International Journal of

Therapies and Rehabilitation Research [E-ISSN: 2278-0343]

http://www.scopemed.org/?jid=12
IJTRR 2015, 4: 5 I doi: 10.5455/ijtrr.000000105

Original Article Open Access

IMPACT OF ACTIVE CYCLE OF BREATHING TECHNIQUE ON FUNCTIONAL

CAPACITY IN PATIENT WITH BRONCHIECTASIS
Shereen Hamed Elsayed1, Walid Kamal Mohammed Abdel Basset2, 3, Karim Ahmed Fathy4
1
Department of Physical Therapy for Cardiovascular / Respiratory Disorder and Geriatrics, Faculty of Physical
Therapy, Cairo University, Egypt.
2
Department of Physical Therapy for Cardiovascular / Respiratory Disorder and Geriatrics, Cairo University
Hospitals, Cairo University, Egypt.
3
Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Prince Sattam
bin Abdul-Aziz University (Formerly Salman bin Abdul-Aziz University), Saudi Arabia.
4
Department of Physical Therapy for Cardiovascular / Respiratory Disorder and Geriatrics, October 6 University,
Egypt.
Corresponding Author:
Walid Kamal Mohammed Abdel Basset, PhD PT, Physical Therapy and Health Rehabilitation Department, College
of Applied Medical Sciences, Prince Sattam bin Abdul-Aziz University(Formerly Salman bin Abdul-Aziz University),
Alkharj, Saudi Arabia, e-mail: walidkamal.wr@gmail.com
Mobile: 00966561014872
Abstract
Back ground and Purpose: Bronchiectasis is associated with impairment of the mucociliary escalator and
retention of secretions within the bronchial tree, making airway clearance a primary concern in the
management of bronchiectasis.
Patients and methodology:
Objective: The objective of this study was to determine the effect of active cycle of breathing as an airway
clearance technique on functional capacity in adults with productive bronchiectasis by using six minute walk
test and dyspnea index.
Design: The study was cohort design carried out on 45 patients (mean age 54. 93± 3.82 years) of both genders
with stable productive bronchiectasis receiving multiple sessions (3 times/week for two months) of active
cycle of breathing.
Measurements: Pre and post treatment measures were recorded for functional capacity in form of six minute
walk test and dyspnea index.
Results: All 45 patients were stable during the study period. The functional capacity and level of dyspnea
were significantly improved post treatment sessions with mean difference 48.06 for six minute walk test and
29.2 for dyspnea index.
Conclusion: The active cycle of breathing technique is an effective method for airway clearance and
improving functional capacity in patients with bronchiectasis.
Key words: (Bronchiectasis, Active cycle of breathing, Functional Capacity, 6 Minute Walk Test, Dyspnea
Index).
Introduction clearance is a physical defense mechanism, which
Bronchiectasis is a disease with the protects the lungs from damage caused by inhaled
potential to cause devastating illness, including or endogenous pitiless within the airway.
repaired respiratory infections requiring antibiotics, Bronchiectasis, in concert with damage to cilia,
disabling productive cough, shortness of breath and leads to deterioration of the uncoiling explorer and
occasional Hemoptysis . [1] retention of secretions [2].
Bronchiectasis is allied with the impairment Until the late 1970s, physiotherapy for
of the mucociliary escalator and retention of airway clearance was mainly a passive treatment,
secretions within the bronchial tree, causing airway with the therapist prodding manual techniques of
percussion, vibration and shaking with the patient

