The discussion brings the right report to closure. Discussion section "make sense" of research results. This is the most important section of any research report.
The main aim of the study was to assess the respiratory status of children with wheezing, implement selected measures and to evaluate the effectiveness of the measures. The study was conducted in G.K.N.M. Hospital, Coimbatore in the month of June. Each child's baseline information was collected and they were assessed for selected respiratory parameters under the subheadings of respiratory rate, oxygen saturation, wheeze score, retraction score and dyspnoea grade. After the initial assessment, the selected measures like nebulization with oxygen and nebulization without oxygen were implemented. Ongoing assessments were done at an interval of 5 minutes, 10 minutes, 15 minutes and 30 minutes on the selected respiratory parameters and interventions were carried out by the staff nurse in the Pediatric OPD.
5.1 Demographic Data of Children with Selected Respiratory Diseases: Fifty children with selected respiratory diseases were selected and 25 children were assigned to each group. Majority of children with wheezing were between the age group of 3-5 years and most of the children were males.
The above findings were supported by a descriptive study which was conducted to assess the prevalence and causes of under five mortality and morbidity, and the findings of the study reported that acute respiratory infections are the most common cause and the morbidity was significantly higher in boys as compared to girls. (Grover, 2007).
About 32% of the children belonged to joint family. The present study showed that the type of cooking fuel used in all the houses were LPG.
The above result finding was supported by a descriptive study which was conducted to ascertain various factors precipitating ARI in children and the study concluded overcrowding as a risk factor of ARI in children. (Mukhopadhya, 2001)
5.2 Profile Regarding Family History of Smoking Habits: The present study revealed that 20% of children in the nebulization with oxygen group had history of smoking habits in the family whereas in nebulization without oxygen group, 12% of children had the history of smoking habit in the family.
This above result has documented in a community based survey which states that overcrowding and smoking at home are associated with wheezing in under five children. (Salem, 2004).
5.3 Profile regarding Family History of Respiratory Diseases: About 20% of children in nebulization with oxygen group had a family history of asthma whereas in nebulization without oxygen group, 20% children had a family history of asthma and 12% children had a family history of COPD.
A similar study was conducted to assess the risk factors associated with lower respiratory infections in under five children and the results showed that history of LRTI in the family especially, the respiratory infections in the mother and the siblings are the significant risk factors. (Broor, 2001)
5.4 Profile Regarding History of Respiratory Diseases in Children: Majority (64%) of children in the nebulization with oxygen group had wheeze associated lower respiratory infection (WALRI) whereas in nebulization without oxygen group, 60% had WALRI, 28% of children had asthma and 12% of them had hyper reactive airway disease.
The above findings were supported by a community-based survey was carried out in Basra governorate, Iraq, to estimate the prevalence of wheeze among children under 5 years old and to identify possible risk factors. It was found that 15.8% of the 424 preschool children enrolled in the study had a history of wheeze. More wheezy children lived in the city (16.3%) than in the rural area (15.0%). (Hassan, 2004).
Regarding the onset of respiratory diseases, 56% of children in nebulization with oxygen group developed respiratory diseases before 1 year of age whereas in nebulization without oxygen group, 44%of the children developed it before 1 year of age. Regarding the duration of the disease, 56% of children in nebulization with oxygen group had the duration of less than 1 year whereas in nebulization without oxygen group, 40% of children had duration of less than 1 year.
The above findings were supported by a case control study done to assess the risk factors of respiratory infections in children. The result showed previous history of respiratory disease as one of the risk factors of recurrent respiratory infections in under five children. (Shah, 2010).
With regard to the regularity of the treatment, 12% of the children in nebulization with oxygen group are on regular treatment whereas 24% of the children were on regular treatment in nebulization without oxygen group. Majority of the children (66.66%) were using a combination of salbutamol-fluticasone inhaler in both groups.
A similar cross sectional study was conducted on recurrent wheezing revealed that 84.6% of the wheezy children were treated with β2-agonists and 18.5% children were treated with inhaled corticosteroids (Neto, 2007).
5.5 Administration of Nebulization with Oxygen and Nebulization without Oxygen to Children with Wheezing: In this study, pre assessment was done on selected respiratory parameters including respiratory rate, oxygen saturation, wheeze score, retraction score and dyspnoea grade. Nebulization with oxygen and nebulization without oxygen were given for a period of 15- 20 minutes to fifty children with wheezing. After the treatment, post assessments of selected respiratory parameters were done at 5 minutes, 10 minutes, 15 minutes and 30 minutes of the treatment. There are several modes of treatment in improving the wheeze symptoms in children. Nebulization is the focus of most of the researches as it is the most efficient and cost effective method.
