Ceyhan and Tekinsoy Kartin Trials (2022)23:707

https://doi.org/10.1186/s13063-022-06603-3

RESEARCH Open Access

The effects of breathing exercises

and inhaler training in patients with COPD
on the severity of dyspnea and life quality:
a randomized controlled trial
Yasemin Ceyhan1*   and Pınar Tekinsoy Kartin2   

Abstract
Background: Severe dyspnea and poor quality of life are common in chronic obstructive pulmonary disease (COPD).
The most important reason for this is wrong applications in inhaler treatment. In addition, inhaler treatments that sup-
port non-pharmacological methods increase the effectiveness of the drug. The aim of this study was to determine the
effects of breathing exercises and inhaler training for chronic obstructive pulmonary disease patients on the severity
of dyspnea and life quality.
Methods: The research was a randomized controlled trial. A total of 67 patients with COPD were included. The
patients were randomized into two groups. Intervention group 1 were given pursed lip breathing exercise and inhaler
training and Intervention group 2 were given only inhaler training. A follow-up after 4 weeks was carried out in both
groups. Patient outcomes in both groups were assessed by a COPD assessment test (CAT), the Modified Medical
Research Council (mMRC) scale, and the St. George’s Respiratory Questionnaire scale (SGRQ). This study followed the
CONSORT checklist for randomized controlled trials. In the data analysis, independent t, Mann-Whitney U, ANOVA,
Wilcoxon analysis, and Pearson chi-square tests were used.
Results: The pursed lips exercise and inhaler drug use skills of patients in both groups increased (p<0.001). The
median value of the CAT and mMRC scores were statistically significant for both groups (p<0.005). The mean of life
quality scores of patients in both groups decreased, and this result was found to be statistically significant in all sub-
dimensions and in the total scale score for both groups (p<0.001). Although the increase in the quality of life and the
decrease in the severity of dyspnea of the patients in both groups were significant, neither group was superior to the
other (p>0.05).
Conclusions: As a result of the study, it was found that the skill of using the inhaler and the life quality of the patients
increased, and the severity of dyspnea decreased. Supporting inhaler treatments with non-pharmacological methods
can increase drug efficacy and quality of life.
Trial registration: ClinicalTrials.gov NCT04739488. Registered on 21 Feb 2021.
Keywords: COPD, Inhaler training, Breathing exercises, Dyspnea, Quality of life, Randomized controlled trial

*Correspondence: yasemin-ceyhan@hotmail.com Background

1
Department of Internal Medicine, Kirsehir Ahi Evran University Faculty Chronic obstructive pulmonary disease (COPD) is an
of Health Sciences Nursing Department, Bağbaşı Campus Faculty of Health important respiratory disease both in Turkey and in the
Sciences 3rd Floor, Downtown, Kirşehir, Turkey
Full list of author information is available at the end of the article rest of the world [1]. It is an important health problem

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Ceyhan and Tekinsoy Kartin Trials (2022)23:707 Page 2 of 11

