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Effect Of Pursed Lips Breathing for Peak Expiratory Flow Rate,
Oxygen Saturation, Dynamic Hyperinflation : Systematic Review
1 2 3
Rudi Hariyono ,Soedarsono ,Makhfudli
1Department of Medical Surgical Nursing, Faculty of Nursing Universitas Airlangga Surabaya
2Departement of Lung Disease Dr.Soetomo Hospital Surabaya
3Department of Community Nursing, Faculty of Nursing Universitas Airlangga Surabaya
Email : rudihariyono86@gmail.com
Keywords : Pursed Lip Breathing, Peak Expiratory Flow Rate, Oxygen Saturation,Dynamic Hiperinflation
Abstract : Background : Pursed Lips Breathing is a pulmonary rehabilitation therapy that can reduce peak expiratory
flow rate, mean expiratory flow rate, decrease airway resistance and improve lung elasticity. This systematic
review aims to determine the effect of pursed lip breathing on peak expiratory flow rate, oxygen saturation,
dynamic hyperinflation Methods : Information relating to this study was found in several journal databases
such as MEDLINE, PubMed, Ebsco, CINAHL, Elsevier ScienceDirect, which are respiratory journals and a
collection of research abstracts identified from 2000 to 2017.Results : Pursed lip breathing is an effective
therapy against an increase in PEFR prediction by an average of, oxygen saturation and a decrease in
dynamic hyperinflation. Conclusion : Pursed lip breathing is an easy and inexpensive therapy, which may be
applicable in solving gas exchange problems and breathing patterns disorders
1 BACKGROUND Nagarwala and Retharekar, 2015), increase tidal
volume, increase ventilation per minute, oxygen
Patients with chronic lung disease have abnormal saturation, reduce respiratory rate (Ugalde et al.,
lung function and have dyspnea, productive cough 2000)
and general fatigue. Dyspnea is a major problem in This study aims to conduct a systematic review
these patients and is strongly associated with to answer question
decreased physical ability. Dynamic hyperinflation 1 Does PLB affect oxygen saturation?
leads to the occurrence of dyspnea and has 2 Does PLB affect PEFR?
consequences of limited functional capacity in 3 Does PLB affect dynamic hyperinflation?
patients with chronic lung disease (Maind,
Nagarwala and Retharekar, 2015). In addition,
patients with chronic lung disease, also experience 2 METHODS
impaired oxygen saturation and decreased PEFR.
Pursed lips breathing is a pulmonary 2.1 Types of Studies
rehabilitation program that has content about In order to understand the interventions that
education and breathing exercises for patients with demonstrate success in past research is expected to
chronic respiratory lung disorders such as chronic be used effectively in clinical practice, the research
obstructive pulmonary disease and asthma. Pursed design used in this systematic review in addition to
lips breathing is beneficial for increasing gas RCT is also considered quasi-experimental,
exchange, reducing respiratory rate and end controlled clinical trials. It is estimated that this type
expiratory volume, as well as decreasing dynamic of research design may provide information about
hyperinflation (Visser, Dekhuijzen and Heijdra, patient populations that are more typical than those
2011) encountered in the primary care setting. In this
.In addition, this non-pharmacological therapy review, experimental studies are classified as RCTs,
has the benefit of increasing peak expiratory flow when groups of interventions are randomly allocated
rate and mean expiratory flow rate, reducing airway compared, different control groups may receive
resistance, improving pulmonary elasticity (Maind, other treatment modalities or without treatment.
