Management Of Chronic Obstructive Pulmonary Disease Biology Essay

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Chronic obstructive pulmonary disease remains a major health care burden and the leading cause of death that is increasing in prevalence worldwide (Hurd S; Chest 2000).

Chronic obstructive pulmonary disease is a respiratory ailment that is commonly under-diagnosed and life-threatening, which alters the normal breathing pattern and is not fully reversible. It includes two distinct entities, chronic bronchitis and emphysema, one rarely occurring without a degree of the other.

The American thoracic society along with the European respiratory society (2005) has described COPD as, a disease state in which there is progressive airflow limitation that cannot be completely reversed. It is caused by cigarette smoking and exposure to noxious particles which triggers inflammatory process in the lung parenchyma. Moreover, COPD is a preventable as well as a treatable disease.

Based on the World Health Organisation report in 'World Health Statistics - 2008', the deaths caused by Chronic Obstructive Pulmonary Disease in 2005 were above three million, placing it at the sixth leading cause of death and it is expected to rise to the third place by the year 2030.

In India, a study conducted by Prof S.K.Jindal published in Indian Journal of Medical Research in 2006 reported that 5% men and 2.75% women making a total of 18 million Indian populations are suffering from this disease.

1.1 BACKGROUND OF THE PROBLEM

In Chronic Obstructive Pulmonary Disease, there is hypertrophy of the mucus secreting glands resulting in increased mucus production. The ciliary action is reduced resulting in impaired removal of secretions. Thereby the air passages become clogged with mucus.

The alveoli walls lose their elasticity and collapse thereby closing the air passages. The air passages collapse during exhalation, therefore the inhaled air is unable to escape and remains trapped in the lungs as stale air.

The airway collapse due to decreased elasticity and the clogging of mucus increases the airflow resistance thereby increasing air trapping leading to hyperinflation of the lungs. This increases the work of breathing. The contractile force of the respiratory muscle decreases due to the altered length tension relationship of the respiratory muscles. This decreases the muscle strength and endurance.

Reduced respiratory muscle strength and airway narrowing reduces the Forced Expiratory Volume (FEV) and Peak Expiratory Flow Rate (PEFR).

In due course, Dyspnoea becomes the common complaint. This limits the physical activity making the patients more sedentary and the condition worsens.

1.2 NEED FOR THE STUDY

Secretion removal remains a vital part in the management of chronic obstructive pulmonary disease.

The conventional Chest Physical therapy techniques include Diaphragmatic breathing exercise, Clapping, Vibration, Chest wall mobility exercises and Postural drainage. These techniques have shown to be effective in clearing secretions. But deleterious effects of these manual techniques have also been demonstrated by Campbell AH, O'Connell JM and Wilson F6. They are prone to induce bronchospasm and blunt the reduction in FEV1.

Active Cycle of Breathing Technique (ACBT) and Autogenic Drainage (AD) require active participation of the patient. Active cycle of breathing technique include cycles of repetitive breathing control, thoracic expansion and forced expiration.

Autogenic drainage is a respiratory technique which utilizes the expiratory airflow to mobilize the secretions. More research is required to compare the effects of Active cycle of breathing technique and Autogenic drainage, and to justify their inclusion in treatment protocol.

1.3 STATEMENT OF PROBLEM

This study analyses the effects of Active cycle of breathing technique and Autogenic drainage as airway clearance techniques on improving pulmonary parameters in COPD patients.

The study is entitled as, "A Comparison of Active Cycle of Breathing Technique and Autogenic Drainage on improving Pulmonary Functions in patients with Chronic Obstructive Pulmonary Disease."

1.4 OBJECTIVE OF THE STUDY

 To improve the breathing pattern

 To improve the pulmonary function

 To reduce dyspnea

 To analyse the effects of Active cycle of breathing technique and Autogenic drainage

1.5 HYPOTHESES

The study is done on the background of Null hypotheses (Ho) which states that,

"There is no significant difference between Active Cycle of Breathing Technique and Autogenic Drainage on improving pulmonary functions in patients with Chronic Obstructive Pulmonary Disease"

2. REVIEW OF LITERATURE

 William E. DeTurk, PT., PhD. and Lawrence P. Cahalin, PT., MS., CCS has described Chronic Obstructive Pulmonary Disease as group of diseases where premature airway closure results in air trapping, increased lung volume and increased lung compliance. These features ultimately results in hypoxia and hypercapnia.

