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Deep Breathing Exercise and Active Range of Motion Influence Physiological

Response of Congestive Heart Failure Patients

Article  in  Nurse Media Journal of Nursing · April 2020

DOI: 10.14710/nmjn.v10i1.25318

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 Nurse Media Journal of Nursing, 10(1), 2020, 57-65
Available online at [Link]
DOI: 10.14710/nmjn.v10i1.25318

Deep Breathing Exercise and Active Range of Motion

Influence Physiological Response of Congestive Heart
Failure Patients

Novita Nirmalasari1, Mardiyono Mardiyono2, Edi Dharmana 3, Thohar Arifin3

1
Department of Nursing, Faculty of Health, Jenderal Achmad Yani Yogyakarta University, Indonesia
2
Department of Nursing, Health Polytechnic of Semarang, Indonesia
3
Faculty of Medicine , Universitas Diponegoro, Indonesia
Corresponding Author: Novita Nirmalasari (novitanirmalasari@[Link])

Received: 6 September 2019 Revised: 9 March 2020 Accepted: 12 April 2020

ABSTRACT

Background: Dyspnea and physiological changes are clinical manifestations of

Congestive Heart Failure (CHF) due to respiratory failure. Deep breathing exercise
combined with active range of motion increases respiratory muscles and blood
circulation. As a result, it reduces breathing effort and decreases blood pressure .
Purpose: This research aimed to analyze the influence of deep breathing exercise and
active range of motion (ROM) on the physiological response of CHF patients.
Methods: This study used a quasi-experiment with pretest-posttest control group design
recruiting 32 respondents by stratified random sampling technique. The intervention
was done three times a day for three days. Deep breathing exercise for thirty times and
continued with active range of motion for five times each movement. Digital
sphygmomanometer and digital watch were used as measuring instruments. Data were
analyzed using independent and paired t-tests.
Result: The results showed that there were significant differences in the systole
(p=0.000), diastole (p=0.000) and respiratory rates (p=0.003) after the intervention
compared to the control group. There was also a significant difference in systolic blood
pressure between the intervention and the control group (p=0.003). However, no
significant difference in diastole and respiratory rates was found.
Conclusion: Deep breathing exercise combined with active range of motion decreases
the systole in CHF patients. Further research is expected to lengthen the time of
intervention to allow better significance.

Keywords: Active range of motion; CHF; deep breathing exercise; physiological

response

How to Cite: Nirmalasari, N., Mardiyono, M., Dharmana, E., & Arifin, T. (2020). Deep
breathing exercise and active range of motion influence physiological response of
congestive heart failure patients. Nurse Media Journal of Nursing, 10(1), 57-65. doi:
doi:10.14710/nmjn.v10i1.25318
Permalink/DOI: [Link]

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 Nurse Media Journal of Nursing, 10(1), 2020, 58

BACKGROUND
Heart and blood vessel diseases are one of the major health problems in both developed
and developing countries. This disease is the first leading cause of death in the world,
and the prevalence is estimated to continually increase up to 23.3 million in 2030
(Ministry of Health Republic of Indonesia [MoHRI], 2014; Yancy et al., 2013). Similar
phenomena also occur in Indonesia. The result of Basic Health Research (Riskesdas) by
the Ministry of Health, Republic of Indonesia in 2013 reported that the prevalence of
heart failure in Indonesia reached 0.3% (MoHRI, 2013). The highest prevalence in Java
island occurs in Yogyakarta Province, with the percentage of 0.25 % (MoHRI, 2014).
The increasing prevalence will cause problems for diseases, disabilities, and socio-
economic problems for family, communities, and the state (MoHRI, 2014; Ziaeian &
Fonarow, 2016). Therefore, comprehensive management for heart failure, especially
symptom management, needs to be addressed.

