Download RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA
SYNOPSIS
FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1
Name of the candidate
Mr. K. N. NAGARAJ GOWDA
Diana College of Nursing
2
3
Name of the
No. 68, Chokkanahalli,
Institution
Jakkur Post, Bangalore – 64
Course of Study and
Master of Science in Nursing
Subject
4
Child Health Nursing.
Date of Admission to
14/6/2011
Course
A study to assess the Peak Expiratory Flow Rate
5
Title of the Topic
(PEFR) values among children in selected schools at
Bangalore.
1
6. Brief resume of the intended work:
INTRODUCTION
Asthma is the most common chronic inflammatory disease in children and is
a major global health problem which exerts a substantial burden on the family, health
care services and on the society as a whole.1 Prevalence of asthma in children is
increasing day by day globally supported by different studies in different countries.
Pulmonary function tests of various types are utilized clinically and
epidemiologically to measure functional status in order to assess the disease.2
Pulmonary function testing in a child differs from that in adult, largely because of the
volume change that occurs from birth through the period of growth to the adulthood.3
However, most of them are cumbersome, expensive and difficult to obtain
reproducible results in children.
Pulmonary function is known to vary with age, sex, height, weight, race and
geographic locations.4 India, being a subcontinent, changes in pulmonary functions
can occur between children of South Indian origin and children of other regions.
The Peak Expiratory Flow Rate (PEFR) measurement is a simple,
reproducible and reliable way of judging the degree of airway obstruction in various
obstructive pulmonary diseases, especially asthma. Peak expiratory flow rate is easily
measured by using a mini-Wright’s Peak Flow Meter (m WPFM), which is easy to
use, reliable and can be recorded even by the patients or by the parents at home.5
This instrument is cheap, portable, understandable and useful for physicians in
managing children with respiratory diseases, particularly valuable for assessing
children aged as low as 3 years, as younger children can not perform the other
pulmonary function test reproducibly.6
PEFR is highly sensitive and accurate index of airway obstruction. It can used
as a guideline for admission and discharge of asthma when: PEFR value >60% of
expected - admission is probably unnecessary, 40-60% of expected - consider
admission and, <40% of expected – admission is probably necessary.7
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6.1 NEED FOR THE STUDY
The PEFR is an accepted index of pulmonary function and is widely used in
respiratory medicine. Serial PEFR monitoring is a convenient method in investigation
and diagnosis of occupational asthma and often is used alone in the assessment of
asthmatic patients. Recent studies showed that personal best PEFR is a useful concept
for asthma self management plans when determined as the highest PEFR over the
previous 2 weeks.3
Peak expiratory flow rate (PEFR) has been shown to be very useful in the
routine monitoring of healthy and asthmatic children. There is a need for a simple,
effective technique such as the PEFR measurement to screen for and control asthma
in the community, particularly when the prevalence of asthma and asthma-related
hospital admissions are rising. With better control of asthma, the number of children
admitted to hospital is likely to decrease, and management costs, in terms of funds
and time reduced.8
PEFR measurement can reveal the diurnal variability of airway of patients
who have been suffering from reactive airway disease but not in normal children that
gives the early clue to have the diagnosis and management. Fall of peak expiratory
flow rate in a child with asthma is an impending sign of acute asthma. The response
to treatment can be monitored by using serial PEFR measurements. 9
Studies relating to PEFR and anthropometry among growing children are
necessary in India as the mosaic of Indian population spreading over such a differing
geography is varied and complex. A researcher studied PEFR values in healthy North
Indian school children, which were similar to the findings from the western
countries.10
A study found that PEFR in South Indian school children was lower than that
observed in Western and North Indian children.11 Another study observed the PEFR
values among North Indian school children in Punjab and found that the height and
the standardized value of PEFR showed no rural-urban differences.12
3
An article reported higher predicted values of PEFR among children from
Maharashtra than those in children from the other Indian states.13
A researcher
measured the PEFR of healthy tribal children living at high altitude in the Himalayas
and found that the values are comparable with those of North Indian urban children.14
An investigator studied PEFR measurements in rural children of Rajasthan and
found that they were lower than those reported for Caucasian and urban Indian
children of the same height.15
An expert panel of the National Asthma Education and Prevention Program
recommended periodic assessment of pulmonary function by spirometry or peak flow
rate monitoring. If peak flow rate monitoring is used, a written asthma action plan
should use the patient’s personal best peak flow, rather than published norms, as a
reference value.16
A study noted that children have poor compliance with recording peak flow
rate measurements in symptom diaries.17
Peak flow rate measurement may be of
lower utility in younger children and elderly patients, but it has been shown to be of
greater benefit in children who are poor or are members of minority groups.18
Studies also showed that at given height, older children had a higher vital
capacity.19
Another study found sudden changes in lung function during the
adolescent growth spurt.20
Peak expiratory flow rate measurement gives the idea of status of airway
caliber of respiratory system and regulatory function of respiration which some times
is affected by certain progressive neurological disease.
