The Effect of Autogenic Training with Pursed Lips Breathing to

Anxiety and Forced Expiratory Volume in One Second (FEV

) COPD

Patients

Titik Agustiyaningsih

, Muhammad Amin

and Makhfudli

Departement of Nursing, Faculty of Health Science, University of Muhammadiyah Malang, Jalan Bendungan Sutami 188,

Malang, Indonesia 65145

Faculty of Nursing, Airlangga University, Jalan Mulyorejo Surabaya, Indonesia 60115

Keywords: Autogenic training, relaxation, pursed lips breathing, anxiety, FEV1, and COPD.

Abstract: COPD patients will experience increased airflow resistance, air trapping, and pulmonary hyperinflation. This

condition causes a decrease in FEV1 and symptoms of shortness will occur earlier. The purpose of this study

was to explain the effect of autogenic training with pursed lips breathing on anxiety and FEV1 of COPD

patients. This research used Quasy Experiment with Pre-Post approach of control group design. The

population of this research were PPOK patient in RSUD Kanjuruhan Kepanjen Malang Regency and RST

dr.Soepraoen Malang. Sampling was done by Simple Random Sampling technique according to inclusion

criteria with total of 40 patients. The autogenic training intervention with pursed lips breathing had done 3

times a week for 4 weeks. So the total exercise as much as 12 times. Instruments used to measure anxiety are

Zung-Self Rating Anxiety Scale (SAS / SRAS) and FEV1 using spirometry. Data analysis using Paired t test,

Wilcoxon and Multivariate Manova test. Multivariate test result Manova got significance value 0,021 (α 0,05).

This means that autogenic training with pursed lips breathing is effective in reducing anxiety and increasing

the value of FEV1 in COPD patients. Autogenic training with pursed lips breathing can reduce anxiety and

increase FEV1 values if done regularly.

1 INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) is a

disease that causes increased airflow resistance, water

trapping, and pulmonary hyperinflation. The

condition of pulmonary hyperinflation will cause

mechanical inspiratory loss of the muscle resulting in

increased ventilatory imbalances in breathing,

strength and ability of the breathing effort to meet the

tidal volume. Respiratory CPR patients become rapid

and muscle fatigue diaphragm occurs, this is due to a

decrease in blood flow to muscle and muscle

weakness that causes increased anaerobic metabolism

which aggravate lung work and support the

occurrence of activity limitations. This condition will

cause a decrease in Forced Expiratory Volume in One

Second (FEV1) (GOLD, 2017) . As a result of a

decrease in FEV1 it will affect the degree of severity

or severity in people with COPD characterized by

symptoms of shortness of breath so that this causes

the patient COPD experience anxiety (Vestbo et al.,

2013).

Research conducted by researcher in RSUD

KanjuruhanKepanjen Malang Regency got data from

Respiratory clinic average every year treat 360-400

patient COPD and in RST Soepraoen mean every

year treat 250-300 patient COPD. Results of

interviews on 20 patients found that the patient is an

active smoker and experienced shortness of breath

such as choking and cough with phlegm. These

symptoms make 11 out of 20 patients experience

anxiety if the disease does not heal and fear of death.

This phenomenon indicates the presence of self-care

requests in patients with COPD who experience

deficits in taking care of themselves as a result of

various symptoms that arise as a manifestation of

COPD disease. One role of nurses in the management

of COPD patients is to do supportive educative

associated with pulmonary rehabilitation of one of the

autogenic training techniques with pursed lips

breathing to reduce anxiety and increase the value of

FEV1. The combination of these two techniques has

Agustiyaningsih, T., Amin, M. and Makhfudli, .

The Effect of Autogenic Training with Pursed Lips Breathing to Anxiety and Forced Expiratory Volume in One Second (FEV1) COPD Patients.

DOI: 10.5220/0009121200530059

In Proceedings of the 2nd Health Science International Conference (HSIC 2019), pages 53-59

ISBN: 978-989-758-462-6

never been done in RSUD KanjuruhanKepanjen

Malang Regency and RST Soepraoen Malang.

2 METHODS

This research used Quasy Experiment with pre-post

test control group design. The population of the study

were COPD patient in RSUD KanjuruhanKepanjen

Malang and RST dr.Soepraoen Malang. Sampling

was performed by simple random sampling with total

of 40 respondents divided into 2 groups (treatment

group and control group). The study protocol has

passed the ethical test with "Ethical Approval" No.

