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The Active Cycle of Breathing
PHYSIOTHERAPY
Technique (ACBT) – ACBT Video

(For ACBT patient information sheets in

PHYSIOTHERAPY
different languages go to – ACBT)
 The active
cycle of The active cycle of breathing is a technique

breathing used for:

technique

clearance of excess
 Forced
secretions from the lungs
Expiration
Technique
improving ventilation of
the lungs
 Positive
Expiratory
Pressure
The technique can be performed in any
Therapy
breath enhancing position and no equipment
is required. When used to clear secretions, it
 Oscillating
may also be effective when performed in the
Positive
shower, where steam can assist with the
Expiratory
humidi�cation of the airways.
Pressure
 Therapy ACBT has three components:

 Autogenic
Drainage breathing control

 Gravity thoracic expansion

Assisted exercises
Drainage
huf�ng
 Manual
Techniques
The �exibility of the regimen (the number of

 Inhalation deep breaths, the number of huffs and the

Therapy via a length of the periods of breathing control)

Nebuliser and order of the components varies with the

patients’ condition and should be adapted to
 Af�oVest suit the individual (Fig 1). Each component
plays a key role in the clearance of
 Expiration secretions.  A longer period of breathing
with an open control is generally required in the presence
glottis in the of wheeze, shortness of breath, an irritable
lateral cough and anxiety.
posture
                                             
 Breathing
Dysfunction

Fig. 1.  BC – breathing

control; TEE – thoracic
expansion exercise: FET –
forced expiration
technique (diagram
 courtesy of CF blue
booklet).

A typical cycle of ACBT consists of:

breathing control (until the

patient is settled and ready
to commence)

thoracic expansion
exercises – 3 to 5

breathing control (until

patient returns to their
normal resting breathing
rate)

thoracic expansion
exercises – 3 to 5

breathing control

huffs – at the appropriate

inspiratory volume,
depending on the position
of the sputum

breathing control

Huf�ng after each set of thoracic expansion

exercises is generally required when there
are larger quantities of sputum to be cleared
which may vary on a daily basis. With small
amounts of sputum the patient may only
need to huff at the end of each cycle.

The cycle is repeated until the huff is non-

productive or it is time for a rest.
It must be explained to patients with mild
disease that this technique may not result in
the expectoration of any sputum. The cycle
may move the small amount of sputum out of
the peripheral airways and, with the
assistance of the muco-ciliary escalator in the
non-affected parts of the lung, it may be
swallowed or coughed up an hour or so after
practicing the technique.

Prescription:

position (as prescribed by

therapist – either sitting,
side lying, supine or prone)

after bronchodilators (if

prescribed)

repeat cycles as prescribed

by therapist

most sessions will take

approximately 10 minutes

extra sessions may be

required during an
exacerbation

with or without a
prescribed nebuliser

The patient should be given written

instructions including the technique and
prescription.

Description of the technique (see ACBT

video)
Posture

When this technique is taught in the sitting

position, the importance of the correct
posture should be explained to the patient.

Instruct them to sit in a well-supported chair

with a neutral lumbar spine and the neck and
shoulders relaxed. This enhances the
function of the diaphragm and the pelvic
�oor and minimises musculoskeletal stress
(Fig. 2).

Fig. 2 sitting posture

Breathing control

Breathing control is the period of relaxed

breathing, at the patients’ own rate, between
more active parts of the cycle.

Patients should be encouraged to breathe in

through their nose to humidify, warm and
�lter the air and to decrease the turbulence
of inspired �ow.

It is tidal volume breathing, preferably with

the neck and shoulders relaxed and the
diaphragm contracting for inspiration. It
assists with recovery from shortness of
breath, fatigue and signs of bronchospasm.
Breathing control should continue until the
person feels ready to progress to the other
stages in the cycle.

Physiology – Breathing in a
slow and relaxed manner
reduces the work of
breathing and consequently
the oxygen requirements.
Hyperventilation is also a
known trigger for
bronchospasm in some
people (Van den Elshout et
al 1991).

Thoracic expansion exercises

Thoracic expansion exercises are deep

breathing exercises which focus on
inspiration. The patient is instructed to
breathe in slowly and deeply (preferably
through their nose, unless they are using a
nebuliser) with minimal accessory muscle
use. When a maximal inspiration has been
achieved, the patient may be asked to do an
end inspiratory breath hold for three seconds
before passive expiration. This is repeated for
up to �ve breaths.

