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. 2023 Feb 2;2(2):CD007862.
doi: 10.1002/14651858.CD007862.pub5.

Active cycle of breathing technique for cystic fibrosis

Lisa M Wilson  1 , Ian J Saldanha  2 , Karen A Robinson  3
Affiliations

Active cycle of breathing technique for cystic fibrosis

Lisa M Wilson et al. Cochrane Database Syst Rev. .

Abstract

Background: People with cystic fibrosis (CF) experience chronic airway infections as a result of mucus buildup within the lungs. Repeated infections often cause lung damage and disease. Airway clearance therapies aim to improve mucus clearance, increase sputum production, and improve airway function. The active cycle of breathing technique (ACBT) is an airway clearance method that uses a cycle of techniques to loosen airway secretions including breathing control, thoracic expansion exercises, and the forced expiration technique. This is an update of a previously published review.

Objectives: To compare the clinical effectiveness of ACBT with other airway clearance therapies in CF.

Search methods: We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched clinical trials registries and the reference lists of relevant articles and reviews. Date of last search: 29 March 2021.

Selection criteria: We included randomised or quasi-randomised controlled clinical studies, including cross-over studies, comparing ACBT with other airway clearance therapies in CF.

Data collection and analysis: Two review authors independently screened each article, abstracted data and assessed the risk of bias of each study. We used GRADE to assess our confidence in the evidence assessing quality of life, participant preference, adverse events, forced expiratory volume in one second (FEV1) % predicted, forced vital capacity (FVC) % predicted, sputum weight, and number of pulmonary exacerbations.

Main results: Our search identified 99 studies, of which 22 (559 participants) met the inclusion criteria. Eight randomised controlled studies (259 participants) were included in the analysis; five were of cross-over design. The 14 remaining studies were cross-over studies with inadequate reports for complete assessment. The study size ranged from seven to 65 participants. The age of the participants ranged from six to 63 years (mean age 18.7 years). In 13 studies follow up lasted a single day. However, there were two long-term randomised controlled studies with follow up of one to three years. Most of the studies did not report on key quality items, and therefore, have an unclear risk of bias in terms of random sequence generation, allocation concealment, and outcome assessor blinding. Due to the nature of the intervention, none of the studies blinded participants or the personnel applying the interventions. However, most of the studies reported on all planned outcomes, had adequate follow up, assessed compliance, and used an intention-to-treat analysis. Included studies compared ACBT with autogenic drainage, airway oscillating devices (AOD), high-frequency chest compression devices, conventional chest physiotherapy (CCPT), positive expiratory pressure (PEP), and exercise. We found no difference in quality of life between ACBT and PEP mask therapy, AOD, other breathing techniques, or exercise (very low-certainty evidence). There was no difference in individual preference between ACBT and other breathing techniques (very low-certainty evidence). One study comparing ACBT with ACBT plus postural exercise reported no deaths and no adverse events (very low-certainty evidence). We found no differences in lung function (forced expiratory volume in one second (FEV1) % predicted and forced vital capacity (FVC) % predicted), oxygen saturation or expectorated sputum between ACBT and any other technique (very low-certainty evidence). There were no differences in the number of pulmonary exacerbations between people using ACBT and people using CCPT (low-certainty evidence) or ACBT with exercise (very low-certainty evidence), the only comparisons to report this outcome.

Authors' conclusions: There is little evidence to support or reject the use of the ACBT over any other airway clearance therapy and ACBT is comparable with other therapies in outcomes such as participant preference, quality of life, exercise tolerance, lung function, sputum weight, oxygen saturation, and number of pulmonary exacerbations. Longer-term studies are needed to more adequately assess the effects of ACBT on outcomes important for people with cystic fibrosis such as quality of life and preference.

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Conflict of interest statement

Lisa Wilson declares no known potential conflict of interest.

Ian Saldahna declares no known potential conflict of interest.