As no physician can
understand the status of progress and treatment of diabetes mellitus without doing
simple blood sugar test, no clinician could not manage a patient with potential renal
failure without an estimation of blood urea level. Hence PEFR can be used as
pulmonary function test in the same way.21
4
PEFR can be used not only to see the airway obstruction, but can also be used
to classify the severity of diseases of airway obstruction and its management that
serves as a guide line for admission and discharge of asthma patients.7
It is recognized that allied health care professionals play an important role in
helping children to identify and manage asthma at home and reinforce appropriate life
styles. With the above view in mind and with the investigator’s personal experience,
the investigator had the curiosity to assess the PEFR values in school children.
6.2 REVIEW OF LITERATURE:
The review of literature for the proposed study is classified under the following
sub headings:
1. Literature related to assessment of PEFR values among school children.
2.
Literature related to correlation between PEFR values and anthropometric
parameters among children
1. Literature related to assessment of PEFR values among school children.
A study was conducted to develop a peak expiratory flow rate nomogram for
Libyan children among 900 children randomly selected from four Tripoli primary
schools. 670 (330 girls and 340 boys) with age range between 4.5 – 14.9 years,
fulfilled the selection criteria. Peak expiratory flow rate was recorded in standing
position using a mini-wright peak flow meter. Anthropometric measurements such as
weight, height, head circumference and mid-upper-arm circumference were recorded
and surface area and body mass index were calculated. The findings showed that
PEFR to be significantly related to height (r = 0.74), age (r = 0.70), surface area (r =
0.64) and weight (r = 0.62).22
A study was conducted on growth and other factors affecting peak expiratory
flow rate among urban and rural children by means of a simple questionnaire and with
measurements of height, weight, and peak expiratory flow rates.3061 children from
city and rural population were studied. The findings revealed that children with
asthma or other respiratory diseases had lower peak expiratory flow rates, and
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younger children living in rural areas had higher rates. In 2828 healthy children, the
peak expiratory flow rate increased with age, height, and weight. There was an
increase in the slope of this line for both age and height at 12 years to 145cm in girls,
and at 14 years to155cm in boys.23
A study was conducted to assess the effects of malnutrition on the growth of
lung function. 376 Indian school children aged 6 – 12 years were studied. Peak
expiratory flow rate was measured with Wright Peak Flow Meter and nutritional
status was assessed by calculating the percentage of height for age and weight for
height using Harvard standards. The results showed that after standardizing for height
and sex, the PEFR of 30 wasted children was significantly reduced but that of 135
stunted children the PEFR was higher than average. It was concluded that current
malnutrition has a negative effect on PEFR, possibly due to impaired muscle
function.24
A study was conducted in young children to assess bronchodilator response
and monitor asthma status at home. Thirty nine children aged between three and ten
years were recruited. PEFR was measured six times in each child at two minute
intervals. The results showed that less than half (13 of 39) of the children made their
maximum blow in the first three manoeuvres. The co-efficient of variation of the
measurement was 8.8% suggesting a change in PEFR greater than 17.6% is necessary
to demonstrate a response to bronchodilator.25
A study was conducted to evaluate the effects of various size ranges of
Particulate Matter (PM) on peak expiratory flow rate of asthmatic children. Thirty
children, aged 6 to 12 years, who live near the fixed monitoring site in Sin-Chung
city, Taipei country, Taiwan were recruited for the study. Personal exposures to
Particulate Matter were measured continuously using a portable particle monitor. The
peak expiratory flow rate of each participant was monitored daily in the morning and
