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The role of thoracic expansion exercises during the active cycle of

breathing techniques

Article  in  Physiotherapy Theory and Practice · July 2009

DOI: 10.3109/09593989709036458

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 pliysiofhcfa~' h Itarfirc (1997) 13, 155- 162
and ~
0 1997 Erlbaum (UK) Taylor & Francis Ltd

The role of thoracic expansion exercises during the

active cycle of breathing techniques

Dianne White, Kathy Stiller and Kristyn Willson

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Fifteen adult cystic fibrosis patients completed a randomised two-period, two-

treatment crossover study to investigate whether it is necessary to perform thoracic
expansion exercises during the active cycle of breathing techniques (ACBT) with
postural drainage. Treatment A comprised the ACBT with postural drainage,
incorporating thoracic expansion exercises. Treatment B was as described for
treatment A with the exclusion of the thoracic expansion exercises. During
treatment By the thoracic expansion exercises were replaced with a n equivalent
period of relaxed breathing. No significant differences were found between
treatments A a n d B for spirometry, sputum weight o r oxygen saturation measured
For personal use only.

up to 30 min post-treatment. This suggests that, if desired, thoracic expansion

exercises can be omitted from the ACBT with postural drainage a n d be replaced
with relaxed breathing with n o obvious loss of effect or detrimental sequelae in the
short term.

relaxed breathing (breathing control) between

INTRODUCTI0N
each of these components (Webber and Pryor,
The active cycle of breathing techniques (ACBT) 1993). The thoracic expansion exercises are in-
combined with postural drainage have been corporated into the regimen, as they are believed
shown to be effective in enhancing the clearance to assist in the loosening and removal of pul-
of the excessive and tenacious sputum produced monary secretions, improve collateral ventilation
by patients with cystic fibrosis (Pryor and Webber, and also, in conjunction with the relaxed breath-
1979; Steven, Pryor, Webber and Hodson, 1992). ing, prevent the occurrence of fatigue, broncho-
The ACBT regimen consists of thoracic ex- spasm and oxygen desaturation (Pryor and
pansion exercises, low- and high-volume huffing Webber, 1979; Pryor, Webber and Hodson,
and/or coughing interspersed with periods of 1990; Webber and Pryor, 1993). Our experience
has been that while thoracic expansion exercises
are relatively easy to teach patients, they often
D. White, Adult Cystic Fibrosis Unit and omit this component of the ACBT when per-
Department of Physiotherapy, K. Stiller, forming independent treatment due to lack of
Department of Physiotherapy, K. Willson,
Statistician, Royal Adelaide Hospital, North concentration and effort. The aim of this study
Terrace, Adelaide, SA 5000, Australia was to evaluate the need for performing thoracic
(Reprint requests to DW) expansion exercises during the ACBT with pos-
Accepted for publication December 1996 tural drainage.
 156 PHYSIOTHERAPY THEORY AND PRACTICE

METHODS Prior to the study, all patients had their ACBT

reviewed by a physiotherapist (D.W.) to ensure
it was being performed correctly. The ACBT
Subjects was performed as follows:
Consecutive patients with an established diag- A period of relaxed breathing (breathing con-
nosis of cystic fibrosis (according to genotype), trol) where patients breathed normally in a
admitted to the Royal Adelaide Hospital with an relaxed manner for four to six breaths.
exacerbation of their pulmonary disease and who Four to six thoracic expansion exercises. Each
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gave their informed written consent, were con- exercise consisted of deep inspiration from
sidered for inclusion in the study. Patients were resting end-expiratory volume, followed by a
excluded if they presented following surgery or breath hold for 2-3 sec and, finally, relaxed
with a pneumothorax, gross haemoptysis, or if expiration. During the period of instruction,
they were admitted for terminal care. The study the physiotherapist gave manual pressure to
was approved by the Research Ethics Committee the lateral chest wall to encourage expansion
of the Royal Adelaide Hospital. of the lower chest.
Once the patients were established on intra- 0 Relaxed breathing for four to six breaths.
venous antibiotics and other medical treatment 0 One to two huffs from mid to low lung volume.
was stabilised, each was randomly allocated to 0 Relaxed breathing for four to six breaths.
a treatment using a two-period, two-treatment 0 One to two huffs from high lung volume and/
crossover trial design. T o minimise the effect of or cough with expectoration as required.
For personal use only.

