32

Journal of the Royal Society of Medicine Supplement No. 16 Volume 82 1989

Autogenic drainage: a modern approach to physiotherapy in cystic fibrosis

M H Schoni MD

Alpine Kinderklinik Pro Juventute, CH-7270 Davos Platz, Switzerland

Keywords: cystic fibrosis; physiotherapy; autogenic drainage; PEP mask; forced expiration technique

Introduction The aim of chest physiotherapy is to prevent respiratory complications and to improve pulmonary function in cases of acute or chronic pulmonary disease. The goals of physical intervention are to maintain normal movement of the chest, to strengthen auxiliary respiratory muscles, to mobilize secretions, to prevent unproductive cough, to maintain or improve exercise tolerance, to learn some breath relieving body positions, and finally to improve self esteem. To reach these goals, several techniques have been developed which can be used according to patients' needs. This paper reviews the approaches to physiotherapy in cystic fibrosis (CF).

concluded that the efficiency of postural drainage is improved by using forced expiration. Since postural drainage is known to have some adverse effects on oxygen saturation, and because stopping chest physiotherapy for as little as 3 weeks6 results in a reversible worsening of lung function, other therapies have been evaluated.
Forced expiration technique (FET) Apart from regular physical exercise or special breathing exercises, the forced expiratory technique was the first self-performed chest physiotherapy reported to be useful for CF patients, and is based on the concept of the equal pressure point (EPP) theory of Mead et al.'0. It has also been shown that FET was as effective as conventional physiotherapy in inducing cough and mucus clearance9. Support of this technique has also been given by the observation that transpulmonary pressure during FET was significantly less than during coughing, and therefore less airway compression occurred. The main advantage of this technique is that it is easily performed alone by the patient and thus avoids dependence on other individuals for treatment. This technique has, however, been questioned by Rossman" and others6 who found that (i) direct coughing was as effective as any other techniques in the removal of secretions and (ii) that any lung function test failed to show any relief of airway obstruction despite elimination of various amounts of sputum. Vigorous coughing (11 times over 10 min) was comparable to conventional physiotherapy with postural drainage and clapping in terms of the resulting sputum production and in influencing flows at mid or low lung volume in another study'2. From this, it would be reasonable to instruct a patient that vigorous coughing can be used to replace chest physiotherapy when it is impractical to perform the latter.
Positive expiratory pressure breathing (PEP) Some investigators have introduced helping devices to support physiotherapy interventions, to improve the loosening of sticky secretions, to increase the volume of removable sputum, to provide selfperformed chest physiotherapy and to avoid high pulmonary pressure swings as they occur during coughing. A lightweight vibrator can be used to support percussion and this form of therapy has been shown to be as effective as therapist-administered chest percussion and vibration'3. A randomized study evaluated whether positive expiratory pressure (PEP), applied with a face mask, improved the ketchup bottle method'4. Despite the fact that only minor improvements in sputum amount was observed

Historical reports Since 1935 there have been several differing ideas about physical therapy'. The most common breathing exercises used to be pursed-lips breathing, controlled deep breathing to open up poorly ventilated areas, breathing with prolonged expiration and upper chest pressure, and diaphragmatic breathing. Improvement of lung function was reported by Miller2 after 3-month breathing training for patients with chronic airway obstruction. This, however, was challenged by Sinclair3, and later by Becklake et al.4. The mainstay of pulmonary therapy in CF has long been postural drainage with percussion and vibration. However, since postural drainage with percussion represents only one special aspect of a multimodal therapy, its efficacy is unclear.
Postural drainage and percussion (clapping) The goal of postural drainage and percussion of the chest is to increase the rate of removal of secretion from a particular segment or lobe of the lung by gravitation. The results are frequently excellent in patients with bronchiectasis. Immediate improvement of maximal expiratory flows and specific airway conductance have been described5'6. However, others have not been able to reproduce these results7. The comparison of chest clapping and postural drainage and emptying a ketchup bottle8 has stimulated researchers and physiotherapists to investigate, clinically and scientifically, the effects of the traditionally applied physical therapy. The opinion that the volume of secretions has to be large enough (> 30 ml/d) to be jarred loose by percussion or vibration has been challenged by Pryor et aL9 who combined a forced expiration technique (FET/huffing) with conventional assisted postural drainage and percussion. Despite the fact that this new forced expiration technique resulted in only a small measurable improvement of lung function (increase of FEV1 of 6%) these authors

