JIKO (Jurnal Ilmiah Keperawatan Orthopedi) Vol. 5 No.

2 (2021) 62

Volume. 5 Number. 2 Jurnal Ilmiah Keperawatan

Period: July – December 2021; page 62-68 Orthopedi (JIKO)
p-ISSN : 2580-1112; e-ISSN : 2655-6669 Article history:
Copyrighr @2020 Received: September 16, 2021
The author owns the copyright of this article Revised: February 11, 2022
journal homepage: https://ejournal.akperfatmawati.ac.id Accepted: February 13, 2022
DOI : 10.46749/jiko.v5i2.73

The Position of Leaning Forward to Reduce Breathing of COPD

Patients: Literature Review

Aat Djanatunisah1, Riri Maria2

1
Master of Nursing Student Specialization in Medical Surgery, FIK UI, 2FIK UI lecturers
Fatmawati Hospital, Jl. RS. Fatmawati, Cilandak, South Jakarta 12430
E-mail: djanatunisah@gmail.com

Abstract
COPD patients often experience shortness of breath as a result of inflammation in the lungs
that develops in the long term. COPD is generally characterized by difficulty breathing,
coughing with phlegm, and wheezing or wheezing. In this condition, the patient often finds a
comfortable position to reduce shortness of breath. The aim of this study was to look at
appropriate and effective interventions in reducing spasms in COPD patients. This literature
study was created by analyzing scientific articles, at least in retrospective research from 2012 to
2020 and in English. Data obtained from databases include Pubmed, CINAHL, Scopus,
Proquest and Google Scholar with the keywords position for breathing in COPD, position
forward lean trunk for short breathing in COPD, and best position for COPD. The results of this
literature obtained 5 articles that match the inclusion and exclusion criteria. The results have
been found that the forward leaning position is effective in reducing shortness of breath in
COPD patients because of the involvement of the respiratory accessory muscles so that the
pulmonary ventilation process is good.

Keywords: Position for breathing, forward leaning position, COPD

Background In 2020, it is estimated that COPD will

Chronic Obstructive Pulmonary become the third cause of death in the
Disease (COPD) is a preventable and world after ischemic heart disease and
treatable disease characterized by cerebrovascular disease (Angelis. Et. Al.,
progressive limited airflow associated 2014). Based on the 2013 Basic Health
with chronic inflammatory response to Research (RISKESDAS) data in
the airways and lungs due to toxic Indonesia, the prevalence of COPD is
particles or gases (Disease Global 3.7%.
Initiative For Chronic Obstructive Lung. The incidence of this disease increases
2017). The incidence of COPD has with increasing age and is higher in men
reached more than 5 percent of the total (4.2%) than in women (3.3%) (Riskesdes,
population and is associated with 2013). In COPD, exacerbations and
increased morbidity and mortality. In comorbids contribute to the overall
America it has become the third leading severity of the disease in a patient.
cause of death with a death rate of more (Disease Global Initiative For Chronic
than 120,000 people each year (Miniño Obstructive Lung. 2017).
et.al., 2011).

