Differences In The Effect Of The Combination Of Home-Based

Walking Exercise And Pursed Lip Breathing With Pranayama

Exercise On Increasing Lung Capacity In Copd Conditions
Nurul Fithriati Haritsah, Yoga Handita Windiaston, Noerdjannah

Health Polytechnic Surakarta Ministry of Health Department of Physiotherapy

ABSTRACT

Background: Data from the pulmonary disease polyclinic at Bangil Hospital showed that there
was an increase in COPD patient visits. In 2018 the number of COPD patients who visited the
pulmonary disease clinic for the last 3 months was 219 COPD patients. COPD patients
experience deficits in caring for themselves due to various symptoms that manifest as a
manifestation of the development of COPD disease. The purpose of this study was to determine
the differences in the effect of the combination of home based walking exercise and pursed lip
breathing with pranayama exercise on increasing lung capacity in COPD conditions.
Subject and Method: The design of this study is a two-group pre and post-test design. As
many as 8 respondents to the pursed lip breathing intervention and home based walking
exercise and 8 respondents to the pranayama exercise according to the inclusion and exclusion
criteria This study compared the effect of Walking Exercises combined with Pursed Lip
Breathing and Pranayama Exercise on increasing lung vital capacity in COPD patients. The
independent variable is lung capacity. The dependent variable is home-based walking exercise
and pursed lip breathing This research was conducted once a week for 12 weeks in May-August
2021 at Dungus Madiun Lung Hospital. All categories were analyzed using SPSS with
MannWhitney.
Result: In group 1, the combination of home-based walking exercise and pursed lip breathing
exercise with a value of p = 0.000 (p <0.05), it can be concluded that the combination of home-
based walking exercise and pursed lip breathing exercise affects increasing lung capacity. In
group II with pranayama exercise intervention, with the result p = 0.000 (p <0.05), it can be
concluded that there was an increase in lung capacity in group II who was given pranayama
exercise. Group 1 has the highest different mean 7.225.
Conclusion: There is an effect of giving a combination of home-based walking exercises and
pursed lip breathing in increasing the lung capacity of COPD patients. There is an effect of
giving pranayama exercise in increasing the lung capacity of COPD patients.

Keywords: home-based walking exercise, pranayama exercise, pursed lip breathing, lung
capacity, COPD

Correspondence:
Nurul Fithriati Haritsah, SST.FT, M.Kes, Health Polytechnic Surakarta Ministry of Health
Department of Physiotherapy. Jl. Letjend Sutoyo, Mojosongo, Jebres, Surakarta, 57127, Central
Java, Indonesia.