 Ray et al in his research have concluded that 4.08% men and 2.55% women from South India with a male-female ratio of 1.6 are suffering from chronic obstructive lung disease.

 The World Health Organisation (WHO) in World Health Statistics 2008 has estimated that 80 million people are suffering from Chronic Airway disease. This disease accounted for 5% of deaths globally that occurred during the year 2005.

 Reddy KS, Shah B, Varghese C, Ramadoss A in 2005 has presented that 7% of deaths in India are due to Chronic respiratory diseases.

 Surinder K. Jindal has reported that Tobacco or cigarette smoking, exposure to Environmental tobacco smoke, indoor solid fuel combustion, outdoor air pollution, Ageing are some of the risk factors of developing COPD.

 Lewis, Dirksen has reported that the only genetic abnormality which results in COPD is Hereditary Alpha 1 Anti Trypsin deficiency.

 Tan WC in 2005has added that low socio-economic status where infections are very common are also risk factors for developing COPD.

 Bates has proposed that changes in the small and large airways, hyperactivity of airways, damage of bronchioles and destruction of alveoli are the principal tissue level changes in chronic airflow limitation.

 Jan Stephen Tecklin and Scott Irwin has published that reduced expiratory airflow, ventilation-perfusion mismatch, increased ratio of Residual lung volume to total lung capacity, hyperinflation are the common pathophysiological changes in Chronic airway obstruction

 Ann Thomson, Alison Skinner and Joan Piercy has published that Cough, Dyspnea related to effort, mucopurulent sputum, barrel chest, wheeze especially in the morning are the common clinical findings in Chronic airflow limitation.

 The European Respiratory Society and the American Thoracic Society COPD guidelines (2005) has classified COPD based on spirometric classification as Mild COPD with FEV1 ≥ 80% predicted; Moderate COPD with FEV1 50-80% predicted; Severe COPD with FEV1 30-50% predicted; Very Severe COPD with FEV1<30% predicted.

 Donna Frownfelter has suggested that Active cycle of breathing technique added with postural drainage and percussion helps the patient in managing secretion clearance independently.

 James B Fink has claimed that ACBT is effective in clearing airway and improving pulmonary function similar to chest physical therapy.

 A. Hristara Papadopoulou and J Tsanakas has compared active cycle of breathing technique and conventional physiotherapy in cystic fibrosis and found that active cycle of breathing technique is more effective in mucus clearance from the distal bronchopulmonary segments thereby improving pulmonary function.

 Marilyn Moffat has suggested that Active cycle of breathing technique is effective in mobilising and clearing excessive mucus secretion. The increase in lung volume which occurs during ACBT reduces the airflow resistance, thereby increasing the pulmonary function.

 W. Darlene Reid and Frank Chung has suggested that active cycle of breathing technique has a shearing effect on mucus thereby mobilizing it from smaller airways to the upper airway. ACBT is better tolerated by patients and can be done without postural drainage.

 Davidson et al compared the effects of autogenic drainage with percussion and postural drainage in cystic fibrosis and found that autogenic drainage was as effective as the other treatments and patients showed a greater preference for autogenic drainage

 Sam H. Ahmedzai and Martin F. Muers has reported that while performing autogenic drainage coughing is suppressed and the method is physically undemanding making it highly applicable to debilitated patient.

 Miller et al compared autogenic drainage and active cycle of breathing technique in cystic fibrosis and found that compared to ACBT, AD cleared mucus faster and both techniques improved the respiratory function.

 Wagener et al demonstrated that there is no reduction in oxygen saturation when autogenic drainage is being performed.

