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ORIGINAL ARTICLE
Year : 2013  |  Volume : 1  |  Issue : 1  |  Page : 14-19

To compare the efficacy of incentive spirometry and resistive inspiratory devices on ventilatory muscle strength in patients with moderate dyspnea in Chronic Obstructive Pulmonary Disease (COPD)


1 Asst. Prof, College of Physiotherapy, Sumandeep Vidyapeeth, Piparia, Vadodara-391760, Gujarat, India
2 Sr. Lecturer, C.U. Shah Physiotherapy College, Surendranagar, Gujarat, India
3 Principal, C.U. Shah Physiotherapy College, Surendranagar, Gujarat, India

Date of Web Publication13-Aug-2018

Correspondence Address:
Kalpesh Satani
Asst. Prof, College of Physiotherapy, Sumandeep Vidyapeeth, Piparia, Vadodara-391760, Gujarat
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Backgrond: Dyspnea is one of the main complain of the COPD patients. In the general setting it is treated by medical and physiotherapeutic intervention. Incentive Spirometry and Resistive Inspiratory Devices are 2 main treatment approaches in physiotherapy.
Objective: The objective of this study is to compare the efficacy of Incentive Spirometry and Resistive Inspiratory Devices on ventilatory muscle strength in COPD patients with mild to moderate dyspnea. Method: 30 COPD patients with mild to moderate dyspnea were randomly assigned to Incentive Spirometry group (Group A) and Resistive Inspiratory Device group (Group B). The duration of protocol was 4 weeks and both the groups received 2 sessions per day. Pre-treatment RPE and IC are compared with post-treatment data i.e, at the end of 4 weeks. Analysis was based on the ICS and Borg’s RPE scale.
Results: The test showed significant improvement (p<0.05) in both ICS and RPE score. Using unpaired t-test mean improvement in group A and B was 566.06 ml and 695.2 ml respectively, t =1.049 (p=0.303) for ICS and using Mann-Whitney ‘U’ test median in group A and B was 2.5, U = 106 (p=0.782) for RPE score, since p>0.05 the comparison showed difference as not significant. This result showed that there is no significant difference between the 2 groups.
Interpretation & Conclusion: It is concluded that there is no significant difference between the 2 groups. Both the interventions (Incentive Spirometer and Resistive Inspiratory Device) are equally effective, both in improving ventilatory muscle strength and reducing the perception of dyspnea in COPD patients with mild to moderate dyspnea.

Keywords: COPD, Ventilatory muscle strength, Incentive Spirometry, Resistive Inspiratory Devices, Inspiratory Capacity, Rating of Perceived Exertion


How to cite this article:
Satani K, Khuman R, Devi S, Nambi G. To compare the efficacy of incentive spirometry and resistive inspiratory devices on ventilatory muscle strength in patients with moderate dyspnea in Chronic Obstructive Pulmonary Disease (COPD). J Integr Health Sci 2013;1:14-9

How to cite this URL:
Satani K, Khuman R, Devi S, Nambi G. To compare the efficacy of incentive spirometry and resistive inspiratory devices on ventilatory muscle strength in patients with moderate dyspnea in Chronic Obstructive Pulmonary Disease (COPD). J Integr Health Sci [serial online] 2013 [cited 2019 Jan 22];1:14-9. Available from: http://www.jihs.in/text.asp?2013/1/1/14/238975




  Background and Objectives: Top


The term chronic obstructive pulmonary disease (COPD) refers to diseases that obstruct airflow. It is a major cause of morbidity and mortality in India with an estimated 12.36 million people suffering from this disease.[1] COPD is a most common disorder of the respiratory system which is characterized by chronic cough, dyspnea, wheezing and mucus secretions. It is associated with a functional weakness of the inspiratory muscles.[2]

COPD produces obstruction to the airflow which affects both the mechanical function and gas exchange function of the lung. Respiratory muscles must work harder to overcome this resistance and therefore it leads to weakness of the respiratory muscles.

