Rajiv Gandhi University of Health s1

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE : ASHA LATHA S AND ADDRESS I YEAR M.Sc NURSING B G S COLLEGE OF NURSING APOLLO B G S HOSPITAL MYSORE

2. NAME OF THE INSTITUTION : B G S COLLEGE OF NURSING MYSORE

3. COURSE OF STUDY AND SUBJECT : I YEAR M.Sc NURSING COMMUNITY HEALTH NURSING

4. DATE OF ADMISSION OF COURSE : 13-6-2008

5. TITLE OF THE TOPIC :“RESPIRATORY HEALTH BEFORE AND AFTER BREATHING EXERCISES AMONG TRAFFIC POLICE.”

1 6. BRIFE RESUME OF THE INTENDED WORK

INTRODUCTION :

“And the Lord God formed man of dust of the ground and breathed into his nostrils the breath of life and man became a living being” (Genesis 2:7)

Health is very much essential for every individual to live in this world. Health has evolved from an individual concern to a world wide social group. WHO has developed “The Global Plan of Action on Workers’ Health (2008-2017)”. According to WHO and ILO estimates for the year 2000 there are 2.0 million work-related deaths per year. WHO estimates that there are only 10-15% of workers who have access to a basic standard of occupational health services. 1,5

Police is one of the profession which is an organized body of civil servants and officers in a city, town, or district, who are responsible for smooth working, effective enforcement of law and order, the prevention and detection of crime. Traffic police are mainly concerned with the highest standard of smooth and safe flow of traffic by effective enforcement of traffic regulations. Traffic Police personnel are exposed to different health and safety risks in their occupation. Traffic police are prone to have hazardous effect on the respiratory health i.e. the respiratory functions are altered.2

Respiratory health means the respiratory system is healthy and functioning normally. Respiratory functions are maintained by the respiratory system. Respiratory system is made up of the organs(lungs) involved in the interchanges of gases(breathing). Breathing is essential for the maintenance of optimum oxidation process in the cells and intracellular (endogenous ) respiration .3

Exercise is the key to the full utilization of the lungs. Breathing exercises means the art of healing aimed to deepen inspiration or expiration or even to alter the rate and rhythm of respiration .The breathing exercises makes to use entire lung and the chest muscles actively and 2 helps to get the needed amount of the oxygen for normal functioning of the body .Air is a vital component for us to live as air breathed in has oxygen (21%) required to generate energy needed by the cell in the body for chemical reactions in presence of oxygen. The environment we live is the only source of air , all living beings too depend on it , for their existence . During the process of breathing the lung ventilation and gas exchange between the body cells and the atmosphere occurs . When this occurs then the respiratory system is said to be healthy.3,9, 5

This can be assessed by using the bio-physical measures. Lung function tests is also called as pulmonary function tests .This evaluates how well our lungs work .Forced Vital Capacity (F V C ) is the total amount of air that can forcibly be blown out after full inspiration , F E V1 is the volume of air that can forcibly blow out in one second , FEV1 / FVC normal is 75 - 80%. The average flow or speed of air coming out of the lung during the middle portion of the expiration is Forced Expiratory Flow (FEF) is 25-75% or 25-50%, mean forced expiratory flow is 200-1200ml. Forced Inspiratory Flow 25%-75% or 25%-50% this is similar to FEF 25%-75% or 25%-50% except the measurement is taken during inspiration. The tests determine how much air the lungs can hold, how quickly the air can move in and out of the lungs, and how well the lungs put oxygen into and remove carbon dioxide from blood. The tests can diagnose lung diseases, measure the severity of lung problems. Spirometry means the measuring of breath its the most common of the Pulmonary Function Tests specifically measuring the measurement of the volume and speed (flow) of air inhaled and exhaled.3

As the brain, is the body's single largest consumer of oxygen represents only about 2% of the body's weight, it utilizes about 20% of the body's oxygen. The brain is sensitive to hypoxia ,without oxygen large numbers of brain cells begin to die. Prolonged hypoxia (e.g. suffocation) results in death. In order to have normal functioning of body one must breath well, full, deep inspirations of pure air fills the lungs and with oxygen purify the blood. Therefore paying attention to breathing, and practicing breathing techniques improve lung capacity and overall well-being.3, 6

