RAJIVGANDHI UNIVERSITY OF HEALTH AND SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
MS. SOWMYA N
M. SC NURSING I YEAR,
MEDICAL-SURGICAL NURSING,
(2010-2012) BATCH
R.R. COLLEGE OF NURSING,
RAJAREDDY LAYOUT
CHIKKABANVARA
BANGALORE -560090.
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
PERFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / MS. SOWMYA NM. Sc NURSING 1st YEAR,
R.R COLLEGE OF NURSING
CHIKKABANARA
BANGALORE-560090
2. / NAME OF INSTITUTION / R.R COLLEGE OF NURSING
CHIKKABANAVARA
BANGALORE-560090
3. / COURSE OF THE STUDY AND SUBJECT / M. Sc NURSING 1st YEAR
MEDICAL-SURGICAL NUESING
4. / DATE OF ADMISSION TO THE COURSE / 10.07.2011
5. / TITLE OF THE STUDY / A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON BREATHING EXERCISE TRAINING ON IMPROVEMENT IN OUTCOME OF DYSPNOEA AMONG PATIENTS WITH RESPIRATORY DISEASES AT SELECTED HOSPITAL, BANGALORE.
6. BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
Life is in breath.
He who half breathes half lives.
In the history of medicine there have always been periods when one diseases or group of related disease presented an unusually grave threat to the health of the individual and to the community. In the particular period in which we live, we concerned by the growing number of men disabled by chronic respiratory disease and by the disruption. Such illness are causing in the life of the individual.
Humans can sense a wide range of respiratory sensations such as respiratory motion, lung position, irritation, urge to cough, pain, chest tightness, sense of effort and respiratory discomfort mainly contribute to the sensation of dyspnoea. Thus dyspnoea appears to be single respiratory sensation. Although dyspnoea arises as the primary symptom in many diseases of the respiratory system. Dyspnoea is frequently the symptom that motivates a patient with pulmonary disease to seek medical assistance. Because dyspnoea is a common symptom in patients with pulmonary disease, heart failure frequently encounters patients with dyspnoea in various clinical situations. This review aims to provide an outline of path physiology and treatment of dyspnoea to assist in their care of patients with dyspnoea.
Dyspnoea or shortness of breath is the result of complex interaction of physiological, psychological, social and environmental factors. Although several sensory receptors located throughout the respiratory system are considered to be responsible for generation of dyspnoea, there is no afferent receptor solely responsible for the sensation of dyspnoea.
Recent neuroimaging studies suggested that neurophysiologic and psychological approaches used as an effective treatment of dyspnoea. So dyspnoea can be managed by giving breathing exercises. Presently disease management include pharmacological therapy. Initially therapy is helpful in management but later on increase in financial burden. Non-pharmacological therapy includes techniques such as breathing exercises, meditation, and asana. Using and learning proper breathing techniques is one of the most benefits that can be done for both short and long term physical and emotional health.
A study regarding the effect of breathing exercises in patients with bronchial asthma with mild to moderate severity was done. In this for 12 weeks patients were trained with breathing exercises. After 12 weeks, results have shown that there is significant improvement in symptoms, forced expiratory volume and peak expiratory flow rates. Thus it proves that breathing exercise improves lung function subjectively and objectively and should be part of therapy.
Unlike other bodily functions the breathe is easily used to communicate between these systems, which gives us excellent tool to help facilitates positive changes. It is only bodily function that we do both voluntarily and involuntarily. We can consciously use breathing to influence the involuntary that regulates blood pressure, heart rate, circulation and many other bodily functions.
During times of emotional stress our sympathetic nervous system is stimulated and affects a number of physical responses. The breathe can be used to directly influence the stressful changes causing a direct stimulation of the parasympathetic nervous system resulting in relaxation and reversal of the changes seen with the stimulation of the sympathetic nervous system.
Breathing exercises can be trained for both negative and positive influences on health. Our exercise promotes relaxation and proper breathing technique will strengthen the lungs. There are many benefits of breathing exercise that is it cleanses the body diseases, steadies the mind and helps in concentration, improve digestion and improve appetite.