A similar experimental study was conducted in Korea to analyze the changes in arterial oxygen saturation during and after salbutamol nebulization and compared the effect of 100%oxygen with the compressed air as the driving gas. The study showed that nebulization with oxygen as the driving gas is better than nebulization using compressed air during salbutamol nebulization. (Yoo. E. S., Seo. J.W...Lee.S.J. 1996)
5.6 Comparison of Mean Difference of Pre and Post Assessments of Respiratory Parameters in Nebulization with Oxygen Group and Nebulization without Oxygen Group: Pre and post assessments of respiratory rate shows that the mean difference was high in nebulization with oxygen group,(1.28 at 5 minutes ,3.92 at 10 minutes,6.08 at15 minutes and 8.88 at 30 minutes) than in nebulization without oxygen group( 0.64 at 5 minutes,2.32 at 10 minutes,4.16 at 15 minutes and 5.68 at 30 minutes).. Assessment of oxygen saturation shows that the mean difference was high in nebulization with oxygen group( 0.76 at 5 minutes, 2 at 10 minutes, 2.84 at 15 minutes and 3.08 at 30 minutes) than in nebulization without oxygen group( 0.16 at 5 minutes,0.96 at 10 minutes,1.64 at 15 minutes and 1.36 at 30 minutes).. The mean difference of retraction score was high in nebulization with oxygen group (0 at 5 minutes, 0.24 at 10 minutes, 0.32 at 15 minutes and 0.36 at 30 minutes) and low in nebulization without oxygen group ( 0.04 at 5 minutes,0.16 at 10 minutes,0.24 at 15 minutes and 0.24 at 30 minutes).This shows that there is a significant improvement in respiratory rate, oxygen saturation and retraction score in nebulization with oxygen group.
Assessment of wheeze score shows that the mean difference was equal in nebulization with oxygen group( 0.12 at 5 minutes, 0.8 at 10 minutes, 0.96 at 15 minutes and 1.08 at 30 minutes) and in nebulization without oxygen group (0.2 at 5 minutes, 0.76 at 10 minutes, 1.08 at 15 minutes and 1.08 at 30 minutes). Assessment of dyspnoea grade also shows that the mean difference was equal in nebulization with oxygen group ( 0 at 5 minutes, 0.08 at 10 minutes,0.12 at 15 minutes and 0.12 at 30 minutes) and in nebulization without oxygen group (0 at 5 minutes,0.08 at 10 minutes,0.12 at 15 minutes and 0.16 at 30 minutes). This shows that nebulization with oxygen and nebulization without oxygen have similar effect in reducing wheezing and dyspnoea grade among children with wheezing.
5.7. Effectiveness of Nebulization with Oxygen and Nebulization without Oxygen in Improving the Respiratory Parameters among Children with Wheezing through Paired't' test Analysis: In nebulization with oxygen group, the calculated 't' value of respiratory rate at 5 minutes(2.67),10 minutes(5),15 minutes(7.89) and at 30 minutes(12.94) were higher than the table value at 0.05 level. It shows that there is a significant difference in pre and post assessments of respiratory rate in nebulization with oxygen group. In nebulization without oxygen group, the calculated't' value of respiratory rate at 5 minutes (1.45) was less than the table value at 0.05 level. It shows that there is no significant difference in pre and post assessment of respiratory rate at 5 minutes in nebulization without oxygen group. The calculated't' value of respiratory rate at 10 minutes (5.39), 15 minutes (10.18) and 30 minutes (13.8) were higher than the table value at 0.05 level. It shows that there is a significant difference in pre and post assessments of respiratory rate at 10 minutes, 15 minutes and 30 minutes in nebulization without oxygen group.
In nebulization with oxygen group, the calculated't' value of oxygen saturation at 5 minutes (3.8), 10 minutes (9.52), 15 minutes (15.77) and 30 minutes (15.24) were higher than the table value at 0.05 level. It shows that there is a significant difference in pre and post assessments of oxygen saturation in nebulization with oxygen group. In nebulization without oxygen group, the calculated't' value of oxygen saturation at 5 minutes (1.23) was less than the table value at 0.05 level. This shows that there is no significant difference in pre and post assessment of oxygen saturation at 5 minutes in nebulization without oxygen group. The calculated't' value of oxygen saturation at 10 minutes (6.25), 15 minutes (7.45) and 30 minutes (6.18) were higher than the tabulated value at 0.05 level. It shows that there is a significant difference in pre and post assessments of oxygen saturation at 10 minutes, 15 minutes and 30 minutes in nebulization without oxygen group.
