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Short-term Effects of Postural Drainage With Clapping vs Autogenic

Drainage on Oxygen Saturation and Sputum Recovery in Patients With
Cystic Fibrosis

Article  in  Chest · October 1995

DOI: 10.1378/chest.108.4.952 · Source: PubMed

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 Short-term Effects of Postural Drainage
With Clapping vs Autogenic Drainage
on Oxygen Saturation and Sputum
Recovery in Patients With Cystic
Fibrosis
Donald R. Giles, Jeffrey S. Wagener, Frank J. Accurso and
Nancy Butler-Simon

Chest 1995;108;952-954
DOI 10.1378/chest.108.4.952
The online version of this article, along with updated information
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1995 BY THE AMERICAN COLLEGE OF CHEST PHYSICIANS
Short-term Effects of Postural Drainage
With Clapping vs Autogenic Drainage on
Oxygen Saturation and Sputum
Recovery
Fibrosis*
in Patients With Cystic
Donald R. Giles, CRTT; Jeffrey S. Wagener, MD; Frank J. Accurso, MD;
and Nancy Butler-Simon, MS, RN, CPNP
To compare the short-term effects of postural drain¬
age with clapping (PD) and autogenic drainage (AD)
on oxygen saturation, pulmonary function, and sputum
recovery, we studied ten patients with cystic fibrosis
(CF) randomly treated with PD or AD on separate
days. Pulse oximetry was monitored and sputum was
collected during and for 1 h following each treatment.
Pulmonary function was measured before and then 1,
15, and 60 min after each treatment. There was no
significant difference in the amount of sputum recov¬
ered with AD (14.0±3.5 g) vs PD (10.4±3.0 g) and no
significant differences in pulmonary function oc¬
curred. Oxygen saturation during PD fell from
93.3±0.7% to 91.2±0.8% (p<0.01) and required 15
/Cystic fibrosis (CF) is a genetic disorder involving
^^
abnormal chloride channels resulting in lung de¬
struction due to chronic mucus impaction and infec¬
tion of the airways. Clearance of this mucus is an im¬
portant part of therapy in CF but is complicated by
impaired mucociliary clearance.1 Conventional ther¬
involves enhanced mucus clearance with postural
apy
drainage assistance
and clapping (PD).2 This therapy, however,
requires from another person and is incon¬
venient for adolescent and adult patients. In addition,
PD has been associated with a fall in oxygen saturation,
suggesting the need for improved secretion removal
techniques.3
Autogenic drainage (AD) is an airway clearance
technique
This
that allows patients to do their own therapy.
provides more independence control over
and
daily care when compared with PD. The short-term
effects of AD, however, have not been compared with
PD. We designed this study to compare the short-term
effects of AD and PD on oxygen saturation, pulmonary
function, and sputum production.
*From the Departments of Respiratory Therapy and Pediatrics, the
Children's Hospital, University of Colorado School of Medicine,
Denver.
Manuscript
1995.
received December 5,1994; revision accepted May 19,
952
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1995 BY THE AMERICAN COLLEGE OF CHEST PHYSICIANS
min following treatment to return to baseline. Oxygen
saturation did not fall during AD and increased to
94.5 ±0.7% by 1 h following treatment (baseline,
93.3±0.8%; p<0.01). We conclude that AD is less likely
to produce oxygen desaturation and may be better
tolerated by patients with CF, while producing similar
benefits in sputum clearance.
(CHEST 1995; 108:952-54)
AD=autogenic drainage; CF=cystic fibrosis; PD=postural
drainage and clapping
Key words: autogenic drainage; cystic fibrosis; postural
drainage
Methods
Patient Population and Study Design
Ten patients diagnosed as having CF by positive sweat ionto¬
phoresis who expressed interest in learning a new form of chest
physiotherapy were entered into the study after written consent by
the patient and their parent (for patients younger than 18 years old).
Each patient received both PD and AD by the same respiratory
therapist at about the same time of day, on separate days, and in
random order. The study was approved by the institutional review
board on human research.
Techniques of Secretion Removal
Postural Drainage and Clapping: Patients received PD for 3 min
in each of seven different positions with
coughing between each
position. PD consisted of placing the patient in different positions
while the therapist manually clapped and vibrated various areas of
the chest wall to increase secretion removal from a particular seg¬
ment of the lung. Following clapping in each
was instructed to huff and
position, the patient
cough expectorate the mobilized mu¬
cus.
to
Autogenic Drainage: Patients were instructed in the technique of
AD described by Schoni.4 The first step involves the
learning to relax and breathe with his/her diaphragm. Oncepatient's
this is
accomplished, the patient breathes at three different lung volumes
(or phases) utilizing a controlled expiratory flow rate to avoid airway
compression. Although the mechanisms are not completely under¬
stood, it is thought that AD loosens mucus from the peripheral
airways and moves it through the midsize airways to the large air¬
ways. Mucus is then expectorated, usually avoiding the paroxysmal
cough often associated with PD. This second step is repeated until
the lungs are clear, usually requiring time similar to PD.
Clinical Investigations
 100
98
96
94
92
90
88
< 86
CO 84 . = Postural Drainage
82 o -
Autogenic Drainage
80
TREATMENT PERIOD Figure 1. Oxygen saturation in patients
o treated with postural drainage with clapping
BASELINE IMMEDIATELY 15 MIN 1 HR (closed circles) or autogenic drainage (open
POST-TX POST-TX circles). Asterisk=p<0.01.
POST-TX

