Rajivgandhi University of Health Sciences, Karnataka s1

DISSERTATION SYNOPSIS

SUBMITTED TO

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

TOWARD PARTIAL FULFILMENT OF

MASTER OF PHYSIOTHERAPY DEGREE COURSE

HIRALBA JOGAJI PARMAR

UNDER THE GUIDANCE OF

Prof. NATARAJAN S.

VIKAS COLLEGE OF PHYSIOTHERAPY URWA-CHILIMBI, MANGALORE-575006

2010 – 2012 RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the Candidate HIRALBA JOGAJI PARMAR And Address VIKAS COLLEGE OF PHYSIOTHERAPY, URWA – CHILIMBI, ASHOKNAGAR P.O., MANGALORE – 575006

2. Name of the Institution VIKAS COLLEGE OF PHYSIOTHERAPY Mangalore.

3. Course of study and subject Master of Physiotherapy in Cardio-respiratory Disorders and Intensive Care

4. Date of admission to Course 15-09-2010

5. Title of the Topic

Effects of Pursed-Lip Breathing exercise on dyspnea in Pulmonary Rehabilitation 6 BRIEF RESUME OF THE INTENDED WORK

6.1) Need for the study

Pursed-lip breathing (PLB) is a maneuver that is frequently taught to patients with chronic obstructive pulmonary disease (COPD) in respiratory physiotherapy programs to improve breathing efficiency and better manage dyspnea during activities of daily living. Researchers first became interested in PLB when emphysema patients were clinically observed to breathe instinctively with the lips semi-closed in an attempt to minimize dyspnea. Although this technique had been described and recommended in the mid-1950’s and beginning of the 1960’s, even now, forty years later there are few studies on PLB in the literature and the factors underlying its efficacy are not well understood.1

While most studies have focused on patients with COPD, some have found that PLB may be beneficial in certain neuromuscular diseases and exercise–induced asthma.1 Patients show a significant decrease in end expiratory lung volume (EELV), with greater reduction occurring with more severe obstruction as defined by forced expiratory volume in one second (FEV1).2-4 Mechanically, EELV represents the point of equilibrium between the forces of elastic recoil of the lungs and the chest wall. A decrease in EELV represents an increase in the elastic recoil of the chest and potentially more energy for inspiration which may occur passively as a result of the potential energy of the chest wall at the end of expiration.5,6 At rest there is a significant increase in Pao2 and Sao2 and a significant decrease in Paco2 due to PLB. No significant changes in the arterial gases during exercise are observed. PLB may improve gas exchange at rest but not during exercise.7

PLB regulates respiration in COPD patients at rest by significantly decreasing breathing frequency and increasing tidal volume.7,8 Thus, this breathing pattern seems to be more effective than spontaneous breathing in COPD patients. Muller et al identified 2 types of patients. The first type, who reported symptom relief had an increase in tidal volume and a significant decrease in breathing frequency when using PLB, while the second type, though reporting no improvement, showed a significant decrease in breathing frequency, although no change in tidal volume. These findings support the idea that not all patients benefit from this breathing pattern.7

PLB causes significant decrease in minute ventilation output in COPD patients both at rest and during exercise.7,4 However, other studies have found no significant differences in minute ventilation. Although findings related to minute ventilation are few and controversial, it can be stated that the increase in tidal volume during PLB is sufficient to maintain minute ventilation unchanged, despite the decrease in breathing frequency.1

PLB significantly reduces the respiratory duty cycle (ratio of inspiratory time to total time) and the diaphragmatic tension time index in COPD patients.9 PLB also causes change in the pattern of respiratory muscle recruitment, increasing recruitment of the accessory muscles of the chest wall and increasing abdominal muscle activity throughout the entire respiratory cycle, while at the same time, decreasing diaphragmatic muscle recruitment. All these changes lead COPD patients to breath more efficiently and consume less oxygen; as a result the propensity of the diaphragm to become fatigued during crisis or physical exercise decreases.10

The impact of PLB on dyspnea in patients with emphysema, who perform PLB instinctively decreased breathlessness in these patients, was produced by the reduction in the variability of expiratory flows, causing a decrease in the Bernoulli effect created by airflow and thereby reducing the tendency of airways to collapse.11 Nonetheless, Breslin et a using the Borg scale to study dyspnoea in COPD patients, compared spontaneous breathing to PLB breathing and found that PLB despite increasing ventilation did not reduce the degree of dyspnoea and even significantly increased it in some patients12, and PLB increased fatigue and respiratory effort, as measured by the Borg scale. The effects of PLB on COPD patients, none of whom had dyspnoea at baseline, showed during submaximal exercise that dyspnoea was more severe in patients who performed PLB than in those who did not.4

From these studies, we can conclude that the effect of PLB on dyspnoea patients is still unclear because results published to date are not consistent with the relief of breathlessness reported by some patients and further studies are necessary.

