Vol. 11, No. 2, November 2023 e-ISSN: 2829-0003 DOI : http://dx.doi.org/10.21776/ub.jik.2023.011.02.06 p-ISSN: 2829-7075 Website : http://www.jik.ub.ac.id
@JNSU. This is an open access article under the CC BY-NC 4.0 license
151 Original Research
The Effect of The Combination of Slow Deep Breathing and Humming on
Improving Oxygen Saturation of Inpatients With Pneumonia at RSUD Jayapura
Susana Jufuwai1*, Dewi Prabawati2, Emiliana Tjitra3
1,2,3STIKES Sint Carolus
*Corresponding author:
Susana Jufuwai STIKES Sint Carolus
Jl. Salemba Raya No. 41 RT 03/RW 05, Paseban, Senin, Kota Jakarta Pusat, Telp: 021-3924094 Email: [email protected]
Article Info ABSTRACT
Article History:
Received 10 Februari 2023 Revised 17 November 2023 Accepted 27 November 2023
Pneumonia is an infectious disease affecting the lower respiratory tract with signs and symptoms such as coughing and shortness of breath. Pneumonia cases in Indonesia are estimated to have 4 million deaths due to pneumonia every year. This study aims to analyze the effectiveness of Slow, Deep Breathing and Humming techniques on changes in oxygen saturation in pneumonia patients at Jayapura Regional Hospital. This quantitative research uses a quasi- experimental pre-test and post-test approach without a control group design. The sample consisted of 30 subjects who were given a slow deep breathing technique intervention of 5 cycles in 15 minutes and humming four cycles in 10 minutes, done once daily for six days. The instruments in the research used the Pulse Oximetry tool. The sampling technique used nonprobability sampling with total sampling. The results showed a difference in SpO2 values before and after the Slow, Deep Breathing, and Humming intervention was carried out in subjects with pneumonia with a p= 0.001 (p < 0.05). It can be interpreted that the Hypothesis (Ha1) is accepted so that it can be concluded that the slow, deep breathing and humming interventions can help improve Sp02. There is a need for further research on nurses' complementary therapy in oxygenation management, where this exercise is one of the nurse's interventions in overcoming decreased SpO2 in pneumonia patients.
Keywords:
Humming Pneumonia
Slow Deep Breathing SpO2
How to cite this article: Jufuwai, S., Prabawati, D., & Tjitra, E. (2023). The Effect of The Combination of Slow Deep Breathing and Humming On Improving Oxygen Saturation of Inpatients With Pneumonia at RSUD Jayapura. Journal of Nursing Science Update, 11(2), 151–160.
152 Introduction
Slow deep breathing exercise is a conscious action to regulate breathing deeply and slowly, which can have a relaxing effect (Pangkey et al., 2019). Because in patients with pneumonia, there is a risk of damage to the mucous membranes of the bronchi and alveolus due to inflammatory processes that disrupt ventilation mechanisms, pulmonary perfusion and ventilation-perfusion suitability that can have an impact on gas exchange disorders (Herdiyanti et al., 2018). World Health Organization (WHO, 2021) data shows that as many as 7 million people and 21% died of pneumonia. The increase in the death rate also occurred in 2021 with the COVID-19 pandemic, from 3.6 million total deaths due to respiratory infections to more than 6 million; this indicates a significant increase in cases from 2019 to 2021 (Every Count Breaths, 2021).
According to data from the Indonesian Lung Doctors Association (PDPI, 2018), there are an estimated 4 million deaths due to pneumonia every year throughout the world and in Indonesia in 2010, pneumonia was included in the top 10 hospitalized diseases where women were 53.95% of men and 46.05%, and the mortality rate reached 20%. (PDPI, 2018).
The prevalence of pneumonia cases in Papua is ranked first (RISKESDAS 2018), namely 3.5%, followed by Bengkulu. Based on data from the Jayapura Regional Hospital from 2020 -2021, there were 371 patients;
this figure is quite an increase compared to 2019, namely 192, while pneumonia data from October to December 2021 amounted to 34 cases of pneumonia (without COVID- 19). Data from January to March 2022 revealed 62 patients with inpatient pneumonia at Jayapura Regional Hospital.
