Rajiv Gandhi University of Health Sciences, Karnataka,



| | |

|6.` |Brief resume of the intended work: |

| |6.1 Need for the study: |

| |The pleural space normally contains less than 20ml of fluid. Pleural effusion occurs when there is excess fluid in the pleural cavity, caused |

| |by disturbed osmotic or hydrostatic pressure in the plasma, or changes in membrane permeability.1 |

| |A pleural effusion may be transudative or exudative. A transudate develops when fluid from the pulmonary capillaries moves into the pleural |

| |space. The fluid is thin & watery, containing a few blood cells & little protein. The pleural surfaces are not involved in producing the |

| |transudate. In contrast, an exudate develops when the pleural surfaces are diseased. The fluid has a high protein content & a great deal of |

| |cellular debris. Exudates is usually caused by inflammation, infection or malignancy.2 |

| |The common transudative causes of pleural effusion are left ventricular failure, cirrhotic liver disease, peritoneal dialysis, |

| |hypoalbuminaemia, nephrotic syndrome, pulmonary embolism, hypothyroidism & mitral stenosis & the common exudative causes are parapneumonic |

| |effusions, malignant neoplasm, pulmonary embolism, rheumatoid arthritis, pancreatitis, autoimmune diseases etc.3 |

| |The clinical features of pleural effusion are increased respiratory rate, increased heart rate, cardiac output and blood pressure, chest pain, |

| |cyanosis & cough (productive or non-productive). The physical signs include reduced chest wall movement on the affected side, stony dullness on|

| |percussion, & reduced or absent breath sounds & vocal resonance. Large effusions cause displacement of the trachea & mediastinum to the |

| |opposite side. 2, 4 In a recent study by Kalantri et al 10 in 278 patients (of whom 57% had pleural effusions) asymmetric chest expansion had a|

| |sensitivity of 74% and a specificity of 91%. Furthermore, when the pretest probability of disease based on other clinical findings was applied,|

| |symmetrical chest expansion was associated with a very low probability (8%) of pleural effusion.5 |

| |The management of each patient with a pleural effusion must be individualized. An etiologic diagnosis is necessary for the appropriate |

| |treatment of the patient. The medical management would include oxygen therapy protocol, hyperinflation therapy protocol & mechanical |

| |ventilation protocol. The surgical management includes pleurodesis & pleuroperitoneal shunt.2, 6 |

| |The physiotherapy management of pleural effusion would include breathing exercises, localized expansion exercises, belt exercises, positioning |

| |etc.7, 8 |

| |Milojevic et al (2003) conducted a study & concluded that patients with pleurisy undergoing laser stimulation presented with faster resorption|

| |of effusion and remission of the subjective symptoms, as well as significant decrease of biochemical acute inflammation parameters in the |

| |peripheral blood and therefore with faster recovery. In patients with pleurisy laser treatment increases regenerative mechanisms of the pleural|

| |surface, thus decreasing the quantity of formed adhesions and resulting in better mobility of the diaphragm.9 |

| |Milojevic et al (2004) conducted a study & concluded that the applied physical therapy (breathing exercises & laser biostimulation) resulted |

| |in significant improvement of all examined lung function parameters & significant improvement of the diaphragm mobility It is finally concluded|

| |that physical treatment should necessarily be included in the treatment of exudative pleurisy.10 Polastri et al( 2012) conducted a study & |

| |concluded that the use of EzPAP allowed lung expansion and mucus clearance.11 |

| |Chest mobilization exercises combine active movements of the trunk or extremities with deep breathing designed to improve the mobility of the |

| |chest wall, trunk, & shoulder girdle. They are used to reinforce or emphasize the depth of inspiration or controlled expiration. The specific |

| |techniques in chest mobilization exercises include- to mobilize one side of the chest, to mobilize the upper chest & stretch the pectoralis |

| |muscles & to mobilize the upper chest & shoulders.12 Vikram et al( 2012) conducted a study & concluded that chest wall stretching exercise |

| |establishes a betterment of respiratory functions such as reduction in dyspnea level and improvement in chest expansion when implementing a |

| |specific stretching protocolin complications like secretion retention & pleural effusion following a percutaneous pig tail nephrostomy.13 |

| |Incentive spirometry, also referred to as sustained maximal inspiration (SMI), is a component of bronchial hygiene therapy. It is designed to |

| |mimic natural sighing or yawning by encouraging the patient to take long, slow, deep breaths. The objectives of this procedure are to increase |

