The Effect of Walking Exercise and Pursed Lips Breathing on Signs

and Symptoms of COPD Patients: A Systematic Review

Arum Dwi Ningsih, Muhammad Amin and Abu Bakar

Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

Keywords: Walking Exercise, Pursed Lips Breathing, COPD.

Abstract: World Health Organization (WHO) at Global Status of Non-communicable diseases in 2015 explained that

COPD is the 4th largest non-communicable disease in the world. Dyspnea, increased respiratory rate,

decreased oxygen saturation and activity intolerance are typical symptoms in COPD patients. These

symptoms correlate to pulmonary function abnormalities such as impairment of FEV1 and FEV1/FVC. The

condition of the patients will become worse if they don’t get therapy and rehabilitation. The purpose of this

systematic review was to identify research about the effect of walking exercise and pursed lips breathing to

clinical symptoms, lung function, and exercise tolerance of COPD patients. Search articles through

database: Pro quest, Scopus, Science Direct, and EBSCO published between 2007 -2017. There are sixteen

research journals. Based on the search results, found 43 journals. After being selected according to the

inclusion criteria, 16 journals have been reviewed. Eleven journals used pursed lips breathing intervention,

while 5 journals on walking exercise intervention in COPD patients. The application of walking exercise

and pursed lips breathing improved symptoms, lung function, and exercise tolerance in COPD patients. We

suggest to do further research with larger sample quantities, increase exercise frequency and the need for

further monitoring.

1 INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a

pulmonary disease that can lead to exacerbations and

progressive life-threatening (GOLD, 2017). Chronic

Obstructive Pulmonary Disease (COPD) is a chronic

lung disease that causes the limitation of air flow in

the lung causing interference with the lung function.

Decreased lung function occurs due to chronic

inflammatory changes in the proximal, peripheral

and pulmonary vascular channels. This condition

results in decreased ventilation function in the lung,

and the patient will experience an increase in

breathing frequency with expiratory length(Black

and Hawks, 2014).

World Health Organization (WHO) in Global

Status of Non-communicable Diseases 2015

explains that COPD is the fourth major non-

communicable disease in the world that has high

mortality after ischemic heart disease, stroke and

lung cancer. Globally, an estimated 3 million deaths

are caused by this disease in 2015 ie, 5% of all

deaths worldwide in that year. More than 90% of

COPD deaths occur in developing countries with a

weak economic level(WHO, 2017).

Shortness of breath and activity intolerance are

major complaints in COPD patients. The shortness

of breath in COPD patients is progressive,

irreversible, and lowers tolerance in activity. The

presence of inflammation, fibrosis, and luminal

exudate in the respiratory tract associated with

decreased FEV1 and FEV1/FVC ratios. Decreased

FEV1 is a characteristic symptom of COPD,

peripheral respiratory tract obstruction causes air

trapped and leads to hyperinflation. Hyperinflation

reduces the inspiratory capacity of functional

residual capacity, especially during exercise

(dynamic hyperinflation), seen as dyspnea and

limited exercise capacity. Hyperinflation that

develops early in the disease is the main mechanism

of the onset of dyspnea (GOLD, 2017).

Pulmonary function in patients with COPD will

get worse if the therapy and rehabilitation are not

well done. COPD patients will experience an

exacerbation and result in respiratory failure.

Patients will also experience complications of heart

function abnormalities. Therefore, it requires the

Ningsih, A., Amin, M. and Bakar, A.

The Effect of Walking Exercise and Pursed Lips Breathing on Signs and Symptoms of COPD Patients: A Systematic Review.

DOI: 10.5220/0008324002870291

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 287-291

ISBN: 978-989-758-336-0

287

management of therapy and treatment of complex

rehabilitation in order to improve the lung function

of COPD patients. Rehabilitation therapy for COPD

patients that can be applied to improve lung function

is to control breathing Pursed Lips Breathing (PLB).