Journal of the Royal Society of Medicine Supplement No. 16 Volume 82 1989

33

when the PEP method was compared to postural drainage, FET, clapping and directed coughing, and despite the absence of any short-term improvement in lung function, the PEP mask was said to be the most acceptable, subjectively. It has been argued that PEP mask breathing affects the peripheral airways and collateral air channels, whereas coughing and FET were only effective in airways where dynamic compression occurs. One month of PEP treatment, however, was not superior to conventional clapping physiotherapy15 whereas 18 months of forced expiration through PEP, a slightly modified PEP technique with high expiratory pressures, increased sputum yield in the range of 20%, increased expiratory flow rates, decreased hyperinflation and lowered airway instability16. The results of comparable studies over short axid long periods are given in Table 1.

Exercises The need to have effective physiotherapy has been demonstrated by the fact that continual physical therapy improves well being and the life of the CF patients. Besides active treatment it has been recognized that sports at school and physical exercises may substitute for chest physiotherapy in a minority of patients. Although one study has shown that 7 weeks of supervised swimming training can improve lung function'7, in another study, 3 months exercise training at home did not improve lung function or exercise tolerance and resulted in poor compliance18. Favourable results of controlled sporting activities compared to physiotherapy were, however, reported by Blomquist'9, Edlund20 and Stanghelle2122. A supplement of the International Journal of Sports Medicine23 has highlighted the benefits and pitfalls of exercise and training in CF patients. Other reports24 suggest that active physical treatment such as PEP mask breathing - and exercise have different immediate effects, with PEP mask breathing being superior to submaximal exercise in terms of sputum production. For. older patients, ergometer exercise training at home improved the sense ofwellbeing and had a positive effect in clearing sputum in an adjunct to routine chest physiotherapy25.

Autogenic drainage (AD)

In the search for an improved self-performed chest physiotherapy to provide independence to the patient and the most effective lung clearance of secretions, Chevaillier introduced a novel technique which was based mainly on precise observation of patients. Mobilization of mucus was constantly observed in children during sleep when one could hear the mucus move. Furthermore daily observations of children showed that during breathing exercises, during anticrisis techniques (positions which are taken during acute asthmatic attacks), during playing and laughing and during FEV, manoeuvres, mucus moved better than most of the time during postural drainage, pursed lip breathing, vibration and clapping. Based on these observations, Chevaillier introduced autogenic drainage (AD) which he described as a series of principles. In his description26, based on a paper by Alexander-7 and later again in a paper by Kraemer et aL28, the principle of reaching the highest possible airflow in different generations of bronchi by controlled breathing was put into practice by a three phase breathing exercise. The aim