that is not only a simple respiratory disease but also breathing exercises and inhaler training on the severity of
occurs with a combination of several underlying prob- dyspnea and life quality in COPD patients.
lems, in which airflow is restricted [2]. The fact that
COPD affects more than one system over time causes Methods
difficulties in treatment and care, as well as an increase Study setting
in deaths. COPD ranks third among the diseases that The research was conducted at Ahi Evran University
cause death both in Turkey and in the rest of the world Training and Research Hospital in Kırşehir province in
[3, 4]. For this reason, it is extremely important to know the Central Anatolia Region of Turkey.
the symptoms that occur in the patient and to be able
to control them. Type of study
The most common symptom of COPD, which devel- The study was a randomized control trial and was con-
ops slowly and often occurs at greater ages, is dysp- ducted between September 2017 and December 2018.
nea, which patients define as air hunger or shortness of
breath [2, 3]. This condition is usually accompanied by Ethical consideration
cough, phlegm, wheezing, restriction of daily activities, In order to carry out the study, approval was obtained
fatigue, insomnia, and pain. Increased symptoms and from Kırşehir Ahi Evran University Training and
restriction of daily activities also decrease the life qual- Research Hospital (numbered 10670833/619 and dated
ity of patients [3, 5–8]. 01 August 2017) and Kırşehir Ahi Evran University Fac-
The most important approach in relieving dyspnea and ulty of Medicine Clinical Research Ethics Committee
other symptoms is an accurate and regular pharmaco- (numbered 2017/384 and dated 21 July 2017). In addi-
logical treatment [4]. The most effective pharmacological tion, verbal and written voluntary informed consent was
treatment is inhaler drug use, because the inhaler allows obtained from the participants before starting the study.
the drug to be delivered directly to the airways and causes
fewer side effects compared to systemic treatment [7]. Randomization and participants
However, the only way to benefit from this effect of the All the COPD patients who applied to the chest diseases
inhaler is to use the drug correctly. In a systematic review outpatient clinic of the hospital formed the population
in 2016, studies in the last 40 years were examined, and of the study. The patients were selected from among the
it was reported that inhaler drug misuse had increased volunteers who were monitored by the collaborating phy-
greatly [9]. Similarly, it was found in many studies that sician, who had applied to a single outpatient clinic and
patients used the inhaler with wrong techniques [9–11]. who met the inclusion criteria. The primary purpose of
When the results of the studies were evaluated, it was determining patient groups was to reduce bias and pre-
seen that most of the errors on the use of the inhaler vent patients from influencing each other. Therefore, the
were related to breathing. Incomplete or incorrect steps method of drawing lots was used. The draw was made
such as failure of expiration before using the inhaler, not by an independent observer other than the researchers.
being able to inhale the drug at the appropriate flow rate Firstly, Intervention 1 (I1) and Intervention 2 (I2) was
and not holding the breath for the appropriate time after written on two different papers, which were folded. The
inhaling the drug suggested that the patients’ inhaler use independent observer was asked to choose one of the
should be supported by breathing exercises. papers. The paper he chose had I2 written on it. There-
In addition to pharmacological treatment in dyspnea fore, all patients who came to the clinician examina-
management, the use of non-pharmacological methods tion that day were included in the I2 group. Those who
such as pursed lip breathing (PLB) leads to better airway came the next day were included in the I1 group. In this
patency and alveolar gas exchange for the patient and a way, patients were recruited into groups on consecutive
decrease in dyspnea severity [12]. Particularly, PLB has days. The patients included in the study are shown in the
been reported as B-level evidence in reducing the severity CONSORT flow diagram (Fig. 1).
of dyspnea. The Canadian Thoracic Society Clinical Prac- Individuals were included in the study who were over
tice Guide emphasizes that the life quality of individuals the age of 18, who had been diagnosed with COPD for
should also be evaluated along with dyspnea in studies at least 3 months, who were using inhalers at least twice
relating to COPD [7]. Considering all this, it is thought a day, who used their drug wrongly, who had not previ-
that patients need to use inhaler drugs in the correct ously taken breathing exercise training, and who had not
steps and to support this use with PLB. However, there participated in a rehabilitation program [10, 11, 13, 14].
are no studies in the literature in which inhaler training Individuals with mental disorders, communication dis-
supported by breathing exercise was applied. Therefore, abilities, and heart disease that could lead to dyspnea and
this study was conducted to determine the effects of unstable angina were not included in the study.
Ceyhan and Tekinsoy Kartin Trials (2022)23:707 Page 3 of 11

Fig. 1 Sample diagram

Sample size In the first step, 89 eligible COPD patients were identi-
Since there is no study similar to our study in the lit- fied. As a result of the interviews with the patients, it was
erature, the effect sizes suggested by Cohen were used understood that 11 patients did not meet the inclusion
to determine the effect size [15]. We utilized a within/ criteria and did not accept to participate in the study,
between repeated measures analysis of variance. “Within” and therefore were not included in the research. The first
refers to expected differences between two time periods follow-up of the study was completed with 78 patients.
(first follow-up and second follow-up) and “between” Thirty-eight patients were in the I1 and 40 patients in
refers to expected differences between the Intervention 1 the I2 group. However, some of these patients could not
and Intervention 2 groups. participate in the second interviews due to the reasons
The number of samples in the study was calculated as stated in Fig. 1, and these patients were also excluded
27 in each group according to the values of estimated from the study.
effect size f=0.25, type 1 error=0.05, power=0.95, num-
ber of groups=2, repetitions=2, correlation among Intervention protocol
repeated measures=0.5, and nonsphericity correction Firstly, the questionnaire forms were given on the first day
ɛ=1. The anticipated drop-out rate was 20%, and the when the patients were included in the study. After com-
study was completed with a total of 67 patients, 32 in pleting the form, the patient was instructed in accord-
Intervention I1 group and 35 in I2 group. The sample size ance with the intervention group. In accordance with the
was calculated using G*Power version 3.1.9.2. training content, patients were asked to continue the pro-
The patients included in the study and their reasons cedures they had learned twice a day for four weeks. In
for leaving are specified in the consort flow chart (Fig. 1). addition, the researchers provided consultancy by calling
Ceyhan and Tekinsoy Kartin Trials (2022)23:707 Page 4 of 11