Pursed Lips Breathing (PLB) is a ventilation

maneuver technique by pursing lips during

expiration (Spahija et al., 2010). Breathing exercises

are performed to get better breathing arrangements

from quicker and shallower breathing to slower and

deeper breathing. The purpose of this exercise is to

reduce and control shortness of breath.

Another therapy that can be done for the

rehabilitation of COPD patients is by doing light

exercise. Mild exercise gradually in COPD patients

can improve exercise tolerance, as well as decrease

dyspnea and fatigue. One form of mild exercise

recommended for activity therapy is walking

exercise. The purpose of this study was to conduct a

systematic review of walking exercise and pursed

lips breathing on clinical symptoms, lung function,

and exercise tolerance of COPD patients.

2 METHODS

In this study, the authors identified the journal

publication of research results on the use of walking

exercise and Pursed Lips Breathing in patients with

COPD. The results of this systematic review is

expected to be applied to health services, especially

nursing. This systematic review is presented in the

form of article consisting of; abstract, introduction,

method, result and discussion, conclusion, and

bibliography.

Search articles using PICOT framework

(Population: COPD patient in criteria of GOLD I, II,

III, and IV with stable condition, Intervention:

Pursed Lips Breathing and walking exercise,

Control: -, Outcome: Clinical symptoms, Pulmonary

function, and Exercise Tolerance, Time: 2007 -

2017, based on the keywords determination of

walking exercise, pursed lips breathing, and COPD.

No other restrictions were used to maximize

literature search. Database search results; Ebscho,

Science Direct, Elsevier, Sage Journals, Scopus,

ProQuest, Pub Med, limited range of 10 years 2007

to 2017 got 43 journals and after further reading, 16

International Journals were chosen to be reviewed.

The literature inclusion criteria was quantitative

research on the use of walking exercise and pursed

lips breathing on clinical symptoms, lung function,

and exercise tolerance of COPD patients with a 10

year limitation (2007-2017). Quantitative research

should meet the criteria of PICOT.The population

used was the COPD patients with the criteria of

GOLD I, II, III, and IV. The patients were stable and

were not undergoing an acute exacerbation.

Intervention used in the form of walking exercise or

pursed lips breathing. Comparison in this study

consisted of at least 1 group of intervention groups

or groups of placebo and intervention, outcomes

produced were clinical symptoms, pulmonary

function, and exercise tolerance. All studies used

English. From all journals, there were 43 journals

and after further election 16 International Journals

were chosen to be reviewed.

Figure 1: Searching Strategy

3 RESULTS

Based on the results review of 16 journals, the data

were collected from United Nation of America for 2

journals, Canada for 2 journals, North Korea for 1

journal, Italia for 1 journal, Brazil for 3 journals,

India for 1 journal, Netherlands for 3 journals,

Germany for 1 journal, and Sweden for 1 journal.

Total of all respondents in the literature were 539

respondents. The research design consisted of 5

Searching articles using PICOT framework

Population : COPD patients with the criteria of

GOLD I, II, III, and IV

Intervention: Walking Exercise and Pursed Lips

Breathing.

Control: -

Outcomes : Clinical symptoms, Pulmonary

function, and Exercise Tolerance

Time : 2007-2017

Search the journal through Boolean Logic in

database; Ebscho, Science direct, Elseiver, Sage

Journals, Scopus, ProQuest , Pub Med

Number of the journals found

(n = 43)

Journals that

do not fit the

criteria

Appropriate

Journal Criteria

(n = 16)

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

288

journals with Randomized control trial, 9 journals

Randomized cross over study and 2 journals cross

sectional study.

Based on 16 journals reviewed, there were 5

journals using walking exercise and 11 journals

using pursed lips breathing in patients with COPD.

Pursed Lips breathing is a breathing technique for

breathing for 2 seconds through the nose with the

mouth closed, then slowly releasing air for 4-6

seconds with a conical mouth (Bhatt et al., 2013).

Respiratory technique is done by various methods.

