spirometry, a test that measures breathing,
it measures the forced expiratory volume in one second (FEV1) which is the greatest
volume of air that can be breathed out in the first second of a large breath. Spirometry
also measures the Forced vital capacity (FVC) which is the greatest volume of air that
can be breathed out in a whole large breath. Normally at least 70% of the FVC comes out
in the 1st
second, ie, FEV1/FVC ratio is >70%.In COPD this ratio is less than normal,
i.e., FEV1/FVC ratio is
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change in minute ventilation, which indicate a substantial slowing of respiratory
frequency.20
Diaphragmatic breathing changes the breathing pattern and it is most helpful in
reducing respiratory rate, minute ventilation and it also increases tidal volume in severe
chronic obstructive pulmonary disease patients.
The study of Levine et al. provides the first evidence that appropriate adaptive
response occur in the inspiratory intercostals muscles of patients with chronic
obstructive pulmonary disease. Levenson et al. states that abdominal muscle contraction
should be encouraged to lengthen the diaphragm and increase its force generating
capacity. In severe COPD patients with hypercapneoa and reduced inspiratory muscle
strength recovering from an episode of acute respiratory failure, deep diaphragmatic
breathing is able to improve blood gases whereas inspiratory muscle effort increases and
dyspnoea worsens. Diaphragmatic breathing (DB) has been claimed, but not
demonstrated, to correct abnormal chest motion, decrease the work of breathing (WOB)
and dyspnoea.
Ambrosino et al. reported improvement in maximal exercise tolerance in mild
COPD patients undergoing deep DB. Campbell and friend postulated that the increased
abdominal motion during DB may shift ventilation towards the base of the lungs. Brach
et al. found that DB did not alter regional ventilation for the group as a whole. Two
people , however, increased ventilation to the base of one lung by more than 20%.
Unfortunately; the authors were not able to explain this finding. The study by Sackner et
al. demonstrated that half of the subjects had minimal abdominal displacement during
DB. Another study by Sackner et al. Showed that DB was associated with distorted chest
wall motion. Diaphragmatic breathing caused increased paradoxical and asynchronous
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movements of the rib cage. The amount of asynchrony was not correlated with disease
severity. Gosselink et al. report increased VO2 and work of breathing in people with
severe COPD who performed DB with no spontaneous changes in respiratory frequency.
The work of breathing was calculated according to the method of Collett et al. which
relates changes in mechanical work to changes in VO2 during loaded breathing.
Gosselink et al. found that during resting breathing, DB increased VO2 (by an
average of 17 ml/min) but had no effect on Vt, breathing frequency, duty cycle (
inspiratory time divided by total respiratory cycle time). When compared with natural
breathing, DB during load breathing was associated with a lower mechanical efficiency,
increased paradoxical rib cage motions and no change in VO2 or dyspnoea.
Diaphragmatic breathing improves the ventilation, decreases work of breathing,
decreases dyspnoea and normalize breathing pattern in patients with chronic obstructive
pulmonary disease.
Breathing techniques are included in the rehabilitation program of patients with
chronic pulmonary disease (COPD). In patients with COPD, breathing techniques aim to
relieve symptoms and ameliorate adverse physiological effects by increasing strength
and endurance of the respiratory muscles, optimizing the pattern of thoraco-abdominal
motion; and reducing dynamic hyperinflation of the rib cage and improving the gas
exchange. Evidence exists to support the effectiveness of purse-lip breathing, forward
leaning position, active expiration and inspiratory muscle training but not for
diaphragmatic breathing.
Diaphragmatic breathing exercises attempts to enhance diaphragmatic exertion
throughout the respiratory cycle for the purpose of reducing accessory muscle use and
providing a more normalized breathing pattern. DB exercises allegedly enhance
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diaphragmatic descent during inspiration and diaphragmatic ascent during expiration.
Diaphragmatic breathing exercises are designed to improve the efficiency of ventilation,
decreases work of breathing, increase the excursion of diaphragm, improve gas exchange
and oxygenation. Diaphragmatic breathing exercises are also used to mobilize secretions
during postural drainage. Diaphragmatic and PLB reveals that the use of PLB appears
tobe an effective way to decrease dyspnoea and improve gas exchange in stable COPD.
Sackner et al reported the effects of DB on VT and respiratory frequency in
patients with COPD respiratory inductance plethysmography was used to measure chest
wall movements, and these changes were calibrated using spirometric measurements to
indicate actual volume change. Gosselink et al found that during resting breathing, DB
increased Vo2, but had no effect on VT, breathing frequency, duty cycle or VE.