In nebulization with oxygen group, the calculated't' value of wheeze score at 5 minutes (1.71) was less than the tabulated value at 0.05 level. It shows that there is no significant difference in pre and post assessment of wheeze score at 5 minutes in nebulization with oxygen group. . The calculated't' value of wheeze score at 10 minutes (10), 15 minutes (24) and 30 minutes (18) were higher than the tabulated value at 0.05 level. It shows that there is a significant difference in pre and post assessments of wheeze score at 10 minutes, 15 minutes and 30 minutes in nebulization with oxygen group. In nebulization without oxygen group, the calculated 't' value of wheeze score at 5 minutes (2.5) was less than the tabulated value at 0.05 level. It shows that there is no significant difference in pre and post assessment of wheeze score at 5 minutes in nebulization without oxygen group. . The calculated 't' value of wheeze score at 10 minutes (7.6), 15 minutes (18) and 30 minutes (18) were higher than the tabulated value at 0.05 level. It shows that there is a significant difference in pre and post assessments of wheeze score at 10 minutes, 15 minutes and 30 minutes in nebulization without oxygen group.
In both nebulization with oxygen group and in nebulization without oxygen group, the calculated 't' value of retraction score at 5 minutes (1 and 1 respectively) was less than the tabulated value at 0.05 level. It shows that there is no significant difference in pre and post assessment of retraction score at 5 minutes in nebulization with oxygen group and in nebulization without oxygen group. In nebulization with oxygen group, the calculated't' value of retraction score at 10 minutes (2.5), 15 minutes (3.37) and 30 minutes (3.27) were higher than the tabulated value at 0.05 level. It shows that there is a significant difference in pre and post assessments of retraction score at 10 minutes, 15 minutes and 30 minutes in nebulization with oxygen group. In nebulization without oxygen group, the calculated 't' value of retraction score at 10 minutes (2.29), 15 minutes (2.67) and 30 minutes (2.67) were higher than the table value at 0.05 level. It shows that there is a significant difference in pre and post assessments of retraction score at 10 minutes, 15 minutes and 30 minutes in nebulization without oxygen group.
In nebulization with oxygen group, the calculated 't' value of dyspnoea grade at 5 minutes (0), 10 minutes (1.14), 15 minutes (1.71) and 30 minutes (1.71) were less than the tabulated value at 0.05 level. It shows that there no significant difference in pre and post assessments of dyspnoea grade in nebulization with oxygen group. In nebulization without oxygen group, the calculated't' value of dyspnoea grade at 5 minutes (0), 10 minutes (1.14) and 15 minutes (1.71) were less than the tabulated value at 0.05 level. This shows that there is no significant difference in pre and post assessments of dyspnoea grade at 5 minutes, 10 minutes and 15 minutes in nebulization without oxygen group. The calculated't' value of dyspnoea grade at 30 minutes (2.29) was higher than the tabulated value at 0.05 level. This shows that there is a significant difference in pre and post assessment of dyspnoea grade at 30 minutes in nebulization without oxygen group.
5.8 Comparison of Respiratory Parameters Between Nebulization with Oxygen Group and Nebulization without Oxygen Group Through Z Test Analysis: In nebulization with oxygen group and in nebulization without oxygen group the calculated 'Z' value of respiratory rate, oxygen saturation, wheeze score, retraction score and dyspnoea grade at 5 minutes were 1.81, 0.27, 1.87, 1.14 and 0 respectively which is less than the tabulated value of 'Z' at 0.05 level. This shows that there is no significant difference in respiratory parameters between both groups after 5 minutes of nebulization.
The calculated 'Z' value of respiratory rate, oxygen saturation, wheeze score, retraction score and dyspnoea grade at 10 minutes in nebulization with oxygen group and nebulization without oxygen group were 1.43, 1.33, 0.89, 0.21 and 0 respectively which is less than the tabulated value of 'Z' at 0.05 level. This shows that there is no significant difference in respiratory parameters between both groups after 10 minutes of treatment.
When comparing the respiratory parameters at 15 minutes between nebulization with oxygen group and nebulization without oxygen group ,the calculated 'Z' value of respiratory rate, oxygen saturation, , retraction score and dyspnoea grade were 1.38,1.5 and 0 respectively which is less than the tabulated value of 'Z' at 0.05 level. The calculated 'Z' value of wheeze score at 15 minutes (2.29) was higher than the tabulated value at 0.05 level. This shows that there is no significant difference in respiratory parameters, except wheeze score, between groups.