was to (a) unstick the peripheral mucus by breathing at low lung volumes, (b) collect the mucus in the middle airways by breathing at tidal volume level and finally (c) evacuate the secretions from the central airways by breathing at higher lung volumes. At the beginning of this breathing technique, inspiration should be slowly through the nose to guarantee optimal moistening and heating of the inspired air; this partly prevents coughing. At the end of an inspiration a short stop of breathing with an open glottis is performed. Expiration is done without pursed lips breathing through the open mouth and open glottis; the latter has to be learned and practised. Whether the glottis is kept open or closed can be verified by gasping without making a sound. By this breathing manoeuvre compression and bronchial obstruction are probably avoided. The first phase of unsticking secretions is then started by a directed increased inspiration followed by deep expiration. By concomitantly lowering mid tidal volume below FRC level, the range of closing volume is automatically reached and secretions from peripheral lung regions are mobilized by compression of peripheral alveolar ducts. Mid respiratory tidal volume is lowered in the range of normal expiratory reserve volume (ERV). The end of inhalation is followed by a short breathing stop with open glottis to ensure equal filling of all the lung segments, including the obstructed ones, by collateral filling. During the next exhalation the alveolar pressure will be the same in most lung parts, with minor paradoxical airflow. The second phase of collecting mucus in the larger bronchi is achieved by deepening inspiration and expiration. Tidal volume breathing is then changed gradually from expiratory reserve volume into the inspiratory reserve volume (IRV) range to mobilize secretions from the apical parts of the lungs as well. The velocity of flow must be controlled to avoid high flow peaks which result in spasm of the collapsible segments at the equal pressure point (EPP). The longer the expiration time, the greater the distance the secretions are transported. In the third and last phase the patient increases flow starting from a level at about the middle of his inspiratory reserve capacity (IRC) and by a small burst of coughing the mucus is finally brought out. At the end of this phase self control of flow is essential to avoid unproductive forced coughing. All the three phases are depicted in Figure 1 which has been drawn according to the published data of Kraemer28. Several points havelto be considered when learning this technique: first, it can only be learned by the help of a trained person; secondly, the patient is in an upright sitting position, undergoes relaxation and concentration, performs diaphragmatic breathing and tries to avoid paradoxical movements of the chest and coughing; thirdly, when learning this technique the patient is guided by tactile and auditive assistance of the teacher, which he gradually takes over and adds his proprioceptive sensations for detecting moving secretions; and finally, sessions of 30-45 min twice a day are necessary. Based on the theory that, with autogenic drainage, higher flows of a longer duration can be achieved when performing partially forced expirations starting from various volumes smaller than the total lung capacity (TLC), we registered flow volume curves from CF patients during autogenic drainage, from which

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Journal of the Royal Society of Medicine Supplement No. 16 Volume 82 1989

Table 1. Summary ofpapers dealing with physiotherapy listed according to year as they appeared since 1979

Author

n
16

Duration of session
98-127 min

Durationi of trial
4 dayq

Techniques

Results
On B treatment time decreased, sputum weight increased, FEVy increased 6% B vs C not significant After course lung function improved; 10 weeks later returned to preswimming level All better than A E was as good as B, C or D No additional benefit from PD or physio help compared to directed coughing

Pryor9

Zach"7
Rossman"

10 6
.

lh
40 min
~~ ~ ~ ~ ~ ~

7 weeks
5 days
~
I.

A: PD, coughing, self percussion, shaking by physio B- PD, FLT, coughing, self percuission C: B+percussion by physio Swimming

DeCesarel
Desmond6

10

n.i.

1 day
6 weeks

10

n-i.

A: spontneous cough B: PD; C: PD+percussion D: PD, deep breathing percussion by physio E: directed coughing Cleariig 99 m Tc aerosol Krpton 81 m scan after PD pereussion and vibration by physiotherapist 3w PD, percussion, vibration at home; 3w without physio .~~~~~~~~~~~~~~~~~~~~~~~~~~~
A: Resting in upright(control) B: Directed coughing C: FET D: FET+PD 99 m Tc clearance Lung function at 30 min and 2 h after physio (PD, percusion, coughing)

Sutton33

10

30 min

4 days

Zapletal7

24

30 min

1 day

De Boeck2

25 min

2 days

Lung function at 1 h after 25 min physio session vs coughing alone

Falk24

14

20-35 min

4 days

A:PD, FET, clapping, cough B: PD+PEP, FET, cough C: PEP, FET, cough D: Pursed lip, cough PEP 15-30 cm H0 randomized, cross over
exercise at home

Holzer'8

86
12

30 min
15 min

3 months

Groth39

1 day

PEP, lung function before

immediate after and 15 min later

Webber34

16 10

n.i. 30 min

4 days

Parker35

4 days

A: PD without percussion B: PD, FET self percussion randomized 4 double coughs/3 min sitting 4 FET/3 min sitting 4PET/3 min in PD
".