the patients twice a week. After the intervention was Chart consisted of 10 items including only the skill of
continued for 4 weeks, the patients were invited for re- using inhaler, to be applied to group I2. Correct steps
evaluation to the hospital, where the second follow-up of were evaluated as 1 point and wrong steps as 0 points in
patients who completed the 4-week procedure was per- both skill charts.
formed. In this follow-up, the questionnaires were given
again and the patients’ inhaler use skills were evaluated. COPD Assessment Test (CAT)
This scale, developed by Jones et al. [16], is used to meas-
Intervention 1 group ure the health status of individuals with COPD. There
In the first interview, sociodemographic information are 8 questions in total in the scale, which is scored as
was obtained from the patients, and their COPD, lev- an increasing Likert scale between 0 and 5. The Turkish
els of dyspnea and life quality, and their skill of using validity and reliability study of the scale was conducted
the inhaler were evaluated. Patients who used their by Yorgancıoglu et al. [17] and reported to be appropri-
drug wrongly were given training, and PLB exercise was ate. The Cronbach’s α coefficient of the scale in this study
taught. In the interview room of the outpatient clinic, the was calculated as 0.95 in the first follow-up and the last
researcher first applied the PLB exercise herself and then follow-up, and it was found to be highly reliable.
repeated the application steps for the patient by both
explaining and showing them until they had learned. St. George’s Respiratory Questionnaire (SGRQ)
Then, the application was made together with the patient This is a quality of life questionnaire specific to patients
and the points that the patient was unable to do were with COPD, developed by Jones and Forde [18]. There
corrected. After the application, the patient was rested are 50 questions in total in the scale, which is scored as
and the training of inhaler drug use was started. an increasing Likert scale between 0 and 5. The Turkish
The researchers used a placebo drug specifically for validity and reliability study of the scale was conducted
each type of inhaler used by the patient to provide train- by Polatlı et al. [19] and reported to be appropriate. Cron-
ing by the demonstration method. The patient was also bach’s α coefficient in this study was calculated as 0.84 in
allowed to repeat the application with a different placebo the first follow-up and 0.88 in the second follow-up, and
drug, and the training was continued until the incor- the scale was found to be highly reliable.
rect steps were corrected. At the end of the training, the
patients were given leaflets enriched with color pictures, Modified Medical Research Council (mMRC) Scale
which they could read at home to remember the steps This was developed by the British Medical Research
they had forgotten. Council in order to provide information about the degree
of dyspnea experienced by the patients with COPD based
Intervention 2 group on their and their perception of the disease [20]. There
In the first interview, the patients’ sociodemographic are 5 questions in total in the scale, which is point as
information was obtained and their COPD, levels of between 0 and 4. It has been stated that the scale can be
dyspnea and life quality and their skill of using the inhaler used safely in the evaluation of dyspnea in studies con-
were evaluated. Then, each patient was taught the correct ducted in Turkey [21]. As it is a one-dimensional scale,
application steps according to the type of inhaler he or the Cronbach’s α coefficient could not be calculated.
she used as described above. The difference of this group
from group I1 was that the patients were given only train- Data analysis
ing on inhaler drug use, and PLB exercise was not given. Data were evaluated with IBM SPSS Statistics 25.0 (Sta-
At the end of the training, inhaler drug use brochures tistical Package for the Social Sciences; IBM Corp.,
were given. Armonk, New York, ABD) and MINITAB statistical
program package. After evaluations were made with the
Data collection Shapiro Wilk normality test, the two-sample independent
Forms prepared by the researchers t-test was used for normal distribution, and the Mann-
These were a Patient Information Form, an Inhaler Use Whitney U test was used for non-normal variables. Com-
Skill Chart, and a Breathing Exercise and Inhaler Use parisons of groups over time were made with two-way
Skill Chart [10, 11, 14, 16]. The Patient Information Form analysis of variance in repeated measurements for varia-
consisted of 19 questions including the sociodemo- bles with normal distribution. Categorical variables were
graphic and disease features of the patients. The Breath- included in the model with dummy coding. Bonferroni
ing Exercise and Inhaler Application Skill Chart consisted correction was applied, and comparisons of the main
of 18 items including the steps of PLB and inhaler use effects and intragroup comparisons for variables that did
to be applied to group I1. The Inhaler Application Skill not show normal distribution were made with Wilcoxon
Ceyhan and Tekinsoy Kartin Trials (2022)23:707 Page 5 of 11