BACKGROUND
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease
(GOLD, 2017). Chronic Obstructive Pulmonary Disease (COPD) is a chronic lung disease that
causes airflow limitation in the lungs resulting in impaired lung function. Decreased lung
function occurs due to chronic inflammation of the proximal, peripheral, and pulmonary
vascular airways. This condition results in decreased ventilation function in the lungs, and the
patient will experience an increase in respiratory rate with prolonged expiration (Black and
Hawks, 2014).
COPD is a disease that ranks fourth as the cause of death in Indonesia. COPD ranks first
in the lung disease group in Indonesia with a morbidity rate (35%). The increase in the
incidence of COPD is due to aging of the population and exposure to risk factors COPD. Chronic
Obstructive Pulmonary Disease (COPD) is a common preventable and treatable disease with
characteristic respiratory symptoms and consequent persistent airflow limitation by airway
and/or alveolar abnormalities usually caused by particulate exposure hazardous or significant
gas.
Characteristics of COPD patients as much as 80.6% are male, and as many as 66.7% are
aged 51-70 years (Tarigan & Juliandi, 2018). The results of other studies showed concordance in
as many as 60.96% of patients COPD is male (ROSHA, 2017). Most COPD patients (> 53%) have
a history of smoking (Huriah & Ningtias, 2017; Tarigan & Juliandi, 2018). Slightly different from
the results of other studies that showed that 45.89% of COPD patients did not have smoking
habits (ROSHA, 2017). The condition of insufficient oxygenation in COPD patients will have a
negative impact on quality his life. The results of previous studies showed that 43.3% of COPD
patients experienced a poor quality of life bad (Ritianingsih, 2017). The results of other studies
show the difference that as much as 71.92%.
COPD patients experience a good quality of life (ROSHA, 2017)
The report from the Global Initiative for Chronic Obstructive Lung Disease (GOLD,
2020) states that in 2010 as many as 384 million people or around 11.7% of the world's
population were sufferers COPD has a death rate of up to three million people each year. In
2011, COPD was recorded as the third leading cause of death in the United States and by 2030,
it is estimated that the death rate from COPD will increase to 4.5 million people each year
(GOLD, 2020). The World Health Organization (WHO) in the 2015 Global Status of Non-
communicable Diseases explained that COPD is the 4th largest non-communicable disease in
the world which has a high mortality rate after ischemic heart disease, stroke, and lung cancer.
Globally, it is estimated that around 3 million deaths were caused by this disease in 2015 i.e., 5%
of all deaths worldwide in that year. More than 90% of COPD deaths occur in developing
countries with weak economies.
Pursed Lips Breathing is used to achieve more controlled and efficient ventilation. This
technique can stimulate relaxation and coordination of the respiratory muscles and help
maximize the expulsion of air during expiration. Thus, the accumulation of air volume in the
lungs can be reduced and ventilation becomes stable. This condition causes the respiration rate
to decrease (Hartono, 2015). Supported by the results of research conducted by Surya P. Bhatt et
al, (2013) showing that the use of Pursed Lips Breathing (PLB) in patients with stable COPD can
increase exercise capacity and reduce respiration rate (RR) (Bhatt et al., 2013).
Walking exercises that are carried out independently at home can gradually increase
tolerance in carrying out activities and improve the health status of COPD patients (Matos-
Garcia et al., 2017). Home-based walking exercise is easy to implement at home and does not
require special costs and equipment. When compared to cycle training, walking exercise is more
significant in increasing endurance walking time by 279 seconds (Leung et al., 2010).
Pranayama exercise is the expansion and control of breathing or controlling breathing
consciously. Pranayama exercise creates an atmosphere of relaxation of the conscious mind in a
deeply relaxed state. When the body begins to relax, breathing will become slow and deep so
that the expansion of the thoracic cage can be maximized, the air that is inhaled and exhaled is
maximal, the volume in the lungs increases so that there is an increase in vital capacity (Worby,
2007).

SUBJECT AND METHOD

1. Study Design
 The design of this study is a two-group pre and post-test design. The study compared the
effect of Walking Exercises combined with Pursed Lip Breathing and Pranayama
Exercise on increasing lung vital capacity in COPD patients. This research was conducted
once a week for 12 weeks in April-June 2021 at Dungus Madiun Lung Hospital.
2. Population and Sample
Data collection for this study was carried out in outpatient and inpatient polyclinics for
pursed lip breathing interventions, home based walking exercise and pranayama
exercise. Respondents were mild COPD patients. The sampling technique is a total
sampling of six-teen respondents. The researcher collected data from 8 respondents to
the pursed lip breathing intervention and home based walking exercise and 8
respondents to the pranayama exercise according to the inclusion and exclusion criteria.
3. Study Variable
The independent variable is lung capacity. The dependent variable is home-based
walking exercise and pursed lip breathing.
4. Operational Definition of Variable
Lung Capacity is the volume of air in the lungs upon the maximum effort of
inspiration.
Home-based walking exercises are walking exercises performed at
home independently.
Pursed lip breathing is a technique that allows people to control their
oxygenation and ventilation.
5. Study Instruments
The measuring instrument used in this study was a spirometer which was used to
measure vital capacity (VC). Spirometry is a pulmonary function test that is useful for
differentiating between restrictive lung disease and for determining the degree (mild,
moderate, or severe) of obstructive or restrictive lung disease. So far, it has been known
that there is a relationship between vital lung capacity values with age, height, and
gender.
6. Data Analysis
This research is a quasi-experimental research with two group pre-test and post-test
group design. Effect of Pursed Lip Breathing Combination with Home Based Walking
Exercise and Pranayama Exercise on Lung Capacity using the Mann Whitney test,
Different test post-test for the Pursed Lip Breathing group with Home Based Walking
Exercise and the Pranayama Exercise group used an unpaired t test because the data was
normally distributed. A different test to determine a better intervention uses a different
test of mean difference because there is a significant difference between the Pursed Lip
Breathing and Home Based Walking Exercise and Pranayama Exercise groups. The data
obtained processed and analyzed using the IBM SPSS 20. All the categories was analyzed
with Mann Whitney U test. After that, the multivariate variable was analysed using linear
regression.
7. Research Ethics
This proposal has been submitted and approved by the Research Ethics
Committee of Faculty of Medicine, University of Muhammadiyah Surakarta with
ethical clearance number 3570/B.2/KEPK-FKUMS/VI/2021.

