Chest Clearance / Physiotherapy: Chest Heart & Stroke Scotland

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Chest Clearance / Physiotherapy

What is chest clearance?
Active cycle of breathing
Oscillatory positive expiratory pressure devices (e.g. 'Acapella®' and 'Flutter®' machines)
Autogenic drainage

What is chest clearance?

Chest clearance exercises help you to clear your chest of as much sputum as you can. This helps to reduce obstruction in your airways and improve the amount of air getting into your lungs. In the long–term chest clearance can help to reduce the number, and frequency, of chest infections you may have.

There are several different techniques that can be used for chest clearance including active cycle of breathing, use of oscillatory positive expiratory pressure devices (e.g. 'Acapella®' and 'Flutter®' machines) and autogenic drainage.

Some people may find one technique works better than another, or is more convenient. It is important that you are shown how to do these exercises / techniques by a respiratory (chest) physiotherapist (physio). He / she will recommend how often you should use these techniques to get the maximum benefit.

Active cycle of breathing

Active cycle of breathing There are 3 components to this technique combining:

Breathing control: relaxed breathing
Deep breathing ( also called 'Thoracic Expansion Exercises' or TEE): expands your chest
'Huffing' (also called 'Forced Expiration Technique' or FET): pushes air out of your lungs.

Here is an example of how these breathing exercises can be used together in a cycle for maximum chest clearance. This can be done sitting or lying but you may have to stay in one position for at least 10 minutes before changing your position to further clear your chest.

1. Breathing Control

This is very useful to learn and master. It combines gentle relaxed breathing, using the lower part of your chest, with relaxation of the upper chest and shoulders.

You shouldn't feel that you are working at breathing. You should allow your tummy to rise as you breathe in and fall as you breathe out. Breathing control encourages a normal breathing pattern and helps to get air into the lower parts of your lungs. It is also helpful if you get breathless.

How to do breathing control

Settle yourself into a chair in a comfortable position.
Make sure your back is well supported.
Rest one hand on your lower rib cage with the other hand on your upper thigh.
Let your shoulders and upper chest relax, think about letting your shoulders go.
Breathe in through your nose and out through your mouth.
Concentrate on letting the lower part of your chest move under your hand.
Feel your hand rise and fall with your chest as you breathe gently in and out.
Breathe at your own rate. Doing this should not tire you.
Continue until your breathing is back under control once more.
Once you feel happy about doing this, you may like to try resting both hands down on your thighs with the palms of the hands facing up.

2. Deep breathing (Thoracic Expansion Exercises or TEE)

This technique expands your chest as far as possible allowing maximum air into your lungs by deep breathing and breath holding. This lets air move behind any trapped mucus, which loosens it allowing you to cough it out.

How to do deep breathing

Take a slow, relaxed deep breath in, as far as you can.
Hold your breath for the count of 3 (the deepest breath you can comfortably hold).
Follow this with a quiet relaxed breath out.
Repeat 3–4 times.

3. Huffing (Forced Expiration Technique or FET)

This technique pushes air out of your lungs: imagine you are steaming up a mirror. The idea is to encourage the sputum up through your airways till it can be cleared out. Too short a 'huff' may not be effective, but too long can lead to bouts of coughing, so you have to practise.

Huffing: how to do it

Take a normal breath in and then with your mouth open, squeeze the air out forcibly, making a 'huffing' sound. You should feel your stomach muscles contract strongly.
Keep 'huffing out' until you can't breathe out any more. (The huff should be long enough to move secretions from the smaller airways).
Repeat 1–2 huffs then pause.
Do breathing control in the pause to avoid wheeziness.*
Repeat as necessary.
When the secretions reach the bigger airways, take a deep breath and huff again or cough to get the sputum into your mouth to clear out.

*The length of the pause will depend on how you are feeling. If you are wheezy, have or are recovering from an infection, you may find you tire easily, so 20 seconds' rest between each huff should give you enough time to recover. If you are well, pauses can be shorter.

Oscillatory positive expiratory pressure devices (OPEPs)

OPEPs (e.g. The Flutter® and Acapella®) are hand–held devices which you can use to help clear mucus.

You breathe out through the device against a slight resistance which creates oscillations, or 'flutters' in the pressure of your airways. This prevents your airways from collapsing and helps loosen any mucus. Your respiratory physio must assess you to see whether one of these devices is suitable for you.

Autogenic drainage

This is another form of breathing exercise which can be used if the other techniques are not suitable for you / you don't find them helpful.

Autogenic drainage involves breathing right out as far as possible to loosen any mucus from the small airways at the edges of your lungs. The mucus can then be moved to the larger more central airways, making it easier to cough up.

How to do autogenic drainage

Choose a comfortable position, e.g. sitting upright and well supported or lying down with a couple of pillows behind your head.
Breathe in slowly, using your lower chest, as in breathing control.
Hold your breath for 3 seconds, allowing air to evenly fill your lungs, resulting in air building up behind any trapped mucus.
Push your breath out, for as long as you can manage, keeping going right to the end.
Take a slow relaxed breath in, don't take a big breath or expand your chest too much.
Breathe out all the way again, pushing all the air out of your chest completely.
As you repeat the cycle, breathe in and out slowly to avoid pushing back the mucus you have just loosened back into your lungs.
Continue with this cycle until you hear or feel the mucus collecting and moving upwards or you feel the urge to cough.
When you feel this take a deeper breath in.
Hold for 3 seconds.
Breathe out hard pushing as much air out as possible.
Finally, when the mucus reaches the larger airways it can be cleared with a cough.

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