analysis. The relationship between categorical variables The median value of the CAT score difference of the
was examined with the exact method of the Pearson chi- patients in group I1 decreased from 35.5 in the first fol-
square test. A value of p<0.05 was considered statistically low-up to 27.0 in the last follow-up and from 34.0 to 29.0
significant in the study. Reliability measurements of the in group I2. This decrease indicated that the patients’
scales were made according to Cronbach’s α coefficient. COPD assessment status was improving, and the result
was statistically significant for both groups (p<0.001). The
Results difference between the total CAT score in the patients’
It was found that 56.3% of group I1 were between the first and last follow-up in I1 and I2 was found to be 5.5
ages of 60 and 69, 56.3% had been diagnosed with COPD in I1 and 3.0 in I2, and the result was statistically signifi-
for 1-4 years, and 90.6% of these patients described their cant (p<0.05). The median value of the mMRC scale score
most common problem as shortness of breath. In group difference of the patients in groups I1 and I2 decreased
I2, 48.6% of the patients were between the ages of 60 and from 4.0 at the first follow-up to 3.0 at the last follow-
69, 48.6% had been diagnosed with COPD for 1–4 years, up. This situation revealed that the severity of dyspnea
and 82.9% of the patients reported that the problem they in patients decreased and the result was statistically sig-
complained about most was shortness of breath. No sta- nificant for both groups (I1=p<0.001, I2=p<0.05). The
tistical difference was found between groups I1 and I2 in differences between the mMRC scores of the patients in
terms of descriptive features (p>0.05) (Table 1). groups I1 and I2 at the first and last follow-up was found
It was observed that most of the patients made errors to be 1.0 in I1 and 0.0 in I2, and the result is statistically
in all steps of the breathing exercise in the first follow- significant (p<0.05) (Table 4). Thus, it was concluded that
up. These errors were observed as inability to breathe breathing exercises and inhaler training applied twice a
through the nose at the appropriate time, inability to per- day for 4 weeks to patients with COPD reduces the sever-
form expiration in twice the time of inspiration and with ity of dyspnea.
appropriate force, inability to purse the lips as if whistling The distribution of life quality scores of the patients in
while exhaling, and inability to continue the application groups I1 and I2 at the first and last follow-up is given
for 10 min. After the training, it was found that most of in Table 5 by correcting for all covariates. The mean of
the steps had been learned, and the difference between life quality scores of patients in both groups decreased
the two follow-ups was significant (p<0.001) (Table 2). in effect, symptom, activity, and overall score of the
When the inhaler drug use steps of the patients in scale from first follow-up to last follow-up. As the score
groups I1 and I2 in the study were examined, it was seen obtained from the quality of life scale decreases, the
that the errors made before the training were quite high life quality of the patients increases. Accordingly, in
in both groups. It was observed that most of the errors sub-dimensions and in the total, life quality level of the
were in steps such as not exhaling before applying the patients in groups I1 and I2 increased compared to their
drug, not being able to apply hand-breath coordina- first follow-up. This result was found to be statistically
tion, not being able to inhale at the appropriate speed, significant in all sub-dimensions and in the total scale
not being able to hold the inhaled drug for 10 s, and not score for the two groups (time effect p<0.001) (Table 5).
performing a mouthwash after using the inhaler. It was When the effect of training on the groups was exam-
found that these steps were learned after the training and ined, it was found that the groups did not have superior-
the difference between the two follow-ups was significant ity over each other in sub-dimensions or total scale score,
(p<0.001). and this did not create a statistically significant difference
The mean scores of the patients received from the (group effect p>0.05). When the effectiveness of training
inhaler types increased in the last follow-up compared on time and among the groups of the patients in groups
to the first follow-up, and this increase was found to be I1 and I2 was analyzed, it was seen that there was no sta-
statistically significant in I1 (p<0.001, p<0.001, p<0.001, tistically significant difference in sub-dimensions or total
p=0.002) and in I2 (p<0.001, p<0.001, p=0.003, p=0.002). scale score (group × time effect p>0.05). Thus, consider-
The differences between the inhaler scores of the patients ing the time effect of group I1, it was found that it did not
in groups I1 and I2 at the first and last follow-up were have any superiority over group I2.
similar in all types of inhaler and no statistical signifi-
cance was found between the differences (p>0.05). This Discussion
shows that the training given to the groups was the same. Although correct inhaler utilization is extremely impor-
The distribution of inhaler types was examined according tant in reducing complaints that can be experienced by
to the first follow-up of the individuals in groups I1 and COPD patients, many studies have revealed that a lot of
I2, and the two groups were found to be similar in this patients use inhalers wrongly [9–11, 22]. In this study,
respect (p>0.05) (Table 3). similar to the literature, it was found that patients made
Ceyhan and Tekinsoy Kartin Trials (2022)23:707 Page 6 of 11