Karen Robinson declares no known potential conflict of interest.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about risk of bias domains for each included study.
3
3
Risk of bias graph: review authors' judgements about risk of bias domains presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1: ACBT versus CCPT, Outcome 1: FEV 1 (L)
1.2
1.2. Analysis
Comparison 1: ACBT versus CCPT, Outcome 2: FVC (L)
1.3
1.3. Analysis
Comparison 1: ACBT versus CCPT, Outcome 3: Pulmonary exacerbation
2.1
2.1. Analysis
Comparison 2: ACBT versus PEP, Outcome 1: FEV 1 (L)
3.1
3.1. Analysis
Comparison 3: ACBT versus AOD (Cornet), Outcome 1: FEV 1 (L)
4.1
4.1. Analysis
Comparison 4: ACBT versus AOD (Flutter), Outcome 1: FEV 1 (L)
4.2
4.2. Analysis
Comparison 4: ACBT versus AOD (Flutter), Outcome 2: Sputum weight
5.1
5.1. Analysis
Comparison 5: ACBT + CCPT versus AOD (Flutter), Outcome 1: FEV 1 (L)
5.2
5.2. Analysis
Comparison 5: ACBT + CCPT versus AOD (Flutter), Outcome 2: FEV 1% predicted
5.3
5.3. Analysis
Comparison 5: ACBT + CCPT versus AOD (Flutter), Outcome 3: FVC (L)
5.4
5.4. Analysis
Comparison 5: ACBT + CCPT versus AOD (Flutter), Outcome 4: FVC % predicted
5.5
5.5. Analysis
Comparison 5: ACBT + CCPT versus AOD (Flutter), Outcome 5: Sputum weight
5.6
5.6. Analysis
Comparison 5: ACBT + CCPT versus AOD (Flutter), Outcome 6: Oxygen saturation
6.1
6.1. Analysis
Comparison 6: ACBT + CCPT versus HFCC (HFCWO), Outcome 1: FEV 1 (L)
6.2
6.2. Analysis
Comparison 6: ACBT + CCPT versus HFCC (HFCWO), Outcome 2: FEV 1% predicted
6.3
6.3. Analysis
Comparison 6: ACBT + CCPT versus HFCC (HFCWO), Outcome 3: FVC (L)
6.4
6.4. Analysis
Comparison 6: ACBT + CCPT versus HFCC (HFCWO), Outcome 4: FVC % predicted
6.5
6.5. Analysis
Comparison 6: ACBT + CCPT versus HFCC (HFCWO), Outcome 5: Sputum weight
6.6
6.6. Analysis
Comparison 6: ACBT + CCPT versus HFCC (HFCWO), Outcome 6: Oxygen saturation
7.1
7.1. Analysis
Comparison 7: ACBT versus AD, Outcome 1: FEV 1 (L)
7.2
7.2. Analysis
Comparison 7: ACBT versus AD, Outcome 2: Sputum weight
8.1
8.1. Analysis
Comparison 8: ACBT + CCPT versus AD, Outcome 1: FEV 1 (L)
8.2
8.2. Analysis
Comparison 8: ACBT + CCPT versus AD, Outcome 2: FEV 1% predicted
8.3
8.3. Analysis
Comparison 8: ACBT + CCPT versus AD, Outcome 3: FVC (L)
8.4
8.4. Analysis
Comparison 8: ACBT + CCPT versus AD, Outcome 4: FVC % predicted
8.5
8.5. Analysis
Comparison 8: ACBT + CCPT versus AD, Outcome 5: Oxygen saturation
8.6
8.6. Analysis
Comparison 8: ACBT + CCPT versus AD, Outcome 6: Sputum weight
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Miller 1995 {published data only}
    1. Hall DO, Miller S, Clayton CB, Nelson R. Chest physiotherapy in cystic fibrosis: A comparative study of autogenic drainage and the active cycle of breathing technique. In: 19th European Cystic Fibrosis Conference; 1994 May 29-June 3; Paris, France. 1994:O64. [CFGD REGISTER: PE28a] - PMC - PubMed
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Mortensen 1991 {published data only}
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Osman 2010 {published and unpublished data}
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Phillips 2004 {published data only}
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Pike 1999 {published data only}
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Pryor 1979 {published data only}
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Pryor 1994 {published data only}
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Pryor 2010 {published data only}
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Reisman 1988 {published data only}
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Steven 1992 {published data only}
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Webber 1985 {published data only}
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References to studies excluded from this review