Pursed lip breathing is often used in patients with severe airway disease. By
opposing the lips during expiration the airway pressure inside the chest is maintained,
preventing the floppy airways from collapsing. Thus overall air flow is increased.22
Falling described PLB as easiest breathing technique and often employed
instinctively. Patients inhale through the nose over several seconds with the mouth
closed and then exhale slowly over 4-6 seconds. Through pursed lips held in a whistling
or kissing position. This is done with or without the contraction of abdominal muscles. 23
PLB is thought to keep airways open by creating a backpressure in the airways. It
is thought to help a patient with COPD with repeated attacks of shortness of breath
.studies suggest that PLB decreases the respiratory rate ,increases the tidal volume and
improves the exercise tolerance.24
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PLB leads to reduced diaphragmatic and increased ribcage and accessory muscle
recruitment. It provides a perception of control over breathing. PLB is performed as
expiratory blowing against pursed lips ,is a pulmonary rehabilitation strategy
instinctively or voluntarily employed in patient with COPD to relieve or control
dyspnoea. 25
Thoman and colleagues reported on comparison of spontaneous breathing.PLB
and slow breathing was done in an attempt to clarify whether the effect of PLB were due
to slowing of respiratory rate. The investigators reported that PLB slow breathing
frequency and that both slow, deep breathing and PLB result in a similar increase in tidal
volume. 26
The 6MWT has first been introduced as a functional exercise test by Lipkin in
1986. Its results are highly correlated with those of the 12 minutes walk test from which
it was derived and with those of cycle ergo meter or treadmill based exercise tests . The
6MWT is also a valuable instrument to assess progression of functional exercise capacity
in different clinical intervention studies. The reliability of the test in healthy elderly
persons is high and it is considered as a valid and reliable test to assess the exercise
capacity of elderly patients with chronic obstructive pulmonary disease. Several authors
studied the determining factors of the 6MWT-distance in healthy adults and propose
either reference equations or normative data for the 6MWT-outcome. Troosters et al.
found that age, gender, height and weight explained 66% of the 6MWT-distance
variability in 51 healthy adults aged 5085 years.
6MWT is used for the objective evaluation of the functional exercise capacity.
The strongest indication for the 6 MWT is for measuring the response to therapeutic
interventions for pulmonary disease. The self paced 6 MWT asses the sub maximal level
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of functional capacity. The 6 MWT is easy to administer, better tolerated and more
reflective of ADL than the other walk test.27
6MWT is a simple test to evaluate the functional capacity by measuring the
distance walked during a defined period of time. In an attempt to accommodate patients
with respiratory disease for whom walking 12 minute was too exhausting. It elevates
global and integrated response of organ involved during exertion like cardiovascular
system, pulmonary system etc.28
The six-minute walk test is an objective method, to measure the ability to
perform daily living activities. It is more often performed, to evaluate the functional
status, monitor therapy, or assess the prognosis in patients with cardiac and pulmonary
diseases. In comparison to traditional pulmonary exercise test, 6MWT needs less
technical support or equipment, making it a simple and inexpensive method to measure
functional capacity. The validity and the reliability of 6MWT was studied in different
conditions, including obstructive lung diseases, interstitial lung diseases, pulmonary
hypertension, heart failure and peripheral arterial diseases.
The improvement in health related quality of life after pulmonary rehabilitation
clearly exceeds the minimal clinically important difference. When disease specific
instruments were used, the lower limit of the 95% confidence interval exceeded the
minimal clinically important difference.29
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CHAPTER 3
METHODOLOGY
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3.1 AIMOF THE STUDY
To evaluate the effectiveness of diaphragmatic breathing exercise and pursed lip
breathing exercise in stable COPD patients.
3.2 OBJECTIVES OF THE STUDY
To evaluate the effectiveness of diaphragmatic breathing exercise in stableCOPD patients.
To evaluate the effectiveness of Pursed lip breathing exercise in stable COPDpatients.
3.3 RESEARCH DESIGN
Pre-test and post-test experimental design.
3.4 HYPOTHESES
Null hypothesis
There is no significant difference between diaphragmatic breathing exercise and pursed
lip breathing exercise in stable COPD patients.
Alternate hypothesis
There is significant difference between diaphragmatic breathing exercise and pursed lip
breathing exercise in stable COPD patients.
3.5 POPULATION
Patients who are diagnosed as stable COPD, referred by pulmonologist were taken as
population of the study.
