KARNATAKA, BANGALORE.
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION1 / Name of the candidate
and Address / SHAH HETSHRI MUKESHKUMAR
SRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTRE,PANDESHWAR,
MANGALORE-575001.
2 /
Name of the Institute
/ SRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTRE, MANGALORE.3 /
Course of study and
Subject / Master of Physiotherapy (MPT)2 years Degree Course.
“Physiotherapy in Cardio – Respiratory diseases and intensive care”
4 /
Date of Admission
To course / 03/06/20095 /
Title of the Topic
/ “Effects of Various Body Positions on Pulmonary Functions and Peak Expiratory Flow Rate (PEFR) in Patients with Chronic Obstructive Pulmonary Disease (COPD)”6.
7. /
Brief resume of the intended work:
6.1 Need for the study:COPD is a disease state characterized by poorly reversible airflow limitation that is usually both progressive and associated with an abnormal inflammatory response of the lung.(1)
The obstruction is generally progressive, may be accompanied by hypersensitivity and may be potentially reversible. (2)
The pathological hallmarks of COPD are obstruction of the lung parenchyma (emphysema), inflammation of the peripheral airways (bronchiolitis) and inflammation of the central airways (chronic bronchitis). The functional limitation of these abnormalities is expiratory airflow limitation.(3)
Patients with COPD show an ongoing cough that produces large amount of mucus, shortness of breath specially with physical activity, wheezing and chest tightness. Severe COPD patients may also have swelling in legs ,feet or ankles , bluish color of lips .(4)
Patients also show reduced inspiratory muscle strength (5) and respiratory complications such as infections which are common in patients who are predisposed to secretion retention such as chronic airway limitations.
Adequate clearance of airway secretions is an essential component of defense mechanism of the respiratory tract against infection, (6) and for that physical therapists depend on the principles of body positioning and gravity dependent bronchial drainage.(7)
Performance of cough and huff by patients is influenced by lung volumes, sensitivity of airway reflexes and the patient’s state of mind.(8,9)
To maintain hygiene of the respiratory tract there is a necessity to formulate techniques for COPD.
Subjects with COPD often show limitation in their ability to carry out their daily living activities due to shortness of breath. Therefore the integral part of physical therapy treatment for patients with COPD often involves recommending optimal patient position to maintain pulmonary functions and PEFR and patient position may affect the length of abdominal muscles that could alter their capacity for active expiration.(10)
Body positions have been shown to affect lung volumes and respiratory muscle biomechanics. .More the upright position, higher the maximal expiratory pressure and flow. (11)
Forced expiratory volumes are higher in standing position as compared to the sitting position.(12)
In healthy subjects spirometric values are higher in standing position compared with sitting position.(13)
According to one study, commonly measured indices of respiratory functions were not different in the tripod position compared to sitting and supine positions.(14)
Another study suggests that the seated leaning forward position is the optimum posture for the patients to generate maximum inspiratory pressures and to obtain greatest subjective relief of dyspnoea.(15)
Many authors have suggested multimodal approach for effects of various body positions on pulmonary functions. But still, there is no concrete evidence for the most effective body position in patients with COPD to maintain hygiene of the affected lung.
So this study aims to see the effect of various body positions on pulmonary functions and PEFR in patients with COPD and to find out which position is more superior.
