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Slow Deep Breathing Reduces High Blood Pressure In Hypertensive Patients

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ABSTRACT Hypertension is a major problem in public health throughout the world. In Indonesia, Hypertension was the first rank of morbidity due to cardiovascular disease. Treatment of ypertension is very crucial in affecting the number of morbidity and mortality. More cases of ypertension are still not diagnosed for more than 70 %. This condition will be a very serious hallenge for health workers to identify and deal with hypertension. Treatment of hypertension an be pharmacological or non- pharmacological. One that needs to be considered in the treatment of hypertension is Slow Deep Breathing. The purpose of the study was to analyze the ffect of Slow Deep Breathing in controlling and lowering high blood pressure in hypertensive atients. Quasi experiment study with pre and posttest control group for 4 weeks interventions, 3 ays a week , 15 minutes long for each session The sample of this research are the patients with ypertension through purposive sampling totally 29 respondents (15 intervention group and 14 n the control group) in Puskesmas Binong Tangerang. The result showed that patients in ntervention group (SDB) had a significant blood pressure lower than control group (non-SDB) p value=0.00 for systolic and p value= 0.015 for diastolic). It is expected that SDB could be more socialize broadly and intensively particularly for patient and family with hypertension.
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SLOW DEEP BREATHING REDUCES HIGH BLOOD PRESSURE
IN HYPERTENSIVE PATIENTS
Dame Elysabeth1), Sedia Simbolon2), Belet Lydia3)
1),2),3) Lecturer Fakultas Ilmu Keperawatan, Universitas Pelita Harapan, Indonesia
ABSTRACT
Hypertension is a major problem in public health throughout the world. In Indonesia,
Hypertension was the first rank of morbidity due to cardiovascular disease. Treatment of
hypertension is very crucial in affecting the number of morbidity and mortality. More cases of
hypertension are still not diagnosed for more than 70 %. This condition will be a very serious
challenge for health workers to identify and deal with hypertension. Treatment of hypertension
can be pharmacological or non- pharmacological. One that needs to be considered in the
treatment of hypertension is Slow Deep Breathing. The purpose of the study was to analyze the
effect of Slow Deep Breathing in controlling and lowering high blood pressure in hypertensive
patients. Quasi experiment study with pre and posttest control group for 4 weeks interventions, 3
days a week , 15 minutes long for each session The sample of this research are the patients with
hypertension through purposive sampling totally 29 respondents (15 intervention group and 14
in the control group) in Puskesmas Binong Tangerang. The result showed that patients in
intervention group (SDB) had a significant blood pressure lower than control group (non-SDB)
(p value=0.00 for systolic and p value= 0.015 for diastolic). It is expected that SDB could be
more socialize broadly and intensively particularly for patient and family with hypertension.
Keywords: Blood Pressure, Hypertension, Slow Deep Breathing (SDB)
I. Introduction
Currently, hypertensions become a major public health problem worldwide. As many as
194 countries reported an increase in cases of hypertension in men and women (World
Health Organization's annual statistics, 2012). The World Health Statistics news release
in 2012, stating that the case of non-communicable disease, particularly hypertension
has increased very dramatically both in countries with high income, and low income.
More worryingly, one in three adults worldwide has hypertension, and this condition is
the cause of half of deaths from stroke and heart disease (WHO, 2012).
In Indonesia, the problem is tend to increase, hypertension also shown from the results
of Household Health Survey (Survey) which increased from 8.3% to 27.5% in 2004
(Ministry of Health National Health Survey (2004) in Rahajeng and Tuminah, 2009).
The survey also noted the prevalence of hypertension in Indonesia in 2009 which is
32.2% based on a survey of blood pressure measurements obtained as much as 7.8% of
the cases that have been diagnosed with hypertension, or as much as 24.7% remain
undiagnosed or not yet covered by health workers. Hypertension can potentially lead to
cardiovascular disease, where cardiovascular disease is the number one cause of death in
Indonesia, namely as much as 20-35%, these data demonstrate that hypertension is
directly proportional to the morbidity and mortality of cardiovascular disease (Setiawan,
2006).
