PLB Kombinasi Salbutamol 2014

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Indian Journal of Physiotherapy & Occupational Therapy. January-March 2014, Vol. 8, No. 1 215

A Randomized Control Trial of Treatment of BronchialAsthma with Inhaled Salbutamol Combined with Pursed

Lip Breathing

Saee Khandagale1, Ronika Agrawal2, M S Barthwal3, Devashri Salvi4

1Physiotherapist, Department of Cardiovascular Rehabilitation and Preventive Cardiology, Noble Hospital, Pune,2Principal, M.A. Rangoonwala College of Physiotherapy and Research, Pune, 3Head of Department,

Pulmonology Department, Military Hospital, Cardio-Thoracic Centre, Pune, 4Physiotherapist, Department of

Cardiovascular Rehabilitation and Preventive Cardiology, Noble Hospital Pune

ABSTRACT

Purpose of the study:To compare immediate and sustained effect of Pursed Lip Breathing (PLB) and

Inhaled Salbutamol with Salbutamol alone on Peak Expiratory Flow Rate (PEFR) and Asthma Control

Questionnaire (ACQ) in Controlled Asthmatics.

Methodology:60 Asthmatics (30 in interventional group, 30 in control group) were selected for the

randomized control trial. On the first day, Pre PEFR was measured and four puffs of Salbutamol

were administered using Metered Dose Inhaler (MDI) and Spacer device in both the groups. For 20

minutes, Interventional group was instructed to perform PLB and post PEFR was measured in both

the groups. For 1 week, interventional group performed PLB and entire procedure performed on day

1 was repeated. ACQ scores were calculated on day 1 and day 8 in both the groups.

Results:The mean increase in PEFR after treatment with Salbutamol and PLB was greater than

Salbutalmol alone on day 1 and 8. The Pre PEFR value on Day 8 significantly increased compared to

day 1 in the interventional group whereas Control group did not have improvement in Pre PEFR

value. ACQ score significantly improved on day 8 in both the groups however on comparingimprovement in both the groups, interventional group had a more significant improvement in the

score. On comparing improvement in Pre and Post PEFR on day1 and Day 8, it did not differ

significantly in individual groups.

Conclusion:Performing PLB following inhalation of Salbutamol enhances bronchodilation in

Asthmatics. Also PLB has a sustained bronchodilatory effect and resulted in a better control of

symptoms of Asthma.

Keywords: Bronchial Asthma, Pursed Lip Breathing, Bronchodilation, Salbutamol, Peak Expiratory FlowRate

INTRODUCTION

In Bronchial Asthma, the airways are obstructed

due to increased bronchial muscle tone, inflammatory

edema in the bronchial wall and mucus in the airways6.

Spirometry is the gold standard for demonstrating

airflow obstruction and PEFR is one of the parameters

used.1 SABA like Salbutamol stimulates beta 2

receptors in the bronchial smooth muscles which cause

bronchodilation. In normal individuals, during

expiration, positive pressure within the airways,

contributes to keep them patent. But, in diseases with

airflow limitation, the airways tend to collapse during

expiration6. Airway collapse theoretically can be

counterbalanced by applying positive expiratory

pressure6. Use of Positive End Expiratory Pressure

(PEEP), Continuous Positive Airway Pressure (CPAP)

and Positive Expiratory Pressure (PEP) and PLB for

the above purpose has been well documented6. PLB is

often seen in patients with severe airway obstruction14.

DOI Number: 10.5958/j.0973-5674.8.1.041


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216 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2014, Vol. 8, No. 1

By opposing the lips during expiration, the airway

pressure inside the chest is maintained, preventing the

floppy airways from collapsing. PLB splints the

airways open during expiration and increases

expiratory time, thereby reducing dyspnea14. It also

reduces Respiratory rate (RR) and increases Tidal

volume (TV) which in turn improves gas exchange5

.When moderately active expiration through half

opened lips is performed, it induces a mouth pressure

of about 5 cm H2O16. Recently, the application of PEP,

CPAP has shown to decrease pulmonary resistance.

