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 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.

ACBT consists of three main phases:

1. Breathing Control
2. Deep Breathing Exercises or thoracic expansion exercises
3. Huffing OR Forced Expiratory Technique (F.E.T)

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. 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. 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 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.

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

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.

Deep Breathing Exercises or Thoracic Expansion Exercises

Deep breathing/thoracic expansion exercises are deep breathing exercises which focus on inspiration and help to loosen secretions . 

1. Relax your upper chest.
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 portion 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 .

Huffing or Forced Expiratory Technique

This is a manoeuvre used to move secretions, mobilised by thoracic expansion exercises, downstream towards the mouth. 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 as coughing alone does not remove sputum from small airways, 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 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 pot. 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 10-15 minutes or until chest feels clearer .

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.

Coughing

If huffing clears your sputum you should not need to cough. However if it does not clear your sputum, then you may need to .

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

Indication

• 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.

Precaution

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.

Positioning

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.

Guidelines:

• Maintain a good breathing pattern with relaxed shoulders and neck.
• 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.
  

Resources

• www.brit-thoracic.org.uk
• www.lunguk.org