RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE
ANNEXURE - II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1
Name of the candidate
and
address(in
MISS. APLONI NEETHA JOSEPH
block
SAHYADRI COLLEGE OF NURSING
letters)
ADAYAR, MANGALORE
2
Name of the institution
SAHYADRI COLLEGE OF NURSING,
SAHYADRI CAMPUS, NH-48, ADYAR,
MANGALORE-575007.
3
Course
of
study
and
M.Sc. NURSING,
subject
MEDICAL AND SURGICAL NURSING
4
Date
of
admission
to 04/07/2011
course
5
Title of the topic:
EFFECTIVENESS OF INCENTIVE SPIROMETRY V/S BALLOON
BLOWING EXERCISE ON SELECTED PULMONARY PARAMETERS
OF
PATIENTS
WITH CHRONIC OBSTRUCTIVE PULMONARY
DISEASE (COPD) IN SELECTED HOSPITALS, MANGALORE.
1
6
BRIEF RESUME OF INTENDED WORK
INTRODUCTION
“A cure is the end of the medical condition or a treatment that is very likely to end it”.
Health is an invaluable part of a human beings life. Without it, people
can become uninspired, de-motivated, and unable to thrive for success. Good health favours
personal efficiency and contributes to an individual’s lifespan and has much to do with
happiness and success. But diseases affect people not only physically, but also emotionally and
socially. Diseases can alter one’s perspective of life. It can be acute or chronic.1
A chronic disease is ’’An impairment of bodily structure and function that
necessitates a modification of the patient’s normal life and has persisted over an extended period
of time”2.
Chronic respiratory disease is found to be one of the most distressful
conditions, badly affecting human life. Every six seconds people with serious respiratory disease
are reminded that their breathing is impaired, and they cannot enjoy life as they used to, as their
activities are restricted and that their lives may not be as long .3
One of the most common chronic respiratory diseases prevailing throughout
the world is Chronic Obstructive Pulmonary Disease. COPD is a chronic lung disease which
refers to several disorders that affect the movement of air in and out of the lung. Although the
most important of these are chronic obstructive bronchitis and emphysema.
Promotion of exercises is found to be the good conservative management for
patients with COPD, because breathing exercises can improve lung functions as well as can
strengthen the respiratory muscles, even when the lungs are diseased. The proposed rationale for
using incentive spirometry and balloon blowing exercise are to prolong exhalation and thereby
improve pulmonary functions.
6.1 NEED FOR THE STUDY:
“Exercise is a medicine for creating change in a person’s physical,emotional and
mental status”
2
COPD is an umbrella term used to describe lung disease associated
with airflow obstruction. Most generally, emphysema and chronic bronchitis either alone or
combined fall in to this category. While bronchitis involves inflammation and scarring of the
main airways, the bronchial tubes, and emphysema is permanent damage to the walls of the air
sacs and loss of lung elasticity, both cause obstruction of the normal air flow. Individuals with
COPD exhibit symptoms such as shortness of breath, chronic cough and chronic mucus
production. COPD is the leading cause of breathing disability in the world. COPD is caused
mainly by smoking, but also by exposure to airborne pollution, to harmful fumes or particles at
home or at work, or by inheriting a genetic deficiency.3
Surprisingly little has actually been learned about COPD. Studies are
very limited, but things do seem to be improving with some very encouraging studies and
clinical trials under way for medications and treatments. There is a very long way to go,
however. The good news is that COPD though considered as a chronic debilitating and general
fatal disease can be managed, controlled and slowed down. The client can have good and long
life with a great deal of quality and joy even after diagnosis with proper treatment, care and
exercise.3
COPD is the 5th biggest killer disease worldwide. Every hour COPD
is estimated to kill over 250 people worldwide. COPD is the only major cause of death whose
incidence is on the increase and is expected to be the third leading cause of death worldwide as
well as in India by 2020.The rate of COPD has been increasing nearly three times faster
amongst women than men.Women are more susceptible to developing COPD than men, their
lung function worsens with less duration of smoking or intensity of smoking than that of men .3
A study was done on global burden of COPD, systematic review and
meta analysis was done for population based prevalence of COPD. Of 67 accepted articles, 62
unique entries 101 overall prevalence. The pooled prevalence of COPDwas 7.6% from 37
studies of chronic bronchitis alone (38 studies) was 6.4% and of emphysema was alone 1.8%.
The prevalence of physiologically defined COPD in adults aged more than 40years is
approximately 9-10%.4
Regular and frequent exercise under supervision can deal with
pulmonary function to a larger extent. Incentive spirometry and balloon blowing exercises are
3
proved in decreasing breathlessness in people suffering from chronic lung disease can increase
exercise tolerance and it strengthens thoracic muscles. Balloon inflation is proved to be cheap
and cost effective method of pulmonary rehabilitation.
A study was conducted on exercise training, a therapy for patients
