5. The Research
ACBT favoured over most alternatives for short-term gains in secretion clearance (Lewis, Williams & Olds,
2011)
Airway clearance techniques safe for COPD, small benefits on some clinical outcomes (Osadnik,
McDonald, Jones, & Holland 2011)
Autogenic drainage as effective as ACBT in clearing secretions and improving O2sat without causing
detrimental cardiac & respiratory rates, and breathlessness in pts with AECOPD (Moiz, Kishore & Belsare,
2007)
5 studies – ACTs did not improve measures of resting lung function (Hill, Patman & Brooks, 2009)
ACTs appear to be safe in people with stable bronchiectasis – may be improvements in sputum
expectoration, selected measures of lung function & health-related quality of life, (Lee, Burge & Holland,
2013)
6. Research, contd.
Solid evidence of effectiveness of different airway clearance techniques in
COPD is scarce
ACBTs, AD, Forced expiration can be effective in treatment of COPD
Evidence for passive techniques – postural drainage/percussion – low
Little evidence – combined use of active techniques and supporting techniques
(O)PEP, postural drainage & vibration in COPD
Need for ‘well-powered controlled clinical trials on the long-term effects of
(combined) airway clearance techniques in COPD’
Ides, Vissers DeBacker, Leemans & DeBacker, 2011
7. Who & What?
Anyone with mucous hypersecretion
COPD with sputum production (>30ml/day), bronchiectesis, cystic
fibrosis/cilliary dysfunction, chronic or post-op atelectasis
Forced Expiratory Technique, Active Cycle of Breathing, Autogenic Drainage,
Oscillating PEP Therapy, Exercise
Also: PEP Devices, High Frequency Chest Wall Oscillation, Intra-pulmonary
Percussor Ventilator, Inhalation Therapy
8. Why?
Gentle (generally), progressive sputum movement through to expectoration
Possible reduction in frequency of infections which prevent further airway
damage and lung function decline
Potential to reduce the rate of progression of lung disease
Efficient – most sputum, shortest time, least energy expenditure
Performed anywhere, at any time
9. Active Cycle of Breathing
Technique (ACBT)
Combinations of breathing control, thoracic
expansion control, and FET
Breathing control – default relaxed breathing
between manoeuvre efforts
Shoulders relaxed, gentle breathing with lower chest
Abdomen should move slightly
Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1210- 1223
10. ACBTs contd.
Thoracic expansion – larger-than-normal breaths,
followed by relaxed exhale
Typically limited to 3-4 deep breaths
11. Forced Expiratory Technique
(FET)
First described by Thompson & Thompson in 1968
Combination of manoeuvres described as a ‘milking
action’
Directed Cough
Forced Huff Exhalation
Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1210- 1223
12. Directed Cough
Standard procedure
Deep breath
Hold, using abdominal muscles to force air against a
closed glottis
Cough with single exertion
Several relaxed breaths before next effort
Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1210- 1223
13. ‘Huff’ Directed Cough/Huff Forced
Exhalation
3-5 slow, deep breaths, inhaling through nose, exhaling through pursed lips, using diaphragmatic
breathing.
Deep breath and hold for 1-3 seconds
Exhale from mid-to-low lung volume.
Normal breath in, squeeze it out by contracting the abdominal and chest wall muscles, with the
mouth open while whispering the word ‘huff’ during exhalation. Repeat several times.
When secretions enter larger airways, exhale from high-to-mid lung volume to clear secretions
Repeat process 2-3 times.
Take relaxed breaths before next efforts
Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1210-1223
17. Autogenic Drainage
Described by Jean Chevaillier in 1967
Deeper than normal breath, and exhale in a gentle but
active way
Preparation & Position
Inspiration
Expiration
Described as ‘unstick, collect & evacuate’
Agostini, P. & Knowles, N. (2007) Autogenic drainage: the technique, physiological basis and evidence. Physiotherapy, 93, p. 157-163.
