RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION

1. Name of the candidate and NEETHU KURIAKOSE

address I YEAR M.Sc. NURSING
(in block letters) LAXMI MEMORIAL COLLEGE OF
NURSING
BALMATTA
MANGALORE

2. Name of the Institution LAXMI MEMORIAL COLLEGE OF

NURSING
BALMATTA
MANGALORE

3. Course of Study and Subject M. Sc. NURSING

CHILD HEALTH NURSING

4. Date of Admission to the course 16.07.2012

5. Title of the Topic

EFFECTIVENESS OF BREATHING EXERCISE AS PLAY WAY

METHOD ON CARDIOPULMONARY PARAMETERS

AMONG CHILDREN (6-12 YEARS) WITH LOWER

RESPIRATORY TRACT INFECTIONS IN SELECTED

HOSPITALS AT MANGALORE

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6. Brief resume of the intended work
6.1 Need for the study

Healthy children brought up in healthy surroundings not only are source of

joy to everyone, but will be India’s greatest resource tomorrow. Children are not
‘little adults’ they are in a dynamic process of growth and development, and are
particularly vulnerable to acute and chronic effects of pollutants in their
environmental, which leads to diseases like acute respiratory infections(ARI),
diarrhoea etc. Among these infectious diseases ARI is one of the leading causes of
mortality and morbidity in young children.1

Lower respiratory tract infections (LRI) inflict a high burden of disease in

children worldwide. Longitudinal descriptive epidemiological data on different
forms of LRI are urgently needed to differentiate this burden. Compare population
based incidence rates between countries and recognize trends. From July 1996 to
June 2000 all children hospitalized with LRI, i.e., laryngo tracheao bronchitis,
Wheezing bronchitis, bronchiolitis (WBB),bronchopneumonia and pneumonia in
the municipal area of Kiel Schleswig Holstein, Germany were analyzed by cross
sectional studies. In the four year observational period 1072 children aged 0 to 16
years (median 23 months) were hospitalized with LRI. 12%(median 28 months)
with LTB, 11%(median 17 months) with bronchitis, 28%(median 13 months) with
WBB, 26% (median 26 months) with bronchopneumonia, 22% (median 47
months) with pneumonia. The prevalence of chronic underlying conditions 20%
and low gestational age (13%) varied in different forms of LRI. The cumulative
incidence rate of LRI rate steadily over 4 years.2

A community based longitudinal study was conducted in Malpe, Udupi

District, and Karnataka, to investigate the incidence of acute respiratory infection
in Children. A cohort of 91 children was followed up for one year, leading to 2047
fortnightly observations. On an average every child had 11.3 months of

follow-up. The overall incidence of acute respiratory infection was 6.42

episodes/child/ year. On an average each episode lasted for 5-6 days. Mean

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duration of acute respiratory tract infection during one year was 32.5 days/child.
Most of the acute respiratory infection episodes in children (91.3%) were of
simple (cough, and cold, no pneumonia) and 8.2% developed pneumonia and only
0.5-1% had severe pneumonia. Incidence of acute respiratory tract was almost
same in male and female children.3

Breathing techniques are helpful for reducing breathing difficulty. The

ultimate goal is for children to be able to relax quickly when faced with stressful
situations. Breathing exercise as an integral part plays a significant role in airway
clearance and parenchymal expansion by improving the efficiency of respiratory
muscles. Modified breathing exercise is mandatory in children because they might
not co-operate like adults. The principle is to attract children and not to create
boredom. It can be accompanied by musical tone that would evince interest in a
child. Various modified forms of breathing exercises like group exercises,
running, balloon blowing, abduction, adduction and forward movement of upper
limbs, blowing air into the water with a straw, blowing a trumpet, flute and mouth
organ playing are found effective in children.4

A study was conducted in Mangalore on effectiveness of deep breathing

exercise on pulmonary function among patients with chronic air flow
inflammation. Out of 40 patients randomly selected, 20 were assigned to
experimental group and next 20 to control group. The PFT parameters (FEV1 &
FVC) were assessed in both group before intervention. Deep breathing exercise
was provided for the experimental group for twice daily for 7 days. On the 7 th day
PFT parameters of both groups were assessed. The result showed the mean score
of FVC and FEV1 is 23.80 and 26.80 respectively for experimental group, where
as 7.70 and 6.90(p<0.05) for the control group. The study concluded that deep
breathing exercise is effective in improving pulmonary parameters.5

There are many exercises which are easy to perform but if breathing
exercise could be incorporates as play activity for the child he/she would have

more acceptance. So it was felt need of researcher to develop simple breathing

exercise in such a form that will enable children to perform these exercises
frequently that will improve their lung expansion, reduces respiratory secretions

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and thus respiratory complications. Above studies and references motivated the
researcher to carry out this research study.

