Article Versions
Export Article
Cite this article
  • Normal Style
  • MLA Style
  • APA Style
  • Chicago Style
Research Article
Open Access Peer-reviewed

Effectiveness of Breathing Techniques on Dyspnea among Critically Ill Chronic Obstructive Pulmonary Disease

Marwa Fathalla Mostafa , Asmaa Ibrahem Abo Seada
American Journal of Nursing Research. 2018, 6(6), 645-649. DOI: 10.12691/ajnr-6-6-35
Received September 22, 2018; Revised October 23, 2018; Accepted October 28, 2018

Abstract

Background: Chronic obstructive pulmonary disease (COPD) is one of the most reported problems in intensive care units (ICUs). It is a major cause of disability and death worldwide. Breathing techniques are an essential part of a comprehensive pulmonary rehabilitation program for COPD patients. Performing breathing techniques reduce the frequent dyspnea, promote relaxation and improve pulmonary function. Aim: To evaluate the effectiveness of breathing techniques on dyspnea among critically ill chronic obstructive pulmonary disease. Method Quasi-experimental research design was used in this study. The study involved 50 adult COPD patients recruited from pulmonary ICU at Mansoura University Hospitals in Egypt. Patients were divided into two groups randomly 25 patients in the control group and 25 patients in the intervention group. Data were collected using the demographic and health-relevant data, physiological and ABG parameters of patients and finally the modified medical research council dyspnea scale. Results: After undergoing breathing exercises in the intervention group, the mean score of dyspnea was significantly reduced (P< 0.001). Also, there was a significant improvement in the patients' physiological and ABG parameters compared to the control group. Conclusion: breathing techniques improve dyspnea in critically ill COPD patients. Recommendations: Respiratory breathing techniques should be used as a routine non-pharmacological, safe, and low-cost method in rehabilitation care for patients with COPD.

1. Introduction

Chronic obstructive pulmonary disease (COPD) is a serious respiratory disorder. The prevalence was measured at about 10 million in Egypt 1. The Global Institute for Chronic Obstructive Lung Disease (GOLD) estimates that by 2020, COPD will have ranked third among the world's sixth most common causes of death and will have been the fifth disabling disease 2. The COPD burden is rising globally and there are massive physical, economic and mortality costs and moderate to severe COPD affects more than 65 million people 3. COPD is characterized by emphysema and chronic bronchitis, resulting in breathlessness, cough, and sputum 4. Two important symptoms in patients with COPD, which are also among the common complaints, are fatigue and shortness of breath (dyspnea) 5.

Chronic obstructive pulmonary disease is associated with irreversible airway obstruction that cannot be cured with medical treatments, but using some ways can stop the worsening of COPD symptoms 6. Today, pulmonary rehabilitation (PR) is developed as a non-pharmacological approach focusing on the needs of patients and their families. PR aims to help patients achieve independence and maintain the maximum level of autonomy and function in society 7. One of the cornerstones in the treatment of COPD is the use of breathing exercises designed to increase tidal volume, diminish uneven ventilation and increase pulmonary function 8.

For COPD patients, breathing techniques help to relieve symptoms and enhance adverse physiological effects by increasing breathing muscle strength and endurance; improving the thoracoabdominal movement pattern; reducing dynamic rib cage hyperinflation and enhancing gas exchange 9. Since critical care nurses spend more time with patients, it is necessary to focus on non-pharmacological, low-cost and non-invasive methods as an effective way to reduce costs and manpower and improve the level of health and quality of life for critically ill COPD patients 10.

Although breathing exercises are commonly used as part of pulmonary rehabilitation programs, data supporting their use alone are limited. There are few studies researched in Egyptian contexts exploring the effect of breathing exercises on pulmonary function among COPD patients. With this background, the current study was conducted to investigate the effectiveness of breathing technique on reducing dyspnea among patients with COPD in ICU.

1.1. The Study Aim

This study aims to evaluate the effectiveness of breathing techniques on dyspnea among critically ill chronic obstructive pulmonary disease.

2. Method

2.1. Research Design

Quasi-experimental research design was used to evaluate the effect of an independent variable (breathing techniques) on the dependent variable (dyspnea).

2.2. Research Hypothesis

We hypothesized that COPD patients who receive breathing techniques would have dyspnea improvement than those who do not receive breathing techniques.