spontaneous improvement, the treatment re-

gimens were performed on consecutive days at The duration of the periods of relaxed breath-
approximately the same time of day. Other ing and/or thoracic expansion exercises was
patient management (e.g. medication, exercise) varied within the above parameters depending
did not alter during the 2 days of the study. on the response of the patient (e.g. symptoms of
Bronchodilators were administered prior to treat- bronchospasm, breathlessness or tiredness). Only
ment by nebuliser or metered dose inhaler. Mode two postural drainage positions were used during
of bronchodilator administration remained con- any one treatment session. Each position was
stant for each patient on the 2 days of the study. maintained for a minimum of 10 min until huffing
Treatment commenced within 5 min of com- or coughing sounded clear and became non-
pletion of bronchodilator administration for all productive. For two patients with copious sputum
patients. who always had productive coughs, treatment
was continued until the patient and physio-
Treatments therapist subjectively believed most secretions
had been cleared. The postural drainage po-
Treatment A consisted of the ACBT with postural sitions selected were those that drained the areas
drainage, incorporating the thoracic expansion of the lungs that were most affected, as decided
exercises (Webber, 1990). Treatment B was as by auscultation, chest X-ray and/or were sub-
described for treatment A with the exclusion of jectively felt by the patient to be congested. The
the thoracic expansion exercises. During the time same postural drainage positions were used in
the patient would normally have been performing the same order for both treatments during the
the thoracic expansion exercises, he or she con- study period for any one patient, but the positions
tinued further relaxed breathing (breathing con- used varied between patients. If manual chest
trol). T o ascertain the length of time needed for wall percussion or vibrations had previously been
relaxed breathing alone, the time spent per- demonstrated to enhance sputum clearance and
forming the cycle of relaxed breathing and thor- were therefore usually part of a patient’s treat-
acic expansion exercises was measured before ment regimen, these were performed by a physio-
the study. therapist (D.W) during the thoracic expansion
 PHYSIOTHERAPY THEORY AND PRACTICE 157

exercises (treatment A) or the equivalent time performed with the patient sitting on the edge of
during the relaxed breathing (treatment B). the bed and wearing a noseclip was recorded at
Otherwise, the treatments were performed in- each measurement time. Sputum expectorated
dependently by the patient with verbal instruction was collected from the time of administration of
by a physiotherapist (D.W.) if required. bronchodilator until 30 rnin post-treatment and
the wet weight measured on a calibrated scale
accurate to three decimal points (Mettler [Bas
Measurements Ball Balance). Pulse oximetry (Ohmeda, Biox
model 3740) using a finger probe was commenced
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Each patient's age, sex, height and weight were immediately following bronchodilator ad-
recorded and body mass index [weight (kg)/ ministration and continued until 30 min post-
height (m')] calculated. Each patient's disease treatment.
severity was classified according to their FEV, as All data were collected by the same physio-
follows: severe 140% of the predicted value, therapist throughout the study (D.W.) At the
moderate =41-70% of the predicted value, mild end of the study, the patients were asked which
>70% of the predicted value. The number of treatment they preferred and why.
days post-admission and use of bronchodilators,
steroids and antibiotics were noted from the
patient's case notes and medication charts. The Statist icaI analysis
number of patients requiring percussion or vi-
brations during treatment was also recorded. Analyses were performed using the SAS (version
For personal use only.