 Jamal Ali Moiz, Belsare, Kamal Kishore conducted a study on thirty male acute exacerbation COPD patients comparing ACBT and AD. They concluded that ACBT and AD are equally effective in improving secretion clearance and can be included in the treatment protocol.

 Savci S, I D Inal, Arikan H compared the effects of Active cycle of breathing technique and Autogenic drainage and concluded that Autogenic drainage is as effective as ACBT and Peak Expiratory Flow Rate showed greater increase in AD group.

 Vitacca, L. Bianchi, Ambrosino, Clini has reported that deep diaphragmatic breathing exercise increases the tidal volume and improves the blood gases besides worsening dyspnea and increasing the work of breathing.

 Scot Irwin has published that diaphragmatic breathing exercise improves oxygenation, reduces the respiratory rate and minimizes the post-operative complications.

 Haggerty MC, Z Wallack and Jones have reported that FEV1 is used in identifying and classifying Chronic Obstructive Pulmonary Disease

 Anthonisen, Kiley has reported FEV1 as the classical lung parameter to describe the progression of a treatment in chronic obstructive pulmonary disease.

 Nicola A.H and Amir S has reported that Peak Expiratory Flow Rate indicates the patient's inspiratory and expiratory effort and is a comparatively inexpensive measure of pulmonary function that can be easily performed by the patient.

 Patricia A. Downie has suggested PEFR measured through peak flow meter as the easiest and most reproducible method for monitoring lung function

 Karla R, Sunita C, Robert M. Smith has reported Modified Borg Scale as a valid and reliable tool which can be used in monitoring the treatment outcome in COPD patients.

 Cazzola, P.J.Barnes, P.Palange has reported modified borg scale as a standard method for rating dyspnea in patients with COPD. It is easily reproducible in both long term and short term.

3. MATERIALS AND METHODOLOGY

The purpose of this study is to analyse the effects of Active Cycle of Breathing Technique and Autogenic Drainage on improving lung function in patients with chronic obstructive lung disease. The research design was selected so that it may serve as a guideline for planning and implementing the study in a way that is most likely to achieve the goal.

3.1 MATERIALS

Inch tape

Stethoscope

Sphygmomanometer

Physical therapy assessment chart

Patient assessment chart

Peak flow meter

Chair

3.2 METHODOLOGY

3.2.1 Study Design

This is a two group simple randomized experimental study design done in the pre test - post test format.

3.2.2 Study Setting

This study was carried out in the Department of Pulmonology and Critical Care, Sri Ramakrishna Hospital, Coimbatore.

3.2.3 Study Duration

This study was carried out for a period of six months.

3.2.4 Sampling

Thirty subjects with chronic obstructive lung disease are selected and assigned to two groups of fifteen each through simple random sampling.

Group A - this group underwent diaphragmatic breathing exercise and Active cycle of breathing technique

Group B - this group underwent diaphragmatic breathing exercise and Autogenic Drainage

3.2.5 Inclusive Criteria

Mild and Moderate chronic obstructive disease patients

Both males and females

Age limit of 30 - 50 years

Patients willing to participate on a voluntary basis

3.2.6 Exclusive Criteria

Chronic COPD

Acute exacerbations of COPD

Restrictive lung disorders

Asthma

Bronchiectasis

Tuberculosis

Pulmonary embolism

Pneumothorax

Uncontrolled hypertension

Uncontrolled diabetes

Systemic diseases

Haemodynamic instability

Previous abdominal or thoracic surgeries

Hernia

3.2.7 Outcome Parameters

Forced Expiratory Volume in 1 second (FEV1)

Peak Expiratory Flow Rate (PEFR)

Rate of Perceived Exertion (RPE)

Data Collection Procedure

The patients are treated daily from the day of referral. The outcome parameters are recorded on the day of referral and on the 7th day of treatment in the patient's assessment chart.

3.2.9 Statistical Tools

Pre test and post test values of the study are collected and assessed for variations in improvement and their results were analyzed using Independent 't' Test

Where,

S= combined standard deviation

d1 and d2 = Difference between initial and final readings in Group A and Group B respectively.

n1 and n2 = Number of patients in Group A and Group B respectively.

