Public Health of Indonesia

Budiono, et al. Public Health of Indonesia. 2017 August;3(3):117-123 ISSN: 2477-1570

http://stikbar.org/ycabpublisher/index.php/PHI/index
Original Research

THE EFFECT OF PURSED LIPS BREATHING IN INCREASING

OXYGEN SATURATION IN PATIENTS WITH CHRONIC
OBSTRUCTIVE PULMONARY DISEASE IN INTERNAL WARD 2 OF
THE GENERAL HOSPITAL OF DR. R. SOEDARSONO PASURUAN
Budiono*, Mustayah, Aindrianingsih

Department of Nursing, Polytechnic of Health Malang, Ministry of Health Republic of Indonesia

Accepted: 5 September 2017

*Correspondence:
Budiono
Department of Nursing, Polytechnic of Health Malang
Ministry of Health Republic of Indonesia | E-mail: budisumodiwiryo@gmail.com

Copyright: © the author(s), YCAB publisher and Public Health of Indonesia. This is an open-access article
distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits
unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is
properly cited.

ABSTRACT
Background: Chronic obstructive pulmonary disease is a leading cause of death and disability. Thus, the
effort to reduce the symptoms, such as dyspnea is necessity. Pursed lip breathing is assumed increasing
oxygen saturation.
Objective: This study aims to determine the effect of pursed lips breathing in increasing oxygen saturation
in patients with COPD in internal ward 2 of the General Hospital of Dr. R. Soedarsono Pasuruan on May 16
- June 30, 2017.
Methods: This was a pre-experimental design with pre-posttest design. There were 24 patients with COPD
selected using simple random sampling technique. Pulse oximetry (oximeter pulse fingertip) was used to
measure oxygen saturation. Data were analyzed using Wilcoxon Sign Rank Test.
Results: Findings showed p-value 0.000 (<0.05), which indicated that there was a statistically significant
difference in oxygen saturation before and after pursed lips breathing.
Conclusion: There was a significant effect of pursed lips breathing on oxygen saturation in patients with
COPD in the internal ward 2 of the general hospital of Dr. R. Soedarsono Pasuruan. Thus, pursed lips
breathing could be applied as a nursing intervention in patients with COPD.

Key words: Pursed lips breathing, COPD, oxygen saturation

BACKGROUND cough, sputum production increases and

Chronic Obstructive Pulmonary Disease wheezing. At a later stage, COPD results in
(COPD) is an irreversible condition in impaired activity tolerance, fatigue, loss of
which airway constriction occurs, appetite, weight loss and disruption of
increased airflow obstruction and loss of sleep cycles.1
lung elastic recoil. The condition causes air Shortness of breath or dyspnea is a
trapped and disturbed gas exchange common symptom in people with COPD.
resulting in the syndrome of dyspnea, The cause of shortness of breath is not only

   
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due to obstruction in the bronchus or people suffering from COPD in the world,
bronchospasm alone, but also due to the with 65 million people suffering from
presence of hyperinflation. This tightness moderate to severe COPD. This disease is
complaint can be overcome by maintaining the leading cause of fifth death in the
adequate ventilation and gas exchange by world. It is estimated that more than 3
changing the lying position, ambulation, million people died of COPD in 2005,
deep breathing exercises and effective which is equivalent to 5% of all deaths
cough to remove mucus.2 globally.5 In Indonesia, the incidence of
One of the deep breathing exercises COPD was ranked fifth of eleven non-
that can be done to reduce dyspnea is by communicable diseases and the prevalence
pursed lips breathing (PLB) technique. of COPD averaged 3.7%.6 The results of
Pursed Lips Breathing is a breathing the non-infectious disease survey by the
exercise that consists of two mechanisms, Directorate General of PPM & PL at 5
namely strong and deep inspiration, and provincial hospitals in Indonesia (West
active and long expiration. PLB helps the Java, Central Java, East Java, Lampung
client to control the breath. Pursed lips and South Sumatra) in 2004 showed that
provide resistance to the air flowing out of COPD was ranked first among the
the lungs, thereby prolonging the contributors (35%), followed by bronchial
exhalation and preventing airway collapse asthma (33%), lung cancer (30%) and
by maintaining positive pressure on the others (2%).7
airway, CO2 in the lung can be removed The results of preliminary study at
and O2 fills more alveoli. High differences the General Hospital of Dr. R. Soedarsono
in the O2 pressure gradient increase gas Pasuruan on November 1, 2016 revealed
exchange, in alveoli to pulmonary that the intervention conducted in patients
capillaries.3 with COPD were by giving oxygen and
Pursed Lips Breathing causes the semi fowler position. There was no pursed
inspiratory muscles to work more lip breathing technique. Thus, regarding
optimally so that the burden on the the phenomena and interventions provided.
inspiratory muscles is reduced. Research This study aimed to examine the effect of
showed that the pattern of PLB Pursed Lips Breathing in increasing
significantly increased tidal volume (TV) oxygen saturation in patients with COPD.
and lowered respiration rate than natural
breathing.4 Increasing the amount of
oxygen that moves to the pulmonary METHODS
capillaries increases the amount of oxygen Design
bound by Hb and can bind SaO2. Oxygen This was a pre-experimental design with
saturation (SaO2) is the ratio of pre-posttest design.
oxygenated hemoglobin (HbO2) level to
hemoglobin in the blood (total HbO2 and Population and Sample
deoxygenated hemoglobin), thus SaO2 The study population was 98 people
increases. Sherwood (2001) suggests that suffering from COPD treated in Internal
increasing PaO2 increases Hb affinity to Room 2 of the General Hospital of Dr. R.
oxygen, and a decrease in the amount of Soedarsono Pasuruan. The sample was 24
CO2 will also increase the affinity of Hb to patients with COPD selected using simple
oxygen and vice versa.4 random sampling technique that met the
According to the World Health specified inclusion and exclusion criteria
Organization (WHO), there are 600 million from 16 May to 30 June 2017.