Dyspnea is a hallmark symptom of Congestive Heart Failure (CHF). Dyspnea impairs

functional capacity and quality of life. Dyspnea caused by ventricular dysfunction
causes decreased cardiac output and increased pulmonary venous pressure resulting in
pulmonary congestion. This ultimately leads to extravasation of fluid into the interstitial
space and lung alveoli, which reduces pulmonary compliance and impairs the ease of
breathing. Patients who have the NYHA functional class of III-IV will be having high
levels of dyspnea complaints (Kupper, Bonhof, Westerhuis, Widdershoven & Denollet,
2016). Patients with NYHA IV will be panting every day, even during mild activity or
at rest. This is because dyspnea affects the decrease in tissue oxygenation and energy
production, so that patient’s daily activity will also decrease, which can lower the
quality of patients’ life (Sepdianto & Maria, 2013). The pharmacological management
provided for these patients includes cardiac glycoside, diuretic therapy, and vasodilator
therapy (Shah, Gandhi, Srivastava, Shah, & Mansukhani, 2017). However, studies in
the form of systematic review and meta-analysis revealed that heart failure
rehabilitation is recommended for low and moderate risk of heart failure (NYHA II and
III) (Sagar et al., 2015).

Cardiac rehabilitation can be useful in clinically stable patients with heart failure
(Yancy et al., 2013). The American Heart Association recommends physical exercise to
be performed in patients with stable CHF. Physical exercise is done 20-30 minutes with
a frequency of 3-5 times each week. Before beginning physical exercise, patients with
CHF require a comprehensive assessment of risk stratification and are recommended to
rest due to fatigue. This exercise is one of the hospitalized exercises (inpatient) that can
be performed to the patients with NYHA II and III. Gradual activity management in
such patients is a mild and regular physical activity so that peripheral blood circulation
and tissue perfusion conditions can be improved (Adsett, Hons & Robbie, 2010;
Alvarez, Hannawi & Guha, 2016). Moreover, giving position and breathing exercises
can be done to reduce effort and improve respiratory muscle function. Tolerable
exercise can be managed to improve tissue perfusion and facilitate circulation. Exercise
training or regular physical activity is recommended as safe and effective for patients
with heart failure (Yancy et al., 2013).

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 Nurse Media Journal of Nursing, 10(1), 2020, 59

Breathing exercise is an exercise to improve breathing and functional performance

(Cahalin & Arena, 2015). One of the breathing exercises that can be done is a deep
breathing exercise, a nursing activity, that serves to increase the function of respiratory
muscles resulting in ventilation and oxygenation improvement (Bulechek, Butcher,
Dochterman, & Wagner, 2013; Herdman, Kamitsuru, & North American Nursing
Diagnosis Association, 2014; Kupper et al., 2016). Sepdianto and Maria (2013), in their
study, reported that breathing exercise in patients with heart failure for 15 minutes as
many as three times a day within 14 days reduces dyspnea. A systematic review of 27
studies also showed that physical exercise could increase oxygen saturation and quality
of life of patients with heart failure (Jewiss, Ostman, & Smart, 2016). Therefore, it is
important to conduct a study to examine the influence of breathing exercise and active
range of motion in CHF patients.

The use of deep breathing exercises and active range of motion as a nursing intervention
in CHF patients has not been widely studied in Indonesia. There are no studies that
combine the two interventions. This encourages researchers to study the effect of deep
breathing exercise and active range of motion on dyspnea in CHF patients.

PURPOSE
This research aimed to examine the effect of deep breathing exercises combined with an
active range of motion on physiological response in CHF patients.

METHODS
Research design and samples
The study used a pretest-posttest quasi-experimental research design with a control
group, and was conducted in two hospitals in Yogyakarta, Indonesia. A stratified
random sampling method was utilized to recruit the samples of NYHA II and III CHF
patients who met the inclusion criteria, which were stable hemodynamic status, no
weakness in both extremities, more than 17 years old, and receiving the same
pharmacological treatment. Whereas, the exclusion criteria included the patients with
neuro-musculoskeletal, severe systemic, mental and communication disorders, and
respiratory diseases. As many as thirty-two respondents who met the inclusion and
exclusion criteria were recruited. They were then divided into the equally same number
between the intervention and control groups.