| |trans-pulmonary pressure and inspiratory volumes, improve inspiratory muscle performance and re-establish or stimulate the normal pattern of |

| |pulmonary hyperinflation.14 Agostini et al (2009) conducted a study & concluded that physiological evidence suggests |

| |that incentive spirometry may be appropriate for lung re-expansion following major thoracic surgery.15 Ferreira et al(2010) conducted a study |

| |& concluded that patients that were submitted to incentive spirometry present reduction of dyspnea and lower effort sensation after the 6-MWT, |

| |and also a better quality of life 18 months after CABG.16 |

| |Breath Stacking (BS) is a technique used to help prevent lung and chest wall stiffness and to keep the lungs clear of secretions. The benefits |

| |of breath stacking are- keep the lungs clear of infection, keep the air sacs open in your lungs, keep the chest wall flexible which allows you |

| |to take bigger breaths on your own, keep the lungs clear of mucous plugs & improve one’s ability to cough.17 Dias et al (2008) conducted a |

| |study & concluded that the breath stacking technique was shown to be effective. This technique was better than incentive spirometry for |

| |generating and sustaining have been described, this technique can probably be used safely and effectively, particularly in uncooperative |

| |patients.17 Baker et al (1990) conducted a study & concluded that when compared with IC, "breath stacking" (valved) maneuvers increased |

| |inspired volume by an average of 15 to 20% (p less than 0.05). More importantly, there was a several fold increase in the time over which high |

| |lung volume was sustained (p less than 0.001).19 Larissa et al (2012) conducted a study & concluded that data from both the intra-examiner and |

| |inter-examiner analyses suggest that the BS technique is reproducible. This technique mobilizes greater lung volumes than conventional |

| |spirometry.20 Stacked breathing is an entirely new & similar concept in which an individual breathes in 3-4 times without expiration, each time|

| |filling the lung a little bit more up to VC. This technique is a very effective way for an individual with weak respiratory muscles to achieve |

| |a full inspiration prior to a cough. The glottis closes between each attempt allowing for a build up of volume within the lungs.21 |

| |Chest mobility exercises are effective in improving the mobility of the chest wall, trunk, shoulders, increasing ventilation on that side of |

| |the chest, emphasizing depth of inspiration & controlling expiration. These exercises are effective in improving the chest expansion in |

| |subjects with pleural effusion. Study done by Vikram M et al (2012) concludes that chest mobility exercises have resulted in betterment of |

| |respiratory functions such as reduction in dyspnea level & significant improvement in chest expansion when implementing a specific stretching |

| |protocol in complications such as secretion retention & pleural effusion following a percutaneous pig tail nephrostomy.16 Incentive spirometry |

| |has been found to be appropriate for lung re-expansion following major thoracic surgery19 but it is not known whether Incentive spirometry can|

| |produce similar kind of re-expansion in subjects with unilateral pleural effusion. Also, the Breath stacking technique has shown to be |

| |effective particularly in uncooperative patients following abdominal surgeries15 & in mobilizing greater lung volumes17 & in achieving and |

| |sustaining deep inspiration, even in uncoached patients.13 But it is not known whether it will have similar effects in patients with unilateral|

| |pleural effusion. Therefore, there exists a need to compare the effectiveness of chest mobility exercises with incentive spirometry & chest |

| |mobility exercises with stacked breathing on the chest expansion in patients with unilateral pleural effusion. |

| |Hypothesis: |

| |There will be no significant difference between the effectiveness of chest mobility exercises with incentive spirometry & chest mobility |

| |exercises with stacked breathing on chest expansion in subjects with unilateral pleural effusion. |

| |6.2 Review of Literature: |

| |Review on Pleural Effusion: |

| |M. Polastri et al (2012) conducted a case study to describe the postoperative treatment of a left pleural effusion that occurred in a patient |

| |who had undergone aortic surgery & forty eight hours postoperatively, a left pleural effusion was observed. Pulmonary CT confirmed almost |

| |complete atelectasis of the left lung resulting from secretions and pleural effusion. The EzPAP with a mouthpiece was used with the patient |

| |sitting & the session included breathing exercises and manual chest therapy, lasted 30 minutes and was repeated twice in the afternoon on the |

| |first day of admittance to the cardiac ward. During the second session on the same day, the patient was encouraged to cough & a large amount of|

| |mucus was expectorated at one time. A marked difference was observed in the imaging studies: those obtained on the third day showed a decrease |

