PERBANDINGAN PENGARUH LATIHAN INCENTIVE SPIROMETRY DAN LATIHAN PERNAPASAN DIAFRAGMA TERHADAP NILAI PEAK COUGH FLOW PASCA-CORONA VIRUS DISEASE-19
Abstract
Background : Post-Covid-19 is associated with the ability to function stones that can interfere with daily activities and work. Spirometry Incentive Exercises and diaphragmatic breathing exercises can increase the peak cough flow value on post-Covid-19.
Objective : To find out the comparison between Incentive Spirometry and diaphragmatic breathing exercises on the peak cough flow value on post-Covid-19.
Materials and Methods: This research is a The Control Group Pre-Post Test Group Design. Subjects were divided into 2 groups, namely Group 1 exercise with volume oriented Incentive spirometry, frequency of 2x exercise sets/day, 20 repetitions in 1 exercise set, rest between repetitions of 5 seconds, Group 2 diaphragmatic breathing exercise with a frequency of 2x exercise sets/day, 1 exercise set. with 6x breath cycle. Both exercises were performed 6x a week for 4 weeks. Before and after intervention, patients were evaluated using peak cough flow Results: There were 24 subjects (7 males, 17 females) aged 40–65 years, there was a very significant difference between the median initial PCF value and the median final PCF value in diaphragmatic breathing exercises (Z = -3.104 with p value = 0.001) on incentive spirometry exercise (Z = -3,070 with p value = 0.001) and comparison between Incentive Spirometry exercise with median value of diaphragmatic breathing exercise on post-Covid-19 peak cough flow value (Z = - 3.748 with p value <0.001).
Conclusion: There was an increase in the peak cough flow value after exercise in both groups, but the increase in the peak cough flow value in the Incentive Spirometry exercise was higher than the diaphragmatic breathing exercise.
References
Demeco A, Marotta N, et al. Rehab of patients post Covid-19: a literature review, 2020.
Perhimpunan Dokter Spesialis Rehabilitasi Medik Indonesia. Panduan tatalaksana rehabilitasi Covid-19 edisi kedua Jakarta: Perhimpunan Dokter Spesialis Rehabilitasi Medik Indonesia; 2021. Hal.1-33.
Gao Y, Yan L, Huang Y, et al. Structure of the RNA-dependent RNA polymerase from Covid-19 virus. Science 2020;368:779–82.
Covid-19 Map Johns Hopkins coronavirus resourse center. https://coronavirus.jhu.edu/map.html
Data Covid-19 Indonesia terbaru https://covid19.go.id
Data Covid-19 Sulawesi utara https://corona.sulutprov.go.id
Greenhalgh T, Knight M, A’Court, C et al 2020. Management of post-acute Covid-19 in primary care. BMJ, 370:m3026. Doi: 10.1136/bmj.m3026.PMID: 32784198. 2020
Hui Li MD, et al. SARS-COV2 a viral sepsis: observations hypothesis 2020 https://doi.org/10.1016/ S0140-6736(20)30920-X 2020
Gilbert M, Pullano G, Pinotti F, et al. Preparedness and vulnerability of African countries against importations of Covid-19: a modelling study. Lancet 2020;395:871–7.
Assaf G, Davis H, McCorkell et al. Report:what does Covid-19 Recoverry actually look like? An analysis of the prolonged Covid-19 symptomssurvey by patient-Led Research Tea. Patient Led Research Team London UK: The Covid-19 Body poliklinikkliniktic slack group. Avaible: https: //patientresearchcovid19.com 2020
Mariya J, et al Correlation of peak cough flow rate with expiratory flow rate in patients with chronic respiratory diseases
Park J, Lee SC, Choi WA Et Al How respiratorory muscle strength correlates with cough capacity in patients with respiratory muscle weakness. Yonsei Med Journal, vol III, no 51, 2010,329-327
Restrepo RD, Wettstein R et al. Incentive spirometry AARC Clinical practice guideline. 2011 78
Kirshblum S and Brooks M. Rehabilitation of spinal cord injury. In Delisa’s Physycal Medicine and rehabilitation principles and practice. 5th ed. Lippincott Williams and wilkins. Philadelphia.