Health Research (Riskesdas) (2007) shows the majority of cases remain undiagnosed
hypertension in the community, where only 7.2% of the population who already know
have hypertension and only 0.4% of cases were taking medication hypertension. These
shows there are still many cases of hypertension are not known and handled so that it
becomes a serious threat to the people of Indonesia. In Banten, the prevalence of
hypertension 27.6%. The percentage of cases based on the diagnosis and or a history of
taking drug hypertension was 9.4% higher than the national rate (7.6%) (Rahajeng and
Tuminah, 2009).
Nurses as one of the health workers spread across the community has a role to provide
nursing care of patients with hypertension. Treatment of hypertension is very important
and necessary to prevent further complications of hypertension which can lead to death.
Proper handling of hypertension will reduce the risk of increased morbidity and
mortality in hypertensive patients. Hypertension management include anti-hypertensive
drugs and non-pharmacological form of lifestyle modification, exercise, diet, alcohol
consumption, weight control, setting the intake of sodium, potassium, relaxation and
stress reduction techniques, yoga, meditation, biofeedback to use tool breathing
regulator that can lower blood pressure (Mourya, Mahajan, Singh and Jain, 2009). One
that needs to be considered in the treatment of hypertension is Slow Deep Breathing
(SDB). SDB is a natural innovation technique in lowering blood pressure by reducing
the respiratory rate to 6 times per minute through the mechanism of increased sensitivity
barorefleks and decrease sympathetic activity and activation of chemo reflex thus
potentially lowering blood pressure.
Elliott et al (2004) conducted a study on 149 patients with hypertension; it was found
that there is a significant reduction in systolic blood pressure in patients who do more
than 180 minutes for 8 weeks using tools to guide the breathing. Schein et al (2009)
conducted a similar study back and get that a given intervention group SDB decreased
blood pressure compared with the control group. Schein et al concluded that the setting
of respiratory potentially therapeutic in reducing risk and can be used as adjunctive
therapy of hypertension. Research by Anderson, McNeedly, and Windham (2010)
Regular Slow-Breathing Exercise Effects on Blood Pressure and Breathing Patterns at
Rest for 4 weeks for 15 minutes with deep breathing experimental group and the control
group with normal breathing but more relaxed. Observations carried out 3 times a day at
night, morning and afternoon. SDB intervention significantly lowered blood pressure at
rest.
Research on the effects of SDB also performed by Meles, Giannattasio, Failla, Gentile,
Capra and Mancia (2004) in 73 patients with moderate hypertension, obtained an
average reduction of 5.5 mmHg systolic and diastolic by 3.6 mmHg after intervention
SDB given daily for 8 weeks for 15 minutes. Based on the above research evidence,
SDB showed antihypertensive effect is quite effective, practical, and without side
effects.
II. Methods
This study was approved by the ethical committee of the team and the Research Institute
of Community Services (LPPM) Universitas Pelita Harapan (UPH). The study design
was used with a quasi-experimental study of pre and posttest control group design lasts
for 3 months in 2013. Samples were taken using purposive sampling technique with the
inclusion criteria for patients who are willing to become respondents with primary
hypertension degrees 1 and 2 in accordance with the degree of hypertension by the Joint
National Committee (JNC) aged 25-60 years. Patients with impaired cognitive function
panic disorder, major psychiatric disorder. Stroke patients, seizures, heart failure,
chronic renal failure, respiratory problems including asthma or chronic obstructive
pulmonary disease, and pregnancy cannot be respondents in this study.
Implementation of SDB performed during each 4-week, 3 times a week and 15 minutes
of each intervention. All respondents were given an explanation and asked for informed
consent in research before signing a letter of approval of research. To be consistent
implementation at each meeting SDB, SDB guided practice using SDB video made by
the research team. The procedure for doing SDB featured in the video are as follows: 1)
Set the position of the patient in the sitting position, 2) Ask the patient put his hand on
her stomach, 3) Encourage the patient to breathe slowly and deeply through the nose,
inhale for 3 seconds, while feeling the abdomen expands when you inhale, 4) Ask the
patient to hold their breath for 3 seconds, 5) Patients pursed lips (lip position as when
whistling), exhale through the mouth slowly within 6 seconds while cooking the
abdomen move down, 6) repeat steps 1 through 5 for 15 minutes.
