Effect of Pursed-Lip Breathing With Different I:E Ratios on Respiratory Outcomes in COPD Patients (PLB I:E Ratio)

Effectiveness of Different Inspiratory-Expiratory Ratios (1:3, 1:4, and 1:5) in Pursed-Lip Breathing on Respiratory Rate, Oxygen Saturation, and Dyspnea in Patients With Chronic Obstructive Pulmonary Disease: A Quasi-Experimental Study

The goal of this clinical trial is to evaluate whether different inspiratory-expiratory (I:E) ratios in the pursed-lip breathing (PLB) technique can improve respiratory outcomes in patients with stable Chronic Obstructive Pulmonary Disease (COPD) aged 40 years and older. The primary purpose is to determine whether a specific breathing intervention can improve respiratory function.

The main questions it aims to answer are:

Does PLB with different I:E ratios (1:3, 1:4, and 1:5) reduce respiratory rate in COPD patients? Does PLB with different I:E ratios improve oxygen saturation and reduce dyspnea severity?

Researchers will compare PLB with I:E ratios of 1:3, 1:4, and 1:5 and a control group receiving standard care to see if different ratios produce different effects on respiratory rate, oxygen saturation, and dyspnea levels.

Participants will:

Perform pursed-lip breathing using assigned I:E ratios (1:3, 1:4, or 1:5) for 10 minutes Be assigned to either an intervention group or a control group (standard care) Have their respiratory rate measured before and after the intervention Have their oxygen saturation measured using a pulse oximeter Report their dyspnea level using the Modified Borg Scale before and after the intervention

Study Overview

• Status: Not yet recruiting
• Conditions: Chronic Obstructive Pulmonary Disease (COPD)
• Intervention / Treatment: Other: Participants perform PLB with inspiratory-expiratory ratio 1:3 (2 seconds inspiration, 6 seconds expiration); Other: Participants perform PLB with inspiratory-expiratory ratio 1:4 (2 seconds inspiration, 8 seconds expiration); Other: Participants perform PLB with inspiratory-expiratory ratio 1:5 (2 seconds inspiration, 10 seconds expiration)

Detailed Description

Chronic Obstructive Pulmonary Disease (COPD) is a progressive respiratory condition characterized by persistent airflow limitation, dyspnea, and impaired gas exchange. It remains a leading cause of morbidity and mortality worldwide, with a disproportionately high burden in low- and middle-income countries. Dyspnea is one of the most debilitating symptoms experienced by COPD patients and is closely associated with reduced functional capacity and quality of life. Non-pharmacological interventions, particularly breathing exercises, play an important role in symptom management.

Pursed-lip breathing (PLB) is a simple, low-cost, and widely recommended breathing technique in COPD management. It works by prolonging the expiratory phase, increasing positive airway pressure, preventing airway collapse, and improving ventilation efficiency. Despite its widespread use, there is currently no standardized inspiratory-expiratory (I:E) ratio for PLB. Variations in clinical practice may result in inconsistent outcomes, and evidence comparing different I:E ratios remains limited.

This study aims to evaluate the effectiveness of three commonly recommended I:E ratios (1:3, 1:4, and 1:5) in PLB on respiratory outcomes in patients with stable COPD. The outcomes of interest include respiratory rate, peripheral oxygen saturation (SpO₂), and dyspnea severity as measured by the Modified Borg Scale. By comparing these ratios, the study seeks to identify the most effective breathing pattern for optimizing respiratory function.

This study employs a quasi-experimental design with a pretest-posttest control group approach. A total of 122 participants diagnosed with stable COPD will be recruited from Respira Hospital Yogyakarta, Indonesia. Participants will be randomly assigned into four groups: three intervention groups receiving PLB with different I:E ratios (1:3, 1:4, and 1:5), and one control group receiving standard care without structured PLB intervention.

The intervention will be conducted in a controlled clinical setting. Participants in the intervention groups will be instructed to perform PLB in a seated high-Fowler position for 10 minutes under supervision. Each group will follow a specific breathing pattern: inhalation through the nose followed by prolonged exhalation through pursed lips according to the assigned I:E ratio. The control group will receive standard care without guided PLB.

Outcome measurements will be taken at baseline (pre-intervention) and immediately after the intervention. Respiratory rate will be measured by direct observation for one minute, oxygen saturation will be assessed using a calibrated pulse oximeter, and dyspnea will be evaluated using the Modified Borg Scale (0-10). Data will be analyzed using appropriate statistical tests to compare within-group and between-group differences.