2.3. Research Setting

This study was carried out at the University Hospital of Mansoura, pulmonary ICU. This ICU provides service for patients with respiratory problems. It consists of six beds separated by curtains. The patient-nurse ratio was 1:2.

2.4. Subjects

A convenience sample of 50 conscious adult with definite diagnosis of COPD by a physician, either gender, admitted to the previously mentioned setting. Patients were assigned in two groups 25 patients as an intervention group (breathing techniques) and 25 patients as a control group who received routine hospital nursing care. Patients were assigned according to a computer-generated randomization list.

2.5. Exclusion Criteria

Mechanically ventilated patients with organ failure, cancer, or inability to cooperate were excluded from the study.

2.6. Tool for Data Collection

One tool was used for data collection in this study, it consists of three parts:

Part I: Patient's Demographic and Health-Relevant Characteristics

It included age, gender, date of ICU admission, level of education, smoking history, medical history and length of ICU stay.

Part II: Patient's Parameters Sheet

This part developed by the researcher, it consisted of the following:

Vital signs parameters as respiratory rate, blood pressure, and heart rate.

Arterial Blood Gases (ABGs) parameters such as PaO2, PaCo2, PH, and SO2.

Part III: Modified Medical Research Council Dyspnea Scale: this part adopted from Bestall et al., 11. It consists of 6 questions concerning perceived activity-related breathlessness and includes Grade1=0, Grade2=1, Grade3=2, Grade4=3, Grade5=4 in five grades from 1 to 5. Where category 0 represents no dyspnea; category 1 represents slight dyspnea; category 2 represents moderate dyspnea; category 3 represents moderately severe; category 4 represents severe dyspnea, and category 5 represents very severe dyspnea. The patient was assessed at baseline (on admission) and 7- day controlled breathing program.

2.7. Procedure

The study population included all COPD patients hospitalized in the previous setting from 20/05/2017 to 15/11/2017. During patient hospitalization, the researcher administered the breathing techniques which included relaxation exercises, active expiration and breathing pursed-lips, twice a day for one week. The session lasted 30 minutes and the participants patients were instructed to take a 3-minute break if necessary. Dyspnea scale was calculated before and after breathing techniques in both groups

2.8. Ethical Considerations

Before starting the study, ethical approval was obtained from the Faculty of Nursing's Research Ethics Committee, Mansoura University. Permission was obtained from the ICU authorities to conduct the study. Eligible patients were informed about the aim, procedure, benefits, and risks of the study. They were informed that they participated voluntarily in this study and have the right to accept or refuse to participate without penalty. Confidentiality of data was assured by coding.

2.9. Statistical Analysis

All statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) version 20.0. The mean ± standard deviation of parametric data was expressed. The χ2 test and Monte Carlo test were used to compare between the intervention group and the control group. The Pearson Chi-square test measures all groups ' categorical variables. The statistically significant P-value < 0.05 was found. Pearson correlation is normally distributed for one or both continuous variables while spearman correlation is distributed for other variables.

3. Results

Table 1 shows demographic characteristics and health-relevant data of the patients, it was found that approximately nearly half of COPD patients in both the intervention and control groups ranged between 50 and 60 years of age. As regard gender, it was found that more than three quarters of patients in both groups were males. It represents 76% for the intervention group compared to 68% for the control group. Concerning the marital status, the current study reveals that 88% and 80% of the intervention and control group were married. Most patients were illiterate 56% in the intervention compared to 44% in control group. Regarding smoking, it was observed that the majority of patients (68%, 64%) in the intervention and the control group were smokers. No significant differences were found between the intervention group and the control group regarding their demographic data and health-relevant characteristics.

Table 2 represents a comparison between the control and intervention groups throughout intervention as regards dyspnea scale, it can be seen that none (0.0%) of the patients in the intervention group had grade 5 of dyspnea (very severe dyspnea) post the breathing techniques program compared to 0.24% of patients in the control group. 8% of the intervention group who used breathing techniques had severe dyspnea compared to 68% in the control group. The mean score of dyspnea scale had changed in breathing technique group after breathing procedure (before the procedure: 3.00±0.76& after the procedure: 3.28±0.79). There were no statistically significant differences between the both groups before the breathing techniques program (p=0.903) compared to a highly significant differences between both groups following the breathing techniques program (p<0.001).