Shereen H et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (5): 287-293
appropriately positioned However, the findings
related to hazards such as transmission hypoxia and
hemoptysis due to / case techniques, resultant poor
compliance and chronic cause of the disease,
necessitating its need for self-management and lead
to the development of alternative methods [3].
Various airway clearance techniques have
been used in the physiotherapy management of
patients with bronchiectasis. A recent summary
showed that the active cycle of breathing technique
in the UK, however, no studies have demonstrated
that this technique is more effective than any other
[4, 5]
. patients with productive bronchiectasis.
Airway clearance techniques are considered
as an integral component of management. Active
cycle of breathing technique is widely interceded
composing breathing control, thoracic expansion
exercise and forced expiratory technique [6].
The active cycles of breathing technique
consists of a cycle of huffs from mid to low lung
volume dispersed with deep breathing and replaced
abdominal breathing. The components include
breathing control for 10-15 sec., thoracic expansion
exercises (deep breathing exercises with emphasis
inspiratory hold for 3 sec before expiration) and
forced expiration (three huffs) in a set cycle [7].
COPD and bronchiectasis can lead to severe
disability as the disease advances. The six minute
walk rest is commonly used to measure functional
capacity in these patients and has three potential
outcomes; walking distance, oxygen destruction and
perceived exertion assessed by the Borg scale, all
reflecting different aspects of these diseases [8].
The six minute walk test is widely used to
assess change in functional exercise capacity
following a pulmonary rehabilitation with the
primary outcome reported being the distance
walked [9].
It's also a reliable and safe tool to assess the
functional status of patients suffering from chronic
cardiac and pulmonary diseases. It's also useful in
detecting the effectiveness of different forms of
treatment for these patients [10].
Typically this test is administered in an
enclosed indoor condor, free of distractions, and
patients are asked to cover as much distance as
they can in 6 minutes. This environment is
somewhat artificial and many not reflect activities
that individual usually do on a daily basis [11].
Dyspnea is the term generally applied to sensations
Shereen H et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (5): 287-293
experience of by individuals who complain of
unpleasant or uncomfortable, respiratory
sensations many definitions of dyspnea have been
offered, including difficult, labored Uncomfortable
breathing an ownerless of repository distress and as
uncomfortable sensation of breathing. These
definitions have sometimes mixed the true
symptom with physical signs [12].
Purpose of the Study:
The aim of this study is to determine the
effect of active cycle of breathing as an airway
clearance technique on functional capacity in
Subjects and Methodology:-
Subjects: Forty five volunteer patients of both
genders who suffered from productive
bronchiectasis with age ranged from 50-60 years
had participated in this study. Patients suffering
from musculoskeletal and cardiac problems were
excluded from this study. All patients were enrolled
in multiple active cycle of breathing technique (3
times/weak for 2 months) as an airway clearance
technique then we started to compare the pre- and
post- results of this technique on the functional
capacity of these patients by using the 6 minute
walk test and the dyspnea index questionnaire.
Methods
A) Evaluation procedures:
1- Six minute walk test:
The 6 minute walk test was conducted in a
temperature-controlled measured and marked
corridor (30 meters). The turnaround points were
marked with a come. A starting line, which marked
the beginning and end of each 30m, was marked on
the floor using bright by colored tape [13].
Reasons for immediately stopping a 6 MWT
include chest pain, intolerable dyspnea, leg cramps
and role appearance. If the test was stopped for any
of these reasons, the patient should sit or lie supine
as appropriate depending on the severity or the
event and the oxygen should be administrated as
apposite [14].
The patients sit on a chair at least 10
minutes before starting. During this time measure
oxy-hemoglobin saturation and heart rate by pulse
oxymeter. Patients was instructed to walk similar to
their maximal habitual walking form and to end at
their own place, attempting to cover as much
distance as possible within 6 min. During walking
the examiner recorded the time, distance walked,
contribution of tests and also monitored oxy-
hemoglobin saturation continuously by using the
pulse oxymeter. The test was stopped for safety
purposes if the rational oxygen saturation dropped
less than 86% [15].
2- Dyspnea Index Questionnaire:
The Patients were asked to do the activities
according the questionnaire before treatment and
offer it. The prognosis detected by increasing the
activity and the quality of doing for every patient.
The severity of shortness of breath
experienced during 21 different activities of daily
living associated with various levels of exertion and
to rote 3 questions about limitation in his daily life.
The patient was asked to estimate the degree of
shortness of breath anticipated for activities he did
not perform. The questionnaire is scored by
summing the responses across all 24 items to obtain
overall score. Scores ranged from 0 to 120.
B) Training:
Active cycle of breathing technique (ACBT)
Eaton et al., 2010[16] stated that active cycle
of breathing technique is used to mobilize and clear
excess pulmonary secretions from the lung
peripheries without increasing airflow obstruction.
It's a combination of thoracic expansion exercises
interspersed with breathing control followed by
expiratory technique with an open glottis combined
with periods of breathing control.
1- Chest expansions:
-Breath gently at normal rate and depth using the
lower chest (breathing control).
-Breath in slowly and deeply using the lower chest
then pause.
-Breath out fully but not forcefully.
-Repeat for a further two breaths.
-Return to breathing control.
-Take three further slow deep breaths.
-Return to breathing control.
2- Forced expiratory technique:
-Take a slightly bigger than normal breath in.
-Open your mouth and keep it O shaped.
-Breathe out more for cheerfully using your
abdominal muscles to assist. This should sound like
a forced sigh. This is described abseiling.
-Repeat for a further two breaths.
-Return to breathing control.
-Cough to clear sputum if necessary.
-Return to breathing control until you are ready to
begin another cycle.
Statistical Analysis:-
The data were collected from patients pre-
and post-treatment. Descriptive statistics was done
in the form of mean and standard deviation.
Inferential statistics assessed changes using
dependent t-test to assess changes within group,
analysis was done using SPSS version 17 and
Relatives changes percentage was calculated
according to:
post−pre
Relatives changes percentage = pre ×100
Results
(1) Six minute walk test distance:
Table and figure (1) demonstrated the 6
minute walk test distance pre and post treatment
procedures. There was a significant difference in the
dependent t-rest between pre and post treatment 6
minute walk test as the mean value of pre-
treatment was (82.26 ± 27.32) and for post-
treatment was (130.33 ± 43.85) where the t-value
was (7.54) and P-value was (0.0001). The
percentage of improvement was 58.42%

