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Effectiveness of a Blowing Toy on Physiological Parameters of Children With Lower Respiratory Tract Infection
*Corresponding author: Dr. Renita Priya Dsouza, Department of Child Health Nursing, Yenepoya Nursing College, Yenepoya (Deemed to be University), Mangaluru, Karnataka, India. renipriya.dsouza@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Pachayathodi A, Dsouza RP, Lobo MR. Effectiveness of a Blowing Toy on Physiological Parameters of Children With Lower Respiratory Tract Infection. J Health Allied Sci NU. 2025;15:494-9. doi: 10.25259/JHASNU_18_2025
Abstract
Objectives
To assess the effectiveness of blowing toy therapy on physiological parameters among children with lower respiratory tract infection (LRTI).
Material and Methods
A quasi-experimental, pre-test post-test control group design was used in the present study. A non-probability purposive sampling technique was employed to select the sample and they were allocated into intervention (n=30) and control group respectively (n=30). Physiological parameters were assessed on the day of admission, 3rd day of admission before administering the intervention, and 5th day of admission after 4 days of intervention. Children in the intervention group received blowing toy therapy and children in the control group received routine care. The data were collected using observation proforma. The obtained data was analysed using descriptive and inferential statistics.
Results
Majority of the participants were three to seven years old. Pneumonia was the most prevalent diagnosis in the intervention group, whereas wheeze associated lower respiratory tract infection (WALRI) was prevalent in the control group. A significant improvement in the physiological parameters (respiratory rate, oxygen saturation, breath sounds, and use of accessory muscles) of intervention group children was seen between pre-test and post-test-2, whereas in control group the significant difference was observed only in the oxygen saturation level (P=0.001).
Conclusion
The study concludes that blowing toy therapy is effective in improving physiological parameters of children with LRTI.
Keywords
Blowing toy
Children
Lower respiratory tract infection
Physiological parameters
Wheeze associated lower respiratory tract infection
INTRODUCTION
Children represent a significant portion of healthcare consumers due to their less developed immune systems, making them more susceptible to frequent infections and necessitating frequent visits to hospitals for treatment. Children are prone to acute respiratory infections (ARI), which still remains one of the major causes of mortality in underdeveloped and developing countries.[1] ARIs are broadly classified into upper respiratory tract infections and lower respiratory tract infections (LRTIs). LRTIs represent a significant burden on pediatric healthcare worldwide, posing substantial challenges in diagnosis, management, and prevention. Among children, LRTIs encompass a spectrum of illnesses ranging from mild respiratory tract infections to severe conditions such as pneumonia and bronchiolitis, often leading to considerable morbidity and mortality, particularly in children below 5 years of age.[2]
LRTIs refer to any infection involving the parts of the respiratory tract below the larynx and mainly include conditions like bronchitis, bronchiolitis, and bronchopneumonia. The clinical presentation of LRTIs in children can vary widely, ranging from mild cough and rhinorrhoea to severe respiratory distress requiring intensive care support. The common clinical manifestations are cough, fever, nasal discharge, tachypnea, retractions, and abnormal respiratory sounds such as wheezing or crackles.[3] Despite advancements in access to healthcare services, improvements in children’s nutrition status, efforts to promote exclusive breastfeeding during the first six months of life, appropriate use of antibiotics, and increased vaccination coverage, the prevention of lower respiratory tract infections (LRTIs) remains a significant challenge.[4] Factors like poor socio-economic status, living in overcrowded areas, air pollution, sudden changes in weather, etc, make children prone to contracting LRTIs.[5]
The majority of children with LRTIs can be managed in primary healthcare settings with oral antibiotics. Some children who are severely affected may require hospital admissions for monitoring the condition, administration of intravenous antibiotics and supportive care. A few of them may require care in paediatric intensive care units.[6] While medical interventions play a crucial role in the management of LRTIs, there is growing recognition of non-medical approaches in enhancing respiratory health and improving outcomes in affected children. Among the array of non-medical management strategies, breathing exercises have emerged as a promising adjunctive therapy for children with LRTIs. These exercises encompass a variety of techniques aimed at optimising respiratory function, enhancing airway clearance, and improving lung capacity. By incorporating breathing exercises into the holistic management of LRTIs, healthcare providers can empower children and their caregivers with valuable tools to alleviate symptoms, facilitate recovery, and promote long-term respiratory health.[7-9]
Breathing exercises offer significant benefits for children experiencing respiratory difficulties, aiding in lung strengthening and respiratory control.[10] However, engaging children in conventional breathing techniques can prove challenging due to their natural inclination towards play and activity. Integrating playful elements into therapeutic interventions presents a promising solution to this challenge. For instance, blow toy therapy, involving blowing into toys or devices, not only makes the exercise more enjoyable but also targets the respiratory muscles effectively. While research on the efficacy of blow toy therapy is still in its early stages, initial studies suggest positive outcomes in improving respiratory parameters. Despite limited empirical evidence, the integration of playful interventions like blow toy therapy holds promise in enhancing paediatric respiratory care.[11-13]
MATERIAL AND METHODS
A quantitative quasi-experimental, pre-test post-test control group design was employed for this study. Ethical approval for the study was obtained from the ethical committee of the university (Approval number: YEC2/873). Participant information sheet was given and explained to the participants and parents. Informed consent was obtained from all the parents, and assent was obtained from the children themselves. Confidentiality of the and anonymity of patients were maintained throughout the study.