X1 and X2 = Mean of Group A and Group B respectively.

4. TREATMENT TECHNIQUES

4.1 ACTIVE CYCLE OF BREATHING TECHNIQUE

The Active cycle of breathing technique combines repeated cycles of three stages. They are:

Breathing control

Thoracic expansion exercises

Forced expiratory technique

This technique involves flexible regimens which can be adapted for every patient's convenience. Each set can be performed in desired number of repetitions as the condition requires. The treatment can be stopped when two consecutive huffs at low lung volume remains unproductive and dry. This technique can be performed to a maximum of 20 minutes per session for 2 sessions in a day.

4.1.1 Breathing Control

This phase involves diaphragmatic breathing in normal tidal volume for 5 - 10 seconds. This is a relaxation phase. It should be ensured that the patient's upper chest and shoulders are relaxed and only the lower chest and abdomen are active.

4.1.2 Thoracic Expansion Exercises

This phase emphasises on inspiration. Deep inspiration followed by a breath hold of 3-4 seconds is encouraged. Additional proprioceptive facilitation can be provided by placing the patient's hand over the thorax.

4.1.3 Forced Expiratory Technique

This phase includes one or two effective huffs with breath control in between. An effective huff is performed with mouth O-shaped and glottis open. The abdominal muscles are recruited to produce greater expiratory force. Huffing at low lung volume will mobilise the secretions from distal airways and huffing at high lung volume will clear those secretions.

4.2 AUTOGENIC DRAINAGE

Autogenic drainage is a self-drainage technique that utilises expiratory airflow to mobilise the secretions. This involves three phases,

Unsticking phase

Collecting phase

Evacuating phase

4.2.1 Unsticking Phase

In this phase the patient is instructed to take a quite inspiration and then a deep exhalation in the expiratory reserve volume. This low lung volume breathing mobilise the secretions into the larger airways.

4.2.2 Collecting Phase

In this phase the patient is instructed to breathe from low to mid lung volume into the inspiratory reserve volume. This mobilises the secretions from the larger airways into the central airways.

4.2.3 Evacuating Phase

In this phase the patient is instructed to breathe in high lung volume so that the secretions are mobilised into the trachea. Then the secretions can be evacuated by huffing.

This technique can be performed for 30 - 40 minutes per session for two sessions in a day.

5. DATA PRESENTATION, ANALYSIS AND INTERPRETATION

5.1 DATA PRESENTATION

5.1.1 Demographic Data

Group - A (Active Cycle of Breathing Technique)

Age in years

No. Of patients

Males

Females

30-40

6

3

40-50

4

2

Total = 15

Group - B (Autogenic Drainage)

Age in years

No. Of patients

Males

Females

30-40

5

4

40-50

4

2

Total = 15

5.1.2 FORCED EXPIRATORY VOLUME IN ONE SECOND

a) Group - A (Active Cycle of Breathing Technique)

Pre test

Post test

Difference d1

68

78

10

66

74

8

75

80

5

70

77

7

64

73

9

64

75

11

64

72

8

63

70

7

75

81

6

73

82

9

75

83

8

69

75

6

69

76

7

71

79

8

75

82

7

Mean = 65.13

Mean =77.13

Mean = 7.73

FEV1 IN ACBT Group

b) Group - B (Autogenic Drainage)

Pre test

Post test

Difference d2

71

80

9

75

85

10

65

74

9

65

75

10

72

82

10

59

70

11

61

72

11

68

77

9

63

72

9

72

80

8

71

81

10

68

76

8

65

75

10

73

83

10

70

79

9

Mean = 67.86

Mean =77.4

Mean = 10.73

FEV1 IN AD Group

5.1.3 Peak Expiratory Flow Rate

a) Group - A (Active Cycle of Breathing Technique)

Pre test

Post test

Difference d1

140

240

100

120

180

60

120

200

80

100

150

50

160

250

90

160

230

70

130

210

80

150

220

70

130

190

60

100

160

60

170

220

50

100

190

90

180

250

70

110

180

70

130

210

80

Mean = 133.33

Mean = 205.33

Mean = 72

PEFR in ACBT Group

b) Group - B (Autogenic Drainage)