Table 3 indicates that there are no statistically significant differences between the intervention and the control group before breathing technique concerning vital signs parameters and arterial blood gases parameters, while the mean score of respiration had changed in breathing technique group after breathing procedure (before the procedure: 64.08±7.25 & after the procedure: 75.16±8.70). Regarding the arterial blood gases (ABG) parameters, it was found that ABG mean improvement from pre breathing technique to post breathing technique, the mean score of PH had changed in breathing technique group after breathing procedure (before =7.17±0.81 & after =33.28±0.79), the mean score of paco2 had changed in breathing technique after breathing procedure (before =7.37±0.06& after =42.24±6.99) and the result was noted highly significant in paO2, saO2 after breathing technique procedure.

4. Discussion

Evidence suggests that applying non-pharmacological interventions to COPD patients such as forward-leaning posture and respiratory exercises can enhance airflow and reduce symptoms of dyspnea and psychological problems, as well as improve patients' outcomes. Therefore, the present study was designed to evaluate dyspnea score, following one week course of breathing techniques.

In the current study, as a baseline for comparison, significant differences were not elicited in both the intervention and the control groups regarding demographic characteristics such as age, gender, and smoking. This is in line with the findings of the Brazilian study that demonstrated similar demographic characteristics of subjects assigned to the control group and the group of yoga 12.

With respect to gender, the findings of this study indicated that the majority of patients were males in both groups. These findings correlate with Castelino et al., 13 who reported that most of his research studies were males (90.7%). Males were affected more than females by the COPD. This may be attributed to the nature of males about smoking cigarettes habits. The same results were documented in an epidemiological study 14. The study also revealed that approximately nearly half of COPD patients in both the intervention and control groups were aged between 50 and 60 years of age. In line with Steele et al., 15 who announced the sample of the study over the age of 57. This result is incompatible with Navarro et al., 16 who found that the bulk of the sample was 65 years old. Concerning smoking, more than half of the patients were smokers in both groups. This is in line with the results of de Llano et al., 17 who reported that the COPD patient is either a smoker or has a history of smoking among more than half of cases. In accordance with this finding Horner's study 18 found that smoking is the main cause of 85% COPD conditions. Also, Buist and colleagues 19 stated that smoking was recognized as the most important causative factor for COPD patients.

On comparing the study and intervention group regarding vital signs parameter, the results of the study showed that statistically significant differences in respiration rates between the two groups mean scores after breathing strategies have been introduced. In agreement with our results, the impact of pursed breathing lips on exercise capacity in stable COPD patients was studied by Bhatt et al., 20 who found that the respiratory level decreased and the exercise efficiency increased. On the other hand, Jones et al., 21 recorded that blood pressure levels in patients with COPD were lower than BP readings before exercise.

Dyspnea in COPD is due to several causes. Expiratory airflow obstruction is an important cause, but not the only one. Certain factors include inspiratory muscle dysfunction, gas exchange disorders, and heart disease 21.

Concerning dyspnea score grade, our results showed that there was an improvement in baseline dyspnea score grade in patients who received breathing techniques training in comparison with the control group. This may be due to breathing exercise which enhancing or maintaining respiratory function, and improving overall health. Our study finding is agreed with a similar study done by Al Karn, et al., 23 who studied ''the effectiveness of pulmonary rehabilitation on pulmonary function parameters and dyspnea in patients with stable COPD'' and found that dyspnea score grade improved in breathing exercise study participants.

This result is also in line with Valenza et al., 24 who found that the dyspnea scores significantly improved in the intervention group (P=0.004), while the control group's dyspnea score decreased between baseline and discharge.

These results are consistent with El Hoshy et al., 25 who reported that a statistically significant improvement in the study group after the exercise program of the COPD patient compared to the control group receiving an unstructured program. This finding is also supported by Harver et al., 26 who revealed that targeted inspiratory muscle training results are significant increases in respiratory muscle function and significant decreases in dyspnea. It supports the idea of enhancing dyspnea by improving the inspiratory muscle strength 22.

The study of Lisboa et al., 27 found that the patients trained with breathing techniques were able to make greater efforts and perform more challenging tasks than before encouraging breathing exercise and were able to perform tasks more rapidly without dyspnea.