6.1 NEED FOR THE STUDY.

3 The spurt in air pollution levels in Mysore might just take the sheen out of the city a survey conducted on air quality, noise levels and vehicular flow by an Environmental Education Centre of Chennai and Mysore Grahakara Parishat conducted the survey, which was sponsored by the Union Ministry of Environment and Forests in October 2008 has yielded shocking results. “Mysoreans are exposed to air and noise pollution which are above permissible limits.”11

National Ambient Air Quality Standards define permissible limits for various types of air pollution. The permissible limit for non-industrial areas are — suspended particulate matter 200 micrograms per cubic centimeter, oxides of nitrogen 80 mig/cc and sulphur dioxide 80 mig/cc. However, according to the survey, suspended particulate matter values ranged from 297 micrograms per cubic centimeter at Chamundipuram to 457 micrograms per cubic centimeter at K.R. Circle.This shows that presently there is an increase in the air pollutants in Mysore city. 7,11

Air pollutants consist of three main components — suspended particulate matter or dust and soot; oxides of nitrogen and sulphur dioxide. Suspended particulate matter can cause cancer, aggravate pre-existing lung and heart conditions and slow down healing of wounds by affecting blood coagulability. Oxides of nitrogen cause respiratory diseases such as bronchitis and pneumonia and aggravate asthma and reduce immunity. Sulphur dioxide acts just as oxides of nitrogen do on human health.5,9,13

The health effects of air pollutants are both immediate and delayed . Studies (2001) India indicated that the impact of air pollution on the Traffic Police is about 87% on respiratory health affected by the vehicular air pollutants. The major population affected directly by the vehicular source of air pollutants are the traffic police personnel. The Government General and Chest hospital, Hyderabad conducted survey in the twin cities Hyderabad and Secunderabad among 800 traffic police constables who were exposed to dust and vehicular pollution. They found that 45% were suffering from the respiratory and non-respiratory health problems.12

4 The Traffic Police are the personnel who work among all the major vehicular pollutants for 7-10hrs of duty with limited ventilation and excessive congestion to the respiratory system. Exposure to environmental pollutants is known to be harmful to health, in general and to lungs in particular. In this aspect Traffic police are at particular risk due to the nature of their job, since they are exposed to emissions from the vehicles can increase oxidant stress; decrease the levels of antioxidants and nitric oxide. This imbalance in the oxidant and antioxidant system may lead to lung damage and is likely to cause respiratory problems in individuals exposed to air pollution.10

There are many research studies conducted on the effects of air pollution on general health of traffic police and recommendations are given for the use of the protective devices. Most of the research studies are directed to find out the incidence and prevalence of the respiratory problems but limited research are by nursing professionals regarding assessment and interventions related to the respiratory health maintenance.

Hence the researcher felt that, it would be useful and beneficial if there is a use of the exercises among Traffic police as they are in the risk bound area. The main purpose of breathing exercises is to make the respiratory system function at its best. This automatically improves the circulatory system without which the processes of digestion and crimination will suffer.3,6

In Mysore City the researcher has located 256 traffic police under The Commissioner of Police Mysore with 3 Traffic Police station as N.R .Traffic Zone , K R. Traffic Zone and Devaraja Traffic zone with 1 Traffic Police Inspector,2 Traffic Police Sub-Inspectors,5 Assistant Sub – Inspectors,21 Head Constables in each zone and 56 Police constables under 2 zone and 57 in one zone. Then found that no research studies have been performed among the Traffic personnel regarding respiratory health till date, guided by all these facts the researcher is encouraged to conduct a study among traffic police regarding respiratory health before and after breathing exercises.

6.2 REVIEW OF LITERATURE :

5 The review literature are presented under the following headings: 1.Studies regarding respiratory health in general 2.Studies related to breathing exercises and respiratory health 3. Studies related to the respiratory health among traffic police

1.Studies regarding respiratory health in general.

