Autogenic drainage

Autogenic drainage

1. Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia. Autogenic Drainage(AD) Submitted by – Mehnaz Farkhunda Submitted to -Dr. Jamal Ali Moiz Subject – Physiotherapy in Cardiopulmonary Conditions (BPT402) BPT 4 th yr Date- 5/01/2021 1

2. Introduction Autogenic Drainage (AD) is an airway clearance technique which uses controlled breathing at varied lung volumes to help clear secretions from the smaller peripheral airways to the larger central airways. This technique aims to assist in the removal of sputum and reduce the frequency of chest infections. The technique, developed by Jean Chevaillier in Belgium in 1967, aims to maximize expiratory airflow, while avoiding dynamic airway collapse. AD utilizes expiratory airflow. The rationale for the technique is the generation of shearing forces induced by airflow. The speed of the expiratory flow may mobilise secretions by shearing them from the bronchial walls and transporting them from the peripheral to the central airways. 2

3. Indications AD is particularly suited to people with chronic hypersecretory disease, cystic fibrosis, bronchiectasis. People with hemoptysis. Asthma or for those at risk of panic attacks. 3

4. STAGES Stage 1: loosen the mucus in the smaller peripheral airways by breathing at low lung volumes (Unstick) Stage 2: collecting the mucus from the middle airways by breathing at low to medium (tidal) lung volumes (Collect) Stage 3: removal of the mucus from the central larger airways by breathing at mid (tidal) to high lung volumes (Evacuate) By breathing at different levels, secretions can be moved from different parts of the airways. Secretions lower down in the airways are moved by breathing at low lung volumes (with only a small amount of air in the lungs). By breathing at higher lung volumes (with a larger sized breath), secretions which are higher up in the airways can be moved and cleared. 4

5.  1 – small peripheral airways  2 – medium airways  3 –  large central airways 5

6. The specific style of breathing described is performed at different lung volumes, usually starting within the expiratory reserve volume (ERV) and progressing into the inspiratory reserve volume (IRV). 6

7. How to perform the technique Preparation C hoose a breath-stimulating position like sitting or reclining. Before commencing the technique, if the patient has symptoms of an upper airway blockage, it may be necessary to clear the upper airways by blowing the nose or, if necessary, using a nasal spray or sinus rinse.Bronchodiators, Inhalers or nebulisers should be taken as prescribed to moisten and dilate the airways, facilitating bronchial clearance. The nose is blown if necessary, and the throat cleared of secretions to reduce resistance to airflow. One hand should be placed to feel the work of the abdominal muscles and the other hand placed on the upper chest. 7

8. Start with a slow breath in through the nose, followed by a 2 to 3 second breath hold to facilitate collateral ventilation. As the technique requires an open glottis, some patients may need to breathe in through their mouth, with or without the assistance of a piece of wide tubing (also used for huffing). Exhale with the glottis open (via the nose is preferable but many patients prefer mouth as it enhances the auditory feedback). The expiratory force must be controlled in such a way that the expiratory airflow reaches the highest possible velocity without causing early airway compression. Patients with dynamic airway collapse may only need to breathe out with a relaxed sigh. Starting with low-volume breaths from expiratory reserve volume, repeat breaths (inhalation and exhalation) until secretions are felt or heard gathering in the airways(Crackles). Patients will need to use their abdominal muscles to expel the air at low lung volumes. This may take a number of breaths. 8

9. Once the sputum is heard (crackling) at low volume breaths, during the last part of each expiration, move to larger tidal volume breaths until the sputum is heard, or felt, to collect. This may also take a number of breaths. Breathe at mid (tidal) to high lung volumes,  the collected sputum will reach the upper airways where it can be cleared by a high volume huff and cough. T he vibrations of the mucus may also be felt with the hand placed on the upper chest. High-frequency vibrations will indicate the presence of secretions in the small peripheral airways, and low-frequency vibrations will indicate the presence of secretions in more central airways. 9

10. Assessment breath first • Breathe in (inspiration) gently through your nose with your mouth open (open glottis) and breathe out fully through an open mouth .If you hear crackles at the end of the assessment breath. This means the mucus is in the smaller peripheral airways. If the crackles are at the beginning of the breath(larger central airways) out then you should start with high volume breaths. Stage 1: Take a small breath in slowly through your nose, keeping your mouth open • Hold your breath for 2–3 seconds • Breathe out through your mouth allowing your abdominal muscles to tense, breathe out fast but not forcibly• Repeat this until you feel or hear the mucus moving up into the middle airways or hear crackles. Stage 2: Medium lung volumes (collection phase) • Once the mucus is felt or heard crackling, take a slightly bigger breath to move up to medium (tidal) lung volumes • Continue to repeat the cycle until you feel or hear the mucus is collecting in the upper airways. 10

11. Stage 3 : High lung volumes (removal phase) Once the mucus has collected take a full breath in Breathe out through your open mouth taking care not to breathe out fully Repeat this until you can hear or feel the sputum is ready to clear Complete one or two high volume huffs followed by a cough to clear the mucus . 11

12. 12

13. Points to remember(guidelines) Try not to cough until the mucus is in the larger central airways as a premature cough will lead to impaired clearance. At all stages, the patient must be encouraged to suppress their cough until the sputum is in the central airways and ready to be easily expectorated. Use only one or two huffs/coughs to clear mucus and avoid repetitive coughing. The key to autogenic drainage is to always breathe at the lung volumes where you can hear your sputum crackle. To keep the sputum audible you need to adapt your breathing to keep your mouth open when you breathe out (open glottis.) If you hear wheezing on your out breath then you are using too much force. Slow your breath out to reduce the flow of air . 13

14. Benefits of AD No equipment is required Patients can perform their airway clearance independently Less effort is be required to expectorate which reduces stress on the pelvic floor 14

15. Disadvantages of AD Patients generally need to be over 8 years old. The technique can be difficult to teach. Patients need the cognitive ability to understand the basic physiology behind the technique. To benefit from the auditory feedback, patients need to have a moderate or large amount of sputum. 15

16. References Physiotherapy in Respiratory Care by Alexandra Hough,3 rd edition. Autogenic drainage: the technique, physiological basis and evidence by Paula Agostini , Nicola Knowles https://www.uhb.nhs.uk/Downloads/pdf/PiAutogenicDrainage.pdf https://www.physio-pedia.com/Autogenic_Drainage#cite_note-1 https://bronchiectasis.com.au/physiotherapy/techniques/autogenic-drainage 16