A calibrated portable spirometer (Pony model, 6.1 1) statistical software package. Repeated
Cosmed) was used to measure forced vital cap- measures analysis of variance was used for con-
acity (FVC), forced expiratory volume in 1 sec tinuous scores and non-parametric tests (Wil-
(FEV,), forced expiratory flow between 25 and coxon test) where skewed distributions were
75% of vital capacity (FEF25-750,Jand FEV,/FVC encountered. Probability values of less than 0.05
prior to administration of bronchodilator, just were deemed significant.
prior to commencement of treatment and im- It was determined statistically (STPLAN ver-
mediately and 30 rnin post-treatment. The high- sion 4, B. Brown, University of Texas) that a
est of three satisfactory FVC manoeuvres sample size of 13 subjects was required, allowing
for a Type 1 error of 0.05, a Type 2 error
of 0.20 (statistical power of 80%), an inherent
Table 1
variability of 9% (FEV,/FVC) (Nickerson et al,
Profiles of the patients included in the Wdy (n= 15)' 1980), assuming a correlation of 0.8 for the paired
difference and considering a difference of 5% to
Age (years) 21.8 f 5.2 be clinically significant.
Sex, F/M ( n ) 8ll
Body mass index 19.9k 1.6
Days post-admission 7.0f2.6
Disease severity ( n ) RESULTS
Mild (FEV1>70%pred.) 3
Moderate (FEV, = 41-70% pred.) 4
Severe (FEV, ~ 4 0 % pred.) 8 Fifteen patients were included in the study. Treat-
Medication ments were given in the order A/B on nine
Bronchodilators ( n ) 15 occasions and B/A on six occasions. Table 1
Inhaled steroids ( n ) 10 gives the profiles of the patients who participated
Parenteral steroids ( n ) 1
Antibiotics ( n ) 15 in the study. Total treatment time ranged from
Percussion/vibrations given during 2 19 to 37 min. The mean length ( & SD) of treat-
treatment ( n ) ment time was not significantly different (t-test,
'Values are meansf standard deviations unless otherwise P=O.9) between treatment A (27.3f6.1 min)
stated. and treatment B (27.5f5.7 min).
 158 PHYSIOTHERAPY THEORY AND PRACTICE

The results of spirometry and oximetry ac- advocated that thoracic expansion exercises are
cording to treatment group are shown in Figs 1 an integral component of the ACBT, the findings
and 2 and Table 2 (data are pooled according of this study question such a claim. For our
to treatment group and irrespective of treatment sample of adult cystic fibrosis patients, there
order). There were no significant differences de- were no significantdifferencesseen in spirometry,
tected between treatments A and B for any of sputum weight or oxygen saturation when the
these data. Other spirometric data were recorded thoracic expansion exercises were replaced by
(e.g. peak expiratory flow rate, isovolume flow an equivalent period of relaxed breathing. It is
rates at 25%, 50% and 75% of vital capacity), acknowledged, however, that thoracic expansion
Physiother Theory Pract Downloaded from informahealthcare.com by Inst of Medical & Veterinary Sci on 09/18/13

but the results were not included for the sake of exercises may have a beneficial effect on para-
brevity - there were no significant differences in meters whose measurement was beyond the scope
these data between treatments A and B. The of this study (e.g. ventilation distribution).
mean (+SD) sputum weight cleared was not There was a large variation in the weight of
significantly different (P=0.17, paired t-test; P= sputum produced by patients (1.3-95.0 g). It
0.36, Wilcoxon signed rank test) between treat- could be argued that this degree of variability
ment A (23.8f23.1 g) and treatment B may have masked any differences between the
(20.4 f 15.9 g). two treatments and the study should have been
As far as the patients’ preferences for treat- restricted to patients with copious sputum. How-
ment are concerned, six patients preferred treat- ever, in clinical practice, most cystic fibrosis
ment B (no thoracic expansion exercises) for the patients receive treatment aimed at improving
reasons that it required less effort or con- clearance of secretions, particularly during an in-
For personal use only.

