Intervention Pursed Lips Breathing Exercise for Decrease Breathelness on

Chronic Obstructive Pulmonary Disease

Sabirin Berampu, Ari Wibowo, Isidorus Jehaman, Redi Tantangan, Timbul Siahaan, Raynald

Ignatius Ginting

Faculty of Nursing and Physiotherapy, Institut Kesehatan Medistra Lubuk Pakam, Indonesia

Keywords: Chronic Obstructive Pulmonary Disease, Breathelness mechanism and Pursed Lips Breathing Exercise.

Abstract: Chronic Obstructive Pulmonary Disease is a chronic lung disease characterized by limited air flow in

respiratory tract that is not completely reversible and is progressive. Helped to reduce mortality in patients

with chronic obstructive pulmonary disease by breathing exercises, namely Pursed Lips breathing exercise.

The study aims to determine the effect of pursed lips breathing exercise on reducing the scale of tightness in

patients with chronic obstructive pulmonary disease. This method is pre experimental with design using one

group pre-test and post-test design, samples are 18 respondents with purposive sampling technique that is

adjusted to the inclusion and exclusion criteria. Data analysis uses paired sample t-test. The results showed

that the administration of pursed lips breathing exercise influenced the reduction of the tightness scale in

patients with chronic obstructive pulmonary disease. Giving pursed lips breathing exercise is very effective

against reducing the scale of shortness of breath in patients with chronic obstructive pulmonary disease.

1 INTRODUCTION

Chronic Obstructive Pulmonary Disease

(COPD) is a chronic lung disease characterized by

limited air flow in the respiratory tract that is not

completely reversible and is progressive. Some

problems will arise that result in respiratory failure

which is defined as ventilation failure and

oxygenation failure due to respiratory center

disorders, repiratory muscle disorders and acute

inflammation of lung tissue that causes shortness of

breathing (Muliasaria, Indrawatib, 2018 and Endrian,

Noviati, Trisnawati, et all, 2019).

World Health Organization (WHO) report there

is 600 million people got COPD in the world with 65

million people heavy COPD. In 2002 COPD was the

fifth leading cause of death in the world and is

estimated to be the third leading cause of death

worldwide in 2030. More than 3 million people died

from COPD in 2005, which is equivalent to 5% of all

deaths globally (WHO, 2015).

Mortality due to COPD is increasing. As for the

World Health Organization (WHO) report in the

World Health Report in 2012, five major lung

diseases accounted for 17.4% of all deaths in the

world, each with 7.2% lung infections, COPD 4.8%,

tuberculosis 3.0%, lung cancer / trachea / bronchi

2.1%, and asthma 0.3%.

Decreased quality of life in COPD patients is

supported by the results of a study conducted by

Reherison in France in 2009-2010 of 400 COPD

sufferers over 40 years. The results showed that

COPD affected the decline in quality of life in 50.6%

of respondents with a p value < 0.02. Decreased

quality of life in COPD patients was most influenced

by decreased tolerance of activity (Rehersion, 2014).

According to the Gold Initiative for Chronic

Obstructive Lung Disease (GOLD), which is referred

as COPD, is lung disease that can be prevented and

treated, characterized by a continuous flow of air that

is usually progressive and is associated with an

increased inflammatory response in the airways and

lungs to particles or gases that are poisonous or

dangerous (GOLD, 2015).

In Indonesia, prevalence of COPD cases

according to the Ministry of Health of Republic of

Indonesia (2014) mentions in Central Java Province

as much as 3.4%. The results of the North Sumatra

Provincial Health Office research, in 6 (six) General

Hospitals in North Sumatra, COPD Incidence Rate

(AK) in 2010 was 5.8% and in 2014 it increased by

7.2% (DINKES, 2014) .

196

Berampu, S., Wibowo, A., Jehaman, I., Tantangan, R., Siahaan, T. and Ginting, R.

Intervention Pursed Lips Breathing Exercise for Decrease Breathelness on Chronic Obstructive Pulmonary Disease.

DOI: 10.5220/0009469601960202

In Proceedings of the International Conference on Health Informatics and Medical Application Technology (ICHIMAT 2019), pages 196-202

ISBN: 978-989-758-460-2

However, this does not rule out the possibility

that this percentage figure can increase along with the

increasing number of smokers, and air pollution that

exceeds the threshold in North Sumatra Province.

Based on the results of preliminary study survey

which was obtained from the Medical Record of the

Grandmed Lubuk Pakam Hospital, data on COPD

sufferers in 2016 were as many as 170 people while

in September to December 2017 there were 50

people.