Drug therapy is the main treatment in patients with COPD which includes Bronchodilators, Mucolytics, appropriate Antibiotics and Corticosteroids. Following drug therapy, physical rehabilitation is the only management which reduces dyspnea.[3]

Ventilatory Muscle Training (VMT) is an important component of the physical rehabilitation which improves the strength and endurance of the respiratory muscles. The different types of ventilatory muscle training includes Incentive Spirometry, inspiratory resistance training with various Resistive Inspiratory Devices, and different breathing techniques for the relief of dyspnea.[4]

Incentive Spirometry and Resistive Inspiratory Devices are widely used to improve inspiratory muscle strength and to reduce dyspnea. These devices offer resistance while performing inspiration. Incentive Spirometer is a simple instrument which provides visual and auditory feed-back to the patient while performing inspiration, so that patient can achieve their preset goals. It encourages deep breathing and a sustained inspiration.[5]

Resistive Inspiratory Devices are hand-held devices of varying diameter. The resistance is increased by decreasing the diameter of the devices and resistance is decreased by increasing the diameter of the devices airway.[6] [Figure 1]
Figure 1: patient performing Incentive spirometry

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Both these devices improve ventilatory muscle strength and endurance and reduce dyspnea.[5]Hence, the aim of the study is to compare the efficacy of Incentive Spirometer and Resistive Inspiratory Devices on ventilatory muscle strength on patients with moderate dyspnea.

The use of Incentive Spirometer and Resistive Inspiratory Devices as a means of improving ventilatory muscle strength in subjects with COPD has not been studied with the importance it deserves. This study aims at determining efficacy of Incentive Spirometer and Resistive Inspiratory Devices for improving strength and endurance of inspiratory muscles and also to determine their positive effects on Dyspnea in subjects with COPD.


  Material and Methodology Top


The subjects from an institutional cardiorespiratory department with COPD were screened by a therapist A. The included subjects were of 30-50 years, with Borg’s scale between 2 and 5. They were excluded if there is Bronchial Asthma, Unstable vital parameters, on Mechanical Ventilator, Congenital, Rheumatic or ischemic heart disease, active lung infections like Pneumonia, Rib fracture and/or Flail chest subjects.

30 male COPD patients fulfilling inclusion criteria, after thorough physical evaluation were divided into 2 groups, each group consists of 15 patients each. Age distribution of the subjects was showed in the table [Table 1].The study obtained ethical clearance from Institutional Review Board.
Table 1: Descriptive statistics of age

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Interventions

A second therapist B, who was aware of group allocation, provided predefined treatment protocol to both groups for the period of 4 weeks.The subjects of group- A were not allowed to communicate with that of group-B to provide blinding of subjects.

15 patients diagnosed as Chronic Obstructive Pulmonary Diseases by the physician were evaluated using the assessment form and COPD questionnaire. After that patients were made to perform 6 minute Walk test at a comfortable walking speed. After 6 minute, patients were shown a modified Borg’s scale and asked to mark a number which express their perceived exertion. Inspiratory capacity was recorded with the help of Electronic Spirometer.

Incentive Spirometry

The patients were positioned on a treatment couch in semi-Fowler’s position with adequate back support. Patients were asked to take three to four slow, easy breaths and maximally exhale with the forth breath. The patients were asked to place mouth piece of Incentive Spirometer in mouth, and maximally inhaled through the mouth piece. As the patient inhaled through the mouth piece, a pressure drop occurs and causes the ball in the tube to rise to a level equivalent to the flow around it. At the end of maximal inspiration, the patients were asked to hold and then to exhale.This sequence was repeated for 5 to 10 times in each session. Treatment was given 2 times per day for the period of 4 weeks.