Improvement of ventilation seen only in patients with severe disease When off therapy significant decrease of FVC (3%), FEF25-75 (20%), FEV1 (10%) Significant long-term effect, no immediate effect During C, D more clearing than during A, B. Wet sputum morewith B, C, D than A, FET and FET+PD superior to direct coughing FEF 25 decreased, sGaw increased of 10-20%. Direct cinema demonstration ofbronchial narrowing Static lung volumes not affected. FEF 50 and FEF 25 increased 14% resp. 22% with coughing alone 18%, 25% resp. after physio Sputum amodnt B, C> D, A lung function: no effect after A FVC decreased 6.6% Saturation: decreased A>B, C, D; incr B, C, D C subjectively best accepted No effect on lung function and on exercise tolerance, compliance at home poor During PEP FRC increased Decrease of washout volume lung clearance index and trapped gas. No effect on TLC, TV, RV Sputum weight A 57, B 52 g B: FEV1 -improved (no values)
Sputum production, amount radioaerosol clearance better after FET, FET+PD than after cough alone No effect on FVC, FEV1 PEFR on the 5% significance level Decrease of lung function in the range of the natural course of lung function deterioration No differences in FEV, FVC, PEFR; more sputum on
PET+PI)
continued

Rogers36
Van der

16
74

n.i.

4 days
-

PET PET+percussion

FET+PD
n.i.
2
years

FET

Laag37
VerboonM

1.5 h

4 days

FET FET+PD

Journal of the Royal Society of Medicine Supplement No. 16 Volume 82 1989 Table 1 continued

35

Author

n
15 12

Duration of session
30 min n.i.

Duration of trial
1 month 3 days

Techniques

Results
No differences in lung function after one month Significant improvement with FET+PD in FEV1, FVC, PEFR, FEF50, no change in TLC, RV, DLCO Sputum in A, B > C A vs B not significant PEP has no additional positive effect Increased yield of sputum (20%). Increased expiration flow rates, decreased hyperinflation, decreased airway instability Improvement of Po2, small changes in lung function during physical exercise

Tyrrell"5
Webber40

Conventional physio vs PEP

FET vs FET+PEP

Webber4"

18

n.i.

3 days

A: FET+PD B: FET+PEP+PD C: FET+PEP sitting Forced expiration through PEP

Oberwaldner16

20

20-90 min

18 months

Blomquist19

11

30 min

12 months

6 months physical exercises 6 months physical

Hardy3l

20 min

1 day

exercises+FET Infants mean age 3.1 months PD, percussion vibration

Swimming

Edlund20

10

50 min

12 weeks

Stanghelle2"
Stanghelle22

3-9 h per week

5 years 8 weeks
2 days 2 days

4 on training, regular physical exercise, 4 did no training

8 8
12

Schlemper29
Falk24

100 min per week 30 min

15 min

Daily trampoline exercise

Autogenic drainage (AD)
vs PEP PEP vs bicycle exercise

After physio decreased compliance, decreased work of breathing and power of breathing Improved clinical status, improved exercise tolerance, lung function not changed Those who trained improved lung function and peak 02 uptake No changes in lung function
More sputum on AD 16.3 g than on PEP 5.8 g (means) Sputum weight during PEP higher than during exercise, no differences in lung function 12 had peak work capacity peak minute ventilation and minute oxygen consumption improved. Sputum yield improved in 6 No changes in lung function 12 produced more sputum on AD. Clinical scores the same in each group

Salh25

16

15 min 5 times/week

2 months

Bicycle ergometry at home

McIlwaine30

18

n.i.

2 months

1: PD+percussion 2: PEP+huffing 3: AD cross over randomized

Abbreviations: PD, postural drainage; AD, autogenic drainage; PEP, positive expiratory pressure; FET, forced expiration technique; n.i., not indicated; FVC, forced vital capacity; FEV1, forced expiratory volume in one second; FEF 25,50,75, forced expiratory flow at 25%, 50%, 75% of vital capacity; FEF 25-75, forced expiratory flow between FEF 25% and 75%; PEFR, peak expiratory flow rate; TLC, total lung capacity; TGV, thoracic gas volume; RV, residual volume; sGaw, specific airway conductance

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Journal of the Royal Society of Medicine Supplement No. 16 Volume 82 1989

NOMAU
PHASE: 1
2

RV

kl

I_

Figure 1. Phases of autogenic drainage shown on a spirogram of a normal person Phase 1: unstick, phase 2: collect, phase 3: evacuate. (Vt=tidal volume, ERV=expiratory reserve volume, RV=reserve volume, FRC= functional residual capacity, IRV= inspiratory reserve voume;IRV+ Vt+ERV= vital capacity)