in the evening for two weeks. The results indicated that there was no statistical
significance between personal particulate matter exposure and PEFR measurements in
asthmatic children. The study concluded that not only fine particles but also coarse
particle are likely to contribute to the exacerbation of asthma in children.26
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A cross sectional study was conducted to measures the lung volume in
liters/minute using Peak Expiratory Flow Meter. The PEFR values of primary school
children 10 to 12 years of age in a high air pollution level area were compared with
the PEFR values of those in low air pollution level area. Data were obtained by
questionnaire. Physical examination included age, sex, height, weight, and PEFR
values. PEFR values were measured by Mini Wright Peak Expiratory Flow Meter
from three blows. The highest volume was taken as the PEFR value. Statistical
analysis was done by t-test and the results showed that the PEFR values did not differ
significantly between the two groups. The study concluded that the PEFR values in
high air pollution level area were statistically different when compared with those in
low air pollution level area.27
2. Literature related to correlation between PEFR values and anthropometric
parameters among children
A cross sectional study was conducted in south Gujarat region of India to
obtain reference values for Forced Expiratory Volume in one second (FEV1), Forced
Vital Capacity (FVC), Forced Expiratory Volume ratio in one second (FEV1%) and
PEFR among children aged 8 – 14 years. This study was conducted among 655
normal healthy school children (408 boys and 247 girls) of Surat city aged 8 – 14
years studying in V to VII standard during November 2007 to April 2008. The results
showed that FVC, FEV1 and PEFR were found to be statistically significant in the
study groups. For FVC and FEV1 highest correlation was found with age in girls and
height in boys. For FEV1% significant negative correlation was found with age and
height in both sexes, but positive correlation was found with surface area. Similarly,
PEFR showed highest correlation with surface area in boys than girls.28
A study was conducted to assess the importance of asthma management using
PEFR among children of 4-18 years of age. The Mini Wright Peak Flow Meter
spirometry was used for the study. 1563 children from a total sample of 2389 were
included for the study. The findings showed that PEFR increased with height, age,
weight, sitting height and body surface area. The reference value of PEFR for height
was found to be higher for both the sexes. When these results were compared with
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those from other countries, the values for boys of the same height were lower than
those for European children, but higher for African and Turkish children.29
A study was conducted to determine the normal values of PEFR among
healthy children from Babol, Iran. This study was randomly done on 1050 primary
and secondary school students in Babol. Mini Wright Peak Flow Meter was used for
measurement of PEFR. The findings revealed that there was a high correlation found
between the obtained PEFR values and Anthropometric variants. The correlation
between PEFR and height was most significant whereas between PEFR and weight
the correlation was found to be low.30
A study was conducted to evaluate the usefulness of measuring Peak
Expiratory Flow Rate through Methacholine Inhalation Challenge Test (MIC) for
diagnosing the airway hyper responsiveness in childhood. A total of 30 subjects aged
from 7 to 15 years with recurrent cough were enrolled in this study. The findings
revealed that there were significant correlation with reduction rates and recovery rates
between Forced Expiratory Volume V1 (FEV1) and PEFR respectively.31
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STATEMENT OF PROBLEM:
A study to assess the Peak Expiratory Flow Rate (PEFR) values among
children
in
selected
schools
at
Bangalore.
6.3 OBJECTIVES OF THE STUDY
1. To assess the values of Peak Expiratory Flow Rate (PEFR) among school
children.
2. To find out the correlation between Peak Expiratory Flow Rate (PEFR) values
and anthropometric parameters of school children
3. To find out the association between PEFR values and selected demographic
variables of school children.
