Active Cycle of Breathing Technique

Original Editor -Faye Underwood

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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.

It's used to:

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

ACBT consists of three main phases:

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

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).

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. It is the resting period between the more active parts of the technique. 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.

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

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 .

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 .

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.

Huffing or Forced Expiratory Technique

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. 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 as coughing alone cannot remove sputum from small airways. 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.

Historically, huffs have been described as "low," "medium," or "high" volume, depending on the lung volume from which they were initiated. However, recent guidance suggests that the term "high volume huff" is misleading and inappropriate.

Therefore, current best practice recommends avoiding the term "high volume huff" but instead describes the huff in terms of the lung volume at which the mobilisation of secretions is expected to take effect:

• Low lung volume huff: Aims to clear secretions from more distal or peripheral airways. A longer expiratory time is associated with low lung volume huff.
• Mid-lung volume huff: A short sharp huff mobilizes secretions from mid-lung to more proximal airways.
• Avoid initiating huffs from maximal inspiration (i.e., true high lung volume) unless specifically indicated.

Low-lung Volume Huff

This type of huff is initiated after a normal tidal breath or a slightly deeper breath and helps to move secretions from the peripheral (smaller) airways towards the more central airways in the mid-lung region.

• Take a normal-sized breath in.
• Open your mouth and huff out steadily and actively until your lungs feel almost empty.
• Imagine trying to fog up a mirror with your breath – this keeps your glottis open while you squeeze the secretions from the bottom part of your lungs to the mid-lung level.

This is the most effective huff for mobilising mucus from the lower parts of your lungs.

Mid-Lung Volume Huff

Once secretions have been mobilised centrally, a short sharp huff starting from mid-lung volume can help move the secretions closer to the throat area where you can cough them up more easily.

• Take a medium size breath in, and perform a short and sharp squeeze.
• This may trigger a cough to help with final clearance.

Avoid taking a deep breath and forcefully huffing from full lung capacity, as recent guidance suggests this is not effective and may cause airway closure or fatigue.

If you hear crackles during your huff, this may indicate that secretions are ready to be cleared, and it could be the right time to cough and expectorate into a tissue or sputum pot. Try to avoid excessive coughing, as it can cause fatigue and reduce the effectiveness of the technique. Continue to repeat the cycle of breathing control, thoracic expansion, and huffing for around 10 minutes or until your chest feels clearer.

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.

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.

Indications

• Post surgical /pain (rib fracture/ICC).
• Chronic increased sputum production e.g. in Chronic bronchitis, cystic fibrosis.
• Acute increase sputum production.
• Poor expansion.
• Sputum Retention.
• SOBAR/SOBOE.
• Cystic Fibrosis.
• Bronchiectasis.
• Atelectasis.
• Respiratory muscle weakness.
• Mechanical ventilation.
• 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.

• 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.

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 . 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 .

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

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.

Possible side effects

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

Resources

• www.brit-thoracic.org.uk
• www.lunguk.org
• www.bronchiectasis,com,au
• www. bronchiectasis.com.au/