Medical management of COPD clients (Zhang,

Mehta 2018) among others, with pharmacological

and non-pharmacological treatment. According to

Ghanbari, Shirmohamadi, Paryad, 2018, the handling

of COPD disease clients does not only rely on

pharmacological therapy, but also non-

pharmacological therapy which is carried out by

Physiotherapy.

Physiotherapy is form of health service aimed at

individuals or groups to develop, maintain and restore

body movements and functions throughout the life

cycle using manual handling, increased motion,

equipment (physical, electrotherapy and mechanical),

function training, communication (PMK No 56,

2016).

Some physiotherapy interventions can be done

by reduced scale of tightness are warming and

relaxation such as giving short wave diathermy,

infrared, chest physiotherapy and effective cough

exercises. One technique for administering Chest

Physiotherapy is breathing exercises that can be done

including inspirational muscle exercises such as

pursed lips breathing exercise.

Pursed lips breathing exercise is a breathing

exercise to regulate the frequency and pattern of

breathing to reduce air trapping, improve alveoli

ventilation to improve gas exchange without

increasing respiratory work, regulate and coordinate

respiratory rate so that breathing is more effective and

reduce shortness of breath. Pursed lips breathing

exercise is a breathing exercise for the patient sits and

inspires when the patient's expiration exhales through

the mouth almost closed like whistling slowly

(Mendes, Moraes, Hoffman, et all, 2018).

The advantages of physiotherapy using the

pursed lips breathing exercise technique are exercises

that are easily performed by all patients who

experience breathing problems or shortness of breath.

Besides being easy to do pursed lips breathing

exercise also has no side effects, just if the patient

often does this exercise technique will be very helpful

to reduce shortness of breath.

Some literature reveals that use of pursed lips

breathing exercise seems to be an effective way of

reducing dyspnea, reducing respiratory rate, and

increasing gas exchange in COPD patients. This

positive effect appears to be related to the technique's

ability to reduce airway constriction during

recurrence of disease (Potdar, 2018).

The researchers have examined the effects of

pursed lips breathing exercise on the parameters of

ventilation and arterial blood gas in people with

COPD. They uniformly report that the technique

reduces the respiratory rate and partial pressure of

carbon dioxide in arterial blood can increase tidal

volume. Pursed lips breathing exercise also increases

the persial pressure of oxygen in arterial blood and

also the percentage of hemoglobin (Sakhaei,

Sadagheyani, Zinalpoor, 2018).

The results of Sachdeva's research, Pawaria,

Kalra (2018) that there is an effect of giving pursed

lips breathing exercise on reducing the frequency of

attacks in patients with chronic obstructive

pulmonary disease. Budiono, Mustayah,

Aindrianingsih, (2017) research results show that

there is an effect of giving pursed lips breathing

exercise to decrease Respiratory Rate (RR) and

Increased Pulsed Oxygen Saturation (SpO2) in

patients with chronic obstructive pulmonary disease

with p value = 0.000 for Respiratory Rate (RR).

The results of Bakti's research (2015) show that

there is an effect of giving pursed lip breathing to

decrease the level of shortness of breath in patients

with chronic obstructive pulmonary disease with a

value of P = 0.014 for the control group and P = 0.002

for the treatment group. Sachdeva, Pawaria, Kalra,

research results (2018) showed that there was an

effect of pursed lips breathing exercise on increasing

vital lung capacity in patients with chronic

obstructive pulmonary disease with a p value of

0.001. Based on the background above and the

author's interest to find out more about the benefits of

pursed lips breathing exercise in COPD cases. So the

authors take the title "The Effect of pursed lips

breathing exercise on the Reduction of Shortness

Scale in COPD Patients at GrandMed Lubuk Pakam

Hospital". The purpose of this study was to identify

the characteristics of COPD patients undergoing

inpatient at the Grandmed Lubuk Pakam Hospital in

2018.

2 METHODOLOGY

This study uses pre experimental method with the

design used in this study, namely by using one group

pre test and post test design. The sampling technique

used in this study was to use a purposive sampling

Intervention Pursed Lips Breathing Exercise for Decrease Breathelness on Chronic Obstructive Pulmonary Disease

197

method carried out by including all patients

undergoing inpatient at the Grandmed Lubuk Pakam

Hospital in April-May 2018 with a diagnosis from the

doctor being a COPD and the results of a positive X-

Ray Photo of COPD that meet the inclusion and

exclusion criteria. The number of samples in this

study were 18 people.

