Thorax 1995;50:165-169 165 Chest physiotherapy in : a comparative study of autogenic drainage and the active cycle of techniques with

S Miller, D 0 Hall, C B Clayton, R Nelson

Abstract with percussion. Thompson and Thompson in Background - Autogenic drainage has 1968 developed the forced expiration technique been suggested as an alternative method to improve the efficiency of secretion removal.6 of chest physiotherapy in patients with Pryor et al explained the mechanism of this cystic fibrosis. In this study autogenic technique using Mead's concept of the equal drainage was compared with the active pressure point78 and studied this method com- cycle of breathing techniques (ACBT) to- bined with postural drainage in patients with gether with postural drainage. cystic fibrosis.9 Since the early 1980s most Methods - Eighteen patients with cystic cystic fibrosis centres in Britain have taught this fibrosis took part in a randomised two-day form ofhome management for chest clearance. crossover trial. There were two sessions of The name of the method has recently been one method ofphysiotherapy on each day, changed to the active cycle of breathing tech- either autogenic drainage or ACBT. The niques (ACBT). study days were one week apart. On each In recent years new methods of chest clear- day the patients were monitored for six ance have been developed,'0 among which are hours. movement was quantified positive expiratory pressure mask therapy by a radioaerosol technique. Airway clear- (PEP)," high pressure PEP,'2 and autogenic ance was studied qualitatively using drainage.'3 xenon-133 scintigraphic studies at the start Autogenic drainage was developed by and end ofeach day. Expectorated sputum Chevaillier in Belgium. This technique aims to was collected during and for one hour after reach the highest possible airflow in the differ- each session ofphysiotherapy. Pulmonary ent generations of bronchi to move secretions functions tests were performed before and and does not involve any forced expiration. after each session. Oxygen saturation There has been little research into the effects (Sao,) and heart rate were measured be- ofautogenic drainage in comparision with other fore, during, and after each session. methods,'1'7 and none comparing it with Results - Autogenic drainage cleared ACBT. mucus from the lungs faster than ACBT In chest physiotherapy it has become clear over the whole day. Both methods im- that judging a method by the amount ofsputum proved ventilation, as assessed by the expectorated is not always correct. Mucus xenon-133 ventilation studies. No overall clearance of radiolabelled aerosol gives a pic- differences were found in the pulmonary ture of where mucus is in the lungs, if it is function test results, but more patients had moving from a particular area, and whether an improved forced expiratory flow from there is any effect on the more peripheral air- 25% to 75% with autogenic drainage, while ways. Scintigraphic studies have shown that Physiotherapy more showed an improved forced vital ca- mucus may be swallowed during and after Department pacity with ACBT. No differences were treatment as it is visible in the stomach, sug- S Miller found in sputum weight and heart rate, gesting that measurement of the amount of Medical Physics nor in mean Sao, over the series, but four sputum expectorated can be misleading.'8-20 It Department patients desaturated during ACBT. was therefore decided to compare these two D 0 Hall Conclusions - Autogenic drainage was methods using lung scintigraphy. C B Clayton found to be as good as ACBT at clearing Paediatric mucus in patients with cystic fibrosis and Department is therefore an effective method of home Methods R Nelson physiotherapy. Patients with cystic fib- The study was carried out to determine whether Royal Victoria rosis should be assessed as to which autogenic drainage, a technique carried out at Infirmary, method suits them best. only 17% of centres in the UK, was as effective Newcastle upon Tyne (Thorax 1995;5O:165-169) in clearing lung mucus as ACBT, the standard NE1 4LP, UK method used at 96% of centres.'0 The study Reprint requests to: also looked for differences between the meth- Dr D 0 Hall. Keywords: cystic fibrosis, autogenic drainage, active ods, particularly in the clearance of central and Received 12 April 1994 cycle of breathing techniques, physiotherapy. Returned to authors peripheral airways. 