1. Autogenic DrainageDr. Vinod Ravaliya, MPT (Cardiothoracic) KMPIP, Shree Krishna Hospital Karamsad

2. Who developed it?" Self drainage" developed in Belgium in the late1960s by Chevaillier (asthmatic patients). During1980s utilized throughout Europe to treat patientswith retention of secretions. 3. 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. 4. How to Perform it? Begin with some gentle relaxed breaths known asbreathing control. Take a very slow deep breath in through your nose, toyour absolute maximum possible. Pause at the end of the full breath with your mouthslightly open and count for 3-4 seconds. Start by sitting ina comfortable upright position. Breathe out through your mouth. This should be active(you can feel your tummy muscles tighten) but should notbe forced. You should listen and feel for secretions crackling as youbreath out Are the crackles at the beginning, middle or endof your breath out? Beginning = high up in large tubes ofyour chestMiddle = in the middle sized tubesEnd = in the small tubes 5. 3 Phases of AD Technique UNSTICK 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. 6. Fig. Phases of Autogenic Drainage 7. 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. 8. 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. 9. 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. 10. Each level requires about 2-3 minutes. The fullcycle takes 6-9 minutes. When mucus is felt inthe larger, central airways, do 2-3 effective "Huff"type coughs. The Huff cough uses the mid tohigh lung volumes of level III. 11. What not to do? Try to stop yourself from coughing until thelast phase of AD when the secretions arehigher up, and are more ready to be coughedup. Try to relax with breathing control if you feel thedesire to cough or between cycles. AD breathsare very gentle so you should not start to feeltight or wheezy. AD should be done until yoursputum is cleared, or you need a rest. 12. FlutterDr.Vinod K Ravaliya, MPT(Cardiothoracic)KMPIP, Shree Krishna HospitalKaramsad 13. Flutter Developed in Switzerland, early 1990s. The patient exhales into the device against a resistance(5-20cmH2O) generated by a ball covering the openingof an enclosed upward and widening cone. Themovement of the ball during expiration creates anoscillating frequency between 8-26Hz 14. Theoretical Physiology Incorporates- positive expiratory pressure(adjusted by flow rate)- oral high frequency oscillation (angle of device)- active breathing exercises. Oscillating positive pressure prevents earlyairway collapse. The rhythmic variation of airwaydiameter and airflow promotes mucusmobilization. Oscillation approximates the ciliabeat frequency of 12Hz. 15. Application Instructions say practice 2-3 times daily for 3-10minutes. Take a deep breath with a 2-3 secondhold then exhale fully adjusting the angle andflowrate to attain optimal vibration. Perform 5-15then increase the depth of breath and speed ofexhalation to precipitate cough and mucusexpectoration. The Flutter can be incorporated into the ACBTduring the thoracic expansion phase, but isdifficult to combine with postural drainage.Appears to be less effective than posturaldrainage and manual techniques in large sputumproducers. 16. Indications Retained secretions (particularly if sticky) Patients seeking freedom from postural drainageand assistance who prefer the upright posture fortreatment, or where postural drainage and/ormanual techniques are contra indicated. Good for children, stimulates cough. 17. Precautions Similar to those for PEP- untreated pneumothorax, severe haemoptysis, facial fractures/surgery, sinusitis or ear problems. Some clients report early uncontrolled coughing particularly in the presence of hyper-reactive airways 18. Thanks