625-KEPK. The autogenic training intervention with

pursed lips breathing had done 3 times a week for 4

weeks. So the total exercise as much as 12 times. Prior

to the exercise, respondents were given first modules

and videos that serve as a guide in carrying out the

exercise. Pre test (measurement of anxiety and FEV

)

performed in the first week and post test (anxiety

measurements and FEV

) was performed in the fourth

week at the time the patient controls to the pulmonary

poly. Instruments used to measure anxiety are Zung-

Self Rating Anxiety Scale (SAS / SRAS) and FEV

using spirometry. Statistical test using Paired t test,

Wilcoxon and Multivariate Manovatest.Wilcoxon

test results obtained p value 0,000 for the anxiety

variable and FEV

treatment group. This means that

there is an effect of autogenic training with pursed

lips breathing on anxiety and FEV

in the treatment

group. While in the control group, paired t-test results

obtained p 0,081 for anxiety variable and Wilcoxon

test results obtained p 0.195 for variable FEV

. So it

can be concluded that there is no difference in pre and

post values of anxiety and FEV

variables in the

control group. Multivariate Manova test results

obtained significance value of 0.021 (α 0.05). This

means that autogenic training with pursed lips

breathing is effective in reducing anxiety and

increasing the value of FEV

in COPD patients.

3 RESULTS AND DISCUSSION

Based on table 1 shows that the characteristics of

respondents by age, most respondents have age 56-65

years as many as 26 respondents (65%).

Characteristics of male gender is more than female

that is 36 respondents (90%). Characteristics of

education, the highest number of respondents is the

primary education of 13 respondents (32.5%).

Characteristic of the work, most of the respondents

are sales there are 15 respondents (37.5%). Most

respondents for IMT mostly enter the normal

category as many as 36 respondents (90%), for

GOLD-based characteristics mostly GOLD 2 entry as

many as 15 respondents (37.5%) and respondents

mostly have a smoking history of 35 respondents

(37.5% ). Based on homogeneity test, it was found

that the characteristics of age, sex, education,

occupation, BMI, GOLD and smoking history

showed homogeneous (p> 0,05).

Table 2 shows that after the data analysis test

using wilcoxon test in the treatment group obtained p

0,000 which means there is influence of autogenic

training with pursed lips breathing to anxiety. In the

control group after test data analysis using paired t

test (α 0.05) obtained p 0.081 which means there is no

difference in pre and post anxiety values in the control

group.

Table 3 shows that after test data analysis using

wilcoxon test in the treatment group obtained p 0,000

which means there is influence of autogenic training

with pursed lips breathing against FEV1. In the

control group after the data analysis test by using the

test wilcoxon test obtained p 0.195 which means there

is no difference in pre and post FEV1 values in the

control group.

Table 4 shows that the individual variance-

covariance equation testing for each variable shows a

Box Test value of 0.590 which means that the

variance-covariance of all variables is the same for

each group, so that in decision-making the statistical

test results can be seen in Wilks' Lambda. Levene test

on each variable shows p> 0,05 means variant of

anxious and FEV1 variables respectively are

homogeneous between treatments. Manova test

results showed a significance value of 0.021 (α 0.05)

indicating that there was an average difference

between anxiety and FEV1 values in the treatment

group and control group. This suggests that there is

simultaneously an effect of autogenic training with

pursed lips breathing in COPD patients.

The results showed that there was an effect of

autogenic training (AT) with pursed lips breathing

(PLB) to the anxieties of COPD patients. Based on

the mean of pre test and post test, most of treatment

group experienced decrease of anxiety level after

giving AT with PLB. The decrease in anxiety levels

is characterized by decreased anxiety symptoms in

most treatment group patients. In the control group

the average level of anxiety did not change.

Based on the results of multivariate manova test,

it is known that the Partial Eta Squat value is higher

in the anxiety variable when compared with the FEV1

variable. This suggests that autogenic training with

HSIC 2019 - The Health Science International Conference

pursed lips breathing has a greater effect in

decreasing anxiety.The results of this study are in line

with other studies that show that AT affects anxiety.