Sampling criteria
Participants were selected from the paediatric ward of the selected tertiary care hospital in South India. The study included children who were in the age group of 3 to 12 years, admitted with LRTI and were accompanied by a parent or caregiver. Children who were critically ill and in need of intensive care, or were physically or mentally challenged were excluded.
Sample size
Sample size estimation was done using the G*Power software for independent sample t-test. At a 95% confidence level and 80% power, with a standard effect size of 0.5, the minimum sample size required in each group was calculated as 30, totaling 60 participants.
Tools
The study utilised demographic proforma and clinical observation proforma as its primary tools, incorporating parameters, such as the child’s respiratory rate, oxygen saturation levels, breath sounds, and assessment of accessory muscle usage. These tools were meticulously developed by the researcher and subjected to validation by experts including paediatricians, pulmonologists, and a paediatric nursing faculty. The reliability of the tool was assessed using the inter rater method. The obtained reliability score showed that the tool is reliable (r=0.83).
Data collection procedure
A non-probability purposive sampling technique was employed to select and allocate participants into intervention (n=30) and control groups (n=30). The data were first collected for control group children followed by the intervention group. Demographic information and physiological parameters were observed by the investigator in both intervention and control groups using a clinical observation proforma. The intervention group received a blowing toy intervention utilising a funky toy designed to be blown through the mouth, featuring a floating ball at the distal end. When air is blown into the toy, the ball moves upwards and remains elevated until the blowing ceases. Children in the intervention group were instructed to blow the toy ten times each session, at intervals of two hours, amounting to six cycles per day for four days, under the supervision of the researcher. The control group received routine care throughout the study period. For the intervention group, post-test-1 was conducted after two days of intervention, before commencing intervention on the third day. Post-test-2 was conducted after four days of intervention, on the morning of the fifth day. For the control group, post-test-1 was conducted on the third day, and post-test-2 on the fifth day of admission.
RESULTS
The data were analysed using Statistical Package for Social Sciences 20 (SPSS 20) software. The data were analysed in terms of objectives and hypotheses of the study using both descriptive and inferential statistics.
Demographic characteristics
In both the intervention and control groups, the majority of participants fell within the 3-7 years age bracket, comprising 66.7% and 56.7% of the respective groups. Male children constituted the predominant gender in both groups, accounting for 63.3% in the intervention group and 70% in the control group. Within the intervention group, pneumonia was the most prevalent diagnosis, with 40% of participants being diagnosed with this condition. Conversely, in the control group, the majority (43.3%) were diagnosed with wheeze associated lower respiratory tract infection (WALRI). A notable portion (36.7%) of participants in the intervention group had a history of previous hospitalisation, with 23.3% of them being admitted previously due to LRTI. In both groups, more than half of the participants had previously received home treatment for respiratory illnesses, with steam inhalation being the most commonly administered therapy. During the current admission, 46.7% of participants in the intervention group and 60% in the control group were prescribed a combination of antibiotics, bronchodilators, and corticosteroids. Demographic characteristics in both the intervention and control group were homogenous.
Effectiveness of blowing-toy on physiological parameters of children with LRTI
A comparison of pre- and post-test respiratory rate and oxygen saturation revealed that the intervention group experienced significant improvements in both parameters over time. Specifically, the respiratory rate decreased markedly from 46.43 ± 6.64 at pre-test to 29.27 ± 3.35 at post-test 2, with a highly significant ANOVA result (F = 204.428, p = 0.001). Similarly, oxygen saturation in the intervention group increased significantly from 93.50 ± 0.63 to 98.87 ± 0.94 (F = 637.967, p = 0.001). In contrast, the control group showed no significant change in the respiratory rate (F = 14.493, p = 0.061), and only a modest but statistically significant improvement in oxygen saturation (F = 31.250, p = 0.01).
