RESEARCH PROPOSAL

Immediate Effects of Active Cycle of Breathing Techniques vs. Autogenic Drainage for Airway
Clearance in Subjects with Bronchiectasis A Randomized Cross Over Study

MPT (CARDIO RESPIRATORY DISORDERS)

MS. SMRITI

DEPARTMENT OF PHYSIOTHERAPY

FR. MULLER MEDICAL COLLEGE

MANGALORE-575002

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 Rajiv Gandhi University of Health Science, Karnataka, Bangalore

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the Candidate SMRITI

and DEPT. OF PHYSIOTHERAPY

Address FATHER MULLER MEDICAL COLLEGE

(in block letter) KANKANADY,

MANGALORE-575002

2. Name of the Institution FATHER MULLER MEDICAL COLLEGE

3. Course of the study and subject MASTER OF PHYSIOTHERAPY

(CARDIO RESPIRATORY DISORDERS)

4. Date of admission to Course 30.07.2011

5. Title of the Topic

Immediate Effects of Active Cycle of Breathing Techniques vs. Autogenic

Drainage for airway clearance in subjects with Bronchiectasis a randomized
cross over study

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6. BRIEF RESUME OF THE INTENDED WORK

6.1 Need of the study

Bronchiectasis is defined as an abnormal destruction and dilatation of large
airways. The characteristic features of this disease are repeated pulmonary infections
requiring antibiotics, inability to expectorate productive cough, shortness of breath and
occasional haemoptysis.1 Impaired clearance of sputum results in a vicious cycle of
colonization and infection of bronchi with pathogenic organisms, dilation of bronchi
and further production of sputum. There is increased production of mucus in
Bronchiectasis with impaired mucociliary system. This gives rise to mucus
accumulation, chronic cough, airway obstruction and bacterial infection.2
Improper airway clearance will lead to atelectasis, infection, increased airway
resistance, increased work of breathing and ultimately hypoxemia and tissue
hypoxaemia.3 Since Airway clearance is an important component of the management
of patients with Bronchiectasis. Chest physiotherapy is being considered as an integral
part of Bronchiectasis management which aims to clear the airways so that the
pulmonary functions will be improved. The conventional chest physiotherapy for
airway clearance includes postural drainage with vibration, clapping, percussion and
breathing exercises. Various new airway clearance techniques are Autogenic drainage,
ACBT, Positive Expiratory Pressure, high pressure PEP, Flutter and Acapella.4
Active cycle of breathing technique is a form of airway clearance that improves
lung function without decreasing oxygenation. ACBT is used to mobilize and clear
excess bronchial secretions. The components of the ACBT are breathing control,
thoracic expansion exercises, and the forced expiratory technique. ACBT can be used
with/without an assistant.5 It was first documented by Thompson and Thompson in
1968.
Autogenic drainage was developed in 1967 by Chevaillier in Belgium and has
been modified by the Germans. This is to attain the highest possible expiratory flows
to move secretions from peripheral to central airways, without forced expirations and
associated airway closure. Autogenic drainage uses controlled breathing to maximize

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expiratory flow with minimal airway closure, starting with the small airways and
moving secretions from smaller to larger airways in 3 phases: unsticking, collection,
and evacuation. The patient moves mucus with a relaxed sighing exhalation,
regulating airflow and velocity with use of expiratory muscles, avoiding unnecessary
expiratory resistance. Optimal level of airflow is achieved without forcing the
expiration.6
There is little research done to study the effects of Autogenic drainage in
comparison with other airway clearance techniques and none comparing it with ACBT
in Bronchiectasis.

Operational Definitions

ACBT is a cycle of techniques of breathing control (tidal breathing at the
patient's own rate and depth, encouraging use of the lower chest with
relaxation of the upper chest and shoulders), thoracic expansion exercises
(deep breathing exercises emphasizing inspiration with or without a breath
hold; expiration is quiet and relaxed) and the forced expiration technique (one
or two huffs combined with periods of breathing control.7

Autogenic drainage is breathing at different lung volumes and expiration is
used to move the mucus. The aim is to maximize expiratory flow. Breathing at
low lung volumes, in the individual patient, is used to mobilize (unstuck) more
peripherally situated mucus. Breathing around the individual's tidal volume is
said to collect mucus in the middle range, and, with breathing around high lung
volumes expectoration of secretions (evacuated) from the central airways is
promoted. When sufficient mucus has reached the upper airways, it may be
cleared by a cough.8

Conventional chest physical therapy(PT) is an airway clearance technique
that combines manual percussion of the chest wall by a therapist, strategic
positioning of the patient for mucus drainage, and cough and breathing
techniques (diaphragmatic breathing).9

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Research Question
Which of the two techniques (ACBT or Autogenic Drainage) is more effective for
airway clearance in subjects with Bronchiectasis?
Null hypothesis
Active Cycle of Breathing Techniques has same immediate effect as Autogenic
Drainage for airway clearance in subjects with Bronchiectasis.
Hypothesis
Active Cycle of Breathing Techniques has better immediate effect as Autogenic
Drainage for airway clearance in subjects with Bronchiectasis.