RESULT
1. Sample Characteristics
 Characteristics Category Frequency Percentage
Gender Male 5 62.50%
Female 3 37.50%
Age 31-40 1 12.50%
41-50 5 62.50%
51-60 2 25%

The results of the Mann-Whitney test combination of pursed lip breathing and home-based
walking exercise with pranayama exercise on the level of lung capacity in 16 respondents (8
respondents to pursed lip breathing intervention and home based walking exercise and 8
respondents to pranayama exercise) showed a sig (2-tailed) value of 0.000 in each intervention,
so from the Mann-Whitney test results, it can be interpreted that there is the effect of a
combination of pursed lip breathing and home-based walking exercise with pranayama exercise
on increasing lung capacity values in mild COPD patients.

Table 1. Changes In Lung Capacity Pre And Post The Combination Of Pursed Lip
Breathing And Home Based Exercises With Pranayama Exercises
Combination Of Pursed Lip Breathing And Home Pranayama Exercises
Based Exercises
Mean SD p Mean SD p
Pre 95.39 0.701 0.001 95.83 0.710 0.001
Post 98.08 1.234 97.54 0.811

The results of the Mann Whitney oxygen saturation test of post pursed lip breathing and home
based walking exercise on pranayama exercise in 16 respondents showed a sig (2-tailed) value of
0.000, which means that there is a difference in lung capacity values between pursed lip
breathing and home based walking exercise with pranayama exercise.

Table 2. Difference In Lung Capacity Pre And Post The Combination Of Pursed Lip
Breathing And Home Based Exercises With Pranayama Exercises
Variable n Mean p
Rank
Pursed lip breathing and home based walking 8 7.22
exercises < 0.001
Pranayama exercises 8 2.94

Then, to find out which group is better seen from the different means before and after the
pa00da treatment of each group. The group that had a higher mean difference before and after
treatment than the other groups was better at increasing lung capacity. In this study, the group
that had a higher mean differential was Group 1 or the home-based walking exercise and pursed
lip breathing group with a result of 7.225