Regarding ABG parameters after breathing techniques, the findings of the present study have shown that the intervention group has significantly improved all ABG parameters. On the same line, Tymruk-Skoropad et al., study 27 in Beni-Suef, Egypt found that ABG parameters improved in the study group compared to the control group which cleared in the presence of statistically significant decrease in PaCO2 and a statistically significant increase in PaO2, HCO3 and SaO2. Moreover, El khateeb et al., 28 stated that El khateeb et al. 29 reported that in the respiratory training group there was a statistically significant increase in both PO2 and Sat O2 compared to the control group.

5. Conclusion and Recommendations

Based on the obtained findings, it is noted that breathing techniques show significant improvement in dyspnea, physiological and ABG patients' outcome. It was concluded that respiratory breathing techniques should be used as a routine non-pharmacological, safe, and low-cost method in rehabilitation care for patients with COPD.

References

[1]  Said, A. F., Ewis, A. A., Omran, A. A., Magdy, M. E., & Saleeb, M. F. (2015). Prevalence and predictors of chronic obstructive pulmonary disease among high-risk Egyptians. Egyptian Journal of Bronchology, 9(1), 27.
In article      
 
[2]  Jokar, Z., Mohammadi, F., Khankeh, H. R., & Fallah Tafti, S. (2013). Effect of home-based pulmonary rehabilitation on fatigue in patients with COPD. Journal of hayat, 18(5), 64-72.
In article      View Article  PubMed
 
[3]  Fraser, J. F., Spooner, A. J., Dunster, K. R., Anstey, C. M., & Corley, A. (2016). Nasal high flow oxygen therapy in patients with COPD reduces respiratory rate and tissue carbon dioxide while increasing tidal and end-expiratory lung volumes: a randomised crossover trial. Thorax, 71(8), 759-761.
In article      View Article  PubMed  PubMed
 
[4]  Tariq, S. M., & Thomas, E. C. (2017). Maintenance therapy in COPD: time to phase out ICS and switch to the new LAMA/LABA inhalers?. International journal of chronic obstructive pulmonary disease, 12, 1877.
In article      View Article  PubMed  PubMed
 
[5]  Deng, G. J., Liu, F. R., Zhong, Q. L., Chen, J., Yang, M. F., & He, H. G. (2013). The effect of non‐pharmacological staged interventions on fatigue and dyspnoea in patients with chronic obstructive pulmonary disease: A randomized controlled trial. International journal of nursing practice, 19(6), 636-643.
In article      View Article  PubMed
 
[6]  Agusti, A., Fabbri, L. M., Singh, D., Vestbo, J., Celli, B., Franssen, F. M., ... & Papi, A. (2018). Inhaled corticosteroids in COPD: friend or foe?. European Respiratory Journal, 52(6).
In article      View Article  PubMed
 
[7]  Liu, X. L., Tan, J. Y., Wang, T., Zhang, Q., Zhang, M., Yao, L. Q., & Chen, J. X. (2014). Effectiveness of home‐based pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a meta‐analysis of randomized controlled trials. Rehabilitation Nursing, 39(1), 36-59.
In article      View Article  PubMed
 
[8]  Ghanbari, A., Shirmohamadi, N., Paryad, E., Bazghale, M., & Mohammadpourhodki, R. (2018). Effect of Breathing Exercises on Fatigue Dimensions in Patients with COPD. Medical Science and Discovery, 5(4), 174-179.
In article      View Article
 
[9]  Cancelliero-Gaiad, K. M., Ike, D., Pantoni, C. B., Borghi-Silva, A., & Costa, D. (2014). Respiratory pattern of diaphragmatic breathing and pilates breathing in COPD subjects. Brazilian journal of physical therapy, 18(4), 291-299.
In article      View Article  PubMed  PubMed
 
[10]  Theander, K., Jakobsson, P., Jörgensen, N., & Unosson, M. (2009). Effects of pulmonary rehabilitation on fatigue, functional status and health perceptions in patients with chronic obstructive pulmonary disease: a randomized controlled trial. Clinical rehabilitation, 23(2), 125-136.
In article      View Article  PubMed
 
[11]  Bestall, J. C., Paul, E. A., Garrod, R., Garnham, R., Jones, P. W., & Wedzicha, J. A. (1999). Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax, 54(7), 581-586.
In article      View Article  PubMed  PubMed
 
