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Airway clearance techniqueAutogenic DrainageWho developed it?" Self drainage" developed in Belgium in the late 1960's by Chevaillier (asthmatic patients). During 1980's utilized throughout Europe to treat patients with retention of secretions.

What is AD?Autogenic Drainage, or AD, is a breathing technique that uses controlled breathing and minimal coughing to clear secretions from your chest. It involves hearing and feeling your secretions as you breathe out and controlling the desire to cough until secretions are high up and easily reached with minimal effort.

How to Perform it?Begin with some gentle relaxed breaths known as breathing control.Take a very slow deep breath in through your nose, to your absolute maximum possible.Pause at the end of the full breath with your mouth slightly open and count for 3-4 seconds. Start by sitting in a comfortable upright position.Breathe out through your mouth. This should be active (you can feel your tummy muscles tighten) but should not be forced.You should listen and feel for secretions crackling as you breath out Are the crackles at the beginning, middle or end of your breath out? Beginning = high up in large tubes of your chestMiddle= in the middle sized tubesEnd= in the small tubes

3 Phases of AD TechniqueUNSTICK SECRETIONS - breathe as much air out of your chest as you can then take a small breath in, using you tummy, feeling your breath at the bottom of your chest. You may hear secretions start to crackle. Resist any desire to cough.Repeat for at least 3 breaths.

COLLECT SECRETIONS - as the crackle of secretions starts to get louder change to medium sized breaths in. Feel the breaths more in the middle of your chest. Repeat for at least 3 breaths.

EVACUATE SECRETIONS - when the crackles are louder still, take long, slow, full breaths in to your absolute maximum.Repeat for at least 3 breaths.

Fig. Phases of Autogenic Drainage

Level One: "Unsticking" of mucus by low lung level breathing. First, exhale completely; inhale a small to normal breath. Hold the breath for 1-3 seconds, then exhale completely again. This step is repeated for 1-3 minutes. Repeat until crackles are heard when breathing out.

Level Two: "Collecting" the mucus in larger or mid-sized airways. Take in a slightly larger breath. Hold for 1-3 seconds, and then exhale, but not as low as in level one. Repeat this step for 1-3 minutes. Listen for crackles at the end of exhaling. Continue for 2-3 more breaths. Then proceed to level III.Level Three: "Evacuating" the mucus in the central airways is achieved by breathing at normal to high volumes. Take in a slow deep breath. Hold the breath for 1-3 seconds. Exhale forcefully with open glottis. This moves the mucus into your mouth. Then spit it out into a container or tissue.

Each level requires about 2-3 minutes. The full cycle takes 6-9 minutes. When mucus is felt in the larger, central airways, do 2-3 effective "Huff" type coughs. The Huff cough uses the mid to high lung volumes of level III.What not to do?Try to stop yourself from coughing until the last phase of AD when the secretions are higher up, and are more ready to be coughed up.

Try to relax with breathing control if you feel the desire to cough or between cycles. AD breaths are very gentle so you should not start to feel tight or wheezy. AD should be done until your sputum is cleared, or you need a rest.

PEPPEP therapy was first developed in Denmark in the 1970s, as a low-pressure system. High-pressure PEP therapy was developed in Austria, as an adjunct or supplement to traditional airway-clearance methods, and the usual patient interface was a face mask.The theoretical benefit of PEP therapy is the ability to enhance and promote mucus clearance by either preventing airway collapse by stenting the airways or increasing intrathoracic pressure distal to retained secretions, by collateral ventilation or by increasing functional residual capacity.The traditional main components of the device, however, remain the same, and consist of a oneway valve connected to either a small-exit orifice or, more commonly, an adjustable expiratory resistor. A disposable or permanent manometer is incorporated into the system between the one-way valve and the resistor to measure the expiratory pressure (Fig. 1).

Tightening the expiratory resistor decreases the ability of flow to move rapidly through the device and hence increases the expiratory pressure through flow retard. Lowpressure PEP devices typically generate a pressure range of 520 cm H2O at mid-expiration.the high-pressure PEP range as 26 102 cm H2O, which is typically achieved by performing a forced expiratory maneuver directly into a PEP mask after a maximal inspiration. PEP therapy can be administered with the assistance of a respiratory therapist or caregiver, or independently by the patient (Fig. 2) after the patient receives appropriate instruction and does a return demonstration to the instructor. The duration and frequency of treatment should be tailored for each individual, based on the patients specific indications and response to airway clearance therapy.

Contraindications to PEPPatients who are unable to tolerate the in work of breathingICP > 20 mm HgHemodynamic instabilityEpistaxisUntreated pneumothoraxRecent facial, oral or skull surgery or traumaEsophageal surgeryActive hemoptysisNauseaKnown or suspected tympanic rupture or other middle ear problemOscillatory PEP TherapyOPEP therapy was first developed and described in Switzerland, as an adjunct or supplement to traditional airway clearance methods.OPEP combines the purported benefits previously described for PEP with airway vibrations or oscillations. The theoretical benefits of oscillations have been described as a 2-fold effect in airway clearance. Oscillations reportedly decrease the viscoelastic properties of mucus, which makes it easier to mobilize mucus up the airways, and create short bursts of increased expiratory airflow that assist in mobilizing secretions up the airways.Secretion removal is then facilitated by the patient forcing deep exhalations through the device or with subsequent coughing and/or huffing techniquesCOMMON TYPES OF OPEP :Acapella Quake, and FlutterflutterThe Flutter is a handheld device shaped like a pipe, which contains a high-density stainless steel ball that sits in a circular cone inside the bowl of the pipe (Fig. 3).The cover over the ball has perforations that allow expiratory airflow to pass through the device. The Flutter can be used with the patient sitting upright or lying on either side, if a horizontal position is more comfortable and advantageous for the patient. Whatever position the patient uses, the Flutter bowl must be pointed upward (Fig. 4) for maximum efficacy and proper operation.

The basic operation of the Flutter occurs when expiratory flow through the mouthpiece causes the ball to rise and fall within the cone, which creates a PEP between 5 cm H2O and 35 cm H2O. The vibrations, which are typically in the range 826 Hz,7 create airflow pulsations throughout the airways. The Flutter can be tilted (frequently referred to as tuning) slightly upward or downward to change the vibration frequency. Table 2 describes the instructional steps for Flutter therapy.

Acapella

Designed by Smiths Medical CompanySimilar to the flutter valve but with greater functionality (AOD)Utilizes a counterweighted plug and magnet to achieve valve closure (not gravity dependent)3 Models: Green model-Low flow ( < 15 L/min, adjustable resistance)Blue Model- High flow ( > 15 L/min, adjustable resistance)Choice (any flow, adjustable frequency)

QuakeThe Quake device has a manually operated rotating handle that creates the oscillations, and the oscillation frequency is controlled by how quickly the handle is rotated. Rotating the handle slowly creates a low-frequency oscillation and a higher pulsatile expiratory pressure. Rotating the handle quickly provides faster oscillations while decreasing the pulsatile expiratory pressure. Reportedly the Quake can be dissembled for cleaning and its operation and function are not gravity-dependent