18. Preparation & Position
Clear upper airways, ie, nose & throat – huffing or
coughing
Take prescribed nebulizers or inhalers
Find comfortable, unrestricted position
20. Expiration
Active, silent sigh
At least as long as inspiration, but exhaling a little longer
helps to achieve low lung volume stage
Urge to cough should be suppressed until secretions are
high enough to expectorate successfully
Utilize controlled cough or huff for expectoration
21. The process
‘unstick’ – low volume breathing
‘collect’ – breathe based on frequency vibrations
‘evacuate’ – only when secretions have made their
way to upper/central airways or mouth
Agostini, P. & Knowles, N. (2007) Autogenic drainage: the technique, physiological basis and evidence. Physiotherapy, 93, p. 159.
24. “Which alternative to recommend depends
on the ability, motivation, preference,
needs and resources of each patient.”
Pryor, et. Al (2010), p. 191.
27. References
Agostini, P. & Knowles, N. (2007). Autogenic Drainage: the technique, physiological basis and evidence.
Physiotherapy, 93, p. 157-163.
Fink, J.B. (2007). Forced expiratory technique, directed cough, and autogenic drainage. Respiratory Care,
52(9), p.1210-1223.
Hill, K., Patman, S., Brooks, D. (2010, February). Effect of airway clearance techniques in patients
experiencing an acute exacerbation of chronic obstructive pulmonary disease: A systematic review.
Chronic Respiratory Disease, 7 (1), p. 9-17.
Lee, A.L, Burge, A., Holland, A.E. (2013). Airway clearance techniques for bronchiectasis (Review). The
Cochrane Collaboration, 5, p. i-36.
Lewis, K.L., Williams, M.T., Olds, T.S. (2012). The active cycle of breathing technique: A systematic review
and meta-analysis. Respiratory Medicine, 106, p. 155-172.
28. References cont.
Mckoy, N.A., Odelola, S.I.J. & Robinson, K.A. (12 December 2012). A comparison of active cycle of
breathing technique (ACBT) to other methods of airway clearance therapies in patients with cystic fibrosis.
Cochrane Summaries, The Cochrane Group.
Melam, G.R., Zakaria, A.R., Buragadda, S., Sharma D. & Alghamdi, M. (2010). Comparison of autogenic
drainage & active cycle of breathing techniques on FEV1, FVC & PEFR in chronic obstructive pulmonary
disease. World Applied Sciences Journal, 20(6), p. 818-822.
Moiz, J.A., Kishore, K. & Belsare., D.R. (2005). A comparison of autogenic drainage and the active cycle
of breathing techniques in patients with acute exacerbation of chronic obstructive pulmonary disease.
Indian Journal of Physiotherapy and Occupational Therapy, 1(2), downloaded July 21/14 from
http://www.indmedica.com/journals.php?journalid=10&issueid=93&articleid=1272&action=article
30. References contd.
Pryor, A.J., Tannenbaum, E., Scott, S.F., Burgess, J., Cramer, D., Gyi, K. & Hodson, M.E. (2010). Beyond
postural drainage and percussion: Airway clearance in people with cystic fibrosis. Journal of Cystic
Fibrosis, 9, p. 187-192.
Samis, L. (2013, January). Airway clearance techniques for chronic lung disease.
Venturelli, E., Crisafulli, E., DeBiase, A., Righi, D., Berrighi, D., Cavicchioli, P.P., Vagheggini, G., Dabrosca,
F., Balbi, B., Paneroni, M., Bianchi, L., Vitacca, M., Galimberti, V., Zaurino, M., Schiavoni, G., Iattoni, A.,
Ambrosino, N., & Clini., E.M. (2013, April). Efficacy of temporary positive expiratory pressure (TPEP) in
patients with lung diseases and chronic mucus hypersecretion. The UNIKO project: a multicentre
randomized controlled trial. Clinical Rehabilitation 27 (4), p. 336-346.
