Airway Clearance

Techniques In Chronic Lung

DiseaseA Refresher

Audrey Wall, RN, BScN, CRECindy Erikson, BSc., RN October, 2014

ConflictsNo professional conflicts to declare.

Is chocolate really a vegetable?

OutlineBenefitsActive Cycle of BreathingAutogenic DrainageDevicesExercise & Lifestyle considerations

ObjectivesOverview of airway clearance techniquesPracticePractical look at available PEP/OPEP devicesDiscussion

The ResearchACBT 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)

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

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

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

Active Cycle of Breathing Technique (ACBT)

Combinations of breathing control, thoracic expansion control, and FETBreathing control – default relaxed breathing between manoeuvre efforts

Shoulders relaxed, gentle breathing with lower chestAbdomen should move slightly

Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1210- 1223

ACBTs contd.Thoracic expansion – larger-than-normal breaths, followed by relaxed exhale

Typically limited to 3-4 deep breaths

Forced Expiratory Technique (FET)

First described by Thompson & Thompson in 1968Combination of manoeuvres described as a ‘milking action’

Directed CoughForced Huff Exhalation

Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1210- 1223

Directed CoughStandard procedure

Deep breathHold, using abdominal muscles to force air against a closed glottisCough with single exertionSeveral relaxed breaths before next effort

Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1210- 1223

‘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 secondsExhale 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 secretionsRepeat 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

ACBT - A

Breathing Control

Thoracic Expansion Exercises

Breathing Control

HuffForced

Expir

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Tech

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Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1216, Fig. 6.

ACBT - BBreathing

Control

Thoracic Expansion Exercises

Breathing control

Huff

Huff

Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1216, Fig. 6.

Forc

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ACBT - CBreathing Control

Thoracic Expansion Exercises

Breathing Control

Thoracic Expansion Exercises

Breathing Control

Huff

Breathing Control

Fink, J.B. (2007). Forced Expiratory Technique, Directed Cough and Autogenic Drainage. Respiratory Care, 52(9), p. 1216, Fig 6.

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Autogenic DrainageDescribed by Jean Chevaillier in 1967Deeper than normal breath, and exhale in a gentle but active wayPreparation & PositionInspirationExpirationDescribed as ‘unstick, collect & evacuate’

Agostini, P. & Knowles, N. (2007) Autogenic drainage: the technique, physiological basis and evidence. Physiotherapy, 93, p. 157-163.

Preparation & PositionClear upper airways, ie, nose & throat – huffing or coughingTake prescribed nebulizers or inhalersFind comfortable, unrestricted position

InspirationPerformed slowly, through the noseHeld for 2-4 secondsUp to twice the size of normal tidal breath

ExpirationActive, silent sighAt least as long as inspiration, but exhaling a little longer helps to achieve low lung volume stageUrge to cough should be suppressed until secretions are high enough to expectorate successfullyUtilize controlled cough or huff for expectoration

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.

COLLECT

EVACUATE

UNSTICK

Devices

Flutter

Acapella

Aerobika

Quake

“Which alternative to recommend depends on the ability, motivation, preference, needs and resources of

each patient.”

Pryor, et. Al (2010), p. 191.

Lifestyle Considerations

http://o2maxfitness.com/9-things-need-know-strength-training/

http://www.yorktraditionalacupuncture.co.uk/Stop-Smoking-York-Acupuncture

http://chasingamiracle.com/2013/01/singing-a-song-2/

ReferencesAgostini, 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.

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

References contd. Osadnik, C.R., McDonald, C.F., Jones, A.P., Holland, A.E. (2012, 14 Mar). Airway clearance techniques for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, DOI: 10.1002/14651858.CD008328.pub2

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.

References – pt. guidesAutogenic 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

References – SingingGrasch, 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

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