This study is expected to contribute to the development of evidence-based guidelines for PLB implementation in COPD management, particularly in determining the optimal I:E ratio. The findings may help standardize clinical practice, improve respiratory outcomes, and enhance the quality of life of COPD patients. Additionally, the results may provide a foundation for future research on breathing techniques and non-pharmacological interventions in respiratory care.

• Study Type: Interventional
• Enrollment (Estimated): 122
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Scholastica Fina Aryu Puspasari, Master; Phone Number: +62821-3433-1244; Email: scholastica_fina@stikespantirapih.ac.id
• Study Contact Backup: Name: Bernadeta Eka Noviati, Magister; Phone Number: +62 896-2816-5916; Email: eka_noviati@stikespantirapih.ac.id

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Diagnosed with stable COPD
• Age ≥ 40 years
• Able to follow breathing instructions
• Willing to participate and provide informed consent

Exclusion Criteria:

• Cognitive impairment or decreased consciousness
• Severe cardiovascular disease (heart failure, coronary artery disease, pulmonary hypertension)
• Asthma-COPD overlap (ACO)
• Acute respiratory infection (e.g., pneumonia)
• Neuromuscular disorders affecting respiratory muscles

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Arm Group 1, PLB I:E 1:3; Participants perform PLB with inspiratory-expiratory ratio 1:3 (2 seconds inspiration, 6 seconds expiration)	Other: Participants perform PLB with inspiratory-expiratory ratio 1:3 (2 seconds inspiration, 6 seconds expiration); Participants will be allocated into four study arms: three intervention groups and one control group. Intervention Groups (PLB with Different I:E Ratios): Participants in the intervention arms will perform Pursed-Lip Breathing (PLB) with specific inspiratory-to-expiratory (I:E) ratios as follows: Group 1: I:E ratio 1:3 (2 seconds inspiration, 6 seconds expiration) The procedure will be conducted in a seated position (high Fowler's position). Participants will be instructed to inhale slowly through the nose and exhale through pursed lips according to the assigned ratio. A metronome will be used to standardize breathing timing. Each session will last approximately 10 minutes and will be supervised by the researcher to ensure correct technique and safety. stru
Experimental: Arm Group 2, PLB I:E 1:4; Participants perform PLB with inspiratory-expiratory ratio 1:4 (2 seconds inspiration, 8 seconds expiration)	Other: Participants perform PLB with inspiratory-expiratory ratio 1:4 (2 seconds inspiration, 8 seconds expiration); Participants will be allocated into four study arms: three intervention groups and one control group. Intervention Groups (PLB with Different I:E Ratios): Participants in the intervention arms will perform Pursed-Lip Breathing (PLB) with specific inspiratory-to-expiratory (I:E) ratios as follows: Group 2: I:E ratio 1:4 (2 seconds inspiration, 8 seconds expiration) The procedure will be conducted in a seated position (high Fowler's position). Participants will be instructed to inhale slowly through the nose and exhale through pursed lips according to the assigned ratio. A metronome will be used to standardize breathing timing. Each session will last approximately 10 minutes and will be supervised by the researcher to ensure correct technique and safety.
Experimental: Arm Group 3, PLB I:E 1:5; Participants perform PLB with inspiratory-expiratory ratio 1:5 (2 seconds inspiration, 10 seconds expiration)	Other: Participants perform PLB with inspiratory-expiratory ratio 1:5 (2 seconds inspiration, 10 seconds expiration); Participants will be allocated into four study arms: three intervention groups and one control group. Intervention Groups (PLB with Different I:E Ratios): Participants in the intervention arms will perform Pursed-Lip Breathing (PLB) with specific inspiratory-to-expiratory (I:E) ratios as follows: Group 3: I:E ratio 1:5 (2 seconds inspiration, 10 seconds expiration) The procedure will be conducted in a seated position (high Fowler's position). Participants will be instructed to inhale slowly through the nose and exhale through pursed lips according to the assigned ratio. A metronome will be used to standardize breathing timing. Each session will last approximately 10 minutes and will be supervised by the researcher to ensure correct technique and safety.
No Intervention: Arm Group 4, Standard Therapy; Participants receive standard care without structured PLB intervention

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Primary Outcome 1: Respiratory Rate	Respiratory rate measured as the number of breaths per minute at rest using direct observation for 60 seconds	Baseline and immediately after 10-minute intervention
Primary Outcome 2: Oxygen Saturation (SpO₂)	Peripheral oxygen saturation measured using a calibrated pulse oximeter at rest.	Baseline and immediately after 10-minute intervention
Primary Outcome 3 Dyspnea Level	Dyspnea assessed using the Modified Borg Scale (0-10), where higher scores indicate more severe breathlessness.	Baseline and immediately after 10-minute intervention