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3.6 STUDY SETTINGS
1. Department of physiotherapy, Chest Hospital, Kozhikode.
3.7 SAMPLES AND SAMPLING METHOD
30 Patients who are diagnosed as stable COPD, referred by Pulmonologist were
selected as samples for the study from the population using convenience sampling
method.
3.8 SELECTION CRITERIA
Inclusion criteria
1. Patients diagnosed as Stable COPD.
2. Haemodynamically stable COPD patients
3. Both male and female patients
4. Patients with 50 to 70 yr old
5. Moderate COPD patients.
6. FEV1 with 50-80%
Exclusion Criteria
1. Patients with cardiac, metabolic, or endocrine disorders
2. Acute exacerbation of COPD
3. Thoracic or abdominal surgery within last 2 months
4. Patients with unstable vital sign
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5. Patient with pleural disorder
6. Mentally retarded patients and un co operative patients
7. Patients with unstable cardiac disease
8. Subjects who are not able to do spirometry
9. Patients like infectious diseases like tuberculosis and pneumonia
10. Any orthopaedic deformities of the chest
3.9 VARIABLES OF THE STUDY
Independent variables
Diaphragmatic breathing exercise Pursed lip breathing exercise
Dependent variables
FEV1,FVC Six minute walk test
3.10 RESEARCH TOOLS
1. Sphygmomanometer.
2. Spirometer.
3. Respiratory assessment form.
4. Borgs scale for rate of perceived exertion.
5. Stethoscope.
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6. Inch tape.
7. Stop watch.
3.11 DURATION OF THE STUDY
Total duration of study was six weeks.
3.12 DATA COLLECTION PROCEDURE
30 Subjects were selected on the basics of inclusion and exclusion criteria. All the
subjects were divided equally into two groups, Group A and Group B. Each group
consisted of 15 subjects, the study procedures were explained to the subjects and
informed consent was obtained prior to study. Before starting the training, pre-test scores
were measured by using Pulmonary function test and six minute walk test.
Group A- Subjects in Group A (n=15) received Diaphragmatic breathing exercises as
per the appendix
Group B- Subjects in Group B (n=15) received Pursed lip breathing exercise as per the
appendix
At the end of sixth week post test scores of both groups were taken by using
Pulmonary function test and six minute walk test.
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CHAPER 4
DATA ANALYSIS
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DATA ANALYSIS
Data was analysed using a paired T test to find out within group difference
of dependent variable and a univariate analysis of variance to find out
between group differences. There was one within group factor which was
time and a between subject factor which was group. All data was analysed
using SPSS version 12.O with significance level kept at 0.05.
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CHAPTER 5
RESULTS
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RESULTS
Six minute walk test.
A T test was done to analyse the within group difference of six minute walk test.
There was a significant improvement for six minute walk test in group A from pre to
post. T value (14, 0.05) = -10.088, P
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CHAPTER 6
DISCUSSION
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6.1 DISCUSSION
The study is an experimental comparative study to find out the effectiveness of
DB & PLB exercise in patients with stable COPD. The patients are divided in to group A
and group B comprising of 15 patients each. Both groups were trained twice daily for 15
minutes for 5 days per week for 6 weeks. The Outcome measurement of the study was
6MWT, spirometry of measurement of FEV1 and FVC. Group A received PBE and
group B received PLB exercises.
Group which received DBE showed significant improvement in 6 MWT than the
PLB exercises group and PLB group showed significant improvement in FEV1 and FVC
compared with DBE group. But there was no significant improvement in FEV1 and FVC
in DBE group from pre to post. In both groups there was significant improvement in
6MWT from pre to post.
Pursed lip breathing results in a positive expiatory pressure and is thought to have
similarities with continuous positive airway pressure and positive end expiratory
pressure. By creating an obstruction at the lip, this active expiration may be intensified
and the resulting greater increase in positive expiratory pressure may increase bronchial
pressure and thus tansmural pressure, leading to a diminution of airway collapse: In
various studies there was a linear relationship between the effectiveness of PEP
breathing in decreasing the nonelectric resistance across the lung and airway and the
collapsibility of airways
Bianchi R et al assessed the volumes of chest wall compartments using an
optoelectronic plethysmograph and concluded that by decreasing respiratory frequency
and lengthening expiratory time, pursed lip breathing decreases end expiratory volume of
chest wall, which is mostly at the abdominal level et al. decrease in end expiratory
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volume of abdomen and modulates the breathlessness. Changes in end expiratory volume
of chest wall are related to baseline airway obstruction (FEV1) but not due to
hyperinflation. So, improvement in dyspnoea observed after breathing exercises can be
attributed to the decrease in respiratory rate, increase in tidal volume, decreased
physiological dead space to tidal volume ratio, improved blood gases and decrease the
work of breathing by decreasing or preventing airway collapse and promoting more
homogenous ventilation as observed in various clinical trials of breathing exercises.