Pre test

Post test

Difference d2

130

250

120

110

170

60

150

240

90

100

180

80

130

220

90

100

200

100

100

190

90

150

250

100

130

200

70

130

220

90

100

190

90

110

200

90

120

230

110

140

230

90

100

190

90

Mean = 120

Mean = 210.67

Mean = 90.66

PEFR IN AD GROUP

5.1.4 Rate Of Perceived Exertion

a) Group - A (Active cycle of breathing technique)

Pre test

Post test

Difference d1

6

3

3

8

7

2

5

2

3

6

4

2

4

2

2

7

5

4

4

2

2

6

2

4

3

1

2

8

4

4

5

2

3

8

6

2

7

4

3

6

4

2

7

5

2

Mean = 6

Mean = 3.53

Mean =2.67

RPE IN ACBT GROUP

b) Group - B (Autogenic Drainage)

Pre test

Post test

Difference d2

4

0.5

3.5

8

5

3

4

0

4

5

2

3

6

3

3

7

5

4

8

5

3

5

1

4

5

2

3

6

0.5

5.5

8

4

4

7

4

3

4

1

3

6

4

2

7

5

2

Mean = 6

Mean = 2.8

Mean = 3.33

RPE IN AD GROUP

5.2 DATA ANALYSIS & INTERPRETATION

Independent 't' test is used to compare the significance in the improvements shown between the Groups A and B using the following formula,

5.2.1 Forced Expiratory Volume In One Second (FEV1)

FORCED EXPIRATORY VOLUME IN ONE SECOND (FEV1)

GROUP

Mean value

Calculated

't' value

Table

't' Value

Pre-test

Post-test

SD

Group A

65.13

77.13

1.29

3.82

2.048

Group B

67.86

77.4

The difference between the post-test and pre-test values of Group A & Group B regarding Forced expiratory volume in one second is 3.82. The 't' value obtained (3.82) is greater than the table value showing that there is a significant difference between the Groups A&B.

COMPARISON OF FEV1 IN ACBT AND AD GROUPS

5.2.2 Peak Expiratory Flow Rate (PEFR)

PEAK EXPIRATORY FLOW RATE (PEFR)

GROUP

Mean value

Calculated

't' value

Table

't' value

Pre-test

Post-test

SD

Group A

133.33

205.33

14.6

3.51

2.048

Group B

120

210.67

The difference between the post-test and pre-test values of Group A & Group B regarding Peak expiratory flow rate is 3.51. The 't' value obtained (3.51) is greater than the table 't' value showing that there is a significant difference between the Groups A&B.

COMPARISON OF RPE IN ACBT AND AD GROUPS

5.2.3 Rate Of Perceived Exertion (RPE)

RATE OF PERCEIVED EXERTION (RPE)

GROUP

Mean value

Calculated

't' value

Table

't' value

Pre-test

Post-test

SD

Group A

6

3.53

0.849

2.15

2.048

Group B

6

2.8

The difference between the post-test and pre-test values of Group A & Group B regarding Rate of perceived exertion is 2.15. The 't' value (2.15) obtained is greater than the table 't' value showing that there is a significant difference between the Groups A&B.

COMPARISON OF RPE IN ACBT AND AD GROUPS

6. DISCUSSION

The main objective of this study is to analyze the efficacy of Active Cycle of Breathing Technique (ACBT) and Autogenic drainage (AD) on improving the pulmonary function in Chronic Obstructive Pulmonary Disease patients.

Thirty subjects were assigned to two groups of fifteen each of which one group received Active cycle of breathing technique and the other received Autogenic drainage. Both the groups received diaphragmatic breathing exercise as a common treatment. The outcome parameters that were assessed are:

Forced Expiratory Volume in one second (FEV1)

Peak Expiratory Flow rate (PEFR)

Rate of Perceived Exertion (RPE)

The improvement within a group is analysed by comparing the mean values of the pre test readings and post test readings. The improvement among two groups are analysed using independent 't' test at a significance level of 0.05.