Resistive Inspiratory Devices

The patients were positioned on treatment couch in semi Fowler’s position with adequate back rest. Then patients were given a mouth piece of Resistive Inspiratory Device fitted with a specific aperture opening disc, and nose clip was placed on the nose, so that breathing was done through the mouth. They were instructed to inhale through the mouth piece of Resistive Inspiratory Device, which was instructed to keep in the mouth for the period of 1-minute. The training was gradually increased in such way that they were able to perform twice a day for 15 minutes in each session. The progression was initially focus on increasing the duration to 30 minutes, then the intensity was increased by using a smaller aperture disc. (Figure 2]
Figure 2: Training with Resistive Inspiratory Devices

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Both the group received pre- and post-treatment evaluation on the first day before the treatment and at the end of fourth week after the treatment.

Outcome Measures

Another therapist C, who was blinded to group allocation, took all post treatment outcome measure at the end of 4 weeks. Inspiratory Capacity (measured with the help of electronic spirometer) and Rate of Perceived Exertion (RPE) were used as an outcome measure to assess baseline values and progression.

Statistical Analysis

All statistical analysis was done using SPSS 16 for windows software. The level of significant was set at p=0.05. Descriptive analysis was used to calculate Mean and Standard deviation. The inter group comparison of demographic details were performed using independent “t” test. Non parametric Mann Whitney “U” Test and Wilcoxon Sign Rank Test was used for inter group and intra group comparisons.


  Result Top


The pre-treatment Inspiratory Capacity (p=<0.05) and Rate of Perceived Exertion (p=0.001) shows that there is no significant difference (p>0.05) and it proves the pre-treatment group homogeneity[Table 2]. Pre and post treatment comparison for ICS (p=0.303) and RPE (p=0.782, U=106) shows significant difference (p<0.05) within the groups [Table 3] [Figure 3],[Figure 4]. It indicates that both the treatment programs ICS and RPE were effective in improving Inspiratory Capacity and reducing dyspnea in COPD patients.
Table 2: Pre-treatment group comparison

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Table 3: Post-treatment group comparison

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Figure 3: Intergroup comparison of mean

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Figure 4: Intergroup comparison of mean

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The post treatment inter group comparison of ICS (p=0.303) and RPE (p=0.782) shows no significant difference (p>0.05) in the improvement between two groups[Table 3] [Figure 1]&[Figure 2]. This result showed that there is no significant difference between 2 groups.


  Discussion Top


In this study, efforts were made to examine the effects of Incentive Spirometer and Resistive Inspiratory Devices as a treatment for improving ventilatory muscle strength in patients with mild to moderate dyspnea in COPD. The study was done on 30 COPD patients with mild to moderate dyspnea diagnosed by physician. The patients were randomly divided into 2 groups consisting of 15 subjects each. Group A was treated with Incentive Spirometry and Group B with Resistive Inspiratory Devices for a duration of 4 weeks. The results demonstrated that the patients treated with both the intervention were highly significant in improving ventilatory muscle strength and hence decreasing the exertional dyspnea.

However statistically there was no significant difference between the 2 groups.

The overall comparison of Inspiratory capacity score and RPE score in Group A was done by using student’s paired't’ test and Wilcoxon Signed Rank test. The t value of inspiratory capacity score from pre-treatment to week 4 post-treatment was 6.615 (p = 0.000 VHS). The Z- value of RPE from pretreatment to week 4 post-treatment was -3.427 (p = 0.001 SIG). According to these results, Incentive Spirometry is highly effective in improving Inspiratory Capacity and reducing the dyspnea which could be due to improvement in ventilatory muscle strength which supports the results of Weiner et al, they treated patients using Incentive Spirometry and other specific inspiratory muscle training and reported increased lung functions and inspiratory muscle strength.[7]

The overall comparison of the Inspiratory capacity score and RPE score in Group B was done by using student’s paired’t’ test and Wilcoxon Signed Rank test. The t value of inspiratory capacity score from pre-treatment to week 4 post-treatment was 8.472 (p = 0.000 VHS). The Z- value of RPE from pretreatment to week 4 post-treatment was -3.427 (p = 0.001 SIG). According to this result Resistive Inspiratory Device is highly effective in improving Inspiratory Capacity and reducing the dyspnea which could be due to improvement in ventilatory muscle strength which supports the results of Walczak et al, they treated patients using small and medium orifice of P-flex device and reported good effectiveness and tolerance by stable COPD patients.[8]

