The Effect of Pranayama Practiced With Rain Sounds on Self-Efficacy, Dyspnea, and Respiratory Functions in Patients With COPD

Chronic Obstructive Pulmonary Disease (COPD) is a heterogeneous disease that develops as a result of irreversible airway obstruction and is characterized by lung tissue destruction. COPD is a progressive inflammatory disease of the lungs and is among the most common respiratory diseases (1). The World Health Organization predicts that COPD will rank third among the leading causes of death within the next 10 years (2). The high morbidity and mortality rates associated with COPD also lead to an increased economic burden. Although the prevalence of COPD varies among countries, the risk factors are found to be similar (3). When examining these risk factors, it is evident that there are numerous environmental and genetic factors, such as tobacco use, inhalation of harmful gases, environmental pollution, exposure to mining dust, cooking over open fires, alpha-1-antitrypsin (AAT) deficiency, and mutations in the TNF-α cytokine (4). Inhalation of these harmful gases leads to a pathological inflammatory response, mucus hypersecretion, and alveolar destruction. This, in turn, results in abnormal remodeling of the airways, increased airway resistance, and a decrease in the elasticity of the lung parenchyma (5). The symptoms and signs of the disease worsen as the disease progresses. While mild symptoms such as intermittent coughing, shortness of breath, and reluctance to engage in physically demanding activities are observed in the early stages of the disease, as the disease progresses, many symptoms-such as chronic cough, chest pain, fatigue, weight loss, and increased mucus secretion-become apparent, in contrast to the early stage (6). Individuals with COPD typically present to the hospital with dyspnea, chronic cough, increased sputum production, and wheezing, and many have experienced an exacerbation before seeking hospital care. The diagnosis is made through clinical evaluation and spirometry (7). For a diagnosis of COPD, the post-bronchodilator FEV1/FVC ratio must be less than 0.7. COPD is classified into four stages based on the percentage of FEV1: Stage 1 (FEV1 ≥ 80%), Stage 2 (50% ≤ FEV1 < 79) Stage 3 (30% ≤ FEV1 < 49%) and Stage 4 (FEV1 < 30%) (2). The goal of COPD treatment is to alleviate symptoms and reduce disease severity and the number of exacerbations. To this end, both pharmacological and nonpharmacological methods are used. Pharmacological methods include bronchodilators, antimuscarinic drugs, corticosteroids, phosphodiesterase-4 inhibitors, and mucolytic agents. Treatment is tailored to the patient's symptoms and the number of attacks (8). Nonpharmacological methods include quitting smoking, physical activity, oxygen therapy, nutrition, pulmonary rehabilitation, breathing exercises, and progressive muscle relaxation exercises (9). In addition to pulmonary rehabilitation, yoga-which incorporates breathing exercises-is also among the nonpharmacological methods. Yoga is a spiritual practice consisting of three components: pranayama, asana, and meditation (10). While asana refers to changing one's physical posture, pranayama refers to the expansion of life force through breath control and involves the processes of inhalation and exhalation. There are many different types of asanas, including Sirshana (headstand), Sarvangasana (shoulder stand), Paschimothanasana (seated forward bend), and Padahastasana (standing forward bend), and the purpose of all of them is to increase lung capacity by serving as a preparatory exercise before pranayama (11). Pranayama consists of three steps: Puraka, Rechaka, and Kumbhaka (inhalation, exhalation, and holding the breath after inhalation). While Puraka explains the subtleties of slow inhalation, Rechaka explains the subtleties of slow exhalation. There are many different types of pranayama techniques, including Nadishodhanam, Kapalbhati, Bhastrika, Ujjayi, Bhramari, Sheetali, Sheetkari, Suryabhedana, Murccha, and Plavini.

The purpose of all types of pranayama breathing is to maintain physical and mental health. In addition, each of these pranayama techniques produces different physiological effects depending on its duration and type (12).

• Nadishodhanam (alternate nostril breathing); this is the simplest type of pranayama to practice. It affects the autonomic nervous system, specifically the sympathetic and parasympathetic systems. It involves the following steps (13): Sit in a comfortable position. Use your thumb to close your right nostril and breathe in through your left nostril.

Slowly release your thumb and close your left nostril with your ring finger. Then, exhale slowly through your right nostril, followed by inhaling through your right nostril and exhaling slowly through your left nostril.

• Bhramari pranayama involves inhaling rapidly while making a sound like a male bee and exhaling slowly while making a sound like a female bee (14).