Fl ow (V) l/sec

technique preliminary results have been presented29, showing that the mean sputum amount with AD was 16.34 g and with PEP mask breathing it was 5.82.6 g, (n=8 CFI's, age 4-17 years, immediate effect after one session with AD or PEP). In this same report it is claimed that trapped gas was significantly reduced. However, these data have never been published in a peer reviewed journal, and results are, therefore, to be interpreted with caution. Autogenic drainage has also been compared with PEP, PD and conventional physiotherapy by a cross-over design by the Vancouver Children's Hospital group30. These authors reported that after a two month period of therapy several advantages ofAD or PEP over conventional therapy occurred in patients with hyperreactive airways with more sputum produced with AD. These results agree with our own experiences. In a two week's controlled inpatient study no statistically significant improvement of lung function occurred, but sputum production decreased and transcutaneous oxygen saturation improved.

Volius (V)

Figure 2. Forced flow-volume curve (fat line) and partial flowvolume curves (small lines as they are produced in AD) from a patient doing autogenic drainage; explanation see text

a representative experiment is shown in Figure 2. During forced expiration, (thick line) compression occurs at low lung volumes, whereas, during AD, higher flow transients with the same low lung volumes are achieved without bronchial collapse. Thus, it seems that moving secretions is made easier in the peripheral parts of the lung. However, parts of this technique have been challenged by German physiotherapists and clinicans who stated that breathing in the ERV range was seldom observed in their patients due to difficulties to lower mid tidal volume level. Therefore, they simplified the procedure so that the patient begins by moving his mid tidal volume up and down by deepening breaths and comfortably adapts the process to his individual need without undue force or effort. After a breath arrest of about 2-3 s at the end of every inspiration, a passive, relaxed but rather fast expiration to normal expiratory level follows, succeeded by an actively performed expiration supported by expiratory intercostal muscles and thus driving down exhalation to low ERV. Therefore, this 'German' technique uses a combination of diaphragmatic and rib-cage breathing. In patients with easily collapsible airways, a proximal expiratory stenosis such as pursed lips or nose breathing is recommended. Using this modified

Conclusions Several techni-ques are available today for effective physiotherapy in CF patients. No single technique is better than the others, so an individual adjustment of a specific technique has to be determined for every patient. General rules cannot be given but guidelines can be suggested to adjust the techniques to the needs of the patient. Age, severity of the disease, concomitant pathology, familiarity with the technique, family background, social situation, intelligence, self esteem and acceptance have to be considered when the physiotherapy regimen is considered for a patient. A multidisciplinary approach is needed, with the views of physicians, nurses, physiotherapists, sport therapists, parents and friends being taken into account when devising the physical therapy for each patient. The best technique' for any patient is the one which he feels most comfortable with and is able to continue, which produces the largest amount of sputum, and which maintains acceptable health according to the stage of disease. It is also known that the enthusiasm of the physiotherapist, physician or teacher affects the level of benefit received from the treatment. In this way, every effort we direct towards the individual needs of the patient is rewarded by his or her well being.

Acknowledgment: The author thanks Mrs Rita Kieselmann,

Munich, for assistance in teaching autogenic drainage in our clinic.
References 1 Livingstone JL, Gillespie M. The value of breathing exercises in asthma. Lancet 1935;i:705-6 2 Miller WF. A physiologic evaluation of the effects of diaphragmatic breathing training in patients with chronic pulmonary emphysema. Am JMed 1954;17:471-9 3 Sinclair JD. The effects of breathing exercises in pulmonary emphysema. Thorax 1955;10:246-52 4 Becklake MR, McGregor M, Goldman HL, Brando JL. A study of the effects of physiotherapy in chronic hypertrophic emphysema using lung function tests. Dis Chest

5 Feldman J, Traver GA, Taussig LM. Maximal expiratery flows after postural drainage. Am Rev Respir Die 1979; 119:239-43 6 Desmond KJ, Schwenk WF, Eli Thomas PT, Beaudry PH, Coates AL. Immediate and long term effects of chest physiotherapy in patients with cystic fibrosis. J Pediatr 1983;103:538-42