6.2 Review of Literature:
1. S P Bhatt et al (2009) did study on effect of tripod position on objective parameters of respiratory function in stable COPD and found no difference in commonly measured indices of respiratory functions in tripod position as compared to sitting and standing positions. (14)
2. Ebrahim Razi et al (2007) did a study on the effect of positioning on spirometric values in obese asthmatic patients and found no effects of standing and sitting positions on spirometric values in obese asthmatic patients with BMI ≥ 30.(16)
3. Domingos et al (2004) did study on spirometric values in obese and non obese subjects on orthostatic sitting and supine positions and found decrease in spirometric values in supine position as compared to sitting and standing positions.(17)
4. Charbel Badr et al (2002) did an experimental study on the effects of body position on maximal expiratory pressure and flow and concluded that the more upright the position , the higher the MEP and PEFR.(11)
5. Fiona Manning et al (1999) did a study on effects of side lying on lung function in older individuals and found that side lying positions resulted in decrease in FEV1 and FVC, which is consistent with the well documented effects of the supine position and this result supports to the idea that the body position has a profound effect on lung function and respiratory mechanics.(18)
6. Lapier et al (1999) did preliminary study on effect of sitting and standing position on pulmonary function in patients with COPD. They found that sitting position with upper extremities fixed may enhance pulmonary function at rest or during exercise as compared to standing position. This suggested that position affects the force generating capacity of the respiratory muscles in patients with COPD.(10)
7. Lalloo U G et al ( 1991) did study on effect of standing versus sitting position on spirometric indices in healthy subjects and found higher spirometric indices in the standing position as compared to sitting position.(13)
8. I.E.Haffejee et al (1988) did a study on effect of supine posture on PEFR in asthma and found significant drop in the PEFR readings in supine position in asthmatic children, this reverted back to baseline levels on assuming an upright posture at the end of the test.(19)
9. Elizabeth Dean (1985) did study on effect of body position on pulmonary function and found that the V/Q matching can be directly manipulated by patient positioning and warrants being considered as a treatment to improve respiratory gas exchange in patients with respiratory disease or who may be at the risk of developing pulmonary complications.(7)
10.Townsend MC ( 1984) did study on spirometric forced
expiratory volumes measured in the standing versus sitting
posture and found slight but significant higher forced expiratory
volumes in standing posture as compared to sitting posture.(12)
11.S O’ Neill et al (1983) did an experimental study on postural
relief of dyspnoea in severe chronic airflow limitation:
relationship to respiratory muscle strength and concluded that
the seated leaning forward position is the optimum posture for
the patients to generate maximum inspiratory pressures and to
obtain greatest subjective relief of dyspnoea.(15)
12.BARACH AL (1974)did study on postural relief of dyspnoea
and found that minute ventilation and accessory muscle
recruitment are less in supine and forward leaning positions as
compared to the erect positions in patients with COPD.(20)
6.3 Objective of the study:
1. To find out the effects of various body positions on pulmonary functions and PEFR in patients with COPD.
2. To find out most superior and effective body position to maintain pulmonary function in COPD patients.
6.4 Hypothesis:
Experimental hypothesis:
There will be significant change, in pulmonary function and PEFR in case of COPD patients, with different body positions.
Null Hypothesis:
There will not be significant change in pulmonary function and
PEFR in case of COPD patients due to different body positions.
Materials and method:
7.1 Source of data
Patients diagnosed with mild to moderate COPD based on GOLD criteria by the physician in :
a) Swapn healthcare hospital pvt ltd.
Isanpur
Ahmedabad
b) Pathik medical nursing home
Paldi
Ahmedabad
7.2 Method of data collection
The subjects diagnosed with mild to moderate COPD based on GOLD criteria, who will fulfill inclusion criteria. The sample size will be 30.
Sampling
Purposive sampling
Base line parameters
FVC , FEV1 and FEV1/FVC ratio will be recorded in standing position prior to the testing.
Measurement procedure
Written consent will be taken from the patients. The procedure will be explained to them.
If subjects are on medication, they will be asked to take their medications 15min prior to the testing.
6 different body positions used in this study will be:
1) Standing
2) Chair sitting
3) Tripod position (14)
4) Long sitting : Upper body forms 900 angle with the
legs
5) Three quarter sitting : upper body forms 1300 angle
with the legs
6) Right side lying
Each subject will be placed first in randomly selected position and will be allowed to take rest for 5 min in each position.
Then subjects will be asked to perform three tests of PEFR with as much as rest desired by the subject between each trial and all pulmonary functions and PEFR will be recorded.
Testing will be terminated if the subject withdraws consent , becomes short of breath , is too tired to continue , can not tolerate the position or is unable to perform the test correctly in that position.
Materials to be used
1)PC based spirometer with MEDI : : SPIRO software
2) Nose clips
3)Peak flow meter
Inclusion Criteria
- Subjects diagnosed with mild to moderate COPD based on
GOLD criteria
- Have FEV1 values less than 80% predicted normal
Values.
Exclusion Criteria
- Any previous thoracic surgery
- Had any predominantly fibrotic lung disease
- Exacerbation 4 weeks prior to the testing
- Had any orthopedic conditions preventing patients to
assume required position
-Any uncontrolled medical condition that precluded safe
participation in the study
-Subjects with co-morbidities such as hyper tension, congestive
heart failure, diabetes mellitus, tuberculosis, inter current
respiratory illness.
Statistical Analysis
Study design - Cross - sectional observation study
Test - ANOVA
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, Please describe briefly.
YES.
