The Use of Active Cycle of Breathing Technique (ACBT) In Pulmonary Physiotherapy: A Critical Review of the Literature Lauro G. Villegas Jr.
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1 The Use of Active Cycle of Breathing Technique (ACBT) In Pulmonary Physiotherapy: A Critical Review of the Literature Lauro G. Villegas Jr., PTRP Keywords: Active Cycle of Breathing Technique (ACBT), Pulmonary physiotherapy, airway clearance Abstract Active cycle of breathing technique (ACBT) is a widely known physiotherapy technique for airway clearance in patients with pulmonary conditions that produces mucus regularly. The aim of this literature review is to discover the available literature that proves the effectiveness of ACBT. The databases used in searching were purely electronic, namely PubMed, PEDro and ScienceDirect. The keywords used were ACBT OR active cycle of breathing technique. Five studies were obtained and appraised using the PEDro tool with scores ranging from 3-5/10. Four out of the five studies compared ACBT with other forms of pulmonary physiotherapy for airway clearance, and one compared ACBT without head down tilt with ACBT with head down tilt. All of the studies proved the effectiveness of ACBT in clearing the airways in different pulmonary conditions with secretions but none reported the superiority of ACBT over other pulmonary physiotherapy techniques or vice versa. Introduction Airway clearance would always be an integral part of physical therapy intervention for in-patients with pulmonary conditions. Any chronic lung disease that presents with excessive bronchial secretions is treated with physical therapy using different techniques of airway clearance (Cecins, Jenkins, Pengelley, & Ryan, 1999). These airway clearance techniques may involve the conventional treatment and some other new approaches. Conventional chest physiotherapy has been described by Cecins et al in 1999 and Syed, Maiya & Kumar in 2009 to be gravity-assisted positions for mucus drainage, manual percussion of the chest wall by a therapist, vibrations, coughing and breathing techniques (diaphragmatic breathing). On the other hand, those considered to be new approaches to pulmonary physiotherapy are those that involves active participation from the patient such as Active Cycle of Breathing Technique (ACBT), Autogenic Drainage (AD) (Syed et al, 2009), Positive Expiratory Pressure Mask Therapy (PEP), High Pressure PEP, (Miller, Hall, Clayton, & Nelson, 1995), and Flutter (Inal-Ince, Savci, Topeli, & Arikan, 2004) and (Thompson, Harrison, Ashley, Day, & Smith, 2002). Daily use of these techniques is very common in patients with lung conditions that presents with problems in expelling secretions. Through this these techniques, clearing the airways and improving alveolar ventilations can be achieved thus preventing secondary complications of accumulated secretions like infections, further airway damage and lung function deterioration (Cecins et al, 1999). Among these new approaches, the ACBT is found to be one of those that can be done with or without assistance from the physical therapist (PT) and is shown to be more effective than the conventional chest physiotherapy in terms of weight and rate of sputum expectorated (Cecins et al, 1999 by Pryor et al 1979). However Miller et al, 1995 emphasized the fact that inaccuracy in measuring the effectiveness of a pulmophysiotherapy technique might occur when using amount of sputum expectorated 1
2 because Scintigraphic studies have shown that the patient may swallow mucus during and after treatment. ACBT is also being done in different ways for different conditions. Through this literature review, information in terms of ACBT s effectiveness over other pulmophysiotherapy techniques whether conventional or a new approach will be reported. ACBT also results in different outcomes, this review also aims to discover the available literature that shows the different outcomes ACBT can improve or address in different pulmonary conditions. Search Strategy Purely electronic databases were used in searching for the studies to be reviewed. These electronic databases include PubMed, PEDro and ScienceDirect. The keywords used in searching were ACBT OR Active cycle of breathing technique, Pulmonary Physiotherapy, Chest Physiotherapy, sputum clearance, sputum clearance OR airway clearance. All of the yields were scanned and hits were examined through its abstract and obtained studies were those that have free available full text. Chosen studies to be obtained were those that compare ACBT with other pulmonary physiotherapy techniques or compares ACBT in different types of application. A total of 5 studies were appraised using the PEDro tool as all