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COPD can cause interference with the leaning forward to reduce the tightness
oxygenation process of the entire body and maximize the work of the breathing
due to alveolar damage and changes in muscles.
respiratory physiology. These damage Leaning forward in COPD patients
and changes can cause inflammation of improves the pressure-length relationship
the bronchi and result in damage to the and the geometry of the diaphragm,
walls of the terminal bronchioles and which improves the breathing process.
cause obstruction or early closure of the (Sharp. Et. Al., 1980). Leaning forward
expiratory phase resulting in airway also aims at contraction of the diaphragm
limitations that are not completely to increase chest wall motion, thereby
reversible due to the inflammatory increasing lung volume changes
response. (Singh. Et.al., 2019) (Delgado. Et. Al., 1982). Leaning forward
Chronic airflow inhibition in COPD is with both arms and head can increase the
a combination of small airway disease activity of the inspiratory accessory
and parenchymal destruction with muscles during inspiration in COPD.
differing patient-to-patient contributions. (Kim. Et. Al., 2012). Leaning forward
In fact, COPD is a group of diseases with with arm supports while standing or
clinical symptoms similar to those of sitting increases the recruitment of the
chronic bronchitis, emphysema, asthma, inspiratory accessory muscles namely the
bronchiectasis, and bronchiolitis. Airway sternocleidomastoid (SCM) and scalenus
obstruction that occurs in patients with (Sc). which increases the anterior-to-
COPD is caused by diseases of the posterior intercostal movement. (Montes.
airways and damage to the lung Et. Al., 2018).
parenchyma. (Stockley. Et. Al., 2009). Leaning forward will raise the
According to Chronic Obstructive diaphragm and external intercostal
Pulmonary Disease (COPD) International muscles to a position of approximately 45
(2012), patients with Chronic Obstructive degrees. The diaphragm muscles are the
Pulmonary Disease (COPD) experience main muscles of inspiration and the
changes in the shape of the chest. The external intercostal muscles are also the
deformation that occurs is the muscles of inspiration. The diaphragm
proportional diameter of the antero- muscle which is at a position of 45
posterior and transverse chest shape, degrees causes the earth's gravitational
often called barrel chest. Difficulty force to work quite adequately on the
breathing also occurs in patients with main muscle of inspiration compared to a
Chronic Obstructive Pulmonary Disease sitting or half-sitting position.
(COPD), which is breathing using a The gravitational force of the earth
breathing muscle for a long time, then acting on the diaphragm muscle makes it
muscle hypertrophy and widening easier for the muscle to contract and
between the ribs or the intercostal area move downward, increasing the volume
will occur. of the thoracic cavity by increasing its
Breathing support muscles are vertical length. Likewise with the external
necessary for the lungs to expand intercostal muscles, the earth's
properly during the ventilation process. gravitational force acting on the muscle
Therefore, in order for the breathing makes it easier for the ribs to lift outward,
muscles to work properly, a position is thereby enlarging the thoracic cavity in
needed that can help develop the lungs. the anteroposterior dimension.
One of the nursing interventions given is
to adjust the position of the patient Materials and Methods

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Search for relevant articles using weakness of the respiratory muscles that
databases such as CINAHL, Pubmed, occurs in COPD patients. Several studies
Google scholar, Scopus and Proquest. on position are also combined with
Search for articles using keywords: physiotherapy which aims to increase
position for breathing, Forward leaning lung capacity volume, inspiratory and
position, COPD. The articles taken were expiratory respiratory function and to
selected using inclusion and exclusion clear the airway of secretions in COPD
criteria including articles in English, patients. From the research results
published between 2012-2020, all COPD obtained, an assessment of standardized
patients from degrees 0-IV and healthy measuring instruments such as EMG,
respondents and full text. spirometry, microRPM, qualisys motion
The author also uses several design capture system, inductive respiratory
studies from several studies obtained such plethysmography, oximetry and OEP has
as quasi experimental design, and cross been carried out so that the assessment is
sectional. more accurate.
This research also exists as a follow-
Result up to previous studies conducted by
Based on the search results by entering several researchers so that the results are
keywords obtained from Pubmed 2 more relevant and effective. The results
articles, CINAHL 2 articles, Scopus 4 of the research analyzed stated that the
articles, Google scholar 375 and Proquest forward leaning position of the
9,629 articles. After sorting it was diaphragm muscle and external
obtained from, Scopus 3 articles, intercostal muscles experienced an
Proquest 2 articles and Google scholar 2, increase in activity which caused the
a total of 11 articles. earth's gravity to work quite adequately
However, only 7 articles have the on the inspiratory main muscles
structure of an article and relate to the compared to sitting or half-sitting
position of the patient to reduce tightness positions. (Booth., 2006). The earth's
in COPD patients. Furthermore, gravitational force acting on the
skimming and scanning were carried out, diaphragm muscle makes it easier for
there were 4 articles issued on the these muscles to contract moving
grounds that the research did not meet the downward, increasing the volume of the
inclusion criteria. thoracic cavity by increasing the vertical
length of the chest cavity, as well as the
Discussion external intercostal muscles, the earth's
Based on the 7 articles analyzed, it gravitational force acting on these
consisted of a quasi-experimental study muscles makes it easier for the ribs to be
of 5 articles and 2 cross-sectional articles. lifted out so that it enlarges the thoracic
Of the 7 articles, 6 articles assessed cavity. in the anteroposterior dimension
different positions to improve respiratory (Khasanah. 2013).
muscles and lung function, while 1 article The enlarged thoracic cavity causes
assessed forward leaning combined with the pressure in the thoracic cavity to
physiotherapy or breathing exercises. expand and forces the lungs to expand,
The results of the 7 articles state that thereby decreasing the intra-alveolar
leaning forward can increase the activity pressure. The drop in intra-alveolar
of the respiratory muscles and breathing pressure is lower than the atmospheric
accessory muscles thereby helping to pressure causing air to flow into the
reduce shortness of breath due to pleura. This process suggests that leaning