Table (1): Mean and ±SD, t and p-values of 6 minute walk test distance pre- and post- treatment.
Group 6 min walk test distance
Pre treatment Post treatment
Mean 82.26 130.33
± SD ± 27.32 ± 43.85
Mean difference 48.06
Percentage of improvement 58.42%
t-value 7.54
P-value 0.0001
S S
SD: Standard Deviation. P-Value: Probability value.
S: Significance. S: Significant.

Shereen H et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (5): 287-293
 150
130.33

100
82.26

50

0
Pre treatment Post treatment
Fig. (1): Mean and ±SD, t and p-values of 6 min walk test distance pre and post treatment.

(2) Dyspnea index:

Table and figure (2) demonstrated the Dyspnea index pre and post treatment. There was a significant
difference in the dependent t-test between pre- and post- treatment procedures. The mean value of pre-
treatment was (100.73± 14.91) and for post-treatment was (71.53± 15.58) where the t-value was (10.25) and p-
value was (0-0001). The percentage of improvement was 28.98%
Table (2): Mean and ±SD, t and p-values of Dyspnea index pre- and post- treatment.
Group Dyspnea index
Pre treatment Post treatment
Mean 100.73 71.53
± SD ± 14.91 ± 15.58
Mean difference 29.2
Percentage of improvement 28.98%
t-value 10.25
P-value 0.0001
S S
SD: Standard Deviation. P-Value: Probability value.
S: Significance. S: Significant.

120
100.73
100
80 71.53

60
40
20
0
Pre treatment Post treatment
Fig. (2): Mean and ±SD, t and p-values of Dyspnea index pre and post treatment.
Discussion The present study was designed to
Chronic obstructive pulmonary diseases and investigate the effect of active cycle of breathing
bronchiectasis are becoming an increasingly technique on functional capacity in patients with
important cause of morbidity and mortality bronchiectasis. This study assessed by applying 6
worldwide in those ever age of 45 years. The minute walk test and shortness of breath
sociologic impact of these diseases burden to questionnaire. Assessment ways measured pre- and
tremendous. There is strong evidence that post-treatment to direct progress.
occupational exposures and another key Forty five patients received treatment with
[17]
preventable risk factor . active cycle of breathing technique. They have been
taught 3 times / week for 2 successive months.