Shine D, Saad s, comparison of effectiveness of diaphragmatic breathing and pursed-lip expiration exercises in improving the forced expiratory flow rate and chest expansion in patients with bronchial asthma doi 10.15621/jiphy/2016/v312/94871
Mendes L, Moraes K, Hoffman M. Effects of Diaphragmatic Breathing With and Without Pursed-Lips Breathing in Subjects With COPD. respiratory care 2019
Tresia Fransisca et al. effect IMT with Incentive spirometry and control breathing exercise for punctional capacity and quality of life in COPD patients
Shidiq A.et al. Pulmonary Rehabilitation in Covid-19 patients: A scoping review of current practice and its application during the pandemic 2020 DOI: 10.5606/tftrd.2020.6889
Alvaro Reyes , Adrian Castillo the effects of respiratory muscle training on peak cough flow in patients with parkinson’s disease: a randomised control trial 2018
Shety N, Samuel S Et Al Comparison of diaphragmatic breathing exercises, volume and flow oriented incentive spirometry on respiratory function in stroke subjects: A Non-Randomized study Doi: 10.1177/0972753121990193 2021
Magda E, Ramadan D, Ishak S Et al, Effect of incentive spirometer exercise on pulmonary functions in children with spastic cerebral palsy, Egyptian journal of bronchology 2019
Lu-Lu Yang, Ting Yang, Pulmonary rehabilitation for patients with coronavirus disease 2019 (Covid-19), Chronic Diseases and Translational Medicine, Volume 6, Issue 2, 2020, pages 79-86, ISSN 2095-882X, https://doi.org/10.1016/j.cdtm.2020.05.002.
Phillips M, Turner S, Wade D Et Al Rehabilitation in the wake of Covid-19 A phoenix from the ashes. British society of rehabilitation medicine 1:1-19. Available from: https://www.bsrm.org.uk/downloads/Covid-19bsrmissue1-published-27-4- 2020.pdf
Singhal T. A Review of Coronavirus Disease-2019 (Covid-19). The Indian Journal of Pediatrics (April 2020). https://doi.org/10.1007/s12098-020-03263-6 79
Lanying Du, Yuxian He, Zhou Y Et Al The spike protein of SARS-CoV--a target for vaccine and therapeutic development. National Library of medicine doi:10.1038/nrmicro2090.Epub 2009 Feb
Wang Q,Zhang Y,Wu, L Et Al. Structural and Functional Basis ofSARS-CoV-2EntrybyUsingHumanACE2 https://doi.org/10.1016/j.cell.2020.03.045
Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020;395:507–13.
Hussin A. Rothan and Siddappa N. Byrareddy. (2020). The epidemiology and pathogenesis of coronavirus disease (Covid-19) outbreak. Journal of Autoimmunity,. https://doi.org/10.1016/j.jaut.2020.102433
Zhao HM, Xie YX, Wang C; Chinese Association of Rehabilitation Medicine; Respiratory Rehabilitation Committee of Chinese Association of Rehabilitation Medicine; Cardiopulmonary Rehabilitation Group of Chinese Society of Physical Medicine and Rehabilitation. Recommendations for respiratory rehabilitation in adults with coronavirus disease 2019. Chin Med J (Engl). 2020 Jul;133(13):1595- 1602. doi: 10.1097/CM9.0000000000000848. PMID: 32251002; PMCID: PMC7470013.
Blough SH, et.al. Prevalence of Covid-19: A Look behind the Scenes. Mini review. April 2020. doi: 10.20944/preprints202004.0179.v2
Sutrisno, Pane R, Andrianto. Rehabilitasi medik pasca menderita Covid-19. Airlangga University press 2021.
Perhimpunan Dokter Paru di Indonesia Diagnosis dan Penatalaksanaan Pneumonia Covid-19 di Indonesia.. 2020).
Ioannis P. Trougakos et al 2021 “Insights to SARS-CoV-2 life cycle, pathophysiology, and rationalized treatments that target Covid-19 clinical complications
Joseph T, Ashkan M. International Pulmonologist’s Consensus On Covid-19. India; 2020
Ozakinci H, Sak SD. Lung Pathology in Covid-19 Disease: We Must Be Aware!. Turk Thorac J. 2020 May; 21(3): 217–218. doi: 10.5152/TurkThoracJ.2020.20049 80
Nila SH et. Al. Covid-19:Pathogenesis,cytokine storm and therapeutic potential of interferon. Cytokine & Growth Factor ReviewsVolume 53, June 2020, p.66-70.
