Thorax 1995;50:165-169 165 Chest physiotherapy in cystic fibrosis: a comparative study of autogenic drainage and the active cycle of breathing techniques with postural drainage 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. Mucus 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.