Active Cycle of Breathing Technique: Difference between revisions

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== Introduction  ==


== Introduction ==
The Active Cycle of Breathing Techniques (ACBT) is an active breathing technique performed by the patient and can be used to mobilize and clear excess pulmonary secretions and to generally improve lung function. It is a flexible method of treatment that can be used in conjunction with positioning and adapted for use with most patients. Each component can be used individually or as part of the ACBT cycle depending on the patient's problem. Once ACBT has been taught, the patient can be encouraged to use it independently without the supervision of a physiotherapist. This exercise does not require the use of any special equipment.  


The Active Cycle of Breathing Techniques (ACBT) is an active breathing technique performed by the patient to help clear their sputum put of the lungs. The ACBT is a group of techniques which use breathing exercises to improve the effectiveness of a cough, loosen and clear secretions and improve ventilation.<ref>Thomson A, Skinner A, Piercy J. Tidy's Physiotherapy. 12th edition.Butterworth Heinemann publication.</ref>
It's used to: 
# Loosen and clear secretions from the lungs<ref name=":4" />.This helps reduced the risk of chest infections.
# Improve ventilation in the lungs.
# Improve the effectiveness of a cough <ref>Thomson A, Skinner A, Piercy J. Tidy's Physiotherapy. 12th edition.Butterworth Heinemann publication.</ref><ref name=":3" />.


ACBT consists of three main phases:<ref name="Larner and Galey">Larner E, Galey P. Active cycle of breathing technique. Available from: http://www.nnuh.nhs.uk/docs%5Cdocuments%5C580.pdf (accessed 20 Oct 2013).</ref>
'''ACBT consists of three main phases''':  


#Breathing Control  
#Breathing Control  
#Deep Breathing Exercises or thoracic expansion exercises
#Deep Breathing Exercises or Thoracic Expansion Exercises
#Huffing OR Forced Expiratory Technique (F.E.T)
#Huffing or Forced Expiratory Technique (FET) <ref name="Larner and Galey">Larner E, Galey P. Active cycle of breathing technique. Available from: http://www.nnuh.nhs.uk/docs%5Cdocuments%5C580.pdf.</ref>


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.
The technique can be modified according to the condition of the patient. 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. this may include [[percussion]] or expiratory vibrations.
 
A randomized control trial showed positive effects of active cycle breathing technique along with routine chest physiotherapy on arterial oxygenation, heart rate, and pain perception following Coronary Artery Bypass Surgery (CABG)<ref>Derakhtanjani AS, Jaberi AA, Haydari S, Bonabi TN. [https://www.ncbi.nlm.nih.gov/pubmed/31903332 Comparison the Effect of Active Cyclic Breathing Technique and Routine Chest Physiotherapy on Pain and Respiratory Parameters After Coronary Artery Graft Surgery]: A Randomized Clinical Trial. Anesthesiology and Pain Medicine. 2019 Oct;9(5).</ref>.


=== Breathing Control  ===
=== 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<ref name="NHS">Emma Larner &amp; Penny Galey.THE ACTIVE CYCLE OF BREATHING TECHNIQUE (ACBT).Sept 2002 – review date Sept 2004.</ref>. Breathing should be performed gently through the nose using as little effort as possible. If this is not possible then breathing should be done by mouth. If it is necessary to breathe out through the mouth this should be done with ‘pursed lips breathing’. While performing this technique it is important to encourage the patient use it as an opportunity to reduce any tension they may have. Encouraging the patient to close their eyes while performing Breathing Control can also be beneficial in helping to promote relaxation.&nbsp;It is very important to use Breathing Control in between the more active exercises of ACBT as it allows for relaxation of the airways<ref name="ACPRC">The Active Cycle of Breathing Techniques.Association of Chartered Physiotherapists in Respiratory Care.Leaflet no.GL-05.Available at http://www.acprc.org.uk/dmdocuments/GL-05%20ACBT.pdf</ref>. Breathing Control can also help you when you are short of breath, feeling fearful, anxious or in a panic. The length of time spent performing Breathing Control will vary depending on how breathless the patient feels.
Breathing control is used to relax the airways and relieve the symptoms of wheezing and tightness which normally occur after coughing or breathlessness<ref name="NHS">Emma Larner &amp; Penny Galey.THE ACTIVE CYCLE OF BREATHING TECHNIQUE (ACBT).Sept 2002 – review date Sept 2004.</ref>. It is the resting period between the more active parts of the technique.<ref name="ACPRC" /> 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<ref name="ACPRC">The Active Cycle of Breathing Techniques.Association of Chartered Physiotherapists in Respiratory Care.Leaflet no.GL-05.Available at http://www.acprc.org.uk/dmdocuments/GL-05%20ACBT.pdf</ref>.