Shari brosnahan et al. 2020 Covid-19 and Respiratory System Disorders Current Knowledge, Future Clinical, and Translational Research Questions
Mo X, et.al. Abnormal pulmonary function in Covid-19 patients at time of hospital discharge.ResearchArticle.EurRespi J.2020
ZhuF, et al. Effects of respiratory rehabilitation on patients with novel coronavirus (Covid-19) pneumonia in the rehabilitation phase: protocol for asystematic review and meta-analysis. BMJ Open 2020. doi:10.1136/bmjopen-2020-039771
Karyono DR, Wicaksana AL. Current prevalence, characteristics, and comorbidities of patients with Covid-19 in Indonesia. Original article. Journal of Community Empowerment for Health. August 2020. doi:10.22146/jcoemph.57325
ZhuF, et al. Effects of respiratory rehabilitation on patients with novel coronavirus (Covid-19) pneumonia in the rehabilitation phase: protocol for asystematic review and meta-analysis. BMJ Open 2020. doi:10.1136/bmjopen-2020-039771
Huang C, Wang Y, Li X, Ren L, Zhao J, Zang Li, Fan G. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet. 24 jan 2020.
Goërtz YMJ, Van Herck M, Delbressine JM, et al. Persistent symptoms 3 months after a SARS-CoV-2 infection: the post-Covid-19 syndrome?. ERJ Open Res 2020; in press (https://doi.org/10.1183/23120541.00542-2020).
Susanto A, Rozaliyani A, epidemioological and Clinical Features of Covid-19 Patients http://dx.doi.org/10.21109/kesmas.v0i0.5233.g1187
Greenhalg dkk Management of post-acute covid-19 in primary care 10.1136/bmj.m3026
Xiaoneng M, Wenhua J, Zhuquan S Abnormal pulmonary function in Covid-19 patients at time of hospital discharge eur Respir J PMID: 32381497
Carfi A, BArnabei R, Landi F Et Al Persistent symptoms in patients after acute Covid-19, doi:10.1001/jama.2020.1260
Susanto A, Rozaliyani A, epidemioological and Clinical Features of Covid-19 Patients http://dx.doi.org/10.21109/kesmas.v0i0.5233.g1187 81
States M, Et Al 2020 Epidemiological alert complications and squele of Covid-19 complications from Covid-19. PAHO_WHO
Demertzis, Z,D Et Al. 2020 Cardiac sequelae of novel coronavirus disease 2019 (Covid-19): a clinical series. European Heart Journal-case reports pp1-6 doi: 10.1093/ehjcr/ytaa179
Xiong, Q Et Al 2021. Clinical sequelae of Covid-19 survivors in Wuhan, China: a single-centre longitudinal study. Clinical Microbiology and Infection. European Society of Clinical Microbiology and Infecton Disease, 27(1); 89-95
Schaller, T et al 2020. Prior and novel coronavirus, coronavirus disease 2019 and human reproduction; what is known?
Carsana l Et Al 2020. Pulmonary post-mortem finding in a series of Covid-19 cases from northern Italy: a two-centre descriptive study. The Lancet Infectious Diseases, 20(10): 1135-1140. Doi: 10.1016/s1473-3099(20)30434-5
Gentile, f., et al. 2020. Covid-19 and risk of pulmonary fibrosis: the importance of planning ahead. iEuropean Journal of Preventive Cardiology, 27(13):1442-1446. Doi: 10.1177/2047487320932695
Jin,C., et al. 2020. A pattern catogorization of CT findings to predict outcome of Covid-19 pneumonia . frontiers public health
British Thoracic Society, guidance on respiratory follow up of patients with a clicoradiological diagnosis of Covid-19 pneumonia 2020
Wang Z, Qiang W, Ke H. A Handbook of 2019-nCoV Pneumonia Control and Prevention. Hubei Science and Technologi Press. China; 2020.
Cozzi D, et. Al. Chest X ray in new Coronavirus Disease 2019 (COVID 19) infection:findings and correlation with clinical outcome. Chest Radiology.2020
Homerton university hospital. Post covid-10 patient information pack 2020 avalaible from:https://www.hackneycitizen.co.uk/wp-content/uploads/post-Covid19-information-pack-5pdf
Wang,F., Kream, R.M and Stefano, G.B. 2020 Long-term respiratory and neurological sequaelae of Covid-19. Medical Science Monitor, 26:1-10. doi: 10.12659/MSM.928996.
