What is Autogenic Drainage?

Autogenic Drainage (AD), is an airway clearance 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. [1]

It uses breathing at different lung volumes to loosen, mobilise and move secretions in thre e stages towards the
larger central airways. (fig.1)
It consists of three stages:(fig.2)

Stage 1 :- Unstick secretions - breathe as much air out of your chest as you can then take a small breath in, using
your abdominals, 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)

Stage 3:-Evacuate secretions - when the crackles are louder still, take long, slow, full breaths in to 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)
The velocity or force of the expiratory airflow must be adjusted at each level of inspiration so that the highest
possible airflow is reached in that generation of bronchi, without being high enough to cause the airways to collapse
during coughing. Autogenic drainage does not utilise Postural Drainage  positions but is performed while sitting
upright.

Rationale behind the Autogenic Drainage Technique

The rationale for the technique is the generation of shearing forces induced by airflow. The speed of the expiratory
flow may mobilise secretions by shearing them from the bronchial walls and transporting them from the peripheral
to the central airways.

Procedure :
Posture (Fig.3)
 Choose a breath-stimulating position like sitting or reclining. Relax, with the neck slightly extended.

1. Clear your nose and throat by blowing your nose and huffing.
Breathing in
2. Slowly breathe in through the nose to keep the upper airways open. Use the diaphragm and/or the abdomen if
possible.
3. 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. See picture below. The size of breath and level at which you breathe depends on where the mucus
is located.
4. 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.
Breathing out
5. 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.
6. At low lung level breathing use your abdominal muscles. Squeeze all the air out until you can breathe out no
more.
7. 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.
8. Repeat the cycle. Inhale slowly to avoid sending the mucus back down. Keep breathing at the low level until
the mucus collects and moves upward. Signs of this are:
 Crackling of the mucus can be heard as you exhale.
 You feel the mucus moving up.
 You feel a strong urge to cough.
9. 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.
10. 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.
11. 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. Do sessions of AD more often if you still have
mucus present at the end of a session.

Benefits of AD
 No equipment is required
 Patients can perform their airway clearance independently
 Less effort is be required to expectorate which reduces stress on the pelvic floor

Disadvantages of AD
 Patients generally need to be over 8 years old
 The technique can be difficult to teach
 Patients need the cognitive ability to understand the basic physiology behind the technique
 To benefit from the auditory feedback, patients need to have a moderate or large amount of sputum

Evidence:
Published studies of autogenic drainage are limited with the majority of trials being in the cystic fibrosis (CF) cohort.
The physiological rationale lends support for the use of AD in non-CF bronchiectasis.

In a long term study of patients with CF comparing AD with postural drainage and percussion, the patients
expressed a marked preference for AD (Davidson et al 1992).

In a comparison with ACBT, postural drainage and manual techniques, AD was found to be equally effective in
improving lung function in patients with COPD with copious secretions (Savci 2000).

Greater expectoration was achieved with AD compared to PEP therapy (Lindemann 1990).

The long term effects of AD on quality of life and lung function, compared to other airway clearance techniques, was
similar (Pryor 2010).
 There are no studies evaluating assisted AD (AAD) in the bronchiectasis population group. In the Cystic fibrosis
population, studies have found no provocation of GOR has been associated with AAD, bouncing or the combination
of both (Van Ginderdeuren 2001, 2003).

Active cycle of breathing technique

Introduction
The Active Cycle of Breathing Techniques (ACBT) is an active breathing technique performed by the patient to help
clear sputum out of the lungs. It is a group of techniques which uses breathing exercises to achieve the following:

1. Loosen and clear secretions from the lungs.

2. Improve ventilation in the lungs.
3. Improve the effectiveness of a cough [1][2].

ACBT consists of three main phases:

1. Breathing Control
2. Deep Breathing Exercises or Thoracic Expansion Exercises
3. Huffing or Forced Expiratory Technique (FET) [3]

Additionally, a manual technique (MT) or positive pressure can be added if and when indicated, to create a more
complex cycle to help improve removal of secretions on the lungs.
 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 [4]. Encouraging the patient to close their eyes while performing breathing
control can also be beneficial in helping to promote relaxation. It is very important to use breathing control in
between the more active exercises of ACBT as it allows for relaxation of the airways [5].

Breathing Control can also help when one is experiencing shortness of breath, fear, anxiety or is in a panic. The
length of time spent performing breathing control may vary depending on how breathless the patient feels.

When using this technique with a patient as part of the ACBT, the patient may be instructed to usually 6 breaths.

Instructions to patient:

1. Breathe in and out gently through your nose if you can. If you cannot, breathe through your mouth instead.
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  [5][6].

Deep Breathing Exercises or Thoracic Expansion Exercises

Deep breathing/thoracic expansion exercises are deep breathing exercises which focus on inspiration [6] and help to
loosen secretions on the lungs [7]. 
 Instructions to patient:

1. Try to keep your chest and shoulders relaxed.

2. Take a long, slow, deep breath in, through your nose if you can.
3. 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)
4. Breathe out gently and relaxed, like a sigh. Don’t force the air out.
5. 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 [4][8].

