method of removal of secretions from the lungs. patient need to learn an art of keeping their lungs free from secretions in chronic respiratory disorders like COPD, Asthma, Bronchiectasis, Cystic fibrosis.

1. Autogenic Drainage
Dr. Vinod Ravaliya, MPT (Cardiothoracic)
KMPIP, Shree Krishna Hospital
Karamsad

2. Who developed it?
" Self drainage" developed in Belgium in the late
1960's by Chevaillier (asthmatic patients). During
1980's utilized throughout Europe to treat patients
with retention of secretions.

3. What is AD?
 Autogenic Drainage, or ‘AD’, is a breathing
technique that uses controlled breathing and
minimal coughing to clear secretions from your
chest. It involves hearing and feeling your
secretions as you breathe out and controlling the
desire to cough until secretions are high up and
easily reached with minimal effort.

4. How to Perform it?
 Begin with some gentle relaxed breaths known as
breathing control.
 Take a very slow deep breath in through your nose, to
your absolute maximum possible.
 Pause at the end of the full breath with your mouth
slightly open and count for 3-4 seconds. Start by sitting in
a comfortable upright position.
 Breathe out through your mouth. This should be active
(you can feel your tummy muscles tighten) but should not
be forced.
 You should listen and feel for secretions crackling as you
breath out Are the crackles at the beginning, middle or end
of your breath out? Beginning = high up in large tubes of
your chest
Middle = in the middle sized tubes
End = in the small tubes

5. 3 Phases of AD Technique
 UNSTICK SECRETIONS - breathe as much air out of your
chest as you can then take a small breath in, using you
tummy, feeling your breath at the bottom of your chest.
You may hear secretions start to crackle. Resist any desire
to cough.
Repeat for at least 3 breaths.
 COLLECT SECRETIONS - as the crackle of secretions
starts to get louder change to medium sized breaths in.
Feel the breaths more in the middle of your chest.
Repeat for at least 3 breaths.
 EVACUATE SECRETIONS - when the crackles are louder
still, take long, slow, full breaths in to your absolute
maximum.
Repeat for at least 3 breaths.

6. Fig. Phases of Autogenic Drainage

7.  Level One: "Unsticking" of mucus by low lung
level breathing. First, exhale completely; inhale a
small to normal breath. Hold the breath for 1-3
seconds, then exhale completely again. This step
is repeated for 1-3 minutes. Repeat until crackles
are heard when breathing out.

8.  Level Two: "Collecting" the mucus in larger or
mid-sized airways. Take in a slightly larger
breath. Hold for 1-3 seconds, and then
exhale, but not as low as in level one. Repeat
this step for 1-3 minutes. Listen for crackles at
the end of exhaling. Continue for 2-3 more
breaths. Then proceed to level III.

9.  Level Three: "Evacuating" the mucus in the
central airways is achieved by breathing at
normal to high volumes. Take in a slow deep
breath. Hold the breath for 1-3 seconds. Exhale
forcefully with open glottis. This moves the
mucus into your mouth. Then spit it out into a
container or tissue.

10. Each level requires about 2-3 minutes. The full
cycle takes 6-9 minutes. When mucus is felt in
the larger, central airways, do 2-3 effective "Huff"
type coughs. The Huff cough uses the mid to
high lung volumes of level III.

11. What not to do?
 Try to stop yourself from coughing until the
last phase of AD when the secretions are
higher up, and are more ready to be coughed
up.
 Try to relax with breathing control if you feel the
desire to cough or between cycles. AD breaths
are very gentle so you should not start to feel
tight or wheezy. AD should be done until your
sputum is cleared, or you need a rest.

14. Flutter
Dr.Vinod K Ravaliya, MPT
(Cardiothoracic)
KMPIP, Shree Krishna Hospital
Karamsad

15. Flutter
 Developed in Switzerland, early 1990's.
 The patient exhales into the device against a resistance
(5-20cmH2O) generated by a ball covering the opening
of an enclosed upward and widening cone. The
movement of the ball during expiration creates an
oscillating frequency between 8-26Hz

16. Theoretical Physiology
 Incorporates- positive expiratory pressure
(adjusted by flow rate)
- oral high frequency oscillation (angle of
device)
- active breathing exercises.
 Oscillating positive pressure prevents early
airway collapse. The rhythmic variation of airway
diameter and airflow promotes mucus
mobilization. Oscillation approximates the cilia
'beat' frequency of 12Hz.

17. Application
 Instructions say practice 2-3 times daily for 3-10
minutes. Take a deep breath with a 2-3 second
hold then exhale fully adjusting the angle and
flowrate to attain optimal vibration. Perform 5-15
then increase the depth of breath and speed of
exhalation to precipitate cough and mucus
expectoration.
 The Flutter can be incorporated into the ACBT
during the thoracic expansion phase, but is
difficult to combine with postural drainage.
Appears to be less effective than postural
drainage and manual techniques in large sputum
producers.

18. Indications
 Retained secretions (particularly if sticky)
 Patients seeking freedom from postural drainage
and assistance who prefer the upright posture for
treatment, or where postural drainage and/or
manual techniques are contra indicated.
 Good for children, stimulates cough.

19. Precautions
 Similar to those for PEP- untreated
pneumothorax, severe haemoptysis, facial
fractures/surgery, sinusitis or ear problems. Some
clients report early uncontrolled coughing
particularly in the presence of hyper-reactive
airways

20. Thanks