ACTRN12605000471684 {published data only}
    1. ACTRN12605000471684. Chest physiotherapy use and gastro-oesophageal reflux symptoms in adults with cystic fibrosis. anzctr.org.au/ACTRN12605000471684.aspx (first received 23 September 2005).
ACTRN12614001233617 {published data only}
    1. ACTRN12614001233617. Does the bubble­-positive expiratory pressure (PEP) device improve secretion clearance compared to the active cycle of breathing technique (ACBT) or no intervention (control) in people with non­-cystic fibrosis bronchiectasis? anzctr.org.au/ACTRN12614001233617.aspx (first received 25 November 2014).
ACTRN12619000224123 {published data only}
    1. ACTRN12619000224123. Modified forced expiration technique using expiratory resistance in adults with cystic fibrosis: A pilot study. anzctr.org.au/ACTRN12619000224123.aspx (first received 15 February 2019). [CFGD REGISTER: PE333]
ACTRN12619001681145 {published data only}
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Andreasson 1987 {published data only}
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Asher 1982 {published data only}
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Bain 1988 {published data only}
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Baldwin 1994 {published data only}
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Braggion 1995 {published data only}
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Castle 1994 {published data only}
    1. Castle T, Metcalfe C, Knox A. A comparison between the active cycle of breathing technique (A.C.B.T.) and positive expiratory pressure (PEP) mask plus A.C.B.T. on sputum production and lung volumes in adults with cystic fibrosis. In: 19th European Cystic Fibrosis Conference; 1994 May 29-June 3; Paris, France. 1994:O17. [CFGD REGISTER: PE49]
Chatham 1998 {published data only}
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ChiCTR1800019989 {published data only}
    1. ChiCTR1800019989. Study for rehabilitation effect of the active cycle of breathing technique combined with 5A model in patients undergoing lung cancer surgery. www.chictr.org.cn/showproj.aspx?proj=32782 (first registered 11 December 2018).
Davies 2012 {published data only}
    1. Banks A, Davies G, Agent P, Osman L, Bilton D, Hodson M. The use of high frequency chest wall oscillation during an acute infective pulmonary exacerbation of cystic fibrosis. European Respiratory Journal 2012;40(Suppl 56):Abstract no: 3483. [CFGD REGISTER: PE197b]
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Desmond 1983 {published data only}
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Falk 1984 {published data only}
    1. Falk M, Kelstrup M, Andersen JB, Kinoshita T, Falk P, Stovring S, et al. Improving the ketchup bottle method with positive expiratory pressure, PEP, in cystic fibrosis. European Journal of Respiratory Diseases 1984;65(6):423-32. [CFGD REGISTER: PE7] - PubMed
Falk 1993 {published data only}
    1. Falk M, Mortensen J, Kelstrup M, Lanng S, Larsen L, Ulrik CS. Short-term effects of positive expiratory pressure and the forced expiration technique on mucus clearance and lung function in CF. Pediatric Pulmonology 1993;16(Suppl 9):241. [CFGD REGISTER: PE48a]
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Gursli 2017 {published data only}
    1. Gursli S, Quittner A, Jahnsen RB, Skrede B, Stuge B, Bakkeheim E. Airway clearance physiotherapy and health-related quality of life in cystic fibrosis - a substudy of a series of n-of-1 randomised controlled trials. Journal of Cystic Fibrosis 2022;21(Suppl):S126. [CFGD REGISTER: PE206d] - PMC - PubMed
    1. Gursli S, Sandvik L, Bakkeheim E, Skrede B, Stuge B. Airway clearance therapy and quality of life in cystic fibrosis: a pilot study of a series of n-of-1 randomised controlled trials. Pediatric Pulmonology 2017;52 Suppl 47:395-6. [CFGD REGISTER: PE206c] - PMC - PubMed
    1. Gursli S, Sandvik L, Bakkeheim E, Skrede B, Stuge B. Evaluation of a novel technique in airway clearance therapy - Specific Cough Technique (SCT) in cystic fibrosis: a pilot study of a series of N-of-1 randomised controlled trials. SAGE open medicine 2017;5:no pagination. [CFGD REGISTER: PE206b] - PMC - PubMed
    1. Gursli S, Sandvik L, Skrede B, Stuge B. Individual efficacy of cough technique versus forced expiration technique in cystic fibrosis. Journal of Cystic Fibrosis 2013;12 Suppl 1:S103. [ABSTRACT NO.: 214] [CENTRAL: 875195] [CFGD REGISTER: PE206a]
    1. NCT01266473. Study of individualized physiotherapy for airway clearance in cystic fibrosis [Efficacy study of physiotherapy for airway clearance in cystic fibrosis. Randomized controlled trials in single subjects (N of 1 RCT`s)]. www.clinicaltrials.gov/show/NCT01266473 (first registered 24 December 2010). [CFGD REGISTER: PE206e]
Hasani 1991 {published data only}
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Hasani 1994 {published data only}
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References to other published versions of this review

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