These studies indicate that expiratory positive pressure

dilates the airways and improves the distribution of

ventilation, which might leave the airways available

for better deposition of inhaled medication4. Thus the

observation of effects of PLB and the above studies

raises the question whether PLB has any additional

effect over Bronchodilation induced byBronchodilators and if it has is it sustained? Asthmatics

rely entirely on the prescribed bronchodilators to gain

symptomatic relief and the amount of bronchodilation

achieved is primarily dependent on the

pharmacological characteristics of the drug used.

Hence some patients require more frequent use of the

drug or an increase in the dosage to achieve

symptomatic relief but then they are exposed to higher

doses of the pharmacological agent which might put

the patient at risk of developing adverse drug reactions

such as tremors, anxiety, headache, muscle cramps,

and palpitations1. Hence, there is a need of a non-

pharmacological means of enhancing the efficacy of

the bronchodilation achieved by a bronchodilator.

Hence, this study enquires the effect of PLB on the

efficacy of bronchodilation achieved by

bronchodilators in asthmatics.

MATERIAL AND METHOD

Sixty patients from Asthma Clinic, Military

Hospital, Cardio-Thoracic Centre, Pune were included.

By random allocation sampling method, they were

divided in two groups- 30 in Interventional group

(Group 1) and 30 in Control group (Group 2).

Characteristics of 60 patients are shown in Table 1 All

had a history of BA, with wheezing and dyspnea

relieved by bronchodilator, hyper responsive airways,

allergy and/or eosinophilia. They were never smokers

or had stopped smoking for more than 5 years. They

all needed daily bronchodilator treatment with SABA

and/or oral theophylline and all patients used daily

inhaled corticosteroid. They had all previously showed

an increase in forced expiratory volume in the firstsecond (FEV1) or PEFR of at least 15 percent of

predicted after inhalation of SABA. Patients in an acute

exacerbation of asthma were excluded. On the

assessment days, treatment with oral bronchodilators

was withheld for 12 hours and inhaled bronchodilators

were also withheld for 6 hours. Tea and coffee was not

allowed before each study day commencing at 10 AM.

Inhaled corticosteroid therapy was continued. The

patients were given detail verbal information about

the procedure and written consent to participate was

obtained from all. The research study was approvedby Ethical Committee of M A. Rangoonwala College

of Physiotherapy and Research, Pune.

Table 1. Characteristics of 60 patients with Bronchial Asthma

Size Age Male Female PrePEFR ACQScorel/min on Day 1 on day1

Group1 30 41.1 15 15 321.66 13.53

Group2 30 42.6 14 16 285.66 13.26

Instruments

1. Wrights peak flow meter

2. Asthalin MDI

3. Spacer

4. Stop watch

PROCEDURE

Each subject was studied on two separate days with

an interval of 7 days in between. On the first day,

subject adopted a comfortable sitting position. Their

PEFR was assessed using Wrights Peak Flow Meter.

Four puffs of Salbutamol using a MDI with 750ml

conespacer were given. After Inhalation of Salbutamol,

Control group(Group 2) was instructed to wait for 20

min whereas Interventional Group (group 1)

performed PLB for 20 min. They were asked to perform

4 repetition of PLB in the beginning of every minute

and the remaining time of the minute, subject was


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instructed to breathe normally. Thus in 20 minutes, 80

repetitions were performed. At the end of 20 minutes,

PEFR of both the groups was assessed again. Group 2

was called after a week whereas Group 1 was

explained the protocol for 7 days and a diary was given

to maintain the regularity of the protocol. They were

instructed to perform PLB for 10 minutes, thrice a day.At the beginning of every minute, 4 repetitions of PLB

were performed thus in 10 minutes, 40 repetitions were

performed. After 7 days the entire procedure

performed on first day was repeated for both the

groups. ACQ Score was recorded on 1stand 8thday.

DATA ANALYSIS

Paired t test and Independent t test is used for

within group and between group comparisons.

p value of less than 0.05 was considered to besignificant with 95 percent confidence interval.

Analysis of data was done using SPSS version 18.