centration and was less tiring. Three preferred patient admission, regardless of the amount of
treatment A (with thoracic expansion exercises), sputum they produce. Furthermore, it has been
as they believed it cleared more secretions. Six demonstrated that sputum weight may not be
patients did not prefer one treatment over the representative of the quantity of mucus in the
other. airways and, conversely, even unproductive
coughing may increase mucociliary clearance
(Hasani, Pavia, Agnew and Clarke, 1991, 1994a,
DISCUSSION b). In addition, the quantity of sputum (weight
or volume) cleared during treatment has not
Although it is accepted that the ACBT with been found to correlate with improvements in
postural drainage is an effective treatment for pulmonary function (Cochrane, Webber and
the clearance of retained and/or excessive pul- Clarke, 1977; Feldman, Traver and Taussig,
monary secretions, studies such as this assist in 1979; Hasani et al, 1994a, b). Considering these
the clarification of which components of the points, we believe that sputum weight (or volume)
technique are essential. Previous studies have should not be used as the main indicator of
demonstrated that postural drainage enhances treatment effectiveness. The rationale for meas-
sputum clearance when added to the ACBT uring sputum weight in this study was that it has
(Sutton et al, 1983; Steven et al, 1992). The need often been used to measure the effectiveness of
for percussion is less certain. Although Sutton et treatment in previous studies. As noted earlier,
al (1985) and Gallon (1991) found significantly there was no significant difference in the mean
improved clearance of sputum when percussion weight of sputum produced between treatments
was included in treatment regimens, other au- A and B. In addition, if individual patient results
thors have found no significant benefit in terms are examined, nine patients produced more spu-
of sputum clearance with the use of percussion tum during treatment A and six patients produced
(Murphy, Concannon and Fitzgerald, 1983; Sut- more sputum during treatment B. Thus there is
ton et al, 1985; Webber, Parker, Hofmeyr and no evidence to suggest that one treatment was
Hodson, 1985; Wollmer, Ursing, Midgren and more effective than the other in terms of sputum
Eriksson, 1985). Although it has been strongly clearance.
 PHYSIOTHERAPY THEORY AND PRACTICE 159

Table 2
Oxygen saturation for patients according to treatment group but
irrespective of treatment order'

Treatment A Treatment B Pvalue

Pre-treatment 95.2k0.60 94.5k 0.60 0.24

During treatment
Position 1 94.0 0.60 93.4k 0.59 0.29
Position 2 93.2k0.60 92.5f 0.59 0.23
Post-treatment
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0-10 min 93.1k0.60 93.2k0.59 0.91

11-20 min 93.5f 0.61 93.1k0.60 0.43
21-30 min 93.3k 0.61 92.7k 0.65 0.38
Values are mean percentageskstandard errors. Multivariate analysis of variance
was used for statistical analysis. Oxygen saturation was recorded by the oximeter
every 30 sec and the mean value calculated for each time period.
For personal use only.

0
Pre-
bronchodilator
Immediately
pre-treatment
Fig. 1 Absolute values for FVC, FEV, and FEF2b75X.A,treatment A; .,
Immediately
post-treatment
30 minutes
post-treatment
treatment 6. FVC =forced vital
capacity, FEV, =forced expiratory volume in 1 sec. FEF2e75X=forced expiratory flow rate between 25 and 75%
of vital capacity. For the sake of clarity, standard error bars are not shown. Standard errors were as follows:
FVC, 0.22 at all times; FEV,, 0.18 at all times; FEF21r75K, 0.23 at all times.
 Physiother Theory Pract Downloaded from informahealthcare.com by Inst of Medical & Veterinary Sci on 09/18/13
For personal use only.

100

90

80
FVC percentage predicted
(solid lines)
70 FEV,/FVC percentage predicted
(dashed lines)
60 FEViFVC%

50

40

30
F E F K ~percentage predicted

20

10

0
Pre- Immediately Immediately 30 minutes
bronchodilator pre-tmatment post-treatment post-treatment

Fig. 2 Percentage predicted values for FVC, FEV,, FEVJFVC and FEF=,= and absolute values for FEVJFVC. A,treatment A; treatment B. FVC=forced
vital capacity, EV,=fOrCed expiratory volume in 1 sec, FEFBm=forced expiratory flow rate between 25 and 75% of vital capacity. For the sake of clarity,