18 May 1994 Revised version received Chest physiotherapy in the treatment of cystic 1 September 1994 Accepted for publication fibrosis is long established.' The conventional PATIENTS 8 November 1994 treatment for many years was postural drainage Eighteen patients (10 men) aged 11-32 years 166 Miller, Hall, Clayton, Nelson with cystic fibrosis were studied. Shwachman- lower chest (breathing control) for ap- Kulczycki scores,21 modified with the Chrispin- proximately six breaths, followed by 3-4 deep Norman score,22 were between 34 and 87. All inspirations offull capacity, then another period patients were clinically stable at the time of of breathing control. Finally, the patient per- the study and were not receiving intravenous formed one or two forced expirations (huffs) antibiotics. A lower age limit of 11 years was from mid to low lung volume. If secretions set because of the high degree of patient were felt to be high enough in the proximal cooperation necessary. Informed consent, as airways a huff was performed at a higher lung approved by the hospital ethics committee, volume. Patients were encouraged to cough was obtained from all patients. ARSAC and expectorate only ifthe secretions were high (Administration of Radioactive Substances enough. After the huffs and/or cough a further Advisory Committee) approval was also ob- period of gentle lower chest breathing control tained for the use of radioactive preparations. was performed, and the cycle repeated. Self- The patients were tested before the study for clapping was performed on a limited basis dur- reversibility to a bronchodilator. If there was a ing the deep inspiration phase. positive response patients received a nebulised On the day autogenic drainage was per- bronchodilator before each session of physio- formed the patient's position for the treatment therapy; if there was no response they received was sitting or supine. The posture, if sitting, nebulised saline. was upright with the neck slightly extended; if Each patient was studied over two days one lying it was flat with the arms away from the week apart to prevent any carry over effect. On body and the thorax unrestricted. each day the patient performed two sessions of The patient began by performing dia- physiotherapy- morning and afternoon. They phragmatic breathing at a low lung volume. were all fully trained in both methods, but all Inspiration was slow with a pause of three had used ACBT for many years before learning seconds, and expiration was done as a sigh with autogenic drainage. Patients were asked to be an open glottis and with as high a velocity as regular with their home physiotherapy in the possible but no forced expiration. During this week leading up to the trial and in the inter- low lung volume breathing, expiration was en- vening period. couraged down to the expiratory reserve vol- ume. When the patient felt secretions to be moving, the volume of inspiration became PHYSIOTHERAPY TECHNIQUES deeper and the expiration did not go down as Before physiotherapy the patients inhaled a far as the expiratory reserve volume. As the pretreatment nebuliser of salbutamol or saline, secretions moved up the bronchial tree to the depending on established reversibility studies. large airways the patient performed higher lung Volumes of 4 ml were nebulised (2 5 ml sal- volume breathing, tidal volume to inspiratory butamol and 1-5 ml saline, or 4 ml saline) in a reserve volume. Only when the secretions were Medicaid system 22 nebuliser with a mouth- felt to be as high as possible did expectoration piece powered by a Medicaid CR60 com- occur. The patients were taught to suppress pressor. This took approximately eight minutes. the cough to allow this. The cycle of breathing In accordance with established practice, on the exercises was repeated throughout the 30 min- day ACBT was performed the patients were ute morning and afternoon treatment sessions. asked to breath normally, while on the day autogenic drainage was performed they did autogenic drainage breathing exercises during MEASUREMENTS inhalation. A 30 minute treatment session then A xenon-133 gas ventilation study was carried followed. On each day there was a morning out at the start of the day. First breath, equi- and an afternoon session consisting of eight librium, and washout pictures were recorded minutes inhalation through the nebuliser and by a gamma camera (Siemens ZLC 7500) 30 minutes of chest clearance per session. For linked to a nuclear medicine