of them are randomized cross over trials. Synthesis and Discussion This review included five studies with randomized cross over trial as the design. Four of the five studies compared the effectiveness of ACBT with conventional chest PT (Syed et al, 2009), autogenic drainage (Miller et al, 1995), flutter device (Thompson, 2002), and one study compared ACBT combined with noninvasive ventilation from non-invasive ventilation alone (Inal-Ince et al, 2004). On the other hand, One study compared the effectiveness of ACBT in two postural positions wherein it may be applied, namely horizontal position without head down tilt and with head down tilt. This study was conducted by Cecins et al in 1999, A withinsubjects cross over design which utilized participants with bronchiectasis that produces more than 20g of sputum per day. The results of this study showed were no significant difference in terms of the number of productive coughs, weight of sputum expectorated, weight of sputum produced in 24 hours and no significant changes in Oxygen Saturation (S A O 2 ) and FEV 1 whether the between ACBT was applied in the horizontal position or with head down position. Based from these results ACBT in the horizontal position is just as effective as the ACBT with head down position and based from the questionnaire the participants answered, it reflected that they preferred the ACBT without head down tilt because of less breathlessness and more comfortable. Conditions or diagnosis where ACBT is applied varies. Miller et al, 1995 compared ACBT with autogenic drainage in patients with cystic fibrosis, Syed et al, 2009 compared ACBT with conventional chest physiotherapy and Thompson et al, 2002 compared the flutter device and ACBT both in patients with non cystic fibrosis Bronchiectasis or productive Bronchiectasis and lastly the comparison between non invasive ventilation plus ACBT versus non invasive ventilation alone are done in patients with acute hypercapnic respiratory failure by Inal-Ince et al, Even though the diagnosis where ACBT is applied in the studies varies, the similarities between these studies are the outcomes of interest. Three of these four studies had similar outcomes of interest. Miller et al, 1995, Syed et al, 2009 and Thompson et al, 2002 all had mucus/airway clearance as the major 2
3 outcome which will be measured by the sputum weight, Pulmonary function test (PFT) (Miller et al 1995 and Syed et al 2009), FEV (Miller et al, 1995 and Thompson et al 2002) and S A O 2 (Miller et al, 1995). All the three studies included the patient s treatment preference. Only one study had different outcomes, the study done by Inal-Ince, 2004 which had the length of time not requiring non invasive ventilation as the primary outcome and the secondary outcome measures were acute physiology score, change/s in arterial blood gas values, total duration of non invasive ventilation and length of stay in the intensive care unit. Out of the four studies, three showed that ACBT is as effective as other pulmonary physiotherapy techniques in clearing airways. Miller et al, 1995, Syed et al, 2009 and Thompson et al, 2002 showed no superiority of ACBT over other techniques such as autogenic drainage, conventional chest physiotherapy and flutter device rather these techniques are just equal in terms of clearing the airways based from the results of the outcome measures. Miller et al, 1995 concluded that there were increased rates of mucus clearance and that there was improved FEV more often on the days autogenic drainage was performed. Though no significant difference in terms of sputum weights, PFT, S A O 2 and HR changes were found between ACBT and autogenic drainage. Overall in this study both ACBT and autogenic drainage showed effectiveness in clearing lung obstructions. The study done by Syed et al, 2009 found no statistical difference in wet sputum weight and volume, PFT values, FEV 1 and FVC between groups though there was a statistical difference in within groups pre and post intervention results in FEV 1 and FVC. The study concluded that ACBT is equally effective as the conventional chest physiotherapy. Thompson et al, 2002 showed no significant difference in any outcome used in their study between the groups in ACBT and the flutter device. FEV 1 showed a statistical significance but it did not show any clinically meaningful change or significance. Generally the study concluded that flutter is as effective as ACBT in assisting sputum clearance in patients with non cystic fibrosis bronchiectasis. The study that used a different outcome from the three is the study done by Inal-Ince et al, The results of this study showed greater decrease in arterial CO 2 pressure and duration of