To facilitate a maximal inspiration, proprioceptive feedback, with the therapist, or patient, placing their hands on
the thoracic cage, can be beneficial. This has been associated with increased chest wall movement and improved
ventilation [6].

Huffing or Forced Expiratory Technique

This is a manoeuvre used to move secretions, mobilised by deep breathing/thoracic expansion exercises,
downstream towards the mouth [6]. A huff is exhaling through an open mouth and throat instead of coughing. Huffing
helps moves sputum from the small airways to the larger airways, from where they are removed by coughing [4] as
coughing alone can not remove sputum from small airways [5].

There are two types of huff:

Medium Volume Huff

This helps to move secretions that are lower down in your airways.
Take a normal sized breath in and then an active, long breath out until your lungs feel quite empty. Imagine you are
trying to steam up a mirror.

High Volume Huff

This helps to move secretions in your upper airways.

Take a deep breath in, open your mouth wide and huff out quickly.

Only perform 1-2 huffs together, as repeatedly huffing can make your chest tight.

Listen for crackles when you huff, If you can hear these, you may now need to cough and clear secretions; try to spit
them out into a tissue or a sputum bowl. Try to avoid excessive coughing as this may reduce how effective the
technique is and make it excessively tiring.

Repeat the whole cycle for about 10 minutes or until chest feels clearer [7] .

Small long huffs move sputum from low down into chest whereas big short huffs moves sputum from higher up into
chest, so use this huff when it feels ready to come out, but not before; huffs work via dynamic compression [5].
Coughing

Coughing should be incorporated if huffing alone does not clear your sputum. However if it does clear your sputum,
then you may need to cough [8].

It is very important to avoid long bouts of coughing as these can be very tiring and may make you feel breathless, or
make your throat or chest sore or tight. You should only cough if the sputum can be cleared easily, if not return, to
the beginning of the cycle [2].
 Indications
 Post surgical /pain (rib fracture/ICC).
 Chronic increased sputum production e.g in Chronic bronchitis, cystic fibrosis [9].
 Acute increase sputum production.
 Poor expansion.
 Sputum Retention.
 SOBAR/SOBOE.
 Cystic Fibrosis.
 Bronchiectasis.
 Atelectasis.
 Respiratory muscle weakness.
 Mechanical ventilation.
 Asthma.

Precaution
It is important to constantly assess for dizziness or increased shortness of breath throughout ACBT. If a patient feels
dizzy during deep breathing, decrease the number of deep breaths taken during each cycle and return to breathing
control to reduce dizziness [10].

Positioning
ACBT can be performed in sitting or in a postural drainage position. Initially you could start in a sitting position
until you are comfortable and confident to try different ones. Extensive evidence supports its effectiveness in sitting
or gravity assisted positions [5][6][7]. Although, the best position for you to do the ACBT in will depend on your medical
condition and how well it works for you. When in sitting, maintain a good breathing pattern with relaxed shoulders
and neck. Whatever position you use make sure you are comfortable, well supported and relaxed.

The ACBT may be performed with or without an assistant providing vibration, percussion and shaking. Self
percussion/compression may be included by the patient [6][8].

Duration and Frequency

Duration for ACBT should be for about 10 minutes and ideally until your chest feels clear of sputum.

You may need to do ACBT only once or twice a day when you are well. When you have more sputum, you may need
to do it more often. When you are unwell or have more sputum, you may need to do shorter and/ or more frequent
sessions[5][7].

Percussion
Introduction
Chest Percussion is one of the intervention for airway clearance which augments the mobilization of secretions in
one or more lung segments to the central airways by placing the patient in various positions so gravity assists in the
drainage process.Gravity-assisted positioning will facilitate he clearance of secretions in patients with abnormalities
of the cilia.

Percussion can be performed in two ways-

1. Manual Percussion
2. Mechanical Percussion [1]

Technique
 Patient should be in a comfortable or painless position.
 Chest percussion is performed with cupped hands which strike's the patient chest wall in an alternating
rhythmic manner over the lung segments being drained.
 Therapist should try to keep shoulders, elbows and wrist loose and mobile during the maneuver.
 Duration: Several minutes or until the patient needs to alter the position to cough [1]

Positions for Chest Percussion:

Source: Moncy01 Author: Moncy01 Permission: This file is licensed under the  Creative Commons  Attribution-Share Alike 4.0 International  license.
 LOBE OF LUNG SEGMENTS OF LUNG PATIENT'S POSITION AREA OF P

UPPER LOBE Anterior apical segments Sitting with back supported Percussion is applied directly under the clav
(Right & Left)
Posterior apical segments Sitting with head down on a table Percussion is applied above the scapulae. Fi
shoulders.

Anterior segments Supine Percussion is applied bilaterally, directly ov

Posterior segment (left) Patient lies one-quarter turn from prone and rests on the Percussion is applied directly over the left sc
right side. Head and shoulders are elevated 45 degrees or approximately 18 inches, if pillows are
used.

Posterior segment (right) Patient lies flat and one-quarter turn from prone on the left Percussion is applied directly over the right
side.