   
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Intervention Research Instruments
The researcher taught the respondents the To measure O2 saturation, pulse oximetry
pursed lips breathing exercise. After the (oximeter pulse fingertip) was used.
respondents did the intervention correctly
based on the standard of procedure adopted Research Ethics
from Smeltzer & Bare (2007),2 then the Ethical research in this study was obtained
oxygen saturation was measured as pretest from the Ethics Commission of Poltekkes
data. The respondents were given pursed Kemenkes Malang. The study permission
lips breathing intervention approximately was also obtained from the General
15 minutes and a break of 2 minutes. Hospital of Dr. R. Soedarsono Pasuruan.
Intervention was given 3 times a day Informed consent was performed to each
(morning, afternoon and evening) for 4 respondent.
days. Posttest was implemented after 4
days intervention. While the measurement Data analysis
of oxygen saturation based on standard of Univariate analysis was performed in the
procedure adopted from Potter & Perry.8 form of frequency distribution. The
Pursed lip breathing is a breathing statistical test in this study used Wilcoxon
technique designed to make your breaths sign rank test to know the difference of
more effective by making them slower and oxygen saturation before and after
more intentional. The technique of pursed intervention in COPD patients. The data
lips breathing as follows: 1) Sit with back normality test used Shapiro-Wilk analysis
straight or lie down. Relaxing shoulders as to know the normality of data.
much as possible; 2) Inhaling through nose
for two seconds and feeling the air move
into abdomen. Trying to fill abdomen with RESULTS
air instead of just lungs; 3) Purse lips like Characteristics of the respondents
blowing on hot food and then breathe out Table 1 shows that 71% of respondents
slowly, taking twice as long to exhale as were males and 29% of them were
taking to breathe in; 4) Then repeat. Over females.
time, increase the inhale and exhale counts
from 2 seconds to 4 seconds, and so on.9

Table 1. Characteristic of respondents based on gender

Gender f %
Male 17 71
Female 7 29
Total 24 100

Table 2. Characteristic of respondents based on age

N Min Max Mean SD Confident
Interval
24 31 69 57.74 9.939 49.34

Based on table 2, it is known that the years old, and the oldest was 69 years old,
average age of the respondents was 57.74 with standard deviation of 9.939 and
years old, with the youngest age was 31 confident interval of 49.34.

   
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 Table 3. Characteristic of respondents based on educational level
Educational Level f %
Elementary School 7 29
Junior High School 6 25
Senior High School 10 42
Bachelor degree 1 4
Total 24 100

Table 3 shows that 42% of respondents’ that the majority of the respondents
educational level was senior high school, worked in private organizations/companies
25% was junior high school, and 29% was (59%).
elementary school. While Table 4 shows

Table 4. Characteristic of respondents based on job

Jobs f %
Civil servants 0 0
Private 14 59
Entrepreneur 2 8
Farmer/fisherman 6 25
Unemployed 2 8
Total 24 100

Oxygen Saturation in patients with COPD

Table 5. Oxygen saturation before and after Pursed lips breathing in patients with COPD
Oxygen Pretest Posttest
Saturation f % f %
<95 % 14 58 0 0
≥95 % 10 42 24 100
Total 24 100 24 100

Based on table 5, it can be seen that before While after pursed lips breathing, the
doing pursed lips breathing, more than half oxygen saturation value was in the normal
of respondents (58%) had the oxygen range (≥95%) in all respondents.
saturation value below normal (<95%).