[12]  Arnall, D. A., Camacho, C. I., & Tomás, J. M. (2014). Effects of inspiratory muscle training and yoga breathing exercises on respiratory muscle function in institutionalized frail older adults: a randomized controlled trial. Journal of Geriatric Physical Therapy, 37(2), 65-75.
In article      View Article  PubMed
 
[13]  Castelino, F., Prabhu, M., Pai, M. S., Kamath, A., Mohapatra, A. K., Devi, E. S., ... & Nayak, S. G. (2017). Socio-demographic and clinical characteristics of Chronic Obstructive Pulmonary Disease (COPD) patients. Manipal Journal of Nursing and Health Sciences (MJNHS), 3(2), 55-58.
In article      
 
[14]  Barnes, P. J. (2016). Sex differences in chronic obstructive pulmonary disease mechanisms.
In article      View Article  PubMed
 
[15]  Steele, B. G., Belza, B., Hunziker, J., Holt, L., Legro, M., Coppersmith, J., ... & Lakshminaryan, S. (2003). Monitoring daily activity during pulmonary rehabilitation using a triaxial accelerometer. Journal of Cardiopulmonary Rehabilitation and Prevention, 23(2), 139-142.
In article      View Article  PubMed
 
[16]  Navarro, J. L. C., Medina, M. A. P., López, P. J. T., Albero, J. S., Rodríguez, A. C., & Laborda, E. A. (2014). Quality of Life in Patients With Chronic Obstructive Pulmonary Disease in the Province of Albacete (Spain). Chest, 145(3), 394A.
In article      View Article
 
[17]  de Llano, L. P., Cosío, B. G., Iglesias, A., de las Cuevas, N., Soler-Cataluña, J. J., Izquierdo, J. L., ... & Torrego, A. (2018). Mixed Th2 and non-Th2 inflammatory pattern in the asthma–COPD overlap: a network approach. International journal of chronic obstructive pulmonary disease, 13, 591.
In article      View Article  PubMed  PubMed
 
[18]  Horner, A., Soriano, J. B., Puhan, M. A., Studnicka, M., Kaiser, B., Vanfleteren, L. E., ... & Ancochea, J. (2017). Altitude and COPD prevalence: analysis of the PREPOCOL-PLATINO-BOLD-EPI-SCAN study. Respiratory research, 18(1), 162.
In article      View Article  PubMed  PubMed
 
[19]  Buist, A. S., Vollmer, W. M., & McBurnie, M. A. (2008). Worldwide burden of COPD in high-and low-income countries. Part I. The Burden of Obstructive Lung Disease (BOLD) Initiative [State of the Art Series. Chronic obstructive pulmonary disease in high-and low-income countries. Edited by G. Marks and M. Chan-Yeung. Number 6 in the series]. The international journal of tuberculosis and lung disease, 12(7), 703-708.
In article      
 
[20]  Bhatt, S. P., Luqman-Arafath, T. K., Gupta, A. K., Mohan, A., Stoltzfus, J. C., Dey, T., ... & Guleria, R. (2013). Volitional pursed lips breathing in patients with stable chronic obstructive pulmonary disease improves exercise capacity. Chronic Respiratory Disease, 10(1), 5-10.
In article      View Article  PubMed
 
[21]  Jones, C. U., Sangthong, B., Pachirat, O., & Jones, D. A. (2015). Slow breathing training reduces resting blood pressure and the pressure responses to exercise. Physiological research, 64(5).
In article      
 
[22]  Maddocks, M., Kon, S. S., Canavan, J. L., Jones, S. E., Nolan, C. M., Labey, A., ... & Man, W. D. (2016). Physical frailty and pulmonary rehabilitation in COPD: a prospective cohort study. Thorax, 71(11), 988-995.
In article      View Article  PubMed  PubMed
 
[23]  Al Karn, A. F., Hassan, W. A., El Fadl, A. A. A., & Mahmoud, M. A. (2018). Effectiveness of pulmonary rehabilitation on pulmonary function parameters and dyspnea in patients with stable chronic obstructive pulmonary disease. Egyptian Journal of Bronchology, 12(2), 149.
In article      
 