6.1NEED OF THE STUDY
Dyspnoea appears not to be single respiratory sensation. Dyspnoea often arises as the primary symptom in many disease of the respiratory system. Dyspnoea is frequently the symptom that motivates a patient with pulmonary disease to seek medical assistance. There are many causes for dyspnoea; some causes are directly related to the underlined disease especially if the diagnosis is respiratory in nature. And the disease mainly includes bronchial asthma and chronic obstructive pulmonary disease.
The World Health Organisation (WHO) estimated 300 million people suffer from asthma and 2, 55,000 people died of asthma (WHO), 2004. The asthma statistics in India in 2004 details 57.5 estimated total deaths and 5.1 estimated deaths per 1 lakh population. And 277 disability adjusted life year (DALYs) per 1 lakh and 268 age standardised disability adjusted life year (DALYs) per 1 lakh. The global statistics of asthma(WHO 2004) details2, 87,000 (0.5%) of total global deaths. In this 1, 51,000 men, 1,36,000 women and DALYs includes 8,856,000 for men 7,461,000 women and 1.8 standardised death per 1 lakh and 19.4 million disability and constitutes 6.6 million YLD among men and 1.8 million YLD in high income countries.
In India, it is estimated about 57,000 deaths were attributed to asthma (WHO 2004). It is one of the leading causesof morbidity and mortality in rural India.
A study was conducted by lal et al 2003 on asthma and the study reveals asthma creates a substantial burden on individuals and families as it is more often under diagnosed and under treated.
A study was conducted by masoli et al 2003 showed the global burden of asthma estimates approximately 300 million people worldwide currently have asthma. The study suggested that asthma prevalence increases globally by 50% every decade. With the projected increase in the proportion of worlds urban population from 45-50% in 2025.there is likely to be marked increase in the number of asthmatics’ world wide over the next two decades. It is estimated that there may be additional 100 million persons with asthma by 2025.
Chronic obstructive pulmonary disease is one of the leading cause of death,illness and disability in the united states and estimates 10 million American adults were diagnosed with the condition in 2000,but the data from the national health survey suggest that as many as 24 million Americans were actually affected .in 2000 chronic obstructive caused about 119,000 deaths,726,000 hospitalizations and 1.5 million visits to hospital emergency rooms.
From 1980-2000 the death rate from COPD for women rose from 20.1 death per 100,000 women to 56.7 deaths per 100,000 women ,while for men the rate grew from 73.0 deaths per 100,000 men to 82.6 deaths per 100,000 men.
United States women also had more copd related hospitalisation (404,000) than men (322,000) and more emergency room visits (898,000) than men (551, 00) in 2000.in addition 2009 marked the first year in which more women (59,936) than men (59,118) died from copd.
Clinical studies including 1000s of participants spanning a 30 year period offer pervasive evidence that the most significant factor in health and longevity is how well you breathe.
The Framingham study focused on the long term predictive power of vital capacity and forced exhalation volume as the primary markers for life span and pulmonary function measurement appears to be an indicator of general health and vigour and literally to a measure of living capacity.
A study was to explore dyspnoea self management in African American with chronic obstructive pulmonary disease resulting from sarcoidosis.the study concluded that self care actions should be encouraged and thought and self care resources facilitated. The breathing techniques used by patients with copd and those with sarcodosis should be considered during patient and family education.
Hence the investigator felt that it is very essential to educate about breathing exercises to patients having dyspnoea in respiratory diseases.
6.2REVIEW OF LITERATURE
The review of literature is defined as a broad, comprehensive in depth, systematic and critical review of scholarly publications, unpublished scholarly print materials, audio visual materials and personal communications.