Esteve et al found that breathing pattern training, enhanced with visual feedback
increased the FEV1, and FVC in patients with COPD following pulmonary rehabilitation
having breathing exercises as a component and this area needs further evaluation by
more clinical trials.
Thoman R, proposed that those segments of lungs with greatest fall or greater
increase in flow resistance will receive disproportionately less of the tidal volume.
Therefore, the abnormal and uneven distribution of gases in emphysema will be
accentuated with increased respiratory rate. So the slowing of respiration alone would be
expected to enhance the ventilation of those subdivisions of the lung which normally are
under ventilated. They found that tidal volume increases while respiratory rate decreases
and CO2 elimination improves without significant change in forced residual capacity and
volume of slow space by pulsed lip breathing. They found that indeed there was an
increase in ventilatory rates of those most slowly ventilated lung components, when
respiratory rate slowed down with pursed lip breathing. Mueller et al also observed that
pursed lip breathing was accompanied by both increased tidal volume and decreased
respiratory rate, more so in subjects who claimed benefit from pursed lip breathing in
comparison to the subjects who did not feel improvement with pursed lip breathing. An
improvement in PO2 was observed in both groups during rest, but not during exercise
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and he concluded that benefits of pursed lip breathing were due to decreased airway
collapse, decreased respiratory rate, and increased tidal volume but found no relationship
between symptomatic benefit from pursed lip breathing and improvement in ABG.
Mueller as well as other investigators found that although pursed lip breathing
was more effective in the sense that less air exchange was required to absorb a given
amount of oxygen, there was no increase in oxygen uptake This suggests that PLB does
not significantly alter the work of breathing. It is known that hyperactivity of the
inspiratory muscles is a cause for the sensation of dyspnoea. Their assumption that
decrease in dyspnoea sensation which is often thought to be related to pursed lip
breathing might be caused by reduced activity of respiratory muscle is still a matter of
debate. Through encouraging the use of diaphragm, the principal and efficient muscle of
inspiration, the oxygen cost of breathing can be decreased. Decreasing the use of
accessory muscles also decreases the work of breathing. The bio feed can be used to
discourage accessory muscle firing during the ventilatory cycles. Because use of the
diaphragm as in diaphragmatic breathing was found to increase rather than decrease the
level of dyspnea at present routine use of diaphragmatic breathing in pulmonary
rehabilitation is not recommended.
Killian and co workers showed that exercise capacity in COPD patient is mainly
limited by subjective symptoms such as muscle fatigue and dyspnoea without the patient
reaching their physiological limitations. Now as this is well known that a vicious cycle
of exertional dyspnoea, exercise and activity limitation, psychosocial illness are the
major causes of poor health related quality of life in COPD patients, there are increasing
evidence that physical reconditioning which is most essential component of pulmonary
rehabilitation can improve the exercise capacity and health related quality of lives.
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Casciari RJ et al found in their study that breathing retraining increases exercise
performance in subjects with severe chronic obstructive pulmonary disease.
Schans et al observed that positive expiratory pressure breathing of 5 cm H2O
which is in range of mouth pressure reached during expiration with pursed lip in patients
with COPD increases the efficiency of ventilation at rest and during exercise, since same
work load is achieved with less ventilation. So the improvement in exercise tolerance
seems to be due to the decrease in the sensation of dyspnoea. Thats why these patients
do not feel panic at the time of respiratory distress. Their self-confidence could be
improved, which progressively increases activities of daily living that mimics exercise of
physical reconditioning that can ultimately restore the patient to the highest level of
functional capacity and improved health related quality of life. However, the effect on
quality of life has not been evaluated by other workers.
Evidence suggests that diaphragmatic breathing does not change regional
ventilation in people with COPD. This technique increase total ventilation but if so ,this
suggest this may due to the slower ,deeper breathing patterns that may occur during DB
rather than an exaggeration of abdominal motion. Some authors noted an increase in the
work of breathing; this may be due to increased paradoxical rib motion during DB. The
relaxed expiration effects of less air tapping, results in reduction of hyperinflation, which
turns into reduced respiratory rate, dyspnoea and improved tidal volume and oxygen
saturation in resting condition. A study by Gosse link proved deep breathing exercise
which includes diaphragmatic breathing immediate decrease respiratory rate, dyspnea
and anxiety. Jones et al confirmed that DB results lower oxygen cost and respiratory rate.