Research instrument and data collection

The instruments used in this study were digital sphygmomanometer and digital watch to
measure blood pressure and respiratory rate. Pre-test and post-test on both groups were
conducted in the first and third days, respectively. All respondents in both groups were
measured their blood pressure and respiratory rates. The pre-test measurements were
performed 15 minutes before the intervention began, while the post-tests were done 15
minutes after the intervention ended. Interventions were initiated after 48 hours of
hospital admission. The intervention was started by deep breathing exercises for 30
times, followed by an active range of motion gradually on the hands, legs, hips, and
knees with each movement performed for five times. This intervention was done three
times a day for three days. On the other hand, the control group obtained standard
intervention, which was a semi-fowler position.

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 Nurse Media Journal of Nursing, 10(1), 2020, 60

Data analysis
A paired t-test was used to analyze the mean difference before and after the
intervention, while an independent t-test was used to compare the mean differences
between the intervention and the control groups.

Ethical consideration
Prior to the study, all respondents expressing agreement to participate in the study were
informed of the objectives, benefits, and procedures of the research. They were also
requested to sign informed consent. In terms of the privacy and confidentiality of
respondents, providing training fairly, benefits, and avoiding dangerous actions were
ensured during the study. This research had been reviewed and obtained ethical
permission from the ethics and research committee in the Faculty of Medicine,
Diponegoro University, Semarang, Indonesia, with the number of ethical approval of
202/EC/FK-RSDK/IV/2017.

RESULTS
Characteristics of respondents
The results of the study showed that more than half of the respondents in the
intervention and the control group were women and aged more than 60 years. A
majority of the respondents in both groups had common co-morbidities, which were
hypertension. The proportion of respondents who had NYHA II was the same as NYHA
III in both groups (50%), while most respondents in both groups obtained diuretic drugs
(Table 1).

Table 1. Characteristics of respondents (n=32)

Intervention Control Total

Characteristic p
f (%) f (%) f (%)
Age
18 – 45 years old 2 (12.5) 2 (12.5) 4 (12.5)
46 – 60 years old 3 (18.8) 6 (37.5) 9 (28.1) 0.132*
> 60 years old 11 (68.7) 8 (50.0) 19 (59.4)
Gender
Man 7 (43.8) 7 (43.8) 14 (43.8)
0.341**
Woman 9 (56.2) 9 (56.2) 18 (56.2)
Co-morbidities
Hypertension 10 (62.4) 7 (43.7) 17 (53.1)
Diabetes mellitus 3 (18.7) 4 (25.0) 7 (21.9)
Kidney failure 1 (6.3) 3 (18.7) 4 (12.6) 0.333*
Anemia 1 (6.3) 1 (6.3) 2 (6.2)
Gastritis 1 (6.3) 1 (6.3) 2 (6.2)
NYHA class
NYHA II 8 (50.0) 8 (50.0) 8 (50)
1.000**
NYHA III 8 (50.0) 8 (50.0) 8 (50)
Pharmacological therapy
Diuretic 6 (37.5) 8 (50.0) 14 (43.7)
Vasodilator 3 (18.8) 5 (31.3) 8 (25.0) 0.242*
Diuretic and vasodilator 7 (43.8) 3 (18.8) 10 (31.3)
*Mann-Whitney Test **Chi-Square

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 Nurse Media Journal of Nursing, 10(1), 2020, 61

Effects of deep breathing exercise and active range of motion on blood pressure in
CHF patients
The analyses of the effects of deep breathing exercise and active range of motion on
physiological responses, including systole and diastole in the intervention group and
control group, were shown in Table 2 and Table 3. There was a higher decrease in the
mean of systole and diastole after the intervention compared to the control group. There
were also significant differences in the systole (p=0.000) and diastole (p=0.000) in the
intervention group (Table 2).