There were 6 journals that apply pursed lips

breathing during exercise. 6 journals applied the

PLB when the patient is rested and relaxes with

duration of 10 minutes. 1 journal applied PLB at the

time of recovery after light exercise. 1 journal

applied PLB with a combination of mouth taping,

and 1 journal applied PLB in 3 different positions

i.e. PLB applied with neutral sitting position, arm

support position, or arm and head support position.

From the results of those journals’ review,

walking exercise was applied with several methods.

Research conducted by Gagnon, P., et al, applied

walking exercises by performing a warm-up phase

for 90 seconds, followed by a casual walking

exercise in open areas and flat floors. The walk was

10 meters (Gagnon et al., 2012).

Research conducted by Roos, P., et al. applied

exercise training and home base walking program

for 10 weeks. Exercise training was carried out by

applying treadmill and cycling program for 10

minutes and the patient was educated to apply home

based walking exercise at least 30 minutes per

session, at least once a week, and exercise time was

added 5 minutes per week(de Roos et al., 2017).

Research conducted by Dreher, M., et al.,

applied 6 MWT and Stair-climbing in the hospital

area (Dreher et al., 2008). This is similar to a study

conducted by Vaes, Anouk., Et al., which

implemented 6 MWT by comparing walking with a

collator and modern drainage(Vaes et al., 2012).

Research conducted by Leung, Regina W. M. et al.,

applied walking exercise at the hospital for 8 weeks.

The exercise performed 3 times per week with

exercise duration of 30 to 45 minutes per session

(Leung et al., 2010).

The clinical symptoms analyzed by this

systematic review consisted of dyspnea, respiratory

rate (RR), and oxygen saturation (SaO2). RR

measurements were done manually, whereas to

assess oxygen saturation using pulse ox-meter.

Measurement of dyspnea was by using instrument in

the form of questionnaire. There were 2 journals that

assessed dyspnea with Visual Analog Scale (VAS),

3 journals with mMRC Dyspnea Scale, 6 Journals

with Borg Scale dyspnea, 1 journal with BDI Scale,

and 1 journal with Chronic Respiratory Disease

Questionnaire Dyspne Scale. Pulmonary function in

the results of the study was measured using a

spirometer.

There were several measurements to measure the

exercise tolerance of COPD patients i.e. 2 journals

using 6 MWD test, 2 journals with Endurance

Shuttle Walking Test, 1 journal with 6 MWT test, 1

journal with walking test treadmill, 1 journal with

physical function scale, 1 journal with ISWT , 1

journal with ESWT and 1 journal with Personal

Activity Monitor (PAM).

The results of the journal analysis showed that

walking exercise and pursed lips breathing provide a

positive impact on the improvement of clinical

symptoms, lung function and exercise tolerance.

There were 6 journals for the improvement on

shortness of breath symptom, 6 journals decreased

RR, and 5 journals for increased oxygen saturation.

In addition, the improvement of lung function was

looked significant.

There were 2 journals of FEV1 grade upgrades, 2

FVC value improvement journals, 2 PEFR score

improvement journals, 1 FEV1 / FVC grade

improvement journal and 2 TV value refining

journals. Interval walking exercise and pursed lips

breathing significantly had a positive impact on

exercise tolerance; as many as 9 journals have

improved exercise tolerance in the respondents.

4 DISCUSSION

This systematic review identified one of breathing

techniques that was pursed lips breathing (PLB) and

light exercise that was walking exercise applied to

COPD patients. Identification was aimed at

reviewing the benefits of applying pursed lips

breathing and walking exercise to clinical

symptoms, lung function and exercise tolerance.

Based on the study of 16 journals, it was known that

there were 12 journals which reviewed the benefits

of pursed lips breathing and walking exercise on the

change of clinical signs and symptoms of COPD

patients. There were improvements in oxygen

saturation, respiratory rate and dyspnea scale of

COPD patients.

Study conducted by Bhatt, et al., found that after

applying Pursed Lips breathing, patients would

experience increased exercise capacity. Patients

revealed decreased dyspnea, and RR frequency.