The intergroup comparison of inspiratory capacity score and RPE score was done using the unpaired’t’ test and Mann Whitney ‘U’ test respectively. The inspiratory capacity score in group A showed a mean improvement of 566.06 and group B showed a mean improvement of 695.2, t = 1.049 (p = 0.303) which was not significant. The RPE score in group A and B showed a mean decrement of 2.5, U = 106 (p = 0.782) which was not significant. Statistically there was no significant difference between the 2 groups. Clinically both the interventions were equally effective in improving Inspiratory Capacity and reducing dyspnea which could be due to improvement in ventilatory muscle strength.


  Conclusion Top


This study provided evidence to support the use of Incentive Spirometer and Resistive Inspiratory Devices to improve ventilatory muscle strength in patients with mild to moderate dyspnea in COPD. In conclusion,both the treatment programs are equally effective in improving Inspiratory Capacity and reducing dyspnea which could be due to improvement in ventilatory muscle strength.


  Limitations of the Study Top


  • The study is conducted for a short duration and no follow up is done with the patients so, study shows only immediate effects and not the long term effects.
  • In this study, the effects of extrinsic factors such as administration of drugs like Bronchodilators, Beta blockers, Corticosteroids, etc. and intakes of caffeine in the diet are not considered while including patients in the study.



  Scope for Further Study Top


  • Further study can be done to check the combined effects of Incentive Spirometry and Resistive Inspiratory Devices.
  • The exact mechanism behind the reduction of dyspnea following training and the relationship between the reduction of dyspnea and ventilatory muscle training can be studied in more detail.



  Acknowledgement Top


All our best wishes to those valuable subjects & supporter of this study.

Conflict of Interest

We declare that there were no conflicts of interest in the entire journey of the study.



 
  References Top

1.
Jindal SK, Aggarwal AN, Gupta D, A review of population studies from India to estimate national burden of chronic obstructive pulmonary disease and its association with smoking, Indian J Chest Dis Allied Sci. 2001 Jul-Sep;43(3):139-47.  Back to cited text no. 1
    
2.
Larson JL, Covey MK, Corbrige S, Inspiratory muscle strength in COPD, AACN Clin Issues. 2002 May; 13(2):320-32.  Back to cited text no. 2
    
3.
K. Hill, SC Jenkins, DR Hillman, et al, Dyspnea in COPD-Can inspiratory muscle training help?, Australian Journal of physiotherapy. 2004; 50:169-80.  Back to cited text no. 3
    
4.
Carolyn Kisner, Lynn Allen Colby, Therapeutic Exercise; Foundation and Techniques, Jaypee Books, New Delhi: 4th edition, 2002, pp749-56.  Back to cited text no. 4
    
5.
Donna Frownfelter, Elizabeth Dean, Cardiovascular and Pulmonary Physical Therapy: evidence and practice, Mosby Elsevier, St Louis: 4th edition, 2006, pp763-64.  Back to cited text no. 5
    
6.
Ellen A Hilegass, H Steven Sadowsky, Essential of Cardiopulmonary Physical Therapy, Saunders,USA: 2nd edition, 2001, pp529-530.  Back to cited text no. 6
    
7.
Weiner P, Man A, Weiner M et al , The effect of incentive Spirometry and inspiratory muscle training on pulmonary function after lung resection, Journal of thoracic and cardiovascular surgery. 1997; 113(3):552-557.  Back to cited text no. 7
    
8.
Walczak J, Koziorowski A, Results of respiratory muscle training in patients with COPD with a moderately severe course, PneumonolAlergol Pol. 1997; 65(7-8):487-493.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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