The FEV1 values showed improvement in ACBT group as well as in AD group. In ACBT group, the mean pre-test value was 65.13 and the mean post-test value was 77.13. One patient recorded the highest improvement of 11% and one patient recorded the least improvement of 5% in the FEV1 values. Thus the FEV1 value has shown improvement in the ACBT group.

In Autogenic drainage group, the mean pre-test value was 67.86 and the mean post-test value was 77.4. Two patients showed highest improvement of 11% and one patient recorded the lowest improvement of 8%. Thus FEV1 value has shown improvement in Autogenic drainage group too.

On comparing the improvement of FEV1 in both the groups using independent't' test, the 't' value obtained was 3.82. At 28 degrees of freedom the table't' value is 2.048 with 0.05 significance. Thus the obtained 't' value is greater, emphasizing that there is a significant difference between both the groups. Among both the groups the autogenic drainage group has showed greater improvement compared to the active cycle of breathing technique group.

The Peak expiratory flow rate also showed improvement in both the groups. In the Active cycle of breathing Technique group, one patient showed greater improvement of 100 litres and one patient showed the least improvement of 50 litres. The mean pre-test value was 133.33 and the mean post-test value was 205.33.

In the Autogenic drainage group, the mean pre-test value was 120 and the mean post-test value was 210.67 with one patient recording the highest improvement of 120 litres and one patient recording the lowest improvement of 60 litres. Thus peak expiratory flow rate has increased in both the groups, with Autogenic drainage group showing greater improvement.

The independent't' test analysis of both the groups also revealed a 't' value of 3.51 which was greater than the table 't' value 2.048. Thus there is a significant difference between both the groups on improving peak expiratory flow rate.

Analysis of the third parameter, Rate of Perceived Exertion, showed a mean pre-test value of 6 and a mean post-test value of 3.53 in the Active of breathing technique group. One patient recorded the highest difference of 4 in the rating and eight others recorded the least difference of 2.

In Autogenic drainage group, the mean pre-test value was 6 and the mean post-test value was 2.8. One patient recorded the highest difference of 5.5 and two others recorded a minimal difference of 2 in the rating. Thus, there is greater reduction of perceived exertion in the Autogenic drainage group.

The independent't' test analysis of both the groups revealed a table 't' value of 2.15 which is greater than the table 't' value of 2.048 showing that there is a significant difference between both the groups.

Thus independent 't' test analysis of all the three parameters showed a statistically significant difference between both the groups. The mean post-test values of each parameter have demonstrated greater improvement in the autogenic drainage group.

CONCLUSION

The outcome of the statistical analysis reveals that both the treatments, Active cycle of breathing technique and Autogenic drainage improve pulmonary function in Chronic Obstructive pulmonary disease patients. But comparatively Autogenic drainage has shown greater improvement than active cycle of breathing technique. This study proposes and provides the evidence that Autogenic drainage is as effective as Active cycle of breathing technique on improving pulmonary function in COPD patients.

Thus, the Null hypothesis is rejected and it can be concluded that there is a significant difference between Active cycle of breathing technique and Autogenic drainage on improving pulmonary function in COPD patients.

LIMITATIONS

Though carried out with the best of efforts, the study has the following limitations:

The sample studied was small and much stipulated

The study was a short-term study

Modified Borg scale is a subjective scale wherein reduces its reliability

The criterion for patient selection was much stipulated and only mild to moderate COPD patients without any other pulmonary pathology were selected. Severe COPD patients are excluded. Thus, the scope of the result is very constrained.

To perform these two techniques, patience and good understanding is needed.

Seasonal variations which can alter the pulmonary functions cannot be neglected.

SUGGESTIONS

The further studies could be modified to accommodate the following changes:

Study with larger population is recommended

Study with long term follow is suggested

Study with severe COPD patients can also be done

Study can be conducted with these techniques in lung diseases other than COPD to compare their efficiency

More objective parameters can be utilized in recording the efficacy of some parameters.

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