Respiratory control during the pursed lips breathing

period caused decreased vicious cycle interrupts in

air trapping. This occurred because of lower central

nervous transmission, and leaded to a lower

dissociation between actual ventilator signals and

The Effect of Walking Exercise and Pursed Lips Breathing on Signs and Symptoms of COPD Patients: A Systematic Review

289

perceived effort, resulting in lower perceived

dyspnea perception (Bhatt et al., 2013).

Based on research conducted by Leung et al., it

was known that the grand walk training could reduce

dyspnea and Respiration Rate (RR). In addition, this

exercise could reduce the production of carbon

dioxide, and increased minute ventilation when

compared to basic data. Reduction of carbon dioxide

and minute ventilation could increase the oxidative

capacity of trained muscles with walking exercise,

thereby reducing dyspnea (Leung et al., 2010).

Based on the results of 16 journals review, it was

known that there were 4 journals of research which

proved that pursed lips breathing and walking

exercise gave advantage towards lung function

improvements, namely FEV1 (%), FVC, PEFR and

FEV1 / FVC. This breathing technique used a

second pursing strategy lips together during exhale.

Thus, the airways became exposed, with respiratory

pressure back and air emptying process when

expiration became better (Maind et al., 2015).

In a study conducted by Bhatt, et al, found that

the breath-control technique with pursed lips

breathing increased 20% FEV1 and FVC, and

reduced water trapping. Reduction of hyperinflation

was due to an increase in expiratory volume

resulting in an increase in tidal volume. Decreased

respiratory frequency also occurred due to

adjustment of time perfusion and ventilation (VA /

Q). In addition, by doing Walking exercise, it could

improve the efficiency and capacity of the oxygen

transport system, increased VO2 max, improved

aerobic and anaerobic work capacity, increased

cardiac output and stroke volume, increased blood

distribution efficiency and shortened recovery time

(Bhatt et al., 2013).

Based on the results of 16 journals review, it was

known that there were 9 journals of research which

proved that pursed lips breathing and walking

exercise gave advantage against improvement of

exercise tolerance in COPD patients. Physical

exercise in people with COPD resulted in increased

exercise tolerance due to increased maximum work

capacity with low oxygen consumption. Improved

exercise tolerance was an indication of the efficient

use of oxygen in the tissues and tolerance of lactic

acid. Based on research conducted by de Roos, et al,

it was known that the combination of exercise

training and home based walking program could

improve Physical activity (PA). Patients who had an

increased level of exercise tolerance, then the use of

peripheral oxygen could be efficient (de Roos et al.,

2017).

Walking exercise and pursed lips breathing

performed regularly can improve clinical signs and

symptoms, lung function and physical activity of

COPD patients. This is because by doing this

exercise, the patient is able to increase expiratory

strength characterized by increased FEV1, as well as

tidal volume improvement. So that the perfusion of

ventilation to the maximum and the activity

tolerance for the better.

5 CONCLUSIONS

Systematic review on Evaluation for the Effect of

Walking Exercise and Pursed Lips Breathing on

Clinical Symptoms, Lung Function and Exercise

Tolerance of COPD Patients found that the

application of pursed lips breathing and walking

exercise techniques could provide positive

improvement in COPD patients. This was certainly

very effective if applied to COPD patients, since

lung damage was not completely reversible, so it

was important to keep patients in stable condition

and prevent exacerbations.

The nursing implication of this systematic review

was improving the health of COPD patients.

Walking exercise and Pursed lips breathing could be

applied in nursing care in patients with COPD. This

could be included in the nursing care plan by

conducting health education to the patient, that was

about how to do walking exercise and pursed lips

breathing and its benefits to COPD patients. Nurses

could evaluate the successful implementation of

walking exercise and pursed lips breathing and its

clinical effects.

The lack of this systematic review is on the

criteria of research journals, ie not having uniformity

in terms of research methods. The journal in this

study revealed that the research method did not

always use the control group as a comparison.

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