When using this technique with a patient as part of the ACBT, the patient should be instructed to usually 6 breaths.   
Breathing Control can also help when one is experiencing shortness of breath, fear, signs of bronchospasm, anxiety or is in a panic. The length of time spent performing breathing control may vary depending on how breathless the patient feels.   


Instructions to patient: Rest one hand on your stomach and keep your shoulders relaxed to drop down. Feel your stomach rise as you breathe in and fall when you breathe out.  
When using this technique with a patient as part of the ACBT, the patient may be instructed to usually take 6 breaths. 
 
Instructions to patient:
# 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).
# If you breathe out through your mouth, it's best to use breathing control with ‘pursed lips breathing’.
# Try to let go of any tension in your body with each breath out and keep your shoulders relaxed.
# Gradually try to make the breaths slower.  
# Try closing your eyes to help you to focus on your breathing and to relax.
# Breathing control should continue until the person feels ready to progress to the other stages in the cycle <ref name="ACPRC" /><ref name=":0" />.
# Pay close attention that the individual performing the ACBT is not doing trick movements (extension of neck, trunk leaning forward etc.) and not using the accessory muscles for breathing.


=== Deep Breathing Exercises or Thoracic Expansion Exercises  ===
=== Deep Breathing Exercises or Thoracic Expansion Exercises  ===


Deep breathing/thoracic expansion exercises are deep breathing exercises which focus on inspiration<ref name=":0">Bronchiectasis Toolbox: The Active Cycle of Breathing. Retrieved on 2nd July, 2018 http://bronchiectasis.com.au/physiotherapy/techniques/the-active-cycle-of-breathing-technique</ref> and help to loosen secretions <ref>Oxford University Hospitals. The Active Cycle of Breathing Techniques.p3 https://www.ouh.nhs.uk/patient-guide/leaflets/files/11659Pbreathing.pdf. Accessed 2nd July, 2018</ref>. <br>  
Deep breathing/thoracic expansion exercises are deep breathing exercises that focus on inspiration<ref name=":0">Bronchiectasis Toolbox: The Active Cycle of Breathing. http://bronchiectasis.com.au/physiotherapy/techniques/the-active-cycle-of-breathing-technique (Accessed on 2nd July, 2018)</ref> and help to loosen secretions accumulated at the [[Lung Anatomy|lungs]] <ref name=":1">Oxford University Hospitals. The Active Cycle of Breathing Techniques.p3 https://www.ouh.nhs.uk/patient-guide/leaflets/files/11659Pbreathing.pdf. (Accessed 2nd July, 2018).</ref>. Inspiration is active and usually combined with a three-second, end-inspiratory hold before a passive, relaxed and unforced expiration<ref name=":5">McIlwaine MP, Van Ginderdeuren F. Physiotherapy for people with cystic fibrosis: from infant to adult.https://www.ecfs.eu/sites/default/files/general-content-files/working-groups/IPG%20CF_Blue%20Booklet_7th%20edition%202019.pdf.</ref>.