Table 2. Differences in blood pressure of CHF patients (n=32)

Control Group Intervention Group

Blood pressure
MeanSD t p MeanSD t p
Systole
Pre-test 128.3125.34 128.2516.97
1.877 0.080* 6.483 0.000*
Post-test 123.0033.31 110.1916.46
Diastole
Pre-test 74.8820.14 73.5010.49
1.338 0.201* 4.748 0.000*
Post-test 70.4416.57 65.0310.27
*paired t-test

As seen in Table 3, there was a significant difference in the mean difference of systolic
blood pressure between the intervention and the control group (p=0.003). However, the
mean difference of diastole was not significantly different between the groups
(p=0.296). It meant that deep breathing exercises combined with active range of motion
decreased the systole, yet the diastole compared with the hospital standard care.

Table 3. Effects of deep breathing exercise and active range of motion on blood
pressure of CHF patients (n=32)

Intervention Group Control Group

Blood pressure
MeanSD MeanSD t p
Systole
Pre-test – Post-test 18.0611.14 5.3111.32 3.210 0.003*
Diastole
Pre-test – Post-test 8.447.11 4.4413.26 1.063 0.296*
*independent t-test

Effects of deep breathing exercise and active range of motion on respiratory rate in
CHF patients
The analyses of the effect of deep breathing exercise and active range of motion on the
respiratory rate of CHF patients in the intervention group and control group can be seen
in Table 4 and Table 5. Table 4 shows that respiratory rates in the intervention group
decreased significantly (p=0.003) compared to the control group (p=0.417).

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 Nurse Media Journal of Nursing, 10(1), 2020, 62

Table 4. Differences in respiratory rates of CHF patients (n=32)

Control Group Intervention Group

Respiratory Rate
MeanSD t p MeanSD t p
Pre-test 27.002.31 25.443.14
0.835 0.417 3.503 0.003*
Post-test 26.003.72 22.441.36
*paired t-test

The decrease in respiratory rates in the intervention group (3.00+3.43) was higher than
the control group (1.00+4.79). However, there was no significant difference in the
respiratory rates between the intervention and the control group (p=0.184). This meant
that deep breathing exercises and active range of motion were less effective at reducing
respiratory rates than the hospital-based interventions (Table 5).

Table 5. Effect of deep breathing exercise and active range of motion on the respiratory
rate in CHF patients (n=32)

Intervention Group Control Group

Respiratory rates
MeanSD MeanSD t p
Pre-test – Post-test 3.003.43 1.004.79 1.359 0.184*
*independent t-test

DISCUSSION
Effects of deep breathing exercise and active range of motion interventions on
physiological response: Blood pressure in CHF patients
The results of this study showed that deep breathing exercises and active range of
motion significantly decreased the systole, but the diastole compared to the standard
care from the hospital. The results of previous studies also showed similar results that
breathing exercises were able to reduce systolic blood pressure by 3 mmHg (p=0.021)
and diastolic pressure by 6.2 mmHg (p=0.000) in patients with heart failure within 14
days (Sepdianto & Maria, 2013). Another research also revealed that three-week breath
exercises were capable of decreasing systolic 5.90.8 (p<0.001) and diastolic 1.40.8
(p<0.005) (Lee et al., 2003). A study conducted by Joseph et al. (2005) also showed that
controlled breathing decreased systolic and diastolic from 149.77±3.7 to 141.1±4 mm
Hg (p<0.05) and from 82.7±3 to 77.8±3.7 mm Hg (p<0.01). Futhermore, Jewiss et al.
(2016) also pointed out that physical exercise could increase oxygen saturation and
quality of life of patients with heart failure.

Deep breathing exercises in patients with heart failure can improve cardiac autonomic
regulation and decrease the sensitivity of chemoreceptors. This exercise will increase
left ventricular ejection fraction, decrease pulmonary pressure, and decrease pulmonary
edema. This may be due to an increased ventilator mechanism due to the regulation or
modulation of cardiopulmonary reflex (Parati et al., 2008). In addition, a range of
motion is a physical exercise that can affect blood pressure because the efficiency of the
heart or the ability of the heart will increase in accordance with the changes that occur
in the form of heart frequency, stroke contents, and bulk heart. Regular physical
exercise is done 3-5 times a week with a long exercise of 20-60 minutes once exercise,

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 Nurse Media Journal of Nursing, 10(1), 2020, 63

and it can lower blood pressure. The decrease in blood pressure, among others, occurs
because the blood vessels undergo dilation and relaxation (Arovah, 2010; Badriyah,
Kadarsih, & Yogyakarta, 2014). The finding showed that there was no significant
difference in the diastole between the intervention and the control group. This
insignificant difference might due to the small sample size.