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6.2 Review of Literature
Currie et al. in their study on Impaired tracheobronchial clearance in
Bronchiectasis concluded that all the patients with Bronchiectasis expectorated
purulent sputum daily, had reduced FEV 1 and were unable to avoid coughing during
the six hour observation period. The study was done in thirty- seven subjects who were
non- smokers and measurements were done for PFT and weight of sputum.10
Mortensen J and colleagues in their study found that Positive Expiratory Pressure
(PEP) or Postural Drainage (PD) measured under similar circumstances in the study
were equally effective. The study recruited ten subjects. Measurements of PFT and
weight of the sputum. The total or overall benefits of these physiotherapy techniques
on lung clearance is not found because of a statistically significant increase in numbers
of productive coughs during and after PEP and PD for the first 30 minutes compared
with the control experiment and radio aerosol techniques are preferable to simple
indices such as weight of sputum expectorated.11
Another study was conducted on Airway Clearance in Bronchiectasis comparing
ACBT and Acapella which concluded that Acapella is as effective a method of airway
clearance as ACBT and may offer a user-friendly alternative to ACBT for patients with
Bronchiectasis. Twenty patients were included for the study and they measured
spirometry, Spo2, breathlessness before and after treatment. They also recorded weight
of the sputum, number of coughs and patient preference. Majority of patients preferred
Acapella technique for airway clearance.12
In another crossover study done to compare ACBT and conventional chest physical
therapy on airway clearance in Bronchiectasis, the conclusion was ACBT in
therapeutic positions is found to be equally effective as conventional chest physical
therapy on airway clearance in patients with Bronchiectasis. 35 patients were recruited
in the study and measurement of PFT, weight and volume of sputum, patient
preference was done. Patients rated ACBT as more comfortable than conventional
therapy, and hence can be used as preferred modality for airway clearance in
Bronchiectasis patients.9
Thompson C S and colleagues in their study on comparison of Flutter and ACBT
in seventeen patients concluded that daily use of the Flutter device in the home is as

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effective as ACBT in patients with non-cystic fibrosis Bronchiectasis and has a high
level of patient acceptability. The outcome measures taken were weight of sputum,
PEFR and breathlessness on Borg scale. Health status (Chronic Respiratory Disease
Questionnaire) and ventilator function did not change significantly during either
treatment period. There was no significant change in peak expiratory flow rate or in
breathlessness (Borg score) after individual physiotherapy sessions with either
technique.13
Miller S and colleagues in their study on Cystic Fibrosis explained that autogenic
drainage cleared mucus from the lungs faster than ACBT over the whole day and more
patients had an improved forced expiratory flow from 25% to 75% with autogenic
drainage while more showed improved forced vital capacity with ACBT. The study
was done on 18 patients with cystic fibrosis and the outcome measures were sputum
weight, PFT, Spo2, patient preference and heart rate.14
Savci et al. in their study found that Autogenic drainage is as effective as the
ACBT in cleaning secretions and improving lung functions. The study was done on
thirty patients for twenty days. The effects of long-term treatment was assessed using
PFT, 6- minute walk test, arterial blood gases and dyspnoea perception.15

6.3 Objective of the study

To find the immediate effect of Active Cycle of Breathing Techniques on
airway clearance in patients with Bronchiectasis.

To find the immediate effect of Autogenic Drainage on airway clearance in

patients with Bronchiectasis.

To compare the effects of ACBT and autogenic drainage (AD) for airway
clearance in patients with Bronchiectasis.

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7. MATERIAL AND METHODS

7.1 Source of data

Subjects admitted in Father Muller Medical College Hospital, diagnosed with

Bronchiectasis will be recruited for the study with physicians consent.

7.2 Method of data collection including sampling procedure :

Study Design:

Randomized cross over trial

Sample Procedure:

The patients who are diagnosed with Bronchiectasis and referred to physiotherapy and
fulfill the inclusion criteria will be included in the study. Written informed consent will
be obtained from the subjects.
Sample Size, Methodology:
26 subjects will be selected based on inclusion and exclusion criteria based on
purposive sampling technique. The sample size was calculated based on the
previous studies and power analysis was done. Routine respiratory assessment will
be done for all the subjects. All the subjects will receive ACBT and Autogenic
drainage treatment. The sequence of Autogenic drainage and ACBT will be
randomized. The outcome measures SpO2, breathlessness, PFT, respiratory rate,
heart rate will be measured before the treatment. On 1st and 2nd day, all the subjects
will receive either ACBT or Autogenic drainage and measurement of all outcome
measures along with weight of the sputum will be taken. All the medication and
routine treatment will not be altered on both the days. At the end of the 2nd day,
patient preference will be asked by the patient in their local language. All the
subjects will be given conventional chest physiotherapy. SpO 2 will be monitored
throughout the treatment session. Comparison of the outcome measures will be done
to find the effects of both the airway clearance techniques in Bronchiectasis.