[24]  Valenza, M. C., Valenza-Peña, G., Torres-Sánchez, I., González-Jiménez, E., Conde-Valero, A., & Valenza-Demet, G. (2014). Effectiveness of controlled breathing techniques on anxiety and depression in hospitalized patients with COPD: a randomized clinical trial. Respiratory care, 59(2), 209-215.
In article      View Article  PubMed
 
[25]  El Hoshy, M. S., Eshmawey, H. A., & El Tawab, S. S. (2017). Outcome of pulmonary rehabilitation in patients with COPD: Comparison between patients receiving exercise training and those receiving exercise training and CPAP. Egyptian Journal of Chest Diseases and Tuberculosis, 66(4), 609-616.
In article      View Article
 
[26]  Harver, A., Mahler, D. A., & Daubenspeck, J. A. (1989). Targeted inspiratory muscle training improves respiratory muscle function and reduces dyspnea in patients with chronic obstructive pulmonary disease. Annals of Internal Medicine, 111(2), 117-124.
In article      View Article  PubMed
 
[27]  Lisboa, C., Villafranca, C., Leiva, A., Cruz, E., Pertuze, J., & Borzone, G. (1997). Inspiratory muscle training in chronic airflow limitation: effect on exercise performance. European Respiratory Journal, 10(3), 537-542.
In article      
 
[28]  Tymruk-Skoropad, K., Tsizh, L., Vynogradskyi, B., & Pavlova, I. (2018). Physical therapy in chronic obstructive pulmonary disease (analysis of the evidence-based medicine). Physiotherapy Quarterly, 26(2), 1-8.
In article      View Article
 
[29]  Elkhateeb, NB., Elhadidi, AA., & Masood, HH., (2015). Pulmonary rehabilitation in chronic obstructive pulmonary disease. Egyptian Journal of Chest Diseases and Tuberculosis, 64, 359-369.
In article      View Article
 

Published with license by Science and Education Publishing, Copyright © 2018 Marwa Fathalla Mostafa and Asmaa Ibrahem Abo Seada

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Marwa Fathalla Mostafa, Asmaa Ibrahem Abo Seada. Effectiveness of Breathing Techniques on Dyspnea among Critically Ill Chronic Obstructive Pulmonary Disease. American Journal of Nursing Research. Vol. 6, No. 6, 2018, pp 645-649. http://pubs.sciepub.com/ajnr/6/6/35
MLA Style
Mostafa, Marwa Fathalla, and Asmaa Ibrahem Abo Seada. "Effectiveness of Breathing Techniques on Dyspnea among Critically Ill Chronic Obstructive Pulmonary Disease." American Journal of Nursing Research 6.6 (2018): 645-649.
APA Style
Mostafa, M. F. , & Seada, A. I. A. (2018). Effectiveness of Breathing Techniques on Dyspnea among Critically Ill Chronic Obstructive Pulmonary Disease. American Journal of Nursing Research, 6(6), 645-649.
Chicago Style
Mostafa, Marwa Fathalla, and Asmaa Ibrahem Abo Seada. "Effectiveness of Breathing Techniques on Dyspnea among Critically Ill Chronic Obstructive Pulmonary Disease." American Journal of Nursing Research 6, no. 6 (2018): 645-649.
Share
  • Table 3. Comparison between the control and the intervention groups throughout breathing techniques intervention according to patients' parameters
[1]  Said, A. F., Ewis, A. A., Omran, A. A., Magdy, M. E., & Saleeb, M. F. (2015). Prevalence and predictors of chronic obstructive pulmonary disease among high-risk Egyptians. Egyptian Journal of Bronchology, 9(1), 27.
In article      
 
[2]  Jokar, Z., Mohammadi, F., Khankeh, H. R., & Fallah Tafti, S. (2013). Effect of home-based pulmonary rehabilitation on fatigue in patients with COPD. Journal of hayat, 18(5), 64-72.
In article      View Article  PubMed
 
[3]  Fraser, J. F., Spooner, A. J., Dunster, K. R., Anstey, C. M., & Corley, A. (2016). Nasal high flow oxygen therapy in patients with COPD reduces respiratory rate and tissue carbon dioxide while increasing tidal and end-expiratory lung volumes: a randomised crossover trial. Thorax, 71(8), 759-761.
In article      View Article  PubMed  PubMed
 