with COPD .In this ,11 patients with chronic obstructive pulmonary disease completed an 18week program of exercise training with subjective and objective improvement. Increased
activities of daily living were noted by these patients and substantiated by analysis of exercise
diaries. The results were resting and exercise heart rate and breathlessness decreased, and
maximum tolerated work load increased significantly in all patients. 5
A study was conducted on pulmonary rehabilitation in patients with
COPD. In this study 40 patients of stable COPD having severe airflow obstruction was included.
Rehabilitation included walking, breathing exercise, controlled coughing and changes in life
style activities. Exercise of 30 min duration was performed at home twice daily for 4 weeks
supervision. Six-minute walking distance, FEV1 [forced expiratory volume in first sec of
expiration] and various indices of chronic respiratory disease questionnaire were measured in
samples before and after intervention. The study concluded that domiciliary pulmonary
rehabilitation for 4 weeks resulted in significant improvement in the quality of life and exercise
tolerance with an improvement in FEV1.6
Many studies proved that incentive spirometry increases inspiratory
volume, maintain alveolar ventilation, increases vital capacity and inspiratory reserve volume
and even prevent atelectasis. Many articles say that balloon inflating exercise can increase
pulmonary parameters.Hence, the investigator felt that there is a need to conduct a study on
effectiveness of incentive spirometry and balloon blowing exercise on patients with COPD .
6.2 REVIEW OF LITERATURE
The study was conducted to evaluate the effects of incentive
spirometer[IS] on pulmonary function tests, arterial blood gases [ABG], dyspnoea and healthrelated quality of life in patients hospitalized for COPD . A total of 27 consecutive patients
(mean age, 68.4 +/- 7.9 years; 26 males) admitted for COPD exacerbations were recruited for
the study. In total, 15 (IS treatment group) used IS for 2 months, together with medical
treatment. The remaining 12 (medical treatment group) were given only medical treatment.
Pulmonary function and blood gases were measured. Assessment of dyspnoea by visual
4
analogue scale (VAS) and quality of life using the St. George's Respiratory Questionnaire
(SGRQ) were performed at admission and after 2 months of treatment. The activity, impact and
total scores for the SGRQ improved (all P < or = 0.0001), PaCO2 values decreased (P = 0.02),
PaO2 and PAO2 values increased (P = 0.02 and P = 0.01, respectively) in the IS treatment
group.. The study concluded that IS improved ABG ,pulmonary functions and health-related
quality of life in patients with COPD exacerbations. 7
A study on regular balloon inflation for patients with chronic bronchitis
was conducted to check the effect of regular lung exercise on severity of symptoms particularly
breathlessness. 28 patients were randomly recruited with spirometrically proved airway
obstruction. The 13 patients randomised to the study group had a mean age of 65 years and a
mean FEV1: FVC ratio [forced expiratory volume in first sec of expiration /forced vital
capacity] of 0:43. The 15 controls had a mean age of 69 years and an FEV1: FVC ratio of 0:46.
The results proved a significant reduction in the breathlessness score after regular balloon
inflation, together with slight, improvements in wellbeing and 6minute walking distance in the
balloon group. 8
A study was conducted on significance of regularly blowing up ordinary
rubber balloons in people suffering from chronic lung disease. Randomly 22 participants with
chronic bronchitis and emphysema were selected. In that 11 women 9 men with average age 65,
were randomly assigned to the balloon blowing group and asked to inflate one new ordinary
balloon to a diameter of 7 inches, 40 times a day for 8 weeks. The rest, 11 men whose mean age
was 69 years was taken as control group, without treatment. Before and after the study,
pulmonary technicians assessed the pulmonary abilities of all participants. And the study
reported a significant reduction in breathlessness after regular balloon inflation.9
A study was conducted on incentive spirometry [IS] performance as a
reliable indicator of pulmonary function in the early post-operative period after lobectomy.
Nineteen patients [16 men, 3 women]of 60 years of age undergone lobectomy for lung cancer
was selected .All had obstructive pattern with FEV1/FVC below75%. Lung volumes, including
functional residual capacity [FRC] and residual volume [RV] measured using spirometry and
the helium dilution technique and ARE measured pre-operatively and post-operatively at 1, 2, 3
and 8 and at 2 months. IS performance was well correlated (R) during the first 8 postoperative
days with vital capacity (VC) (R between 0.667 and 0.870) mainly due to the excellent
correlation with the inspiratory reserve volume (IRV, R between 0.680 and 0.895) but was
5
poorly correlated with expiratory reserve volume (R below 0.340), RV (R below 0.180), and
FRC (R below 0.470). The study concluded that, IS can be used as a simple mean to follow lung
function, especially VC and IRV, in the postoperative period in spontaneously breathing
patients. IS is non-invasive and can be performed repeatedly at the bedside in the intensive care