#Relax your upper chest.
Instructions to patient:
#Take a long, slow, 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)
#Try to keep your chest and [[Acromioclavicular Joint|shoulders]] relaxed.
#Take a long, slow and deep breath in, through your [[Upper Respiratory Airways|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.
#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 portion of the cycle<ref name="NHS" /><ref>Association of Chartered Physiotherapists in Respiratory Care. The Active Cycle of Breathing Techniques. 2011, GL-05 p2</ref>.<br>
#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 <ref name="NHS" /><ref name=":2">Association of Chartered Physiotherapists in Respiratory Care. The Active Cycle of Breathing Techniques. 2011, GL-05 p2 http://www.acprc.org.uk/Data/Publication_Downloads/GL-05ACBT.pdf (Accessed 1st July, 2018).</ref>.  
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 <ref name=":0" />.
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 <ref name=":0" />.
A breath hold can be added to the deep breath to compensate for ''asynchronous ventilation'' which may be present in some respiratory conditions due to sputum retention and / or atelectasis.<ref name=":0" />


=== Huffing or Forced Expiratory Technique  ===
=== Huffing or Forced Expiratory Technique  ===


This is a manoeuvre used to move secretions, mobilised by thoracic expansion exercises, downstream towards the mouth<ref name=":0" />. A huff is exhaling through an open mouth and throat instead of coughing. Huffing moves sputum from the small airways to the larger airways, from where they are removed by coughing<ref name="NHS" /> as coughing alone does not remove sputum from small airways<ref name="ACPRC" />, There are two types of huff: <br>
This is a technique used to move secretions, mobilized by deep breathing/thoracic expansion exercises, downstream towards the Mouth in order to cough it out or remove it through [[suctioning]]<ref name=":0" />. 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<ref name="NHS" /> as coughing alone can not remove sputum from small airways<ref name="ACPRC" />.When initially taught, the patient is instructed to take a medium breath in and to breathe out with mild to moderate force and extended expiratory flow, with the glottis open. The length of the huff and force of contraction of the muscles of expiration should be altered to optimize clearance of secretions by maximizing air flow<ref name=":5" />.
 
There are two types of huff:  
 
# Medium Volume Huff
# High Volume 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 or your specs.


#Take a small-medium sized breath in
==== High Volume Huff ====
#Squeeze the breath out by contracting your tummy muscles and keep your mouth and throat open to perform a huff. This small-medium sized huff helps with the removal of sputum in the lower reaches of the lungs.
This helps to move secretions in your upper airways.  
#To remove sputum in the higher portions of the lungs take a large breath in.
#Squeeze the air out as before to perform a huff.
#Cough and expectorate any sputum. If no sputum is produced with 1 or 2 coughs, try to stop coughing by encouraging the patient to use Breathing Control, the main technique used in between the more active stages of the as ACBT.
#Allow your breathing to settle with breathing control and then repeat the cycle until your chest feels clear.<br>


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.<ref name="ACPRC" /><br>
Take a deep breath in, open your mouth wide and huff out quickly.


Instructions to patient:
Only perform 1-2 huffs together, as repeatedly huffing can make your chest tight.
#Take a medium sized breath in.
#Squeeze the breath out fairly hard and fast keeping mouth and throat open. Imagine trying to steam up a mirror or blow a tissue held out in front of you.
#Attempt to clear sputum 2-3 times then return to breathing control (Phase one) to relax airways.
#Repeat as above except for a larger breath in to remove secretions/sputum in other areas of the lungs.&nbsp;


== Indication  ==
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.


*Post surgical /pain (rib fracture/ICC).
Repeat the whole cycle for about 10 minutes or until the chest feels clearer<ref name=":1" />.
*Chronic increased sputum production e.g in Chronic bronchitis, cystic fibrosis<ref>McKoy NA, Saldanha IJ, Odelola OA, Robinson KA.Active cycle of breathing technique for cystic fibrosis. Cochrane Database Syst Rev. 2012 Dec 12;12:CD007862.</ref>.
 
