Iran Journal of Nursing

Introduction
Chronic obstructive pulmonary disease (COPD) is a debilitating respiratory disease and one of the main causes of death and disability in the world. One of the important symptoms of this disease is shortness of breath, decreased lung volume, and fatigue, which requires long-term treatment and care. The respiratory support treatments, along with drug therapy, are among the prescribed treatments to improve the respiratory condition and improve the symptoms of these patients.
Fatigue is one of the common symptoms in patients with COPD, which prevents them from performing individual and social tasks and reduces their ability to work and have recreational activities. It has a negative impact on the economic status and quality of life of affected people. The COPD patients who suffers from fatigue do not want to participate in social activities which reduces their social interactions. This issue can lead to social isolation and eventually reduce the ability of the person to deal with the disease, because participation in treatment programs requires enough energy. Therefore, having an active life is necessary for the treatment plan of these people. Breathing exercises are a type of training that can be used for people with a variety of respiratory-related problems. Improper breathing can disrupt the exchange of oxygen and carbon dioxide, contributing to anxiety, panic attacks, fatigue, and other physical and emotional disorders. It is believed that physiotherapy techniques can be used in patients with COPD. The present study aims to determine the effect of breathing exercises and chest physiotherapy on fatigue in patients with COPD.

Methods 
This is a quasi-experimental study that was conducted on 45 patients with COPD who were selected by a convenience sampling method from among those referred to Dr. Dabaghian’s lung clinic in Mahabad county, Iran, in 2023. Using the random number table, they were divided into two experimental groups of breathing exercises (n=15) and chest physiotherapy(n=15) and one control group (n=15). The sampling was done from April to July 2023. The inclusion criteria were willingness to participate in the study, definitive diagnosis of COPD by a pulmonary specialist, having COPD stage 2 or 3, the ability to perform breathing exercises and lung physiotherapy, no acute respiratory infections in the past six months, and no other chronic and debilitating diseases such as heart failure. The exclusion criteria were: worsening of the disease, irregular participation in chest physiotherapy and breathing exercises (absence for more than two sessions), lack of cooperation in performing breathing exercises and chest physiotherapy, and death. 
Before and after the intervention, Krupp’s Fatigue Severity Scale (FSS) was completed by each patient. The intervention group 1 performed breathing exercises for six weeks, while the intervention group 2 received chest physiotherapy for six weeks. The control group received no intervention. Data analysis was done using paired t-test, one-way analysis of variance, chi-square test, and one-way analysis of covariance in SPSS software, version 26.

Results 
There was no significant difference in age, history of disease, sex, marital status, education level, job status, economic status, underlying diseases, history of hospitalization, and history of using breathing exercises among the groups, and the three groups were homogenous (P<0.05). The results of Shapiro-Wilk test confirmed the normality of the data distribution. The mean FSS score of patients before the intervention in the breathing exercise group was 40±12.32; in the chest physiotherapy group, 41.93±13.29; and in the control group 35.28±12.80, but the difference was not statistically significant (P=0.404). After the intervention, the scores changed to 32.87±11.70, 31.60±10.20, and 44.07±9.44, respectively, and the difference was statistically significant (P<0.001). This indicates that the FSS score increased in the control group and reduced in the intervention groups. 

Conclusion 
The results of the study showed that the fatigue in the intervention groups was reduced compared to the control group. The group received chest physiotherapy showed a greater reduction in fatigue compared to the breathing exercise group, but this difference was not statistically significant. It is recommended to use these treatment methods to reduce the fatigue of COPD patients. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee of Islamic Azad University, Najafabad branch (Code: IR.IAU.NAJAFABAD.REC.1402.050). All participants signed the informed consent form.

Funding
This article was extracted from the master's thesis of Sakineh Ghafari at the Faculty of Nursing and Midwifery, Islamic Azad University, Najaf Abad branch. This research has not received any financial aid from government, private or non-profit organizations.

Authors' contributions
Conceived, designed, and supervised the study: Fatemeh Salmani; Collected the data and drafted the manuscript: Sakineh Ghafari; Edited and reviewed the manuscript: Mehrdad Azarbarzin and Fatemeh Salmani.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank all the patients participated in this study and Dr. Dabaghian for assistance in conducting this research.


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