Autogenic Drainage

Introduction
Autogenic drainage is a respiratory self-drainage technique that utilises
controlled experitory airflow (tidal breathing) to mobilise secretions. It consists of
three phases:
Loosening peripheral secretions by breathing at low lung volumes (slow, deep air
movement)
Collecting secretions from central airways by breathing at low to middle lung
volumes (slow, mid-range air movement)
Expelling secretions from the central airways by breathing at mid to high lung
volumes (shallow air movements)
The velocity or force of the expiratory airflow must be adjusted at each level of
inspiration so that the highest possible airflow is reached in that generation of
bronchi, without being high enough to cause the airways to collapse during
coughing. Autogenic drainage does not utilise Postural Drainage positions but is
performed while sitting upright.
Instruction
Posture:
Choose a breath-stimulating position like sitting or reclining. Relax, with the neck
slightly extended.
Clear your nose and throat by blowing your nose and huffing.
Breathing in
Slowly breathe in through the nose to keep the upper airways open. Use the
diaphragm and/or the abdomen if possible.
First take a large breath in, hold it for a moment. Breathe all the way out for as
long as you can. Now you are at low lung volume. See picture below. The size of
breath and level at which you breathe depends on where the mucus is located.
Take a small to normal breath in, and pause. Hold your breath for about 3
seconds. All the upper airways should be kept open. This improves the even
filling of all lung parts. The pause allows time for the air to get behind the mucus.
Breathing out
Breathe out through the mouth. Keep the upper airways open. This is your glottis,
throat and mouth. Breathing out is done in a sighing manner. When you force
your breath out the airways can collapse. You will hear a wheeze.
At low lung level breathing use your abdominal muscles. Squeeze all the air out
until you can breathe out no more.
You hear the mucus rattling in the airways when breathing the right way. Put a
hand on your upper chest, and feel the mucus vibrating. High frequencies mean
that the mucus is in the small airways. Low frequencies mean that the mucus is
in the large airways. Using this feedback lets you easily adjust the technique.

Repeat the cycle. Inhale slowly to avoid sending the mucus back down. Keep
breathing at the low level until the mucus collects and moves upward. Signs of
this are:
Crackling of the mucus can be heard as you exhale.
You feel the mucus moving up.
You feel a strong urge to cough.
The level of breathing is raised when any of the above occurs. Refer to the
picture below. Moving the breathing from lower to higher lung area takes the
mucus with it.
Finally the collected mucus reaches the large airways where it can be cleared by
a high lung volume huff. Don't cough until the mucus is in the larger airways.
Cough only if a huff did not move the mucus to the mouth.
You have now finished one cycle. Take a break of one to two minutes. Relax and
perform breathing control before you start on the next cycle. The cycles are
repeated during the session. A session lasts between twenty to forty-five minutes
or until you feel all the mucus has been cleared. Do sessions of AD more often if
you still have mucus present at the end of a session.
ACBT
Introduction
The Active Cycle of Breathing Techniques (ACBT) is an active breathing technique
performed by the patient to help clear their sputum the lungs.The ACBT is a
group of techniques which use breathing exercises to improves the effectiveness
of cough, loosen and clear secretions and improve ventilation.[1]
ACBT consists of three main phases:[2]

Breathing Control
Deep Breathing Exercises or thoracic expansion exercises
Huffing OR Forced Expiratory Technique (F.E.T)

Additionally, a manual technique (MT) or positive pressure can be added if and

when indicated, to create a more complex cycle to help improve removal of
secretions on the lungs. .
Breathing Control
Breathing control is used to relax the airways and relieve the symptoms of
wheezing and tighness which normally occur after coughing or breathlesness[3].
Breathing should be performed gently through the nose using as little effort as
possible. If this is not possible then breathing should be done by mouth. If it is
necessary to breath out through the mouth this should be done with pursed lips
breathing. While performing this technique it is important to encourage the
patient use it as an opportunity to reduce any tension they may have,
Encouraging the patient to close their eyes while performing Breath Control can
also be beneficial in helping to promote relaxation. It is very important to use
Breathing Control in between the more active exercises of ACBT as it allows for

relaxation of the airways[4]. Breathing Control can also help you when you are
short of breath or feeling fearful, anxious or in a panic. The length of time spent
performing Breathing Control will vary depending on how breathless patient feels.
When using this technique with a patient as part of the ACBT the patient should
be instructed to usually 6 breaths. Instructions to patient: Rest one hand on your
stomach and keep your shoulders relaxed to drop down. Feel your stomach rise
as you breathe in and fall when you breathe out.
Deep Breathing Exercises
Deep breathing is used to get air behind the sputum stuck in small airways:[4]
Relax your upper chest.
Breathe in slowly and deeply.
Breathe out gently until your lungs are empty dont force the air out.
Repeat 3 4 times, if the patient feels light headed then it is important that they
revert back to the Breathing Control portion of the cycle.
At the end of the breath in, hold the air in your lungs for 3 seconds (this is known
as an inspiratory hold).[3]
Deep breathing/thoracic expansion exercises recruit the collateral ventilatory
system assisting, the movement of air distal to mucus plugs in the peripheral
airways.[5]
Deep breaths to utilise collateral channels and get air behind sputum to mobilise
it towards larger airways and towards the mouth. Instructions to patient:
Relax your shoulders.
Place both hands on either side of ribs.
Breathe in deeply feeling as your ribs expand.
Breathe out gently as far as you can until your lungs feel empty.
Deep breathing/thoracic expansion is usually repeated 4 times.
Huffing or FET
The FET is an integral part of the ACBT described by Pryor and Webber [6].
A huff is exhaling through an open mouth and throat instead of coughing.Huffing
moves sputum from the small airways to the larger airways, from where they are
removed by coughing[3]. Coughing alone does not remove sputum from small
airways.[4]
Take a small-medium sized breath in.
Squeeze the breath out by contracting your tummy muscles and keep your
mouth and throat open to perform a huff. This small-medium sized huff helps with
the removal of sputum in the lower reaches of the lungs.
To remove sputum in the higher portions of the lungs take a large breath in.
Squeeze the air out as before to perform a huff.