Many pneumonia patients hospitalized at Jayapura Regional Hospital experienced mild and moderate hypoxemia conditions and symptoms of shortness of breath.
However, in the management of nurses, there still needs to be more independent intervention from nurses. This study aims to analyze the effectiveness of applying the Slow, Deep Breathing, and Humming techniques to change oxygen saturation in pneumonia patients at Jayapura Hospital.
According to the results of research from Mertha et al. (2018), slow deep breathing exercises have a significant effect on increasing the oxygen saturation value of COPD patients. Related research that supports the results of this study is the research of Iryanita and Afifah (2015), which states that slow, deep breathing exercise causes oxygen absorption and tidal volume and ventilation efficiency to increase so that the vital capacities of the lungs will also increase and will affect oxygen saturation.
Humming helps reduce breathing speed / slow down breathing. Humming will change breathing to be calmer; when breathing activity decreases, the activity of the mind will decrease. This is because the vibration can stimulate the brain, namely, the hypothalamus to activate the adrenocorticotropin system (ACTH This is because the vibrations can stimulate the brain, namely the hypothalamus, to activate the adrenocorticotropin (ACTH) system so that ACTH inhibits the release of cortisol production, but what the brain produces is endorphins. (Zhakar R, 2020). Humming Implementation can be done anytime and by anyone and does not cause side effects.
Method
This quantitative research uses the quasi-approach of pre-test and post-test experiments without a control group design.
With the population of 30 people who experienced changes in oxygen saturation at Jayapura Regional Hospital. The sampling technique used nonprobability sampling with total sampling. The sample that met the inclusion criteria in this study totalled 30 subjects.
The instruments used as data collection tools are slow deep breathing (SDB) and humming SOP forms, daily activity assessment sheets, and SpO2 pre and post- assessment sheets. The procedure for collecting data is to determine potential subjects; after that, the research team explains the rules of the research and the interventions that will be carried out.
Oxygen saturation is measured before and after the intervention, where oxygen saturation will be measured again 1 minute after the intervention is given.
153 The administration of slow deep breathing intervention for 15 minutes every day (with a duration of holding breath of 2-3 seconds with a rest period every 2 minutes, so that in 15 minutes SDB is carried out five cycles) after that continued by humming for 10-15 minutes carried out 3-4 times. This intervention will be carried out for six days of treatment, according to research from Dewy (2020); after the intervention is completed, the data will be analyzed.
Data processing and analysis carried out in research are pre-analysis stage, initial assessment, preliminary action, primary analysis, and interpretation stage. Ethics in this study uses three basic principles of research ethics: respect for a person, which includes Informed consent, autonomy (autonomy), confidentiality (confidentiality), justice (justice), and beneficence (doing good) (KEPPKN Kemkes, 2019).
Results and Discussion
Table 1. Demographic Characteristics of Pneumonia Subjects at Jayapura Regional Hospital (n=30)
Variable N %
Age (years)
Late teens: 17-25 5 16.7
Early adulthood: 26-35 7 23.3
Late adulthood: 36-45 7 23.3
Early elderly: 46-55 1 3.3
Final elderly: 56-65 10 33.4
Sex Man 16 53.3
Woman 14 46.7
History of Disease
History of the disease 23 76.7
respiratory tract Disorders
No history of disease 7 23.3
Smoking Habits
Smoking 23 76.7
No smoking 7 23.3
Alcohol Habits
Drinking Alcohol 16 53.3
Not Drinking Alcohol 14 46.7
Body Mass Index
Skinny Weight: < 17.0 15 50
Light Skinny: ≥ 17.0-18.4 10 33.3
Normal: 18.5-25.0 5 16.7
Table 1 shows that most subjects are the late elderly 56-65 years: 10 subjects (33.4%) and 16 male subjects (53.3%).
They had a history of respiratory system disorders, which are chronic obstructive
pulmonary disease, asthma, bronchitis, pulmonary tuberculosis, and pleural effusion, as many as 23 subjects (76,7%), habit of drinking alcohol 16 subjects (53.3%), skinny weight 15 subjects (50%).