6.2 Review of literature

A study showed the effects of breathing exercises taught by physical

therapists to 40 post operative upper abdominal surgery patients aged between 10-
15 years at USA. The experimental group received the breathing exercises in
addition to the incentive spirometry, balloon blowing ultra sonic nebulisation, and
routine instructions by nurses in deep breathing and coughing provided for the
control groups. 38 % post operative pulmonary complication rate was found for
the control group. The experimental group, whose subjects were instructed and
monitored by physical therapist, had only a 16 percent complication rate. The post
operative pulmonary complications were defined as temperature higher than
38.50C, radiographic changes or abnormal breath sounds. This study indicates a
need standardised the method of deep breathing in a manner different from that
routinely taught by nurses.6

A study to compare exhaled NO concentrations considered as the method

of choice, with 2 sample methods that are easily performed by children 100 and 1
well controlled, stable allergic asthmatic children(median age 11.7 years). 29
children (29%) were not able to perform a constant flow exhalation of at least 3
sec. NO concentrations (means plus or minus SEM) were 5.3+0.2 parts per billion
(ppb) at the end- expiratory plateau, 5.2+0.3 ppb in balloons (intra class
correlation co-efficient (ri) = 0.73) and 8.0+0.4 ppb during tidal breathing
(p<0.001, ri =0.53 compared to plateau values). Mean values of NO during tidal
breathing increased significantly with time. It was concluded that, in asthmatic
children, the end expiratory plateau concentration of NO during exhalation at
20% of the vital capacity per sec is similar to values obtained if the balloon
method.7

A study was conducted at USA and the main objective of this study is to
manage respiratory distress and pain of the children who had undergone surgery
especially abdominal surgery. In this study questioners were emailed to 109
haemophilia social workers in the US listed in the CDC directory. The survey

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consisted of 14 questions, mainly closed-ended. Nominal and linger light scales
were used. 29 workers completed the survey (27% participation), 26(93%) of
respondents taught that breathing exercises with help of interesting toys are more
effective to manage respiratory distress and pain among children age group of 3-
10 years who had undergone a surgery. Thus finally social work respondents
indicated that distraction by pop-up toys, sensory toys; light-up toys are most
effective to reduce respiratory distress as well as pain in post operative children
with age group of 3-10 years.8

A study was conducted to evaluate the effectiveness of combined self

management and relaxation-breathing training for children with moderate to
severe asthma compared to self management only training. Two-group
experimental design was used. Participants were randomly assigned to an
experimental or comparison group and matched by gender, age, and asthma
severity. Both groups participated in an asthma self management programme.
Children in the experimental group were also given 30 min of training in a
relaxation breathing technique and a CD for home practice. Data on anxiety
levels, self perceived health status, asthma signs/symptoms, peak expiratory flow
rate, and medication use were collected at base line and at the end of the 12 week
intervention. Anxiety was significantly lower for children in the experimental
group than in the comparison group. Differences in the other four physiological
variables were also noted between pre and post intervention, but these changes
did not differ significantly between groups. The study concluded that the
combination of self management and relaxation breathing training can reduce
anxiety.9

A randomized study was conducted to evaluate the effects of a 3 year

home exercise program on pulmonary function and exercise tolerance in mildly to
moderately impaired patients with cystic fibrosis (CF) and to assess whether

regular breathing exercise is a realistic treatment option. Seventy two patients

with CF (7-19 years) were randomly assigned to an exercise group (a minimum of
20 minutes of breathing exercise, at a heart rate of approximately 150 beats/min, 3
times weekly) or a control group (usual physical activity participation).Pulmonary
function, exercise tolerance, clinical status, hospitalization, and compliance with