Small long huffs move sputum from low down into chest whereas big, short huffs move 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<ref name="ACPRC" />.
 
[[File:The Active Cycle of Breathing Technique..png|center|Active Cycle of Breathing Technique|thumb]]
 
=== Coughing ===
Coughing should be incorporated if huffing alone does not clear your sputum. However, if it does clear your sputum, then you may not need to cough<ref name=":2" />.
 
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<ref name=":3">Guy’s and St Thomas’ NHS Foundation Trust. Active Cycle of Breathing Techniques (ACBT). 2018, 3607:2 https://www.guysandstthomas.nhs.uk/resources/patient-information/therapies/physiotherapy/active-cycles-of-breathing-techniques.pdf (Accessed on 1st July, 2018).</ref>.
{{#ev:youtube|sawZdkp7QtQ|350}} <ref>10 ACBT for Respiratory illness. Available from: http://www.youtube.com/watch?v=sawZdkp7QtQ (accessed 20 Oct 2013).</ref>
== Indications  ==
 
*Post surgical /pain ([[Rib stress fracture in rowers|rib fracture]]/ICC).
*Chronic increased sputum production e.g. in [[Chronic Bronchitis|Chronic bronchitis]], [[Cystic Fibrosis|cystic fibrosis]]<ref name=":4">McKoy NA, Saldanha IJ, Odelola OA, Robinson KA.[https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007862.pub4/abstract Active cycle of breathing technique for cystic fibrosis]. Cochrane Database of Systematic Reviews. 2016(7).
</ref>.
*Acute increase sputum production.
*Acute increase sputum production.
*Poor expansion.
*Poor expansion.
*Sputum Retention.
*Sputum Retention.
*SOBAR/SOBOE.
*SOBAR/SOBOE.
*Cystic Fibrosis.
*[[Cystic Fibrosis]].
*Bronchiectasis.
*[[Bronchiectasis]].<ref>Elsayed SH, Basset WK, Fathy KA. [https://www.researchgate.net/publication/283076530_IMPACT_OF_ACTIVE_CYCLE_OF_BREATHING_TECHNIQUE_ON_FUNCTIONAL_CAPACITY_IN_PATIENT_WITH_BRONCHIECTASIS Impact of active cycle of breathing technique on functional capacity in patient with bronchiectasis]. International Journal of Therapies and Rehabilitation Research. 2015;4(5):287.</ref>
*Atelectasis.
*[[Atelectasis]].
*Respiratory muscle weakness.
*[[Respiratory Muscle Training|Respiratory muscle weakness]].
*Mechanical ventilation.
*[[Ventilation and Weaning|Mechanical ventilation]].
*Asthma.
*[[Asthma]].
*Increased breathing rate/effort.
*Audible rattling in airways.
*Palpable secretions.
 
== 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<ref name="Beverley">Cross J, Broad MA, Harden B, Quint M, Ritson P, Thomas S. Respiratory physiotherapy: An on-call survival guide. Elsevier Health Sciences; 2008 Nov 25.</ref>.
* Inadequate pain control where needed.
* Bronchospasm.
* Acute, unstable head, neck or spinal surgery.
 
== Contraindications  ==
* Patients not spontaneously breathing.
* Unconscious patient.
* Patients who are unable to follow instructions.
* Agitated or confused.


== Clinical Presentation ==
== Positioning ==


It is important to constantly assess for dizziness or increased shortness of breath throughout ACBT. If patient feels dizzy during deep breathing decrease the number of deep breaths taken during each cycle and return to normal breathing to reduce dizziness.<ref name="Beverley">Harden B, Cross J, Broad MA, Quint M, Ritson P, Thomas S. Respiratory Physiotherapy: An On-Call Survival Guide, 2e. London: Churchill Livingstone, 2008.</ref><br>
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 <ref name="ACPRC" /><ref name=":1" /><ref>Lewis LK, Williams MT, Olds TS. The active cycle of breathing technique: a systematic review and meta-analysis. Respiratory medicine. 2012 Feb 1;106(2):155-72.
</ref>. 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, back supported as this promotes the function of diaphragm and decrease stress on musculoskeletal. Whatever position you use make sure you are comfortable, well supported and relaxed.