The results of Kwon (2009) reported that AT is

effective in reducing stress levels in pregnant women,

according to a study by Murakami et al. (2006) AT

supports the development of mental energy to create

a positive self-image and self-efficacy and reduce

anxiety levels in patients. Goto et al (2012) also

reported that AT reduces anxiety in patients with

chronic subjective headaches. A meta-analysis of

experimental studies showing AT has a positive effect

for relieving stress in seven cases out of eight.

Table 1: Distribution of frequency based on the characteristics of respondents.

Characteristic Group Total %

p value

Treatment Group

(n=20)

Control Group

(n=20)

F % F %

Age

Age 46-55 years

Age 56-65 years

Age> 65 years

Gender

Male

Female

Education

Elementary School

Junior High School

Senior High School

College

Work

Unwork

Veteran

Farm

Trader

Teacher

Entrepeneur

IMT

≤ 18,5 (kg/m

)

18,5 – 24,9 (kg/m

)

25 – 24,9 (kg/m

)

≥ 30 (kg/m

)

GOLD

FEV1≥80%

50%≤ FEV1< 80%

30%≤ FEV1< 50%

FEV1 < 30%

Smoke

1. Smoke

2. Do not smoke

32,5

7,5

17,5

37,5

2,5

12,5

37,5

17,5

87,5

12,5

0,513

1,000

0,532

0,528

0,728

0,146

0,633

The Effect of Autogenic Training with Pursed Lips Breathing to Anxiety and Forced Expiratory Volume in One Second (FEV1) COPD

Patients

Table 2: The results of normality test data of each group on anxiety variables.

Variables Group Pre-test

(Mean±SD)

Min-

Maks

Post-test

(Mean±SD)

Min-

Maks

Δ P

value

Anxiety Treatment 45,75±7,166 31 - 67

36,80±8,58 26 - 64 -8,95 0,000

Control 40,75±9,9

25 - 63 45,05±11,3 28 - 65 4,3 0,081

Table 3: The results of normality test data of each group on FEV

variables.

Variables Group Pre-test

(Mean±SD)

Min-

Maks

Post-test

(Mean±SD)

Min-

Maks

Δ P

value

FEV

(liter)

Treatment 0,9925±0,36127 0,59-2,01 1,148±0,4453 0,65-2,19 0,155 0,000

Control 0,8850±0,45041 0,49-2,51 0,8730±0,4800 0,48-2,51 0,0120 0,195

Table 4: The result of multivariate autogenic training with pursed lips breathing in treatment group and control group.

Variabel

N Box Test p value

Box M F df1 df2 Levene Manova

Anxiety 20

0,590 0,639 3 2,599

0,155

0,021

FEV

20 0,826

In this study, it was found that the level of stress

response in the experimental group was lower than in

the control group. This shows that the AT program

has a positive effect on the ability of nursing students

to cope with stress. In line with research conducted

by Lim et al (2015) AT provides an acceptable

approach to stress reduction in nursing students, but

no significant interactions were found for objective

indicators of heart rate variation. COPD patients,

clinically depressed and at least twice as likely to

experience prolonged anxiety. Anxiety in patients

with COPD would be associated with increased risk

of exacerbations, worse health status associated with

quality of life of the patient, worsening of the patient's

condition causing the patient to be hospitalized

(Coventry et al., 2013). Other symptoms commonly

experienced by COPD patients other than anxiety and

depression are emotional unstable, low coping

strategies, feelings of helplessness, feelings of

powerlessness, loss of freedom, social isolation and

disturbance in relationships with others. The

prevalence of anxiety in COPD patients is 10-50%,

whereas the prevalence of COPD depression is 12-

50% (Cleland, Lee, & Hall, 2007).

One of the interventions that can be performed on

COPD patients is to provide education, rehabilitation

and relaxation programs by carrying out breathing

exercises to achieve controlled ventilation, efisisen

and reduce respiratory work. PLB is a therapy that

can be done in the lung rehabilitation program

performed during the activity or at rest that gives

impact to reduce symptoms and improve the quality

of life of patients with COPD (Rossi et al., 2014). The

PLB improves expiration by increasing the expiratory

phase and preventing the prolapse of the airway. PLB

is a technique that can be used to help breathe more

effectively, allowing it to get the needed oxygen. PLB

train to exhale more slowly, so that breathe easier and

comfortable at rest or activity. Breathing with PLB

will increase pressure in the oral cavity, this pressure

will be passed through the bronchial branches so as to

prevent water trapping and small airway collapse

during expiration. Increased pressure on the oral

cavity and pressure is passed through the bronchial

branches so as to increase the value of forced

expiratory volume in one second (FEV1) in COPD

(Smeltzer, S.C.,& Bare, B.G.,Hinkle, J.L.,&Cheever,

2013).