Shereen H et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (5): 287-293
Analysis of the results showed that there was a
significant improvement in 6 minute walk test and
with scoping in shortness of breath questionnaire.
Several studies agreed with results of the
current study. Kulkorni, 2012[18] compared the
effect of autogenic drainage and pursed lip
breathing versus active cycle of breathing in
hospitalized bronchitis patients. Pulmonary
functions (FEV1, FEV1/FVC) were assessed and
discussed using Medical Research council scale
before and after treatment sessions. The results
concluded that ACBT is better used Iran autogenic
Drainage and pursed lip breathing in bronchiectasis
patients and is easy adaptable by patients [18].
Paneeth et al., 2012[19] conducted a
randomized study for 30 patients with
bronchiectasis, is patients treated with active cycle
of breathing technique and the other is treated with
postural drainage. Pre and post evaluation were
done by FVC, FEV1, PEFR and SPO2 by using
pulmonary function test and pulse oxymeter. The
study concluded that both of postural drainage and
ACBT have significant effect in clearance of airways
and improving the pulmonary function in
bronchiectasis but ACBT has the better effect than
postural drainage in airway clearance, FVC, FEV1
and SPO2[19].
Nafeez, et al., 2009[7] compared the efficacy of
commonly used conventional treatment with ACBT
in bronchiectasis patients with varied etiology. The
techniques used are widely practiced in pulmonary
care of the patients and care proven safe and
effective. Isotonic has been well documented as the
most important risk factor in the development of
COPD and bronchiectasis. Prolonged smoking
causes the mucus hyper-secretion associated with
enlargement of the mucus-secreting tissue and
mucosal inflammation of the airways. The results of
result of this study are not in accordance to those of
Pryor & wetter, wherein ACBT has been shown to
be more effective than conventional cheers physical
therapy for the amount of sputum expectorated in
bronchiectasis patients [7].
In agreement with the present study, the
findings of Patterson et al., 2004[20] which
demonstrated that ACBT was a more effective
airway clearance technique than incremental
respiratory endurance. ACBT is an important factor
and component of the care package effaced to
patient with bronchiectasis. In this study more than
Shereen H et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (5): 287-293
half of the patients perceived that ACBT was a more
effective method of airway clearance [20].
Eaton et al., 2007[21] stated the first study to
systematically evaluate the acute acceptability and
tolerability as well as acute efficacy of airway
clearance techniques (Flutter and ACBT with and
without PD) in bronchiectasis. ACBT with PD was
superior to ACBT alone as measured by sputum
production. But ACBT was significantly more
comfort than ACBT with PD which causing greater
interference with daily life [21].
In contrast Janet et al., 2005[22]
demonstrated that A capella device is as effective
method of airway clearance as ACBT in patients with
bronchiectasis. Evidence for the use of ACBT in
bronchiectasis is limited and focuses on four
randomized controlled trials. A randomized
controlled trial compared the efficacy of mineral
controlled trial compared the efficacy of ACBT with
flutter in 17 patients for 4 weeks of each technique
in a crossover design. No significant differences
were found in daily significant differences were
found in daily sputum weight produced between
treatments [22].
However, in the study of Jamal et al.,
[23]
2007 subjects were demonstrated a significant in
provident in oxygen saturation in treatment with
autogenic drainage (AD) and active cycle of
breathing. The tendency towards Righter oxygen
saturation in treatment with autogenic drainage and
active cycle of breathing. The tendency towards
righter oxygen saturation was with AD than ACBT
and therefore, the difference found statistically
significant [23].
This was very much in accordance to finding
of Savci et al., 2000[24] who found that in AD
treatment. Increase in oxygen saturation might have
been the results of removal of remitted mucus plugs
from the airways, lead to improved alveolar
ventilation from the airways, lead to improved
alveolar ventilation optimized ventilation-perfusion
mismatch, and finally improved oxygen transport to
the tissue [25].
Robinson et al., 2012[26] compared the
clinical effectiveness of ACBT with other airway
clearance therapies including studies composed
ACBT to autogenic drainage, airway oscillating
devices, high frequency compression devices, and
conventional chest physiotherapy. There is
insufficient evidence to support or reject the use of
ACBT over any other airway clearance therapy. Four
studies, with four different comparators, found that
ACBT was comparable to other therapies in
outcomes such as patient preference, lung function,
sputum weight, oxygen saturating and member of
pulmonary exacerbations [26].
Conclusion:
Active cycle of breathing technique produce
significant and remarkable benefits on exercise
tolerance and functional capacity via 6 minute walk