Wasch J, Backers T, Paulsen F Upper and lower respiratory tract. Ventral view. Sobotta Anatomy textbook page 275 1st Edition Elsevier 82
John Hall, Michael Hall Regulation Respiration. Guyton and hall Medical physiology Textbook pg 531-540
Katch VL, McArdle WD, Katch FI, editors. The pulmonary system and exercise. Essentials of exercise physiology. Edisi ke-4. Philadelphia: Lippincott; 2011. Halaman 265–99.
Tortora G, Derrickson B. The respiratory system In: principles of anatomy & physiology fifteen Edition
Martini, Frederic, H., & Judi, Nath, L. Fundamental of anatomy and physiology. 10th edition. California: Pearson Education. 2015. 998-9.
De Troyer, A. Respiratory muscle function. Dalam: Cherniack Neils, Altose Murray D, Homma Ikuo. Rehabilitation of the patient with respiratory disease. Bab 3. New York: McGraw-Hill professional; 2009. Halaman 21-32.
Cohen E, Mier A, Heywood P, Murphy K, Boultbee J, Guz A. Diaphragmatic movement in hemiplegic patients measured by ultrasonography. Thoraks Journal. 2014; 49: 890-5.
Shields Et Al Diaphragmatic function, paralysis and eventration
Lunardi AC, et.al. Effect of Volume-Oriented Versus Flow-Oriented Incentive spirometry on Chest Wall Volumes, Inspiratory Muscle Activity, and Thoracoabdominal Synchrony in the Elderly. Respiratory care. March 2014. doi : 10.4187/respcare.02665
Basoglu OK et.al. The efficacy of Incentive spirometry in patients with COPD. Original article. Respirology. 2005. p349-353
Eltorai AE, et.al. Clinical Effectiveness of Incentive spirometry for the Prevention of Postoperative Pulmonary Complications. Respir Care. March 2018. doi: 10.4187/respcare.05679.
Choi Jy, Rha Dw, Park Es, change in pulmonary after incentive spirometer exercise in children with cp spastic Yonsei Med J, 2016.
Huang CH, 2011 Comparison of inspiratory muscle training for patien with COPD vol.110 no.8 pp 518-526.
Parreira VF, et.al. Assessment of tidal volume and thoracoabdominal motion using volume and flow-oriented incentive spirometers in healthy subjects. Braz J Med Biol Res, July 2005. doi: 10.1590/S0100-879X2005000700014 83.
Restrepo RD, et.al . AARC (American Association for Respiratory Care) clinical practice guideline. Incentive spirometry: 2011. doi: 10.4187/respcare.01471.
Eltorai A, Baird G, Pangborn J, financial inpact of incentive spirometry inquiry 2018; 554695801879499.
Gayathiri T, Efficacy of Incentive spirometry in Expiratory Muscle Training Following Abdominal Surgery T. 2020,USA doi: https://dx.doi.org/10.13005/bpj/2131.
El kader, Ashmawy Aerobic Exercise Training and Incentive Spirometry Can Control Age-Related Respiratory Muscles Performance Changes in Elderly DOI:10.29333/EJGM/82360.
Pascotini FS, Ramos MC, Silva AMV. Volume oriented versus flow oriented spirometer over respiratory parameters among the elderly. 2013.
Seyller H Et Al, The role of incentive spirometry for patients with Covid-19. 2021 doi: 10.1016/j.ajem.2021.05.034
Kumar N, Et Al Lessons from clinical practice during Covid-19 pandemic doi: 10.1016/j.tacc.2020.06.008.
Townsend L, et al. Persistent fatigue following SARS-CoV-2 infection is common and independent of severity of initial infection. PLoS ONE 15(11): e0240784. doi: 10.1371/journal.pone.0240784.
Seo K, Hwan PS, Park K. The effects of inspiratory diaphragm breathing exercise and expiratory pursed-lip breathing exercise on chronic stroke patients’ respiratory muscle activation. J Phys Ther Sci 2017;29(3):465-469.