88 The 9th International Nursing Conference 2018
“Nurses at The Forefront in Transforming Care, Science, and research”
Study designs without control group but with pursed Spahija PLBrest PLBexercise Dyspnea,TV
lips breathing protocol, alone or with other adjuvant (2005)
therapy were also included. Studies that do not use Araujo 6MWT+PLB 6MWT+Non DH
the pursed lips breathing protocol are not included in (2015) and PLB and
this naration. Only studies published in English in TGlittre+PL TGlittre+Non
2000-2017 are included in this review. Information B PLB
relating to this research was found in several journal Cabral Constant Constant IC,SaO2,PE
databases such as MEDLINE, PubMed, Ebsco, (2015) work rate work rate F
CINAHL, ScienceDirect. exercise+PL exercise+CB
B
Visser,2011 PLB - IC, SaO2
2.2 Types of Participants Bianci PLB - TV
The study populations considered in this review (2007)
Ramos PLB Non-PLB SpO
include subjects who are adults of all ages, male and (2009) 2
female, who have chronic lung disease (asthma,
emphysema, chronic bonkhitis). Tabel.2 PLB for Oxygen saturation
2.3 Types of Interventions Experimental Control
2.3.1 Inclusions Author,Year MeanSD MeanSD
Research using pursed lips breathing protocol, either Faager,2008 85.7±5 86.9±5
used alone or in combination. Spahija,2010 95.2±3.7 97.4±1.2
2.3.2 Exclusions Cabral,2015 94±4.1 93.1±4.6
Garrord,2005 90.5±4.4 90.4±4.3
Interventions that include any of the above listed Vijayakumar,2017 d = 1,67
treatments as adjunctive, either alone or in Visser,2011 d = 0.97
combination, without the protocol of pursed lips
breathing. Ramos,2009 98±1 96±2
2.4 Types of Outcome Measures Tabel.3 PLB for PEFR
Only relevant outcome measures for clinical practice Author,Year Experimental Control
are reported in this review. Some of the outcome MeanSD MeanSD
measured in this research are arterial oxygen Shine,2016 108.2±53.45 113±36.34
saturation and oxygen saturation pulse, peak Faager,2008 240±86 238±85
expiratory flow rate and dynamic hyperinflation
represented from spirometry result that is inspiratory Cabral,2015 53.3±17.8 40.2±8.6
capacity and Functional Residual Capacity. Vijayakumar,2017 d = 54,67 L/m
3 RESULTS Tabel.4 PLB for dynamic hyperinflation
Criteria Experimental Control
Measure
Table.1 Table of intervention, comparison and outcome Author,Year MeanSD MeanSD
Study Intervention Comparison Outcome Cabral,2015 IC (%) 1.35±0.39 1.19±0.33
G Faager ESWT + ESWT+MT SpO2,PEF Bianci,2007 TLC(%) 118±19 100±16
(2008) PLB VT (L)
Vijayakumar PLB - SaO2,PEFR, Spahija,2005 1.27±0.39 0.83±0.29
(2017) Rr Araujo,2015 DH(L) 0.24±0.2 0.22±0.24
Spahija PLBrest,PL PLBno VO2 IC(L)
(2010) Brec,PLBex peak,Wpeak Visser,2011 d= 0.089
, SaO2 IC: inspiratory capacity, TLC : Total Lung Capacity, VT :
Garrord ISWT + PLB ISWT + Non Rr,Dyspnea, Volume tidal
(2005) PLB SaO DH: dynamic hyperinflation
2
Shine (2016) PLB DB Chest
Expasion,P
EFR
The 9th International Nursing Conference 2018
“Nurses at The Forefront in Transforming Care, Science, and research” 89
4 DISCUSSION airway constriction during expiration, an effect
associated with a decrease in resistive pressure down
Pursed lips breathing is a breathing technique used in the airway wall. Therefore, PLB breathing is
in pulmonary rehabilitation. This technique has a expected to benefit people with more severe airway
positive impact on oxygen saturation, peak narrowing at expiration. Based on these evidence
expiratory flow rate, dynamic hyperinflation. indicates that PLB can be a valuable rehabilitation
therapy in certain cases and there is no reason to
4.1 Effect of PLB for oxygen saturation teach diaphragmatic breathing to a population of
The increase in SpO2 during PLB is due to an patients with chronic lung disease. To date, no
increase in expiratory duration and an increase in research has been found that investigates that
tidal volume that causes lung discharges diaphragmatic breathing techniques are used for
homogeneously, thus maintaining intrabronkial patients with chronic lung disease during the course
pressure and supporting gas exchange and of action, which may require the use of breathing
ventilation. In addition, it should also be mentioned techniques over a long period of time. (Ramos,
that patients who experience a decrease in dyspnea Vanderlei and Texeira, 2009)
while using PLB may also decrease the final This should be the focus of future research.
expiratory lung volume and larger reserves. This According to research conducted by Shine, 2016
will lead to an increase in end-inspiratory lung pursed lips breathing showed the treatment group
volume (Ramos, Vanderlei and Texeira, 2009) performed pursed lips breathing therapy there is an
In a study conducted by Faager, the 2008 group increase in PEFR by 108.2 ± 53.45, while in the
that did not use PLB showed a decrease in average research conducted by Faager 2008 showed an
saturation of oxygen by 1.2% compared with those increase in oxygen at 240 ± 86. Results of research
doing PLB, while research conducted by conducted by Cabral, 2015 53.3 ± 17.8. This
Vijayakumar, 2017 showed an increase of 1.67% indicates that the pursed lips breathing effectively to
oxygen saturation. improve PEFR which will reduce the severity of
According to research conducted by Faager 2008 lung disease in patients.