computer system the purposes of the study we standardised the (Bartec System 3). These images were assessed postural drainage positions so that as much of by a radiologist experienced in both cystic fib- the lungs as possible would be treated on the rosis and scintigraphy to confirm that the pa- ACBT days for comparison with autogenic tient's condition was essentially the same on drainage which is a whole lung treatment. We both days, and to group the patients into mild, do not recommend that these same postural moderate, and severe disease according to the drainage positions should be adhered to as a pattern ofxenon distribution in the lungs. From rigid regimen for all patients. the tenth patient onwards the ventilation study On the day ACBT was performed, postural was repeated at the end of both days to look drainage was performed on a Chesham frame. for changes in lung ventilation due to the treat- In the morning session postural drainage po- ment.23 sitions were adopted to drain the posterior Pulmonary function tests were carried out lower lobes, anterior lower lobes, left lower using a spirometer (Vitalograph Alpha) which lobes, and right lower lobes, and in the after- was calibrated daily. Vital capacity (VC), forced noon the left middle lobe, right middle lobe, vital capacity (FVC), forced expiratory volume anterior upper lobe, and apical upper lobe. in one second (FEVy), peak expiratory flow Each position was held for seven and a half (PEF), and forced expiratory flow from 25- minutes. In each postural drainage position the 75% (FEF2,75) were recorded at the beginning ACBT was performed several times, com- of the day and before and after each session mencing with tidal volume breathing with the of chest clearance. Oxygen saturation levels Chest physiotherapy in cystic fibrosis 167

(Sao2) and heart rate were recorded during the methods over the study days. However, each treatment session using a Nellcor pulse four patients with moderate to severe disease oximeter, and resting levels were recorded be- desaturated during the morning ACBT session, fore and after. and one of these patients also desaturated in After the ventilation study, pulmonary func- the afternoon ACBT session. No patients tion tests, Sao2, and heart rate recordings had desaturated during any autogenic drainage been performed, the patient inhaled human session. serum albumin aerosol labelled with tech- netium-99m (Solco Venticoll supplied by Inc- star). A Medicaid System 22 Optimist nebuliser HEART RATE powered by a Medicaid CR60 air compressor The change in heart rate from the value meas- delivered the aerosol. The aerosol particles had ured just before treatment to the average value a mass median diameter of 0 9 ,um and a geo- during and immediately after treatment was metric standard deviation of 1-4 jm.24 calculated for each patient. The results were The patients inhaled the aerosol via a mouth- not clinically significant. piece while wearing a noseclip and sitting up- right. They were asked to breath normally and, approximately every 10 breaths, to breath in PATIENT PREFERENCE slowly and deeply and hold their breath for Nine patients preferred autogenic drainage, three seconds.25 The inhalation time was 20 eight preferred ACBT, and one patient had no minutes. At the start of each session a static preference. posterior image of the distribution of the radio- labelled aerosol in the lungs was acquired for 150 seconds on the gamma camera with the PULMONARY FUNCTION TESTS patient sitting. Dynamic images were taken Taken overall, pulmonary function tests during the physiotherapy. Further static pos- showed no significant difference between the terior images were recorded immediately after two methods. However, more patients had an the end of each session and about one hour improved FEF25,- on autogenic drainage than later (the exact time varied according to camera on ACBT, while the converse was true for FVC availability). (table 1). The static images were corrected for back- ground and radioactive decay, and regions of interest were drawn over the right and left lungs SPUTUM WEIGHTS to measure retained activity. The equilibrium Sputum was collected and weighed during and ventilation images were used to draw the lung for up to one hour after each physiotherapy outlines and to designate a central and peri- session. The average weight in one day was 23 pheral lung region. Using a single compartment (range 2-105) g. The