== Procedure  ==
The ACBT may be performed with or without an assistant providing vibration, percussion and shaking. Self-percussion/compression may be included by the patient <ref name=":0" /><ref name=":2" />.


ACBT can be performed in sitting, lying or side-lying positions. Initially you should 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. A minimum of ten minutes in each productive position is recommended. The ACBT may be performed with or without an assistant providing vibration, percussion and shaking. Self percussion/compression may be included by the patient.<br>  
It has been shown that the horizontal, side lying position is as effective as the head down tipped position and preferred by individuals<ref name=":5" />.  
[[Image:ACBT.PNG]]


'''Guidelines:'''
== Duration and Frequency ==
*Maintain a good breathing pattern with relaxed shoulders and neck.
Duration for ACBT should be for about 10 minutes and ideally until your chest feels clear of sputum.
*Breathe in through nose and out through mouth. Breathing should be slow, like “sighing out”. This can help minimise any wheezing.
*Remember the principles of Diaphragmatic breathing.<br>


{{#ev:youtube|tpRil5WSXlo}}
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<ref name="ACPRC" /><ref name=":1" />.


{{#ev:youtube|sawZdkp7QtQ|350}} <ref>10 ACBT for Respiratory illness. Available from: http://www.youtube.com/watch?v=sawZdkp7QtQ (accessed 20 Oct 2013).</ref>  
{{#ev:youtube|tpRil5WSXlo|300}} <ref>Active cycle of breathing technique. Available from: http://www.youtube.com/watch?v=tpRil5WSXlo(accessed 4/4/2020).</ref>
== Possible side effects  ==
* Bronchospasm with hyper-reactive airways.
* Reduced oxygen saturations/ shortness of breath.
* Cardiac arrhythmias.
* [[Atelectasis|Atelectasis.]]
* Fatigue.


== Resources  ==
== Resources  ==
Line 92: Line 147:
*[http://www.brit-thoracic.org.uk/ www.brit-thoracic.org.uk]
*[http://www.brit-thoracic.org.uk/ www.brit-thoracic.org.uk]
*[http://www.blf.org.uk/Home www.lunguk.org]
*[http://www.blf.org.uk/Home www.lunguk.org]
*[http://bronchiectasis.com.au/physiotherapy/techniques/the-active-cycle-of-breathing-technique www.bronchiectasis,com,au]
*[https://bronchiectasis.com.au/ www. bronchiectasis.com.au/]


== References  ==
== References  ==
Line 97: Line 154:
<references />
<references />


[[Category:Interventions]] [[Category:Exercise_Therapy]] [[Category:Cardiopulmonary]]
[[Category:Interventions]]  
[[Category:Exercise_Therapy]]  
[[Category:Cardiopulmonary]]
[[Category:Older People/Geriatrics]]
[[Category:Older People/Geriatrics - Interventions]]
[[Category:Respiratory Disease - Interventions]]
[[Category:Respiratory Disease - Interventions]]

Latest revision as of 08:45, 22 January 2024

Original Editor ­- Faye Underwood

Top Contributors - Faye Underwood, Temi Olagunju, Aarti Sareen, Magdalena Hytros, Admin, Kim Jackson, Khloud Shreif, Scott Buxton, Uchechukwu Chukwuemeka, Arinola Young, Vidya Acharya, Alex Curran, Lauren Lopez, 127.0.0.1, Tony Lowe, Mohit Chand, Evan Thomas, WikiSysop and Adam Vallely Farrell  

Introduction[edit | edit source]

The Active Cycle of Breathing Techniques (ACBT) is an active breathing technique performed by the patient and can be used to mobilize and clear excess pulmonary secretions and to generally improve lung function. It is a flexible method of treatment that can be used in conjunction with positioning and adapted for use with most patients. Each component can be used individually or as part of the ACBT cycle depending on the patient's problem. Once ACBT has been taught, the patient can be encouraged to use it independently without the supervision of a physiotherapist. This exercise does not require the use of any special equipment.

