To Assess the Effectiveness of Selected Breathing Exercises among Chronic Obstructive Pulmonary Disease Patients

Mortality rate of chronic obstructive pulmonary disease (COPD) is more than 3 million people every year, making it 3rd largest cause of death in the world. It has been estimated that by the year 2030. chronic obstructive pulmonary disease will become the third biggest cause of death. chronic obstructive pulmonary disease (COPD) is a progressive irreversible airway disease characterized by emphysema and chronic bronchitis, resulting in breathlessness, cough and sputum as the disease progresses, subjects with COPD experience increasing deterioration of their health-related quality of life (HRQOL), with greater impairment in their ability to work and declining participation in social and physical activities. Hence practicing pursed lip breathing exercise in their daily routine will improve their breathing pattern and quality of life. Objectives: 1. To assess the breathing pattern of chronic obstructive pulmonary disease patient. 2. To assess the effectiveness of selected breathing exercises among the chronic obstructive pulmonary disease patients. Original Research Article Dhengare and Pohekar; JPRI, 33(54B): 354-361, 2021; Article no.JPRI.76013 355 3. To associate the effectiveness of selected breathing exercises among chronic obstructive pulmonary disease patient with their demographic variables. Materials and Methods: The research approach used for the study was interventional evaluatory approach. The study was conducted in respiratory unit at Wardha City Maharashtra, India, using one group pre test post test design without control group. Non probability purposive sampling technique was used for selecting 60 COPD patients. On the first day pre test assessment of breathing pattern with the help of borg rating scale and provided pursed lip breathing exercise for 20 minutes, 2 times in a day and it was continued for 15 days followed by post test on the 15 th day. The data collected, tabulated and analysed in terms of objectives of study using descriptive and inferential statistics. Results: The mean post test score. The overall comparison of selected breathing exercise among COPD patients at rest pre test score was higher 3.48 with SD of ±1.25 when compare with at rest post test score which was 0.91 with SD of ±0.85.The statistical Student’s paired t test implies that the difference in the selected breathing exercise among COPD patients was found to be 18.98 which is statistically significant at 0.05% level of significance. Also the overall comparison of selected breathing exercise among COPD patients during activity pre test score was higher 7.95 with SD of ±1.50 when compared with during activity post test score which was 2.76 with SD of ±1.02. The statistical Student’s paired t test implies that the difference in the selected breathing exercise among COPD patients was found to be 18.98 which is statistically significant at 0.05% level of significance. Hence it is statistically interpreted that effectiveness of selected breathing exercises among COPD patients at rest and during activity in post test was effective. The tabulated values was much higher than the calculated’ values at 5% level of significance, also the calculated ‘p-value which was much higher than the acceptable level of significance i.e. ‘p’=0.05. Hence the association of effectiveness of selected breathing exercises is statistically not associated with demographic variables. Conclusion: According to the results of this study, patients with Chronic Obstructive Pulmonary disease patients who practiced pursed lip breathing exercise 20 minutes, 2 times a day for 15 days had improvement of the breathing pattern which was statistically proved. Hence pursed lip breathing exercise was cost effective, non invasive, and highly feasible. Hence the researcher concluded that pursed lip breathing exercise can be practice as an effective intervention on improving breathing pattern among chronic obstructive pulmonary disease patients.


INTRODUCTION
Chronic Obstructive Pulmonary Disease (COPD) is a progressive, non recoverable airway disease defined by emphysema and chronic bronchitis, resulting in breathlessness, cough and sputum. As the disease progresses, subjects with COPD experience a growing decline in their health related quality of life (HRQOL) with a substantial deterioration in their ability to work and a reduction in their participation in social and physical activities [1].
Chronic obstructive pulmonary disease (COPD) is a major respiratory disease affecting the quality and length of life around the globe. The World Health Organization describes COPD as a lung disease characterized by recurrent obstruction of lung airflow which obstructs normal breathing and is not completely reversible [2].
It is estimated that COPD is at risk of 3.15 million deaths per year and that there were 251 million COPD diseases worldwide in 2016 [3].
It is the term used to refer to chronic lung diseases that restrict lung airflow, but Chronic Obstructive Pulmonary Disease (COPD) does not refer to a specific disease. Today chronic emphysema and bronchitis are no longer used but are treated with COPD. The signs of COPD are ' need for oxygen, ' excessive sputum development, breathlessness, chronic coughing. COPD is not just a "smoker's cough," but also a low diagnostic, critically lung disease that may increasingly lead to death [4].
The healthcare burden of COPD can be as high as $50 billion in countries like US where COPD is the third leading cause of mortality [5]. Due to its association with smoking and environmental pollution, the burden is much higher in low and middle-income countries. An estimation shows that more than 90% COPD-related deaths happen in those countries and India is no exception for sch a tremendous public health problem [3,6].