31. References – pt. guides
Autogenic Drainiage. UNM Hospitals. Downloaded August 5/14 from http://hospitals.unm.edu/cf/autogenic_drainage.shtml
Active Cycle of Breathing Technique (ACBT) . Downoaded August 5/14, from
http://www.nnuh.nhs.uk/docs%5Cdocuments%5C580.pdf
Active cycle of breathing techniques: A patient’s guid. Papworth Hospital, NHS. Downloaded August 5/14 from
http://www.papworthhospital.nhs.uk/docs/leaflets/PI47_Active_cycle_of_breathing_techniques.pdf
Chest Clearance (Autogenic Drainage). NHS Tayside. Downloaded August 5/14 from
http://www.nhstayside.scot.nhs.uk/RMCN/patient_leaflets/Chest%20Clearance%20(Autogenic%20Drainage)(PIL).pdf
Living with CF. Downloaded August 5/14 from http://www.cfcareli.com/livingwithcf_acts_ad.php
The Active Cycle of Breathing Techniques. Association of Chartered Physiotherapists in Respiratory Care. Downloaded August
5/14 from http://www.acprc.org.uk/Data/Publication_Downloads/GL-05ACBT.pdf
32. References – Singing
Grasch, A., Boley, T.M., Colle, J., Henkle, J.Q., Todd, S.T & Hazelrigg, S.O. (2013-03-07 20:36:42 UTC)
Daily Singing Practice as a Means of Improving Pulmonary Function and Quality of Life in Emphysema
Patients. Cureus 5(3): e103. doi:10.7759/cureus.103
Irons, J.Y., Kenny, D.T. & Chang, A.B. (2011, April 13). The effects of singing for children and adults with
bronchiectasis. Cochrane Summaries online, downloaded August 15, 2014 from
http://summaries.cochrane.org/CD007729/AIRWAYS_the-effects-of-singing-for-children-and-adults-with-
bronchiectasis
Irons, J.Y., Petocz, P., Kenny, D.T. & Chang, A.B. (10 JUN 2014). Singing as an adjunct therapy for
children and adults with cystic fibrosis. Cochrane cystic Fibrosis and Genetic Disorders Group, The
Cochrane Library.
Lord , V.M., Hume, V.J., Kelly, J.L., Cave, P., Silver, J., Waldman, M., White, C., Smith, C., Tanner, R.,
Sanchez, M., Man, W.D-C., Polkey, M.I. & Hopkinson, N. (2012). Singing classes for chronic obstructive
pulmonary disease: a randomized controlled trial. BMC Pulmonary Medicine. 12(69): doi:10.1186/1471-
2466-23-69
33. Singing refs contd.
Lord, V.M., Cave, P., Hume, V.J., Flude, E.J., Evans, A., Kelly, J.L., Polkey, M.I. & Hopkinson, N.S. (2010).
Singing teaching as a therapy for chronic respiratory disease – a randomised controlled trail and qualitative
evaluation. BMC Pulmonary Medicine, 10(41). doi:10.1186/1471-2466-10-41
Morrison, I. & Clift, S. (2012). Singing and people with COPD. Singing, Wellbeing and Health: context,
evidence and practice. 2. Sidney De Haan Research Centre for Arts and Health, Canterbury Christ
Church University, Folkstone, Kent, UK
Skingley, A., Page, S., Clift. S., Morrison, I., Coulton, S., Treadwell, P., Vella-Burrows, T., Salisbury, I. &
Shipton, M. (2014). “Singing for Breathing”: Participants’ perceptions of a group singing programme for
people with COPD. Arts & Health: An International Journal for Research, Policy and Practice. 6(1), p. 59-
74. doi:10.1080/17533015.2013.840853
Editor's Notes
Lewis, Willams & Olds – Systematic Review & Meta-analysis of active cycle of breathing techniques – 24 studies, 10 comparators identified – most common – conventional chest physio, PEP and a control; sputum wet weight, FVC & FEV1; meta-analysis on sputum wet weight – increase in sputum wet weight during and up to 1 hr post ACBT
Osadnik, McDonald, Jones & Holland – 28 studies, 907 participants in review – small sample sizes, overall poor quality r/t inadequate blinding and allocation procedures. Looked at AECOPD, stable COPD; performing ACBTs during AECOPD reduced the likelihood of needing mechanical assistance to breathe, as well as length of time for which it was required. ACBTs during stable COPD did not appear to affect flare-ups or hospitalizations, but may provide some improvement in quality of life.