ventilation needed in the ACBT group. There was no significant difference as to the length of stay in the intensive care unit between the ACBT plus non-invasive ventilation (NIV) group and NIV group. The most significant result of this study is that it provided evidence that ACBT could shorten the length of time required for non-invasive ventilation of patients with acute hypercapnic respiratory failure. Four out of five studies included in this literature review considered the patient s preference of intervention as one of the major outcomes of interest in their study. The four studies had different results in terms of patient preferences, Miller et al, 1995 reported that the participants in their study had equal preference between ACBT and autogenic drainage. On the other hand, Syed et al, 2009 emphasized the patients preference on ACBT over the conventional chest physiotherapy in terms of comfort through visual analog scale (VAS). Thompson et al, 2002 recognized the participants predilection for the flutter device over ACBT for routine daily use of expelling sputum. And lastly the study that compared ACBT in two positions namely ACBT in horizontal position and ACBT in head down position by Cecins et al in According to the study, most of the participants preferred the ACBT without 3
4 head down position because it was more comfortable, caused fewer headaches, easier and less tiring. Conclusion This literature review emphasized on the fact that the available evidences to prove the effectiveness of ACBT are mainly composed of studies with randomized cross over designs. ACBT is applied in different conditions and diagnosis but similarly, majority of the studies used airway clearance as the primary outcome of interest. Generally the five studies included in this literature review proved ACBT to be effective for sputum clearance but there was no superiority of ACBT over other pulmonary physiotherapy techniques. Majority of the studies included patient s preference of treatment as one of the outcomes, this might imply that patient s treatment preference could be a factor to adherence since airway clearance is a daily routine of patients with pulmonary conditions that produces mucus regularly. Appendix Review of Methodological Quality PEDro 1. Eligibility criteria were specified 2. Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which treatments were received) Cecins et al, 1999 ds: Subjects, ü Study Design, 661 Syed et al, 2009 ds, 194 ds, 194 Miller et al, 1995 ds and Patients, Inal-Ince et al 2004 ds: Subjec ts, ds: Subjec ts, 68 Thompson et al, 2002 ds : Study Design, Allocation was concealed 4. The groups were similar at baseline regarding the most important prognostic indicators 5. There was blinding of all subjects 662 ü Table 5 and Result s, ü Measure ments, 166 ü Table 1 and 4, Result s: 70 ü Table 1 4
5 PEDro 6. There was blinding of all therapists who administered the therapy 7. There was blinding of all assessors who measured at least one key outcome 8. Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups 9. All subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by intention to treat 10. The results of between-group statistical comparisons are reported for at least one key outcome 11. The study provides both point measures and measures of variability for atleast one key outcome Cecins et al, Syed et al, Miller et al, Inal-Ince Thompson et al 2004 et al, ü Result s, 195 ü Patient, 165 and Table 2 ü Physio therapy Techniq ues, 166 Discussio n and Tables 2 and 3, , 4 and 5 3, 4, 5 and 6 1 and 2 ü Result s, 70 77%, Results, 447 ü Table 1 3 and 4 3 and Total 4/10 5/10 4/10 5/10 3/10 5
6 References Cecins, N., Jenkins, S., Pengelley, J., & Ryan, G. (1999). The active cycle of breathing techniques- to tip or not to tip?. Respiratory Medicine, 93, Syed, N., Maiya, A., & Kumar, S. (2009). Active Cycles of Breathing Technique (ACBT) versus conventional chest physical therapy on airway clearance in bronchiectasis-a crossover trial. Advances in Physiotherapy, 11, DOI: / Miller, S., Hall, D., Clayton, C., & Nelson, R. (1995). Chest physiotherapy in cystic fibrosis:a comparative study of autogenic drainage and the active cycle of breathing techniques with postural drainage. Thorax, 50, Inal-Ince, D., Savci, S., Topeli, A., & Arikan, H. (2004). Active cycle of breathing techniques in non-invasive ventilation for acute hypercapnic respiratory failure. Australian Journal of Physiotherapy, 50, Thompson, C., Harrison, S., Ashley, J., Day, K., & Smith, D. (2002). Randomised crossover study of the Flutter device and the active cycle of breathing technique in non-cystic fibrosis bronchiectasis. Thorax, 57,
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