Suryanarayan.D (2007) The Environment Pollution Research Centre (EPRC) of KEM Hospital’s department of chest medicine Mumbai carried out a study project to take note of the growing environmental pollution and its impact on children as an ‘asthma prevalence study’ among school students from six areas across the city — Worli, Khar, Andheri, Borivli, Bhandup and Maravli (Chembur) Out of 650 students surveyed, almost 15 per cent reported breathing problems at some time in their lives. But only 3.9 per cent were taking medication. Complaints included allergic rhinitis, chronic cough, frequent colds, tightening of the chest muscles when breathing, wheezing, and chronic obstructive pulmonary disorder. And, 108 students reported breathlessness with a cold, while 98 complained of breathlessness on exposure to smoke due to increasing in the growing environmental pollution. 14

Sagar.A (2006) National Institute of Health and Family Welfare, conducted a comparative study of air pollution-related morbidity among exposed population. They assessed the pattern of morbidity in two areas of Delhi, one highly polluted area (HPA) and the other low polluted area (LPA). 640 subjects were interviewed regarding socioeconomic status and exposure history. Symptoms during the last month were recorded in a questionnaire and weight, height and peak expiratory flow rate (PEFR) were measured. Air pollution data were obtained from the monitoring stations of Central Pollution Control Board (CPCB). Majority of the patients in both the areas were educated till primary but 24% in HPA and 13% in LPA were graduates. Current levels of all pollutants (except SO2 and NOx) were above the safety levels prescribed by CPCB in both the areas. The mean number of symptoms experienced by subjects of HPA was more as compared to LPA (P < 0.05). Frequency of occurrence of symptoms varied with duration of stay in the study

6 area. Children were affected more than the adults. They concluded that air pollution has a deleterious effect on various systems of the body. They found the difference in mean PEFR values among the populations in LPA and HPA were found to be statistically significant (P < 0.05).15

Padhi. B.K (2006) conducted an assessment of 750 adults for intra-urban variability in outdoor air quality and its health risks in West Bengal, India. Ambient air quality along with micrometeorological data was measured in a suburban area, from March 2006 to February 2007 in order to assess the intra-urban variability of air pollutants in different parts of the city. The prevalence of asthma and respiratory disorders were determined using a questionnaire survey. The association between intra-urban variability of air pollution and respiratory diseases were evaluated with logistic regression analyses. Compared with subjects staying 5.0 km away from a main road to those subjects living within 0.5 km and 1.0 km had odds ratios of 1.00 (95% CI, 0.85 to 1.50), 3.57 (95% CI, 3.00 to 3.95), and 3.00 (95% CI, 2.85 to 3.50), respectively for doctor-diagnosed asthma. They concluded that residential exposure to highly trafficked roads is associated with respiratory diseases.16

Rosa AM (2000-2005) a cross-sectional study was conducted to analyze hospitalizations for respiratory diseases among children under 15 years of age in an area at Brazil, with high levels of environmental pollution. They found that 12,777 such admissions, of which 8,142 (63.7%) were for respiratory diseases. The principal causes of admission included pneumonia (90.7%) and respiratory insufficiency (8.5%). Admissions of children fewer than 5 years of age for pneumonia were 4 times than the expected number for the city. Children under 12 months of age were the most frequently hospitalized, with an average increase of 32.4 admissions per 1,000 children per year. As the high number of pediatric admissions for respiratory diseases were found it is logical to consider it a priority area for investigation and monitoring of the environmental risk factors for such diseases.17

Wilson D, (2002) from University of Occupational and Environmental Health, Japan Conducted Respiratory symptoms among residents of a heavy-industry province Prevalence and risk factors. They assessed the prevalence of respiratory symptoms and their risks in relation to personal, occupational and environmental risk factors in a heavy-industry province. Lifestyle,

7 health, residential and occupational data were obtained from 31,704 adults of six cities of China, using self-assessment questionnaires. The crude prevalence rates (PRs) for persistent cough, persistent phlegm, wheeze and asthma were 2.3, 3.8, 2.1 and 1.0%, respectively. The odds ratios (ORs) of all four respiratory symptoms examined were increased by: smoking (ORs from 2.06 to 5.02), occupational dust (ORs from 1.35 to 1.72), occupational gas (ORs from 1.48 to 1.72) and presence of irritating smoke during cooking (ORs from 1.54 to 2.22). Increasing values of each risk factor were generally associated with dose-response trends in prevalence rates and risks (all p for trend <0.01). The risks of respiratory symptoms in population were increased by smoking, occupational exposures to dust and gas, and combined residence-related exposures such as living close to a main road, factory or chimney, indoor coal use and the presence of irritating smoke during cooking, among other risk factors.18

