Effectiveness of a Breathing Training Program on Quality of Life in Patients with Predialysis Chronic Kidney Disease: A Randomized Controlled Trial

INTRODUCTION

Chronic kidney disease (CKD) is a rapidly increasing illness with high rate of morbidity and mortality. The prognosis is generally poor with worsening of physical functioning leading to psychological distress.[1] CKD patients have suboptimal quality of life (QOL) in comparison with normal general population.[2] In all stages of kidney disease, QOL is decreased.[3] An important aspect of health and well-being is QOL. Effectiveness of any treatment is determined by QOL. Since chronic diseases are immedicable, the target is to better the health of patients.[456]

Previous conducted studies/researches have revealed that exercises involving breathing have beneficial results on different systems of the human body.[78910111213141516] Breathing exercises can improve the prognosis of CKD. Since beneficial effects of breathing exercises were found in chronically ill patients in other population, there was a probability for a similar study in patients suffering from CKD. The study was aimed to determine if breathing training program is beneficial to enhance the QOL of CKD patients. The objective was to assess/evaluate the effectiveness of a breathing training program on QOL in patients with predialysis CKD.

METHODS

A randomized controlled trial was carried out at PGIMER, Chandigarh. In the study, predialysis CKD patients between the age group of 18–65 years, who have clinically stable course for last 1 month and estimated glomerular filtration rate between 15 and 45 ml/min/1.73 m² were included. Those on dialysis, pregnant or lactating females were excluded. Using lottery method, randomization into intervention and control group was done. Individuals were interviewed using pro forma containing socio demographic variables and clinical profile. Assessment of QOL was assessed in both experimental and control group by using Kidney Disease and QOL questionnaire (KDQOL™-36) at baseline and after 4 weeks in both the group.

Intervention: Breathing training program consisting of three breathing exercises, i.e. Alternate nostril breathing or anulom-vilom, 4-7-8 breathing exercise and breath counting.[1718] It was taught with the help of a video and demonstration to the individuals in the intervention group individually.

The first practice session of the breathing exercises was demonstrated by the researcher. The individuals were then asked to perform return demonstration which was evaluated by the researcher for correct technique. The individuals in the experimental group were handed over a prerecorded video to practice the exercises at home. The individuals were asked to perform breathing exercises at home for 5 min three times a day daily.

• Frequency – thrice daily

• Number of sessions – three times a day for 4 weeks, i.e., total 90 sessions

• How long each session – 5 min

• Total intervention – 4 weeks' intervention period with total 15 min/day.

The video acted as a reminder and reference to the patients about the steps to be followed. A daily record sheet was given to the individuals to record daily the date and time of performing the breathing exercises.

Follow-up was done via phone calls made by the researcher (every 7^th day) to the individuals to ensure that they are doing the breathing exercises. The control group received routine care. Assessment of QOL was done after 4 weeks in both the groups by the same researcher.

RESULTS

Participants were recruited between July and October, 2016. Among 77 individuals screened, 15 individuals were excluded because they did not meet eligibility criteria [Figure 1]. Sixty-two patients were enrolled and randomized using lottery method into intervention and control group. One subject from each group was lost to follow-up. Analysis was done only for the 60 individuals who completed the posttest questionnaires. The dialysis-specific component was excluded because only predialysis patients were included.

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Figure 1

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Mean age was 51.83 ± 10.27 years in control and 52.06 ± 6.97 years in intervention group. 70% were males in control and 50% were males in intervention group. In Table 1, the baseline sociodemographic and clinical profile of the individuals are mentioned. Both the groups were comparable as per P > 0.05. Change in KDQOL™-36 scores for the subscales symptom/problem list and SF-12 physical health composite showed significant difference in mean score in the group receiving intervention. No significant difference was observed in mean score in the control group post intervention [Table 2]. KDQOL™-36 scores for the subscales-effects of kidney disease, symptom/problem list and burden of kidney disease were comparable at baseline [Table 3]. The t-test analyses revealed that the score changes were significantly greater in the group receiving intervention than in the control group in the subscale effects of kidney disease (P = 0.04), SF-12 physical functioning or physical health component (P = 0.01) and SF-12 mental functioning or mental health composite (P = 0.003).

DISCUSSION

In the present randomized trial, we evaluated the effectiveness of a breathing training program on QOL in patients with pre-dialysis CKD. The breathing training program administered to pre-dialysis CKD patients showed significant improvement in patients' KDQOL™-36 scores in the intervention group.

The findings of the present study are supported by observation of studies reported earlier. It was stated by Pal et al.[7] that a brief time of breathing induces a reaction of relaxation, indicating a decrease in sympathetic nervous system activity, reduces the result of strain as well as stress on the human body, boosts cardiovascular as well as respiratory functions, improves the physical and mental health. Tsai et al.[8] showed that there is significant improvement in the mental component summary and the role emotional domain in hemodialysis patients in the breathing training group. Malathi[9] revealed significant increase in the QOL amidst patients suffering from COPD with breathing training program. Yoyok et al.[10] showed that breathing exercise which is done on a regular basis increase the secretion of IgG, endorphins and decrease blood glucose. Silva et al.[11] stated that practicing deep breathing exercises significantly decreased the diastolic blood pressure and anxiety level in patients with Coronary Artery Disease. It was also found that yoga breathing improve mental QOL, sleep and reduces anxiety among patients with cancer.[12] In another study, there is reduction in anxiety, pain, fatigue and insomnia in patients on hemodialysis.[13] Vitality and mental health scores of patients with obstructive sleep apnea improved with relaxation breathing training.[14] A scrutiny of researches of patients with asthma showed that QOL improved after they were taught and performed diaphragmatic breathing.[15] Other studies have shown that breathing leads to relaxation. They help to promote relaxation, inner peace and calmness while reducing stress, agitation and anxiety. The regular practice of breathing exercise decreases strain and stress on the human body, betters physical and mental health.[16]

In present study, the mean age was 52.06 ± 6.97 years in the intervention and 51.83 ± 10.27 years in the control group. Most participants were males, married, Hindu by religion and educated up to secondary level. Similar finding were reported by Guerra-Guerrero et al.[19] and Kim et al.[20] The most common co-morbidity was hypertension (HTN) followed by diabetes. Hypertension being most common co morbidity could be due to the deterioration in kidney function leading to hypertension. This finding was in contrast to Kim et al.[20] where diabetes was the most common followed by HTN.

Our results indicate that breathing training program can be successful in upgrading QOL of patients. This intervention helps in promoting relaxation to the body and mind, it provides a feeling of well-being, improves the normal physiological function of the body thus improving physical and mental health. The benefits of breathing exercises are well worth the effort and a person is less prone to health issues.

Breathing training program can be voluntarily incorporated by nurses into the charge of such suffering patients. Furthermore, this intervention can be a beneficial aid that any nurse or caregiver might utilize for the betterment of other patients. This intervention seems to give nurses a pathway to offer support to a vulnerable population. Nurses can promote QOL through patient education and planning programs such as breathing training programs.

Limitations of the study: Long term or continuing follow up is required to see total impact of breathing training program on QOL. The duration of the data collection was limited, therefore, generalization cannot be made from the findings out of the small study sample.

CONCLUSIONS

The study was aimed to assess or evaluate the effectiveness of a breathing training program on QOL in patients with predialysis CKD. The study showed that as per KDQOL™-36, significant difference was noted between the intervention and control group. It is concluded that breathing training program is significantly effective in improving QOL in CKD patients.