Vol 5, No 05 (2017)

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Sejal G Yadav et al IJSRE Volume 05 Issue 05 May 2017 Page 6484

Volume||5||Issue||05||May-2017||Pages-6484-6490||ISSN(e):2321-7545 Website: http://ijsae.in

Index Copernicus Value- 56.65 DOI: http://dx.doi.org/10.18535/ijsre/v5i05.20

Effect of Ice and Airflow Stimulation Versus Controlled Breathing Exercise to Reduce

Dyspnea in Patients With Obstructive Lung Disease

Authors

Sejal G Yadav1, Kedar Sule2, Tushar J Palekar3

1

Cardio-respi dept. Dr. D. Y. Patil college of physiotherapy, Dr. D. Y Patil vidhyapeeth Pune, India

2

Assistance professor, Dr. D. Y. Patil College of physiotherapy, Dr. D. Y. Patil vidhyapeeth Pune, India

3

Principal, Dr. D. Y. Patil College Of Physiotherapy , Dr. D. Y. Patil Vidhyapeeth Pune,India. [email protected], [email protected], [email protected]

Corresponding Author:

Sejal G Yadav,

Department of cardio-respiratory, Dr.D.Y.Patil college of physiotherapy Dr. D.Y. patil vidhyapeeth pune,india.

Email id:[email protected]

ABSTRACT

Introduction: Dyspnea is a disabling distressing symptoms that is common in advance disease affecting millions of people worldwide. Current palliative strategies are partially effective in managing this symptom so, aim of this study is to compare the effectiveness of airflow and facial cooling stimulation versus controlled breathing exercise to reduce dyspnea in patient with COPD.

Material & Methods: In this randomized cross over study ,30 Subjects with age group between 45-80 years were diagnosed with moderate to severe COPD according to GOLD’S criteria were divided into two groups of treatment according to chit method. First day Patient received either airflow stimulation therapy (by ice and table fan) or controlled breathing (pursed-lip breathing and diaphragmatic breathing) for 5 minute of duration. Second day the same patient receive the another group of treatment .Pre and Post RR, Oxygen saturation, Rate of perceived exertion by Modified Borg scale (RPE) were recorded.

Results: T test was used to analyze the data collected. The p-value for RR is 0.091. The p-value for spo2 is 0.692.and the p-value for RPE is 0.064. Therefore, it showed that it were not statistically significant.

Conclusion: In this study we conclude that Airflow stimulation and controlled breathing exercise both are effective in relieving dyspnea. But when compared the both method, facial icing and airflow stimulation are more effective, easy, inexpensive and earlier relief therapy than the controlled breathing exercise.

Key Words: Breathlessness, ice and airflow stimulation, diaphragmatic breathing and pursed lip breathing,

INTRODUCTION

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DYSPNEA

Dyspnea or shortness of breath is the feeling or feelings associated with impaired breathing. The American Thoracic Society defines it as "a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity," the degree of distress involved, and its burden or impact on activities of daily living. Distinct sensations include effort/work, chest tightness, and air hunger (the feeling of not enough oxygen) [1]

Dyspnea is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations. In 85% of cases it is due to asthma, pneumonia, cardiac ischemia, interstitial lung disease, congestive heart failure, chronic obstructive pulmonary disease, or psychogenic causes, such as panic disorder and anxiety.

The prevalence of dyspnea in cancer patients has been reported to be between 21% and 90%, depending upon the stage of cancer and selection criteria of patients. It is particularly common in patients who have primary lung cancer or metastatic involvement of the lung.

The Anatomy Of Breathing: Respiratory activity is complex. [3] The respiratory center in the medulla and pons coordinates the activity of the diaphragm, the intercostal muscles, and accessory muscles of respiration. It receive sensory information from central and peripheral chemotherapy in blood vessels; peripheral mechanoreceptors from muscles, tendons and joints; and pulmonary vagal afferents. These vagal afferents include pulmonary stretch receptors that are activated by lung inflation, pulmonary irritant receptors triggered by air flow and smooth muscle tone, and alveolar C fibbers that respond to pulmonary interstitial and capillary pressure. These afferents may also send information directly to the cerebral cortex. It is believed the cerebral cortex integrates this sensory input with other cognitive and emotional factors , as well as with motor information from the respiratory center. Normally, there is no awareness of breathing. However if any of these inputs are pertubated, an uncomfortable awareness of breathing may occur.

Cortical areas involved in the perception and modulation of dyspnea have been identified by applying functional brain imaging using positron emission tomography. These studies implicate areas such as the anterior insula and the posterior cingulate gyrus as locations of particular activity in respiration.

These complex and diffuse data regarding pathophysiology can be conceptually summarized in 3 Components:

Work of Breathing: The increased effort required for breathing against increased resistance or breathing with weakened muscles is perceived as dyspnea.