Cahalin LP, Braga M, Matsuo Y, Hernandez ED. Efficacy of diaphragmatic breathing in persons with chronic obstructive pulmonary disease: a review of the literature. J Cardiopulm Rehabil 2002;22(1): 7-21.
Fernandes M et al. Efficacy of diaphragmatic breathing in patients with chronic obstructive pulmonary disease.
Vitacca M, Clini E, Bianchi L, Ambrosino N. Acute effects of deep diaphragmatic breathing in COPD patients with chronic respiratory insufficiency. Eur Respir J 1998;11(2):408-415. 84
Cancelliero-Gaiad KM, Ike D, Pantoni CB, Borghi-Silva A, Costa D. Respiratory pattern of diaphragmatic breathing and pilates breathing in COPD subjects. Braz J Phys Ther 2014;18(4):291-299.
Liu K, Chen Y, Lin R Clinical features of Covid-19 in elderly patients: A comparison with young and middle-aged patients doi: 10.1016/j.jinf.2020.03.005 Epub 2020 Mar
Gosselink RA, Wagenaar RC, Rijswijk H, Sargeant AJ, Decramer ML. Diaphragmatic breathing reduces efficiency of breathing in pa- tients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1995;151(4):1136- 1142.
Li-sheng Wang , Yi-ru Wang , Da-wei Ye , et al. Review of the 2019 Novel Coronavirus (Covid-19) based on current evidence. International Journal of Antimicrobial Agent. (2020).doi: 10.1016/j.ijantimicag.2020.105948.
Amy parkin et al A Multidisciplinary NHS Covid-19 Service to Manage PostCovid-19 Syndrome in the Community DOI:10.1177/25013272110109949.
Widya naralia t et al 2021 The Effectiveness of Breathing Exercises for Post Covid19 Patients during Rehabilitation: A Literature Review.
Blaney F, Sawyer T Sonographic measurement of diaphragmatic motion after upper abdominal surgery: A comparison of three breathing manoeuvres https://doi.org/10.3109/09593989709036464.
Manzano R, Carvatha C, Et Al Chest physiotherapy during immediate postoperative period among patients undergoing upper abdominal surgery: randomized clinical trial.
Mellies U, Goebel C, Optimum Insufflation Capacity and Peak Cough Flow in Neuromuscular Disorders Copyright © 2014 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201406-264OC
Cardoso Et Al Evaluation of peak cough flow in Brazilian healthy adult. International archievers of medicine, vol.5 pp 25.
Winck J.C The value of cough peak flow measurements in the assessment of extubation or decannulayion readiness 2015 Journal of pulmonology.
Smina M, Et Al Cough peak flows and extubation outcomes chest. 2003; 124 (1);262-8 85
Loveridge J and White V, Breathlessness and cough. In Common medical presentations, Elsevier, Philadelphia, pp 108-112.
Mills C, Respiratory muscle training theory and practice. Churchil livingstone, china pp26-30 2016.
Sharma S, Hashmi MF, Alhajjaj MS, Cough journal of allergy and clinical immunology.
Umesh G, Lallo, Barnes P, Chung K. Pathophysiology and clinical presentation of cough DOI:https://doi.org/10.1016/S0091-6749(96)70022-2.
Yasutaka U et al In: Clinical Significance of Cough Peak Flow and Its Non Contact Measurement via Cough Sounds: A Narrative Review:2020.
P.R Rodrigues et al 2017 peak cough flow measurement with a pneumotacograph and a portable peak flow meter in patients with neuromuscular disease.
Freitas FS, Ibiapina C, Alvim C. Relationship between cough strength and functional level in elderly. Revista brasileira de fisiotherapis, vol 14, no.6, pp470- 47.
Kamikawa N, Taito S, 2016 Effect of different levels of pressure relieving air mattress firmness on cough strength. PLOS one.
Lasserson, Mills K, Polkey M,. Differences in motor activation of voluntaru and reflex cough in humans. 2006 doi: 10.1136/thx.2005.057901
Adeyini B, Erharbor G. The Peak flow meter and its use in clinical practice. African Journal Of respiratory medicine, vol.10.
Jiang C, Esquinas A Evaluation of cough peak expiratory flow as a predictor of successful mechanical ventilation discontinuation: a narrative review of the literature https://doi.org/10.1186/s40560-017-0229-9.