Sputum was collected during and for 1 h following treatment. sulted in less of a fall in oxygen saturation and an in¬
Total sputum wet weight was recorded to the nearest gram. creased oxygen saturation after 1 h, while producing
Physiologic Evaluation similar sputum recovery in these patients with CF. This
Patients were randomly assigned to receive either PD or AD at suggests that AD may be useful, and for some patients
their first visit and then received the alternate treatment during with CF, superior to PD as a secretion clearance
their second visit. Patients who were currently receiving broncho¬ technique. saturation in these
dilator therapy at home received a bronchodilator 30 min before
their first pulmonary function test and treatment. During treat¬
Oxygen study patients with CF
increased both during and following AD. The de-
ments, the oxygen saturation was monitored continuously with a
pulse oximeter (Nellcor N-200; Nellcor Inc; Pleasanton, Calif) and
additional recordings were made immediately after, 15 min after,
and 1 h after each treatment. FVC, FEVi, peak expiratory flow rate, FVC
forced expiratory flow at 25%, 50%, and 75% of vital capacity, and
the forced expiratory flow at the midportion of vital capacity were
measured (Express Spirometry System; Cybermedics; Boulder,
Colo) and recorded as percentages of predicted values. Measure¬
ments were obtained before each treatment, and immediately af¬
ter, 15 min, and 1 h following each treatment. >

Statistical Analysis
0
Data were analyzed through repeated measures analysis of vari¬ 80-
ance using a commercially available statistical software package
(SAS). Differences were tested for significance at a=0.05 level. 70- FEVI
Q
LU
60>
Results da
The
ranged from
patients (seven male and three female)
ten
12 to 42 years old (mean, 23.2 years).
a.
50-

40- -4.*i
During PD, oxygen saturation fell from 93.3±0.7% > 30-

to 91.2±0.8% (p<0.01). Oxygen saturation fell great¬ 20-

est when each patient was placed in the head down
(Trendelenburg) positions. Fifteen minutes after PD,
saturation returned to pretreatment values.
100n
PEAK FLOW
oxygen 90-

During AD, oxygen saturation increased from 80-

93.3±0.8% to 94.9±0.7% (p<0.01). Oxygen saturation 70-
was maintained at a higher level 1 h following AD 60-
(94.5±0.7%; p<0.01) (Fig 1). O
50-
There were no significant differences noted in pul¬ 40-
Postural Drainage
monary function test results with either treatment (Fig
. =

< 30-
2). Treatment o m
Autogenic Drainage
o" Period
Sputum recovery was similar between AD and PD Pre-tx Immediately 15 min 1 hour
(14±3 g vs 10.4±3 g) (Fig 3). Post-tx Post-tx Post-tx