154
Table 2. Distribution of Subjects Based on Oxygen Saturation for 6 Days of Slow, Deep Breathing and Humming Treatment at Jayapura Regional Hospital (n=30)
Characteristics Before Intervention After Intervention
N % N %
Day 1
Normal: 95-100% 0 0 15 50
Mild Hypoxemia: 90-94% 13 43.3 12 40
Moderate Hypoxemia:76-89% 17 56.7 3 10
Day 2
Normal: 95-100% 2 6.7 15 50
Mild Hypoxemia: 90-94% 13 43.3 14 46.7
Moderate Hypoxemia:76-89% 15 50 1 3.3
Day 3
Normal: 95-100% 3 10.0 18 60
Mild Hypoxemia: 90-94% 14 46.7 12 40
Moderate Hypoxemia:76-89% 13 43.3 0 0
Day 4
Normal: 95-100% 7 23.3 28 93.3
Mild Hypoxemia: 90-94% 20 66.7 2 6.7
Moderate Hypoxemia:76-89% 3 10.0 0 0
Day 5
Normal: 95-100% 12 40.0 29 96.7
Mild Hypoxemia: 90-94% 17 56.7 1 3.3
Moderate Hypoxemia: 76-89% 1 3.3 0 0
Day 6
Normal: 95-100% 21 70,0 30 100
Mild Hypoxemia: 90-94% 9 30,0 0 0
Moderate Hypoxemia:76-89% 0 0 0 0
Based on Table 2, it indicates that on Day 1, the proportion of subjects before SDB and Humming SpO2 value is 56.7%, while the subjects with mild hypoxemia are within proportions 43.3% and average 0%. On Day 1, the proportion of subjects after SDB and Humming improved the SpO2 value, normalising 50% of subjects.
On Day 2, before SDB and Humming, 6.7% of subjects had normal SpO2 values, and the proportion of subjects was reduced from 56.7% with moderate hypoxemia to 50%. In contrast, on Day 2, after SDB and Humming, the proportion of subjects with normal SpO2 values increased significantly from 6.7% to 50%.
On Day 3, before SDB and Humming, 10% of subjects with normal SpO2 values were recorded, and the proportion of subjects with moderate hypoxemia went from 56.7% to 43.3%. In contrast, on Day 3 After SDB and Humming, the proportion of subjects with normal SpO2 values also increased quite a lot from 10% to 60%
Compared to the SpO2 on Day 2 after SDB
and Humming, saw improvement in SpO2 on Day 3 mainly reduced proportion of subjects with moderate hypoxemia from 4.3% to 0%.
On Day 4 before SDB and Humming, 23.3% of subjects were recorded who had normal SpO2 values and reduced the proportion of subjects by 43.3%, while in Day 4 After SDB and Humming, the proportion of subjects who were already normal values with normal SpO2 values also increased quite a lot from 23.3% to 93.3%.
On Day 5 before SDB and Humming, 40.0% of subjects with normal SpO2 values were recorded, and the proportion of subjects with moderate hypoxemia was from 10.0% to 3.3%. In contrast, on Day 5, after SDB and Humming, the proportion of subjects with normal SpO2 values increased quite a bit, from 40% to 96.7%.
In Day 6 before SDB and Humming were recorded, 70.0% of subjects had normal SpO2 values, and the proportion of subjects with moderate hypoxemia from 3.3% and all were good or 0%, and day 6 After SDB and Humming, the proportion of subjects with
155 normal SpO2 values also increased quite a lot from 70% to 100%.
Bivariate Analysis
Bivariate analysis aims to assess the difference in oxygen saturation before and after the intervention is carried out. The tests used were paired samples t-test and
Wilcoxon test to analyze the results of observations in pairs (before and after) from two data sets and whether they differed.
Wilcoxon signed-rank test is used only for ordinal and nominal type data, but the data does not follow the normal distribution. The results of the data analysis can be seen below.
