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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 2 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 5 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 6 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 7 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 8 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. 9 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. 10 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. 11 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. 12 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. 13 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. 18 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. 19 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 20