Hemoglobin and erythrocytes in patients with COPD

Table 6. Hemoglobin and erythrocytes in patients with COPD

Hemoglobin (Hb) Erythrocytes
Range
f % f %
Normal 22 91 22 91
Less 2 9 2 9
Total 24 100 24 100

Table 6 shows that the majority of 4.374 with p-value 0.000 (<0.05), which
respondents (91%) had normal hemoglobin indicated that there was a statistically
and erythrocytes. While Wilcoxon test as significant difference of oxygen saturation
shown in the Table 7 showed Z count - before and after intervention.

   
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Difference of oxygen saturation before and after intervention

Table 7. Difference of oxygen saturation before and after pursed lips breathing using Wilcoxon test
Variable Intervention n Mean SD Z p-value
Oxygen saturation Before 24 94.33 0.963 -4.374 0.000
After 24 98.13 1.035

DISCUSSION and this will stabilize the respiratory

The aim of this study was to examine the pattern to be effective.10
effect of pursed lip breathing technique on Forcible expiration will increase the
oxygen saturation in patients with COPD. strength of intra-abdominal muscle
Findings of this study revealed that there contraction compared to passive
were statistically significant differences of expiration, so that intra-abdominal pressure
oxygen saturation before and after pursed also increases, as well as the movement of
lip breathing in patients with COPD. It the diaphragm to make the thoracic cavity
could be said that pursed lip breathing is smaller. The smaller thoracic cavity causes
effective in increasing oxygen saturation. intra-alveolus pressure increased and
This result is in line with the study of exceeds atmospheric air pressure. The
Astuti10 indicated that the provision of condition will cause air to flow out of the
pursed lip breathing has a significant effect lungs into the atmosphere. The forced
on changes in respiratory patterns in expiration of breathing pursed lips
patients with emphysema. Khasanah4 also breathing will also cause airway
stated that pursed lip breathing effectively obstruction to be removed so that
decreases respiration rates, shortness of respiratory resistance decreases.4
breath and improve SaO2. Similarly, Aini11 Through a strong and deep
mentioned that breathing retraining gives inspiration mechanism, pursed lips
an effect in improving lung ventilation breathing helps increase the intake of O2
function of patient with COPD. into the alveoli. The high O2 pressure in
In addition, Widiyani12 revealed that the alveolus compared with the O2
pursed lips breathing exercise had a pressure in the pulmonary capillaries, or
significant influence on the peak of low CO2 pressure in the alveolus
expiratory exposure of patients with compared with the high pressure of CO2 in
chronic bronchitis, and increase the peak the pulmonary capillaries, lead to increased
flow of expiration in active smokers gradient pressure of the gases between the
Ariestanti.13 two sides. A high degree of O2 pressure
Pursed lip breathing is a breathing gradient increases the gas exchange, i.e.
exercise to improve the lung mechanics the diffusion of O2 from the alveolus to the
and breathing all at once. The practice of pulmonary capillaries. The difference of
pursed lips breathing by prolonging the high CO2 pressure also increases the gas
exhalation will increase the amount of exchange of CO2 diffusion from the
trapped carbon dioxide and increase the pulmonary capillaries to the alveolus for
transport of oxygen, so that the medulla subsequent expulsion into the atmosphere.4
oblongata is not stimulated to increase the Increasing the amount of oxygen that
effort of breathing because there has been a moves to the pulmonary capillaries
balance of gas homeostasis in the body, increases the amount of oxygen bound by
Hb and can bind the oxygen saturation. Hb

   
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is a component of red blood cells, which bronchial hyperactivity in asthma clients as
the increased number of red blood cells well as on healthy clients.3 This will lead
will automatically increase Hb levels. to decreased lung function. However, by
In this study, the majority of doing pursed lips breathing 3 times a day
respondents were males (71%). This could for 4 days can reduce respiratory work,
be because of the smoking habits. increase maximum alveolar inflation, and
According to Susanti,14 half of all people train the respiratory muscles.
who smoke have a chance of damage or This study provides the insight of
airway obstruction, and 10-20% of them knowledge regarding the effect of pursed
develop significantly into COPD. In lips breathing on oxygen saturation in
addition, Astuti10 stated that emphysema in patients with COPD. However,
Indonesia increases along with the confounding variables might influence the
increasing risk factors such as increasing results of this study. Experimental study
number of people smoking at young age. with pretest posttest with control group
In fact, most of respondents in this study design is needed for further explanation.
aged 31-60 years. However, certain aspects
of lung function, such as vital capacity and
strong expansion volume, will decline with CONCLUSION
age. COPD aggravates many physiological Based on the results of this study, it can be
changes were associated with aging and concluded that there was a significant
results in airway obstruction in bronchitis effect of pursed lips breathing on oxygen
and loss of elastic pulmonary growth in saturation in patients with COPD in the
emphysema.3 internal ward 2 of the General Hospital of
On the other hand, low level of Dr. R. Soedarsono Pasuruan. Thus, pursed
education is also revealed in this study, lips breathing could be applied as a nursing
which might affect health risk behaviors. intervention in the hospital.
Some types of jobs that directly become a
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