Pursed Lip Breathing With Arm Ergometry After Chin Supported Position in COPD Patients.

Randomized control Trial, Purposive sampling was used to obtain the sample for the study and then randomly allocated into groups by coin toss method. Data collected from July 2019 to January 2020, was conducted at Rehman Medical Institute Peshawar. To determine the effects of pursed lip breathing with arm ergometry after chin support position on heart rate, respiratory parameters, pulmonary function tests and quality of life in COPD patients.

Chronic Obstructive Lung Disease (COPD), a major worldwide epidemic is the 4th leading cause of death around the globe and though, with rise in worldwide life expectancy and tobacco smoking, predominantly in developing countries, it is likely to be the 3rd leading cause of mortality by 2020. In Pakistan, mortality rate caused by COPD is expected to reach 71 deaths per 100,000 that is globally the fourth leading death rate among 25 most populated countries.

The condition is in the focus worldwide, since its increased prevalence, morbidity and mortality rate create alarming challenges for health-care professionals. In spite of latest trends in decline of COPD consistent death rates and few current achievements in anti-smoking efforts in many western countries, the elevating influence of increasing age in an ever-growing global population, combined with factors as high smoking rates and pollution of air in Asia, will confirm that COPD will last as an ever-increasing issue into the 21st century.

A variety of environmental and intrinsic risk factors are involved in the development of COPD which affect at different time points during an individual's life span. Smoking is a dominant risk factor comprising of 80% of the COPD cases.

During the previous 5 years, an exceeding quantity of risk factors excluding smoking have been associated with the COPD development, predominantly in developing countries.

Exercise intolerance is a challenging result of COPD and often happens during arm activities. . Exercise intolerance can be best described by the concept of dynamic hyperinflation. The thoracic motion is regulated due to hyperinflation and thus capacity to increase tidal volume during exercise is limited. Many research studies have established that there is limited arm exercise capacity, and patients often complain of notable dyspnea and fatigue during arm activities essential in daily life. Two mechanisms have been recommended: neuro-mechanical dysfunction of respiratory musculature, that are diaphragm and accessory respiratory muscles, thoracic-abdominal asynchronous and changes in lung volume during upper limb activities. Impairments in ventilatory mechanics in COPD patients result in termination of arm exercises at lower workloads compared with healthy subjects.

When these patients were asked to open their mouths to breathe out instead of using pursed lips Breathing (PLB) they immediately developed severe dyspnea and suffocation. The term PLB was utilized as the patients had lips almost completely sealed while they were exhaling. However, the term pursed lip or puckered lip breathing was not well characterized, and the techniques taught to patients varied depending on the clinician. PLB was defined as a self-induced type of positive-pressure breath. One definition given by Wikipedia, is that PLB is a breathing technique that consists of exhaling through tightly pressed lip (pursed lips) and inhaling through nose with mouth closed. The "tightly" is the word that can be subjective and open to interpretation. The online free medical dictionary gives a very similar definition as Wikipedia; however, it removed "tightly" from the "tightly pursed lip". Regardless of "tightly pursed lip" vs. "pressed lip", the purpose of this breathing is to slow down the air flow during the exhalation to build up back pressure in the airway to avoid a sudden drop in intra-pulmonary pressure resulting in alveolar and airway collapse. Pursed lip breathing, is a strategic breathing training often used by COPD patients to obtain relief from dyspnea.

A shift in the pattern of recruitment of inspiratory and expiratory muscles with PLB exercise. There is a better activity in the rib cage and accessory muscles than with activity of diaphragm. The diaphragmatic tension-time index is decreased. Consequently, PLB by altering recruitment pattern decreases the possibility of fatigue of diaphragm and improves breathlessness. It also upsurges recruitment of abdominal expiratory musculature. Expiratory muscle recruitment does not only ease expiration but also aids in inspiration by developing the length-tension relationship of the inspiratory muscles.

Body positioning is one of the controlled breathing maneuvers to improve the respiratory muscle functioning and decreasing dyspnea. That is why the COPD patients often assume the tripod position, which is, sitting with forward lean of trunk and arm support, during breathlessness. This position develops the length-tension relationship of diaphragm and decreases the activity of sternocleidomastoid and scalene muscles thus improving thoraco-abdominal movement and reducing breathlessness. The arm support in this position recruits pectoralis major and pectoralis minor musculature to improve rib elevation

Eligibility Criteria:
Inclusion Criteria:

* Mild to moderate stage COPD according to GOLD criteria {i-e Global Initiative for Obstructive Lung Disease (GOLD) }

Exclusion Criteria:

* COPD patient with angina pectoris,
* third degree heart block,
* congestive heart failure and
* orthopedic or neuromuscular conditions (cervical involvement which aggravate symptoms) or radiculopathy