Chemical: Medullary chemoreceptors predominantly sense hypercapnia. Carotid and aortic body chemoreceptors predominantly sense hypoxemia. Signals from these chemoreceptors can produce dyspnea independent of increased respiratory effort. Hypoxemia appears to play a less important role than is commonly believed. This conclusion is supported by the observation that it takes moderately severe levels of hypoxemia to trigger the Peripheral chemoreceptors. In addition, the compensatory increase in ventilation triggered by Hypoxemia drives down the co2 level, Which then partially negates the effect of the hypoxemia.

Finally, many studies have documented that most patients with cancer and dyspnea are not Hypoxemic.

Neuromuscular Dissociation: When there is a mismatch between brain set points and sensory feedback

from the periphery, dyspnea occurs. For example, when researcher limit the inspiratory flow rate at which a subject is allowed to breath , dyspnea results despite no change in respiratory work or chemical status. Pursed lip breathing: pursed lip breathing is a strategy that involves lightly pursing the lips together during controlled exhalation. This breathing pattern often is adopted spontaneously by patient with COPD to deal with episode of dyspnea. It is thought to keep airway open by creating backpressure in the airways.[4]

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Positions To Relieve Dyspnea

 High side lying  Forward lean sitting  Relaxed sitting

 Forward lean standing and  Relaxed standing

Effect of Airflow And Ice Therapy To Reduce Dyspnea

A simple electric fan could provide rapid relief for the long term breathlessness .medicals believe cool air stimulate nerves in the face that are stimulated when people dive into cold water, prompting the body to conserve oxygen This persistent cold temperature triggers what is called the diving reflex.[5]

There is some evidence that a source of cool air directed onto the face may reduce breathlessness in adults, suggesting that stimulation of cold receptors located in the upper airway may be responsible for the relief of breathlessness. Some of these cold receptors are innervated by the vagus nerve and monitor the changes of flow in the upper airway by detecting changes in temperature.[6]

In addition to the cold receptors, there are at least four or five different types of airway receptors innervated by the vagus that may mediate dyspnea and other sensations, although the role of vagal afferents is uncertain and is likely to be complex. The major receptors in the lung parenchyma are slowly adapting stretch receptors (SARs), rapidly adapting stretch receptors (RARs), and C-fibre receptors.[7]

One theory is the flow of cool air affects cold temperature receptors in the face specifically the trigeminal nerve, which runs under the skin in the nose and mouth.

MATERIALS AND METHODS

Inclusion Criteria: patient having age criteria of 45-80 year. Males and females are included.

Patient diagnosed with 2 & 3 grades of COPD condition

Exclusion Criteria: Any facial injury and surgery. Sinusitis.

Patient with respiratory failure.

Patient having dyspnea on cardiac origin Patient having allergic rhinitis and Bronchitis.

Patients having asthma.

Materials : ice pack, fan, Pulse oxymeter, stopwatch, Chair, Sphygmomanometer.

Two small cones to mark the turn around points.

Ethical clearance for the study was obtained. 30 subjects were screened according to the inclusion & exclusion criteria. 30 subjects who had Moderate to severe COPD according to GOLD criteria in which FEV1 was between the 30 to 80% of predicted value were selected after post bronchodilator PFT.

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Sejal G Yadav et al IJSRE Volume 05 Issue 05 May 2017 Page 6487 To make the patient dyspneic we conducted the 6MWT and after that we gave the treatment. Baseline parameters pre Respiratory rate, spo2, blood pressure, modified Borg scale were taken. Patients were instructed to walk from end to end at the corridor of the hospital which is 30 meters long. Patients at their own pace, while attempting to cover as much distance as possible in the allotted 6 min without supplement of oxygen. Timed the walk and recorded the distance traveled. Verbal encouragements to the patients were given. At the end of the 6MWT, the total distance covered was recorded to the nearest meter.[7]

Dyspnea severity by the modified Borg scale, respiratory rate, Blood pressure and pulsed oxygen saturation were measured at the end of the tests. Tests were not done if spo2 before test was lower than 90%.[7]

Then immediately after the 6MWT, The Ice and airflow stimulation was given as allocate treatment. Following the post intervention test parameter recorded.

Ice And Airflow Techniques (Group A)

Patient was made to lie in comfortable semi fowler position.

Facial muscle icing was given using ice pack wrapped in cloth over cheeks and nose in butterfly pattern and over forehead for 5 minutes.