Table 3. Influence of Subject Characteristics Against Sp02
Characteristics of Age (years) Average SpO2 (%) P-Value
Before After
Late teens: 17-25 88.20 97.00 < 0.001
Early adulthood: 26-35 89.42 97.42
Late adulthood: 36-45 86.57 97.00
Early elderly: 46-55 81.00 98.00
Late elderly: 56-65 88.70 97.40
Table 4. Comparison of Average Oxygen Saturation Valuesof
Pneumonia Patients Before and After Intervention Slow Deep Breathing and Humming
O2 Saturation Mean SD Mean 95% CI P-Value T
Before 88.03 4.97 9.36 11.12 sd 7.611 <0.001 10.896
Table 3. from the results of the t-test showed data on the influence of the subject's characteristics (age, sex, history of respiratory diseases, smoking habits, alcohol drinking habits and BMI) on the improvement or average SpO2 between before and after being given slow deep breathing and humming with a P value of <
0.001. Table 4. show the results of t-test data
before Day 0 is given SDB intervention and Humming. On the first day, the average value was 88.03%, SD was 4.97 and after being given an intervention until the sixth day, there was an increase in the average value of 97.40% with an elementary value of 1.037 and the difference in elementary school was 9.36.
Multivariate Analysis
Table 5. ANOVA Test Result
Table 6. Lower And Upper Bound For 95% Confidence Intervals
Model Sum of Squares Df Mean Square F Sig.
Regression N 4.707 6 0.784 0.681 0.667
Residual 26.493 23 1.152
Total 31.200 29
Model Variable T Sig. 95.0% Confidence Interval for B
Lower Bound Upper Bound
1 Constant 79.618 <0.001 95.649 100.752
156
Table 7. Coefficients Test
Table 8. The Meaningfulness Value of The Influence of Characteristics, SDB and Humming On SpO2 Values Partially and Simultaneously
Variable P value
Partial
Age 0.30
Sex 0.97
History of respiratory disease 0.77
Smoking habits 0.37
Alcohol drinking habits 0.85
IMT 0.57
SDB dan Humming 0.001
Simultan/Omnibus Characteristics. and SDB. and Humming 0.681
Based on the results of the ANOVA test (Table 5), a significant regression value of 0.667 > 0.05 was obtained, which means that the independent and confounding variables do not affect the bond variable together. The simultaneous test results (F test) show the value of F (0.681) > 0.05, which means that the independent variable and the confounding variable do not jointly affect the dependent variable. A statistical model test was obtained explaining the contribution between independent variables with dependent variables of 38.8% and the remaining 61.2% explained by variables outside the model that were not included in the study.
Table 6 shows Lower And Upper Bound For 95% Confidence Intervals. Based on the coefficients' results (Table 7), significance was obtained from age 0.30, gender 0.97, disease history 0.77, smoking habit 0.37, alcohol habit 0.85, and body mass index 0.57. From the results, it can be concluded that partially, those with a P value
> 0.05. Table 8 shows the test results for characteristics using a linear regression test, which partially shows that the p-value is >
0.05. slow, deep beating and humming partially significantly affect the value of SpO2 with a value of p = <0.001.
Influence of Subject Characteristics On SpO2 The 30 subjects in this study are mainly in the elderly age group, which is 56-65 years by 39.4%, with a slightly more significant proportion of males, i.e. (57.6%). Generally, patients with pneumonia have a history of respiratory diseases (87,9%), and it turns out that patients do not smoke entirely a lot (69.7%). Meanwhile, patients with a habit of drinking alcohol as much as 57.6% and patients with a light, thin body mass index (≥17.0-18.4) were quite a lot, namely 63.6%.
Research results from Priyanto (2010) showed that there is an influence of elderly age, gender, smoking habits, and drinking habits on the oxygen saturation value of patients with pneumonia with p value 0.000
<0,005. Research from Torres (2013) and Lee et al. (2015) said that the BMI status of the thin category has a higher risk of pneumonia incidence with a P-value <0.001.
Slow Deep breathing exercise is one of the respiratory exercises that is widely developed in nursing studies. This exercise aims to improve the ability of the respiratory muscles, which is useful for improving lung compliance to improve ventilation function and oxygenation (Herdiyanti et al., 2018).
Humming is one of the exercises to relieve anxiety, frustration, and anxiety. This is in line
Variables Coeff value
Age 1.05 0.30 0.15 0.47
Sex 0.04 0.97 0.02 1.06
History Of Disease 0.29 0.77 0.14 0.86
Smoking Habits 0.90 0.37 1.85 0.73
Alcohol Habits 0.18 0.85 1.43 1.19
Body Mass Index 0.57 0.79 0.79 0.45
157 with the purpose of this study. This study uses Catrine Kolkaba's nursing theory about comfort; in the study, before being given the intervention of slow, deep breathing and humming, subjects had difficulty breathing, experienced difficulty sleeping, and were uncomfortable with their condition, but after being given the intervention slow deep breathing and Humming patients experience a change in atmosphere that is to become calmer and more relaxed.