6.2) Review of Literature

1. Spahija in a study investigated the effect of volitional pursed-lips breathing (PLB) on breathing pattern, respiratory mechanics, operational lung volumes, and dyspnea in 8 COPD patients. Wearing a tight–fitting transparent facemask, patients breathed for 8 min each, with and without PLB at rest and during exercise. Results showed that PLB promoted a slower and deeper breathing pattern both at rest and during exercise. Whereas patients had no dyspnea with or without PLB at rest, during exercise dyspnoea was variably affected by PLB across patients. Changes in the individual dyspnea scores with PLB during exercise were significantly correlated with changes in the end–expiratory lung volume (EELV). They concluded that PLB can have a variable effect on dyspnea when performed volitionally during exercise by patients with COPD. The effect of PLB on dyspnea is related to the combined change that it promotes in the tidal volume and EELV and their impact on the available capacity of the respiratory muscles to meet the demands placed on them in terms of pressure generation.9

2. Nield MA, Soo Hoo GW, Roper JM, Santiago S conducted a randomized, controlled study to compare 2 programs of prolonging expiratory time (pursed–lips breathing and expiratory muscle training) on dyspnoea and functional performance in 40 COPD patients. Subjects were randomized to 1. Pursed–lip breathing, 2. Expiratory muscle training or 3. Control. Changes over time in dyspnea [modified Borg after 6-minute walk distance (6MWD) and shortness of Breath questionnaire] and functional performance (Human activity Profile and physical function scale of short Form 36-item Health Survey) were assessed with a multilevel modelling procedure. Results showed that significant reduction for the modified Borg scale after 6MWD and physical function from baseline to 12 weeks were only present for PLB. They concluded that Pursed-lips breathing provided sustained improvement in exertional dyspnea and physical function.

3. Tiep BL, Burns M, Kao D, Madison R, Herrera conducted a randomized, controlled study to evaluate the efficacy of PLB in improving arterial oxygen saturation, removal of CO2 and relieving dyspnea. Twelve hypoxemic subjects with stable COLD were randomly assigned to either the PLB or control group consisting of general relaxation. The SaO2 was monitored via ear oximetry, and respiratory rate and tidal volume were monitored using a strain gauge transducer and the minute volume was calculated. The PLB was taught by an experienced instructor using the ear oximeter as a monitoring display with a goal toward increasing SaO2. The subject was taught general relaxation with the aid of pleasant music. Comparison of general relaxation and PLB treatments using an A-B-A crossover study design showed, a significant improvement in SaO2 over baseline in both groups, whereas general relaxation did not. They concluded that patients can learn to increase their SaO2 by PLB using ear oximetry adjunctively.

4. Nield MA, Soo Hoo GW, Roper JM, and Santiago S, a study to compare 3 methods for teaching a breathing strategy of prolonged, gentle exhalation on dyspnea relief and improved health-related quality of life (HQOL) in patients with severe COPD. 53 subjects were randomized to either: 1. control; 2. inspiratory muscle training (IMT); 3. expiratory muscle training (EMT); or 4. structured PLB with oxygen saturation level as feedback. Results showed that dyspnea was significantly different for the PLB group, but not IMT or EMT, as compared to the control group. They concluded that only PLB group showed a sustained improvement in dyspnea, mental health and physical function. 5. Jones AYM, Dean E and Chow CCS conducted a study to compare the oxygen cost of 3 common breathing exercises believed to reduce oxygen cost (i.e work of breathing) with that of spontaneous breathing in patients chronic obstructive pulmonary disease. Thirty subjects with stable, moderately severe COPD participated. Oxygen consumption and respiratory rate (RR) during spontaneous breathing at rest (SB) were recorded for 10 minutes. Subjects then performed 3 breathing exercise in random order, with a rest between exercises: diaphragmatic breathing (DB), pursed-lip breathing (PLB) and a combination of DB and PLB (CB). Oxygen consumption and RR were measured. Results showed O2 consumption and RR was lower during the breathing exercise. Also RR was high during SB, followed by DB, PLB and CB. They concluded that, given that patients do not spontaneously adopt the breathing pattern with the least VO2 and RR studies are needed that focus on understanding the mechanics and the energetics of the spontaneous breathing pattern people with COPD, and its determinants, to provide a rational basis for physical therapy management, and 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.10