| |in the opacity of the left lung, which was completely white on admission. At follow-up 56 days later, total resolution was observed. The author|

| |concluded the use of EzPAP allowed lung expansion and mucus clearance using only one instrument.11 |

| |Dipali P Rana et al (2012) conducted a study to identify the effect of positioning on pulmonary functions in Unilateral Pleural Effusion. |

| |Randomly selected 25 subjects, irrespective of sex, of the age group 20-50 years with unilateral pleural effusion were included in the study & |

| |it was concluded that the FVC, FEV1 and FEV1/FVC values between the three different positions showed no significant difference (p>0.10) |

| |although the mean values of FVC in sitting position was higher than mean value of FVC in lateral positions.22 |

| |Enrique Dias-Guzman et al (2008) conducted a study to compare the sensitivity & specificity of different physical signs of pleural effusion to |

| |those of conventional chest radiography & concluded that in 278 patients (of whom 57% had pleural effusions), asymmetric chest expansion had a |

| |sensitivity of 74% and a specificity of 91%. Furthermore, when the pretest probability of disease based on other clinical findings was applied,|

| |symmetrical chest expansion was associated with a very low probability (8%) of pleural effusion.5 |

| |Hulzebos EH et al (2007) conducted a study which aimed to evaluate the prophylactic efficacy of preoperative physiotherapy, including |

| |inspiratory muscle training (IMT), on the incidence of postoperative pulmonary complications (PPCs) in high-risk patients scheduled for |

| |elective coronary artery bypass grafting (CABG). A total of 279 were enrolled and monitored up to discharge from hospital. Patients were |

| |randomly assigned to receive either preoperative IMT (n=140) or usual care (n=139). Both groups received the same postoperative treatment. The |

| |author concluded that preoperative physiotherapy, including IMT, statistically significantly reduced the incidence of PPCs and the duration of |

| |post operative hospitalization in patients at high risk of developing a pulmonary complication on undergoing CABG.23 |

| |Milojević M et al (2004) conducted a study which aimed to find out the following: 1) Is lung function improved by physical therapy; 2) Can |

| |adhesions be diminished and mobility of the affected hemidiaphragm improved by physical treatment. Physical treatment consisted of directed |

| |breathing exercises and laser biostimulation. The author concluded that the applied physical therapy resulted in: 1) significant improvement of|

| |all examined lung function parameters in the examined group, which was not registered in the control group; 2) significant improvement of the |

| |diaphragm mobility in general. It is finally concluded that physical treatment should necessarily be included in the treatment of |

| |exudative pleurisy.10 |

| |Milojević M et al (2003) conducted a study on effects of laser biostimulation on patients with pleurisy. The analysis included 25 patients & |

| |apart from conservative treatment, these patients were treated with laser biostimulation of acupuncture points and local region for ten days.. |

| |The author concluded patients with pleurisy undergoing laser stimulation presented with faster resorption of effusion and remission of the |

| |subjective symptoms, as well as significant decrease of biochemical acute inflammation parameters in the peripheral blood and therefore with |

| |faster recovery. In patients with pleurisy laser treatment increases regenerative mechanisms of the pleural surface, thus decreasing the |

| |quantity of formed adhesions and resulting in better mobility of the diaphragm.9 |

| |Review on Chest Mobility Exercises: |

| |Vikram M et al (2012) conducted a study where chest physiotherapy was executed on a 15-year-old girl who had complications such as secretion |

| |retention and pleural effusion following percutaneous pigtail nephrostomy.. Chest mobility exercises composed of an intercostal stretch on a |

| |determined intercostal space using index fingers, thoracic rotation and anterior compression with stretching in sitting position to improve |

| |respiratory functions. Following 9th sessions of treatment patient demonstrated satisfactory improvement by means of increasing in chest |

| |expansion and reduction in dyspnea level without using supplemental oxygen. The author concluded that there was a betterment of respiratory |

| |functions such as reduction in dyspnea level and improvement in chest expansion when implementing a specific stretching protocol. 13 |

| |Review on Breath Stacking and Incentive Spirometry: |

| |Larissa Andrade de Sá Feitosa1 et al (2012) conducted a study to identify the reproducibility of the Breath stacking technique in healthy |

| |volunteers and to compare BS with conventional spirometry with regard to inspiratory capacity. Eighty-five healthy volunteers (21.78 ± 2.79 |

| |years; 41 men, 44 women) underwent spirometry and BS. BS was performed with a unidirectional inspiratory valve by two different examiners. |

