The document discusses various airway clearance techniques including active cycle of breathing techniques (ACBT), autogenic drainage, percussion, and vibration/shaking. ACBT uses breathing control, deep breathing exercises, and huffing to loosen and clear secretions from the lungs. Autogenic drainage uses different breathing patterns at low, middle, and high lung volumes to mobilize mucus. Percussion and vibration techniques involve manual chest compressions timed with breathing to enhance mucus clearance. These techniques aim to improve lung ventilation, cough effectiveness, and clear secretions from the airways.

1. ACBT
AUTOGENIC DRAINAGE
PERCUSSION
VIBRATION & SHAKING
By – Bimal Maurya
Galgotias University

2. ACBT stands for Active Cycle of Breathing Techniques.
ACBT is a set of breathing exercises that loosens and moves
the sputum from your airways. It is a flexible method of
treatment that can be used in conjunction with positioning
and adapted for use with most patients.
ACBT is used to:
Loosen and clear secretions from the lungs.
Improve ventilation in the lungs.
Improve the effectiveness of a cough.
ACBT

3. ACBT consists of three main phases:
1.Breathing Control
2.Deep Breathing Exercises or Thoracic Expansion Exercises
3.Huffing or Forced Expiratory Technique (FET)

4. Breathing Control
Breathing control is used to relax the airways and relieve the symptoms of wheezing
and tightness which normally occur after coughing or breathlessness.
The patient to close their eyes while performing breathing control can also be
beneficial in helping to promote relaxation.
Breathing Control can also help when one is experiencing shortness of breath, fear,
signs of bronchospasm, anxiety or is in a panic.
When using this technique with a patient as part of the ACBT, the patient may be
instructed to usually take 6 breaths.

5. Instructions to patient:
1. Breathe in and out gently through your nose if you can. If you cannot, breathe through
your mouth instead(patient breathe according to his own rate).
2. If you breathe out through your mouth, it's best to use breathing control with ‘pursed
lips breathing’.
3. Try to let go of any tension in your body with each breath out and keep your shoulders
relaxed.
4. Gradually try to make the breaths slower.
5. Try closing your eyes to help you to focus on your breathing and to relax.
6. Breathing control should continue until the person feels ready to progress to the other
stages in the cycle.

6. Deep Breathing Exercises
Deep breathing/thoracic expansion exercises are the breathing exercises that
focus on inspiration and help to loosen secretions on the lungs.
Instructions to patient:
 Try to keep your chest and shoulders relaxed.
 Take a long, slow and deep breath in, through your nose if you can.
 At the end of the breath in, hold the air in your lungs for 2-3 seconds
before breathing out (this is known as an inspiratory hold)
 Breathe out gently and relaxed, like a sigh. Don’t force the air out.
 Repeat 3 – 5 times. If the patient feels light-headed then it is important
that they revert back to the breathing control phase of the cycle.

7. Huffing or huff coughing
Also called forced expiration technique, huff cough at different,
controlled lengths to move mucus up to the larger airways.
This huffing should be repeated until all mucus has been
huffed out of the lungs.

9. Autogenic Drainage
What is AD?
Autogenic Drainage (AD), is an airway clearance technique that is characterised by
breathing control, where the individual aims to adjust the rate, depth, and location of
lung volumes during respiration.
It uses breathing at different lung volumes to loosen, mobilize, and move secretions in
three stages towards the larger central airways.

10. Stages
It consists of three stages:
Stage 1
Unstick secretions - breathe as much air out of your chest as you can then take a small
breath in, using your tummy, feeling your breath at the bottom of your chest. You may
hear secretions start to crackle. Resist any desire to cough.
Loosening peripheral secretions by breathing at low lung volumes (slow, deep air
movement)
Repeat for at least 3 breaths.
Stage 2
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.
Collecting secretions from central airways by breathing at low to middle lung volumes
(slow, mid-range air movement)

11. Stage 3
Evacuate secretions - when the crackles are louder still, take long, slow, full breaths
into your absolute maximum.
Repeat for at least 3 breaths.
Expelling secretions from the central airways by breathing at mid to high lung volumes
(shallow air movements)

12. Procedure
Sit in a well-supported position with a neutral lumbar spine and the neck and
shoulders relaxed.
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. 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.

13. 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, breath using 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 a low level until the mucus collects and moves upward. Signs of this
are:
The crackling of the mucus can be heard as you exhale.
You feel the mucus moving up.
You feel a strong urge to cough.

14. 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

15. Percussion
Percussion is a manual technique used by respiratory physiotherapists to
improve airway clearance by mobilizing secretions in one or more lung
segments to the central airways. Percussion over an affected area
produces an energy wave, which is transmitted to the lungs and airways.
Percussion can be performed in two ways-
1.Manual Percussion
2.Mechanical Percussion

16. Equipments required for percussion
•The equipment required here is cupped hand of caregiver to deliver the force required to
drain the thick or the retained secretions, thin towel and a drainage table.
•Padded rubber nipples, pediatric anesthesia masks, padded medicine cups or bell
end of stethoscope may be used to provide percussion to infants.
•Electric or pneumatic percussors of different models are available in variable
intensities and frequencies for adults and older pediatric population which can stimulate
percussion mechanically. This enables patient to apply self-percussion more effectively.

17. Technique and treatment with Percussion
 Position the hand in cup. It is must that the position should be maintained this way
till the end of the treatment.
 The sound heard must be hollow and not of a slap. If erythema occurs, it is result of
slapping or not trapping enough air between the hands and the chest wall.
 Rate of percussion, 100-480 times/min.
 The force applied must be equal. The rate should be slowed down if the force of
non dominant and dominant hand doesn't match.
 Hand position should be such that the percussion is avoided on bony prominence
like spine of scapula, clavicle, spinous processes of vertebrae.
 Percussion must be avoided on floating ribs as they have single attachment . Patient
may be taught to self percuss with one hand over the areas which are reachable.

18. Vibrations
Vibration to the chest wall is the manual application of fine oscillatory
movements, of high frequency, with chest compression timed with
expiration.
While vibration is being administered, the patient is instructed to take
slow deep breaths (thoracic expansion exercises) to enhance the effect of
airflow on the movement of secretions .
The physiotherapist, or family member, places their hands on the
patients’ chest, either one hand on top of the other, or side by side,
depending on the size of the chest wall.
As the patient breathes out, a rapid oscillatory movement is applied in
the direction of the normal movement of the ribs and is transmitted
through the chest using body weight.

19. INDICATIONS
 Cystic Fibrosis
 Bronchitis
 Emphysema
 Pneumonia
 Asthma
 Pulmonary Edema
 Occupational Lung Disease

20. Contraindications
 Hemoptysis
 Tension Pneumothorax
 Open wounds or burn in thoracic area
 Pulmonary embolism
 Subcutaneous emphysema