Top of Form
Geddes EL,et al (2008) conducted a study to update an original systematic review to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and endurance, exercise capacity,dyspnoeaand quality of life for adults with chronic obstructive pulmonary disease (COPD). Randomized controlled trials, published in English, with adults with stable COPD, comparing IMT to sham IMT or no intervention, low versus high intensity IMT, and different modes of IMT were included. Nineteen of 274 articles in the original search met the inclusion criteria. The updated search revealed 17 additional articles; 6 met the inclusion criteria, all of which compared targeted, threshold or normocapneic hyperventilation IMT to sham IMT. An update of the sub-group analysis comparing IMT versus sham IMT was performed with 10 studies from original review and 6 from the update. Sixteen meta-analyses are reported. Results shown that significant improvements in inspiratory muscle strength PI(max), PI(max) % predicted, peak inspiratory flow rate), inspiratory muscle endurance (RMET, inspiratory threshold loading, MVV), exercise capacity Ve(max), Borg Score for Respiratory Effort, 6MWT), TransitionalDyspnoeaIndex (focal score, functional impairment, magnitude of task, magnitude of effort), and the Chronic Respiratory Disease Questionnaire (quality of life). Results suggest that targeted, threshold or normocapneic hyperventilation IMT significantly increases inspiratory muscle strength and endurance, improves outcomes of exercise capacity and one measure of quality of life, and decreasesdyspnoeafor adults with stable COPD.
Collins EG,et al (2001) conducted a study regarding breathingpattern retainingand exercise in persons with chronic obstructive pulmonary disease.Theyused a method in pulmonary rehabilitation to help alleviate the symptoms ofdyspnoeaendured by people who suffer from airflow obstruction secondary to chronic obstructive pulmonary disease (COPD). Other techniques such as biofeedback also have been successfully used. The article described the alteredbreathingpatterns used bypatientswith COPD at rest and during physical activity. Theliteratureis reviewed regarding techniques ofbreathingpattern retraining that have been developed to improve the capacity of persons with COPD to perform activities of daily living, a primarily rehabilitative outcome.
Sánchez Riera H,et al,(2001) conducted a study to assess the effect of target-flow inspiratory muscle training (IMT) on respiratory muscle function, exercise performance,dyspnoea, and health-related quality of life (HRQL) inpatientswith COPD. 20patientswith severe COPD were randomly assigned to a training group (group T) or to a control group (group C) following a double-blind procedure.Patientsin 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.The measurements performed 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). Changes indyspneaand HRQL also were measured.Theresults shown 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 (p < 0.003, p < 0.003, and p < 0.05, respectively). The levels of VO(2) and VE did not change in either group. The values for transitionaldyspnoeaindex and HRQL improved in group T at 6 months in comparison with group C (p < 0.003 and p < 0.003, respectively).They concluded that targeted IMT relievesdyspnea, increases the capacity to walk, and improves HRQL in COPDpatients.
Zhang ZQ,et al(2008) conducted a study to observe the effect of pulmonary rehabilitation with respiratory physiology as guide in patients with chronic obstructive pulmonary disease (COPD). Sixty patients of severe and very severe COPD were enrolled for study. They were randomly divided into three groups, and with 20 patients in each group. The patients in group A were given pulmonary rehabilitation guided by respiratory physiology thrice a day, 15 minutes each time for 8 weeks. The patients in group B were given pulmonary rehabilitation with pursed lip respiration thrice a day, 15 minutes per time for 8 weeks. The patients in group C were given no pulmonary rehabilitation. Six minute-walk-distance (6MWD), medical research council (MRC) dyspnoea scale, activities of daily living (ADL), maximal expiratory pressure (MEP), maximal inspiratory pressure (MIP), and quality of life (QOL) were determined before and after respective pulmonary rehabilitation course.The results shown that there were 3, 5, 5 patients in group A, group B, group C dropped off in the course of rehabilitation respectively.The patients' body status, shortness of breath, social activity, home chores in group A and group B, and uneasiness in group A after pulmonary rehabilitation were improved. The effect of the pulmonary rehabilitation with the guide of respiratory physiology is better than that of the pulmonary rehabilitation with pursed lip respiration, and it can be considered as a more effective pulmonary rehabilitation method for the patients with severe and very severe COPD.
Ritz T, et al (2003) conducted a review of the behavioural interventions in asthma and breathing training. And the review found that the systematic documenting in the benefits of these techniques in asthma patients. The physiological rationale of abdominal breathing in asthma is not clear, and adverse effects have been reported in chronic obstructive states. Theoretical analysis and empirical observations suggest positive effects of pursed-lip breathing and nasal breathing but clinical evidence is lacking. Modification of breathing patterns alone does not yield any significant benefit. There is limited evidence that inspiratory muscle training and hypoventilation training can help reduce medication consumption, in particular beta-adrenergic inhaler use. Breathing exercises do not seem to have any substantial effect on parameters of basal lung function. They suggested additional research on the psychological and physiological mechanisms of individual breathing techniques in asthma, differential effects in sub-groups of asthma patients, and the generalization of training effects on dailylife.