5
therapy were monitored during scheduled visits to the hospital’s CF clinic. The
result showed that sixty five patients were included in the analyses. The control
group demonstrated a greater annual decline in percent of predicted forced vital
capacity compared with the exercise group(mean slope+SD,-2.42+4.15 vs.-
0.25+2.81;P=.02),with a similar trend for forced expiratory volume in 1 second (-
3.47+4.93 vs.-1.46+3.55;P=.07). Patients remained complaint with the exercise
program over the study period. An improved sense of well being was reported
with the exercise. The study concluded that pulmonary function declined more
slowly in the exercise group than in the control group, suggesting a benefit for
patients with CF participating in regular breathing exercise. Consistent
compliance with the home exercise program and a self reported positive attitude
toward exercise provide further evidence of the feasibility and value of including
a breathing exercise program in the conventional treatment regimen of patients
with CF.10

A quasi experimental study was conducted to assess the effect of selected

breathing exercise on cardiopulmonary parameters of children with abdominal
surgery. Thirty children with abdominal surgery were selected using non
probability purposive sampling. Fifteen children in experimental group were
supervised breathing teaching and 15 children in control group with no
intervention. Selected breathing exercise was taught one day prior to surgery to
the children of experimental group. Cardio pulmonary parameters of children
were recorded on first, second and third post operative day, the parameters were
assessed twice in the day with 3 hours of interval between two recordings. On
post operative day 1, difference was found in mean respiratory rate (t=1.86) and
mean lung volume (t=2.169) of children of both the group. On post operative day
2nd (t=1.71) and 3rd (t=1.877) difference was found in mean lung volume change

was not found between the cardio pulmonary parameters of children of

experimental group with abdominal surgery before and after intervention. It
indicates that the selected breathing exercise which has given in the form of play
was found to be effective in prevention of post operative cardio pulmonary
complications.11

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6.3 Statement of the problem

Effectiveness of breathing exercise as play way method on cardio

pulmonary parameters among children (6-12 years) with lower respiratory tract
infections in selected hospitals at Mangalore.

6.4 Objectives of the study

1. To assess cardiopulmonary parameters on children (6-12 years) with lower

respiratory tract infections in experimental group and control group.

2. To evaluate the effectiveness of breathing exercise as play way method on

cardio pulmonary parameters.

3. To find the association of post test cardiopulmonary parameters with

selected demographic variables.

6.5 Operational variables

1. Effectiveness: It refers to producing intended results.12

In this study, it refers to the desired change that can be brought

about by breathing exercise on cardiopulmonary parameters as measured
by an observational checklist.

2. Breathing exercise: Technique for breathing learning to control the rate

and depth of breathing.13

In this study breathing exercise refers to balloon blowing exercise.

3. Play way methods: To occupy oneself in amusement, sports or other

recreation.14

In this study breathing exercise in the form of play with the help of
a balloon. Child will be encouraged to inflate a new ordinary balloon to a
diameter of 7 inches 10 times a day. This will be repeated for three days.
During the procedure the child will be asked to inhale maximum air and
inflate the balloon with maximum expiration.

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4. Cardio pulmonary parameters: Cardiopulmonary means relating to the
heart and lungs.15 And parameter means measurable or quantifiable
characteristic or feature.16

In this study it refers to variables reflecting the status of cardio

pulmonary function. They are as follows:

a. Respiratory rate: Number of breaths per minute before and after

intervention this is assessed manually.

b. Pulse: Number of heartbeats per minute before and after

intervention this is assessed manually.

c. Blood pressure: Pressure in the artery that pushs up the column of

mercury equal to pressure strength and is assessed by
sphygmomanometer before and after intervention.

d. Chest expansion: In this study chest expansion means increase in

chest circumference during the process of breathing inhalation and
which is measured by measuring tape before and after the
intervention.

e. Breath sound: In this study breath sound refers to adventitious

vibration which is produced by movement of air inside the lung
and is assessed with the help of stethoscope before and after the
intervention.

f. Cough: In this study cough is expectorant from the lungs or throat

which is either in dry or liquid form and is assessed by observation
for its colour, consistency and amount.

5. Lower respiratory tract infections: Lower respiratory tract infections is

the term used to describe infections affecting the lower respiratory tract.17

In this study, lower respiratory tract infections refer to infections

affecting the trachea, bronchi, bronchioles and lungs.