LINGULA Patient lies one-quarter turn from supine on the right side, Percussion is applied just under the left brea
(left) supported with pillows and in a 30 degrees head-down position.

MIDDLE LOBE Patient lies one-quarter turn from supine on the left side, Percussion is applied under the right breast.
(right) supported with pillows behind the back and in a 30 degrees head-down position.

LOWER LOBE Anterior segments Patient lies supine, pillows under the knees, in a 45 degrees head-down position. Percussion is applied bilaterally over the low
(Right & Left)
Posterior segments Patient lies prone with a pillow under the abdomen in a 45� Percussion is applied bilaterally over the low
head-down position

Lateral segments Patient lies on the right side in a 45 degrees head-down position. Percussion is applied over the lower lateral a
(left)

Lateral segments Patient lies on the left side in a 45 degrees head-down position. Percussion is applied over the lower lateral a
(right)

Superior segments Patient lies prone with a pillow under the abdomen to flatten the Percussion is applied bilaterally, directly bel
back.
Guidelines

(Manual respiratory techniques guidelines for practice 2015)[2]

ACTION RATIONALE

Prepare the patient by giving a clear explanation of the treatment Minimises distress and informs the patient of the procedure

Obtain consent from the patient Confirms the patient is willing to take the treatment

Auscultate the patient's chest To ensure no bronchospasm is present prior to the treatment and to assess
which area(s) of the lung(s) is/are to be treated

Check the patient's skin integrity over the area of the rib cage to be treated and take care to avoid To ensure skin is intact and no areas of skin are damaged
performing manual techniques over a portacath and lines and drains

Check the patient's SpO2 level To ensure desaturation is detected if it occurs during the treatment

Position the patient to optimise secretion clearance. This may include modified postural drainage Tilting or side lying the patient may use gravity to assist the mobilization
positions. of secretions

When performing chest percussion a towel may be placed over the area to be treated. However, The technique should not be performed on bare skin as this may be
avoid to much padding uncomfortable for the patient,but to much padding may reduce the
effectivness of the technique

Perform chest percussion rhythmically with a loose wrist and a cupped hand over the lung area that This creates an energy wave that is transmitted to the lung parenchyma to
is to be treated loosen secreations

A slow single handed technique or a rapid double handed technique can be used Depending on patients preference. A slow single handed technique may be
more suitable if the patient is at risk of bronchospasm

Observe the patient to ensure they are not holding their breathe Breathe holding may cause oxygen desaturation
 Encourage the patient to perform three to four thoracic expansion during chest percussion This can prevent desaturation

If the patient is prone to desaturation, monitor the patients' oxygen saturations and respiratory rate To ensure the patient remains stable during the treatment.
throughout the procedure. Supplementary oxygen may be required during treatment

To perform shaking and vibrations the hands are placed over the area where secretions are to be Chest compression assists the mobilisation of secretions from peripheral to
mobilized from and oscillations directed inwards against the chest in the direction of bucket handle more central airways
rib movement

The height of the bed should be adjusted to allow the therapist to use their body weight to assist To augment expiratory flow and mobilise secretions. The therapist must be
with the vibratory/compression action aware of their own posture to protect heir back.

Encourage the patient to take a deep inhalation and perform the technique on their exhalation To encourage movement of secretions during expiratory flow

Encourage the patient to relax their breathing in between the technique To prevent airway closure, desaturation or bronchospasm

Use forced expiratory technique or coughing to assist the patient to expectorate Allows secretions that have mobilized to central airways to be expelled

Document the physiotherapy treatment and its outcome in the patients medical notes To provide a legal record of the treatment and to communicate it;s outcome
with other health care professionals.

Indications
 Patients with pulmonary disease that are associated with increased production or viscosity of mucus, such as
chronic bronchitis and cystic fibrosis.
 Patients who are on prolonged bed rest.
 Patients who have received general anesthesia and who have painful incisions that restrict deep breathing and
coughing postoperatively.
 Any patient who is on ventilator if he or she is stable enough to tolerate the treatment.
 Patients with acute or chronic lung disease, e.g. COPD.
 Patients who are generally weak or elderly.
 Patients with artificial airways. [1]
 Contraindications
 Over fractures, spinal fusion, or osteoporotic bone.
 Over tumor area.
 If a patient has a pulmonary embolous.
 If a patient has a condition in which hemorrhage could easily occur.
 If the patient has an unstable angina.
 If the patient has a chest wall pain.
 In recent neurosurgery head down position is contraindicated. [1]

Key Evidence
1. Chest percussions has been shown to cause an increase in hypoaxemia, but when short periods of percussions
(<30 sec) have been combined with three or four thoracic expansion exercises, no fall in oxygen saturation has been
seen.
2. Some patients with severe lung disease demonstrate oxygen desaturation with self chest percussion. This may
b due to the work of the additional upper limb activity.
3. in patients with neuro-muscular weakness or paralysis and in those who are intellectually impaired, in
addition to in infants and in small children, percussion technique (manual and mechanical) may be a useful airway
clearance technique which stimulates cough possibly by mobilization of secretions. [3]