RESULT:

Improvement in PEFR was significantly higher on

Day 1 and Day 8 in Group 1 than Group 2 (p


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Graph 5 TV which provides load fluctuations on airway smooth

muscle that are necessary to keep them in a flexible

and less contractile state. But in sever Asthmatics

thickening and edema could occur because the airways

are more inflamed11. However, in a study done by

Annelies M. Slats et al, Systemic anti-inflammatory

treatment with inhaled corticosteroids reducesinflammatory process in the airways in clinically stable

patients with persistent asthma, and therefore

optimizes the bronchodialatory effect of increased tidal

volume11. All subjects included in the study have been

prescribed with oral corticosteroids regularly. Thus the

positive pressure created during expiration and

increase in TV during PLB might be causing relaxation

of the smooth muscles thus decreasing airway

resistance.

In patients with expiratory airflow limitation,

collapse of airways during expiration occurs to greaterextent than in healthy subjects and during PLB, the

pressure gradients are moved from the airways to the

PLB resistance, leaving airways more open4. In this

way the distribution of the ventilation and thereby the

deposition of inhaled medication might be improved,

giving further bronchodilation4. The retarded

expiration might allow more time for retaining the

medication in distal airways4.

To assess the sustained effect of PLB; group 1

performed PLB for a week. As seen in Graph 2 themean Improvement in the PrePEFR reading on 8thday

was 19 liters/min and it was of statistical significance

(p0.05). Improvement in prePEFR in group 1 could

probably be due to a cumulative bronchodilatory effect

of PLB performed over a period of 7 days. Thus the

effects of PLB like increase in TV, decrease in RR along

with improvement in distribution of drugs inhaled and

additional effect on dilation of airways improved

airway patency and the degree of obstruction reduced.

Also the increase in TV results into influx of a larger

volume of air into the lungs and increased expansion

of the lung parenchyma7. This increased inflation

applies a radial traction on the walls of airways

producing a dilatory effect7. Radial traction is by the

virtue of the interdependence between

intraparechymal airways and the surrounding

parenchyma. It is sustained by network of alveolar

attachment to the airway wall.7This Bronchodilatory

effect has been demonstrated in mild Asthmatics and

clinically stable patients who have been prescribed

with oral corticosteroids regularly.11

PEFR Difference on both the days did not differ

statistically in the individual groups (p>0.05)

DISCUSSION

This study is a Prospective Interventional study

comparing PEFR in Interventional and Control Group.

Also whether PLB has sustained effect is reviewed by

measuring PEFR after a week.

As seen in Graph 1, on the day 1 the improvement

in PEFR in Intervention group (1) was 24 liters/min

more than in Control Group (2) and similarly on day

8, the improvement was 20 liters/min. This increase

in the PEFR values of Group 1 over group 2 was

statistically significant (p


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As seen in Graph 3, ACQ score on day 1 and day 8

of both the groups were reviewed and the symptoms

of Asthma had reduced significantly in both groups

on day 8 (p


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14. Jennifer Pryor, S Ammani Prasad;Pulmonary

Rehabilitation in Chronic Respiratory disease;

Physiotherapy for Respiratory and Cardiac

Problems- Adults and Pardiatrics; Fourth Edition;

Chapter 13; pg no 453

15. Van der Schans et al; 1995; Mouth pressures

during pursed lip breathing. Physiotherapytheory and Practice 11: 29- 34

16. Mueller RE et al, 1970; Ventilation and arterial

Blood gas changes induced by Pursed lip

breathing. Journal of Applied

Physiology28(6):784-789

17. Ingram RH et al; Effect of Pursed lip expiration

on the pulmonary pressure flow relationship in

obstructive lung diseases; Am Rev Respir Dis

1967; 96:381-88

18. Martin JG et al; Effect of continuous positive

airway pressure on respiratory mechanics and

pattern of breathing in induced asthma; Am Rev

Respir Dis 1982; 126: 812-17

19. Wilson BA et al; Effects of positive end expiratorypressure breathing on exercise induced asthma;

Int J Sports Med 1981;2:27-30

20. Groth S et al; Positive expiratory pressure(PEP

mask) physiotherapy improves ventilation and

reduces volume of trapped gas in cystic fibrosis;

Bull Eur Physiopathol Respir 1985; 21:339-43


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PLB Kombinasi Salbutamol 2014

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