Table 1 Distribution of introductory features of Intervention 1 and Intervention 2 groups

Group

Introductory Features Group I1 (n=32) Group I2 (n=35) Total (n=67) Test

p
n % n % n %

Age group
40–49 years 1 18.8 2 5.7 3 4.5 0.937
50–59 years 6 3.1 8 22.9 14 20.9
60–69 years 18 56.3 17 48.6 35 52.2
70 years and older 7 21.8 8 22.8 15 22.4
Gender
Female 3 9.4 4 11.4 7 10.4 1.000
Male 29 90.6 31 88.6 60 89.6
Educational status
Illiterate/primary school 21 65.6 28 80.0 49 73.0 0.107
Secondary school/high school 8 25.0 4 11.4 12 18.0
Associate degree/bachelor’s degree 3 9.4 3 8.6 6 9.0
Marital status
Married 31 96.9 33 94.3 64 95.5 1.000
Single 1 3.1 2 5.7 3 4.5
Time since diagnosis
1–4 years 18 56.3 17 48.6 35 52.2 0.763
5–9 years 5 15.6 8 22.9 13 19.4
10 years + 9 28.1 10 28.6 19 28.4
Smoking status
Smoker 5 15.6 9 25.7 14 20.9 0.598
Ex-smoker 24 75.0 24 68.6 48 71.6
Non-smoker 3 9.4 2 5.7 5 7.5
Alcohol drinking status
Ex-drinker 9 28.1 9 25.7 18 26.9 0.885
Non-drinker 23 71.9 26 74.3 49 73.1
The most common problems*
Shortness of breath 29 90.6 29 82.9 58 86.6 0.480
Cough 19 59.4 24 68.6 43 64.2 0.433
Phlegm 16 50.0 23 65.7 39 58.2 0.223
Fatigue 10 31.3 7 20.0 17 25.4 0.401
Insomnia 8 25.0 6 17.1 14 20.9 0.551
Wheezing 8 25.0 12 34.3 20 29.9 0.437
Sweating 4 12.5 10 28.6 14 20.9 0.138
Hospitalization status (last 1 year)
Yes 13 40.7 10 28.6 24 35.8 0.763
No 19 59.3 25 71.4 43 64.2
Duration of hospital stay
1-4 days 6 46.2 4 40.0 10 43.5 1.000
5 days + 7 53.8 6 60.0 13 56.5
Type of inhaler**
MDI 24 75.0 26 74.2 50 37.3 **
Diskus/Discair/Sanohaler 14 43.7 19 25.7 33 24.6
Neohaler/Aerolizer 14 43.7 12 34.2 26 19.4
Handihaler 12 37.5 13 37.1 25 18.6
Need to use an extra inhaler during the day
Yes 12 37.5 16 45.7 28 41.8 0.806
No 20 62.5 19 54.3 39 58.2
Training status for inhaler utilization
Trained 18 58.1 26 74.3 44 66.7 0.197
Not trained 13 41.9 9 25.7 22 33.3

*Patients gave more than one answer

**Some patients use more than one inhaler so no comparison could be made
Ceyhan and Tekinsoy Kartin Trials (2022)23:707 Page 7 of 11

Table 2 Breathing exercise skills of patients in the intervention 1 group at the first and last follow-up
Steps of breathing exercise I1 Group (n=32) p*

Yes No
First Last follow-up First Last
follow-up follow-up follow-up

Sit comfortably and breathe through your nose for 2–3 s like smelling flowers 3 32 29 0 <0.001
Purse your lips like whistling and exhale slowly. 4 32 28 0 <0.001
Try to exhale from just your lips in 4–6 s 0 31 32 1 <0.001
Exhale like blowing the flame of a candle but not extinguishing it. 1 31 31 1 <0.001
Do not inflate your cheeks and do not tighten your abdominal muscles while exhaling 2 31 30 1 <0.001
Take a normal comfortable breath after 2 or 3 applications in a row 0 32 32 0 <0.001
Continue this exercise for about 10 min, but rest when you have difficulty 0 32 32 0 <0.001
Rest for 10 min after the exercise and move on to the drug application steps 0 31 32 1 <0.001
*McNemar and two-proportions z test