Among nebulization with oxygen group and nebulization without oxygen group the calculated 'Z' value of respiratory rate, wheeze score, retraction score and dyspnoea grade at 30 minutes were 0.85, 1.5,0 and 0.57 respectively which is less than the tabulated value of 'Z' at 0.05 level. The calculated 'Z' value of oxygen saturation at 10 minutes (2.81) was higher than the tabulated value at 0.05 level. This shows that there is no significant difference in respiratory parameters, except oxygen saturation, between both groups.
5.9 Theoretical Framework: Comparison of Nebulization with Oxygen and Nebulization without Oxygen in Improving the Respiratory Status of Children with Wheezing:
Modified Wiedenbach's Helping Art of Clinical Nursing Model was adopted to compare the effectiveness of nebulization with oxygen and nebulization without oxygen in improving the respiratory status of children with wheezing. 50 children with mild to moderate wheezing were selected as subjects in the study. Pre assessment of respiratory parameters was done. Nebulization with oxygen and nebulization without oxygen were administered for a period of 15-20 minutes and post assessments were done at 5 minutes, 10 minutes, 15 minutes and 30 minutes of nebulization. Comparison of pre and post assessments of respiratory parameters showed a significant improvement in respiratory parameters in both groups. No significant differences in respiratory parameters were observed between nebulization with oxygen group and nebulization without oxygen group.
CHAPTER VI
SUMMARY AND CONCLUSION
The present study was conducted to assess the effectiveness of nebulization with oxygen and nebulization without oxygen in improving the respiratory status of children with wheezing. Relevant literature was reviewed to enrich the knowledge on selected phenomena and it facilitated in selecting appropriate conceptual model, developing a framework and research plan.
Research design adopted for this study was experimental design. The study was conducted in GKNM Hospital, Coimbatore. Using purposive sampling technique, fifty children who presented to the Pediatric OPD with wheezing were selected for the study.
Validity and reliability of the tool was tested through pilot study. Questionnaire was prepared to obtain information on demographic profile, family history of respiratory disease, history of previous respiratory disease and immunization. Pre assessment of respiratory status was done based on five parameters which includes respiratory rate, oxygen saturation, wheeze score, retraction score and dyspnoea grade. Interventions such as nebulization with oxygen and nebulization without oxygen were given for 15-20 minutes. Post assessments were done at 5 minutes, 10 minutes, 15 minutes and at 30 minutes.
6.1 Major Findings of the Study:
Majority (62%) of the children were males.
20% of children had a family history of respiratory diseases.
62 % of children had a diagnosis of wheeze associated lower respiratory tract infection.
All children (100%) in both groups were immunized up to the age.
6.1.1 Findings related to nebulization with oxygen:
1. Pre assessment of respiratory parameters
i. 52% of children had severe distress.
ii. 80% of children had mild desaturation.
iii. 52% of children had entire expiratory wheeze.
iv. 64% of the children had no retractions.
v. 80% of children had no dyspnoea.
2. Post 5 minutes assessment of respiratory parameters
i. 48% of children had severe distress
ii. 68% of children had mild desaturation.
iii. 52% had terminal expiratory wheeze.
iv. 64% of the children had no retractions.
v. 80% of children had no dyspnoea.
3. Post 10 minutes assessment of respiratory parameters
i. 36% of children had severe distress.
ii. 52% of children had normal saturation.
iii. 44% of children had terminal expiratory wheeze.
iv. 84% of the children had no retractions.
v. 88% of children had no dyspnoea.
4. Post 15 minutes assessment of respiratory parameters
i. 36% of children had moderate distress.
ii. 68% of children had normal saturation.
iii. 48% had normal vescicular breath sounds.
iv. 92% of the children had no retractions.
v. 92% of children had no dyspnoea.
5. Post 30 minutes assessment of respiratory parameters
i. 44% of children had normal respiratory rate.
ii. 76% of children had normal saturation.
iii. 56% of children had normal vescicular breath sounds.
iv. 96% of the children had no retractions.
v. 92% of children had no dyspnoea.
3. The paired't' test values of respiratory parameters at 5,10,15,30 minutes are greater than the tabulated value of 't' at 0.05 level. This shows that there is a significant difference in pre and post assessment of respiratory parameters.
6.1.2 Findings related to nebulization without oxygen:
1. Pre assessment of respiratory parameters
i. 40% of children had mild distress.
ii. 88% of children had mild desaturation.
iii. 68% of children had terminal expiratory wheeze.
iv. 72% of the children had no retractions.
v. 80% of children had no dyspnoea.