DISCUSSION
1. Effect of Pursed Lip Breathing and Home-Based Walking Exercise on Lung
Capacity
From the research that the researchers have done, the results show that there is an effect of
pursed lip breathing and home-based walking exercise on lung capacity values. The results of
the Mann Whitney pursed lip breathing test and home-based walking exercise on the level of the
lung capacity of 8 respondents showed p<0.000, so from the Mann-Whitney test results it can
be interpreted that there is an influence between pursed lip breathing and home-based actions
walking exercise on increasing lung capacity values in mild COPD patients.
COPD is motivated by several pathological conditions such as chronic bronchitis,
emphysema, and asthma chronic In chronic bronchitis there is enlargement of the bronchial
mucous glands, goblet cell metaplasia, inflammation, hypertrophy of respiratory smooth muscle
and distortion due to fibrosis. Bronchial epithelium long term inflammation with mucous gland
hypertrophy and increase goblet cell count. There is also damage to cilia and mucociliary
movement, mucus viscosity, and secretion increases, which will then cause obstacles to expel it
(expectoration disorder). Enlargement of the mucous glands can be caused by infection, and
Recurrent inflammation can cause irreversible structural damage to the wall airway. This
damage will cause injury and make the peripheral airway experience narrowing and inhibition.
This condition can develop into a duct obstruction severe breathing, which is then called COPD.
The results of this study are supported by research conducted by Budiono and Mustayah
(2017) which states that there is a significant effect of pursed lip breathing on increasing lung
capacity values. This is also in line with research conducted by Sri, Evita & Yohastuti (2018)
which stated that pursed lip breathing is effective in increasing the respiration rate value in
COPD patients. Pursed lip breathing is a breathing exercise by compressing the lips which aims
to slow expiration, prevent the collapse of the lung units, and help the patient to control the
respiratory rate and depth of breathing so that the patient can achieve control of dyspnea.
Pursing the breathing lips helps COPD sufferers to empty the lungs and slow down the breathing
rate. Pursed Lip Breathing helps to restore the position of the diaphragm which is the breathing
muscle that is located under the lungs. Pursed Lip Breathing also causes the stomach muscles to
contract during expiration, this forces the diaphragm upwards, and helps to empty the lungs, as
a result, COPD sufferers will breathe more slowly and more efficiently (Smeltzer and Bare,
2013).
In line with research from Wootton et al., (2014) Q1 quality and a PEDro score of 8/10
shows the conclusion that Ground-based walking training can improve the quality of life of
patients with moderate to severe COPD. This is shown in the decrease in the Saint George
Respiratory Questionnaire (SGRQ) score. (1) Domain symptoms at baseline (mean±SD= 56 ±
22) and at study completion (mean±SD= 41 ± 14); (2) Domain activity limitations at baseline
(mean±SD=63 ± 19) and at study completion (mean±SD= 59 ±18); (3) Domain impact on
baseline (mean±SD= 33 ± 18) and on study completion (mean±SD= 27 ± 14); (4) SGRQ total
score at baseline (mean±SD= 47 ± 17) and at study completion (mean±SD= 41 ± 14). Also shown
in the increase in Chronic Respiratory Questionnaire (CRQ) scores. (1) Domain dyspnoea at
baseline (mean±SD= 16 ± 5) and at study completion (mean±SD= 19 ± 5); (2) The fatigue
domain at baseline (mean±SD= 17 ± 6) and at study completion (mean±SD= 19 ± 5); (3)
Domain emotional function at baseline (mean±SD= 35 ± 8) and at study completion
(mean±SD= 37 ± 7); (4) Domain mastery at baseline (mean±SD= 21 ± 5) and at study
completion (mean±SD= 22 ± 5); (5) Total CRQ score at baseline (mean±SD= 89 ± 19) and at
study completion (mean±SD= 97 ±18). Limitations in this study were patients with mild COPD
category not included, therefore, researchers cannot easily expand study findings to this group.
In addition, this study did not have any gaps from all objects that were given therapy.
Research by Bhatt et al., (2013) shows that Pursed lips breathing can reduce dyspnea in a
subjective sense, and can reduce RR during the recovery period after doing Pursed lips
breathing. In addition, PLB increases functional exercise tolerance thereby reducing the work of
breathing for the same effective level of effort in reducing shortness of breath. However, it may
present with increased diaphragmatic activity leading to markedly increased muscle activity,
compensating for reduced subjective perception of dyspnea. The advantage of this study is
measuring diaphragm movement during PLB in real time using ultrasonography. The limitation