Table 3 Distribution of inhaler score differences of patients in intervention 1 and intervention 2 groups
Intervention Groups and Tests Inhaler drug types
MDI Diskus/Discair/Sanohaler Neohaler/Aerolizer Handihaler

Intervention 1 group (n=32) First follow-up 6.0 (5.0–7.0) 6.0 (5.5–8.0) 6.0 (5.5–7.5) 6.5 (5.25–7.0)
M (Q1–Q3)
Last follow-up 10.0 (10.0–10.0) 10.0 (10.0–10.0) 10.0 (10.0–10.0) 10.0 (10.0–10.0)
M (Q1–Q3)
Difference* 4.0 (5.0–3.0) 4.0 (4.5–1.5) 4.0 (4.5–2.5) 3.5 (4.75–3.0)
M (Q1–Q3)
p** <0.001 <0.001 <0.001 0.002
Intervention 2 group (n=35) First follow-up 5.0 (4.0–7.0) 6.0 (5.0–7.0) 6.5 (6.0–8.0) 6.0 (5.5–7.5)
M (Q1–Q3)
Last follow-up 10.0 (9.0–10.0) 10.0 (9.0–10.0) 10.0 (9.0–10.0) 10.0 (9.0–10.0)
M (Q1–Q3)
Difference* 5.0 (5.0–3.0) 3.0 (4.0–3.0) 3.0 (3.75–2.0) 3.0 (4.5–2.5)
M (Q1–Q3)
p** <0.001 <0.001 0.003 0.002
I1 and I2 group difference comparison p*** 0.464 0.953 0.173 0.390
I1 and I2 group first follow-up comparison p*** 0.306 0.632 0.460 0.932
M median, Q1 25th percentile, Q3 75th percentile
*The difference was obtained by subtracting the first follow-up score from the last follow-up score
**Since the data are not parametrically distributed, z: Wilcoxon analysis was used
***Since the data are not parametrically distributed, z: Mann-Whitney U test was used

a lot of errors in all types of inhaler. As a result of the fail- drugs was not appropriate. In this study, similar to the lit-
ure of effective expiration before using the drug, which erature, it was found that patients did not expire before
is the leading cause of the errors, drug particles do not using the inhaler and were not able to inhale at the
remain in the airways [23]. Göriş et al. [10] and Özel et al. appropriate flow rate.
[22] reported that expiration was not performed before Retaining the drug by holding the breath for a certain
using the drug. In addition, the drug must be inhaled at period of time after the application of the drug is an
an appropriate flow rate in order for the drug particles important step which is necessary for of the drug parti-
to reach the airways in the periphery [23]. Takaku et al. cles to settle in the airways. A time of approximately 10
[11] showed in a study in 2017 that the flow rate of the s is suggested [24]. In this study, it was observed that the
Ceyhan and Tekinsoy Kartin Trials (2022)23:707 Page 8 of 11