In the elderly, there is a decrease in the physiological function of the lungs, so elderly sufferers are easily infected with respiratory infections/pneumonia. This is in line with Sijabat's research (2020), which shows that a large part of pneumonia is experienced by patients who are elderly;
namely, the most subject is the final elderly age with a P value of < 0.001. So, the results of this study show that there is a significant influence on improving oxygen saturation in patients with pneumonia characteristics.
Smoking can interfere with mucociliary, which can cause an increase in mucus production and the number of abnormal cilia, along with a reduction in the frequency of cilia movement. Umah, (2018).
This is in line with Ali's study et al. (2021), where subjects smoked more, namely 51%;
this was also in line with research from Paulo (2019), where subjects who smoked had more pneumonia, namely 65%.
Alcohol consumption can affect the immune system through changes in molecules that function as signals, namely cytokines, for coordination of the body's defences, thus causing the immune system to be vulnerable to bacterial infections, including respiratory infections. Research results from Sijabat. R.S.
(2020) explain that alcohol habits affect the incidence of pneumonia. The results of this study are supported by the results of research from Simon (2018) and Sijuang (2020), which explain that patients who drink alcohol are more than those who do not drink alcohol.
Average Changes in Daily Oxygen Saturation Before and After Being Given Intervesni Slow Deep Breathing And Humming
The average value of SpO2 before and after slow deep breathing and humming from
Day 0 to Day 6 showed an improvement from moderate hypoxemia of 88.03%, gradually improving close to normal at 94.86%.
Similarly, the average value of Sp02 after slow deep breathing and humming from Day 1 to Day 6 showed success from mild hypoxemia of 93.10% to normal 97.40%. The intervention of slow, deep breathing and humming daily in pneumonia subjects showed that Sp02 breeding became normal after treatment on Day 3.
This shows that the intervention carried out on subjects suffering from pneumonia experienced improvement from day 3 to Day 6. This is in line with the results of research from Ali et al. (2021), showing that there is an influence of deep breathing exercises on reducing the saturation of pneumonia patients with a p-value of 0.001 <0.05. This exercise aims to improve the ability of the respiratory muscles, which helps improve lung compliance to improve ventilation function and oxygenation (Herdiyanti et al., 2018).
This is in line with the research of Mertha et al. (2018) statistical result with test Paired T-test in the treatment group obtained an S.D. value before the intervention of 1.476 and after the intervention of 1.287, with a ρ value of 0.001.
Comparison of Average Oxygen Saturation of Pneumonia Patients Before and After Being Given Slow, Deep Breathing and Humming Interventions
On the first day, the mean value was 88.03, and the SD was 4.97. Moreover, after being given the intervention until the sixth day, there was an increase in the mean value of 97.40 and the S.D. value of 1.037 with the difference in elementary schools of 9.36; this showed that there was a significant difference in SpO2 improvement in pneumonia patients at Jayapura Regional Hospital after being given the intervention, Where slow deep breathing aims to improve the ability of the respiratory muscles which help increase lung compliance to improve ventilation function and improve oxygenation (Herdiyanti et al., 2018). Humming is one of the exercises to relieve anxiety, frustration and anxiety (Trivedi et al., 2023; Bisht, 2022; Tegta, 2015).
158 Conclusion
The results showed a difference in SpO2 values before and after the Slow, Deep Breathing, and Humming interventions were carried out in subjects with pneumonia with a p=0.001 value (p <0.05). In other words, it can be interpreted that the hypothesis (Ha1) is accepted so that it can be concluded that the intervention of Slow, Deep Breathing and Humming can help improve SpO2. So, this exercise is beneficial if done properly and correctly. The names of people who support or assist with the research are written.
Acknowledgement
I respectfully express my gratitude to the following: Regional Hospital of Jayapura and Government of Papua Province and My Husband: Lukanus Sadrach Izaac, S.E., M.M, for love, support and finance.
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