Novel approach on pulmonary rehabilitation for Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) global initiative for chronic obstructive lung disease (GOLD) 1 - 3: A single-blinded randomised controlled trial protocol

A total of 62 AECOPD inpatients (Participants) of GOLD 1 - GOLD 3 category at Mahkota Medical Centre, Malaysia will be participated, according to inclusion and exclusion criteria in this study. The participants were randomised and allocated to both controlled and experimental group which consist of 31 participants each. The baseline assessment consist of four outcome measures namely, pain VAS scale, Modified BORG dyspnea scale, lung volumes and 6 minute walking test (6MWT). Since this study involves vulnerable hospitalised patients prior to lung infections, both blinded assessor and principal researcher should always be in their full personal protective equipment (PPE) throughout this study, to prevent cross -infection. This step is highly essential for infection control measures. Before starting the baseline assessment, a bronchodilator test (BDT) administering nebulized 2.5 mg salbutamol and 0.5 mg ipratropium bromide will be given to the patient. This step is important to ensure any improvement in airflow and lung capacity after taking the bronchodilator medicine. The patient’s vital signs, including blood pressure, heart rate, oxygen saturation and respiratory rate will be recorded. Before starting the 6MWT, the blinded assessor will measure the patient’s pain VAS scale and dyspnea level. The patient will walk along the corridor between two cones that have been marked for six minutes. During this time, heart rate and SpO2 were monitored by portable pulse oximetry (RS PRO Oxygen Oximeter Pulse Oximeter) throughout and recorded before, every 30 seconds and test completion. Dyspnea was recorded on test completion by Modified BORG Dsypnea Scale. Lastly, participant will answer the SGRQ-CM to evaluate each QOL factors. The pre- and post-intervention assessments will take place at the patient’s room in the ward to minimize the environment factor that may influence patient’s performance. Pre-assessment will be done one day before the intervention starts. Participants in experimental group receive autogenic drainage and walking exercise as treatment which will be carried out estimated duration of 45 minutes to 60 minutes for each session, twice per day for four consecutive days, as inpatient. During performing autogenic drainage session, participants will be seated upright in a chair with back supported. The upper airways are cleared from secretions by huffing or blowing the nose. The researcher sits at the side and slightly behind the participant, closes enough to hear the participant's breathing. Participant hands are place on the abdomen to feel the exertion of abdominal muscles and the researcher hand is place on the upper chest to feel the secretions. The technique includes unsticking, collecting and evacuating phases. A series of 10 -20 breaths at low lung volume of inhalation will be done slowly through the nose using diaphragm and at 2-3 seconds inspiration breath hold allowing collateral ventilation to get air behind the secretions. Cough and huff are encouraged at this phase. Exhalation is done through the mouth. The vibration of mucus will be felt by researcher's hand and is place on upper chest then the patient will be asked to breath at normal tidal volume followed by for 10 -12 breaths followed by breathing near the vital capacity. The frequency of the vibrations reveals their locations. High frequency reveals secretions located in small airways. Low frequencies mean that secretions is move to larger airways. At the end of session, the mucus is evacuated by a stronger or maximum expiration or a high-volume huff or cough. A review of each patient record is essential as to assess any adherence if applicable. For walking exercise prescription, applying the standardized moderate intensity exercise (64-76% of their age predicted maximal heart rate (APMHR)) (Kyral et al., 2019), will be measured using the equation HRmax = 220 - age (Shookster et al., 2020), adjacent to each patient’s Modified Borg Dyspnea Level (MBS). Participant will be set to portable pulse oximetry while performing walking exercise to observe the heart rate. Subsequently, participants will be asked to walk along ward corridor (100metre), back and forth, for two rounds with physiotherapist (researcher) supervision, twice per day. Participant will be asked to stop immediately if exceeding maximal heart rate within moderate intensity. No time and distance are required to be recorded during this session. Post intervention assessments are taken after completion of four days with twice sessions per day intervention course, consist of pain VAS scale, Modified BORG Dyspnea Scale, lung volumes and 6MWT. The participants will be later followed up a month (4 weeks) post discharge via phone call. During the phone call, researcher will ask participants based on the St George’s respiratory questionnaire for COPD, Malaysian version (SQRQ- CM). The SQRQ-CM will evaluate (component) the QOL by the. St George’s respiratory questionnaire for COPD, Malaysian version (SQRQ- CM) was used for this study.