Effects of deep breathing exercise and active range of motion interventions on

physiological response: Respiratory rate in CHF patients
The result shows that deep breathing exercises and active range of motion decreased
respiratory rates, although the decrease was not statistically significant compared to the
control group. This was consistent with previous studies. A study showed that breathing
exercise could decrease the frequency of breath (p<0.001) (Sepdianto & Maria, 2013).
Joseph et al. (2005) also reported that controlled breathing decreases respiratory rates
with p <0.05.

Respiratory exercises are performed to improve ventilation and oxygenation. Increased

lung compliance during respiratory exercise may cause the amount of air entering the
lungs to increase, resulting in lower respiratory frequency. Needs of oxygen are met
then the tolerance to the activity will increase. Decreased frequency of breathing after
intervention proves that there is an improvement in respiratory function. Breathing
exercises can optimize lung development and minimize the use of respiratory muscle.
By doing regular breathing exercises, the respiratory function will improve. It was
found to be optimal for improving alveolar ventilation in terms of increased arterial
oxygen saturation and ease and sustainability in terms of respiratory effort (Russo,
Santarelli, & O’Rourke, 2017).

Slow respiration in healthy humans reduces the chemoreflex response to hypercapnia

and hypoxia. Deep breathing can improve lung development capability and affect
perfusion and diffusion functions so that the oxygen supply to the tissues is adequate.
Lower pressure on the intrathorac will cause air to flow from the more atmospheric
pressure high entry into the lungs that have lower pressure as a gas exchange process or
lung ventilation (Cahalin & Arena, 2105).

Moreover, physical exercise will affect oxygen consumption and carbon dioxide
production. A large amount of oxygen will diffuse from the alveoli into the venous
blood back to the lungs. Conversely, the same levels of carbon dioxide enter from the
blood into the alveoli (Jewiss et al., 2016). Thus, ventilation will increase to maintain
appropriate alveolar gas concentrations to allow for increased exchange of oxygen and
carbon dioxide. As the exercise progresses, increased metabolic processes in the muscle
produce more heat, carbon dioxide, and hydrogen ions. This whole factor increases the
oxygen utilization in the muscle, which increases arterial oxygen as well. This results in
more carbon dioxide entering the blood, increasing the levels of carbon dioxide and
hydrogen ions in the blood. Chemoreceptor stimulates the inspiratory center resulting in
increased breathing and depth. Some researchers have suggested that chemoreceptor in
the muscle may also be involved that is by increasing ventilation by increasing tidal
volume. However, after the resting phase, the need for oxygen in the blood will be

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 Nurse Media Journal of Nursing, 10(1), 2020, 64

fulfilled to lower the frequency of breathing (Nagaya, Hayashi, Fujimoto, Maruoka, &
Kobayashi, 2015).

The result of the study showed an insignificant decrease in the respiratory rates between
the intervention and the control group. This might occur due to the short duration of the
intervention time and the affecting factors which could not be totally controlled. Despite
the limitations, this study could show the evidence that deep breathing exercises and
active range of motion decreased the systole, diastole, and respiratory rates.

CONCLUSION
The study found that deep breathing exercises and active range of motion reduced the
systole, diastole, and respiratory rates. However, the reduction in the systole was the
only statistically significant finding compared to the diastole and respiratory rates.
Although there was no significant difference in diastole and respiratory rates between
the intervention and the control group, the intervention group showed better value than
the control group. Further research on the effects of deep breathing exercise and active
range of motion is recommended to conduct by extending the intervention time and
utilizing a larger sample size.

ACKNOWLEDGMENT
The researchers would like to thank all those people and participants who were involved
in contributing to this study.

CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.

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