It's used to:

  1. Loosen and clear secretions from the lungs[1].This helps reduced the risk of chest infections.
  2. Improve ventilation in the lungs.
  3. Improve the effectiveness of a cough [2][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]

The technique can be modified according to the condition of the patient. 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. this may include percussion or expiratory vibrations.

A randomized control trial showed positive effects of active cycle breathing technique along with routine chest physiotherapy on arterial oxygenation, heart rate, and pain perception following Coronary Artery Bypass Surgery (CABG)[5].

Breathing Control[edit | edit source]

Breathing control is used to relax the airways and relieve the symptoms of wheezing and tightness which normally occur after coughing or breathlessness[6]. It is the resting period between the more active parts of the technique.[7] 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[7].

Breathing Control can also help when one is experiencing shortness of breath, fear, signs of bronchospasm, 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 take 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(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 [7][8].
  7. Pay close attention that the individual performing the ACBT is not doing trick movements (extension of neck, trunk leaning forward etc.) and not using the accessory muscles for breathing.

Deep Breathing Exercises or Thoracic Expansion Exercises[edit | edit source]

Deep breathing/thoracic expansion exercises are deep breathing exercises that focus on inspiration[8] and help to loosen secretions accumulated at the lungs [9]. Inspiration is active and usually combined with a three-second, end-inspiratory hold before a passive, relaxed and unforced expiration[10].

Instructions to patient:

  1. Try to keep your chest and shoulders relaxed.
  2. Take a long, slow and 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 [6][11].

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 [8].

A breath hold can be added to the deep breath to compensate for asynchronous ventilation which may be present in some respiratory conditions due to sputum retention and / or atelectasis.[8]

Huffing or Forced Expiratory Technique[edit | edit source]

This is a technique used to move secretions, mobilized by deep breathing/thoracic expansion exercises, downstream towards the Mouth in order to cough it out or remove it through suctioning[8]. 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[6] as coughing alone can not remove sputum from small airways[7].When initially taught, the patient is instructed to take a medium breath in and to breathe out with mild to moderate force and extended expiratory flow, with the glottis open. The length of the huff and force of contraction of the muscles of expiration should be altered to optimize clearance of secretions by maximizing air flow[10].

There are two types of huff:

  1. Medium Volume Huff
  2. High Volume Huff.

Medium Volume Huff[edit | edit source]

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 or your specs.

High Volume Huff[edit | edit source]

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 the chest feels clearer[9].

Small long huffs move sputum from low down into chest whereas big, short huffs move 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[7].

Active Cycle of Breathing Technique

Coughing[edit | edit source]

Coughing should be incorporated if huffing alone does not clear your sputum. However, if it does clear your sputum, then you may not need to cough[11].

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[3].

[12]

Indications[edit | edit source]

Precaution[edit | edit source]

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[14].

  • Inadequate pain control where needed.
  • Bronchospasm.
  • Acute, unstable head, neck or spinal surgery.

Contraindications[edit | edit source]

  • Patients not spontaneously breathing.
  • Unconscious patient.
  • Patients who are unable to follow instructions.
  • Agitated or confused.

Positioning[edit | edit source]

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 [7][9][15]. 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, back supported as this promotes the function of diaphragm and decrease stress on musculoskeletal. 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 [8][11].

It has been shown that the horizontal, side lying position is as effective as the head down tipped position and preferred by individuals[10].

Duration and Frequency[edit | edit source]

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[7][9].

[16]

Possible side effects[edit | edit source]

  • Bronchospasm with hyper-reactive airways.
  • Reduced oxygen saturations/ shortness of breath.
  • Cardiac arrhythmias.
  • Atelectasis.
  • Fatigue.