OPERATIONAL DEFINITIONS
Assess: It refers to the statistical measurement of Peak Expiratory Flow Rate (PEFR)
values as measured by the Mini-Wright Peak Flow Meter.
Peak Expiratory Flow Rate (PEFR): It refers to the maximal expiratory flow rate
sustained by a healthy child using a Mini Wright Flow Meter for at least 10
milliseconds. The children are taught how to use the Mini Wright Flow Meter by
means of demonstration. The highest of the three readings is taken as the PEFR
value.
PEFR Value: It refers to the readings on the flow meter after the child’s maximum
speed of expiration. The readings will be classified into 3 zones of measurement:
Green, Yellow and Red.
Green zone : 80-100% of peak flow readings indicate that there are no respiratory
problems .and asthma is under control.
Yellow zone : 50-79% of peak flow readings indicate that respiratory airways are
narrowed and medications may be required.
Red zone : <50% of peak flow readings indicate medical emergency with severe
airway narrowing and immediate action to be taken.
School children: It refers to healthy children between the ages of 10 to 15 years
studying in V to X standard in selected schools at Bangalore.
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HYPOTHESIS:
H1: There is a significant relationship between the PEFR values and anthropometric
parameters among school children
H2:
There is a significant association between the PEFR values among school
children and their selected demographic variables.
ASSUMPTIONS:
1. School children have inadequate knowledge regarding monitoring and
management of respiratory problems.
2. PEFR values among school children will vary with demographic variables.
3. PEFR testing can be easily learned and performed by school children using Mini
Wright Peak Flow Meter.
4. Reduced PEFR values is correlated with respiratory problems such as asthma and
COPD in children
DELIMITATIONS:
The study is limited to children,
1. between the ages of 10 to 15 years only.
2. of both sexes.
3. healthy children only.
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7. MATERIALS AND METHOD
7.1 Source of Data
Data will be collected from children in selected schools at Bangalore.
7.2 Method of Data
Collection
Descriptive correlational design will be used for the study
Research Design
Setting
Study will be conducted at selected schools in Bangalore
Population
The population for the present study will be school children.
Sample
School children of selected schools in Bangalore will be the samples for
the study.
Sample size
300 school children
Sampling
Simple random sampling technique will be used to select the samples
technique
The study includes children, who are:
Inclusion Criteria
1. available at the time of data collection.
2. willing to participate in the study.
3. able to speak and understand English or Kannada.
The study excludes children, who
Exclusion Criteria
1. have been suffering from asthma or having past history of asthma
or wheeze.
2. are having any thoracic deformity or history of ARI within two
weeks.
3. are having rhonchi or wheeze on auscultation.
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The tool will be divided into the following sections:
Tool
Section A:
1. Structured questionnaire to assess the demographic data of children
attending selected schools at Bangalore.
Section B:
1. Measurement of PEFR values using Mini Wright Peak Flow Meter.
2. Anthropometric measurements
a.
Weight will be measured using a standardized weighing
scale.
b. Height will be measured by Stadiometer.
c. BMI will be measured by using an inch tape and
weighing
scale.
Prior to the period of data collection, the investigator will obtain formal
permission from the concerned authorities of selected schools.
Data collection
The
investigator himself will do the data collection for the study. Informed
consent will be obtained from the parents of the participants of the study.
The investigator uses lottery method to select schools. Then the
investigator uses simple random sampling technique to select samples
from the schools.
Data will be collected by using structured
questionnaire and Mini Wright Peak Flow Meter. The children are taught
how to use the flow meter. The highest of the 3 recorded readings will be
used as the PEFR value of the samples.
Data Analysis,
Data Presentation
The collected data will be organized by
1.Descriptive statistics:
Frequency distribution, mean and standard deviation will be used to
assess the demographic variables.
2.Inferential statistics:
a. Coefficient correlation will be used to assess the correlation
between the PEFR values and anthropometric parameters.
b. Chi-square will be used to find out the association between PEFR
values and demographic variables.
The findings will be presented in the form of tables, diagrams and
graphs.