Changes in lung function in COPD patients leads

to decreased ability of patients in performing daily

activities resulting in deficit in self-care. Based on the

Nursing Teory of Self Care Orem (1971) in Alligood,

M. R., & Tomey (2014) self care is an act of striving

others to develop the ability possessed to be

developed maximally, so that one can maintain

optimal function. In self-care theory, nursing is

defined as a practice activity that aims to mature

people in maximizing the health function they have.

One role of nurses in the management of COPD

patients is to do supportive educative related to

pulmonary rehabilitation of one of the PLB

techniques and AT training.

This PLB breathing exercise will be combined

with relaxation techniques to reduce anxiety and

increase the confidence of COPD patients. According

HSIC 2019 - The Health Science International Conference

to (Cafarella, Effing, Usmani, & Frith, 2012) there are

various relaxation techniques that have been known

and widely used among other guide imagery, yoga,

pilates, taichi, chakra, meditation and autorelaxation

techniques known as Autogenic Training (American

Holistic Nurses’ Association, 2005). Autogenic

Training (AT) is a standard nursing intervention that

has been enrolled in Nursing Intervention

Classification (NIC) and has been used extensively in

nursing orders to address anxiety in various situations

with evidence level I (Ackley, 2008). When

compared to other relaxation techniques, AT is a

simple, easy, and simple relaxation technique that

does not require special clothes or difficult body

styles. AT can be studied easily and can be applied

several minutes a day at the right time even in the

midst of busyness. This technique is performed with

5 standard exercises: feel the extremes of weight and

warm, breathe calmly and regularly, feel the

heartbeat, feel the abdomen warm and head cool and

through the delivery of positive suggestions that

create the effects of psychological relaxation and

ultimately anxiolytic effects (Vidas, Folnegović-

Šmalc, Čatipović, & Kisić, 2011). Autogenic

Training with Pursed Lips Breathing against FEV1 of

COPD patients.

The results showed that there was an effect of AT

with PLB on FEV1 of COPD patient. Based on the

pretest and post test values, the treatment group

experienced a significant increase in FEV1 values

after intervention rather than the control group.

Increased FEV1 was characterized by an increase in

FEV score on pulmonary function examination using

spirometry.

AT performed in this study combined with PLB

from the results of research conducted by Bhatt et al

(2013) found that after applying the PLB, the patient

will experience an increase in exercise capacity.

Patients revealed a decrease in dyspnea and RR

frequency. Respiratory control during the PLB period

causes an interrupts visious cycle in air trapping. This

occurs because of lower central nervous transmission

and causes less dissociation between actual ventilator

signals and perceived effort, resulting in lower

perceived dyspneu perception. The breath control

technique with PLB can increase 20% FEV

and

FVC, as well as reduce water trapping. Reduction of

hyperinflation is due to a decrease in tidal volume.

Decreased respiratory frequency also occurs due to

adjustment of perfusion and ventilation time (VA /

Q).

The results of this study are also in line with

research conducted by EkoSuryantoro that the PLB or

six minutes walk test are equally able to increase the

value of FEV

. However, there was no significant

difference in FEV1 value increase between PLB

group and the six minutes walk test group as indicated

by p value 0.117 (p> 0.05). The average in the PLB

group was 12.86 (standard deviation 16.37), while in

the six minutes walk test group was 6.09 (standard

deviation 9.37). Based on the average value of Pursed

Lips Breathing has a greater tendency in increasing

the value of FEV1 than six minutes walk test. This is

because the PLB is more able to train the respiratory

muscles to prolong expiration and increase airway

resistance when expiratory, thus reducing airway

resistance and trapped air, and shortness of breath.