To facilitate a maximal inspiration,

proprioceptive feedback, with the therapist,
or patient, placing their hands on the
thoracic cage, can be bene�cial. This has
been associated with increased chest wall
movement and improved ventilation (Tucker
1999).
Physiology – Large
inspiratory volumes are
believed to facilitate
collateral ventilation . This
can be further enhanced by
a breath hold. (Menkes &
Traystman 1997).
Resistance to air�ow within
the canals of Martin,
channels of Lambert and
Pores of Kohn, (between
the bronchioles and
alveoli), is usually high,
with little movement
during tidal volume
breaths. With increasing
inspired volumes, the
resistance decreases and
air �ows through these
channels to enhance
expiratory �ow behind the
secretions (see Fig 3).

Fig. 3
Collateral
Ventilation
Channels.

Key – Arrows
– movement
of air �ow, +
signs – air
pressure,
yellow block
– sputum
plug
 At high lung volumes,
achieved during thoracic
expansion exercises, the
expanding forces between
alveoli are greater than at
tidal volume and may assist
with the re-expansion of
lung tissue. This is known
as alveolar inter-dependence
(Fig. 4). During inspiration,
the expanding alveoli exert
forces on the adjacent
alveoli which enhance the
recruitment of lung units.

Fig. 4
Interdependence
of alveoli

A breath hold can be added to the deep

breath to compensate for asynchronous
ventilation which may be present in some
respiratory conditions due to sputum
retention and / or atelectasis. During
inspiration, healthy lung units �ll rapidly
whilst obstructed lung units �ll more slowly.
Units slower to �ll will partially receive their
inspired volume via the collateral channels
(described above) from more rapidly �lling
units (Mead et al 1997).

Huff (see Forced ExpirationTechnique video)

A huff (also called the forced expiration

technique [FET] when combined with
breathing control) is a manoeuvre used to
move secretions, mobilised by thoracic
expansion exercises, downstream towards
the mouth.

When initially taught, the patient is

instructed to take a medium breath in and to
breathe out with mild to moderate force and
extended expiratory �ow, with the glottis
open. The length of the huff and force of
contraction of the muscles of expiration
should be altered to optimise clearance of
secretions (Pryor & Prasad 2008) by
maximising air �ow.

For patients with the cognitive ability, three

levels of huf�ng can be taught. The patient is
instructed to huff with �rst small, then
medium and �nally, large volume inspiratory
breaths, to assist in moving secretions from
the peripheral airways, through the medium
airways, towards the mouth. With all of these
inspiratory volumes, the expiratory force and
length of expiration are the same (see the
physiology section below).

To facilitate the opening of the glottis, the

patient can be taught to perform a huff with
a piece of cardboard spirometry tubing (or
any tubing of a similar diameter) placed at
least four centimetres inside their open
mouth (Fig.5).

If taught appropriately, the FET is probably

the most effective airways clearance
technique (van der Schans 1997).
 Fig. 5 Huf�ng using a
spirometry tube

Physiology – The rationale

behind a huff is based on
the equal pressure point
(EPP) – the point at which
pressure within the bronchi
equals peri-bronchial
pressure (outside the
airway).  (Fig. 6).

Fig. 6 Equal
Pressure
Point

During normal respiration,

the EPP occurs in airways
protected by cartilaginous
rings which help to prevent
airway collapse.

During a forced expiration,

the pressure outside the
airway remains relatively
constant, whilst the
pressure inside the airway
decreases from the
peripheral airways to the
mouth, resulting in airway
compression.

With a forced expiration, a

wave of EPP’s move
peripherally into smaller
airways as the lung volume
decreases and the pressure
within the airway falls.
This, together with the
turbulent air�ow created,
facilitates the movement of
secretions downstream
towards the mouth. The
position of the EPP is
dependent on lung volume
and the pressure outside
the airway. (Fig 7.)The EPP
moves upstream towards
the alveoli when the
volume inside the lungs
decreases and/or the
pressure outside the airway
increases. The EPP moves
downstream towards the
mouth when the volume
inside the lungs increases
and/or the pressure outside
the airway decreases.
Therefore, to move
secretions from peripheral
airways, it is more effective
to commence huf�ng at
low lung volumes and to
progress to medium and
�nally large lung volumes.
 Fig. 7
Movement
of the
Equal
Pressure
Point.

Key:
Blue
segment
– equal
pressure
point, +
sign(s) –
pressure
within
and
outside
the
airway,
arrows –
air�ow

Evidence:

ACBT has been found to be an effective

technique for clearing secretions in patients
with both acute and chronic respiratory
conditions. The majority of studies
have included people with cystic �brosis
(Lewis et al 2012).

Compared to other airways clearance

techniques, ACBT has equivalent short-term
effects on lung function, sputum volume,
oxygen saturation and the number of
pulmonary exacerbations (McKoy 2012).
 Over the long term, similar effects on lung
function, exercise capacity and quality of life
were demonstrated between various airways
clearance techniques (Pryor 2010).

References

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