Blood pressure is measure every visit with digital sphygmomanometer calibrated, done
by researchers and two research assistants. Blood pressure was obtained at baseline
accounted for compared with the blood pressure at the end of the study.
III. Results
This research was conducted in Puskesmas Binong and Puskesmas Siloam Tangerang
District in 2013. The study included a total of 29 patients with primary hypertension
were divided into 15 patients to intervention SDB, the remaining 14 patients as a control
group who were not given SDB. The following is the distribution of the mean blood
pressure before and after the intervention of SDB.
Table 1 Distribution of the average systolic and diastolic blood pressure before and after
in the Intervention group (n= 15)
Intervention Group
Before
After
Mean Systolic Pressure(mmHg)
156.13
130.93
Mean Diastolic pressure (mmHg)
89.13
81.00
Based on the table, in the intervention group mean systolic blood pressure before
intervention was 156.13 and 130.93 mmHg after intervention. For diastolic blood
pressure were obtained before was 89.13 mmHg and after intervention was 81 mmHg.
Table 2 Distribution of the average systolic and diastolic blood pressure before and after
in the control group (n=14)
Control Group
Before
After
Mean Systolic Pressure(mmHg)
156.79
156.21
Mean Diastolic pressure (mmHg)
92.07
89.50
The table 2 shows the mean of systolic pressure before was 156.79 and after was 156.21.
For diastolic blood pressure were obtained before was 92.07 and after was 89.50.
Table 3. The difference of average systolic and diastolic pressure between the control
group and the intervention group (n=29)
Blood Pressure
Mean
p value
Before
After
Systolic
SDB
130.93
0.000
Non- SDB
156.21
Diastolic
SDB
81.00
0.015
Non- SDB
89.50
Table 3 shows that there was a significant difference between intervention and control
group for both systolic (p value= 0.00) and diastolic pressure (p value= 0.015).
IV. Discussion
The statistical results are consistent with the initial hypothesis of researchers; so that the
results of this study support that SDB may reduce or control blood pressure.
SDB intervention showed significant results cannot be separated from the influence of
the implementation of strict procedures and participation of the respondents was being
cooperative, enthusiastic and eager to do this SDB procedure. It was not easy for
participant to follow a regular program, regularly and consistently for 3 times a week
within 4 weeks.
The results of this study also reaffirms previous studies carried out by Shcein et al.
(2001); Bhatt, Arafath, and Guleria (2007); Elliot et al. (2004); Mourya, Mhajan, Singh,
and Jain (2009); Oktiawati (2009); Oneda et al. (2010) Turankar et al. (2011); Bilo et al.
2012, in particular Research Anderson, McNeedly, and Windham (2010), entitled
"Regular Slow-Breathing Exercise Effects on Blood Pressure and Breathing Patterns at
Rest" made to 40 participants with pre hypertension. The participants practiced their
breathing exercises at home for 4 weeks for 15 minutes with deep breathing
experimental group and the control group with normal breathing but more relaxed.
Observations carried out 3 times a day that was at night, morning and afternoon. The
results also confirmed the theory of Potter & Perry that SDB may reduce the pressure by
increasing the sensitivity and decrease the activity of the sympathetic barorefleks and
enable chemo reflex (Joseph et al, 2005).
Nurses as one of the health workers spread across the community has a role to provide
nursing care of patients with hypertension. Treatment of hypertension is very important
and necessary to prevent further complications of hypertension which can lead to death.
Proper handling of hypertension will reduce the risk of increased morbidity and
mortality in hypertensive patients. Through the impact of SDB, nurses can take on roles
as educators and providers of nursing care in patients with hypertension. SDB can be
disseminated more broadly in society, both in service in hospitals, health centers. SDB
procedure is applied, anytime and anywhere by the patient's own and do not have side
effects.
Researchers realized that this study is limited to see the benefits of SDB in patients with
primary hypertension. Other confounding factors may affect the results of blood
pressure, which is not examined yet in this study.