MATERIALS AND METHODS
The research approach used for the study was interventional evaluatory approach. The study was conducted in respiratory unit at Wardha City Maharashtra, India, using one group pre test post test design without control group. Non probability purposive sampling technique was used for selecting 60 COPD patients. On the first day pre test assessment of breathing pattern with the help of borg rating scale and provided pursed lip breathing exercise for 20 minutes, 2 times in a day and it was continued for 15 days followed by post test on the 15 th day. The data collected, tabulated and analysed in terms of objectives of study using descriptive and inferential statistics.

Description of the Tool
The tool consists of two section.
Section A-It consists of demographic variables of the chronic obstructive pulmonary diseases patients such as age, gender, education, income, occupation, duration of disease, knowledge regarding breathing exercise, source of information, number of hospital visits respectively.
Section B-Pursed lip breathing exercise.
-Borg scale score at rest and during activity. -Score interpretation.

Effectiveness of Selected Breathing
Exercises among the Chronic Obstructive Pulmonary Disease Patients

Significance of difference between selected breathing exercises among the COPD patients at rest pre and post test
The overall comparison of selected breathing exercise among COPD patients at rest pre and post test which reveals that at rest pre test score was higher 3.48 with SD of ±1.25 when compared with at rest post test score which was 0.91 with SD of ±0.85.
The statistical Student's paired t test implies that the difference in the selected breathing exercise among COPD patients was found to be 18.98 which is statistically significant at 0.05% level of significance.
Hence it is statistically interpreted that level of selected breathing exercises among COPD patients at rest post test was effective. Thus H1 is accepted and H0 is rejected.

Significance of difference between selected breathing exercises among the COPD patients during activity pre and post test
The overall comparison of selected breathing exercise among COPD patients during activity pre and post test which reveals that during activity pre test score was higher 7.95 with SD of ±1.50 when compared with during activity post test score which was 2.76 with SD of ±1.02.
The statistical Student's paired t test implies that the difference in the selected breathing exercise among COPD patients was found to be 32.60 which is statistically significant at 0.05% level of significance.
Hence it is statistically interpreted that level of selected breathing exercises among COPD patients during activity post test was effective. Thus H1 is accepted and H0 is rejected.

Association Effectiveness of Breathing Exercise with Selected Demographic Variables of Chronic Obstructive
Pulmonary Disease Patients

Association of effectiveness of selected breathing exercises at rest post test with demographic variables
The association of level of selected breathing exercises with demographic characteristics of COPD patients. The tabulated values was much higher than the calculated' values at 5% level of significance. Also the calculated 'p-value which was much higher than the acceptable level of significance i.e. 'p'=0.05. Hence it is interpreted that socio-demographic characteristics of COPD patients is statistically not associated with their level of selected breathing exercise at rest post test.

Association of effectiveness of selected breathing exercises during activity post test with demographic variables
The association of level of selected breathing exercises with demographic characteristics of COPD patients. The tabulated values was much higher than the calculated' values at 5% level of significance except for occupation. Also the calculated 'p-value which was much higher than the acceptable level of significance i.e. 'p'=0.05. Hence it is interpreted socio-demographic characteristics of COPD patients is statistically not associated with their level of selected breathing exercise during activity post test.