[4]  Tariq, S. M., & Thomas, E. C. (2017). Maintenance therapy in COPD: time to phase out ICS and switch to the new LAMA/LABA inhalers?. International journal of chronic obstructive pulmonary disease, 12, 1877.
In article      View Article  PubMed  PubMed
 
[5]  Deng, G. J., Liu, F. R., Zhong, Q. L., Chen, J., Yang, M. F., & He, H. G. (2013). The effect of non‐pharmacological staged interventions on fatigue and dyspnoea in patients with chronic obstructive pulmonary disease: A randomized controlled trial. International journal of nursing practice, 19(6), 636-643.
In article      View Article  PubMed
 
[6]  Agusti, A., Fabbri, L. M., Singh, D., Vestbo, J., Celli, B., Franssen, F. M., ... & Papi, A. (2018). Inhaled corticosteroids in COPD: friend or foe?. European Respiratory Journal, 52(6).
In article      View Article  PubMed
 
[7]  Liu, X. L., Tan, J. Y., Wang, T., Zhang, Q., Zhang, M., Yao, L. Q., & Chen, J. X. (2014). Effectiveness of home‐based pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a meta‐analysis of randomized controlled trials. Rehabilitation Nursing, 39(1), 36-59.
In article      View Article  PubMed
 
[8]  Ghanbari, A., Shirmohamadi, N., Paryad, E., Bazghale, M., & Mohammadpourhodki, R. (2018). Effect of Breathing Exercises on Fatigue Dimensions in Patients with COPD. Medical Science and Discovery, 5(4), 174-179.
In article      View Article
 
[9]  Cancelliero-Gaiad, K. M., Ike, D., Pantoni, C. B., Borghi-Silva, A., & Costa, D. (2014). Respiratory pattern of diaphragmatic breathing and pilates breathing in COPD subjects. Brazilian journal of physical therapy, 18(4), 291-299.
In article      View Article  PubMed  PubMed
 
[10]  Theander, K., Jakobsson, P., Jörgensen, N., & Unosson, M. (2009). Effects of pulmonary rehabilitation on fatigue, functional status and health perceptions in patients with chronic obstructive pulmonary disease: a randomized controlled trial. Clinical rehabilitation, 23(2), 125-136.
In article      View Article  PubMed
 
[11]  Bestall, J. C., Paul, E. A., Garrod, R., Garnham, R., Jones, P. W., & Wedzicha, J. A. (1999). Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax, 54(7), 581-586.
In article      View Article  PubMed  PubMed
 
[12]  Arnall, D. A., Camacho, C. I., & Tomás, J. M. (2014). Effects of inspiratory muscle training and yoga breathing exercises on respiratory muscle function in institutionalized frail older adults: a randomized controlled trial. Journal of Geriatric Physical Therapy, 37(2), 65-75.
In article      View Article  PubMed
 
[13]  Castelino, F., Prabhu, M., Pai, M. S., Kamath, A., Mohapatra, A. K., Devi, E. S., ... & Nayak, S. G. (2017). Socio-demographic and clinical characteristics of Chronic Obstructive Pulmonary Disease (COPD) patients. Manipal Journal of Nursing and Health Sciences (MJNHS), 3(2), 55-58.
In article      
 
[14]  Barnes, P. J. (2016). Sex differences in chronic obstructive pulmonary disease mechanisms.
In article      View Article  PubMed
 
[15]  Steele, B. G., Belza, B., Hunziker, J., Holt, L., Legro, M., Coppersmith, J., ... & Lakshminaryan, S. (2003). Monitoring daily activity during pulmonary rehabilitation using a triaxial accelerometer. Journal of Cardiopulmonary Rehabilitation and Prevention, 23(2), 139-142.
In article      View Article  PubMed
 
[16]  Navarro, J. L. C., Medina, M. A. P., López, P. J. T., Albero, J. S., Rodríguez, A. C., & Laborda, E. A. (2014). Quality of Life in Patients With Chronic Obstructive Pulmonary Disease in the Province of Albacete (Spain). Chest, 145(3), 394A.
In article      View Article
 