2. Studies related to breathing exercises and respiratory health

Skaria .S,( 2007)conducted a study to find the effect of positive expiratory pressure technique over forced expiratory technique on bronchial hygiene in patients with moderate chronic bronchitis in Bangalore. 30 chronic bronchitis patients were divided into two groups (Group A and Group, consisting of 15 subjects each) in a randomized controlled trail study (each of 2 sessions per day for 15 minutes for 5 days weekly for totally 2 weeks.) Improvement in bronchial hygiene was assessed using peak expiratory flow meter, pulse oxy meter and 10-point Modified Borg’s Scale (Rate of perceived exertion, RPE). Group A was treated with positive expiratory pressure technique using flutter device used with slow and deep breathing in through nose for 3-5 seconds breath out through the device fastly than normally. After 4-8 of these breaths, a deep breath with a ‘hold’ at full inspiration was followed by a forced expiration through the flutter device and was followed by a pause for breathing control .Group B received Autogenic Drainage means the upper air ways were cleared of secretions by huffing or blowing the nose. At the end of 2nd week of intervention they found significant improvement in bronchial hygiene with independent ‘t’ test at p< 0.05 in Group A when compared with Group B. There were significant changes in peak expiratory flow rate (with peak expiratory flow meter), O2 saturation (with pulse oxy meter) and dyspnea level (with modified Borg’s scale) in Group A than Group B.19 8 Moiz . J.M,(2007) The effect of a short term treatment of autogenic drainage (AD) and active cycle of breathing techniques (ACBT) were evaluated in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) in Escorts hospital(ward/IMCU ), Faridabad .30 male COPD patients with acute exacerbation were trained to suppress the cough and the Active cycle of breathing exercise was repeated through out the 30-minute treatment session and to clear the upper airways (nose or throat) by huffing or blowing nose the patient began by performing the diaphragmatic breathing at low lung volume inspiration was slow with a pause of three seconds, and expiration was done without forced expiration. Randomly assigned two groups and they performed each technique on successive days. Dependent variables were measured before treatment, during treatment, immediately after treatment and 30 minutes after treatment, sputum volume, SpO2, heart rate, Peak Expiratory Flow Rate (PEFR), respiratory rate, Visual Analog Scale (VAS) and patients preference. General linear model repeated measure of variance was used to examine the changes in dependent variables; level of significance was set at p <0.05. There was statistically significant difference SpO2, HR, and VAS between the treatments however none of these changes was clinically significant. Within treatment analysis showed both the treatments were equally effective in removing secretion, improving oxygenation and thereby decreasing dyspnea.20

Nield MA,(2007), assessed the efficacy of pursed-lips breathing a breathing pattern retraining strategy for dyspnea reduction among 40 subjects of 65 years with COPD in USA. The study aimed to compare 2 programs of prolonging expiratory time (pursed-lips breathing and expiratory muscle training) on dyspnea and functional performance. 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 modeling procedure. Weekly laboratory visits for training were accompanied by structured verbal, written, and audiovisual instruction. Among 40 subjects with chronic obstructive pulmonary disease age 65 years. No significant Group x Time difference was there for PE max (P = .93). Significant reductions for the modified Borg scale after 6MWD (P = .05) and physical function (P = .02) from baseline to 12 weeks were only present for 9 pursed-lips breathing. The finding suggested that Pursed-lips breathing provided sustained improvement in exert ional dyspnea and physical function.21

Sanchez Riera H, (2001) conducted a study to assess the Inspiratory muscle training in patients with COPD in Spain.They aimed to assess the effect of target-flow inspiratory muscle training (IMT) on respiratory muscle function, exercise performance, dyspnea, and health-related quality of life (HRQL). 20 patients with severe COPD were randomly assigned to a training group (group T) or to a control group (group C) following a double-blind procedure. Patients in group T (n = 10) trained with 60 to 70% maximal sustained inspiratory pressure (SIPmax) as a training load, and those in group C (n = 10) received no training. Group T trained at home for 30 min daily, 6 days a week for 6 months measurements included spirometry, SIPmax, inspiratory muscle strength, and exercise capacity, which included maximal oxygen uptake (VO(2)), and minute ventilation (VE). Exercise performance was evaluated by the distance walked in the shuttle walking test (SWT).They found that significant increases in SIPmax, maximal inspiratory pressure, and SWT only in group T (p < 0.003, p < 0.003, and p < 0.001, respectively), with significant differences after 6 months between the two groups .So they came to the conclusion that IMT relieves dyspnea, increases the capacity to walk, and improves HRQL in COPD patients.22