F
, % predicted, 4.9 at all times; FEVJFVC % predicted, 3.3 at all times; FEVJFVC, 2.9 at all times.
.,
standard error bars are not shown. Standard errors were as follows: N C % predicted, 3.5 pre-kntolin and 3.4 at other times; FEV, % predicted, 4.20 at
all times;, ,E
 PHYSIOTHERAPY THEORY AND PRACTICE 16 1

The mean S p 0 2levels for patients during this exacerbation of their pulmonary disease, the
study remained above 9O0/o. It is possible that ACBT with postural drainage may be simplified if
the use of thoracic expansion exercises may be desired by replacing thoracic expansion exercises
more beneficial for patients who have lower rest- with relaxed breathing with no obvious loss of
ing S p 0 2 levels. It was not possible to analyse effect or apparent detrimental effects in the short
whether the thoracic expansion exercises pre- term and improved patient satisfaction. It should
vented desaturation or bronchospasm during per- be stressed that if thoracic expansion exercises
cussion and vibrations, since only two patients are omitted, they should, until otherwise proven,
received them. As percussion has been shown to be replaced with an equal period of relaxed
Physiother Theory Pract Downloaded from informahealthcare.com by Inst of Medical & Veterinary Sci on 09/18/13

be associated with bronchospasm and/or de- breathing. Further studies are needed to clarify
saturation in previous studies (Campbell, O’Con- the long-term effect of omitting thoracic ex-
nell and Wilson, 1975; Wollmer et al, 1985; pansion exercises from the ACBT with postural
McDonnell, McNicholas and Fitzgerald, 1986; drainage, particularly for patients with varying
Carr, Pryor and Hodson, 1995), it is possible degrees of arterial hypoxaemia or who receive
that their use may necessitate the inclusion of percussion or vibrations. In addition, the effect-
thoracic expansion exercises. iveness of the other components of the ACBT and
The power calculation was based on the use patients with stable pulmonary disease should be
of FEV,/FVC. If other parameters with a higher investigated.
diurnal variability, such as FEV, or FVC, had
been used in the power calculation, the sample
size might not have been large enough to cover Acknowledgements
For personal use only.

the desired power. Nevertheless, the magnitude

The authors would like to thank Mark Holmes, Physician in
Of the differences Seen between treatments A
Charge, Cystic Fibrosis Unit and Naomi Haensel, Director,
and B indicated that the inclusion of additional Physiotherapy, Royal Adelaide Hospital for their support, as
subjects is unlikely to have influenced the results. well as Marie Williams, School of Physiotherapy, University
of South Australia, for her help in editing this article and all
One physiotherapist was responsible for verb- patients who participated in the study,
ally instructing all patients during treatment as
required and collecting all data. This physio-
therapist also performed percussion and vi- References
brations for two patients. While this raises the
possibility of researcher bias, the use of another Campbell AH, O’Connell JM, Wilson F 1975 The effect of
researcher to help with the study was not possible chest physiotherapy upon the FEV, in chronic
bronchitis. Medical Journal of Australia I: 33-35
for the practical reason that this research was Carr L, Pryor JA, Hodson ME 1995 Self chest clapping:
performed as part of a normal clinical workload. Patients’ views and the effects on oxygen saturation.
To help avoid the potential for researcher bias, Physiotherapy 81: 753-757
Cochrane GM, Webber BA, Clarke SW 1977 Effect of
the physiotherapist involved in data collection sputum on pulmonary function. British Medical Journal
and treatment gave standardised instructions for 2: 1181-1 183
pulmonary function testing. All other meas- Feldman J, Traver GA, Taussig LM 1979 Maximal
expiratory flows after postural drainage. American
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intervention from the physiotherapist and there- treatment of patients with copious sputum production.
Respiratory Medicine 85: 45-5 I
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CONCLUSIONS lung clearance during cough and forced expiration
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In summary, the results of this study suggest Hasani A, Pavia D, Agnew JE, Clark SW 1994b Regional
that for adult cystic fibrosis patients with an mucus transport following unproductive cough and
 162 PHYSIOTHERAPY THEORY AND PRACTICE

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obstruction. Chest 105: 1420-1425 Clay MM, Webber B, Parker RA, Clark SW 1985
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For personal use only.

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