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Journal of the Royal Society of Medicine Supplement No. 16 Volume 82 1989 7 Zapletal A, Stefanova J, Horak J, Vavrova V, Samanek M. Chest physiotherapy and airway obstruction in patients with cystic fibrosis - a negative report. Eur J Respir Dis 1983;64:426-33 8 Murray JF. The ketchup-bottle method. N Engl J Med 1979;300:1155-7 9 Pryor JA, Webber BA, Hodson ME, Batten JC. Evaluation of the forced expiration technique as an adjunct to postural drainage in treatment of cystic fibrosis. Br Med J 1979;2:417-8 10 Mead J, Turner J, Macklem PY, Little JB. Significance of the relationship between lung recoil and maximal expiratory flow. J Appi Physiol 1967;22:95-108 11 Rossman CM, Waldes R, Sampson D, Newhouse MT. Effect of chest physiotherapy on the removal of mucus in patients with cystic fibrosis. Am Rev Respir Dis 1982;126:131-5 12 De Boeck Ch, Zinman R. Cough versus chest physiotherapy. Am Rev Respir Dis 1984;129:182-4 13 Hartsell M. The effect of postural drainage, manual percussion and vibration vs. postural drainage and and mechanical vibration on maximal expiratory flows. Am Rev Respir Dis 1978;117:204 14 Falk M, Kelstrup M, Andersen JB, Kinoshita T, Falk P, Stovring S, Gothgen I. Improving the ketchup bottle method with positive expiratory pressure,PEP, in cystic fibrosis. Eur J Respir Dis 1984;65:423-32 15 Tyrrell JC, Martin J, Hiller EJ. PEP mask physiotherapy in cystic fibrosis. 13th Annual Meeting of the European Working Group for Cystic Fibrosis. Book of Abstracts, Jerusalem. 1985:23 16 Oberwaldner B, Evans JC, Zach MS. Forced expiration against a variable resistance: A new chest physiotherapy method in cystic fibrosis. Pediatr Pulmonol 1986;2: 358-67 17 Zach MS, Purrer B, Oberwaldner B. Effect of swimming on forced expiration and sputum clearance in cystic fibrosis. Lancet 1981;ii:1201-3 18 Holzer FJ, Schnall R, Landau LI. The effect of home exercise programme in children with cystic fibrosis and asthma. Aust Paediatr 1984;20:297-302 19 Blomquist M, Freyschuss U, Wiman L-G, Strandvik B. Physical activity and self treatment in cystic fibrosis. Arch Dis Child 1986;61:362-7 20 Edlund LD, French FW, Herbst JJ, Ruttenbuerg HD, Ruhlung RO, Adams TD. Effects of a swimming program on children with cystic fibrosis. Am J Dis Child 1986;140:80-83 21 Stanghelle JK, Michalsen H, Skyberg D. Five-year follow-up of pulmonary function and peak oxygen uptake in 16 year old boys with cystic fibrosis, with special regard to the influence of regular physical exercise. Int J Sports Med 1988;Supplement 9:19-25 22 Stanghelle JK, Hjeltnes N, Bangstad HJ, Michalsen H. Effect of daily short bouts of trampoline exercise during 8 weeks on pulmonary function and the maximal oxygen uptake of children with cystic fibrosis. Int J Sports Med 1988;Supplement 9:32-7 23 Supplement 1, Vol 9, International Journal of Sports Medicine 1988 24 Falk M, Kelstrup M, Andersen JB, Pedersen SS, Rossing I, Dirksen H. PEP treatment or physical exercise- Effects on secretions expectorated and indices of central and peripheral airway function. Congress Abstracts, Exerpta Medica, Asia Pacific Congress Series, 10th International Cystic Fibrosis Congress, Sydney, Australia, 1988;35 25 Salh B, Dodds M, Webb AK. Influence of ergometer training on sputum output and physical fitness in adult cystic fibrosis patients. Congress Abstracts, Excerpta Medica, Asia Pacific Congress Series, 10th International Cystic Fibrosis Congress, Sydney, Australia, 1988;36 26 Chevaillier J. Autogenic Drainage (A.D.) In: Lawson D, ed. Cystic fibrosis: horizons. Chichester: John Wiley, 1984:235 27 Alexander FA. Physikalische Therapie beim kindlichen Asthma bronchiale. Mschr Kinderheilk 1976;124:222-4 28 Kraemer R, Zumbuihl C, Rudeberg A, Lentze, MJ, Chevaillier J. 