mean (SE) difference model, clearance was assumed to be ex- between autogenic drainage and ACBT was ponential. A value of percentage change per not significant (-0 4 (1-8) g). No correlation hour was calculated for each region using a least was found with the results of radiolabelled squares fit to the log ofthe counts, corrected for aerosol clearance, in agreement with reports in radioactivity decay. The time of the first view the literature.'9 was taken to be time zero. For each patient the proportional difference between the rates of change on the two days was calculated. VENTILATION STUDIES Sputum was collected in a preweighed pot Using the intitial '33Xe ventilation study, lung during the nebuliser and treatment period. It condition was found to be mildly affected in was weighed immediately after treatment. Spu- six cases, moderately affected in seven, and tum was then collected for a further hour and severely affected in five patients. The as- weighed again. sessments did not change between study days. A visual analogue score to assess patient The last nine patients (three mild, three mod- preference between autogenic drainage and erate, and three severe) had repeat ventilation ACBT was performed at the end of the second studies performed at the end of the day. More day. Patients were also asked to give two reasons uniform or more widely distributed xenon gas for their preference. on first breath or increased washout rate were regarded as improvements. Examples of two pairs of first breath studies from the start and DATA ANALYSIS The study was analysed using the method out- lined by Hills and Armitage for a two period Table 1 Number of tests out of 36 (18 morning and 18 afternoon) which showed an improvement of >10%, crossover clinical trial.26 Carry over between >15%, and >20% for forced expiratory flow from 25% to the two study periods was tested for but found 75% (FEF25-75) and forced vital capacity (FVC) not to be significant. Differences between the Percentage two methods were tested using the paired t improvement FEF25-75 FVC test. Autogenic Autogenic ACBT drainage ACBT drainage >10% 10 17 17 15 Results >15% 8 11 11 10 OXYGEN SATURATION LEVELS >20% 7 9 8 4 There was no difference in mean Sao, between ACBT =active cycle of breathing techniques. 168 Miller, Hall, Clayton, Nelson not significantly different for the lung periphery. A Dividing the patients according to disease se- verity makes the number in each group very small and therefore impossible to analyse stat- istically. However, any differences are most apparent in the mild and moderate categories. The dynamic images were not used in the quantitative analysis. Inspection of these im- ages showed activity appearing in the stomach, but no major shifts of activity between regions of the lungs.

Discussion Some workers have found falls in Sao, due to B postural drainage and percussion in patients with cystic fibrosis.," while others have not found such a fall when breathing control rests are included.27 In our results falls in Sao2 were found during ACBT with postural drainage despite our inclusion of breathing control, but these did not show in the mean Sao2 results which may explain some of the disagreement in the literature. The patients who preferred autogenic drain- age to ACBT (nine of 18) tended to be those First breath studies from the start (left) and end (right) of the day. (A) Patient with moderate disease, showing improvement at the end of the day. (B) Patient with severe with better concentration who were generally disease, showing no improvement. more compliant with treatment. The con- centration needed to perform autogenic drain- end of the day are shown in the figure. Dark age is an important factor in deciding whether areas show the presence of xenon gas. The first to advise autogenic drainage as a method of patient (A) had moderate lung disease and choice. The time taken to learn autogenic showed improvement at the end of the day. drainage is much longer than the time needed The second patient (B) had severe lung disease to learn ACBT. In general, younger patients and showed no improvement. may lack the necessary concentration. All three of the moderate patients, and one Pulmonary function tests were performed each of the mild and severe patients, showed initially before the inhalation of radiolabelled improvements for both methods of physio- aerosol, and then after physiotherapy. It was therapy on first breath, while