| |Spirometric tests were performed three times, and the BS manoeuvre was evaluated three times by each examiner. Respiratory rate, heart rate and|

| |peripheral arterial oxygen saturation were determined before, during and following the manoeuvre. The author concluded that data from both the |

| |intra-examiner and inter-examiner analyses suggest that the BS technique is reproducible. This technique mobilizes greater lung volumes than |

| |convfentional spirometry.20 |

| |Ferreira GM et al (2010) conducted a study to test if the use of incentive spirometry (IS) associated with expiratory positive airway pressure |

| |(EPAP), after CABG surgery improves dyspnea, effort perceived and quality of life 18 months after CABG. Sixteen patients submitted to a CABG, |

| |were randomized to a control group (n=8) or IS+EPAP group (n=8). The protocol of IS+EPAP was applied in the immediate postoperative period and |

| |following for more 4 weeks in the patient's home. Eighteen months after CABG, the strength of the respiratory muscle, the functional capacity, |

| |the lung function, the quality of life and the level of physical activity were evaluated. The author concluded patients that were submitted to |

| |IS+EPAP present reduction of dyspnea and lower effort sensation after the 6-MWT, and also a better quality of life 18 months after CABG.16 |

| |Agostini P et al (2009) conducted a study to review the evidence for incentive spirometry, examining the physiological basis, equipment and its|

| |use following thoracic surgery. Initially, 106 studies were found in MEDLINE, 99 in EMBASE and 42 in CINAHL. Eight references were found in the|

| |Cochrane Library and one paper in the Chartered Society of Physiotherapy Resource Centre. Four studies and one systematic review investigating |

| |the effects of postoperative physiotherapy and incentive spirometry in thoracic surgery patients were selected and reviewed. The author |

| |concluded incentive spirometry may be appropriate for lung re-expansion following major thoracic surgery. Based on sparse literature, |

| |postoperative physiotherapy regimes with, or without, the use of incentive spirometry appear to be effective following thoracic |

| |surgery compared with no physiotherapy input.15 |

| |Dias CM et al (2008) conducted a study to compare the inspiratory volume during the breath stacking maneuver with the volume during incentive |

| |spirometry, in abdominal surgery patients. Twelve patients, on their first postoperative day, were instructed to take a deep breath through the|

| |Voldyne™ incentive spirometer and to make successive inspiratory efforts using a facemask that had been adapted for performing the breath |

| |stacking maneuver A Wright™ ventilometer allowed inspiratory capacity to be recorded. The author concluded that the breath stacking technique |

| |was shown to be effective. This technique was better than incentive spirometry for generating and sustaining inspiratory volumes. Since no |

| |adverse effects have been described, this technique can probably be used safely and effectively, particularly in uncooperative patients.18 |

| |Elisabeth Westerdahl et al (2001) conducted a study to identify the effectiveness of three deep breathing techniques which was evaluated in 98 |

| |male patients after coronary artery bypass graft surgery. The techniques examined were deep breathing with a blow bottle-device, an inspiratory|

| |resistance-positive expiratory pressure mask (IR-PEP) and performed with no mechanical device. Four days post-operatively there were |

| |significantly decreased vital capacity, inspiratory capacity, forced expiratory volume in 1 second, functional residual capacity, total lung |

| |capacity and single-breath carbon monoxide diffusing capacity in all three groups (p < 0.0001). The author concluded that the Blow bottle |

| |group had significantly less reduction in total lung capacity (p = 0.01) compared to the Deep breathing group, while the IR-PEP group did not |

| |significantly differ from the other two groups.24 |

| |Baker WL et al (1990) conducted a study whether using a one-way valve to prevent exhalation would allow rest between inspiratory efforts and |

| |cause volume to cumulate during successive tidal efforts, improving both the depth and duration of the inspiratory maneuver. 26 subjects |

| |breathed via mouthpiece from a spirometer prefilled with 100% oxygen. Three different maneuvers were performed in random order by all subjects:|

| |(1) standard inspiratory capacity without valve or inspiratory hold, (2) inspiratory capacity (IC) with breath holding aided by a one-way |

| |valve, and (3) uncoached breath-stacking, during which successive tidal breaths were cumulated by one-way valving. A fourth maneuver was added |

| |in the last 13 subjects studied: an initial coached IC effort with subsequent valved stacking of tidal efforts. The author concluded that when |

| |compared with IC, "breath stacking" (valved) maneuvers increased inspired volume by an average of 15 to 20% (p less than 0.05). More |