6. Breslin EH, conducted a randomized study on 13 COPD patients to investigate the pattern of chest wall muscle recruitment during pursed–lip breathing (PLB). Results showed that pursed-lip breathing led to increased rib cage and accessory muscle recruitment during inspiration and expiration, increased abdominal muscle recruitment during expiration, decreased duty cycle of the inspiratory muscles and respiratory rate, and improved SaO2. The study concluded that, the improved SaO2 indicate a mechanism of improving ventilation with PLB while protecting the diaphragm from fatigue in COPD. Alterations in the pattern of respiratory muscle recruitment with PLB may be associated also with the amelioration of dyspnea.12 6.3) Objectives of the study

The objective of this study is to investigate, in a randomized, prospective study, the effect of pursed-lip breathing exercise on dyspnoea in COPD patients. Specifically to determine 1. The effect of PLB exercise in reducing dyspnoea and improving ventilation. 2. The effect of PLB exercise in improving tolerance for physical activity. 7 MATERIALS AND METHODS

7.1 Source of data

Data will be collected from patients who are referred to the Govt. Wenlock hospital, Mangalore, and the out-patient department of Vikas College of Physiotherapy, Mangalore, with diagnosis of COPD and complaints of dyspnoea, after obtaining informed consent.

7.2 Method of collection of data

Hypothesis

Pursed lip breathing exercise is effective in reducing dyspnoea and improving tolerance for physical activity in COPD patients.

Null Hypothesis

Pursed lip breathing exercise is not effective in reducing dyspnoea and improving tolerance for physical activity in COPD patients.

Research Design

Single factor experimental design will be used for this study.

Sampling method

Random sampling method METHODOLOGY

Patients with complaints of dyspnoea, who are diagnosed to have COPD, will be randomly assigned to one of two groups. Each group will consist of 15 patients and will include both male and female patients within the age group of 40-60 years. To be eligible for the study the subjects should fulfill the following inclusion and exclusion criteria

Inclusion Criteria

1. A clinical diagnosis of stable COPD, as defined by American Thoracic Society Criteria

2. No history of Asthma

3. No exacerbation of COPD in the 2 months prior to recruitment

4. No acute chest infection or surgery within the last 2 months

5. Aged 40-60 years of both gender

6. Baseline pre-bronchodilator FEV1 of 25-80% predicted

7. Reversibility of FEV1 post-inhalation of bronchodilator

8. Pre-bronchodilator ratio FEV1/inspiratory vital capacity ≤ 60%

9. TLC greater than TLC predicted

10. Use of nasal corticosteroids, theophyllines, acetylcysteine and all other bronchodilators was allowed

11. Walk independently without aids

Exclusion criteria

1. Current smoker

2. Maintenance treatment of oral steroids or antibiotics

3. Interstitial lung disease

4. Lung cancer 5. Other active lung disease

6. Neuromuscular disorders

7. Spinal deformities

8. Cardiac insufficiency and disorders

9. Psychiatric Morbidity like alcoholism

10. Endocrine disorders

11. Metabolic disorders

12. Active gastrointestinal problems

13. Patients on supplemental oxygen

Interventions

One group, which is a control group, will be trained in Relaxed Diaphragmatic Breathing (RDB), and the other group will be trained in PLB. Both groups will undergo training for 8 weeks.

Group 1: This group will consist of 15 subjects (N=15) of both gender and they will be trained in relaxed diaphragmatic breathing.

RDB is the normal pattern of inspiration and expiration. The instruction given will be breath in slowly through your nose and aim at getting the air to the lower parts of your lungs; remember to relax your tummy and allow the air to under here (the investigator put his hand on the subject’s epigastric/subcostal region). Then relax and let all air out through your mouth, allowing your tummy to sink in.

Group 2: This group will consist of 15 subjects (N=15) of both gender and they will be trained in pursed lip breathing (PLB).

