Active Cycle of Breathing Technique Full Title of Guideline: Author (include email and role): Division & Speciality: Version: 3 Ratified by: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): Active Cycle of Breathing Technique (ACBT) Guideline for Practice Eleanor Douglas Lecturer/Practitioner Physiotherapist Eleanor.douglas@nuh.nhs.uk Clinical Support, Physiotherapy Senior Physiotherapists at NUH Trust wide physiotherapists September, 2021 Any patient who has increased/excessive pulmonary secretions. Specific patient groups may include those with Cystic Fibrosis, Bronchiectasis and post operative patients. Review of research, minor changes to wording, grammar and spelling errors corrected. Meta analysis of randomised controlled trials. Expert Summary of evidence base this committee reports or opinions and / or clinical experiences of guideline has been created from: respected authorities. Recommended best practice based on the clinical experience of the guideline developer. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust. Page 1 of 6
ACTIVE CYCLE OF BREATHING TECHNIQUE (ACBT) GUIDELINE FOR PRACTICE 2018 Version: This replaces the Active Cycle of Breathing Technique (ACBT) Guideline for Practice, September 2015 Review Date: September 2021 Contact: Eleanor Douglas, Lecturer/Practitioner Physiotherapist Ext: 56142 Disclaimer This guideline has been registered with the Nottingham University Hospitals Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in any doubt regarding this procedure, contact a senior colleague. Caution is advised when using guidelines after the review date. Please contact the named above with any comments/feedback. Introduction The ACBT can be used to mobilise and clear excess pulmonary secretions and to generally improve lung function. It is a flexible method of treatment which can be used in conjunction with Gravity Assisted Positioning (GAP) Guidelines, (2018) and adapted for use with most patients. It is a cycle of breathing relaxation, thoracic expansion exercises and active secretion clearance ie: Forced Expiration Technique (huffing). Each component could be used individually or as part of the ACBT depending on the patient s problem. Once ACBT has been taught, the patient can be encouraged to use it independently. Indications: The need to aid removal of retained secretions Atelectasis As prophylaxis against post-operative pulmonary complications To obtain sputum specimens for diagnostic analysis To promote independent chest clearance Contraindications: Patients not spontaneously breathing Unconscious patient Patients unable to follow instructions Precautions: Inadequate pain control of wounds to chest wall/abdomen Rib fractures Bronchospasm Acute unstable head, neck or spinal injury Increased ICP or known intracranial aneurysm Inability to control transmission of infection from patients known or suspected to have to transmission by droplet nuclei e.g. Tuberculosis Page 2 of 6
ACTION Explain procedure to patient and obtain consent Obtain sputum pot/sample pot /tissues Unless being used as a prophylactic treatment, auscultate to assess need Identify most appropriate position for procedure e.g. if patient has right sided secretions, left side lying may be beneficial (and vice versa). Patients with bilateral problems may benefit from upright sitting (see GAP guidelines, 2018) Begin with a short period of breathing control/relaxation (emphasis should be placed on abdominal movement during inspiration). Best carried out in supported upright sitting. Start with 4-6 breaths Then ask the patient to perform 3-4 thoracic expansion exercises (active deep breaths in, keeping shoulders relaxed.) +/- proprioceptive stimulation, by placing the hands over the area where bucket handle chest expansion is to be encouraged An additional hold or sniff maneuver can be used at the end of inspiration The thoracic expansion exercises can be performed with a 3 second end inspiratory hold. This may not be possible for patients who are short of breath Next ask the patient to perform a short period of breathing control/relaxation ( 4-6 breaths) Repeat 3-4 thoracic expansion exercises Pause for a short period of breathing control/ relaxation Thoracic expansion exercises can be combined with chest shaking, vibrations or percussion The patient is then instructed to perform 1-2 huffs at low lung volume (forced expiration with mouth open) RATIONALE To ensure the patient understands procedure and can give informed consent Procedure may mobilise secretions To identify areas of sputum retention/atelectasis Postural drainage and ventilation perfusion ratio need to be considered to maximise the procedures effect and prevent desaturation To relax the patient and encourage them to observe their breathing Allows air to flow via channels of collateral ventilation. This can mobilise secretions and allow re-expansion of atelectasis A small further increase in lung volume can be achieved. May not be appropriate in patients with hyperinflated lungs or who overuse accessory muscles To maximise collateral ventilation. The hold may increase work of breathing for patients who are short of breath To prevent fatigue and hyperventilation To encourage further collateral ventilation To prevent fatigue and hyperventilation To encourage further secretion drainage (See Guidelines on Manual Techniques, 2018) To move secretions from more peripheral airways with minimal airflow disturbance Page 3 of 6
1-2 huffs at high lung volume. To clear secretions from proximal airways A peak flow tube may be used to improve the effectiveness of the huff Helps keep the glottis open Easier to explain technique to patient 1-2 strong coughs To expectorate secretions that have been mobilised The cycle can be continued until the chest is clear of secretions, there is improved air entry or the patient is too fatigued to continue If secretions are cleared or air entry improved, there is no longer an indication for the procedure. Continuing the procedure when the patient is fatigued may compromise respiratory function ACBT Troubleshooting Problem Pain Possible Solution Teach supported cough, especially if the patient has a surgical wound Liaise with medical team re appropriate analgesia Viscous sputum Very breathless Regular saline nebulisers (0.9%) or hypertonic saline (7%) discuss with medical team Consider Mucolytics discuss with medical team Consider using ultrasonic nebuliser prior to ACBT Encourage increased oral hydration (caution if patient on fluid restriction) Ensure patient receiving effective mouth care if nil by mouth Consider PEP, Flutter/Acapella (see Guidelines, 2018) Concentrate on breathing control in relaxed, supported positions Modify ACBT to include just one or two thoracic expansion exercises Perform ACBT in positions designed to both optimise functioning of the diaphragm and allow relaxation of the upper chest e.g. high side lying Good Practice Point Consider the ACBT when recommending airway clearance techniques for adults with Cystic Fibrosis, stable COPD and with non-cystic fibrosis-related bronchiectasis (Bott, 2009) References References There is insufficient evidence to support or reject the use of ACBT over any other airway clearance therapy in patients with CF. ACBT was comparable to other therapies in Bott J outcomes et al (2009) such Physiotherapy as patient preference, management lung function, of the adult, sputum medical weight, spontaneously oxygen saturation, breathing and patient. number Thorax of pulmonary 64: Supplement exacerbations. 1 Longer-term studies are needed to assess the effects of ACBT on outcomes important for patients such as quality of life and patient preference Hough A (2001) Physiotherapy (Mckoy NA, Saldanha in Respiratory IJ, Odelola Care. OA, Nelson Robinson Thornes KA, 2016). Page 4 of 6
References Lewis LK, Williams MT, Olds TS (2012) The active cycle of breathing technique: a systematic review and meta-analysis. Respiratory Medicine 106(2):155-72. Mckoy NA, Saldanha IJ, Odelola OA, Robinson KA (2012) A comparison of active cycle of breathing technique (ACBT) to other methods of airway clearance therapies in patients with cystic fibrosis. Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd007862.pub3/abstract (Acessed: 07/10/2015) Mckoy NA, Wilson LM, Saldanha IJ, Odelola OA, Robinson KA. Active cycle of breathing technique for cystic fibrosis. Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD007862. DOI: 10.1002/14651858.CD007862.pub4. Page 5 of 6
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