Introduction

The Active Cycle of Breathing Techniques (ACBT) is an active breathing

technique performed by the patient to help clear their sputum 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. [1]

ACBT consists of three main phases: [2]

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
breathlesness [3]. 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 Breath 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 [4]. Breathing Control can also help you when you
are short of breath or feeling fearful, anxious or in a panic. The length of
time spent performing Breathing Control will vary depending on how
breathless 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

 Deep breathing is used to get air behind the sputum stuck in small
airways:[4]

1. Relax your upper chest.

2. Breathe in slowly and deeply.
3. Breathe out gently until your lungs are empty dont force the air out.
4. Repeat 3 4 times, if the patient feels light headed then it is important that
they revert back to the Breathing Control portion of the cycle.
5. At the end of the breath in, hold the air in your lungs for 3 seconds (this is
known as an inspiratory hold). [3]

Deep breathing/thoracic expansion exercises recruit the collateral

ventilatory system assisting, the movement of air distal to mucus plugs in
the peripheral airways. [5]

Deep breaths to utilise collateral channels and get air behind sputum to
mobilise it towards larger airways and towards the mouth. Instructions to
patient:

1. Relax your shoulders.

2. Place both hands on either side of ribs.
3. Breathe in deeply feeling as your ribs expand.
4. Breathe out gently as far as you can until your lungs feel empty.

Deep breathing/thoracic expansion is usually repeated 4 times.

Huffing or FET

The FET is an integral part of the ACBT described by Pryor and Webber [6].

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 [3]. Coughing alone does
not remove sputum from small airways. [4]

1. Take a small-medium sized breath in

2. Squeeze the breath out by contracting your tummy muscles and keep your
mouth and throat open to perform a huff. This small-medium sized huff
helps with the removal of sputum in the lower reaches of the lungs.
3. To remove sputum in the higher portions of the lungs take a large breath
in.
4. Squeeze the air out as before to perform a huff.
5. Cough and expectorate any sputum. If no sputum is produced with 1 or 2
coughs, try to stop coughing by encouraging the patient to use Breathing
Control, the main technique used in between the more active stages of the
as ACBT.
6. Allow your breathing to settle with breathing control and then repeat the
cycle until your chest feels clear.

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.[4]

Instructions to patient:

1. Take a medium sized breath in.

2. Squeeze the breath out fairly hard and fast keeping mouth and throat open.
Imagine trying to steam up a mirror or blow a tissue held out in front of
you.
3. Attempt to clear sputum 2-3 times then return to breathing control (Phase
one) to relax airways.
4. Repeat as above except for a larger breath in to remove secretions/sputum
in other areas of the lungs.

Indication
Post surgical /pain (rib fracture/ICC).
Chronic increased sputum production e.g in Chronic bronchitis, cystic
fibrosis[7].
Acute increase sputum production.
Poor expansion.
Sputum Retention.
SOBAR/SOBOE.
Cystic Fibrosis.
Bronchiectasis.
Atelectasis.
Respiratory muscle weakness.
Mechanical ventilation.
Asthma.

Clinical Presentation
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. [8]
 Procedure
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.