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 McKoy NA, Saldanha IJ, Odelola OA, Robinson KA.Active cycle of breathing technique for cystic fibrosis. Cochrane Database of Systematic Reviews. 2016(7).
  2. ↑ Thomson A, Skinner A, Piercy J. Tidy's Physiotherapy. 12th edition.Butterworth Heinemann publication.
  3. ↑ 3.0 3.1 Guy’s and St Thomas’ NHS Foundation Trust. Active Cycle of Breathing Techniques (ACBT). 2018, 3607:2 https://www.guysandstthomas.nhs.uk/resources/patient-information/therapies/physiotherapy/active-cycles-of-breathing-techniques.pdf (Accessed on 1st July, 2018).
  4. ↑ Larner E, Galey P. Active cycle of breathing technique. Available from: http://www.nnuh.nhs.uk/docs%5Cdocuments%5C580.pdf.
  5. ↑ Derakhtanjani AS, Jaberi AA, Haydari S, Bonabi TN. Comparison the Effect of Active Cyclic Breathing Technique and Routine Chest Physiotherapy on Pain and Respiratory Parameters After Coronary Artery Graft Surgery: A Randomized Clinical Trial. Anesthesiology and Pain Medicine. 2019 Oct;9(5).
  6. ↑ 6.0 6.1 6.2 Emma Larner & Penny Galey.THE ACTIVE CYCLE OF BREATHING TECHNIQUE (ACBT).Sept 2002 – review date Sept 2004.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 The Active Cycle of Breathing Techniques.Association of Chartered Physiotherapists in Respiratory Care.Leaflet no.GL-05.Available at http://www.acprc.org.uk/dmdocuments/GL-05%20ACBT.pdf
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Bronchiectasis Toolbox: The Active Cycle of Breathing. http://bronchiectasis.com.au/physiotherapy/techniques/the-active-cycle-of-breathing-technique (Accessed on 2nd July, 2018)
  9. ↑ 9.0 9.1 9.2 9.3 Oxford University Hospitals. The Active Cycle of Breathing Techniques.p3 https://www.ouh.nhs.uk/patient-guide/leaflets/files/11659Pbreathing.pdf. (Accessed 2nd July, 2018).
  10. ↑ 10.0 10.1 10.2 McIlwaine MP, Van Ginderdeuren F. Physiotherapy for people with cystic fibrosis: from infant to adult.https://www.ecfs.eu/sites/default/files/general-content-files/working-groups/IPG%20CF_Blue%20Booklet_7th%20edition%202019.pdf.
  11. ↑ 11.0 11.1 11.2 Association of Chartered Physiotherapists in Respiratory Care. The Active Cycle of Breathing Techniques. 2011, GL-05 p2 http://www.acprc.org.uk/Data/Publication_Downloads/GL-05ACBT.pdf (Accessed 1st July, 2018).
  12. ↑ 10 ACBT for Respiratory illness. Available from: http://www.youtube.com/watch?v=sawZdkp7QtQ (accessed 20 Oct 2013).
  13. ↑ Elsayed SH, Basset WK, Fathy KA. Impact of active cycle of breathing technique on functional capacity in patient with bronchiectasis. International Journal of Therapies and Rehabilitation Research. 2015;4(5):287.
  14. ↑ Cross J, Broad MA, Harden B, Quint M, Ritson P, Thomas S. Respiratory physiotherapy: An on-call survival guide. Elsevier Health Sciences; 2008 Nov 25.
  15. ↑ Lewis LK, Williams MT, Olds TS. The active cycle of breathing technique: a systematic review and meta-analysis. Respiratory medicine. 2012 Feb 1;106(2):155-72.
  16. ↑ Active cycle of breathing technique. Available from: http://www.youtube.com/watch?v=tpRil5WSXlo(accessed 4/4/2020).
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