3. Studies related to the respiratory health among traffic police.

Express News (2006), Vadodara Police in collaboration with Cipla, Dr Manoj Yadav pulmonologist in the four-day free medical check-up for all personnel in the traffic division, specifically for respiratory ailments. Found that about 15 per cent of the personnel in the Vadodara Traffic Department exhibited signs of respiratory ailments and were in need of urgent medical intervention. Traffic police are usually the most susceptible to respiratory diseases as they spend the better part of each day on the city’s most congested roads, exposed to all kinds of vehicular pollution. The medical tests were conducted by Doctors Manoj Yadav and Nishant Soni from the Kailash Hospital in Alkapuri, which specialises in respiratory diseases. The tests included a spirometry test to check lung efficiency, using a specially designed spirometer .Preventive measures had already tried some like pollution masks and pure oxygen inhaling centers. Regular 10 breathing exercises, daily physical workouts and rotation of shifts was recommended to reduce the susceptibility. 23

Dragonieri. S,( 2005), conducted a study to determine the presence of airways inflammation detected by induced sputum in a population of traffic policemen compared to a group of healthy subjects (HS) without any occupational exposure to inhalation of traffic-related air pollution. Twelve non smokers, healthy traffic policemen with a history of exposure to airway pollution and 12 HS underwent sputum induction in Italy. Traffic policemen showed a statistically significant increase in the percentage neutrophil cell count (median and IQ range) compared to the HS (65 and 13.5 vs. 40.5 and 9.5; p < 0.01). They found that policemen chronically exposed to air pollution presented airway neutrophilic inflammation. They recommended that the long term effect of a traffic pollution in airway inflammation and the lung function can be studied .24

Tamura K, (2003) conducted a cross-sectional study to examine the relationship between traffic-based particulate air pollution and chronic, nonspecific respiratory symptoms among traffic policemen in Bangkok. A total of 1,603 policemen were evaluated who lived and worked in areas that had 3 different levels of airborne particulates. They used a modified standardized questionnaire to identify nonspecific respiratory disease (NSRD) in participants. The prevalence of NSRD in heavily polluted, moderately polluted, and suburban areas was 13.0%, 10.9%, and 9.4%, respectively. They concluded that the increased prevalence of respiratory symptoms among traffic policemen was associated with urban traffic air pollution.25

Ingle.S .T(2003), studied the exposure to Vehicular Pollution and Respiratory Impairment of Traffic Policemen in Jalgaon City, India. Studied the ambient air quality monitoring was carried during the May 2003 to April 2004 along the (NH-6) passing through Jalgaon city by School of Environmental and Earth Sciences, North Maharashtra University. The average concentration of SOx 64 μg/m3, NOx 58 μg/m3, particulates (>10 μ) 515 μg/m3 and respirable dust particulates 224 μg/m3 was reported. The investigatiors surveyed the health status and lung function of traffic policemen in the age group of 20–55 year it comprised 60 traffic policemen and as control group 60 healthy young adult natives of same city were included in the study. A questionnaire was used to generate information on self-reported health problems. The spirometric analysis of traffic

11 policemen shows significant variation in Peak Expiratory Flow Rate (PEFR), Forced Expiratory Volume in one second (FEV1) and Forced Vital Capacity (FVC). The study revealed significant respiratory impairment in the traffic policemen due to exposure to vehicular pollution. Overall difference was based on one-way p<0.0001 and <0.0017. Test was performed for comparison of expected and observed values against their individual pulmonary function test in traffic policemen and control group, where p values were significant. They concluded that the traffic policemen are highly vulnerable for respiratory impairment due to vehicular exhaust at workplace environment. The regular periodic health checkup was recommended to understand the impact of vehicular pollution on the health of traffic policemen. 26

Pala.K,(2001) conducted a study to assess the Blood lead levels of traffic policemen.For that he has selected 99 traffic policemen who were included in the study, 21 were office workers in Turkey . Blood lead levels were determined by using an electro-thermal atomic absorption spectrometer (ET-AAS). Average blood lead levels were 9.4±1.6 μg/l and 8.7±1.7 μg/l for policemen working outdoors and indoors, respectively. The difference between the two groups was statistically insignificant (P>0.05). When policemen less than 15 years on duty were taken into account (n=48) the difference between the outdoors and indoors working groups was significant (9.3±1.3 and 8.2±1.8 μg/l, P<0.05). They recommended the prohibition of the use of lead in petrol .