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7.3 Does the study require any investigation or intervention to be conducted on
humans or animals? If describe briefly.
Yes, the study will be conducted on school children at Bangalore. PEFR testing will
be done using the Mini-Wright Peak Flow Meter and their values will be assessed and
correlated.
7.4
Has ethical clearance been obtained from your institution in case of 7.3?
Yes, informed consent will be obtained from concerned authority of the institution
and parents of samples prior to study. Privacy, confidentiality and anonymity will be
guarded. Scientific objectivity of the study will be maintained with honesty and
impartiality.
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ETHICAL COMMITTEE:
A study to assess the Peak Expiratory
Title of the topic
Flow Rate (PEFR) values among
children in selected schools at
Bangalore.
Name of the Candidate
Mr. K. N. NAGARAJ GOWDA
Course of study and subject
M.Sc. (N) I year
CHILD HEALTH NURSING
Prof. Elizabeth Dora
Head of the Department,
Name of the guide
Department of Child Health Nursing.
Diana College of Nursing,
Bangalore – 64
Ethical committee
Approved
14
Members of Ethical Committee:
1. Prof. Veda Vivek
Principal and HOD
Department of Community Health Nursing
Diana College of Nursing, Bangalore – 64.
2. Prof. Elizabeth Dora
Head of the Department
Department of Child Health Nursing
Diana College of Nursing, Bangalore – 64.
3. Prof. Kalaivani
Head of the Department
Department of Obstetrics and Gynecological Nursing
Diana College of Nursing, Bangalore – 64.
4. Prof. Vasantha Chitra.D
Head of the Department
Department of Medical Surgical Nursing
Diana College of Nursing, Bangalore – 64.
5. Prof. Kalai Selvi.S
Head of the Department
Department of Psychiatric Nursing
Diana College of Nursing, Bangalore – 64
6. Prof. Rangappa
Biostatistician, GKVK
Jakkur International Airport Road
Bangalore.
15
8.
LIST OF REFERENCES:
1. Mutius Ev.The burden of childhood asthma. Archieves of Disease in Childhood.
82(Suppl ll): ii2-ll5.
2.Lebowitz MD.The use of peak expiratory flow rate measurement in respiratory
disease. Pediatric Pulmonology 11: 166 – 174
3. Kulpati DDS, Talwar D. Pediatric pulmonary function testing.Indian
Pediatrics:277 – 282
4. Trabelsi Y, Ben Saad H, Tabka Z, et al. Spirometric Reference values in
Tunisian children. Respiration 2004;71:511-8.
5. Wille S and Svensson K. Peak flow in children aged 4 – 16 years Aeta Pediatric
Scand : 544 – 54.
6. .Milner AD and Ingram D. Peak expiratory flow rates in children under 5
years
of age. Archieves of Disease in Childhood : 45 780 – 782.
7.
Taylor MR. Asthma: audit of peak expiratory flow rate guidelines for admission
discharge. Archieves of Disease in Childhood: 70(5): 432 – 434
8. Graff- Lonneving Vet al. Peak expiratory flow rate in healthy Saudi Arabian
children living in Riyadh. Annual of Allergy 1993. 71(5):446-50.
9. Swaminathan s. Pulmonary function testing in office practice
Indian Journal of Pediatrics. 66: 905 – 914.
10. Parmar VR, Kumar L, Malik SK. Normal values of peak expiratory flow rate
in healthy North Indian school children. 6-16years of age. Indian
Pediatrics;14:591-594.
16
11. Malik SK, Jindal SK, Banga N. Peak expiratory flow rates of healthy school
girls from Punjab. Indian Pediatrics;18:161-164.
12. Singh HD, Peri S. Peak expiratory flow rate in South Indian children and
adolescents. Indian Pediatrics;11:473-478.
13. Mahajan KK, Mahajan SK, Maini BK, Srivastava SC. Peak expiratory flow
rate and its Prediction Formula in Haryanavis. Indian Journal of Physiological
Pharmacology 1984:28:319-325.