'Autogene Drainage' bei Patienten mit zystischer Fibrose. Pddiatr Prax 1986;33:223-32 29 Schlemper B, Lindemann H, Bittner P. Ergebnisse einer Vergleichsstudie zwischen autogener Drainage und PEP-Maskenatmung. 7. Ambulanzleitertagung der Deutschen Gesellschaft zur Bekampfung der Mucoviscidose. Schumacher H. ed. 1986. 30 Mcllwaine M, Davison AGF, Wong LTK, Pirie GE, Nakielna EM. Comparison of positive expiratory pressure and autogenic drainage with conventional percussion and drainage therapy in the treatment of CF. Congress Abstracts, Exerpta Medica, Asia Pacific Congress Series, 10th International Cystic Fibrosis Congress, Sydney, Australia, 1988 31 Hardy KA, Wolfson MR, Titinsky M, Motley R, Shaffer H, Schidlow DV. The effect of combined therapy of aerolized bronchodilators and chest physiotherapy on newly diagnosed infants with cystic fibrosis. CF Club Abstracts 1986;27:33 32 DeCesare, JA, Babchyck BM, Colten HR, Treves S. Radionuclide assessment of the effects of chest physical therapy on ventilation in cystic fibrosis. Phys Ther 1982;62:820-5 33 Sutton PP, Parker RA, Webber BA, Newman SP, Garland N, Lopez-Vidriero MT, Pavia D, Clarke SW. Assessment of the forced expiration technique, postural drainage and directed coughing in chest physiotherapy. Eur J Respir Dis 1983;64:62-8 34 Webber BA, Parker RA, Hofmeyr JL, Hodson ME. Evaluation of self-percussion during postural drainage using the forced expiration technique (FET). In: Lawson D, ed. Cystic fibrosis: horizons. Chichester: John Wiley, 1984:229 35 Parker RA, Webber BA, Sutton PP, Newman SP. Garland N, Lopez-Vidriero, Pavia D, Clarke SW. Evaluation of three individual components of postural drainage treatment. In: Lawson D, ed. Cystic fibrosis: horizons. Chichester: John Wiley, 1984:230 36 Rogers D, Tottle J, Pickering DM, Plews E, Davies V, Newcombe RG, Goodchild MC, Dodge JA. Comparison of physiotherapy techniques employed in cystic fibrosis. In: Lawson D, ed Cystic fibrosis: horizons. Chichester: John Wiley, 1984:232 37 Van der LaagJ, Steenbergen H,Helders PJM. Prolonged use of forced expiration technique in cystic fibrosis. In: Lawson D, ed Cystic fibrosis: horizons. Chichester: John Wiley, 1984:233 38 Verboon JML, Bakker W, Dukman JH. Effect of the forced expiration technique and postural drainage in adults with cystic fibrosis. In: Lawson D, ed Cystic fibrosis: horizons. Chichester: John Wiley, 1984:234 39 Groth S, Stafanger G, Dirksen H, Andersen JB, Falk M, Kelstrup M. Positive expiratory pressure (PEP-mask) physiotherapy improves ventilation and reduces volume of trapped gas incystic fibrosis. Bull Eur Physiopathol Respir 1985;21:339-43 40 Webber BA, Hofmeyr JL, Hodson ME, Batten JC. The effects of postural drainage incorporating the forced Expiration technique on pulmonary function in cystic fibrosis. 13th Annual Meeting ofthe European Working Group for Cystic Fibrosis. Book of Abstracts, Jerusalem 1985:24 41 Webber BA, Hofmeyr Jn, Hodson ME, Baten JC. Evaluation of positive expiratory pressure as an adjunct to postural drainage. 13th Annual Meeting of the European Working Group for Cystic Fibrosis. Book of Abstracts, Jerusalem. 1985:95

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