Cough and expectorate any sputum. If no sputum is produced with 1 or 2 coughs,

try to stop coughing by encouraging the patient to use Breathing Control, the
main technique used in between the more active stages of the as ACBT.
Allow your breathing to settle with breathing control and then repeat the cycle
until your chest feels clear.
Small long huffs move sputum from low down into chest whereas big short huffs
moves sputum from higher up into chest, so use this huff when it feels ready to
come out, but not before; huffs work via dynamic compression.[4]
Instructions to patient:
Take a medium sized breath in.
Squeeze the breath out fairly hard and fast keeping mouth and throat open.
Imagine trying to steam up a mirror or blow a tissue held out in front of you.
Attempt to clear sputum 2-3 times then return to breathing control (Phase one) to
relax airways.
Repeat as above except for a larger breath in to remove secretions/sputum in
other areas of the lungs.
Clinical Presentation
It is important to constantly assess for dizzyness or increased shortness of breath
throughout ACBT. If patient feels dizzy during deep breathing decrease the
number of deep breaths taken during each cycle and return to normal breathing
to reduce dizzyness.[8]
Procedure
ACBT can be performed in sitting, lying or side-lying positions. Initially you should
start in a sitting position until you are comfortable and confident to try different
ones.Extensive evidence supports its effectiveness in sitting or gravity assisted
positions. A minimum of ten minutes in each productive position is
recommended. The ACBT may be performed with or without an assistant
providing vibration, percussion and shaking. Self percussion/compression may be
included by the patient.
Pursed lips breathing
How to do pursed lip breathing:
1. Breath in (inhale) slowly through your nose for 2 counts.
2. Feel your belly get larger as you breathe in.
3. Pucker your lips, as if you were going to whistle or blow out a candle.
4. Breathe out (exhale) slowly through your lips for 4 or more counts.
Exhale normally. Do not force air out. Do not hold your breath when you are doing
pursed lip breathing. Repeat these steps until your breathing slows.

Glossopharyngeal Breathing
To breathe in, a series of pumping strokes is produced by action of the lips,
tongue, soft palate, pharynx and larynx. Air is held in the chest by the larynx
which acts as a valve as the mouth is opened for the next gulp. Before starting to
teach a patient glossopharyngeal breathing it is helpful for him to inflate his
chest using an intermittent positive pressure ventilator with a mouthpiece. He
can practice holding the breath while removing the mouthpiece and avoiding
escape of air through the larynx or nose. The most important step in learning GPB
is the up and down movement of the cricoid cartilage while keeping the jaw still.
The patient can practice by watching the movement in a mirror and feeling the
cartilage with his fingers.
When this movement has been achieved a cycle of three steps is practised:
1. The mouth and pharynx are filled with air by depressing the cricoid cartilage
and tongue
2. While maintaining this position the lips are closed, trapping the air
3. The floor of the mouth and cricoid cartilage are allowed to rise to their normal
position while air is pumped through the larynx into the trachea
This sequence should be practised slowly at first and then gradually speeded up
until the movement flows. A leak of air may occur through the nose and, until it is
prevented by the soft palate, a nose dip may be required.
The next stage is to take a maximum breath in and, while holding this breath, to
add several glossopharyngeal gulps, to augment the vital capacity. When correct,
the patient will feel his chest filling with air, and the physiotherapist can test the
'GPB vital capacity' by putting a mouthpiece attached to the expiratory limb of a
Wright's respirometer in the patient's mouth before he exhales.
The respirometer can be used to measure the volume per gulp; the patient will
require less effort and reach his maximum capacity more quickly if he develops a
bigger volume per gulp. A study by Kelleher & Parida (1957) reported a group of
patients in whom the average volume per gulp varied from 25-120 ml, and when
teaching GPB an attempt should be made to achieve at least 60 ml per gulp.
When used for clearance of secretions, 10-20 gulps may be required to obtain a
maximal vital capacity, but if GPB is being used continuously as a substitute for
normal tidal breathing approximately 6-8 gulps may be taken before breathing
out.
Glossopharyngeal breathing would normally be taught with the patient in a
comfortable sitting position, but when mastered should be practiced in positions
useful for the patient to clear his bronchial secretions. After filling his chest to
capacity he signals to the physiotherapist who compresses his chest as he lets

the air out The patient may have sufficient muscle power to apply compression
himself or carers can be taught to give assistance.