Pairwise comparison of respiratory rate and oxygen saturation at different time points of observations has been depicted in Table 1. The intervention group showed statistically significant improvements in both respiratory rate and oxygen saturation across all time points (p = 0.001). In the control group, changes in respiratory rate were not significant (p > 0.05), while oxygen saturation showed significant improvement between pre-test and post-tests (p = 0.001), but not between post-tests 1 and 2 (p = 0.299). This indicates the intervention was effective in improving both parameters.
| n=30+30 | |||||
|---|---|---|---|---|---|
| Physiological parameter | Group | Time | Mean difference | Standard error | p value |
| Respiratory rate | Intervention group | Pre-test vs Post-test 1 | 8.67 | 1.31 | 0.001* |
| Pre-test vs Post-test 2 | 16.97 | 1.31 | 0.001* | ||
| Post-test 1 vs Post-test 2 | 8.30 | 1.31 | 0.001* | ||
| Control group | Pre-test vs Post-test 1 | 3.77 | 0.99 | 0.06 | |
| Pre-test vs Post-test 2 | 2.23 | 0.99 | 0.08 | ||
| Post-test 1 vs Post-test 2 | 1.53 | 0.99 | 0.37 | ||
| Oxygen Saturation | Intervention group | Pre-test vs Post-test 1 | 2.40 | 0.20 | 0.001* |
| Pre-test vs Post-test 2 | 5.37 | 0.20 | 0.001* | ||
| Post-test 1 vs Post-test 2 | 2.97 | 0.20 | 0.001* | ||
| Control group | Pre-test vs Post-test 1 | 2.13 | 0.30 | 0.001* | |
| Pre-test vs Post-test 2 | 1.63 | 0.30 | 0.001* | ||
| Post-test 1Vs Post-test 2 | 0.50 | 0.30 | 0.299 | ||
Test used= ANOVA test with Bonferroni post-hoc test, *Significant(p<0.05).
The inter group comparison of respiratory rate and oxygen saturation, shown in Table 2, reveals that significant difference in the respiratory rate and oxygen saturation level was observed in post-test-2 (p=0.001). while no changes were seen in post-test-1.
| n=30+30 | ||||||
|---|---|---|---|---|---|---|
| Parameteres | Time | Group | Mean ± SD | Mean difference | t value | p value |
| Respiratory rate | Post-test 1 | Intervention group | 37.77 ± 4.62 | 1.37 | 1.225 | 0.225 |
| Control group | 36.40 ± 4.00 | |||||
| Post-test 2 | Intervention group | 29.27 ± 3.35 | 8.47 | 9.209 | 0.001* | |
| Control group | 37.93 ± 3.76 | |||||
| Oxygen Saturation | Post-test 1 | Intervention group | 95.90 ± 0.66 | 0.47 | 1.753 | 0.085 |
| Control group | 96.37 ± 1.30 | |||||
| Post-test 2 | Intervention group | 98.87 ± 0.94 | 3.00 | 14.560 | 0.001* | |
| Control group | 95.87 ± 0.63 | |||||
Test Used= Independent t test, *Significant at p (<0.05).
Table 3 shows that children in both the intervention and control groups had the abnormal breathing sounds like wheezing, rhonchi, and crackles in the pretest and post-test-1. In the intervention group, majority of the children (86.7%) attained normal breath sounds at the end of the intervention which is observed in post-test-2, whereas in control group a small number attained normal breath sounds (10%).
| n=30+30 | ||||
|---|---|---|---|---|
| Group | Breath sounds | Pre-test | Post-test 1 | Post-test 2 |
| f (%) | f (%) | f (%) | ||
| Intervention group | Wheezing | 13 (43.3) | 13 (43.3) | 1 (3.3) |
| Rhonchi | 12 (40.0) | 12 (40.0) | 1 (3.3) | |
| Crackles | 5 (16.7) | 5 (16.7) | 2 (6.7) | |
| Normal breath sounds | - | - | 26 (86.7) | |
| Control group | Wheezing | 18 (60.0) | 18 (60.0) | 16 (53.3) |
| Rhonchi | 12 (40.0) | 12 (40.0) | 11 (36.7) | |
| Crackles | - | - | - | |
| Normal breath sounds | - | - | 3 (10.0) | |
f represents frequency distribution of children according to breath sounds.
Table 4 reveals that abnormal breath sounds of the children with LRTI were significantly reduced in the intervention group (p<0.05), while the changes observed in the control group were not significant.
| n=30+30 | ||||
|---|---|---|---|---|
| Group | Group | Mean Rank | χ2 value | p value |
| Intervention group | Pre-test | 1.57 |
52.00 |
0.001* |
| Post-test 1 | 1.57 | |||
| Post-test 2 | 2.87 | |||
| Control group | Pre-test | 1.95 |
6.00 |
0.110 |
| Post-test 1 | 1.95 | |||
| Post-test 2 | 2.10 | |||
Test Used = Friedman test, *Significant at p (<0.05). LRTI: Lower respiratory tract infections, X2: Chi square value.