pursed lips breathing showed the treatment group
performed pursed lips breathing therapy there is an 4.3 Effect of PLB for dynamic
increase in oxygen saturation of 85.7 ± 5, while on a hyperinflation
research conducted by Spahija, 2010 showed an With the increased Functional Residual Capacity,
increase of 95.2 ± 3.7 oxygen. Results of research sport-induced dynamic hyperinflation will cause
conducted by Cabral, 2015menunjukkkan increase Volume Tidal to disrupt its inspiration volume, and
oxygen saturation was 94 ± 4.1, and research in some patients, to near Total Lung Capacity limits,
conducted by Garrord, 2005 using pursed lip causing a build up of Tidal Volume responses. In
breathing showed an increase in oxygen saturation addition, dynamic hyperinflation has a mechanical
of 90.5 ± 4.4. Ramos dilakukakn research results advantage performed by the inspiratory muscles, and
2009 showed the use of pursed lips breathing the forces inspiratory muscles to work at a higher
oxygen saturation level of 98 ± 1. Meanwhile, in a fraction of their capacity, and has been associated
study conducted Visser, 2011menunjukkan increase with an increase in excessive breathlessness.
of 0.97. This indicates that the effective pursed lips According to research conducted by Cabral, 2015
breathing to increase oxygen saturation. pursed lips breathing showed the treatment group
performed pursed lips breathing therapy there is an
4.2 Effect of PLB for peak expiratory increase in inspiratory capacity of 1:35 ± 0:39, while
flow rate on research conducted by Bianci, 2007 showed an
In a study comparing pursed lips breathing with increase in total lung capacity by 118 ± 19. Results
breathing diaphragms, PEFR measurements after of research conducted by Spahija, 2005 showed an
PLB therapy showed an increase of 2.72%. Research increase in tidal volume 1:27 ± 0:39, and research
conducted by Vijayakumar, 2017 PEFR has conducted by Araujo, 2015 using the pursed lips
improved 54.67 L / min. On the breathing of PLB breathing showed an increase in dynamic
showed more effective in reducing dyspnoea, hyperinflation at 0:24 ± 0.2. Visser dilakukakn
increasing gas exchange in people with chronic research results, in 2011 the use of pursed lips
obstructive pulmonary disease with moderate to breathing showed an increase in inspiratory capacity
severe degree. This positive effect appears to be by 0089. This indicates that the pursed lips breathing
related to the ability of the technique to reduce effectively to increase the dynamic hyperinflation.
90 The 9th International Nursing Conference 2018
“Nurses at The Forefront in Transforming Care, Science, and research”
5 CONCLUSIONS SECTIONAL STUDY’, International Journal of
Current Respiratory Review, 7(16), pp. 17–22.
PLB is a very simple and easy-to-use breathing Ramos, Vanderlei and Texeira (2009) ‘Influence of
technique to reduce obstruction of expiratory flow pursed-lip breathing on heart rate variability and
through the mouth, which produces pressure along cardiorespiratory parameters in subjects with
chronic obstructive pulmonary disease ( COPD )’,
the airway and causes stenting effects that help open 13(4), pp. 13–18.
the airway and assist in the exhale, thus allowing Rossi, R. C. et al. (2014) ‘Effect of Pursed-Lip Breathing
optimal lung discharge(Maind, Nagarwala and in Patients With COPD : Linear and Nonlinear
Retharekar, 2015). This therapy is very effective for Analysis of Cardiac Autonomic Modulation’,
oxygen saturation improvement, peak expiratory 32295388(55), pp. 39–45. doi:
flow rate, dynamic hyperinflation. Prevention and 10.3109/15412555.2013.825593.
control of symptoms is an important element in the Spahija, J. (2005) ‘Effects of Imposed Pursed-Lips
management of patients with chronic lung disease, Breathing on Respiratory Mechanics and ...’,
because the therapy performed for patients with Journal Chest.
Spahija, J., Marchie, M. De and Ghezzo, H. (2010)
chronic lung disease aims to optimize the control of ‘Factors Discriminating Spontaneous Pursed-Lips
symptoms and reduce the risk of exacerbation. Breathing Use in Patients with COPD’, Journal of
(Ramos, Vanderlei and Texeira, 2009). Chronic Obstructive Pulmonary Disease, i(2), pp.
254–261. doi: 10.3109/15412555.2010.496820.
Ugalde, V. et al. (2000) ‘Pursed Lips Breathing Improves
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The 9th International Nursing Conference 2018
“Nurses at The Forefront in Transforming Care, Science, and research” 91
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