the other four noted that pulmonary function decreased by showed no improvement. On washout, six an excessive amount after the morning sessions cleared faster and three cleared slower on auto- in two of the first three patients. Therefore, genic drainage, while with ACBT four cleared from the fourth patient onwards the pulmonary three and two did not change. function tests were repeated after inhalation of faster, slower, the aerosol. This showed an adverse effect in a further seven patients, probably due to bronchoconstriction. This effect rapidly dis- CLEARANCE OF RADIOLABELLED AEROSOL The clearance rates and the proportional appeared but we felt that, where this occurred, pulmonary function tests after physiotherapy differences between the two methods over the been other- whole day are given, grouped according to lung were worse than they would have for wise. This should be noted for further research region for all patients and disease severity inhaled radiolabelled aerosols since there the whole lungs (table 2). Clearance rates were using faster with autogenic drainage than with ACBT may be an adverse effect on deposition. but Repeat ventilation studies showed two types for whole lung and central lung regions, of change. Improvements in first breath images showed areas of the lungs which had been Table 2 Average clearance rates for autogenic drainage and ACBT over the whole day cleared of mucus or where bronchoconstriction for all 18 patients grouped according to lung region, and for the whole lungs grouped decreased. new deficits showed to disease and proportional differences in rates had Conversely, according severity, either that mucus had moved into an area n Mean (SD) Mean (SD) Mean (SE) p was clearance clearance proportional of the lung or that bronchoconstriction rate with rate with difference affecting that area. The changes in washout ACBT AD rates indicated whether airflow and lung com- (%/hour) (%l/hour) pliance had got better or worse. Lung region De Cesare et al23 studied nine with Whole lung 18 3-2(1-4) 3-9(1-4) 0 22(0 09) <0 05 patients Central 18 2-9(1-3) 3-6(1-4) 0-25(0-10) <0 05 cystic fibrosis using krypton-81m ventilation Peripheral 18 4-7(2-0) 5 5(2-2) 0-19(0-12) NS to first breath Disease severity studies (equivalent 133Xe studies) Mild 6 2-7(1-2) 3 8(2 0) 0-35(0-19) NS and found no improvements in three patients Moderate 7 2-8(1-0) 3-3(0 3) 0-21(0-13) NS NS with mild disease, improvements in three Severe 5 4-3(1-5) 4-7(1-3) 0-10(0-23) patients with severe disease, and changes in- Proportional difference is expressed as (1/n)12(AD - ACBT)/(AD + ACBT), where AD and of treatment for three with ACBT are the rates of clearance for individual patients, and n is the number of patients in each dependent patients group. ACBT = active cycle of breathing techniques; AD = autogenic drainage. moderate disease. We cannot say whether the Chest physiotherapy in cystic fibrosis 169 into the future. New York: Stratton, 1976:3-24. changes found in our study were independent 4 Lorin MI, Denning CR. Evaluation of postural drainage by of treatment, although we were looking for measurement of sputum volume and consistency. Am J Phys Med 1971;50:215-9. definite improvements in regional ventilation 5 Maxwell M, Redmond A. Comparative trial of manual and rather than simply changes. The one patient in mechanical percussion techniques with gravity assisted bronchial drainage in patients with cystic fibrosis. Arch our study assessed as mild on first breath, and Dis Child 1979;54:542-4. who showed improvements, expectorated more 6 Thompson B, Thompson HT. Forced expiration exercises in and their effect on FEV,. NZJPhysiother 1968; than 50 g of mucus during each day. The im- 3:19-21. provement in the ventilation in this case was 7 PryorJA, Webber BA, Hodson ME, BattenJC. Evaluation of the forced expiration technique as an adjunct to postural increased uniformity of gas distribution rather drainage in the treatment of cystic fibrosis. BMJ 1979;2: than the clearance of blocked areas. 417-8. 8 Mead J, Turner JM, Macklem PT, Little JB. Significance The ventilation studies indicated that both of the relationship between lung recoil and maximum methods of physiotherapy are effective at clear- expiratory flow. Appl Physiol 1967;22:95-108. 9 PryorJA, Webber BA. An evaluation of the forced expiratory ing lung obstruction caused by mucus. technique as an adjunct to postural drainage. Physio- Aerosol deposition in severe disease is pre- therapy 1979;65:304-7. 