Table 4 Distribution of score differences with COPD assessment few of the patients who did not have any knowledge of
and mMRC scores of the patients in the Intervention 1 and breathing exercises were seen to try with their own effort
Intervention 2 groups at the first and last follow-up to breathe out as if they were whistling when their symp-
Intervention groups and tests CAT​ mMRC toms increased, but it was understood that they could
not perform the procedure correctly. It was determined
I1 group (n=32) First follow-up 35.5 (30.25–38.75) 4.0 (3.0–4.0) at the end of the training that PLB had been learned. It
M (Q1–Q3)
has been reported in the literature that PLB exercise pro-
Last follow-up 27.0 (21.0–32.5) 3.0 (3.0–3.0)
M (Q1–Q3) vides various benefits for patients with COPD. Decrease
Difference* 5.5 (4.0–9.0) 1.0 (0.0–1.0) in severity of dyspnea and the number of ventilations per
M (Q1–Q3) minute and an increase in oxygen saturation and exercise
p** <0.001 <0.001 capacity are among these benefits [14, 25]. In this study, it
I2 group (n=35) First follow-up 34.0 (28.0–36.0) 4.0 (3.0–4.0) was observed that patients in group I1 who were taught
M (Q1–Q3) PLB scored better in CAT (p=0.002) and mMRC dyspnea
Last follow-up 29.0 (20.0–34.0) 3.0 (3.0–4.0) severity (p=0.040) than group I2 (Table 4).
M (Q1–Q3)
While the symptoms caused by COPD affect the daily
Difference* 3.0 (2.0–5.0) 0.0 (0.0–1.0)
M (Q1–Q3) work of an individual, they also determine the perception
p** <0.001 0.001 of the disease. Problems created by COPD in patients
Difference comparison of groups I1 0.002 0.040 were evaluated with CAT. It was found that the CAT
and I2 p*** score of both groups decreased and the results were sig-
M median, Q1 25th percentile, Q3 75th percentile nificant (p<0.001). When the score differences between
*The difference was obtained by subtracting the first follow-up score from the the groups were examined, the greater effect in group I1
last follow-up score revealed that breathing exercise performed in addition to
**Since the data are not parametrically distributed, z: Wilcoxon test was used inhaler training contributed positively to COPD assess-
***Since the data are not parametrically distributed, z: Mann-Whitney U test was ment (Table 4). Similarly, in the literature [26, 27], it is
used
reported in studies involving inhaler training and breath-
ing exercises given to patients with COPD that the total
patients did not pay attention to this step at the first fol- CAT score of the intervention group patients decreased
low-up, but they held their breath for a suitable period and the result was significant compared to the control
after training. group (p<0.05).
When the differences in scores were examined accord- The effect of trainings on the dyspnea severity of
ing to the inhaler types used by the patients, it was patients was evaluated by the mMRC scale, and it was
observed that the lowest score difference in group I1 was revealed that the training given was effective in group I1
in the handihaler group (Table 3). It is thought that this (p<0.001) and group I2 (p=0.001). According to the score
is due to the fact that the patients made the most errors differences between the groups, the effect in group I1 was
in the steps related to breathing during the first follow- higher, and it was found that breathing exercise applied
up, and the breathing exercises given to group I1 were in addition to inhaler training contributed positively to
effective. In addition, it has been supported by many the perception of dyspnea (Table 4). In the literature [7,
studies that the handihaler, which is dry powder inhaler 10, 12, 26, 28, 29], many studies reporting that the train-
type, is easier to use than the other inhaler types [10, 11, ing given to patients with COPD contributed positively to
22]. According to the first follow-up comparison test in the severity of dyspnea support the results of this study.
Table 3, the groups were similar in terms of the inhaler Airway obstruction and accompanying symptoms
types used (p>0.05). In the same way, the fact that the I1 in COPD have a negative effect on the quality of life [7,
and I2 group difference comparison test was not signifi- 8]. The effect of the training given in the study to the
cant in all inhaler types means that the training given was patients on the quality of life was examined, and it was
similar (p>0.05). seen that there were improvements in both groups in
It has been reported in the literature that breath- the sub-dimensions and overall score of the quality of
ing exercises can increase the volume that patients will life scale at the last follow-up compared to the first fol-
inhale before inhaler drug use [23]. In particular, it has low-up. Reports in other studies conducted with COPD
been reported that PLB will reduce dyspnea and the patients that the training given improves the quality of
number of breaths per minute, providing ventilation life [7, 10, 29–31] are similar to the quality of life findings
efficiency so that inhaler drugs will perform better [12]. of this study.
In this study, the patients in group I1 were asked to per- In the present study, quality of life did not make any
form PLB at least twice a day for 10 min. Initially, only a difference in terms of training given to groups I1 and
Ceyhan and Tekinsoy Kartin Trials (2022)23:707 Page 9 of 11

Table 5 Distribution of life quality scores of the patients in Intervention 1 and Intervention 2 groups at the first and last follow-up
SGRQ sub-dimensions and total score Groups Test statistic
p**
Intervention 1 (n=32) Intervention 2 (n=35)
x ± sem x ± sem