Ice pack was applied on the patients face (around the cheek & nose ) and accessory muscles (sternocleidomastoid muscles, upper trapezius ,4 to 10 Degree Celsius)[5]

After that airflow stimulation was given with the help of table fan. Table fan was placed on the central area of face. Distance of the fan from the patients face was at least 5 minutes to relive dyspnea.[6]

Post intervention patients were re-assessed for respiratory rate, SpO2 using pulse oxymeter and rate of

perceived exertion on modified Borg scale.[6]

Controlled Breathing Exercise (Group B)

Diaphragmatic exercise

Patient was made in relax and comfortable position. In which gravity assist the diaphragm, such as a semi fowler‟s position.

Placed the hand on the rectus abdominis just below the anterior costal margin. Asked the patient to breathe in slowly and deeply through the nose. The patient kept the shoulder relaxed and upper chest quite, allowing the abdomen to rise slightly. Then guide the patient to relax and exhaled slowly through the mouth.

The patient practice this three or four times and the rest period was given so that do not allow the patient to hyperventilate.[4]

Pursed lip breathing

The patient was made to assume a comfortable and relaxed position as much as possible.

The patients were made to breathe in slowly and deeply through the nose and then breath out gently through lightly pursed lips as if blowing on and bending the flame of a candle but not blowing it out.

The patient expiration was relaxed so we avoided contraction of the abdomen.[3]

Post intervention patients were re-assessed for respiratory rate, SpO2 using pulse oxymeter and rate of perceived exertion on modified Borg scale.

Next day the same patient underwent 6MWT to induced dyspnea following the 6 MWT to the patients received another treatment and post treatment parameter recorded. Patients were assessed for respiratory rate, SpO2 using pulse oxymeter and rate of perceived exertion on modified Borg scale prior to intervention.

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RESULTS

Table 1- Pre Mean and Post Mean Of Group A and Group B for RR

Table 2- Pre Mean and Post Mean Of Group A and Group B for Spo2

Table 3-Pre Mean and Post Mean Of Group A and Group B for RPE

Table-4 Represent the mean difference among the two groups

Table 1 shows descriptive statistics of within group analysis of RR and the values are pre RR mean and standard deviation of group A is 28.69±6.025 , group B is 30.4± 5.992 and the post RR Mean and standard deviation for group A 24.92±3.762 is and group B is 24.67±5.77

Table 2 shows the descriptive statistics of within group analysis of spo2 and the values are pre spo2 mean and

standard deviation of group A is 95.65±2.171, group B is 97.23±1.423 and the post spo2 mean and standard

deviation of group A is 93.9±3.898 , and group B is 95.13±4.911.

Table 3 shows descriptive statistics of within group analysis of RPE and the values are pre RPE mean and standard deviation of group A is 5.231±2.582, group B is 4.7±1.968 and the post RPE Mean and standard deviation of group A is 3.462±2.533, and group B is 2.233±1.633.

Table 4 shows the mean difference values of all three outcome measures for pre and post for comparison between two groups. The mean difference and SD difference for RR of group A is 3.769±3.35, for spo2 is 1.577±1.554 and for RPE is 1.769±1.336. Now the values of group B for RR is 5.733±4.934, for spo2 1.233±4.15, and for RPE is 2.467±1.408.The p-value for spo2 is 0.692.and the p-value for RPE is 0.064. Therefore, it showed that it were not statistically significant.

GROUP PRE POST P VALUE

A MEAN SD MEAN SD 0.000

28.69 6.025 24.92 3.762

B 30.4 5.992 24.67 5.779 0.000

GROUP PRE POST P-VALUE

A

MEAN SD MEAN SD

0.000

95.65 2.171 93.9 3.898

0.114

B 97.23 3.898 95.13 4.911

GROUP PRE POST P-VALUE

A

MEAN SD MEAN SD

0.000

5.231 2.582 3.462 2.533

0.000

B 4.7 1.968 2.233 1.633

MEAN(DIFF) SD(DIFF) T value P value

GROUP A GROUP B GROUP A GROUP B

1.721 0.091

RR 3.769 5.733 3.35 4.934

SPO2 1.577 1.233 1.554 4.15 0.399 0.692

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DISCUSSION

Dyspnea has an absolute magnitude and consists of a complex body of efferent and afferent signals arising from various kinds of peripheral receptors. The lists of classes of peripheral receptors that respond to Stimuli that are potentially able to generate dyspnea are long: it includes receptors in the upper airway, lower airway, lung parenchyma, and respiratory muscles, as well as peripheral and central chemoreceptor. Mechanorceptors are also recognized as playing important role in producing or modifying dyspnea.[2]

Our study supports the hypothesis that ice and airflow stimulation directed to the face reduce the sensation of dyspnea, demonstrating the significant reduction in RR and RPE and greater improvement in spo2 after

five minute use of ice pack and fan directed to the face compared with controlled breathing exercise.