of this study is that it was not intention-to-treat.
 2. Effect of Pranayama Exercise on Lung Capacity
From the research that the researchers have done, the results show that there is an effect of
Pranayama Exercise on lung capacity. The results of the Pranayama Exercise test on the oxygen
saturation level of 8 respondents showed a sig (2-tailed) value of 0.000, so from the Mann-
Whitney test results, it can be interpreted that there is an influence between the pranayama
exercise action on increasing the value of lung capacity in COPD patients.
The results of this study are supported by research conducted by Sinambela, Tarigan, &
Pandia (2015), based on this study a significant effect was found between pranayama exercise on
increasing lung capacity in the group of respondents with mild degrees of COPD. According to
the Minister of Health of the Republic of Indonesia in 2009, pulmonary rehabilitation can be in
the form of physical exercise and breathing exercises.
The pranayama breathing technique controls the breath and the mind. This exercise can
strengthen the respiratory system, calm the nervous system, and can strengthen the immune
system. The real benefits that can be felt from this exercise are reduced fatigue, and calm
thoughts and emotions (Worby, 2007).
Pranayama is done by regulating and controlling the breath. Breath control consists of
setting the length and duration of inhalation (inhalation) length and the duration of exhalation
(exhalation), as well as breathing stops. The average respiratory frequency reaches 16-18 times
per minute in normal people, by doing yoga breathing exercises the breath speed will become
slower and each breath in and out will be longer and fuller. This condition is called deep
breathing and will enable existing energy to move to reach the cells. This exercise uses deep
breathing relaxation exercises, slow deep breathing, and pursed lip breathing. But this
pranayama practice uses another form of practice, namely breathing using one nostril and
incorporating elements of spirituality at the end of the exercise (Worby, 2007).
The mechanism of yoga breathing exercises (pranayama) for the physical changes that
occur in the body begins with the creation of an atmosphere of conscious relaxation which
systematically leads to a deeply relaxed state. The creation of an atmosphere of relaxation will
eliminate the voices in the mind so that the body will be able to release muscle tension. When
the body begins to relax, the breath becomes slow and deep, so that the respiratory system can
rest. Slowing the rhythm of breathing will make the heart beat slower and have a positive effect
on the entire circulatory system. The sympathetic nervous system will react to relaxation while
the parasympathetic nervous system will respond to relaxation. In addition to the sympathetic
nerves, messages for relaxation are also received by the endocrine glands which are responsible
for most of the emotional and physical states (Worby, 2007).
During forced respiration exercises, the chest and lungs are maximally contracted and
relaxed and the muscles work to their maximum capacity. It is supported that forced respiration
exercises without holding phases can also strengthen the respiratory muscles and increase the
elasticity of the chest and lungs by increasing some of the ventilation functions of the lungs
(Grover et al, 1998).
The position in pranayama is done in padmasana, which is a sitting asana position with legs
crossed by placing one foot or two feet on the opposite thigh. Padmasana provides a natural
position for the spine and upper body and provides a strong and stable position. In the upright
position, the diameter of the main airways increases gradually and the diaphragm is maximally
expanded, the anteroposterior dimension of the thorax is greatest and the pressure on the heart
and lungs is lowest. In this position, the diaphragm is neutralized by increasing breathing
(Unnati et al, 2014).
3. Differences in Oxygen Saturation Values Between Pursed Lip Breathing and
Home Based Walking Exercise with Pranayama Exercise
From the research that the researchers have done, the results show that there are differences
in oxygen saturation values between respondents who have done pursed lip breathing and home-
based walking exercises and respondents who have done pranayama exercises. The results of the
Mann-Whitney test of post-pursed lip breathing and home-based walking exercise lung capacity
on pranayama exercise in 8 respondents showed a sig (2-tailed) value of 0.000, this means that
there is a difference in lung capacity values between pursed lip breathing and home-based
walking exercise and pranayama exercise. Both interventions had the same effect on increasing