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forward makes it easier for patients with muscles involved in the forward leaning
shortness of breath who experience an position and the combination of forward
obstructive airway to inspire without leaning with physiotherapy or breathing
expending too much energy. The process exercises.
of inspiration using less energy can
reduce patient fatigue while breathing and The difference in the angle of the
also minimize oxygen use. forward leaning position
The forward leaning position increases The difference in the degree of tilt in
intraabdominal pressure and decreases the forward leaning position can affect
diaphragmatic pressure to the abdominal lung function such as lung volume, IRV,
cavity during inspiration (Bhatt, et al, ERV and the use of the breathing muscles
2009). The intra-abdominal muscles are to improve pulmonary ventilation
the main muscles for expiration. function. Whereas the tidal volume has
Increased intra-abdominal muscle no difference with the forward leaning
contraction will increase intra-abdominal position with different degrees (Lee et al.
pressure. 2017).
The increase in intra-abdominal In Lee's research. et.al.2017 also stated
pressure will push the diaphragm upward, that a 30 degree forward leaning position
lifting the thoracic cavity, thereby is most effective at improving lung
reducing the size of the thoracic cavity. function because using gravity helps to
Another expiratory muscle, the internal expand the chest and relieves pressure on
intercostal muscle, is positioned forward the abdomen and diaphragm. According
leaning the muscle at an angle of about to Khasanah 2015, leaning forward will
30-45 degrees, which allows the increase the diaphragm and external
gravitational force to work more intercostal muscles to a position of
optimally. The earth's gravity will help approximately 45 degrees.
pull the internal intercostal muscles
downward so that the size of the thoracic The main muscles of the breathing and
cavity becomes smaller. The smaller the the auxiliary muscles are involved in
size of the thoracic cavity makes the intra the forward leaning position
alveolar pressure increase. An increase in The forward leaning position increases
intra alveolar pressure that exceeds intraabdominal muscle pressure and
atmospheric pressure causes air to flow decreases the pressure of the diaphragm
out of the lungs. The increased ventilation muscle to the abdominal cavity during
process in patients with shortness of inspiration (Bhatt, et al, 2009). In a study
breath who are positioned leaning conducted by Kim, et al (2012), the
forward will increase CO2 output and activity of the Scalene and
increase oxygen intake into the intra Sternocledomastoideus muscles
alveoli (Bhatt. Et.al. 2009) significantly increased in forward leaning
This study emphasizes the importance positions with arms supported on the
of giving a forward leaning position in thighs or arms supported by the head
COPD patients in order to reduce compared to neutral positions.
shortness of breath that occurs. Based on Leaning forward with a shoulder
the analysis in giving forward leaning support (pectoralis major and minor
positions, there are things that support the muscles) contributes significantly to the
success of this intervention, including development of the ribs or intercostals
differences in the degree of tilt in the (Gosselink, 2013). According to Montes.
forward leaning position, the respiratory et.al. 2017 forward leaning and 4 point

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kneeling positions can increase positive. This positive pressure will