setting. 10
A study was carried out on respiratory rehabilitation in patients with
COPD that assessed functional or maximal exercise capacity, HRQL [health related quality of
life], or both. Respiratory rehabilitation was defined as exercise training (for at least 4 weeks)
with or without education, psychological support, or both. The most commonly used measure
for HRQL was the chronic respiratory questionnaire, in which responses were presented on a 7point scale. The control groups received no rehabilitation. Within each trial and for each
outcome an effect size was calculated. The overall effect of treatment was compared with its
Minimum Clinically Important Difference (MCID).
Out of 14 trials
done significant
improvements were found for all the outcomes. For two important features of HRQL, dyspnoea
and mastery, the overall treatment effect was larger than the MCID: 1·0 (95% CI 0·6–1·5) and
0·8 (0·5–1·2), respectively, compared with an MCID of 0·5. For functional exercise capacity (6min walk test), the overall effect was 55·7 m (27·8–92·8), and for maximum exercise capacity
(incremental cycle ergometer test), 8·3 W (2·8–16·5).The study concluded that respiratory
rehabilitation relieves dyspnoea and improves control over COPD. 11
A study was conducted on respiratory muscle training with
incentive spirometry resistive breathing device [ISRBD]. This study focused on the effect of
inspiratory muscle training on the strength of the respiratory muscles, exercise performance,
clinical manifestations, and activities of daily living. Inspiratory muscle training was performed
by the use of an ISRBD that gave a linear inspiratory resistance of 50 cm H2O/L/sec at 1 L/sec
flow. Subjects used an ISRBD twice a day for 15 minutes each day for 4 weeks. Strength of
respiratory muscles as measured by PI max and sputum expectoration improved significantly (P
< 0.05) but there was no significant change in exercise performance (12-minute walk distance),
other clinical signs and symptoms, or activities of daily living. Visual feedback given by the
bellows of the ISRBD that inflated and deflated with inspiration and expiration apparently
served as a positive reinforcer and motivator for most subjects. The study concluded with a high
compliance rate (98%) of the participants.12
A study was conducted in Mangalore on effectiveness of deep
6
breathing exercise on pulmonary function among patients with chronic airflow limitation. Out of
40 patients randomly selected, 20 were assigned to experimental group and next 20 to control
group.The PFT parameters (FEV1&FVC) were assessed in both group before intervention. Deep
breathing exercise was provided for the experimental group for twice daily for 7 days.On the 7th
day PFT parameters of both groups were assessed.The result showed the mean score of FVC
and FEV1
is 23.80 and 26.80 respectively for experimental group ,where as 7.70 and
6.90(p<0.05) for the control group. The study concluded that deep breathing exercise is effective
in improving pulmonary parameters.13
6.3 PROBLEM STATEMENT:
Effectiveness of incentive spirometry v/s balloon blowing exercises on selected pulmonary
parameters of patients with chronic obstructive pulmonary disease (COPD) in selected hospitals,
Mangalore.
6.4 OBJECTIVES OF THE STUDY:
The objectives of the study are:
 To assess selected pulmonary parameters before and after interventions among
patients with COPD in both groups.
 To find the effectiveness of incentive spirometry exercise on selected pulmonary
parameters of patients with COPD.
 To find the effectiveness of balloon blowing exercise on selected pulmonary
parameters of patients with COPD.
 To compare the effectiveness of incentive spirometry and balloon blowing
exercise on selected pulmonary parameters of patients with COPD.
 To find an association between pre-test level of pulmonary parameters and the
selected demographic variables of patients with COPD
6.5 OPERATIONAL DEFINITIONS:
7
EFFECTIVENESS:
In this study it refers to the extent to which incentive spirometry and balloon blowing exercise
enhance the pulmonary parameters such as peak expiratory flow rate, chest expansion, breath
holding time and inspiratory capacity of patients with COPD as measured by peak flow meter
,inch tape ,stop clock and incentive spirometer
INCENTIVE SPIROMETRY EXERCISE:
In this study, it refers to expiratory breathing exercise aided by incentive spirometer,
administered 2 cycles per day, eachcycle with 10 expiratory efforts,given once in morning and
once in evening.
BALLOON BLOWING EXERCISE:
In this study, it refers to instructing the patients to blow the balloon to its maximum limit 10
times per cycle, given once in morning and once in evening.
SELECTED PULMONARY PARAMETERS:
In this study, it refers to variables reflecting the status of pulmonary function which includes
peak expiratory flow rate, chest expansion, breath holding time and inspiratory capacity as
measured by peak flow meter ,inch tape, stop clock and incentive spirometer respectively.
PATIENTS:
In this study, it refers to male and female adults between 40 to 60 years of age who have got
admitted in the selected hospital with diagnosis of COPD.
6.6 ASSUMPTIONS:
The study assumes that:
 COPD affects pulmonary parameters
 Active breathing influences pulmonary function
8
6.7 DELIMITATIONS:

Study is confined to selected health care settings of Mangalore.

Study is assessing only a few pulmonary parameters like peak expiratory flow
rate, chest expansion, breath holding time and inspiratory capacity.
6.8 HYPOTHESIS:
Hypothesis will be tested at 0.05 level of significance
H1: The mean post test pulmonary parameters will be significantly higher than mean pre-test
pulmonary parameters after receiving incentive spirometry exercise among patients with COPD
H2: The mean post test pulmonary parameters will be significantly higher than mean pre-test
pulmonary parameters after receiving balloon blowing exercise among patients with COPD
H3: There will be significant difference in pulmonary parameters between patients who receive
incentive spirometry and balloon blowing exercises among patients with COPD
H4: There will be significant association between pre-test level of pulmonary parameters and
selected demographic variables among patients with COPD.
MATERIALS AND METHODS:
7.1 SOURCE OF DATA:
Data will be collected from patients with COPD in a selected hospital, Mangalore.
7.1.1 RESEARCH APPROACH AND RESEARCHDESIGN:
Quantitative research approach will be used for this study
Quasi experimental research design,in which two group pre-test, post test design will be used
for this study
PRE-TEST
TREATMENT
9
POST-TEST
O1
X1
O2
O1
X2
O2
O1- Pre-test assessment of selected pulmonary parameters of patient with COPD
X1- Administration of incentive spirometry exercise
X2-Administration of balloon blowing exercise.
O2- Post-test assessment of selected pulmonary parameters of patient with COPD
7.1.2 SETTING:
Study will be conducted in medical wards of selected hospitals, Mangalore.
7.1.3 POPULATION:
7.
Population of the study consists of adult patients with COPD admitted at selected hospitals,
Mangalore.
7.2 METHOD OF DATA COLLECTION:
7.2.1 SAMPLING PROCEDURE:
Non-probability Purposive sampling will be used to select samples.
7.2.2 SAMPLE SIZE:
Sample consists of 40 patients with COPD, in which 20 patients in incentive spirometry group
and 20 in balloon blowing exercise group.
7.2.3 INCLUSION CRITERIA:
 Both male and female inpatients with COPD.
 Patients with COPD who are in the age group of 40 to 60 years.
7.2.4 EXCLUSION CRITERIA:
10
 Patients with COPD who are critically ill.
 Patients with COPD who practice any other breathing exercises
7.2.5 INSTRUMENTS USED:

Demographic proforma includes age ,gender, education, occupation, habit of
smoking, duration of smoking ,number of beedis or cigarettes used per day

Clinical proforma includes inspiratory capacity(ml), peak expiratory flow
rate(l/min), chest expansion(cm) and breath holding time (sec)
7.2.6 DATA COLLECTION METHOD:

Formal administrative permissions will be obtained from concerned health care
setting authorities.

The nature and purpose of the study will be explained.

Informed consent will be obtained from the participants.

Demographic data and pulmonary parameters will be collected from the samples
by administering tools on pre-test.

Administer incentive spirometry and balloon blowing exercises to respective
groups for 5 days.

The post-test data will be collected from the samples after administering
interventions.
7.2.7 DATA ANALYSIS PLAN:
 Demographic data will be analyzed using descriptive statistics: , frequency ,
percentage ,mean ,median, and standard deviation.
 Effect of incentive spirometry and balloon blowing will be analyzed
using
inferential statistics
Paired‘t’ test will be used for the significance of difference between pre-test and
post-test score of each intervention.
Independent‘t’ test will be used to compare the post-test scores of both groups
11
 Chi-square test will be used to find an association between pre-test level of
pulmonary parameters and selected demographic variables.
7.3 Does the study require any investigations or interventions to be conducted on patient or
other human or animals?
Yes,asapart of study incentive spirometry and balloon blowing exercise will be administered on
patients with COPD,which is of non-invasive type
7.4 Has ethical clearance been obtained from your institution?
Ethical clearance will be obtained from concerned authorities
Formal administrative permission is obtained from concerned authorities
Informed written consent is obtained from participants
12
8. LIST OF REFERENCE
1) Sighting the importance of health to human being[internet] 2009. Available from:
www.chalkmedia.co.uk.org
2) Park k. Textbook of preventive and social medicine. 17thed. Jabalpur: Banarsidasbhanot
publishers;273-94
3) WHO .Chronic obstructive pulmonary disease: Chronic respiratory diseases. Geneva;
2008. Available from: URL:http//www.who.co.in.
4) Halbert RJ, Natoli LJ, GanoA ,Buist AS. Global burden of COPD:systemic review and
meta analysis.ERS Jornal.2006 ;28(3):523-32.
5) Harry B, John F, Robert F. Exercise therapy for patients with COPD. Chest .2011
;57(2):116-121.
6) Rosa G, Casan P, Belde J. Pulmonary rehabilitation in patients with COPD-a randomized
trial. Chest.2000 ;117(4):976-983.
7) BasogluOK ,AtaserverA,Bacakagiy F. The efficacy of incentive spirometry in patients
with COPD. Respirology.2005 ;10(3):349-53.
8) Chuahan AJ , John PM ,Linda G ,Patrick D. Regular balloon blowing for chronic
bronchitis.BMJ.1992 ;304:1668-9.
9) Edward J, Kifer H. Simple exercise for breathlessness. BMJ.2004;24:567-9
10) Baslin R, Morance JJ ,Kahn GJ, Melot C .Incentive spirometry a reliable indicator of
pulmonary function. American college of chest physician .2007 ;3.
11) Wong Y,GuyattGH,King D, Cook DJ, Goldstein RS. Meta analysis respiratory
rehabilitation of chronic obstructive pulmonary disease. Mc master university. ACP J
Club. 1997;126(2):38.
12) Larson M, Kur MJ. Respiratory muscle training with incentive spirometry resistive
breathing device. Journal of heart and lung.1984 ;13(4):341-5
13) Mathew J, D’silva F .A study on effectiveness of deep breathing exercise on pulmonary
function among patients with chronic air flow limitation. International journal of nursing
education. 2011;3:34-7
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