PLB is the normal pattern of inspiration, but expiration was performed by gently blowing through pursed lips. The instruction given will be breath in slowly through your nose and aim at getting the air to the lower parts of your lungs; remember to relax your tummy and allow the air to under here (the investigator put his hand on the subject’s epigastric/subcostal region). Then blow gently through your loosely closed lips, like blowing a candle flame so that it bends but does not blow out.

Evaluation

Before the beginning of the study the subjects’ pre and post-bronchodilator lung volumes and capacities are measured using spirometry to evaluate the FEV1, ratio of FEV1/ inspiratory vital capacity and Total Lung Capacity to find out their eligibility for the study. Further, before the beginning of the study and after 8 weeks of training all patients will be evaluated in the following outcome measures. 1. Respiratory Rate

2. Tidal Volume using spirometry

3. Modified Borg’s Scale of perceived rate of exertion after Six Minute Walk Distance (6 MWD) Test

7.3 Statistical Analysis

The data collected will be analyzed using parametric tests as the data are interval in nature. The intra group pre and post-test data will be analyzed using paired t-test, while the post-test inter group data will be analyzed with unpaired t- test.

7.4 The study requires non-invasive investigations and interventions to be conducted on patients. The investigations to be conducted include physical examination of the Lungs like inspection, palpation, percussion, auscultation, Six minute walk distance test and Lung function tests using Spirometry. Treatment interventions include Relaxed Diaphragmatic Breathing and Pursed-lip Breathing.

7.4 Ethical Clearance Ethical clearance has been obtained from the ethical committee of our institutions to carry out the investigations and interventions on patients necessary for this study. 8 List of References

1. Fregonezi GAF, Resqueti VR, Rous RG. Pursed Lips Breathing. Arch Bronconeumol 2004; 40:279 - 282

2. Bianchi R, Gigliotti F, Romangnoli I, Lalnini B, Castellani C, Grazzini M, et al,. Patterns of chest walk kinematics during pursed lip breathing in patients with COPD. Eur Respir J 2003; 22 (Suppl 45):551.

3. Nerini M,Gigliotti F,Lanini B,Stendardi C,Castellani R, et al.. Changes in global and compartmental lung volumes during pursed lip breathing (PBL) in COPD patients (abstract). Eur Respir J 2001: 18 (Suppl 33):489.

4. Ugalde V, Breslin EH, Walsh SA, Bonekat HW, Abresch Carter GT.. Pursed lips breathing improves ventilation in myotonic muscular dystrophy. Arch Phys Med Rehabil 2000: 81:472-8.

5. Tisi GM. Pulmonary physiology in clinical medicine. 2nd ed. Baltimore: Williams & Wilkins, 1998

6. Henke KG, Sharratt M, Pegelow D, Dempsey JA.. Regulation of end- expiratory lung volume during exercise. J Appl Physiol 1988; 64:135-46.

7. Mueller RE, Petty TL, Filley GF. Ventillation and arterial blood gas changes induced by pursed-lips breathing. J Appl Physiol 1970; 28:784-9

8. Thoman RL, Stoker GL, Ross JC. The efficacy of pursed –lips breathing in patients with chronic obstructive pulmonary disease. Am Rev. Respir Dis 1966, 93 -100-6

9. Spahija J, Marchie M, Grassion A. Pursed – lips breathing during exercise increases dyspnea (abstract) Am Rev Respir Dis 1993: 147-A729.

10. Jones AYM, Dean E, Chow CCS. Comparison of the oxygen cost of breathing exercises and spontaneous breathing in patients with stable chronic obstructive pulmonary disease. Physics Therapy 2003; 83:424-31.

11. Schmitt RW, Wasserman K, Lillington GA. The effect of air flow and oral pressure on the mechanics of breathing in patients with asthma and emphysema. Am Rev Respir Dis 1964;90:564-71 12. Breslin EH. The pattern of respiratory muscle recruitment during pursed lip breathing. Chest 1992 , 101: 75-78

13. 9. Signature of the candidate :

10. Remarks of the Guide

11. Name and Designation of

11.1 Guide : S. NATARAJAN M.P.T. Professor

11.2 Signature :

11.3 Co-Guide : -

11.4 Signature : -

11.5 Head of the Department : Prof. S. NATARAJAN M.P.T.

11.6 Signature :

12. 12.1 Remarks of the Chairman and Principal

12.2 Signature :