Ef icacy of breathing retraining program on bedside assessment of pulmonary function

Ganapathy Sankar U.1, Monisha R.*1, Christopher Amalraj Vallaba Doss2, Palanivel R M3 1SRM College of Occupational therapy, SRMIST, Kattankulathur, , Chennai-603203, Tamilnadu, India 2College of Medicine, Imam Abdulrahman Bin Faisal University, P. O. Box 1982, Dammam 31441, Saudi Arabia 3Deanship of Quality and Academic Accreditation, Imam Abdulrahman Bin Faisal University, P. O. Box 1982, Dammam 31441, Saudi Arabia


INTRODUCTION
In clinical practice, assessment of dyspnea is always a burden and a challenge, because of the subjective experience of quantifying it. The American Tho-racic Society de ines dyspnea as "a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity [it] derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioral responses. (Bianchi et al., 2004) The subjectivity of dyspnea is one of the main dif iculties confronting the clinician whose task it is to determine the diagnosis and judge the severity of the underlying condition. The pathology behind dyspnea is still not fully clear and is now under investigation. Various instruments are used to analyze dyspnea, VAS (visual analog scale), Borg scale are simple measures of intensity of dyspnea and multidimensional questionnaires-dyspnoea pro ile also used commonly (Dechman and Wilson, 2004). These instruments have been validated and are useful for communication. Other disease-speci ic dyspnoea classi ications include the New York Heart Association (NYHA) classi ication. Dyspnoea is the predominant symptom limiting exercise capacity and activity of daily living in patients . It is usually described as a range of different descriptors that varies in intensity and in luences by a patient's experiences. Clinical disorders that affect the heart, lungs and neuromuscular apparatus produce symptoms of dyspnea . Breathing Retraining Program beneit chronic mouth breathers and patients with sleep apnea and dyspnoea (Garrodl et al., 2005). Routine investigations of respiratory functions like volumes, lows, and indices of gas exchange, are non need, and they are not speci ic to diagnosis but give some information about respiratory muscle performance (Jones et al., 2003). But the respiratory muscle dysfunction can be identi ied by conventional respiratory function tests. On occasion, the presence of breathing pattern dysfunction is irst suspected from the pattern of breathing, which is spontaneously adopted by the patients (Manshawi et al., 1986). PFT-pulmonary function testing is more frequently used in assessing the severity of underlying lung disease and the progress of a patient with goof lung function (Garrodl et al., 2005). The ef icacy of pursed-lip breathing (PLB) and diaphragmatic breathing (DB) in the rehabilitation of people with dyspnoea remains unclear and there is no proper teaching of these breathing retraining exercises was done in routine practice (Nield et al., 2007). This study examines the usefulness of these techniques in normalizing the breathing pattern of people with dyspnoea (Jones et al., 2003). The studies included the use of PLB and DB and used outcomes that were measured at the bedside. Pursed-lip breathing is the well-known respiratory rate lowering technique, 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 (Manshawi et al., 1986). Diaphragmatic breathing has negative and positive effects, but the latter appears to be caused by simply slowing the respiratory rate (Spahija et al., 2005). Evidence supports the use of PLB, but not DB, for improving the breathing of people with obstructive lung disease. Despite many studies on the topic, there is no speci ic research has highlighted the effects of breathing retraining program individually without including that under combination technique, the role of breathing retraining techniques such as pursed-lip breathing (PLB)1 and diaphrag-matic breathing (DB)2 in the rehabilitation of people with dyspnoea remains unclear (Stel et al., 2001).

METHODOLOGY
Totally 100 Patients with dyspnoea are included in the study and randomly assigned to Group A and Group B, in that 20 patients were dropped out of the study in 3 days after the commencement of the study, because of the exacerbation of the underlying lung disease and because of other factors. Patients were allocated to group 1 (n=50) was submitted to pursed-lip breathing exercise sessions and dyspnoea score was evaluated at the end of the exercise training. Patients were instructed to practice Pursed-lips breathing by demonstration. The arterial oxygen saturation measured from a pulse oximeter is used to provide feedback Subjects were asked to breathe out through pursed lips and they were instructed to practice PLB for 5 min/d the irst week, 10 min/d the second week, 15 min/d by the third week, and 20 min/d by the fourth week.