V. Conclusion
Based on the results of the data analysis of changes in blood pressure before and after
the implementation of the blood pressure SDB is effective in lowering blood pressure
and maintaining stability in patients with primary hypertension are indicated with p
value 0.000 systolic blood pressure ( = 0.05) and diastolic blood pressure of 0.015.
Future studies should focus on SDB with a larger number of respondents and also
consider confounding factors that may affect the results.
VI. Acknowledgement
This research is funded on the basis of Research Grants; therefore we would like to
thank the Higher Education and LPPM UPH who has supported research activities.
References
Anderson, D.E., Mc Neely, J.D., Windham, B.G. 2010. Regular slow-breathing exercise
effects on blood pressure and breathing patterns at rest. Journal of Human
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Elliott, W., Izzo, J.R., White, W.B., Rosing,D., Snyder, C.s., Alter, A., Gavish, B.,
Black, H.R. 2006. “Graded Blood Pressure Reduction in Hypertensive Outpatients
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Joseph, C.N., Porta, C., Casucci, G., Casiraghi, N., Maffeis M., Rossi, M. Bernardi, L.
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Device-guided breathing exercises at home have a potential to become a nonpharmacologic treatment of high blood pressure (BP). The aim of this study was to evaluate the impact of device-guided breathing exercises on both office and home BP. A total of 79 mild hypertensive individuals, either medicated or unmedicated, with BP > 140/90 mm Hg were enrolled. After a 2-week run-in phase, in both the control and treatment groups daily home blood pressure was monitored for 8 weeks. The treatment group also engaged in 15-min daily sessions with device-guided breathing exercises. A total of 47 treatment patients and 26 control subjects completed the study. In the control group both office and home BP showed small nonsignificant reductions. Device-guided breathing exercises reduced mean office BP (systolic/diastolic) by 5.5/3.6 mm Hg (P < .05 for diastolic) and mean home BP by 5.4/3.2 mm Hg (P < .001 for both). Home BP response reached a plateau after 3 weeks. Our data show that device-guided breathing exercises have an antihypertensive effect that can be seen in conditions closer to daily life than the setting of the physician's office.
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Sympathetic hyperactivity and parasympathetic withdrawal may cause and sustain hypertension. This autonomic imbalance is in turn related to a reduced or reset arterial baroreflex sensitivity and chemoreflex-induced hyperventilation. Slow breathing at 6 breaths/min increases baroreflex sensitivity and reduces sympathetic activity and chemoreflex activation, suggesting a potentially beneficial effect in hypertension. We tested whether slow breathing was capable of modifying blood pressure in hypertensive and control subjects and improving baroreflex sensitivity. Continuous noninvasive blood pressure, RR interval, respiration, and end-tidal CO2 (CO 2-et) were monitored in 20 subjects with essential hypertension (56.4±1.9 years) and in 26 controls (52.3±1.4 years) in sitting position during spontaneous breathing and controlled breathing at slower (6/min) and faster (15/min) breathing rate. Baroreflex sensitivity was measured by autoregressive spectral analysis and "alpha angle" method. Slow breathing decreased systolic and diastolic pressures in hypertensive subjects (from 149.7±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, respectively). Controlled breathing (15/min) decreased systolic (to 142.8±3.9 mm Hg; P<0.05) but not diastolic blood pressure and decreased RR interval (P<0.05) without altering the baroreflex. Similar findings were seen in controls for RR interval. Slow breathing increased baroreflex sensitivity in hypertensives (from 5.8±0.7 to 10.3±2.0 ms/mm Hg; P<0.01) and controls (from 10.9±1.0 to 16.0±1.5 ms/mm Hg; P<0.001) without inducing hyperventilation. During spontaneous breathing, hypertensive subjects showed lower CO2 and faster breathing rate, suggesting hyperventilation and reduced baroreflex sensitivity (P<0.001 versus controls). Slow breathing reduces blood pressure and enhances baroreflex sensitivity in hypertensive patients. These effects appear potentially beneficial in the management of hypertension.
Prevalensi Hipertensi dan Determinannya di Indonesia
  • E Rahajeng
  • S Tuminah
Rahajeng, E., & Tuminah, S. 2009. Prevalensi Hipertensi dan Determinannya di Indonesia. Majalah Kedokteran Indonesia, 59, 580-587.