The pursed-lip breathing shifts a major portion of the inspiratory work of breathing from
the diaphragm to the ribcage muscles, resting the diaphragm and reducing dyspnoea.
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Techniques such as PLB help to reduce respirations while improving the expiratory
phase. Slow controlled expiration postpones small airway collapse, thereby reducing air
trapping that occurs with forced expiration.
Some patients may benefit from Diaphragmatic breathing technique. The patient
is taught to employ only the diaphragm during inspiration and to maximize abdominal
protrusion. During expiration, the patient may contract the abdominal wall muscles to
displace the diaphragm more cephalic. Not all patients with COPD benefit from this
technique; therefore, close clinical monitoring to ascertain efficacy is required.
The study of Levine et al. provides the first evidence that appropriate adaptive
response occur in the inspiratory intercostals muscles of patients with chronic
obstructive pulmonary disease. Levenson et al. states that abdominal muscle contraction
should be encouraged to lengthen the diaphragm and increase its force generating
capacity.
Ambrosino et al. reported improvement in maximal exercise tolerance in mild
COPD patients undergoing deep DB. Campbell and friend postulated that the increased
abdominal motion during DB may shift ventilation towards the base of the lungs. Brach
et al. found that DB did not alter regional ventilation for the group as a whole.
Unfortunately; the authors were not able to explain this finding. The study by Sackner et
al. demonstrated that half of the subjects had minimal abdominal displacement during
DB. Another study by Sackner et al. Showed that DB was associated with distorted chest
wall motion. Diaphragmatic breathing caused increased paradoxical and asynchronous
movements of the rib cage. The amount of asynchrony was not correlated with disease
severity. Gosselink et al. report increased VO2 and work of breathing in people with
severe COPD who performed DB with no spontaneous changes in respiratory frequency.
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The work of breathing was calculated according to the method of Collette et al. which
relates changes in mechanical work to changes in VO2 during loaded breathing.
Dechman G reported that Diaphragmatic breathing improves the ventilation,
decreases work of breathing, decreases dyspnoea and normalize breathing pattern in
patients with chronic obstructive pulmonary disease.
Breathing techniques are included in the rehabilitation program of patients with
chronic pulmonary disease (COPD). In patients with COPD, breathing techniques aim to
relieve symptoms and ameliorate adverse physiological effects by increasing strength
and endurance of the respiratory muscles, optimizing the pattern of thoraco abdominal
motion; and reducing dynamic hyperinflation of the rib cage and improving the gas
exchange. Evidence exists to support the effectiveness of purse-lip breathing, forward
leaning position, active expiration and inspiratory muscle training but not for
diaphragmatic breathing.
Diaphragmatic breathing exercises attempts to enhance diaphragmatic exertion
throughout the respiratory cycle for the purpose of reducing accessory muscle use and
providing a more normalized breathing pattern. DB exercises allegedly enhance
diaphragmatic descent during inspiration and diaphragmatic ascent during expiration.
Diaphragmatic breathing exercises are designed to improve the efficiency of
ventilation, decreases work of breathing, increase the excursion of diaphragm, improve
gas exchange and oxygenation.
The PLB group patients showed markedly reduced RR stable COPD after
performing the breathing exercises. The reduced rate was associated with commensurate
the reduction of COPD .Motley reported that the effect of PLB on ventilatory parameters
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and arterial blood gases in people with COPD. They uniformly reported that the
technique decreases respiratory rate, minute ventilation and increases tidal volume
pursed-lip breathing also has been documented to increases partial pressure of oxygen in
arterial blood, and the percentage of haemoglobin sites that are bound to oxygen in
arterial blood, changes in oxygen consumption are less consistent. Pursed-lip breathing
has been reported to decrease dyspnoea, and therefore, may improve exercise tolerance,
and reduce limitations in activities of daily living.
Breslin reported that, during PLB, decreased diaphragm activity during
inspiration was accompanied by increased use of rib cage muscles. Both abdominal and
rib cage accessory muscle activity increased during expiration. Respiratory rate
decreased as did the duty cycle. In addition, Breslins estimate of the resting diaphragm
tension-time index indicates that, as a group, the subjects were above the diaphragm
fatigue threshold described by Bellemare and Grassino. A breathing pattern above this
threshold purportedly leads to imminent respiratory failure. These data are surprising
because all of the subjects lived in the community and were medically stable.