2. Post 5 minutes assessment of respiratory parameters
i. 44% of children had mild distress.
ii. 84% of children had mild desaturation.
iii. 60% had terminal expiratory wheeze.
iv. 76% of the children no retractions.
v. 80% of children had no dyspnoea.
3. Post 10 minutes assessment of respiratory parameters
i. 40% of children had mild distress.
ii. 60% of children had mild desaturation.
iii. 64% of children had terminal expiratory wheeze.
iv. 88% of the children had no retractions.
v. 88% of children had no dyspnoea.
4. Post 15 minutes assessment of respiratory parameters
i. 36% of children had normal respiratory rate.
ii. 52% of children had mild desaturation.
iii. 76% of children had normal vescicular breath sounds.
iv. 96% of the children had no retractions.
v. 92% of children had no dyspnoea.
5. Post 30 minutes assessment of respiratory parameters
i. 52% of children had normal respiratory rate.
ii. 52% of children had mild desaturation.
iii. 76% of children had normal vescicular breath sounds.
iv. 96% of children had no retractions.
v. 96% of children had no dyspnoea.
3. The paired't' test values of respiratory parameters at 5,10,15,30 minutes are greater than the tabulated value of't' at 0.05 level. This shows that there is a significant difference in pre and post assessment of respiratory parameters.
4.The 'Z' test values of respiratory parameters between nebulization with oxygen group and nebulization without oxygen group at 5,10,15,30 minutes are less than the table value of 'Z' at 0.05 level.This shows that nebulization without oxygen is as effective as nebulization with oxygen in improving the respiratory status of mild to moderate wheezy children.
6.2 Limitations:
6.2.1 Interventions were administered only to outpatients.
6.2.2 Interventions were administered only to mild to moderate wheezy children.
6.2.3 Interventions were administered only to children with selected respiratory diseases.
6.2.4 Interventions were administered only to children receiving combimist nebulization.
6.3 Recommendations:
6.3.1 A new protocol can be prepared regarding the nebulization procedure in the hospital.
6.2.2 In-service education regarding the importance and the cost of oxygen can be given to staff nurses to prevent unnecessary wastage of oxygen.
6.3.3 Education can be given to parents on the importance of regular intake of medicines
6.4 Suggestions:
6.4.1 Similar study can be conducted on children with severe wheezing.
6.4.2 Similar study can be conducted in inpatient settings.
6.4.3 Similar study can be conducted by using other nebulizing agents.
6.4.4 Similar study can be conducted to determine the flow rate of oxygen needed to drive the nebulizer.
6.4.5 Similar study can be conducted to compare the effectiveness of nebulization with oxygen and nebulization without oxygen on a particular disease alone.
6.5 Implications:
The findings of the present study have shown that nebulization without oxygen is as effective as nebulization with oxygen in improving the respiratory status of children with wheezing. The implications of this study are vital to nursing practice, nursing education, nursing administration and nursing research.
6.5.1 Nursing Practice:
This study has important implications in nursing care of children with wheezing as nurses can prevent unnecessary wastage of oxygen and can reduce the cost of nebulization by using simple air driven nebulizer for stable children. Nebulization without oxygen is a simple and cost effective way to bring an immediate reduction in wheezing.
6.5.2 Nursing Education:
Nursing students should develop knowledge and skill in the administration of nebulization and should know its potential benefits in improving the respiratory parameters. They should realize the importance of oxygen as a medicine and should prevent its wastage.
6.5.3 Nursing Administration:
Developing policies and protocols jointly fosters and stress collaboration and it discuss on the expectations of staff working in the pediatric care unit.
Provision should be made for successive implementation of nebulization.
Develop a separate written protocol on nebulization with oxygen and nebulization without oxygen.
Conduct in service education to the staff nurses on these therapies.
6.5.4 Nursing Research:
The main goal of nursing research is to improve the patient care. The present study gives base to conduct the qualitative and quantitative studies on the efficacy of nebulization in improving the respiratory status of children with wheezing. Concerned nurses should be motivated in doing small research studies on this topic. Emphasis should be given to the utilization of research findings. Appropriate utilization of research helps nurses to make evidence based decisions.
Conclusion:
The present study showed that the interventions carried out like nebulization with oxygen and nebulization without oxygen are beneficial in improving the respiratory status of children with mild to moderate wheezing. Nebulization without oxygen which is less expensive is as effective as nebulization with oxygen in improving the respiratory status of children. The present study suggests that simple air driven nebulizers can be used to treat children with mild to moderate wheezing which may prevent unnecessary wastage of resources and reduce the cost of the therapy especially in a developing country like India.