Lee, Burge & Holland – Cochrane review – Airway clearance techniques for bronchiectasis (Review) – 5 studies, 51 participants
Bottom line – more research, perhaps with a more substantial quality of life perspective.
- Can include those people with copious secretions daily, or those who produce more sputum with an exacerbation and during an AECOPD – Hill, Patman, Brooks – Effect of airway clearance techniques….
‘anywhere, any time’ still needs to be a comfortable, relaxed environment – and a reminder that the sounds associated with airway clearance aren’t as exciting to the general population as they are to us…
Larger lung volume increases airflow through peripheral airways and collateral ventilation channels, which increases the gas volume available to mobilize secretions during expiration.
Limited to avoid fatigue and hyperventilation.
Difficult for some people to do diaphragmatic breathing, r/t associated diaphragmatic flattening with disease process. Flexibility of diaphragm isn’t there.
Other modifications include post-op breathing, esp abdominal/thoracic surgery – have pt splint abdomen with a pillow and apply gentle pressure during manoeuvre.
For quadriplegic patients: clinician places palms on the patient’s abdomen, below the diaphragm, and instructs the pt to take 3 deep breaths. On exhale of the 3rd breath, the clinician pushes forcefully inward and upward as the patient coughs (similar to abdominal thrust for unconscious pt with an obstructed airway).
The huff should be active, but not violent or explosive.
May benefit patients with high volumes of mucus production, but without much airway hyperreactivity, atelectasis, or plugged airways – cycle of breathing control, thoracic expansion exercises, breathing control, FET, and then repeating back to breathing control, thoracic expansion exercises, and on and so on.
Bronchospastic patients – longer period of breathing control.
For people with airway plugging, atelectasis, and some reactive airway disease, additional breathing control and thoracic expansion exercises may provide greater benefit.
It’s an airway clearance technique characterized by breathing control, where the person adjusts the rate, depth, and location of respiration to clear chest secretions independently.
Aim of breathing is to achieve highest possible expiratory flow simultaneously in different generations of the bronchi, keeping bronchial resistance low, and avoiding bronchospasm and dynamic airway collapse.
Important to note, this technique requires a great deal of patient cooperation, and is recommended for patients >8yrs old who have a good sense of their own breathing, and can actively participate in the process. Very difficult clearance technique to master, but well worth the time and effort to learn.
Chevaillier suggested a ‘breath-stimulating’ position – ie where the client/patient is comfortable, and their breathing is not restricted.
‘unstick’ – instruct pt to breathe out as far as possible, and then to breathe the functional tidal volume in and out
‘collect’ – pt needs to change volumes at which they breathe – essentially collecting the secretions based on frequencies they hear when breathing – secretions in the peripheral airways vibrate at a high frequency, as opposed to more central secretions which have a reduced frequency. This requires some coaching, and intentional focus on pt’s part. Also requires substantial feedback to the patient – they need to learn how to control volume and flow ranges in their breath so they become attuned to auditory frequency changes (or turbulence) and can modulate their breathing accordingly.
Autogenic drainage is a learned art of finding the correct balance of forces. It requires intentional time and attention, but once learned, equips a person to manage their condition much more independently.
Quitting/cutting down smoking – a given. So many great resources out there – camh, STOP, smoker’s helpline
Diet & exercise. Patient-dependent diet – for the COPDers – ensuring some protein, etc.
Singing. Current research, esp in UK, is showing some benefits of singing, esp with people living with COPD – improvement in QOL, changes in physical breathing – using abdominal/thoracic muscles to breathe rather than shoulders. Instructed singing is important – regular singing OK, but choral singing, with an instructor better – social, breathing exercises, etc.
Research pool is still small, and some research shows insufficient evidence for clinical improvements, but there seems to be an underlying theme of some QOL improvements.