The therapeutic method used in this study is

breathing exercises carried out to get better breathing

regulation from previous breathing which is fast and

shallow to become slower and deeper breathing. The

purpose of breathing exercises, 1) adjust the breathing

pattern and respiratory rate so that it reduces air

trapping, 2) improve the ability of the chest wall

movement, 3) improve ventilation without increasing

respiratory energy, 4) train breathing so that tightness

is reduced, 5) improve the movement of the

diaphragm, 6) increase patient confidence so that it is

calmer

The procedure for implementing Pursed Lips

Breathing Exercise (Figure 1) includes:

 Adjust the position of the patient by sitting on a

bed or chair.

 Put one patient's hand in the abdomen (just

below proceccus xipoideus) and the other hand

in the middle of the chest to feel the chest and

abdomen movements when breathing.

 Take a deep breath through the nose for 4

seconds until the chest and abdomen feel lifted

up and keep the mouth closed for inspiration and

hold the breath for 2 seconds.

 Exhale through closed lips and slightly open

while contracting the abdominal muscles for 4

seconds (Smeltzer, 2008).

 This exercise can be done by the patient himself

every 2-3 hours as much as 6 times

Figure 1: Intervetion Purs Lips Breathing Exercise

3 RESULT

Respondents in this study were chronic obstructive

pulmonary disease patients in GrandMed Lubuk

Pakam Hospital in 2018. With a sample of 18 people.

Based on table 4.1 above, the number of respondents

based on age 51-60 years was 5 people (27.8%), 61-

70 years as many as 6 people (33.3%), 71-80 years as

many as 6 people (33.3 %), and 81-90 years by 1

person (5.6%). Based on the gender of male

respondents as many as 15 people (83.3%) and

women as many as 3 people (16.7%). Based on the

work of self-employed respondents as many as 8

people (44.4%), Farmers as many as 7 people

(38.9%), and civil servants (Civil Servants) as many

as 3 people (16.7%).

Based on Table 1, the MRC scale measurement

results before giving pursed lips breathing exercise

that has an MRC scale value of 2 are 2 people

(11.1%), who have an MRC scale value of 6 people

(33.3%) and those who have an MRC scale 4 grades

were 10 people (55.6%).

Table 1. Result measurement breathleness with MRC

scale pretest Pursed Lips Breathing Exercise

MRC scale n Percentage

Value 0 - -

Value 1 - 0%

Value 2 2 11,1%

Value 3 6 33,3%

Value 4 10 55,6%

Total 18 100%

According to table 2, MRC scale measurement

results obtained after giving pursed lips breathing

exercise, MRC scale in patients with chronic

obstructive pulmonary disease has improved with a

value of 1 by 1 person (5.6%), improvement in value

2 by 8 people (44.4%), improvement value 3 as much

as 8 people (44.4%), and improvement in value 4 as

much as 1 person (5.6%)

Table 2. Result measurement breathleness with MRC

scale posttest Pursed Lips Breathing Exercise

MRC scale n Percentage

value 0 - -

value 1 1 5,6%

value 2 8 44,4%

value 3 8 44,4%

value 4 1 5,6%

Total 18 100%

The mean result of the MRC scale before giving

pursed lips breathing exercise was 3.44 and standard

deviation = 0.705. The mean of the MRC scale after

giving pursed lips breathing exercise was 2.50 and

standard deviation = 0.707. The difference mean Pre

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198

and Post treatment pursed lips breathing exercise was

0.94 with a standard deviation = 0.002.

Hypothesis test results using Paired Sample T-

Test obtained p value = 0,000. From these results it

can be concluded that there is an effect of pursed lips

breathing exercise on reducing the scale of tightness

in COPD patients at Grandmed Lubuk Pakam

Hospital in 2018.

4 DISCUSSION

Based on the results of 18 minority patients aged 81-

90 years as many as 1 person (5.6%) and the majority

age was 61-70 years and 71-80 years as many as 6

people (33.3%). The results of Fajrin, Indra &

Burhanuddin, 2015 and Raad, Smith, Allen, 2019)

showed that the characteristics respondents based on

age were the most stable in COPD patients > 60 years

(58.1%).