6.3 STATEMANT OF THE PROBLEM:

“A study to assess the Respiratory Health before and after Breathing Exercises among Traffic Police in Mysore City”.

6.4 OBJECTIVES OF THE STUDY :

1) To assess the respiratory health among traffic police before and after breathing exercises in experimental group.

12 2) To assess the respiratory health among traffic police before and after breathing exercises in control group.

3.) To test the effectiveness of breathing exercises on respiratory health among traffic police among experimental and control group.

4.) To find out the association between the selected back ground factors and the mean difference on the respiratory health among traffic police in experimental group.

6.5 OPERATIONAL DEFINITIONS:

Respiratory health: refers to a state of well-being in physical and physiological aspects in relation to the respiratory system and also include the sign and symptom of any respiratory illness and lung function measures. They will be measured by questionnaire and spirometery inference .

Breathing exercises: refers to the alternate inspiration and expiration of air into the lungs and out of the lungs respectively. Simple breathing exercises include pursed lip breathing and Diaphragmatic breathing taught using the video teaching .

Effectiveness: refers to the increase in pulmonary function and decrease in respiratory signs and symptoms .It will be measured in terms of mean difference.

Traffic police : refers to the personnel in Police Department who are responsible to carry out the activities related to the traffic maintenance and safety of the public in Mysore City limits.

Selected back ground factors : refers to those factors which are thought to influence the respiratory health like age, sex, height ,periodic medical check up, duty hours ,experience ,habits like smoking etc.

7. MATERIALS AND METHODS

7.1 Source of the Data :Traffic police employed in Mysore City ,Mysore.

13 7.1.1 Research design : An Experimental design.

7.1.2. Setting : Mysore City traffic police station .

7.1.3. Population : Traffic police .

7.2 Methods of data collection

7.2.1 Sampling Procedure : Cluster sampling method will be adopted

for the study.

7.2.2. Sample : Traffic police who are working in Mysore city .

7.2.3. Sample Size:60 traffic police(males and females),Experimental

group : 30 and Control group:30]

7.2.4. Sample criteria:

7.2.4.1 Inclusion Criteria :

1. Traffic police who are posted for the maintenance of the traffic in various areas of Mysore City. 2. Traffic police who are having at least one year of experience. 3. Both male and female traffic police .

7.2.4.2. Exclusion criteria:

1. Traffic police who are unable to participate due to other reasons. 2. Those who were not regular in breathing exercises.

7.2.5. Data collection Method :

 A structured questionnaire for base line data and data on respiratory health.  Spirometry test for Lung function test  Duration of data collection : . 3 weeks for data collection . Follow up will be for two weeks after the pre-test.

7.2.6. Data analysis plan :

14 Both descriptive and the inferential statistics .

7.3 Does the study require any investigation or intervention to be

conducted on patients or humans or animals ?

Yes , Video teaching on breathing exercises and biophysical measure

like spirometry is used to assess the respiratory health.

7.4 Has ethical clearance been obtained from your institution :

Yes ,prior permission from The Commissioner of Police Mysore City will be obtained and consent from the Traffic Police participating in the study will be obtained.

8. List of References :

1. WHO : Programmes and projects ,Occupational health 2008.

Available at www.who.intoccupationalhealth

2. The Free Dictionary ,Traffic control police Available at www.thefreedictionary.com

3 Suddarth and Brunner’ S ,Text Book of Medical Surgical Nursing,10th edition ,Lippincott Williams and Wilkins Pp. 464-484.

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Mosby publishers , 1996.Pp.- 172,917

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9. National Ambient Air Quality Monitoring Series, Central Pollution Control Board

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Little, Brown & Co., 1992, p.729.