Nita Damayanti Effect inspiratory muscle training add-on active cycle of breathing exercise to peak cough flow older female in nursing home 2017.
Booker R, Et Al 2007 Peak expiratory flow measurement Doi: 10.7748/ns2007.06.21.39.42.c4566
Bettger J, Linda J Telerehabilitation in the age of COVID 19 published online 2020 Aug 19. doi: 10.1093/ptj/pzaa151 86.
Mai Tsutsui, 2021 Pulmonary Rehabilitation in a Post-Covid-19 World: Telerehabilitation as a New Standard in Patients with COPD DOI https://doi.org/10.2147/COPD.S263031
Kementrian Kesehatan Republik Indonesia Peraturan Menteri Kesehatan Nomor 20 tahun 2019.
Perhimpunan Dokter Spesialis Rehabilitasi Medik Indonesia. Panduan tatalaksana telerehabilitasi, Perhimpunan Dokter Spesialis Rehabilitasi Medik Indonesia; 2020.
Lopez A, Salvador M, Miguel A. Telemedicine in times of the pandemic produced Covid-19: Implementation of a teleconsultation protocol in a hospital emergency department 2020 https://doi.org/10.3390/healthcare8040357
Werneke M Et Al Telerehabilitation during the covid-19 Pandemic in outpatient rehabilitation settings: a descriptive study.
Li J, Xia W, Zhan C, Liu S, Yin Z, Wang J, et al. A telerehabilitation programme in post-discharge COVID-19 patients (TERECO): a randomised controlled trial. Thorax. (2021). doi: 10.1136/thoraxjnl-2021-217382. [Epub ahead of print].â€
Pangestuti, Santi Dwi, dkk. 2015. Pengaruh Diaphragmatic Breathing Exercise terhadap Fungsi Pernapasan (RR dan APE) pada Lansia di UPT PLSU Kabupaten Jember. E-Jurnal Kesehatan. Vol. 3. No. 1: Januari 2015: hal.80.
Cai, et al (2020)Obesity and Covid-19 Severity in a Designated Hospital in Shenzhen, China.
Powers K.S, Howley T. E. Dalam: Exercise Physiology Theory and aplication to fitness and performance 10th Ed. McGrawal Hill Education. New York. 2013.
Kang S, Et Al. relationship between inspiratory muscle strength and cough capacity in cervical spinal cord injury patients 2006Kaneko H, Suzuki A, Horie J. Effect of cough training and inspiratory muscle training in cough in older adults: A randomized controlled trial. 2022.
Snijders, T., J. P. Nederveen, B. R. McKay, S. Joanisse, L. B. Verdijk, L. van Loon, and G. Parise. Satellite cells in human skeletal muscle plasticity. Frontiers in Physiology 6: 1–21, 2015 87.
Seynnes OR, de Boer M, and Narici MV. Early skeletal muscle hypertrophy and architectural changes in response to high-intensity resistance training. Journal of Applied Physiology 102: 368–373, 2007
Folland JP and Williams AG. The adaptations to strength training: morphological and neurological contributions to increased strength. Sports Medicine 37: 145– 168, 2007.
Joshi M, Mathur N. Pulmonary functions and effect of incentive spirometry during and post-acute period in tetraplegia. IJPMR 2002; 13:28–34.
Kaneko H, Suzuki A, Horie J. Effect of cough training and inspiratory muscle training in cough in older adults: A randomized controlled trial. 2022.
Kang S et al, Relationship between inspiratory muscle strength and cough capacity in cervical spinal cord injured patients 2006.
Shine, shaikhji s comparison of effectiveness of diaphragmatic breathing and pursed-lip expiration exercises in improving the forced expiratory flow rate and chest expansion in patients with bronchial asthma 2016. doi: 10.15621/ijphy/2016/v3i2/94871 3026.
Alaparthi G, Augustine A, Comparison of Diaphragmatic Breathing Exercise, Volume and Flow Incentive Spirometry, on Diaphragm Excursion and Pulmonary Function in Patients Undergoing Laparoscopic Surgery: A Randomized Controlled Trial doi: 10.1155/2016/1967532.
Nikmah S et al. Effectiveness of Incentive Spirometry and Diaphragmatic Breathing Exercise in Lung Function, Functional Capacity and Quality of Life of Bronchial Asthma Allergic Patients 2014.