A notable reduction in the use of accessory muscles for breathing was observed in the intervention group, decreasing from 43.3% at pre-test to 40% at post-test 1, and further to just 10% at post-test 2. In contrast, the control group showed minimal change, with 26.7% at pre-test, remaining the same at post-test 1, and slightly decreasing to 23.3% at post-test 2.
Within the group comparison of effectiveness of blowing toy on use of accessory muscles of breathing in children with LRTI, shown in Table 5, reveals that significant changes were observed in the intervention group (p=0.001), whereas in the control group changes were not significant.
| n=30+30 | ||||
|---|---|---|---|---|
| Group | Group | Mean rank | Friedman test (χ2 value) | p value |
| Intervention group | Pre-test | 1.82 |
18.20 |
0.001* |
| Post-test 1 | 1.87 | |||
| Post-test 2 | 2.32 | |||
| Control group | Pre-test | 1.98 |
2.00 |
0.368 |
| Post-test 1 | 1.98 | |||
| Post-test 2 | 2.03 | |||
*Significance at p<0.05 level, Test used is Friedman test. LRTI: Lower respiratory tract infections, X2: Chi square value.
Hence the formulated null hypothesis H01: There will be no significant difference in physiological parameters of the intervention group during the post test was rejected, and it was concluded that the blowing toy therapy was effective in improving the physiological parameters in children with LRTI.
DISCUSSION
LRTI remains a leading cause of paediatric admissions to hospitals, with pneumonia standing out as a prevalent sub-type, especially burdening healthcare systems in developing nations.[14] The combination of compromised immunity and environmental factors heightens susceptibility to respiratory infections in children, with some progressing to severe illness requiring hospitalisation or intensive care.[15] While pharmacological management and supportive care constitute the cornerstone of LRTI treatment, non-pharmacological interventions, such as play-integrated breathing exercises, have demonstrated efficacy. Children are more likely to engage in breathing exercises when presented in a playful manner.[16,17]
This study aimed to evaluate the effectiveness of blowing toy exercises on the physiological parameters of children hospitalised with LRTI. Results revealed that both the intervention and control groups exhibited tachypnea initially, which normalised following the intervention. Pre-intervention mean oxygen saturation was 93.50 ± 0.63, increasing significantly to 98.87 ± 0.63 post-intervention. Prior to the intervention, 43.3% of the sample displayed abnormal breath sounds, which decreased to 86.7% post-intervention. Additionally, there was a notable reduction in the use of accessory muscles during breathing post-intervention. These findings align with a study which compared balloon therapy vs bubble therapy in children aged 3-12 with LRTI, demonstrating effectiveness in improving tachypnea, oxygen saturation, breath sounds, and accessory muscle usage.[18]
Blow toy therapy proved effective in ameliorating tachypnea among children with LRTI, suggesting that integrating playful breathing exercises, with consistent reinforcement, encourages practice and potentially impacts clinical outcomes positively. A study comparing balloon therapy to spirometry in promoting respiratory function in children with respiratory infections, also indicated a significant difference in pre-test (23.980 ± 1.40) versus post-test (23.060 ± 1.68) respiratory rates among children undergoing balloon therapy (p<0.05).[19] Similarly, another study revealed significant improvement in respiratory parameters of children with LRTI who underwent balloon blowing exercises (p<0.05).[20]
These findings underscore the effectiveness of play-integrated interventions like blow toy therapy in improving physiological parameters in children with LRTI, offering an engaging and accessible therapeutic approach. Our findings are corroborated by a systematic review that demonstrated that blowing exercises positively impact children’s lung capacity, highlighting their potential efficacy in improving respiratory function.[21]
CONCLUSION
The present study concludes that blow toy therapy is effective in improving the physiological parameters of children suffering from LRTI and can yield positive clinical outcomes when combined with pharmacological management. The simplicity of blow toy therapy makes it easy to administer, allowing parents to supervise with assistance from pediatric nurses, thereby promoting family-centered care. Additionally, this therapy represents a cost-effective non-pharmacological breathing technique that can be implemented even in a home setting.The current study had taken a small sample size due to time constraints and was carried out at a single setting hence generalisation of the findings are limited.
Acknowledgement
We acknowledge hospital authorities, staff at paediatric ward, all the participants of the study and their parents for the cooperation rendered throughout the data collection period.
Ethical approval
The research/study approved by the Institutional Review Board at Yenepoya Deemed to be University, number YEC2/873, dated 31st August 2021.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that they have used artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript or image creations.
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