test and scoring with shortness of breath
questionnaire in patients with bronchiectasis. It was
a very simple way to the patient and not expensive
in cost. It assisted in mobilizing secretions. The cycle
of breathing technique was liable and adapted to
needs of individual and helps in re-expansion of lung
tissue. Finally it was a way of relaxation due to the
effect of breathing exercises.
Conflict of Interests
Authors of this work declared that there is
no conflict of interests regarding the publication of
this paper.
References:-
1. Barker, A.; Medical progress bronchiectasis, N.
Eng. J. Med.2002; 346-1383-1393.
2. Hill, S.L.; Webber, B.; Mucus transport and
physiotherapy. Eur. Respire. J.1999, 13:949-50.
3. Sema, S., Inal, D.; Hulya, A.; Comparison of
Autogenic Drainage and Active Cycle of
Breathing Techniques in patients with COPD. J.
Oedipal. Retail. 2000; 20:37-43.
4. O'Neill, B., Bradley, J., McArdle, N.; The current
physiotherapy management of patients with
bronchiectasis: A UK survey, Int. J. Clin. Pract.
2002; 56:34-35.
5. Thompson, C., Harrison, S., Ashley. J.; Day, K.;
Smith, D.; Randomized crossover study of the
flutter device and the active cycle of breathing
in non-cystic fibrosis bronchiectasis-thorax
2002; 57:446-48.
6. Webber, B.A.; Pryoz, J.A.; Physiotherapy skills:
techniques and adjuncts. In Webber BA, Pryor
JA eds. Physiotherapy for respiratory and
cardiac problems. Churchill, Livingstone,
1993:116-29.
7. Nafeez, S.; Arun, G.; Maiya & Siva, K.T.; Active
cycle of breathing technique versus
conventional chest physical therapy on airway
cleanse in bronchiectasis. Advances in
Physiotheropy.2009; 11:193-98.
Shereen H et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (5): 287-293
8. Watevick, M., Jahnnessen, A., Mardie, J.A.,
Bjodal J.M., Aakrast, P., Bakke, P.S., Eagon,
T.M.; Different COPD disease characteristics are
related to different outcomes in the 6 minute
walk test. COPD. 2012; 3:227-34.
9. Sue, J., Nola, M.C.; Six minute walk test in
pulmonary rehabilitation: Do all patients need a
practice test? Respiratory. 2010,15:1192-96.
10. Henk, F.; Multivariable Assessment of the 6 min
walk test in patients with COPD. Am.J. Rasp.
Chit. Case Med. 2001; 163(7): 1567-71.
11. Brooks, D., Solway, S., wlnacht, W., Wang, D.
and Thomas, S.; comparison between an indoor
and an outdoor 6 minute walk test among
individuals with COPD. Arch. Phys. Med,
Rehabilitation. 2003; 84:873-76.
12. Wright, G. Branscomb, B.V.; Dispread,
mechanisms, assessment and Management.
Am. J. Respire. Crit. Care Med. 2000:159(1);
321-40.
13. Bernarding C., Peter, R.E. and Nola, M.; Six
minute walk test in healthy subjects aged 55-57
years. Kesp.Med. 2006; 100:658-65.
14. American Association for respiratory care:
Preliminary rehabilitation, Resp. Care: 2002;
47(s): 617-25.
15. Caminati, A., Bionchi, A., Cassandra, R.,
Mineda, M. and Marrori, S.; Walking distance
on 6 MWT is a prognostic factor in idiopathic
pulmonary fibrosis. Respiratory Medicine. 2009;
103:117-23.
16. Eaton, T., Nola, M.C. et al.; Six minute walk test
in pulmonary rehabilitation: Do all patients and
a practice test? Respelling. 2010, 15:1192-96.
17. El Batanony, M. and Attia, D.; Occupational
exposure as a cause of COPD, Egyptian Journal
of brachylogy. 2009; 3 (1): 11-23.
18. Kulkorni, A.; A comparative study on autogenic
drainage and pursed lip breathing with active
cycle of breathing technique in hospitalized
chronic obstructive pulmonary disease patients.
2012:39-51.
19. Paneeth, B., Faisal, M., Renuka, D.M. Efficacy of
active cycle of breathing and postural drainage
in patient with bronchiectasis innovative journal
of Medical and health Science. 2012; 129-32.
20. Patterson, J.E., Bradely, J.M., Elborn, J.S.;
Airway clearance in bronchiectasis: a
randomized crossover trial of active cycle of
breathing techniques versus test of incremental
 respiratory endurance. Chronic Resp. Dis. 2004;
1:127-30.
21. Eaton, T., Young, P., Zeng, I., et al.; A
randomized evaluation of the acute efficacy,
acceptability and tolerability of Flutter and
Active cycle of breathing with and without
postural drainage in non-cystic fibrosis
bronchiectasis, Chron. Resp. Dis. 2007; 4:23-30.
22. Janet, E.P., Judy, M.B., Onagh, M., Ian, B.,
stuart, J.; Airway clearance in bronchiectasis: a
randomized crossover trial of active cycle of
breathing techniques versus A capella.
Respiration. 2005; 72:239-42.
23. Jamal, A.M., Kampk, Balsare, D.R.; A
comparison of autogenic drainage and the
active cycle of breathing techniques in patients
Shereen H et al., International Journal of Therapies and Rehabilitation Research 2015; 4 (5): 287-293
with a cure exacerbation of COPD. Ind. Journal
of physiotherapy and Occupational therapy.
2007, 1:4-7.
24. Savci, S., Ince, D.I., Anikan, M.; A comparison of
autogenic drainage and the active cycle of
breathing techniques in patients with COPD.
Journal of Cardiopulmonary Rehab. 2000; 20:36-
43.
25. Elizabeth Dean; Oxygen transport: the basis of
cardiopulmonary physical therapy. 1996; 3 rd
ed. P.: 3-21.
26. Robinson, K.A.; Mckay, N., Saldabha, I.;
Odelola. O.A.; Active cycle of breathing
technique for cystic fibrosis. Coc hrane
Database Sys Rev. 2010 Nov 10;(11).pub2.