PLB is a breathing exercise by pressing lips aimed

at slowing expiration, preventing collapse of lung

units, and helping patients to control respiratory rates

as well as respiratory depth, so patients can achieve

control of dyspnea and panic (Smeltzer, S.C.,& Bare,

B.G.,Hinkle, J.L.,&Cheever, 2013). Patients with

COPD usually find it difficult to expirate rather than

inspire, as the tendency to close the airway increases

with extra positive pressure in the chest during

expiration (Guyton, A.C & Hall, 2007). Pursing the

lips of the breathing helps the COPD patient to empty

the lungs and slow the rate of breathing. PLB helps to

restore the diaphragm position which is the

respiratory muscle located below the lung. Usually

when the diaphragm inspiration is curved, the lung

expands and the diaphragm moves downward. PLB

also causes the abdominal muscles to contract when

expiratory, this will force the diaphragm upwards,

and help to empty the lungs, consequently COPD

patients will breathe more slowly and more efficiently

(Petty, T. L., Burns, M. & Tiep, 2005) after people

with COPD breathe more slowly and more

efficiently, it is expected that the patient can perform

a maximum expiratory expression as indicated by an

increase in FEV1 values from the spirometry results.

FEV1 represents volume in the first second at

maximum expiration after maximum inspiration and

is a measure of how quickly the lungs can be emptied

(Reid, W. D. & Chung, 2004).

PLB causes increased pressure in the oral cavity,

then this pressure is passed through the bronchial

branches so as to prevent water trapping and small

airway collapse at expiratory time. Improvements in

air trapping will increase the value of FEV

(Smeltzer,

S.C.,& Bare, B.G.,Hinkle, J.L.,& Cheever, 2013).

PLB can decrease shortness of breath, so the

patient can tolerate the activity and improve the

ability to meet daily needs. If this technique is done

routinely and correctly, it can optimize pulmonary

mechanical function, limiting the increased end-

volume of pulmonary expiration and preventing the

The Effect of Autogenic Training with Pursed Lips Breathing to Anxiety and Forced Expiratory Volume in One Second (FEV1) COPD

Patients

effects of hyperinflation (Sheadan, 2006 in Ariestianti

et al, 2014). This is also in line with research

conducted by Pereira De Araujo et al (2015) against

25 patients with COPD who concluded that PLB may

decrease hyperinflation.

The results obtained data that most of the

respondent's age is ≥ 65 years. At that age included in

the elderly category. In the elderly there will be an

aging process characterized by the decline in the

various structures and functions of cells, tissues and

organ systems (Fatmah, 2010). Lung organ in elderly

also decrease function, so at examination of lung

physiology by using spirometry resulted decrease of

FEV

/ FVC and FEV

The results also showed that most of the sexes

were male and had a history of smoking, thus

impacting pulmonary function decline. This is in line

with the statement of the Global Initiative for Chronic

Obstructive Lung Disease that gender and smoking

history are risk factors for COPD in a person (GOLD,

2017). This study is in line with a study by Nisa et al,

2015 which showed that smoking history and male

sex influenced the FEV

/ FVC ratio.

In this study autogenic training with pursed lips

breathing is done regularly with one weekly practice

mentoring, while the second and third exercises of

patients perform independently with family

assistance. The final result of this research is the

increase of FEV1 value in the treatment group. The

increase in FEV

values indicates the patient's success

in self-care.

Based on the data tabulation of FEV

values in the

control group, it was found that 5 respondents also

experienced an increase in FEV

. This is because

doctors and nurses in RST dr.Soepraoen Malang

provide pharmacological therapy and health

education in COPD patients who undergo outpatient

treatment. Education provided in the form of advice

to patients to comply with prescribed medications that

have been made by doctors, the suggestion to quit

smoking, eat with balanced nutrition, not doing too

heavy activities, and suggestions to perform light

activities in accordance with the ability of patients.

The mean difference of mean intervention group

FEV

was greater when compared to the control

group. Most respondents experienced an increase in

FEV

values in the intervention group. This is

because doctors and nurses at RSUD Kanjuruhan

Kepanjen Malang regency provide pharmacology

therapy and health education in COPD patients who

undergo outpatient, besides respondents also get

intensive mentoring program that is training

autogenic training with pursed lips breathing. So it

can be concluded that procedural treatment in

Respiratory Clinic and autogenic training

intervention with pursed lips breathing shows

improvement in one of the lung function that is

increase FEV

4 CONCLUSIONS

Autogenic Training with Pursed Lips Breathing

significantly reduces anxiety and increases forced

expiratory volume in 1 second (FEV

) in COPD

patients.

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The Effect of Autogenic Training with Pursed Lips Breathing to Anxiety and Forced Expiratory Volume in One Second (FEV1) COPD

Patients