Nihon Kokyuki Gakkai Zasshi et al (1998) conducted a study to evaluate the effects of a short-term pulmonary rehabilitation program on dyspnoea, exercise capacity, and lung function.15 patients with chronic respiratory failure due to pulmonary emphysema were enrolled in such a program for 3 weeks as inpatients. The program consisted of pursed lip breathing, diaphragmatic breathing, respiratory muscle stretch gymnastics, and walking with synchronized breathing. The results had shown that dyspnoea as measured with a visual analogue scale at the end of a 6-minute walk before and after the program (49.7 +/- 4.0% to 24.2 +/- 3.8%) decreased significantly (p < 0.01). As a measure of functional exercise capacity, the 6-minute walking distance (226.9 +/- 32.4 m to 292.1 +/- 35.8 m) increased significantly (p < 0.01). As an indicator of maximal exercise capacity, endurance time on an incremental treadmill test did not improve. Spirometric data did not change during the study. Total lung capacity (TLC) (8.44 +/- 0.70 L to 7.58 +/- 0.74 L) and residual volume (RV) (5.13 +/- 0.53 L to 4.28 +/- 0.59 L) decreased significantly (p < 0.01). The findings suggest that this program relieves dyspnoea, increases the functional capacity and decreases
creases functional exercise capacity, and decreases TLC and RV on patients with chronic respiratory failure due to pulmonary emphysema.
Sutbeyaz ST, et al(2010) conducted a study to determine whether two types of exercise--breathing retraining (BRT) and inspiratory muscle training (IMT)--improve on cardiopulmonary functions and exercise tolerance in patients with stroke. They used a randomized controlled trialtechnique in which forty-five in patients with stroke (24 men, 21 women) were recruited for the study. The subjects were randomized into three groups: 15 assigned to receive inspiratory muscle training (IMT); 15 assigned to received breathing retraining, diaphragmatic breathing and pursed-lips breathing (BRT); 15 assigned to a control group.All study groups participated in a conventional stroke rehabilitation programme. Each subject underwent pulmonary function and cardiopulmonary exercise tests.The results shown that after the training programme, the IMT group had significantly improved forced expiratory volume at 1 second (FEV(1)), forced vital capacity (FVC), vital capacity (VC), forced expiratory flow rate 25-75% (FEF 25-75%) and maximum voluntary ventilation (MVV) values compared with the BRT and control groups, although there were no significant differences between the BRT and control groups (P<0.01). Peak expiratory flow rate (PEF) value was increased significantly in the BTR group compared with the IMT and control groups. The IMT group also had significantly higher peak oxygen consumption (Vo(2peak)) than the BRT and control groups, although there were no significant differences between the BRT and control groups (P<0.001). There was a statistically significant increase in maximum inspiratory pressure (PI (max)) and maximum inspiratory and expiratory pressure (PE (max)) in the BRT group and, PI (max) in the IMT group compared with baseline and the control group. In the IMT group, this was associated with improvements in exercise capacity, sensation of dyspnoea and quality of life.
Van der Schans CP,et al (1997) conducted a study to assess the effect of breathing with a positive expiratory pressure of 5 cm H2O, simulating pursed lips breathing (SPLB), on respiratory muscle activity and pulmonary function during induced airway obstruction. In twelve asthmatic patients, tonic and phasic electromyographic (EMG) activity of the following muscles was obtained: scalene muscle, parasternal muscle, and abdominal muscles. Pulmonary function and EMG measurements were performed before and after propranolol induced airway obstruction.The results shown that simulated pursed lips breathing resulted in a significant increase of functional residual capacity and tidal volume both at baseline and during airway obstruction. Phasic respiratory muscle activity during PEP breathing increased especially at baseline. It shown the beneficial effects of breathing with a positive expiratory pressure of 5 cm H2O, which is similar to pursed lips breathing, cannot be explained by changes in respiratory muscle activity or pulmonary function.