10 Prasad SA. Current concepts in physiotherapy. JR Soc Med dominantly in the central airways, whereas for 1993;86(Suppl 20):23-9. mild disease there is better peripheral de- 11 Falk M, Kelstrup M, Anderson JB, Kinoshita T, Falk P, StovringS, et al. Improving the ketchup bottle method position. The information gained about clear- with positive expiratory pressure PEP in cystic fibrosis. ance is more reliable when deposition is good Eur3 _RespirDis 1984;65:423-32. 12 Oberwaldner B, Evans JC, Zach MS. Forced expirations than when it is poor. As a consequence, pro- against a variable resistance: a new chest physiotherapy portional differences in clearance are likely to method in cystic fibrosis. PediatrPulmonol 1986;2:358-67. 13 Schoni MH. Autogenic drainage: a modern approach to be more reliable for central lung regions, for physiotherapy in cystic fibrosis. J R Soc Med 1989; the whole lungs, and for patients with mild 82(Suppl 16):32-7. 14 Chevaillier J. Autogenic drainage (AD). In: Lawson D, ed. disease. Cystic fibrosis: horizons. Chichester: John Wiley, 1984:235. In conclusion, the results showed increased 15 McIlwaine M, Davidson AGF, Wong LTK, Pirie GE, Nak- ielna EM. Comparison of positive expiratory pressure rates of clearance of mucus on the days when and autogenic drainage with conventional percussion and autogenic drainage was performed. There was drainage therapy in the treatment of cystic fibrosis. Asia Pacific Congress Series, 10th International Cystic Fibrosis no overall difference in sputum weights. Both Congress, Sydney. Excerpta Medica, 1988:120. methods proved able to clear lung obstructions, 16 Mcllwaine PM, Wong LTK, Pirie GE, Davidson AGF. Long term comparative trial of conventional percussion shown by scintigraphic ventilation studies. Pul- and drainage versus autogenic drainage in cystic fibrosis. monary function tests showed no overall XIth International CF Congress Book of Abstracts, Dublin 1992:Allied Health Professionals No. 32 (abstract). difference between the methods, but showed 17 Pfleger A,Theissl B, Oberwaldner B, Zach MS. Self ad- that autogenic drainage improved FEV25 ministered chest physiotherapy in cystic fibrosis: a com- 15 parative study of high pressure PEP and autogenic more often than ACBT, while the converse was drainage. Lung 1992;170:323-30. true for FVC. The patients were found to 18 Rossman CM, Waldes R, Sampson D, Newhouse MT. Effect of chest physiotherapy on the removal of mucus have similar oxygen saturation levels for both in patients with cystic fibrosis. Am Rev Respir Dis 1982; methods, but the ACBT caused desaturation 126:131-5. 19 Mortensen J, Falk M, Groth S, Jensen C.The effects of in some cases. Heart rate changes were not postural drainage and positive expiratory pressure physio- clinically significant. Overall, patients liked therapy on tracheobronchial clearance in cystic fibrosis. Chest 1991;100:1350-7. both methods equally. 20 Isawa T, Teshima T, Hirano T, Ebina A, Motomiya M, Konno K. Lung clearance mechanisms in obstructive airways disease. J Nucl Med 1984;25:447-54. We are grateful to Dr R Lee, consultant radiologist, 21 Shwachman H, Kulczycki LL. Long-term study of one J Matthews, medical statistician, for their invaluable hundred and five patients with cystic fibrosis. Am J Dis

and help during this study. We would also like to Child 1968;96:6-15. clinical medical physics technologists, the physiotherapy 22 Chrispin AR, Norman AP.The systematic evaluation of the partment, and particularly the patients who participated, chest radiograph in cystic fibrosis. Pediatr Radiol 1974;2:

their time and energy. The Optimist nebulisers were 101-6. by MedicAid. 23 De Cesare JA, Babchyck BM, Colten HR, Treves S. Radio- nuclide assessment of the effects of chest on ventilation in cystic fibrosis. Phys Ther 1982;62:820-5. 24O'Doherty MJ, Miller RF. Aerosols for therapy and diag- nosis. EurJNucl Med 1993;20:1201- 13. 1 Cochrane GM, Webber BA, Clarke SW. Effects 25 Clarke SW, Pavia D. Aerosols and the lungs. London: But- on pulmonary function. BMJ 1977;2:1181. terworths, 1984:49-70. 2 Feldman J, Traver GA, Tuassig LM. Maximal 26 Hills M, Armitage P. The two-period cross-over clinical flows after postural drainage. Am Rev Respir Dis trial. Br J Clin Pharmacol 1979;8:7-20. 119:239-45. 27 Pryor JA, Webber BA, Hodson ME. Effects of chest physio-

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