Transversus Abdominis / Internal Oblique spread into the narrowed airway and is
(TrA / IO) during the process of useful for keeping the airway open. With
breathing. the opening of the airway, air can easily
escape through the narrowed airway and
Forward leaning position and easily affects the strength of the
Respiratory physiotherapy respiratory muscles to reduce shortness of
Physiotherapy or breathing exercises breath (Permadi, & Wahyudi, 2017).
are useful for improving chest wall Pursed Lip Breathing or breathing
movement to reduce the work of exercise is done by breathing or inspiring
breathing, muscle accesories and dyspnea through the nose for 2-3 seconds followed
as well as to improve breathing efficiency by slow expiration through the mouth at
and improve ventilation distribution least 2 inspirations (4-6 seconds) carried
(KNGF. 2008). Physiotherapy as a form out for 30 minutes with a resting pause
of non-pharmacological health service tolerance of 5 minutes for 3 times (5
can help sufferers of chronic obstructive interventions, a 5 minute break, continued
pulmonary disease to recover physically 5 minutes to 2 and a 5 minute break,
and improve their breathing patterns so Active Cycle of Breathing
that they can break the chain of Technique(ACBT) is a physiotherapy
complaints that become mutual causes chest that aims to clear the airway in
and effects. Leaning forward in patients with Chronic Obstructive
combination with physiotherapy is very Pulmonary Disease (NHS, 2009).
helpful for clearing the airway and ACBT also aims to reduce shortness of
improving pulmonary ventilation in breath, better control breathing and
COPD patients. management of breathlessness as well as
Purse Lip breathingand the Active better mobilization or movement of the
Cycle of Breathing Technique are thoracic cavity. ACBT consists of three
examples of physiotherapy given to sub-techniques, namely Breathing
COPD patients. Pursed Lip Breathing is a Control (BC), Thoracic expansion
pulmonary rehabilitation that is very easy exercise (TEE) and forced expiration
to do without using assistive devices and technique (FET) which can be done
there are no side effects that aim to together or one by one. Breathing
improve oxygen transport, induce slow exercises increase the inspiratory capacity
and deep breathing patterns, control and stimulate the work of the respiratory
breathing, prevent collapse, and train the muscles.
expiratory muscles to prolong exhalation Huffing exercises increase the tidal
and increase airway pressure during volume and open the collateral system of
expiration and reduce the amount of the airways so that the spitum is easily
trapped air or air trapping (Smeltzer & expelled. Breathing Control aims to re-
Bare, 2013). educate calm and regular breathing
PLB is a breathing exercise that patterns so that patients can save energy
emphasizes the expiration process which for breathing and patients will get used to
is done calmly and relaxed with the aim doing regular breathing when attacks of
of facilitating the process of expelling air shortness of breath. The combination of
trapped by the airways. Through this the two subtechnics can be done together
technique, the air that comes out will be with thoracic cavity mobility exercises
blocked by the lips, which causes the and postural improvement.
pressure in the oral cavity to be more

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Conclusion trunk lean with arm support affects

The forward leaning position is very the activity of accessory respiratory
effective and easy to perform as a nursing muscles and thoracoabdominal
intervention to reduce shortness of breath movement in healthy individuals.
in COPD patients. Leaning forward can Elsevier. Human Movement
increase the activity of the respiratory Science 61.167-176
muscles and breathing accessory muscles, António Mesquita Montesa., Carolina
increasing the volume of the lung Tam., Carlos Crastoa., Cristina
capacity so that the lungs can expand Argel de Meloa., Paulo Carvalhoa.,
maximally and this has been proven by Rita Santosa., Rui Vilarinhoa., João
several studies conducted. Paulo Vilas-Boas. (2017).
The forward leaning position can also Abdominal muscle activity during
be combined or combined with other breathing in different postures in
forms of physiotherapy or breathing COPD "Stage 0" and healthy
exercises as needed to treat respiratory subjects. Elsevier. Respiratory
problems and in COPD patients. Physiology & Neurobiology 238.
Therefore, this intervention can be 14-22
applied in health services as a non- Bhatt, SP., Guleria, R., Luqman-Arafath,
pharmacological therapy in dealing with TK., Gupta, AK., Mohan, A.,
shortness of breath. Nanda, S., & Stoltzfus, JC 2009.
The LOE 7 of this article is Level IV, Effect of tripod position on
so more complex and advanced evidence objective parameters of respiratory
is needed, however, this study can function in stable chronic
represent a tested and proven nursing obstructive pulmonary disease.
intervention that can be administered to Indian J Chest Dis Allied Sci. 51:
COPD patients with breathing problems 83–85
to reduce shortness of breath. Booth., (2006). APARQ (Adolscent
Physical Activity Recall
Reference Questionare. University Sydney:
Albarrati, Ali., Hamayun Zafar., NSW.
Alghadir., Ahmad H., Shahnwaz Delgado, HR, Braun, S R., Skatrud, JB,
Anwer., (2018). Effect of Upright Reddan, WG, & Pegelow, DF
and Slouched Sitting Postures on (1982). Chest wall and abdominal
the Respiratory Muscle Strength in motion during exercise in patient
Healthy Young Males. National with chronic obstructive pulmonary
Library of Medecine. DOI: 10.1155 disease. The American Revieum of
/ 2018/3058970 Pulmonary Disease, 126, 200-2005
Angelis, N., Porpodis, K., Zarogoulidis, Disease Global Initiative For Chronic
P., Spyratos, D., Kioumis, I., Obstructive Lung. Pocket Guide To
Papaiwannou, A., Pitsiou, G. et al. Copd Diagnosis, Management, And
(2014). Airway inflammation in Prevention A Guide for Health Care
chronic obstructive pulmonary Professionals 2017 EDITION.
disease. J. Thorac. Dis. 6, 4 9. Gosselink, 2013.Controlled Breathing
António Mesquita Montesa., Carolina and Dyspnea in Patients with
Tam., Carlos Crastoa., Cristina Chronic Obstructive Pulmonary
Argel de Meloa., Paulo Carvalhoa., Disease (COPD). Journal of
Rita Santosa., Rui Vilarinhoa., João Rehabilitation Research and
Paulo Vilas-Boas. (2018). Forward Development. Vol. 40 No.5.