[17]  de Llano, L. P., Cosío, B. G., Iglesias, A., de las Cuevas, N., Soler-Cataluña, J. J., Izquierdo, J. L., ... & Torrego, A. (2018). Mixed Th2 and non-Th2 inflammatory pattern in the asthma–COPD overlap: a network approach. International journal of chronic obstructive pulmonary disease, 13, 591.
In article      View Article  PubMed  PubMed
 
[18]  Horner, A., Soriano, J. B., Puhan, M. A., Studnicka, M., Kaiser, B., Vanfleteren, L. E., ... & Ancochea, J. (2017). Altitude and COPD prevalence: analysis of the PREPOCOL-PLATINO-BOLD-EPI-SCAN study. Respiratory research, 18(1), 162.
In article      View Article  PubMed  PubMed
 
[19]  Buist, A. S., Vollmer, W. M., & McBurnie, M. A. (2008). Worldwide burden of COPD in high-and low-income countries. Part I. The Burden of Obstructive Lung Disease (BOLD) Initiative [State of the Art Series. Chronic obstructive pulmonary disease in high-and low-income countries. Edited by G. Marks and M. Chan-Yeung. Number 6 in the series]. The international journal of tuberculosis and lung disease, 12(7), 703-708.
In article      
 
[20]  Bhatt, S. P., Luqman-Arafath, T. K., Gupta, A. K., Mohan, A., Stoltzfus, J. C., Dey, T., ... & Guleria, R. (2013). Volitional pursed lips breathing in patients with stable chronic obstructive pulmonary disease improves exercise capacity. Chronic Respiratory Disease, 10(1), 5-10.
In article      View Article  PubMed
 
[21]  Jones, C. U., Sangthong, B., Pachirat, O., & Jones, D. A. (2015). Slow breathing training reduces resting blood pressure and the pressure responses to exercise. Physiological research, 64(5).
In article      
 
[22]  Maddocks, M., Kon, S. S., Canavan, J. L., Jones, S. E., Nolan, C. M., Labey, A., ... & Man, W. D. (2016). Physical frailty and pulmonary rehabilitation in COPD: a prospective cohort study. Thorax, 71(11), 988-995.
In article      View Article  PubMed  PubMed
 
[23]  Al Karn, A. F., Hassan, W. A., El Fadl, A. A. A., & Mahmoud, M. A. (2018). Effectiveness of pulmonary rehabilitation on pulmonary function parameters and dyspnea in patients with stable chronic obstructive pulmonary disease. Egyptian Journal of Bronchology, 12(2), 149.
In article      
 
[24]  Valenza, M. C., Valenza-Peña, G., Torres-Sánchez, I., González-Jiménez, E., Conde-Valero, A., & Valenza-Demet, G. (2014). Effectiveness of controlled breathing techniques on anxiety and depression in hospitalized patients with COPD: a randomized clinical trial. Respiratory care, 59(2), 209-215.
In article      View Article  PubMed
 
[25]  El Hoshy, M. S., Eshmawey, H. A., & El Tawab, S. S. (2017). Outcome of pulmonary rehabilitation in patients with COPD: Comparison between patients receiving exercise training and those receiving exercise training and CPAP. Egyptian Journal of Chest Diseases and Tuberculosis, 66(4), 609-616.
In article      View Article
 
[26]  Harver, A., Mahler, D. A., & Daubenspeck, J. A. (1989). Targeted inspiratory muscle training improves respiratory muscle function and reduces dyspnea in patients with chronic obstructive pulmonary disease. Annals of Internal Medicine, 111(2), 117-124.
In article      View Article  PubMed
 
[27]  Lisboa, C., Villafranca, C., Leiva, A., Cruz, E., Pertuze, J., & Borzone, G. (1997). Inspiratory muscle training in chronic airflow limitation: effect on exercise performance. European Respiratory Journal, 10(3), 537-542.
In article      
 
[28]  Tymruk-Skoropad, K., Tsizh, L., Vynogradskyi, B., & Pavlova, I. (2018). Physical therapy in chronic obstructive pulmonary disease (analysis of the evidence-based medicine). Physiotherapy Quarterly, 26(2), 1-8.
In article      View Article
 
[29]  Elkhateeb, NB., Elhadidi, AA., & Masood, HH., (2015). Pulmonary rehabilitation in chronic obstructive pulmonary disease. Egyptian Journal of Chest Diseases and Tuberculosis, 64, 359-369.
In article      View Article