11.Environmental Education Centre of Chennai and Mysore Grahakara

Parishat conducted the survey on Excessive air and noise

Pollution levels in the city of palaces The Hindu 30th November

2007 P.p.6.

12. The Government General and Chest Hospital (GGCH) has revealed that

45 per cent of traffic policemen suffer from respiratory and non-

respiratory problems.Pollution takes its toll on traffic cops , The Times

Of India 25 Jun 2002, Nihal Koshie, TNN ,Pp.7.

13. Suresh .Y etal , “A study on Oxidant stress, antioxidants and

nitricoxide in traffic police of Hyderabad, India.”, Division of

16 Internal Medicine, Clinical Immunology and Biochemistry,

L.V.Prasad Eye Institute, August 2000. Pp.109(2):321-5

available at http://www.ncbi.nlm.nih.gov/pubmed

14. Deepa Suryanarayan ‘asthma prevalence study’ among school

students KEM study shows that nearly 15 per cent of children may

be suffering from asthma ,Mumbai, Daily News

analysis,Dec11’2007.Pp.3,8

15. Sagar .A,etal, A comparative study of air pollution-related morbidity

among exposed population of Delhi Indian Journal Of Community

Medicine ,Year : 2007 Volume 32 Issue : 4 Page : 268-271

Available URL www.ijcm .org.in/text.asp

16. Padhi BKand Padhy PK ,Assessment of intra-urban variability in

outdoor air quality and its health risks-Centre for Environmental

Studies, Institute of Science, Visva-Bharati University,Santiniketan,

West Bengal, India 2006-2007. 20(11):973-9.

17.Rosa AM ,A cross-sectional study was conducted to analyze

hospitalizations for respiratory diseases among children under 15

years ,University Estado de MatoGross ,Brazil,2000- 2005,34(8):575.

18. Wilson D, Takahashi K, Pan G,et al,A study on respiratory symptoms

among residents of a heavy-industry province in China.Department

of Environmental Epidemiology, Institute of Industrial Ecological

17 Sciences (IIES), University of Occupational and Environmental

Health, , Fukuoka, Japan 2002 .102(11):1536-44

19. Skaria Smibi, Arul Joseph Arun, Jasobanta Sethi, Assesed effect of

positiveexpiratory pressure technique over forced expiratory technique on

bronchial hygiene in patients with moderate chronic bronchitis Goutham

College of Physiotherapy, Bangalore, Indian Journal of Physiotherapy

And Occupational Therapy Vol. 2, No. 3 (2008-07 - 2008-09)

20. Moiz Jamal Ali et al,Compared autogenic drainage and the active cycle

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pattern retraining strategy for dyspnea reduction among COPD patients,

WestLosAngelesHealthcareCenter,LosAngeles,USA,2007. 27(4):237-4.

22.Sánchez Riera H, Montemayor Rubio T, etal ,Assessed Inspiratory

muscle training in patients with COPD: effect on dyspnea, exercise

performance, and quality of life. Pneumology Service, Virgen Del Rocio

University Hospital, Sevilla, Spain,2001 Sep;120(3):748-56.

23. Indian Express ,Express News Service, Breath of fresh air for traffic

cops, 8,2006

18 24. Dragonieri S, et al , Sputum induced cellularity in a group of traffic

policemen Department of Respiratory Diseases, University of Bari, Bari,

Italy. 2006 Aug 15;367(1):433

25. Tamura K.et al .Assessed Particulate air pollution and chronic

respiratory symptoms among trafficpolicemen inBangkok,

Environmental Health Sciences Division, National Institute for

Environmental Studies,Tsukuba, Japan.,2003 Apr;58(4):201-7

26 .Ingle Sopan T.et al ,Assessed Exposure to Vehicular Pollution and

Respiratory Impairment of Traffic Policemen in Jalgaon City,

IndiaSchool of Environmental and Earth Sciences, North Maharashtra

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Uludag University Medical School, Department of Public Health,

aTurkey. 2001 205(5):361-5

9. Signature of Candidate :

10. Remarks of the Guide :

11 Name and designation of Guide : Mrs.K.Vijayalakshmi Vice-Principal

11.1 Signature of guide :

11.2 Head of the Department : Mrs .K. Vijayalakshmi

11.3 Signature :

12 Remarks of Principal :

19 12.1 Signature :