There is a clinical improvement of the six minute walk test after breath exercises
from pre to post test. The ability to walk for a distance is an easy way to measure
exercise capacity in patients with pulmonary diseases. A variety of walk tests, including
self-paced walk tests, controlled-pacing incremental walk tests and time- paced tests, are
considered to be objective measurements of functional capacity. Six minute walk test is
found to be an effective way of assessing exercise tolerance. Its validity, reliability and
reproducibility, were studied in several populations.
The 6MWD had no significant correlation with the level of borg-scale or oxygen
saturation at baseline, or at the end of the test. There were no significant differences in
FEV1, FVC between female and male patients. Spirometric values correlate modestly
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with 6MWD. FVC had a stronger positive correlation with distance walk than FEV1.
The 6MWD had no significant correlation with volumetric lung measurements. There
was a significant correlation between 6MWD in patients with respiratory diseases.
ODonnell and colleagues proposed that people with COPD have a very fine
control of expiratory flow whereby intrathocic pressure is continuously adjusted to a
level that is just enough to attain maximal flow. Furthermore, they proposed that this
active control develops with the disease process, suggesting that imposing retraining
techniques is not uniformly helpful in this population.
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6.2 LIMITATIONS AND SUGGESTIONS
Limitations:
1. The study was performed for a short duration.
2. The study was done on a Small sample size, which decreases the power to detect
treatment effects.
3. The study did not include long term follow up.
4. As the measurements were taken manually, there may be a chance of error
Suggestions
1. To establish the efficacy of the treatment, a large sample sized study is required.2. For more valid result, a long term study must be carried out.3. Follow up programmes can be included to assess the long term effects of
treatment.
4. Further study can be done to check the effects of these techniques on otherconditions.
5. Effects of these techniques on other stages of COPD can be studied.6. Further study should include more measurement tools.
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CHAPTER 7
CONCLUSION
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CONCLUSION
Results indicates that PLB are effective for alleviating the symptoms like
dyspnoea and airflow limitations and both exercises are effective in improving the
exercise tolerance in the management of COPD. This was shown by improvement in
FEV1, FVC and six minute walk test.
PLB help to reduce respirations while improving the expiratory phase .slow
controlled expiration postpones small airway collapse, thereby reducing air trapping that
occurs with forced expiration. Diaphragmatic breathing improves the ventilation,
decreases work of breathing, decreases dyspnoea and normalize breathing pattern in
patients with chronic obstructive pulmonary disease. The effectiveness of DB and PLB is
increasingly being called in to question. In addition, the negative effects of these
procedures have been reported. Interventions that focus on optimizing respiratory
mechanics may result in a better therapeutic outcome rather than a focus on breathing
patterns that primarily may be the result of impaired respiratory mechanics.
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CHAPTER 8
REFERENCES
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REFERENCES
1. Alexandra Hough, physiotherapy in respiratory care- a problem solving approach,1st edition. London: chapman and Hall, 1991, pp.79-80.
2. Anthony S. Fauci., Harrisons principles of internal medicine, 14th edition, vol.2,USA: Mc Graw-Hill companies Inc.., 1998, pp, 1041-1046.
3. Carolyn Kisner, Lynn Allen Colby., Therapeutics exercises foundations andtechniques; 5
thedition 2007, pp.886.
4. Downs AM: Clinical Applications of Airway clearance Techniques. InFrontfelter, D, Dean, E (eds) Cardiovascular and pulmonary physical therapy:
Evidence and practice, ed 4. Mosby, st. Louis, 2006 pp.341-362.
5. Ellen A. Hillegas, H. Stephen sadowsky., Essentials of cardio pulmonaryphysiotherapy. 1st edition, Tokio: W. B. Saunsders Company, 1998, pp. 275-277.
6. Harsh Mohan. Harsh Mohans text book of pathology, 5th edition, India: jaypeeBrothers, 2005, pp.485-491.
7. Jennifer A Pryor, physiotherapy for respiratory and cardiac problems-adults andpediatrics, 3
rdedition, London, London: Churchill Livingstone 2002, pp.205-206.
8. John R. Bach., pulmonary rehabilitation obstructive & paralytic conditions, 1stedition, New Jersy: Hanleus and Beltus inc., 1995, pp.27-33.
9. Levensen . CR: Breathing exercises in Zaidal, CC (ed) pulmonary Managementin physical Therapy. Churchill Livingstone , New York,1992
10.Belman et. Al., Reliability of Borg scale for dyspnoea. Chest Journal, 4, 2002,pp.37.