Discussion Figure 2. Pulmonary function in patients treated with postural

drainag*;e with clapping (closed circles) or autogenic drainage (open
Compared with PD, AD was well tolerated and re¬ circles)
CHEST
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2011 953
1995 BY THE AMERICAN COLLEGE OF CHEST PHYSICIANS
 35
0 Sputum recovery was similar in AD when compared
0
30
25
20
0 improvement in oxygenation we observed with AD is
15 00
10
0
t
t 8
0
Autogenic Drainage
Postural Drainage
Figure 3. Sputum recovery in patients treated with postural
drainage with clapping (closed circles) or autogenic drainage (open
circles).
creased saturation we observed during PD was similar
to results found by McDonnell and coworkers.3 Web¬
ber and Hodson5 reported that PD, combined with the
active cycle of breathing technique, did not produce a
fall, but actually produced a marginal increase in oxy¬
gen saturation during treatment. Although there was a
tendency for oxygen saturation to rise during the
clapping phase of their study, they included pauses
between clapping, which allowed patients an oppor¬
tunity to control their breathing pattern. This ability to
control breathing pattern and avoid the frequently
paroxysmal coughing noted with PD may explain the
overall improved oxygenation we observed.
We did not see a significant improvement in spiro¬
metry results with either PD or AD during the treat¬
ment or 1-h follow-up period in our patients. Kerrebijn
and coworkers6 also found no significant difference in
pulmonary function test results following a PD treat¬
ment. However, Desmond and colleagues' detected
an increased peak expiratory flow at 30 min after PD
treatment and Feldman and associates8 reported that
PD significantly improved lung function at both low
and high lung volumes. Pryor and coworkers9 reported
that PD, combined with the forced expiration tech¬
nique, significantly increased FEVi and FVC imme¬
diately after thetreatment. Five minutes later, the
difference had decreased and by 15, 30, and 45 min,
the difference was no longer significant. We did not
combine PD with the forced expiration technique and
we did not see any trends, either up or down, in air
954
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1995 BY THE AMERICAN COLLEGE OF CHEST PHYSICIANS
flows during our 1-h follow-up period.
with PD. We did not measure 24-h sputum production,
although the variability of this volume is so great that
it is unlikely that we would have seen a more signifi¬
cant difference over a longer time period. Thus, the
unlikely related to absolute mucus clearing, although
improved matching of ventilation to perfusion may
occur owing to redistribution of airway secretions.
Overall, our results suggest that AD and PD have
similar short-term benefits in patients with CF. Mucus
clearance was similar and we did not see any prolonged
harmful effects on pulmonary function. The improving
oxygenation with AD might suggest its advantage, es¬
pecially when one considers the brief worsening oxy¬
genation in patients during PD. However, no single
technique may be best for every patient. Each patient
needs to be repeatedly assessed to determine the most
appropriate and effective technique for that particular
patient. Our study suggests that there are no deleteri¬
ous short-term effects of AD and that this technique
should be considered for secretion removal in older
patients with CF. Further studies will be needed to
address the long-term effects of AD, particularly with
respect to compliance.
References
1 Zach MS, Oberwaldner B. Chest physiotherapy: the mechanical
approach to anti-infective therapy in cystic fibrosis. Infection
1987; 15:381-84
2 Reisman JJ, Rivington-Law B, Corey M, et al. Role of conven¬
tional physiotherapy in cystic fibrosis. J Pediatr 1988; 113:632-36
3 McDonnell T, McNicholas WT, FitzGerald MX. Hypoxemia
during chest physiotherapy in patients with cystic fibrosis. Ir J
Med Sci 1986; 155:345-48
4 Schoni MH. Autogenic drainage: a modern approach to physio¬
therapy in patients with cystic fibrosis. J R Soc Med 1989;
82(suppl):32-7
5 Webber BA, Hodson ME. Effect of chest physiotherapy on ox¬
ygen saturation in patients with cystic fibrosis. Thorax 1990; 45:77
6 Kerrebijn KF, Veentjer R, Bonzet E, et al. The immediate effect
of physiotherapy and aerosol treatment on pulmonary function in
children with cystic fibrosis. Eur J Respir Dis 1982; 63:35-42
7 Desmond KJ, Schwenk WF, Thomas E, et al. Immediate and
long-term effects of chest physiotherapy in patients with cystic
fibrosis. J Pediatr 1983; 103:538-42
8 Feldman J, Traver GA, Taussig LM. Maximal expiratory flows
after postural drainage. Am Rev Respir Dis 1979; 119:239-45
9 PryorJA, Parker RA, Webber BA. Comparison of mechanical and
manual percussion as adjuncts to postural drainage in the treat¬
ment of cystic fibrosis in adolescents and adults. Physiotherapy
1981; 67:140-41
Clinical Investigations
 Short-term Effects of Postural Drainage With Clapping vs
Autogenic Drainage on Oxygen Saturation and Sputum Recovery
in Patients With Cystic Fibrosis
Donald R. Giles, Jeffrey S. Wagener, Frank J. Accurso and Nancy
Butler-Simon
Chest 1995;108; 952-954
DOI 10.1378/chest.108.4.952
This information is current as of July 13, 2011
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