This study intends to measure the pulmonary functions and PEFR in COPD patients to see effect of various body positions.
7.4 Has ethical clearance been obtained from your institutions in case of 7.3?
YES
Consent has been taken from Institute of Ethical Committee.
8. / List or references
1. Global Initiative for COPD : A collaborative project of the National health , lung and blood institute , NIH and the WHO , in press.
2. M Gabriel Khan, Joseph P Lynch III : Pulmonary disease diagnosis and therapy
3. Gaziella Turato, Renzo Zuin, Marina Saetta : Pathogenesis and Pathology of COPD. Respiration 2001;68:117-128.
4. COPD signs and symptoms: National heart lung and blood institute.
5. Rochester DF, Braum NMT: Respiratory muscle strength in COPD . A M Rev Respir Dis 1979;119(2):151-4.
6. New House MT and Bienenstock J(1989) : Respiratory tract Defense Mechanisms.In Baum Gl and Wolinsky E (Eds):Textbook of Pulmonary Diseases. Boston: Little, Brown and Co, pp.21-47.
7. Elizabeth Dean. Effect of body position on pulmonary function. Physical Therapy 1985;65(5):613-618.
8. Hardy KA: A review of airway clearance: new techniques ,
indications and recommendations. Respiratory Care 1994;39:440-452.
9. Jenkins S and Tucker B (1998): Patients’ problems,management and outcomes. In Pryor JA and Webber BA(Eds) : physiotherapy for Respiratory and Cardiac Problems (2nd ed.) London: Churchill Livingstone, pp.821-867.
10. LaPier, Tanya Kinney , Donovan Clair: Sitting and Standing position affect pulmonary function in patients with COPD. Cardiopulmonary Physical Therapy Journal, Winter 1999.
11.Charbel Badr, Mark R Elkins and Elizabeth R Ellis:The effect of
body position on maximal expiratory pressure and flow. Australian
Journal of Physiotherapy 2002;48:95-102.
12.Townsend MC: Spirometric forced expiratory volumes measured
in standing versus sitting posture. Am Rev Respir Dis
1984;30(1):123-4.
13.Umesh G.Lalloo , Margaret R.Becklake , Clifford M.Goldsmith.
Effect of standing versus sitting position on spirometric indices in
healthy subjects. Respiration 1991;58:122-125.
14.S P Bhatt , T . K. Luqman –Arafath, A.K.Gupta, A. Moha S.Nanda
and J.C.Stoltzfus; Effect of tripod position on objective parameters
of Respiratory Function in stable COPD : Indian J Chest Dis Allied
Sci 2009;51:83-85.
15.S O’ Neill , DS McCarthy : Postural relief of dyspnoea in severe
chronic airflow limitation :relationship to respiratory muscle
strength. Thorax 1983;38:595-600.
16.Ebrahim Razi, Gholam Abbass Moosavi; The effect of positioning on
spirometric values in obese asthmatic patients. Iran J Allergy
Immunol 2007;6(3):151-154.
17.Domingos-Benicio NC, Gastaldi AC, Perecin JC, Avena Kde
M,Guimaraes RC, Sologuren MJ, et al. Spirometric values of obese
and non-obese subjects on orthostatic,sitting and supine positions.
Rev Assoc med Bras 2004;50(2):142-7.
18.Fiona Manning, Elizabeth Dean ,Jocelyn Ross, Raja T Abboud ;
Effects of side lying on lung function in older individuals. Physical
Therapy;79(5):456-466.
19.I. E .Haffejee; Effect of supine posture on PEFR in asthma.
Archieves of disease in childhood 1988;63:127-129.
20.Barach AL. COPD: Postural relief of dyspnoea. Arch Phys Med
Rehabilitation 1974 :55; 494-504.
9 /
Signature of the Candidate
/10 /
Remarks of the Guide
/11 / Name and Designation of :
11.1 Guide
11.2 Signature / DR. VARGHESE JOHN
Assistant Professor in physiotherapy
11.3 Co-Guide
(If Any)
11.4 Signature / DR. VIJAY PRATAP SINGHAsst. Prof. in physiotherapy
11.5 Head of the Department
11.6 Signature
/DR. T.JOSELEY SUNDERRAJ PANDIAN
Associate professor in physiotherapy and P.G coordinator12 / 12.1 Remarks of Chairman and Principal
12.2 Signature /
Dr. RAMPRASAD M.
Principal and Associate professor in physiotherapy.14