14. Kashyap S, Puri DS, Bansal SK. Peak expiratory flow rate of healthy tribal
children living at high altitudes in the Himalayas. Indian Pediatrics;29:283-286.
15. Sharma R, Jain A, Arya A, Chowdhary BR. Peak expiratory flow rate of school
going rural children aged 5-14years from Ajmer district. Indian Pediatrics
2002;39:75-78.
16.
National Asthma Education and Prevention Program. Expert Panel
Report3: Guidelines for the Diagnosis and Management of Asthma. Full Report
2007. Bethesda. MD: U.S:Department of Health and Human Services. National
Institutes of Health. National Heart Lung and Blood Institute;2007.1-440.
17.
Kamps AW, Roorda RJ, Brand PL. Peak flow diaries in childhood asthma are
unreliable. Thorax. March 2001:56(3):180-2.
18.
Gorelick MH, Stevens MW, Schultz T, Scribano PV. Difficulty in
obtaining peak expiratory flow measurements in children with acute asthma.
Pediatric Emergency Care. Jan 2004:20(1):22-6.
19.
Engstram J, Karlberg J, Karlberg P. Changes in the vital capacity- height
relationship during the age period 12-21years. Bulletin of European
Physiopathology & Respiratory 1983;19:19-20.
17
20. Sherill DL.Camilli A, Lebowitz MD. On the temporal relationship between
lung function and somatic growth. American Respiratory Disease 1989;140:63844.
21. Dugdale AE and Moeri M. Normal values of forced vital capacity (FVC).
forced expiratory volume (FEV10) and peak flow rate (PFR) in children.
Archieves of Disease in Childhood; 43: 229 – 233
22. F.A. Sagher, M.A. Roushdy and A.M. Hweta. Peak expiratory flow rate
nomogram in Libyan school children.560 – 564.
23. JW Carson, H Hoey, and MR Taylor. Growth and other factors affecting
PEFR. Archieves of Disease in Childhood.64:96-102.
24. R Primhak and FS Coates Malnutrition and peak expiratory flow rate.
European Respiratory Journal.1:801-803.
25. A Greenough, L Everett and JF Price . Recording peak flow properly in
young children. European Respiratory Journal.Nov;3(10):1193-6.
26. Tang CS, Chang LT, Lee HC, Chan CC. Effects of personal particulate
matter on PEFR of asthmatic children. Sci Total invison.2007 Aug,15;382(1):4351.
27. Hasibuan, Ismart Edy, supriatmo, M. Nur, Faisal,A.University of Indonesia.1Feb-2003.
28. Tahera H. Doctor, Sangeeta S. Trivedi, and Rajesh K. Chudasama. Pulmonary
function test in healthy school children.
29. Seo WH, Ahn SH, Park SH, Kim J, Ahn KM, Ko BJ, Lee SI. Importance of
asthma management. Asian Pacific Journal of Allergy & Immunology
2011Jun:29(2):143-9.
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30. Iraj Mohammed Zadeh, Mohammed Gharagazlou and Syed Abbass Fatemi.
Normal values of peak expiratory flow rate;December 2006;195-198.
31. Hwang YJ, Jin YA, Han MY, chang W, Lee KH. Usefulness of measuring
peak expiratory flow rate. Department of Pediatrics. Korea. Journal of Asthma
& Allergy. Clinical Immunology.2002 Sep;22(3):577-583.
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9. Signature of Candidate
There is a great need to study the PEFR values among
10. Remarks of the guide
school children so that the results from the study can
be used to monitor the health status of children in
Bangalore.
Prof. Elizabeth Dora
Head of the Department,
11.1 Name and designation of
Department of Child Health Nursing.
guide
Diana College of Nursing,
Bangalore – 64
11.2 Signature
Prof. Elizabeth Dora
11.3 HOD
Head of the Department,
Department of Child Health Nursing.
Diana College of Nursing,
Bangalore – 64
11.4 Signature
12.1 Remarks of the Principal
The Study is relevant, researchable and forwarded
for further action.
12.2 Signature
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