6.6 Assumptions

The study assumes that:

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 1. The breathing exercises will be effective on cardiopulmonary parameters
of children (6-12 years) with lower respiratory tract infections. The
breathing exercise will provide comfort for the children.

2. Breathing exercises are easy to perform, cost effective and have beneficial
effects on cardio pulmonary parameters.

6.7 Delimitations

The study is delimited to:

1. Children who are diagnosed as having lower respiratory tract infections by

the physician and admitted in the hospital.

2. Children in the age group of 6-12 years.

3. Children who are willing to participate in the study.

6.8 Hypotheses

All the hypotheses will be tested at 0.05 level

H1: There will be significant difference between the pre-test and post test
cardiopulmonary parameters of children (6-12 years) with lower
respiratory tract infections.

H2: There will be a significant association of post test cardiopulmonary

parameters with selected demographic variables.

7. Material and Methods

7.1 Source of data

Data will be collected from children in the age group of 6-12 years
admitted in the hospital with lower respiratory tract infections.

7.1.1 Research design

Research design used for the study is interrupted time series research

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design.

E= O1 X O2 X O3 X O4

C= O1 - O2 - O3 - O4

E= Experimental group

C= Control group

O1= Before intervention

X= Administration of balloon blowing exercises.

O2= Post-test 1 (1st day observation)

O3= Post-test 2 (2nd day observation)

O4= Post-test 3 (3rd day observation)

7.1.2 Setting

The study will be conducted in paediatric ward and ICU of selected

hospitals at Mangalore.

7.1.3 Population

In this study, population consists of children in the age group of 6-12 years
admitted in paediatric ward and ICU with lower respiratory tract infections.

7.2 Method of data collection

7.2.1 Sampling procedure

Non-probability purposive sampling technique will be used to select the

sample. The sample will be randomly assigned to the experimental group and
control group.

7.2.2 Sample size

The sample consists of 30 children (6-12 years) admitted to the paediatric

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ward and ICU at the selected hospital in Mangalore. In this study, 15 children will
be assigned to the experimental group and 15 to the control group.

7.2.3 Inclusion criteria for sampling

Inclusion criteria for sampling refers to children:

1. In the age group of 6-12 years.

2. Who are available on the day of admission.

3. Both male and female children.

4. Who are diagnosed as having lower respiratory tract infections by the

physician.

7.2.4 Exclusion criteria for sampling

Exclusion criteria for sampling refers to children:

1. Who are critically ill.

2. With any congenital defects of mouth and nose.

3. Children whose parents are not permitting to participate in the study.

7.2.5 Instruments intended to be used

1. Demographic Proforma.

2. Observational checklist of cardio pulmonary parameters.

3. Dyspnoea scale.

7.2.6 Data collection method

1. The investigator will obtain the permission prior to data collection from
concerned authority.

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2. The investigator will introduce her to the participants and obtain consent.

3. Children’s cardio pulmonary parameters assessed on the day of admission

for experimental group and control group.

4. Balloon blowing breathing exercise will be administered to the children

(6-12 years) 10 times per cycle, once a day for duration of half an hour for
3 days for the experimental group.

5. Post test will be assessed on the first, second and third day of the
intervention for the experimental group.

7.2.7 Plan for data analysis

 Demographic data will be analysed using frequency and percentage.

 Effectiveness of balloon blowing breathing exercise using mean, median,

standard deviation and paired ‘t’ test.

 Chi square test will be used to find the association between post test levels
of cardiopulmonary parameters and selected demographic variables.

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.

7.4 Has ethical clearance been obtained from your institution in case of
above statement?

Yes, ethical clearance has been obtained.

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8. Bibliography

1. World Health Organization. India Together: tomorrow’s citizen imperilled

today. [online]. Available from: URL:http//www.who.com.

2. Weigl JA, Puppe W, Belke O, Neususs J, Bagci F, Schmitt HJ. The

descriptive epidemiology of severe lower respiratory tract infections in
children in Kiel, Germany. Klin Paediatrics 2005 Sep-Oct;217(5):259-67.

3. Acharya D, Prasanna KS, Nair S, Rao RSP. Acute respiratory infections in

children a community based longitudinal study in south India. Journal of
Public Health 2003 Jan-Mar;47(1):7-13.

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4. Sakshi, Multani NK. Journal of Exercise Science and Physiotherapy
2000;6(2):112- 9.

