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 asa result of irreversible airway obstruction and is characterized by lung tissuedestruction. COPD is a progressive inflammatory disease of the lungs and is among themost common respiratory diseases (1). The World Health Organization predicts that COPDwill rank third among the leading causes of death within the next 10 years (2). The highmorbidity and mortality rates associated with COPD also lead to an increased economicburden. Although the prevalence of COPD varies among countries, the risk factors arefound to be similar (3). When examining these risk factors, it is evident that there arenumerous environmental and genetic factors, such as tobacco use, inhalation of harmfulgases, environmental pollution, exposure to mining dust, cooking over open fires,alpha‐1‐antitrypsin (AAT) deficiency, and mutations in the TNF‐α cytokine (4). Inhalationof these harmful gases leads to a pathological inflammatory response, mucushypersecretion, and alveolar destruction. This, in turn, results in abnormal remodelingof the airways, increased airway resistance, and a decrease in the elasticity of the lungparenchyma (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 toengage in physically demanding activities are observed in the early stages of thedisease, as the disease progresses, many symptoms‐such as chronic cough, chest pain,fatigue, weight loss, and increased mucus secretion‐become apparent, in contrast to theearly stage (6). Individuals with COPD typically present to the hospital with dyspnea,chronic cough, increased sputum production, and wheezing, and many have experienced anexacerbation before seeking hospital care. The diagnosis is made through clinicalevaluation and spirometry (7). For a diagnosis of COPD, the post‐bronchodilator FEV1/FVCratio must be less than 0.7. COPD is classified into four stages based on the percentageof FEV1: Stage 1 (FEV1 ≥ 80%), Stage 2 (50% ≤ FEV1 < 79) Stage 3 (30% ≤ FEV1 < 49%) andStage 4 (FEV1 < 30%) (2). The goal of COPD treatment is to alleviate symptoms and reducedisease severity and the number of exacerbations. To this end, both pharmacological andnonpharmacological methods are used. Pharmacological methods include bronchodilators,antimuscarinic drugs, corticosteroids, phosphodiesterase‐4 inhibitors, and mucolyticagents. 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 musclerelaxation exercises (9). In addition to pulmonary rehabilitation, yoga‐whichincorporates breathing exercises‐is also among the nonpharmacological methods. Yoga is aspiritual practice consisting of three components: pranayama, asana, and meditation (10).While asana refers to changing one's physical posture, pranayama refers to the expansionof life force through breath control and involves the processes of inhalation andexhalation. 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 byserving as a preparatory exercise before pranayama (11). Pranayama consists of threesteps: Puraka, Rechaka, and Kumbhaka (inhalation, exhalation, and holding the breathafter inhalation). While Puraka explains the subtleties of slow inhalation, Rechakaexplains the subtleties of slow exhalation. There are many different types of pranayamatechniques, 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 mentalhealth. In addition, each of these pranayama techniques produces different physiologicaleffects depending on its duration and type (12).• Nadishodhanam (alternate nostril breathing); this is the simplest type of pranayama topractice. It affects the autonomic nervous system, specifically the sympathetic andparasympathetic systems. It involves the following steps (13): Sit in a comfortableposition. Use your thumb to close your right nostril and breathe in through your leftnostril.Slowly release your thumb and close your left nostril with your ring finger. Then, exhaleslowly through your right nostril, followed by inhaling through your right nostril andexhaling slowly through your left nostril.• Bhramari pranayama involves inhaling rapidly while making a sound like a male bee andexhaling slowly while making a sound like a female bee (14).A review of the literature reveals that, according to Jayawardena's systematic review,pranayama has numerous positive effects, including improving symptoms and activity levelsin individuals with chronic obstructive pulmonary disease (COPD), lowering heart rate andsystolic blood pressure in those with bronchial asthma, and enhancing quality of life incancer patients (15).Listening to the sounds of rain and nature is another relaxation technique. These soundsare produced by natural sources such as rain, wind, the ocean, birds, and animals, andpromote physical and mental relaxation. In a study conducted by Kutenai et al. on burnpatients, one group was treated with the Benson relaxation technique, while the othergroup was exposed to nature sounds. The study concluded that patients in the naturesounds group had lower pain levels and a significant reduction in body imagedissatisfaction (16).The study will be conducted using a randomized controlled pre‐test‐post‐test experimentaldesign. The study will be carried out between April 2026 and September 2027 at thePulmonology Outpatient Clinic of the Turgut Özal Medical Center at İnönü University.Both Experiment Group 1 (pranayama group with rain sounds) and Experiment Group 2(pranayama group without rain sounds) will receive information about what pranayamaexercises are, their importance, purpose, and benefits. In addition to standardtreatment, they will practice pranayama breathing exercises twice daily for 15‐20 minutesfor 6 weeks. Experiment Group 1 will practice pranayama breathing exercises with rainsounds, while Experiment Group 2 will practice pranayama breathing exercises without rainsounds. Nadhi sodhana/Nadhi Shudi, also known as alternate nostril breathing, is used tohelp calm the nervous system, soothe the mind, reduce stress, and improve concentration.Because it can be applied to different patient groups and has no complications, Nadhisodhana Pranayama will be used. To ensure patients can perform Nadhi sodhana Pranayamacorrectly and completely, a video demonstrating the technique will be prepared anduploaded to their phones. Additionally, patients will receive a pranayama training andpractice guide. In a room suitable for the patients, the pranayama practice and its stepswill be repeated through both explanation and demonstration until the patient learns, andany points the patient cannot perform will be corrected. Once it is observed that thepatients perform the practice completely, they will be asked to perform pranayamabreathing exercises twice a day for 15‐20 minutes for 6 weeks, and the same researcherwill remind them to practice the breathing technique and keep records in patientmonitoring charts once a day via text message. In addition, patients will be contactedweekly by the researcher to answer any questions they may have regarding pranayamabreathing technique and to discuss their adherence to pranayama breathing exercises, thusensuring the effectiveness and continuity of the practice and monitoring the patients. Ifthe patients assigned to the experimental groups are unable to perform the practice orexperience difficulties, the study with these patients will be terminated. • B) Patientsin the control group will not be given any practice in addition to their medicaltreatment. Individuals will continue their daily lives.• In the final testing phase of the study (at the end of the sixth week), the COPDSelf‐Efficacy Scale, Dyspnea 12 Scale, and Visual Analog Scale will be administered againto experimental groups 1 and 2 one day after the pranayama breathing exercises, and tothe control group 6 weeks after the pre‐test, by the same researcher. A PulmonaryFunction Test will also be performed again. Following the administration of these scalesand the pulmonary function test, all patients in the control group will receive pranayamabreathing exercise training and two sessions at the end of the study. The applicationwill be carried out by Elvan KIRILMAZ.