The results indicated that facial muscle icing decreased pathologic dyspnea in patients with obstructive lung disease. Patients with breathlessness commonly describe subjective relief when seated near an open window or in front of a fan. Physical stimulation or exposure to cold air of nasal or oral mucosa receptors results in decreased breathlessness. The diving response, which causes ventilator depression when the trigeminal area of face is cooled, is one possible mechanism for this effect.

Our study demonstrates that the fan directed to the face reduced the sensation of breathlessness. This reduction in breathlessness may have been achieved by the cooling of nasal or oral mucosal receptors and via the decreased central respiratory drive. Which directly reduce the Respiratory rate, and sensation of dyspnea.[8]

Richard M. Schwartzstein, Karen Lahive, et Al, stated that flow of air or application of cold solutions to the face, nasal mucosa, or pharynx may alter ventilation. They hypothesized that a flow of cold air directed against the cheek would reduce the sensation of breathlessness associated with loaded breathing.

The use of a hand –held fan (airflow stimulation) and ice pack is, patient- directed, safe, practical technique for managing dyspnea in any setting and could be recommended for breathless patients throughout the world.

Controlled breathing techniques, which emphasize diaphragmatic Breathing, are designed to improve the efficiency of ventilation, decrease the work of breathing, increase the excursion of the diaphragm and improve gas exchange and oxygenation. [11]

Rik Gosselink, PT Phd respiratory rehabilitation and respiratory division sep/oct 2003 page 25 -34 et al in their study „controlled breathing and dyspnea in patient with chronic obstructive pulmonary disease.” They found that the efficacy of controlled breathing aimed at improving dyspnea.in patients with COPD, controlled breathing works to relive dyspnea by (1) reducing dynamic hyperinflation of the rib cage and improving gas exchange, and (2) optimizing the pattern of thoracoabdominal motion. Evidence of the effectiveness of controlled breathing on dyspnea is given for pursed-lips breathing, forward leaning position, and inspiratory muscle training.

Diaphragmatic breathing encourages patients to use their abdominal wall when breathing to reduce chest wall motion. This technique increased dyspnea in one study, where as it significantly improved dyspnea after four weeks of training in another study..one study found no significant difference in peak oxygen consumption, 12-minute walk distance, peak work, or endurance work with diaphragmatic breathing. [10] Pursed lip breathing is very popular and excellent “rescue” technique for the acute dyspnea resulting from COPD, emphysema and asthma. Generally however, breathing control techniques are more desirable for chronic, long term breathing comfort.[11]

Hence, airflow and ice stimulation technique as well as controlled breathing showed significant improvement individually in RR, Spo2 and RPE. However on comparison Group A that is ice and airflow

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CONCLUSION

In this study we conclude that Airflow stimulation and controlled breathing exercise both are effective in relieving respiratory rate, dyspnea and increasing spo2 in patients with COPD. But when compared the both

method, among the two methods the facial icing and airflow stimulation are more effective, easy, inexpensive and earlier relief therapy than the controlled breathing exercise.

REFERENCES

1. Global initiative for chronic obstructive lung disease ; Global strategy for diagnosis, 2. Management and prevention of COPD.updated 2011.

3. Donald a. Mahler; denis E.o‟donnell “Dyspnea mechanism,measurement , and 4. Management, third edition [20january 2014].

5. Jay R. Thomas MD, PhD et al “ management of dyspnea.” Third avenue, san Diego, j Support oncol volume 3 [2003 may/ June]

6. C. Kisner ,L.A. Colbey. Therapeutic exercise, Jaypee brother medical publisher 5th addition.2007 7. Roger Dobsonet al, “ could a gust of cool air ease breathlessness ? April 2011

8. Richard M. Schwartzstein, Karen Lahive ,Alan Pope, steven E. Weinberger and J Woodrow Weiss Cold facial stimulation reduce breathlessness induce in normal individuals‟1987

9. Shweta Rasam, Effect of cold stimulation over the face on 6 minute walk distance, oxygen saturation and dyspnea scores in patients with COPD. European respiratory journal 1 september 2014

10. Sarah galbraith does the use of a handheld fan improve chronic dyspnea? A Randomized, controlled, crossover Trial journal of pain and symptom management 5 May 2010.

11. Marcelo Fernandes, “ Efficacy of diaphragmatic breathing in patients with chronic obstructive pulmonary disease chronic respiratory disease ,2011; 8(4) 237-244

12. Cintia laura, “pursed lip breathing reduces dynamic hyperinflation induced by activities of daily living test in patients with chronic obstructive pulmonary disease : A randomized cross-over study. J rehabil Med 2015.

Acknowledgements

The authors thank Dr Kedar Sule and Dr Arijit kumar Das for their comments on protocol design and Colleague Dr. Mayur S Kakade to help for this study and thank all the patients for their co-operation.

Funding