oxygen saturation values but there were differences in the range of increase in lung capacity
before and after the intervention. In the pursed-lip breathing and home-based walking exercise
intervention group, the average lung capacity before the intervention was 95.39% and after the
intervention, the average oxygen saturation value was 98.08%, which means there was an
increase of 2.69%. Whereas in the pranayama exercise intervention group the average lung
capacity value before the intervention was 95.83% and after the intervention, the average lung
capacity value became 97.54% which means there was an increase of 1.71%.
The results of this study are supported by research conducted by Suryantoro et al., (2017)
entitled Differences in the Effectiveness of Pursed Lips Breathing and home-based walking
exercise with Pranayama Exercise on Forced Expiratory which states that both interventions are
equally able to increase FEV1 values with results showing that the average FEV1 post-test in the
pursed lips breathing group was greater than in the pranayama exercise group. This is because
pursed lips breathing is more able to train the respiratory muscles to extend expiration and
increase airway resistance during expiration, thereby reducing airway resistance and trapped
air, as well as shortness of breath. This is because pranayama exercise does not directly train to
breathe such as pursed lips breathing which helps COPD sufferers to exhale more efficiently as
shown by prolonged expiration. Pranayama exercise to be able to increase FEV1 must go
through several processes, starting from increasing O2 intake obtained from physical activity to
the formation of ATP as a material for respiratory muscle contractions to produce forced
expiration (Sherwood, 2012). From the theory above, it can be concluded that both pursed lip
breathing, home-based walking exercise, and pranayama exercise can increase lung capacity
values in mild COPD patients, although the results are not the same. So both pursed lip
breathing and home-based walking exercises or pranayama exercises can be applied to patients
suffering from mild degrees of COPD to increase lung capacity values.
Pursed lip breathing (PLB) is a treatment that can reduce dynamic hyperinflation as
according to Ferracini Cabral et al., (2015) Q1 quality and PEDro5/10 score said that PLB can
help reduce dynamic hyperinflation, increase SPO2, exercise tolerance in COPD patients by
reducing peak expiratory flow (PEF) when doing PLB. Several studies have also reported that
PLB can affect the breathing patterns of COPD patients at rest. In addition to the reduction in
respiratory rate (RR) and increase in tidal volume (TV), there is also a decrease in the
inspiratory duty cycle (Ti/Tot) during PLB, indicating that the inspiratory muscles experience a
longer rest period between muscle contractions during PLB. PLB works on the breathing pattern
by prolonging expiration, reducing functional residual capacity, and increasing ventilation
efficiency. The limitations of this study are that there is no explanation regarding the criteria for
COPD patients according to GOLD, and in this study no intention-to-treat was carried out.
The conclusions from the study entitled "Differences in the Effect of the Combination of
Home-Based Walking Exercise and Pursed Lip Breathing with Pranayama Exercise on
Increasing Lung Capacity in COPD Conditions include: .(1) There is an effect of giving a
combination of home-based walking exercise and pursed lip breathing in increasing lung
capacity COPD patients with a value of p = 0.000 (p <0.005), (2) There is an effect of giving
pranayama exercise in increasing the lung capacity of COPD patients with a value of p = 0.000
(p <0.005), (3)
The combination of home-based walking exercise and pursed lip breathing has more
effect on increasing lung capacity than pranayama exercise with the mean difference in group I
7.22 and group II 2.94 (7.22 > 2.94).

AUTHOR CONTRIBUTION
Nurul Fithriati Haritsah as the main character of the research who chooses the topic, conducts
searches and collects data in this study, compiles research articles. Farid Rahman played a role
in conducting, data analysis and reviewing research documents, and Noerdjannah as the author
of the research report.

FINANCIALL SUPPORT AND SPONSORSHIP

This research was funded by Risbinakes fees from the Ministry of Health.

ACKNOWLEDGEMENT
The author would like to thank the Physiotherapy Study Program, Health Polytechnic of the
Surakarta Ministry of Health, all respondents who agreed as a research sample, and also to all
parties who have helped so that research can run well.

CONFLICT OF INTEREST
There is no conflict of interest.

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