Group B
After getting informed consent signed, patients were allocated into Diaphragmatic breathing group

Method
(n=50) were evaluated with modi ied Borgs scale and there baseline lung function is evaluated with single breath count test and snider match test, the study subjects were instructed to practice Diaphragmatic breathing exercise 5 min/d the irst week, 10 min/d the second week, 15 min/d by the third week, and 20 min/d by the fourth week immediately after breathing retraining program, subjects were asked to perform Single breath count (SBC) by serial counting of numbers after maximal inhalation. SBC is the bedside pulmonary function test that has a good correlation with the gold standard measures of pulmonary function test (PFT), peak expiratory low rate (PEFR), and forced expiratory volume in the irst second (FEV1). SBC is a simple and effective replacement for the laboratory measurement of PFT. Patients were also asked to perform a snider match test. This shows theability of a patient to blow out a match at a distance of 6 or 9 inches was found to be a useful clinical test. This ability was tested in 100 patients. It is used at the bedside of the patient during regular ward rounds.

Data Analysis
Pre and Post-test values of Single Breath Count (SBC) among Group A subjects treated with pursedlip breathing exercise Group B subjects treated with a diaphragmatic breathing exercise

DISCUSSION
This study is restricted in examining a single breathing retraining technique so that the effect of the speci ic technique could be clearly assessed. The study focus was on patients with dyspnoea, reports that included subjects diagnosed with cardiovascular events were not included in the study. Subjects in the PLB and DB groups were instructed to begin daily practice sessions and were given logbooks to record their practice times and any adverse reactions. Weekly visits were made to reinforce their breathing pattern retraining program and to analyze their dedication to the assigned protocol. We excluded participants when the diagnosis was not clearly de ined. PLB is the easiest breathing technique to learn, and Patients were instructed to inhale through the nose over several seconds with the mouth closed and then exhale slowly over 5 to 6 seconds through pursed lips held in a whistling or kissing position. This is done with or without contraction of the abdominal muscles. Patients reported that relief of dyspnea is immediate after practicing to use the PLB technique. Subjects were equally divided into two groups, where group A was instructed to perform pursed-lip breathing, where   PLB is easy to practice and immediately relived dyspnoea. As the equipment required for measuring pulmonary function testing is not generally available in all outpatient and inpatient wards, so this simple bedside screening test, such as the match test described by Snider and single breath count is used as an outcome measure. In the snide match test, subjects were asked to blow out a match held at six to 9 inches from his widely opened mouth.
To determination of the maximum breathing capacity and timed vital capacity equipment not available at the bedside. In this study, a simple bedside pulmonary function test is evaluated. Standard matches are used. After illumination matches were burning steadily, it is held at 9, 6, 3inches from the patient's opened mouth. The subjects were instructed to inspire maximally and expire rapidly to extinguish the illuminated match at an appropriate distance. Instructions were given that the subjects not to do purse lip during expiration he must expire with his mouth completely open to measure true air-low velocity, there must be three trials to assess maximal effort on the part of the patient.
In this study, Single breath count has been statistically increased with a pursed-lip breathing exercise. However, diaphragmatic breathing retraining has also shown improvement in single breath count (Table 1). This inding was con irmed, Professor. Arul Kumaran, in his research, even a single breath count (2017), proved that single breath count is a simple, non-invasive, safe and cost-effective bedside assessment tool and it correlated well with FEV1 and FVC. SBC is a good alternative to pulmonary function testing in resource-poor settings and also in outpatient wards. On the other hand Joel M bart ield (2016), in his research work on single breath counting in the assessment of pulmonary function, concludes that SBC is a reasonable alternative to peak expiratory low rate and he quoted that further investigation in the emergency ward is needed. When comparing snider match test group A and group B showed statistically signi icant value (Table 2). Pursed lip breathing and diaphragmatic breathing, these two breathing retraining strategies show equal improvement in 2 training groups. When the SBC increases, it has a direct in luence on Snider match test distance. After 4 weeks of breathing retraining, both group A trained with pursed-lip breathing and group B trained with Diaphragmatic breathing exercise shows a minimum improvement in six-minute walk test distance. A study was done by Majid Meriem and Jouda Cherif on six-minute walk test correlates in COPD population concluded that six-minute walk test is the reliable assessor of exercise capacity and perceived breathlessness is correlated with walking distance in patients with COPD and The 6MWT was negatively correlated with dyspnea severity (Table 3) CONCLUSION Pursed-lips breathing provided sustained improvement in dyspnea and physical function on comparison with diaphragmatic breathing exercise as this technique is manually adapted by the patients, proper re-education is needed in the practice of these breathing retraining techniques and also the bedside assessment tools are a good correlates of PEFR AND FEV1, FVC and it can be safely concluded that both SBC and snider match test is bedside assessment tools for the assessment of pulmonary function in the emergency and resource-limited settings.

Ethics
Ethical clearance obtained from the department of occupational therapy-SRM medical college hospital and research institute, Kattankulathur, Chennai, India