World Applied Sciences Journal 20 (6): 818-822, 2012

ISSN 1818-4952
IDOSI Publications, 2012
DOI: 10.5829/idosi.wasj.2012.20.06.71125

Comparison of Autogenic Drainage & Active Cycle Breathing Techniques

on FEV1, FVC & PEFR in Chronic Obstructive Pulmonary Disease
1
Ganeswara Rao Melam, 1A.R. Zakaria, 1Syamala Buragadda,
2
Deepesh Sharma and 1Mohammed Abdulrahman Alghamdi

1
College of Applied Medical Sciences,
Departmant of Rehabilitation Sciences,
King Saud University, Riyadh, 11433, Saudi Arabia
2
Clinical Therapist, Department of Physical Therapy, Mohali, India

Abstract: Airway clearance is integral to the management of COPD, yet there is no evidence as to the optimal
modality. This study was conducted to compare the efficacy of two chest clearance techniques, autogenic
drainage and active cycle breathing in COPD patients.Thirty subjects who were 40 - 60 years of age and had
moderate chronic obstructive pulmonary disorder were allocated randomly into three groups, each consisting
of 10 subjects. Group A received autogenic drainage, group B was givenactive cycle breathing technique and
group C received medications. The treatment duration was 5 days per week for 4 weeks. The outcome measure
used was computerized spirometer to evaluate pre& post test values of forced expiratory volume (FEV1), forced
vital capacity (FVC) and peak expiratory flow rate (PEFR). There was significant improvement in FVC, FEV 1&
PEFR values in both A and B groups when compared to group C patients who received only medications with
no additional breathing techniques. But there was no statistical significant difference in FVC, FEV1& PEFR
values between the groups A and B.The results of this study revealed that both autogenic drainage and active
cycle breathing technique are effective in clearance of secretions, which is one of the causes of airway
obstruction in patients with COPD.

Key words: Chronic Obstructive Pulmonary Disease Chest Clearance Pulmonary Rehabilitation Airway
Clearance

INTRODUCTION irreversible airways obstruction due to a combination of

Diseases of respiratory system are the major
causes of illness affecting a greater part of population
worldwide. Chronic Obstructive Pulmonary Disease
(COPD) is a major cause of chronic morbidity and
mortality throughout the world. Many people suffer
from this disease for years and die prematurely from it
or its complications and can be predicted in the coming
decade [1, 2]. COPD is the fourth leading cause of death
in the world and further increase in its prevalence and
mortality.
In United States, the term COPD was introduced
in early 1960s to describe the patients with largely
airways disease and emphysema without defining the
contribution of these conditions to the airway
obstruction. Later American Thoracic Society defined
COPD as a disease state characterized by the presence
of airflow obstruction due to chronic bronchitis or
emphysema. The airflow obstruction is generally
progressive and may be accompanied by airway
reactivity and may be partially reversible [3]. COPD is
the fourth leading cause of death worldwide and is
estimated to be the third leading cause of death by 2020
[4, 5]. Youngest women are at high risk, suggesting a
high incident rate toward the female sex in the gender
distribution of COPD [6].