Measurement of weight of Comparison Measurement of weight of

Outcomes measures
sputum, SpO2, & tools :
HR, RR, sputum, SpO2, HR, RR,
breathlessness, PFT 8 breathlessness, PFT
8. LIST OF REFERENCES
1. Barker A. Medical progress Bronchiectasis. N Engl J Med 2002; 346:1383
1393.
2. King P T, Daviskas E. Pathogenesis and diagnosis of Bronchiectasis. Breathe
2010; 6: 342-351.
3. David E.L, Cough. Physical therapy: 1967; 48: 439-447
4. Hill S. L., Webber B. Physiotherapy for airway clearance in adults. Chest
Physiotherapy Eur Respir J.1999;14: 1418-1424
5. Jeffrey S, Wagener MD, Aree A, Headley RRT. Cystic Fibrosis: Current Trends
in Respiratory Care. Respir Care 2003;48(3):234-245
6. Fink J B, Forced Expiratory Technique, Directed Cough, and Autogenic
Drainage. Respiratory Care 2007;52(9): 1210-1221
7. Pryor J A, Prasad S A. Physiotherapy for Respiratory and Cardiac Problem,
Adult and Pediatrics. Edinburgh: Churchill Livingstone: 2002. 161-242
8. Schoni M H. Autogenic drainage: a modern approach to Physiotherapy in
Cystic Fibrosis. J Royal Soc Med. 1989; 82(suppl 16): 32-37
9. Syed N, Maiya A G. & T. Siva Kumar. ACBT versus conventional chest
physical therapy on airway clearance in Bronchiectasis -A crossover trial.
Advances in Physiotherapy. 2009; 11: 193-198
10. Currie D C, Pavia D, Agnew J E, Lopez- Vidriero M T, Diamond P D, Cole P J,
Clarke S W. Impaired tracheobronchial clearance in Bronchiectasis. Thorax
1987; 42: 126-130
11. Mortensen J, Falk M, Groth C, Jensen C. The effects of postural drainage and
positive expiratory pressure physiotherapy on tracheobronchial clearance in
cystic fibrosis. Chest 1991; 100: 1350-1357
12. Patterson J.E, Bradley J.M, Hewitt O, Bradbury I, Elborn J S. Airway
Clearance in Bronchiectasis: A Randomized Crossover Trial of Active Cycle of
Subjects with Bronchiectasis taken
forversus
Breathing Techniques study(n=26), written
Acapella. consent2005;72:239-242
Respiration
signed by all subjects . Measurement
13. Thompson C S, Harrison S, Ashley J, Day K, Smith D L. Randomized
of SpO2,HR,RR,breathlessness (early
morningdevice
crossover study of the Flutter session)
and the active cycle of breathing
technique in non- cystic fibrosis Bronchiectasis. Thorax 2002; 57: 446-448

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DAY 1 DAY 2
 ACBT or AD ACBT or AD

+ Conventional Chest PT + Conventional Chest PT

9. SIGNATURE OF CANDIDATE

10. REMARK OF THE GUIDE

11. NAME AND DESIGNATION OF MR. NARASIMMAN SWAMINATHAN

11.1 GUIDE PROFESSOR

DEPT OF PHYSIOTHERAPY

11.2 SIGNATURE

11.3 NAME OF THE HEAD OF MR. NARASIMMAN SWAMINATHAN

THE DEPARTMENT
PROFESSOR

11.4 SIGNATURE

12. 12.1 REMARKS OF THE

CHAIRMAN & PRINCIPAL

12.2 SIGNATURE

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 INFORMED CONSENT

Ms. Smriti Date-

M.P.T. (Cardio Respiratory Including Intensive Care)

Father Muller Medical College,

Mangalore-575002

You are requested to be a part of this research study, which is a part of

the curriculum for the course of M.P.T. run by the Rajiv Gandhi University of Health
Science. The purpose of the study is to compare the immediate effects of Active Cycle
of Breathing Techniques vs. Autogenic Drainage for airway clearance in patients with
Bronchiectasis.

On entering in this study you will be tested for measurements of SpO2,

breathlessness, HR and RR. Following the measurements, you will be made to perform
a specific airway clearance technique either active cycle of breathing techniques or
autogenic drainage on 1st and 2nd day. After each of the techniques, weight of the
sputum will be taken and measured. These procedures will not cause any harm to
you. Permission for this study has been acquired from the hospital authorities.

We will clarify any of your queries regarding the study. Your Identity
will remain confidential. You are free to leave this study at any time.

You are requested to sign this consent form.

I, ________________________________________________ voluntarily agree to

participate in this research study. I am fully aware of the procedure that will be carried
out.

Signature of the patient

(This form will be translated in to kannada before the commencement of this

study)

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 DATA COLLECTION FORM

Identification no: Ward/BED No:

Age: Sex:

Weight: Consent- Y/N

Referred by:

Occupation:

Present history:

Past history:

Smoking history:

Allergic history:

Drug History:

Surgical history:

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 DAY 1 DAY 2

TYPE OF TREATMENT

Outcome measures Before After Before After treatment

treatment treatment treatment

Weight of sputum

SpO2

Breathlessness

FEV1

PEFR

Respiratory rate

Heart rate

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