5. Mathew J, D’Silva F. A study on effectiveness of deep breathing exercise

on pulmonary function among patients with chronic air flow limitation
International Journal of Nursing Education 2011;3:34-7.

6. O’Donohue WJ Jr. National survey of the usage of lung expansion

modalities for the prevention and treatment of postoperative atelectasis
following abdominal and thoracic surgery. Chest 1985;87:76-80.

7. Jobsis SL, Schellekens, Kroesbergen A. Sampling of exhaled nitric oxide

in children: end-expiratory plateau, balloon and tidal breathing methods
compared. European Respiratory Journal 1999;13:1406-10.

8. Fung E. Psychological management of fear of needles in children.

Haemophilia 2009;15(3):635-6.

9. Windich BA, Sjoberg I, Dale JC, Eshelman D, Guzzetla CE. Effects of

distraction on pain, fear, and distress during venous port access and
venipuncture in children and adolescents with cancer.

10. Gosselinik R, Schrever K, Cops P, Witvrouwen H, De Leyn P, Troosters T,

Lerut A, Deneffe G, Decramer M. Incentive spirometry does not enhance
recovery after thoracic surgery. Critical Care Medicine 2000
Mar;28(3):679-83.

11. Bernadi L, Spadacini G, Bellwon J. Effect of breathing rate on oxygen

saturation and exercise performance in chronic heart failure. Lancet 1998
May 2;351(9112):1308

12. http://dictionary.reference.com/browse/

13. wellbeing.doctissimo.com

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 14. www.thefreedictionary.com.

15. Chiang LL, Cheng HF, Lin HC, Sheng DF, Kuo HC. The effect of
incentive spirometry on chest expansion and breathing work in children
with surgery: comparison of two methods. Medical Journal of Chang
Gung 2000 Feb;23(2):73-9.

16. Revised and updated illustrated Oxford dictionary, 11th ed. India: Dorling
Kindersley Limited and Oxford University Press India; 2007. p. 259, 222,
451, 532, 826.

17. Marlow DR, Redding AB. Textbook of paediatric nursing. 6 th ed.

Philadelphia: W. B. Saunders; 2006.

9. Signature of the candidate

10. Remarks of the guide

11. Name and designation of (in block letters)

MRS. SANDHYA ALMEIDA ,M.Sc (N)

11.1 Guide
ASSOCIATE PROFESSOR AND HOD
DEPT. OF OBSTETRICS AND
GYNAECOLOGICAL NURSING
LAXMI MEMORIAL COLLEGE OF
NURSING

15
 BALMATTA, MANGALORE

11.2 Signature

11.3 Co-guide (if any) MRS. THERESA LEONILDA

MENDONSCA
ASSOCIATE PROFESSOR AND HOD
DEPT. OF CHILD HEALTH NURSING
LAXMI MEMORIAL COLLEGE OF
NURSING
BALMATTA, MANGALORE

11.4 Signature

12 12.1Head of the department MRS. SANDHYA D’ALMEIDA, M. Sc. (N)

ASSOCIATE PROFESSOR
DEPT. OF OBSTETRICS AND
GYNAECOLOGICAL NURSING
LAXMI MEMORIAL COLLEGE OF
NURSING
BALMATTA, MANGALORE

12.2 Signature

13. 13.1 Remarks of the Chairman and Principal

13.2 Signature

9. Signature of the candidate

10. Remarks of the guide

11. Name and designation of (in block letters)

MRS. SHANTHI S.
11.5 Guide ASST. PROFESSOR
DEPT. OF CHILD HEALTH NURSING
LAXMI MEMORIAL COLLEGE OF
NURSING, MANGALORE

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 11.6 Signature
11.7 Co-guide (if any)
PROF. THERESA LEONILDA
MENDONCA
VICE-PRINCIPAL AND H.O.D.
LAXMI MEMORIAL COLLEGE OF
NURSING, MANGALORE

11.8 Signature
PROF. THERESA LEONILDA
12 12.2 Head of the department MENDONCA
VICE-PRINCIPAL AND H.O.D.
DEPT. OF CHILD HEALTH NURSING
LAXMI MEMORIAL COLLEGE OF
NURSING, MANGALORE

12.2 Signature

13. 13.1 Remarks of the Chairman and Principal

13.2 Signature

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