Corresponding Author: Syamala Buragadda, College of Applied Medical Sciences,

Department of Rehabilitation Sciences, King Saud University, Riyadh, KSA.
P.O. Box-10219, Tel: +966 531262956.
818
 World Appl. Sci. J., 20 (6): 818-822, 2012
Chest physiotherapy referred to a group of
techniques and maneuvers was aimed for improving
lung volumes or facilitating the removal of airway
secretions. These can include percussion, vibration and
postural drainage, active cycle of breathing, continuous
or oscillating positive expiratory pressure (PEP),
intermittent positive pressure ventilation (IPPV), thoracic
expansion exercises and walking programs [7-11].
Advanced methods like positive expiratory technique
using flutter device and autogenic drainage are also used
for improving bronchial hygiene in chronic obstructive
pulmonary disease patient [12].
Autogenic Drainage was introduced by Chevaillier
in Belgium in the year 1967 for the treatment of chronic
obstructive pulmonary disease patients.Autogenic
Drainage is an anti-dyspnoea technique based on quiet
expirations in a relaxed state without the use of postural
drainage positions. Autogenic Drainage has used
diaphragmatic breathing to mobilize secretions by varying
expiratory airflow [13].
Active cycle breathing technique (ACBT) includes
cycle of breathing control, thoracic expansion exercise
and forced expiratory technique. Diaphragmatic breathing
(DB) is intended to help in using the diaphragm correctly
while breathing, strengthen the diaphragm, decrease the
work of breathing by slowing the breathing rate and
decrease the oxygen demand so that one can use less
effort and energy to breathe.
COPD associated with mucus hyper secretion which
in turns leads to decrease lung volumes. A Cochrane
review has concluded that airway clearance techniques
have short-term beneficial effects on mucus transport in
CF however there was no evidence regarding long-term
effects. One uncontrolled study has evaluated the effects
of withdrawing airway clearance for three weeks and
found a detrimental effect on lung function. Beyond this
study, there is little evidence regarding the long-term
efficacy of ACT versus no treatment. Moreover, there is
a scarcity of evidence on literatures which show that there
is significant difference between AD & ACBT on lung
volumes improvement. Hence the present study will
determine the better chest clearance technique to improve
the lung volume in COPD patients.
MATERIALS AND METHODS
The study was conducted after receiving ethical
committee approval and subjects (n=30) were recruited
819
from cardio-pulmonary outpatient department of
Maharishi Markendeswar university hospital, India.
Thirty volunteer male patients of 40 - 60 years of age with
moderate COPD were included in the study. Subjects
with any cardiovascular impairment, musculoskeletal
dysfunction, neurological disease & non-cooperative
patients were excluded.Informed consent was taken from
all the subjects.
Method: Thirty subjects clinically diagnosed have been
used as moderate type of chronic obstructive pulmonary
disorder and were selected according to inclusion and
exclusion criteria and divided randomly into three groups.
Group A received autogenic drainage, group B was given
active cycle of breathing technique and group C received
only medication. Each group consists of 10 subjects.
All three groups were assessed before the training
session to exclude any pre-existing pulmonary and cardiac
conditions. A brief explanation about the treatment
session was given to all the subjects. Thetreatment
duration for group A and B was one session a day for
5 days per week for 4 weeks. The patient was asked to
carry out a maximal inspiration followed by maximal forced
expiration and the pre and post values of FVC, FEV 1 &
PEFR were measured by computerized spirometry. General
instructions such as lips should be tight around the
mouth piece, complete exhalation at least up to 6 seconds,
no exhalation through nose, avoid additional breath
taking during the maneuver and avoid coughing were
given to the patient before testing.
Group a (Autogenic Drainage): The subject was seated
upright in a chair with back support. The upper air ways
were cleared of secretions by huffing or blowing the nose.
Therapist was seated to the side and slightly behind the
subject, closes enough to hear the subjects breathing.
Subjects hands were placed on abdomen to feel the work
of abdominal muscles and the physiotherapists hand
placed on the upper chest to feel the secretions.
Inhalation was done slowly through the nose, using
diaphragm and two to three seconds breath hold allowing
collateral ventilation to get air behind the secretions.
Exhalation was done through the mouth. The vibration of
mucus was felt by therapists hand placed on upper chest.
The frequency of vibrations revealed their locations.
High frequencies reveal secretions located in small
airways. Low frequencies mean that secretions were
moved to larger airways. The technique includes
 World Appl. Sci. J., 20 (6): 818-822, 2012

unsticking, collecting and evacuating phases. At the end Table 1: Demographic characteristics of groups A, B and C

of the session the mucus was evacuated by a stronger Group A Group B Group C
expiration or a high volume huff. The duration of the (n=10) (n=10) (n=10) F value

session depends on the amount and viscosity of the Age (Yrs) 50.45.52 50.95.5 50.65.7 .0153*
secretions. Height (mts) 162.16.0 162.26.08 163.36.12 .1201*
Weight (Kgs) 57.55.58 57.45.71 57.65.56 .0025*

Group B (ACBT): The active cycle of breathing includes *there was no significant difference at the 0.05 level

breathing control, thoracic expansion exercises and forced

Table 2: Baseline measurement of FEV1, FVC &PEFR of Groups A,
expiration technique.
B and C
Group A Group B Group C
Breathing Control: The subjects were placed in well
(n=10) (n=10) (n=10) F value
supported and relaxed half lying position. Therapists
FEV1 (liters) 1.9240.987 1.928.1073 1.925.1019 .0041*
hand was placed on the upper abdomen. As the
FVC (liters) 1.9350.974 1.9310.985 1.9340.929 .0047*
subjects breathed, the hand was felt to rise up during
PEFR (lit/min) 3.136.146 3.13.17 3.135.0180 .0037*
inspiration and out during expiration.
*there was no significant difference at the 0.05 level
Thoracic Expansion Exercises: The subjects were
placed in a comfortable and supported half lying
Table 3: Group comparison of FEV1 of groups A, B & C
position. They were asked to perform deep
Source SS df MS F Fcritical p
inspiration combined with a 3 second hold before the
Between 0.48445 2 0.2422 1149.4 3.3541 <0.01
passive relaxed expiration. Thoracic expansion
Within 0.00569 27 0.0002
exercises were encouraged with proprioceptive
Total 0.49014 29
stimulation, by placing patients or therapists hand
*P at 0.05
over the chest when the movement was encouraged.
It was combined with chest shaking, vibration or
Table 4: Intra-group comparison of FVC of groups A, B & C
chest clapping. These techniques helped in the
Source SS Df MS F Fcritical p
clearance of secretions. The former technique of
Between 0.44426 2 0.2221 996.26 3.3541 <0.01
breathing control was done again.
Within 0.00602 27 0.0002
Forced Expiration Technique: The subjects were
Total 0.45028 29
positioned comfortably in half lying position or high
* P at 0.05
Sitting position. The patient is asked to perform two
forced expirations (huffs) and a period of breathing
Table 5: Intra-group comparison of PEFR in group A, B & C
control. Breathing control given for 2 to 3 seconds
Source SS Df MS F Fcritical p
was followed by Expiration with open glottis.
Between 0.90669 2 0.4533 1072.5 3.3541 <0.01
Coughing or huffing was preferred according to the
Within 0.0047 27 0.0002
subjects comfort. When secretions have reached the
Total 0.91139 29
more proximal upper airways, a huff or cough from a
* P at 0.05
high lung volume was used to clear the secretions.