Collaborators and Investigators

• Sponsor: Scholastica Fina Aryu Puspasari
• Collaborators: STIKes Panti Rapih Yogyakarta
• Investigators: Principal Investigator: Scholastica FA Puspasari, Master, STIKes Panti Rapih Yogyakarta

Publications and helpful links

General Publications

• Hammoda Abu-Odah, Liu, N. X.-L., Wang, T., Zhao, I. Y., Yorke, J., Tan, J.-Y. B., & Molassiotis, A. (2025). Modified Borg Scale (mBorg), the numerical rating scale (NRS), and the Dyspnea-12 scale (D-12): Cross-scale comparison assessing the development of dyspnea in early-stage lung cancer patients. Supportive Care in Cancer, 33(5). https://doi.org/10.1007/s00520-025-09474-x
• Gusmarta, G., & Oktarina, Y. (2025). Case Report : Implementation of Pursed-Lips Breathing Technique on Respiratory Rate and Oxygen Saturation in Chronic Obstructive Pulmonary Disease (COPD) Patients in the Pulmonary Ward of Raden Mattaher Hospital Jambi. Jurnal Keperawatan Universitas Jambi, 9(3), 8-12. https://doi.org/10.22437/jkuj.v9i3.47490
• Cavalheri, V., Burtin, C., Formico, V. R., Nonoyama, M., Jenkins, S., Spruit, M. A., & Hill, K. (2020). Exercise training for people with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, (4), CD010039. https://doi.org/10.1002/14651858.CD010039.pub2
• Burge, A. T., Gadowski, A. M., Jones, A., Romero, L., Smallwood, N. E., Ekström, M., Reinke, L. F., Saggu, R., Wijsenbeek, M., & Holland, A. E. (2024). Breathing techniques to reduce symptoms in people with serious respiratory illness: A systematic review. European Respiratory Review, 33(174), 240012. https://doi.org/10.1183/16000617.0012-2024
• Bhatt, S. P., Nakhmani, A., Fortis, S., Strand, M. J., Silverman, E. K., Sciurba, F. C., et al. (2023). FEV1/FVC severity stages for chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 208(6), 676-684. https://pubmed.ncbi.nlm.nih.gov/37339502/
• Anon. (2025, March 4). What is the recommended inspiratory to expiratory (I:E) ratio for ventilator settings in chronic obstructive pulmonary disease (COPD) exacerbation? Droracle.ai. https://www.droracle.ai/articles/22727/what-is-the-recommended-inspiratory-to-expiratory-ie-ratio

Study record dates

Study Major Dates

• Study Start (Estimated): May 4, 2026
• Primary Completion (Estimated): August 7, 2026
• Study Completion (Estimated): August 14, 2026

Study Registration Dates

• First Submitted: April 30, 2026
• First Submitted That Met QC Criteria: April 30, 2026
• First Posted (Actual): May 7, 2026

Study Record Updates

• Last Update Posted (Actual): May 7, 2026
• Last Update Submitted That Met QC Criteria: April 30, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Keywords: respiratory rate; Oxygen saturation; Pursed-Lip Breathing I:E ratio in COPD; dyspnea scale
• Additional Relevant MeSH Terms: Pathologic Processes; Chronic Disease; Disease Attributes; Respiratory Tract Diseases; Lung Diseases; Lung Diseases, Obstructive; Pathological Conditions, Signs and Symptoms; Pulmonary Disease, Chronic Obstructive; Circulatory and Respiratory Physiological Phenomena; Respiratory Mechanics; Respiration; Respiratory Physiological Phenomena; Inhalation; Exhalation
• Other Study ID Numbers: 0511028601

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: IPD will not be shared because the study involves human participants and the data are subject to institutional and ethical restrictions that limit public data sharing. Only aggregated results will be reported.

Study Data/Documents

1. Study Protocol
   Information identifier: scholastica fina
   Information comments: PLB Ratio
2. Individual Participant Data Set
   Information identifier: scholastica_fina@stikespantira
   Information comments: In excel formula
3. Statistical Analysis Plan
   Information identifier: scholastica_fina@stikespantira
   Information comments: Interventional (Clinical Trial)
4. Informed Consent Form
   Information identifier: scholastica_fina@stikespantira
   Information comments: PIS and IC
5. Data Monitoring Committee Charter
   Information identifier: scholastica_fina@stikespantira
   Information comments: DMC

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No