DISCUSSION
The study was conducted to assess the effectiveness of selected breathing exercises among chronic obstructive pulmonary disease patients it was aimed to improve breathing pattern at rest and during activity. The mean post test score. The overall comparison of selected breathing exercise among COPD patients at rest pre test score was higher 3.48 with SD of ±1.25 when compare with at rest post test score which was 0.91 with SD of ±0.85.
The statistical Student's paired t test implies that the difference in the selected breathing exercise among COPD patients was found to be 18.98 which is statistically significant at 0.05% level of significance.
The overall comparison of selected breathing exercise among COPD patients during activity pre test score was higher 7.95 with SD of ±1.50 when compared with during activity post test score which was 2.76 with SD of ±1.02.
The statistical Student's paired t test implies that the difference in the selected breathing exercise among COPD patients was found to be 18.98 which is statistically significant at 0.05% level of significance.
Hence it is statistically interpreted that effectiveness of selected breathing exercises among COPD patients at rest and during activity in post test was effective. Thus H1 is accepted and H0 is rejected.
The tabulated values was much higher than the calculated' values at 5% level of significance. Also the calculated 'p-value which was much higher than the acceptable level of significance i.e. 'p'=0.05. Hence The association of effectiveness of selected breathing exercises is statistically not associated with demographic variables.  G Dechman [8] conducted a study to evaluate the efficacy of pursed-lip breathing (PLB) and diaphragmatic breathing (DB) in the rehabilitation of people with chronic obstructive pulmonary disease (COPD) remains unclear. This review examines the evidence regarding the usefulness of these techniques in improving the breathing of people with stable COPD.. Pursed-lip breathing slows the respiratory rate, and evidence suggests that this decreases the resistive pressure drop across the airways and, therefore, decreases airway narrowing during expiration. This decrease in airway narrowing may account for the decreased dyspnea some people experience when using this technique. Diaphragmatic breathing has negative and positive effects, but the latter appear to be caused by simply slowing the respiratory rate. They concluded evidence supports the use of PLB, but not DB, for improving the breathing of people with COPD [8].
A similar study was conducted to assess the effectiveness of teaching programme on pulmonary rehabilitation. The objective of the study was to assess the short-term and longterm effects of pulmonary rehabilitation on quality of life. They selected Forty-three out patients with COPD. Patients were randomized to one of three treatment groups: exercise training alone, exercise training plus activity training, and exercise training plus a lecture series. The mean treatment period was 10 weeks. The study concluded that teaching programme with exercise training was effective in improving the knowledge of pulmonary rehabilitation among patient with COPD [9].
Most of the study population belongs to the age group of more than 60 years (68.3%), whereas remaining were between 45 and 60 years (31.7%). There was male predominance (67.1%) among study population as compared to females (32.9%). Guleria et al. have reported similar findings in their study where the maximum number of patients had the age of onset between 40 and 70 years. This findings is in agreement with the study by Narayanagowda et al., in which of 107 patients, the most common age group was 55-65 years (40.19%). The next common age group was 65-75 years (32.71%). This is because it was more commonly seen in patients with advanced lung disease as an expression of deterioration in host defenses at the bronchial mucosal level.
This findings correlate well with the study conducted by Niranjan Mambally Rachaiah et al., in which males accounted for 88%, with a malefemale ratio of 6.33:1. In the present study, all males were smokers, six females patients were nonsmokers, but all of them were exposed to smoke of burnt fuels which is very common in the rural Indian population. In this part of the country, cooking is predominantly by using wood and cow dung. This is possibly a strong risk factor for the development of COPD among female patients. This findings is in agreement with the study by Narayanagowda et al., in which out of 107 patients, 72 were male patients [10-11].
History of smoking was observed in 49% of the study population, and most of the study population had smoking index of 30-39 packs (35%) followed by 20-29 packs (31%), 10-19 packs (14%), and more than 40 packs (14%). History of biomass exposure was observed in 36.9% of the study population. Similarly, the study by Narayanagowda et al., in which out of 72, 45 (62.5%) were smokers and 27 (37.5%) were nonsmokers.
Most of the study population had GOLD Stage C (38%) followed by GOLD Stage B (37%), GOLD Stage D (13%), and GOLD Stage A (12%). This findings is in agreement with the study conducted by Ladeira et al., in which GOLD Stage B (50%) followed by GOLD Stage C (28%) [12][13].
There was a significant decrease in spirometry parameters such as forced-expiratory volume in 1 s (FEV1), forced-vital capacity (FVC), and FEV1/FVC as the GOLD staging increases [14].
Acute exacerbations of COPD is conveniently treated with beta agonist and anticholinergic nebulisations, antibiotics, oxygen supplementation, NIPPV, and steroids. Rarely SSP can complicate COPD. Our patient had consolidation/ partial collapse of the middle lobe along with closed pneumothorax that further aggravated the dyspnoea. A pneumothorax is an accumulation of air in the pleural cavity. Spontaneous pneumothorax (SP) is a cardiopulmonary emergency [15][16]. SSP usually complicates COPD in females more than 60 years of age. It requires immediate treatment [2]. The most common pathology of SSP in COPD is rupture of an apical sub pleural bleb or bulla which occurs in 50-70% of cases [17][18]. Thirty percent of the SSP complicating COPD may not require intercostal tube insertion [19][20]. Cases of COPD with acute exacerbations who do not improve predictably with adequate therapy, SSP should be ruled out. A second CXR or HRCT might be required. In this case the crisis might have been triggered by dual phenomena, that is; infection and SSP. SSP occurs more in emphysema predominant COPD. If the pneumothorax occupies less than 15% of the hemithorax and the patient is asymptomatic then conservative therapy with high flow oxygen is need or else in symptomatic cases the standard treatment is tube thoracostomy [21][22][23]24].

CONCLUSION
According to the results of this study, patients with Chronic Obstructive Pulmonary disease patients who practiced pursed lip breathing exercise 20 minutes, 2 times a day for 15 days had improvement of the breathing pattern which was statistically proved. Hence pursed lip breathing exercise was cost effective, non invasive, and highly feasible. Hence the researcher concluded that pursed lip breathing exercise can be practice as an effective intervention on improving breathing pattern among chronic obstructive pulmonary disease patients.

CONSENT
As per international standard or university standard, patient's written consent has been collected and preserved by the author(s).