RESULTS Significant improvement in the values was seen in

In terms ofage, weight and height there was no
significant difference between the groups.
There was no significant difference in baseline
measurements of FEV1, FVC and PEFR between the
groups.
Pre test and post test values of FVC, FEV1, PEFR
between the three groups were analyzed using one-way
ANOVA and post hoc analysis using tukey test
(Tables 3-5).
groups A and B subjects when compared to those in
group C who received only medications. Pair wise
comparison of mean values showed that there was
significant difference between A and B to that of group C
but there was no difference between the groups A and B.
DISSCUSSION
The findings of the present study revealed that after
4 weeks training program, there was significant difference

820
 World Appl. Sci. J., 20 (6): 818-822, 2012
in the values of FVC, FEV1& PEFR in group A, that
received autogenic drainage technique and group B that
received active cycle of breathing as compared to group
C subjects who were only on medications. But there is
no statistical significant difference in the values of FVC,
FEV1& PEFR between group A and B.
In the present study, AD was given including a
three-phase breathing exercise. The gradually increasing
inspiratory and expiratory reserve volumes from
functional residual capacity and a 2 to 3 second
breath-holding period may have resulted in collateral
filling among the alveoli and improved ventilation and
mobilized secretions [14].
Researchers had done a systemic review on evidence
for Airway clearance physical therapy training in Cystic
fibrosis. They concluded that there was some evidence to
support the physical therapy technique like ACBT, AD
etc and no evidence to discourage their inclusion [14].
Previous studies done to compare the effect of AD and
ACBT on SaO2, PaO2 and dyspnoea in COPD patients
concluded that AD is as effective as ACBT in clearing
secretions and improving lung function. A number of
randomized, controlled trials have demonstrated
consistently that Autogenic drainage & Active cycle
breathing technique improves the lung volumes but
there is no significant difference between the techniques
[15-18].
Previous studies showed that the improvement in
oxygenation with AD is unlikely related to mucus clearing,
although improved matching of ventilation to perfusion
may occur because of redistribution of airway secretions.
In addition, thoracic expansion exercises used in the
ACBT provide communication among the alveoli, improve
ventilation and allow air to flow behind the bronchial
secretions. The underlying mechanism may be that AD
and ACBT used in present study improved lung function
by ensuring collateral ventilation in segments of lungs
which were not previously involved in ventilation [19].
airway clearance techniques reported clinical benefits like
reduced cough, improvement from dyspnoea and exercise
capacity and ultimately leading to a better quality of life
[20].
The results of this study revealed that both AD and
the ACBT are effective techniques in the clearance of
mucus, which is one of the causes of airway obstruction
in patients with COPD. This was shown by improvement
in pulmonary function tests. The findings of our study
has been bolstered by the results of Savci et al. [14] who
conducted a study to compare the effect of AD and
ACBT in 30 clinically stable male COPD patients.
821
The present study undertaken included patients
who had moderate chronic obstructive pulmonary
disease especially the age group between 40-60 years
and who didnt have any other pulmonary or cardiac
complications, hence this study can be generalized only
to moderate chronic obstructive pulmonary disease
patients. Although many treatment methods are
currently in vogue in order to deal these kind of
patients, there is an emergent need of applying the
right technique which suits the patients need .The
growing demand for meeting various problems associated
with pulmonary complications are indeed worth
considering.
Although the AD technique was more difficult
for patients to learn, once patients used the technique
correctly it was found to be effective. The ACBT
application was quite simpler than AD. However, no
single technique may be best for every patient.
Each patient should be assessed to determine the
most appropriate and effective technique. The
implications of present study can be important in
designing a training program for COPD patients to
improve the lung volumes mainly FEV1, FVC & PEFR
and removal of the secretions. Both the techniques are
safe and equally effective in chest clearance and easy to
use by the patients.
This study used only three tools in detecting the
improvement in moderate chronic obstructive pulmonary
patients, studies can be done with other parameters like
rate of perceived exertion and arterial blood gas analysis.
The comparison between active cycle of breathing
technique and autogenic drainage and other training
modes like incentive spirometry can be studied, as the
latter is also concerned with the better outcome in recent
studies. As this study was done only with age group
between 40-60years, study of all age groups can be
undertaken for a better knowledge of treatment outcome
in the future research.
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