8/3/2019 Introduction to Refference
40/46
40
11.carter R,6-minute walk work assessment of functional capacity in patients withCOPD,chest jornal may 2003; 123:pp.1408-1415
12.dechman G., Wilson C.R., Evidence underlying breathing retraining in peoplewith stable COPD, physical therapy, 84, 2004,pp.1189-1197
13.Gosselink R.K.controlled breathing and dyspnoea in patients with COPD,journal of rehabilitation, research and development,40,2003,pp.25-34
14.Gosselink, R.breathing technique in patients with chronic obstructive pulmonarydisease(COPD) chronic Respir dis.2004; 1(3):163-72(issn:1479-9723)
15.Meilan Han, mark J Rosen, spirometry understand for diagnosing COPD chest2007
16.Meilan K Han , spirometry utilization for COPD ; april 200717.sandiego , karla R Kendrick, sunita C Baxi, Robert m smith., usefulness of
modified 0-10 Borg scale in assisting the degree of dysnoea in patients with
COPD and asthma may 2001
18.Vitacca, M.clini ,E. Blanchi , L . Ambrosino , N> Acute effects of deepdiaphragmatic breathing in COPD patients with chronic respiratory insufficiency
. European Respiratory journal,11,1998,pp.408-415
19.ACCP/AACVPR pulmonary rehabilitation guidelines panel. Pulmonaryrehabilitation ; joint ACCP/AACVPR Evidence based guidelines.J.Cardiopulm
Rehabil.1997;17:371-405
8/3/2019 Introduction to Refference
41/46
41
20.G.Viegi, a.Scognamigtio,S.Baladacci,fPistelli,L.Carrozzi pulmonaryenvironmental Epidemiology Group CNRinstitute of Clinical
pathology,Pisa,Italy.Respiration 2001;64,4-19
21.Susan b OSullivan Thomas schmite physical rehabilitation Assessement andTreatment 4
thedition India:jayapee brothers 2001 pp:448
22.Hatem FS Almery.Annuals of Thorax medicine,Six minute walk test inrespiratory disease;A university Hospital experience.2006;vol.1 pp:16-19
23.Carter et .al Chest. Six minute walk work assessement of functional capacity inpatients with COPD. Chest Journal.2003;123:pp 1408-1415
24.Tony Reybrouck, Clinical usefulness and limitation of 6 min walk test in patientswith cardiovascular and pulmonary disease. Chest 2003;vol 23,no.2,pp 325-327
25.T.Troosters ,j.Vilaro,R.Robionvich,A.cases, J Barberus , physiological responsesto six min walk test in patients with COPD. Eur Respir journal 2002
26.Mary B King, JamesO judge , Robert Whipple, Lesile Walfson.Reliability andresponsiveness of two physical performancephysiotherapy journal 20000:80:pp-
8-16
27.R Gosslink, T Troosters and M Decramer. Exercise training in COPD patients.The basic question.Eur. Respir journal jan 2001
28.Vogiatiz J, Nanas S, Roussos C. Interval training as an alternative modality tocontinue exercise in patients with COPD. Eur . Respir J.2008:20:12-19
8/3/2019 Introduction to Refference
42/46
42
29.Salman G F , Mosier M C, Beasley B W,Calkins D R,rehabilitation for patientswith COPD; meta-analysis of randomized controlled trial.J.Gen.Intern
Med.2003.mar,18(3):213-21
30.Lacasse, Brosseau L, milne S, Martin s, Wong E , Guyatt G H,et al, pulmonaryrehabilitation for COPD. Cochrane Database syst.Rev. 2002; (3):CD003793
31.Ries, AL pulmonary rehabilitation and lung volume reduction surgery Fessler, HE Reilly, J sugar Baker , D J eds. Lung volume reduction surgery for emphysema
2004.123-148 marcel Dukker, New York,N
32.Stulbarg, MS, Carrieri- Kohlman, V, semir- Deviren, S,etal, Exercises trainingimproves outcomes of a dyspnea self management program J. Cardio pulmon .
Reholb.2002, 22, 109-121
33.C R Kothari research methodology methods and techniques.2nd edition 200434.S.P Guptha, Statistical methods 12 ed, Sulthanchand and sons publishers 2000,
28th edition.