Effect First follow-up 51.89±3.27 50.04±3.1 F=0.158

p=0.693
Second follow-up 29.47±3.67 33.5±3.5 F=0.606
p=0.440
Test statistic F=87.035 F=51.889
p** p<0.001 p<0.001
*Group × time effect: F=2.989; p*=0.090; group effect: F=0.057; p=0.812; time effect: F=8.876; p=0.004
Symptom First follow-up 65.23±2.87 63.25±2.74 F=0.232
p=0.632
Second follow-up 60.45±2.91 60.14±2.77 F=0.006
p=0.937
Test statistic F=38.552 F=18.209
p** p<0.001 p<0.001
*Group × time effect: F=2.261; p=0.139; group effect: F=0.079; p=0.779; time effect: F=6.114; p=0.017
Activity First follow-up 72.57±2.97 70.53±2.84 F=0.233
p=0.631
Second follow-up 56.69±3.32 56.39±3.17 F=0.004
p=0.949
Test statistic F=40.701 F=35.496
p** p<0.001 p<0.001
*Group × time effect: F=0.241; p=0.626; group effect: F=0.081; p=0.777; time effect: F=17.919; p <0.001
Total First follow-up 60.37±2.71 58.44±2.59 F=0.249
p=0.620
Second follow-up 42.87±3.01 44.88±2.87 F=0.220
p=0.641
Test statistic F=83.798 F=55.362
p** p<0.001 p<0.001
*Group × time effect: F=2.093; p=0.154; group effect: F=0.001; p=0.991; time effect: F=14.257; p <0.001
F, two-way repeated measures Anova
*Group × time effect, the comparison value between groups of the first and last follow-up differences of each group
**Adjusted for age, gender, educational status, marital status, time of diagnosis, smoking status, alcohol drinking status, hospitalization status (last 1 year), duration of
hospital stay, and training status for inhaler utilization

I2. It was expected according to the literature that live with the disease can be positively affected [10, 32].
PLB exercise given to group I1, unlike group I2, would In addition, the statements of the patients in group I2
be significant in terms of quality of life [5, 7, 10]. In a that they received more inhaler training when they
study conducted by Dogan [27] with planned train- were first diagnosed, that they stayed less in the hos-
ing given to patients with COPD, it was reported that pital in the last year and that their stay was shorter,
after PLB training, the scores on the sub-dimensions and that they experienced fewer symptoms such as
of the quality of life scale and the total scale score of shortness of breath, fatigue, and insomnia are factors
the intervention group decreased, and quality of life that may cause a difference between the two groups.
increased. Similarly, in this study, it was seen that the The increase in shortness of breath, which is one of
total quality of life score of group I1, which included the important symptoms of COPD, brings with it the
patients given PLB training, was better than that of symptoms of insomnia and fatigue. These symptoms
group I2. However, there was no statistical significance affect the patient significantly and decrease the quality
between the two groups in terms of the quality of life of life [3, 8, 33].
scale (Table 5). Some features of group I2 in the study The feeling of shortness of breath in particular is an
were thought to affect this significance. Especially, the important factor that affects the daily routine and care
longer time since diagnosis of group I2 shows that the actions of an individual, ultimately decreasing their
patients adapt better to COPD. Studies have reported quality of life. Demir et al. [5] examined the relation-
that as the time since diagnosis increases, learning to ship between dyspnea and quality of life and reported
Ceyhan and Tekinsoy Kartin Trials (2022)23:707 Page 10 of 11

that the quality of life decreased as the severity of dysp- Availability of data and materials
Applicable.
nea increased. In a systematic review, Geddes et al. [34]
reported that the quality of life increased with a decrease
in the severity of dyspnea in COPD patients, but that Declarations
more detailed studies were needed to provide an evi- Ethics approval and consent to participate
dence-level thesis. In this study, the fact that the dyspnea This study was conducted in accordance with the consensus ethical principles
derived from international guidelines including the Declaration of Helsinki.
level of the patients was found to be high and quality of The study was registered at Clini​calTr​ials.​gov as NCT04739488. Ethics commit-
life was low showed similarity with the literature. tee approval numbered 2017/384 and dated 21.07.2017.

Consent for publication

Not applicable.
Conclusions
According to the results of the study, it was found that Competing interests
The authors declare no competing interests.
PLB exercise and inhaler training applied to patients with
COPD improves breathing exercise and inhaler using Author details
1
skills, reduces the negative effects of COPD on the indi- Department of Internal Medicine, Kirsehir Ahi Evran University Faculty
of Health Sciences Nursing Department, Bağbaşı Campus Faculty of Health
vidual, relieves the severity of dyspnea, and improves Sciences 3rd Floor, Downtown, Kirşehir, Turkey. 2 Department of Internal Medi-
the quality of life. In line with these results, the follow- cine, Erciyes University Faculty of Health Sciences Nursing Department, Kosk
ing measures can be suggested: training for inhaler drug District, Kutadgu Bilig Street, Inside the Old Faculty, Melikgazi, Kayseri, Turkey.
use by nurses, teaching non-pharmacological methods Received: 1 November 2021 Accepted: 27 July 2022
such as PLB exercise, the support of nurses for patients
with evidence-based practices in COPD by following the
current literature, establishing special units under the
leadership of COPD nurses in hospitals, conducting reg- References
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