| |importantly, there was a several fold increase in the time over which high lung volume was sustained (p less than 0.001).The results indicate |

| |that one-way valving helps to achieve and sustain deep inspiration, even in uncoached patients.19 |

| |6.3 Objectives of the study: |

| |1. To determine the efficacy of chest mobility exercises & incentive spirometry on chest expansion in subjects with unilateral pleural |

| |effusion. |

| |2. To determine the efficacy of chest mobility exercises & stacked breathing on chest expansion in subjects with unilateral pleural effusion. |

| |3. To compare the efficacy of chest mobility exercises & incentive spirometry with that of chest mobility exercises & stacked breathing on |

| |chest expansion in subjects with unilateral pleural effusion. |

|7. |Materials and Methods: |

| |Source of Data: |

| |ESI Hospital, Rajajinagar, Bangalore. |

| |K C General Hospital, Malleshwaram, Bangalore. |

| |Method of collection of data: |

| |Population : Subjects with Pleural effusion. |

| |Sampling : Convenience sampling. |

| |Sample size : 30. |

| |Type of Study : Experimental study with pre post test design. |

| |Duration of the study : 6 months. |

| |Inclusion Criteria: |

| |Subjects with Unilateral Pleural Effusion. |

| |Age – 20-50 years. |

| |Subjects of both genders. |

| |Subjects diagnosed as pleural effusion by the physician. |

| |Subjects with asymmetrical chest expansion. |

| |Exclusion Criteria: |

| |Orthopaedic conditions. |

| |Hypertension. |

| |Pleural effusion due to transudate conditions like: liver cirrhosis, CCF etc. |

| |Malignant conditions. |

| |Cognitive impairments. |

| |Refusals. |

| |Material used: |

| |Couch. |

| |Paper. |

| |Pen. |

| |Incentive spirometer. |

| |Measuring tape. |

| |Measuring tools: |

| |Thoracic flow cytometry |

| |Methodology |

| |Intervention to be conducted on the participants: |

| |After getting ethical clearance subjects will be enrolled in the study. Patients with unilateral pleural effusion will be recruited from the |

| |medical ward of the hospital. Subjects will be selected based on the inclusion and exclusion criteria. Following an initial assessment the |

| |patients will be assigned to one of the two groups by block randomization. |

| |After randomizing the patient to one of two groups, before the intervention chest expansion will be measured by Thoracic flow cytometry |

| |according to Kakizaki et al.25 Basal expansions was determined by using a tape measure as it is known that pleural effusion accumulates in the |

| |lower zones. Each measurement was obtained after maximal expiration followed by maximum inspiration and another maximal expiration. |

| |Measurements were taken twice and the mean of the two values was recorded. |

| |Group A will receive Chest mobility exercises with Incentive spirometry according to Kisner9 & the AARC guideleines.14 |

| |Group B will receive Chest mobility exercises with Stacked breathing according to Kisner9 & breath stacking technique explained by Providence |

| |Care.17 |

| |Both groups will be instructed to perform the intervention 3 times per day, 7-8 times per session for one week. |

| |Thoracic flow cytometry will be repeated after one week. |

| | |

| |Outcome measures: |

| |Chest expansion. |

| |Statistics: |

| |Data analysis will be performed by SPSS (version 17) for windows. Alpha value will be set as 0.05. |

| |Descriptive statistics will be used to find out mean, standard deviation & range for demographic and outcome variable. |

| |Unpaired t test will be used to find out the homogeneity for baseline & demographic & outcome variable. |

| |Chi square test will be used to find out gender differences among the two groups. |

| |Paired t test will be used to find out significant differences for the chest expansion within the groups. |

| |Unpaired t test will be used to find out significant differences for the chest expansion between the groups. |

| |Microsoft word, excel will be used to generate graph and tables etc. |

| |Does the study require any investigation or intervention to be conducted on patients or other humans or animals? If so please describe briefly.|

| |Yes, the study will be carried out on human subjects of both genders with the age group of 20-50 years having unilateral pleural effusion with |

| |reduced chest expansion, to compare the effectiveness of chest mobility exercises and incentive spirometry versus chest mobility exercises and |

| |stacked breathing. |

| |Has the ethical clearance been obtained from your institution in case of 7.3. |

| |Yes, ethical clearance has been obtained from the institution. As this study will involve human subjects, the ethical clearance has been |

| |obtained from the ethical committee of Padmashree institute of physiotherapy, Nagarbhavi, Bangalore, as per ethical guidelines research from |