These results indicate in elderly patients the

cardiorespiratory system decreased endurance and

decreased function. Changes in the lung wall cause

compliance to decrease and there is a decrease in the

elasticity of the lung parenchyma, an increase in

mucous glands and thickening of the bronchial

mucosa. An increase in airway resistance and

decreased lung function such as forced vital capacity

(FVC) and first-second forced expiratory volume

(Force Vital Expiration Volume 1 / FEV1) (Khairani,

2010).

Based on the results of research conducted on 18

characteristics of the majority male patients as many

as 15 people (83.3%) and women as many as 3 people

(16.7%).

The results of Ritianingsih, Irawaty & Handayani

(2011) research showed that the characteristics of

respondents based on gender were 21 male (58.3%).

The results of this study are also in line with research

conducted by Rahmatika in Aceh Tamiang Hospital

in 2007-2008 based on the severity of severe COPD

suffered by many men because awareness of

treatment increased after the disease became severe

(Permadi, Putra, 2018).

These results show because of the influence of

association. The fewer women who smoke are likely

due to the influence of norms in the community,

namely female smokers are considered to have

negative behavior (Almagro et al, 2010). Male

activity that is very much can also cause lung

disorders one of the factors is often working under the

hot sun, exposed to dust for a long time and continues

to repeat so that it can cause decreased

cardiorespiratory endurance and impaired lung

function.

Based on the results of research conducted on 18

respondents the characteristics of the majority of jobs

are entrepreneurs as many as 8 people (44.4%) and

minority jobs are Civil Servants (PNS) as many as 3

people (16.7%). The results of Fajrin research, Indra,

Burhanuddin 2015 and Raad, Smith, Allen, 2019)

showed that the characteristics of respondents based

on employment in stable COPD patients were self-

employed (54.3%).

This shows that entrepreneurial work is closely

related to allergic and bronchial hyperactivity,

workers who work in dusty environments and are

exposed to chemicals affect the nervous system and

are at risk of suffering from COPD. Another factor

influencing the increased risk of chronic obstructive

pulmonary disease in self-employed is the smoking

habit that is generally still practiced by self-employed

workers.

Shortness of breath is something that is felt by

the patient during inspiration and expiration, causing

disruption of functional activity. Based on the results

of research conducted on 18 people on the MRC scale

measurement before giving pursed lips breathing

exercise that has an MRC scale value of 2 people

(11.1%), who have an MRC scale value of 6 people

(33.3%) and who have an MRC scale value of 4 as

many as 10 people (55.6%), with the average MRC

scale results before being pursed lips breathing

exercise treatment is mean = 3.44 with a standard

deviation = 0.705.

In chronic obstructive pulmonary disease there is

respiratory muscle disorder that is affected by muscle

contraction and respiratory muscle strength. The loss

of lung elasticity causes hyperinflation and chronic

airway obstruction that interferes with the process of

expiration so that the volume of air entering and

leaving is not balanced and there is air trapping. Air

trapping in a long time causes the diaphragm to

flatten, contractions are less effective and its function

as the main muscle of breathing is reduced against

lung ventilation. Various intercostal muscle

compensation and additional inspiration muscles

commonly used in additional activities will be used

continuously until the role of the diaphragm decreases

to 65%. Breath volume shrinks and breath becomes

short so that alveolar hypoventilation occurs which

will increase O2 consumption and decrease patient

reserve power. The frequency of respiration increases

as an attempt to compensate for the small airways and

cause typical shortness of breath (Ubolnuar,

Tantisuwat, Thaveeratitham, et al, 2019).

Intervention Pursed Lips Breathing Exercise for Decrease Breathelness on Chronic Obstructive Pulmonary Disease

199

Based on the results of research conducted on 18

people on the MRC scale measurement after giving

pursed lips breathing exercise, the MRC scale in

patients with chronic obstructive pulmonary disease

has improved with a value of 1 by 1 person (5.6%),

improvement in the value of 2 by 8 people ( 44.4%),

improvement in value 3 by 8 people (44.4%), and

improvement in value 4 by 1 person (5.6%), with the

results of the MRC scale after being given pursed lips

breathing treatment mean = 2.50 with a standard

deviation = 0.707.

People with COPD who experience

hyperinflation of the diaphragm are lower and flatter.

In that situation the movement of the respiratory

muscles is not effective. Breathing pursed lips

breathing exercise aims to provide subjective benefits

to sufferers, namely reducing tightness, anxiety and

tension due to tightness. Pursed Lips

BreathingExercise breathing is done by the patient

sitting and breathing by exhaling through a closed

mouth (like whistling) for 4-6 seconds. This method

is expected to cause pressure during expiration so that

air flow slows and increases pressure in the

abdominal cavity which is passed on to the bronchioli

so that airway collapse during expiration can be

prevented (Sakhaei, Sadagheyani, Zinalpoor, 2018).