35.Green RH, singh SJ, Williams J, Morgan MD. A randomized controlled trial offour weeks versus seven weeks of pulmanory rehabilitation in chronic obstructive
pulmonary disease. Thorx 2001;56:143-5
36.Ries AL, Kaplan RM,Myers R, prewitt LM. Maintenance after pulmonaryrehabilitation in chronic lung disease: a randomized trial. Am J Rspir Crit Care
Med 2003;167:880-8
37.Belman MJ, Botnick WC, Nathan SD, chon KH. Ventilatory load characteristicsduring ventilatory muscle training. Am J Respir Crit Care Med 1994;149:926-9
8/3/2019 Introduction to Refference
43/46
43
38.Lotters F, van Tol B , Kwakkel G , Gosselink R. Effects of controlled inspiratorymuscle training in patients with COPD: a meta-analysis. Eur Respir J
2002;20:570-6
39.Bernard S, Whittom F, Leblanc P, Jobin J, Belleau R, Berube C ,et al. Aerobicand strength training in patients with chronic obstructive pulmonary disease, Am
J Respir Crit Care Med 1999;159:896-901
40.Schols AM, Slangen j,Volovics L, Wouters EF. Weight loss is a reversible factorin the prognosis of chronic obstructive pulmonary disease. Am j Respir Crif Care
Med 1996;157:1791-7
41. Global initiative for chronic obstructive pulmonary disease42.MurrayCJL,LopezAD,Evidence based health policy 1996;274:740-343.SametJM,Definitions and methodology in COPDresearch,In:Hensley M Saunders
N ,eds clinical epidemiology of chronic obstructive pulmonary disease.
Newyork:narcel Dekker;1989 p1-22.
44.Thom TJ .International comparison in COPD mortality,AM REV Respir Dis1989,140 S27-34
45.Vermeire PA,PrideNB ,A splitting look at chronic non specific lung disease.EurRespir.J 1991;4;490-6.
46.Lange .P, Parner J, Vestbo J, SchnohrP,Jensen GA 15 year follow up study ofventilatory function in adults with asthma. N .Engl J Med 1998;339:1194-200.
8/3/2019 Introduction to Refference
44/46
44
47.Humer felts ,Gulsuik ,Skjaerven R ,Nilssen S ,Kvale G,Sulneim O,ET AL.Decline in FEV1 and airflow limitation related to occupational exposures in men
of urban country.
48.Muller JB, Wright JL, Wiggs BR, Pare PD ,Hogg JC .Reassessment ofinflammation of airways in chronic bronchitis.
49.Casio.M, Ghezzo H ,Hogg JC ,Corbin R ,Loveland M ,Dosman J et al ,therelation between structural changes in small airways and pulmonary function test
.N.Engl J Med ,1978,298;1277-81
50.Georgo poolos D, Anthonisen NR, symptoms and signs of COPD. In:cherniack NS,ed. chronic obstructive pulmonary disease. Toronto; WB Saunders:1991
p.357-63.
51.Burrows B, Niden AH, Barclay WR, Kasik JE, chronic obstructive pulmonarydisease H, and Relationship of clinical and physiological findings to the severity
of airways obstruction. AMREV Resp.dis 1965;91:665-78.
52.American Thoracic Society , lung function testing selection of refence values andinterpretativestrategies.AM REV Respir.dis,1991:144:1202-18.
53.Celli BR .Pulmonary rehabilitation in patients with COPD.AMJ Respircrit caremed 1995:152,861-4
54.Vestbo J Sorensent, Lange P,Brix J Torry P, Viskum K, Longterm effects ofinhaled dudesonide in mild and moderate COPD.A randomized control
trial.Lancet 1999:353:1819-23.
55.Chronic obstructive pulmonary disease. From wikipedia, free encyclopaedia
8/3/2019 Introduction to Refference
45/46
45
56.Diaphragmatic breathing reduces efficiency of breathing in patients with chronicobstructive pulmonary disease. Vol.151 ,No 4
57.The effects of pulmonary rehabilitation in elderly patients.58.Comparison of the oxygen cost of breathing exercises and spontaneous breathing
in patients with stable chronic obstructive pulmonary disease.
59.Six minute walk test in respiratory disease: a university hospital experience.60. New strategies to improve exercise tolerance in chronic obstructive pulmonary
disease
61.Dyspnoea in COPD: Can inspiratory muscle training help?62.Inspiratory muscle training in chronic airflow limitation: effect on exercise
performance.
63.Effects of a short term pulmonary rehabilitation program on patients with chronicrespiratory failure due to pulmonary emphysema.
64.Dyspnea in health and obstructive pulmonary disease: the role of respiratorymuscle function and training.
65.Inspiratory muscle training in patients with COPD: effect of dyspnoea, exerciseperformance, and quality of life.
66.Bartlome R Celli, Pulmonary rehabilitation for COPD, Post graduate medicineonline, 1998.
67.Scot Irwin, cardio pulmonary physical therapy,4th edition, U.S: Mosby ,2000
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APPENDICES
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