The Position of Leaning Forward to Reduce Breathing of COPD Patients

 JIKO (Jurnal Ilmiah Keperawatan Orthopedi) Vol. 5 No. 2 (2021) 68

Indonesia KKR. (2013). Basic Health and ventilation in patients with mild
Research 2013. to moderate chronic obstructive
Juncheol Lee., And Dongwook Han. pulmonary disease. Medicine: doi:
(2017). Effect of the trunk forward 10.1097 / MD.0000000000023646
bending angle in sitting position on Permadi, AW., & Wahyudi, AT. (2017).
slow vital capacity. Physical The effect of pursed lip breathing
Therapy Science. 12: 2220–2223. and sustained maximal inspiration
Khasanah, S., & Maryoto, M. (2016). to increase the strength of the
Effect of leaning forward (CKD) respiratory muscles to reduce
with pursed lips breathing (PLB) on complaints of shortness of breath in
the improvement of the respiratory cases of cardio respiration. Interest:
conditions of patients with Chronic Journal of Health Sciences, 6 (2)
Obstructive Pulmonary Disease Singh D., Agusti A., Anzueto A., Barnes
(COPD) PJ., Bourbeau J., Celli BR, et al.
Ki-song Kim., Min-kwang Byun., Won- (2019). Global Strategy for the
hwee Lee., Heon-seock Cynn., Oh- Diagnosis, Management, and
yun Kwon., And Chung-hwi Yi. Prevention of Chronic Obstructive
(2012). Effects of breathing Lung Disease: the GOLD science
maneuver and sitting posture on committee report 2019. The
muscle activity in inspiratory European respiratory journal; 53
accessory muscles in patients with (5).
chronic obstructive pulmonary Sharp, JT, Drutz, WS, Moisan, T., Foster,
disease. Multidisciplinary J., & Machnach, W. (1980).
Respiratory Medicine Postural relief of dyspnoe in severe
KNGF. (2008). Chronic Obstructive chronic obstetrical pulmonary
Pulmonary Disease. Practice disease. The American Review of
Guidelines. England: Royal Dutch Respitaory disease, 122.201-211.
Society For Physical Therapy.
Miniño., BAM., Murphy, SL & Xu, J. Stockley RA., Mannino D., Barnes PJ.
(2011). National Vital Statistics (2009). Burden and Pathogenesis of
Reports Deaths: Final Data for Chronic Obstructive Pulmonary
2008. 59. Disease. Proceedings of the
NHS. (2009). National Health Service American Thoracic Society; 6 (6):
Standard Contract. NHS England. 524-6.
Pp. 1–22. Available at: Zuriati Zuriatia., Melti Suryab., Zahlima.
england.nhs.uk. (2020). Effectiveness Active Cycle
Nutsupa Ubolnuar., Anong Tantisuwat., of Breathing Technique (ACBT)
Premtip Thaveeratitham., Somrat with Pursed Lips Breathing
Lertmaharit., Chathipat Technique (PLBT) to tripod
Kruapanich., Jaturong Chimpalee., position in increase of oxygen
And Witaya Mathiyakom. (2020). saturation in patients with COPD,
Effects of pursed-lip breathing and West Sumatera. Elsevier.
forward trunk lean postures on total Enferimeria Clinica. 164-167.
and compartmental lung volumes

The Position of Leaning Forward to Reduce Breathing of COPD Patients