Besides giving pursed lips breathing exercise can

regulate the frequency and pattern of breathing so as

to reduce air trapping, improve alveoli ventilation to

improve gas exchange without increasing respiratory

work, regulate and coordinate respiratory rate so that

breathing is more effective and reduce shortness of

breath (Xu, He, Han, 2017).

Breathing exercises pursed lips breathing

exercise consists of two mechanisms, namely deep

inspiration and deep and long active expiration. The

process of expiration is normally a process of

exhaling without using excess energy. Breathing

pursed lips breathing exercise involves a long

expiration process.

Breathing exercises with pursed lips breathing

exercise help improve pulmonary compliance to

retrain the respiratory muscles to function properly

and prevent respiratory disstress (Sachdeva, Pawaria,

Kalra, 2018).

Based on the analysis of the Paired T-Test, the

pretestmean = 3.44 with standard deviation = 0.705

while the posttestmean average = 2.50 with standard

deviation = 0.707. The analysis results obtained p

value = 0,000 (p <0.05) which means that there is a

significant influence between the average scale of

MRC before and after pursed lips breathing exercise

to reduce the scale of tightness in patients with

chronic obstructive pulmonary disease, and breathing

exercises pursed. These lips breathing exercises are

good for physiotherapists to apply to patients with

chronic obstructive pulmonary disease for the

development of physiotherapy interventions

(Imashiro, Minakata, Hayata, et all, 2019).

Shortness of breath in patients with chronic

obstructive pulmonary disease before pursed lips

breathing exercise has not yet experienced changes in

the shortness of breath scale, which means that the

patient is still suffering from respiratory muscle

disorders that are affected by muscle contraction and

respiratory muscle strength. The loss of pulmonary

elasticity in COPD causes hyperinflation and chronic

airway obstruction that disrupts the process of

expiration so that the volume of air entering and

leaving is unbalanced and there is air trapping, after

pursed lips breathing exercise which can be seen from

a decrease in the MRC scale, where the patient is able

to adjust the frequency and pattern of breathing so as

to reduce air trapping, improve alveoli ventilation to

improve gas exchange without increasing respiratory

work, regulate and coordinate respiratory rate so that

breathing is more effective and reduce shortness of

breath (Mohamed, 2019).

Pursed lips breathing exercise is a breathing

exercise that consists of two mechanisms namely

deep inspiration and long and deep active expiration.

The process of expiration is normally a process of

exhaling without using excess energy. Breathing

pursed lips breathing exercise involves a long

expiration process.

Deep inspiration and long expiration will certainly

increase the strength of intra-abdominal muscle

contraction so that the intra-abdominal pressure rises

beyond the time of passive expiration. Intra-

abdominal pressure which increases even stronger

will certainly increase the movement of the

diaphragm upward making the thoracic cavity

smaller. Thorak cavity is getting smaller causing intra

alveolar pressure increases so that it exceeds

atmospheric air pressure (Potdar, 2018). Long

exhalation when breathing pursed lips breathing

exercise will also cause airway obstruction to

decrease so that respiratory resistance decreases.

Decreased respiratory resistance will facilitate the air

inhaled and exhaled so that it will reduce shortness of

breath (Mohamed, 2019).

The assumption according to the authors of this

study is that pursed lips breathing exercise is a

breathing muscle exercise that aims to improve the

ability of the muscles of respiration, breathing

patterns, lung ventilation. So that in patients with

chronic obstructive pulmonary disease will cause a

balance in the brain that controls the delivery of

ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology

200

oxygen to the tissues. Tissue carbon dioxide pressure,

chest wall stretch receptors, tissue oxygen demand,

oxygen delivery, and respiratory work can be fulfilled

so that the patient feels relaxed and shortness of

breath is reduced.

5 CONCLUSION

Based on the statistical tests and discussion above, it

can be concluded that Physiotherapy interventions

with lip exercises that are moved affect the reduction

in shortness of breath in COPD patients

ACKNOWLEDGEMENT

Thank you:

 Chancellor of the Medical Institute Medistra

Lubuk Pakam who has provided financial

support and facilities so that research can be

carried out properly and smoothly

 Director of the Grandmed Lubuk Pakam

Hospital who has given permission to carry out

this research

 To all patients who have agreed to be a research

sample

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