| |biomedical research on human subjects, 2000, ICMR, New Delhi. |

| | |

|8. |List of References: |

| |Hough A. Physiotherapy in Respiratory Care.3rd ed.2001.p.98. |

| |Jardins TD, Burton GG. Clinical Manifestations and Assessment of Respiratory Disease. 5th ed. p.319-323. |

| |McGrath EE, Anderson PB. Diagnosis of Pleural Effusion: A systematic approach. American Journal of Critical Care.2011 Mar;20(2). |

| |Colledge NR, Walker BR, Ralston SH. Davidson’s Principles and Practice of Medicine.19th ed.2002.p.501-3. |

| |Guzman ED, Budev MM. Accuracy of the physical examination in evaluating pleural effusion. Cleveland Clinic Journal of Medicine 2008 Apr;75(4). |

| |Scanlan CL, Wilkins RL, Stoller JK. Egan’s Fundamentals of Respiratory Care.7th ed.1999.p.477-83 |

| |Downie PA. Cash’s Textbook of Chest, Heart & Vascular Disorders for Physiotherapists. 4th ed.1987.p.533 |

| |W. Darlene Reid & Frank Chung. Cardiopulmonary Physical Therapy.2004.p.130 |

| |Milojević M, Kuruc V. Laser biostimulation in the treatment of pleurisy. 2003 Nov-Dec;56(11-12):516-20 |

| |Milojević M, Kuruc V. The role of physical rehabilitation in the treatment of exudative pleurisy. 2004 Jan-Feb;57(1-2):13-7. |

| |M. Polastri, A. Pantaleo. Managing a left pleural effusion after aortic surgery; European Review for Medical and Pharmacological Sciences. |

| |2012;16(4 Suppl):78-80 |

| |Carolyn Kisner & Lynn Allen Colby. Therapeutic Exercise. 5th ed.2007.p.867 |

| |Vikram M , Leonard JH, Kamaria K. Chest Wall Stretching Exercise as an Adjunct Modality in Post Operative Pulmonary Management.2012 Mar 4. |

| |AARC Clinical Practice Guideline; Reprinted from the December 1991 issue of Respiratory Care [Respir Care 1991;36(12):1402–1405]. |

| |Agostini P, Singh S. Incentive spirometry following thoracic surgery: what should we be doing? 2009 Jun; 95(2):76-82. Epub 2009 Mar 3. |

| |Ferreira GM, Haeffner MP, Barreto SS, Dall'Ago P. Incentive spirometry with expiratory positive airway pressure brings benefits after |

| |myocardial revascularization. 2010 Feb; 94(2):230-5, 246-51, 233-8. |

| |Providence Care available from URL |

| |Stacking%20handbook.pdf/2008;1-11 |

| |Dias CM, Plácido TR, Ferreira MFB, Guimarães FS, Menezes SLS. Incentive spirometry and breath stacking: effects on the inspiratory capacity of |

| |individuals submitted to abdominal surgery; Rev Bras Fisioter. 2008; 12(2):94-9. |

| |Baker WL, Lamb VJ, Marini JJ. Breath-stacking increases the depth and duration of chest expansion by incentive spirometry. 1990 Feb; |

| |141(2):343-6. |

| |Feitosa LAS, Barbosa PA, Pessoa MF, Rodrigues-Machado MG, Andrade AD. Clinimetric Properties of Breath-stacking Technique for Assessment of |

| |Inspiratory Capacity; Physiother. Res. Int. 17 (2012) 48–54 2011 John Wiley & Sons, Ltd |

| |Moyna J. Parker .Breathing techniques. Physiotherapy in Thoracic Condition. p.213 |

| |Rana DP, Talati N. Effect of Positioning on Pulmonary Functions in Unilateral pleural effusion. 2012 Apr. |

| |Hulzebos EH, Helders PJ, Favié NJ, de Bie RA, Brutel de la Rivière A, van Meeteren NL(2007). |

| |Westerdahl E, Lindmark B, Almgren SO, Tenling A. Chest Physiotherapy After Coronary Artery Bypass Graft Surgery—A Comparison of Three Different|

| |Deep Breathing techniques. J Rehab Med 2001;33: 79–84 |

| |Kakizaki F ,Shibuya M ,Yamazaki T, Yamada M,Suzuki H ,Homma I. Preliminary report on the effects of respiratory muscle stretch gymnastics on |

| |chest wall mobility in patients with COPD. Respir Care 1999; 44:409-14. |

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