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Postural drainage

Postural drainage is a chest physiotherapy technique that uses gravity to assist in clearing mucus and secretions from the lungs by positioning the patient in specific postures that target individual lung segments.^[1] The technique was introduced by William Ewart in 1901 and detailed by H.P. Nelson in 1934, who described postural drainage of the lungs.^[1]^[2] It relies on the anatomical drainage pathways of the bronchial tree to direct secretions toward the trachea for removal through coughing, huffing, or suctioning.^[1]^[3] This non-invasive method is a cornerstone of airway clearance therapy, particularly for individuals with impaired mucociliary function, and is often integrated into broader respiratory care regimens.^[1] It is indicated for conditions involving excessive bronchial secretions, such as cystic fibrosis, bronchiectasis, and chronic obstructive pulmonary disease, with evidence from randomized trials showing benefits in sputum clearance and lung function, especially in patients producing over 30 mL of sputum daily.^[1]^[4]^[3] However, effectiveness varies by patient, and it is not routinely recommended for uncomplicated pneumonia or neuromuscular diseases; contraindications include active hemoptysis and untreated pneumothorax.^[1]^[4]

Introduction

Definition and Purpose

Postural drainage is a gravity-assisted therapeutic technique that involves positioning the body in specific orientations to promote the drainage of mucus and secretions from the peripheral airways of the lungs into the larger central bronchi, facilitating their subsequent clearance through coughing, forced expiration, or mechanical suction. This method relies on the anatomical structure of the bronchial tree, where secretions are mobilized from smaller, distal bronchioles toward the trachea for expulsion.^[1] The primary purpose of postural drainage is to enhance mucociliary clearance in individuals with impaired secretion removal, thereby improving overall ventilation, preventing atelectasis (lung collapse), and supporting the management of respiratory conditions characterized by excessive mucus production, such as cystic fibrosis or bronchiectasis. By aiding the removal of accumulated secretions, it helps optimize gas exchange, reduce airway obstruction, and minimize the risk of secondary infections.^[5]^[6] At its core, the physiology of postural drainage leverages gravitational forces to counteract the inefficiencies of the mucociliary escalator in diseased states, where ciliary dysfunction or viscous mucus hinders natural clearance. In optimal positions, affected lung segments are oriented superior to the carina (the bifurcation point of the trachea), allowing secretions to flow downward from upper to lower airways over a period typically held for 3 to 15 minutes, thereby restoring more effective ventilation-perfusion matching and normalizing functional residual capacity.^[1]^[3]^[5] This technique specifically targets the bronchopulmonary segments, which are the functional subunits of the lung lobes each supplied by independent bronchi and vascular structures, enabling precise drainage based on segmental anatomy. For instance, positions can direct secretions from apical segments in the upper lobes or posterior basal segments in the lower lobes toward central pathways, exploiting the natural drainage routes of these 8 to 10 segments per lung to clear peripheral accumulations efficiently.^[7]^[6]

Historical Development

The concept of leveraging gravity to facilitate the drainage of lung secretions originated in early 20th-century treatments for pulmonary tuberculosis, where ambulatory patients were routinely positioned on specialized racks to promote clearance from affected lung areas. This approach reflected growing recognition of gravity's physiological role in secretion mobilization, predating formalized techniques.^[8] Postural drainage as a systematic therapeutic method was first described in 1934 by H. P. Nelson, a British physician, who outlined specific positioning strategies to enhance bronchial secretion removal through gravity-assisted flow toward central airways. Nelson's work, published in the British Medical Journal, built directly on these earlier TB-related observations and emphasized the technique's application in manual chest physiotherapy for conditions involving mucus accumulation.^[9]^[10] Following World War II, postural drainage gained widespread integration into chest physiotherapy protocols as military and civilian physical therapy programs expanded to address respiratory complications. By the 1950s and 1960s, developments emphasized reproducible techniques to optimize efficacy in hospital-based care.^[11] In the 1980s and 1990s, the rise of structured cystic fibrosis management programs marked a shift toward evidence-informed adaptations of postural drainage, transitioning from routine manual applications to selective use within multimodal airway clearance regimens supported by clinical trials evaluating its role alongside adjuncts like percussion. This evolution prioritized patient tolerance and integration with emerging therapies for chronic suppurative lung diseases. Subsequent guidelines, such as Cochrane reviews as of 2015, have questioned its routine use in favor of alternatives like positive expiratory pressure devices when evidence shows comparable efficacy.^[12]^[13]^[14]

Clinical Applications

Indications and Benefits

Postural drainage is primarily indicated for respiratory conditions characterized by excessive or retained mucus secretions that impair airway clearance. Key conditions include cystic fibrosis, where it aids in managing thick mucus buildup in the lungs; bronchiectasis, which involves chronic airway dilation and infection risk; chronic obstructive pulmonary disease (COPD), particularly in cases with productive cough and sputum retention; pneumonia with significant retained secretions and difficult expectoration (not routinely for uncomplicated cases); atelectasis, caused by mucus plugging leading to lung collapse; and select neuromuscular disorders such as muscular dystrophy with retained secretions, although routine use is not advised by some guidelines (e.g., BTS) due to limited efficacy from weakened respiratory muscles, often requiring adjuncts like assisted coughing.^[1]^[5]^[15]^[16]^[4] The therapy is especially beneficial in scenarios involving daily sputum production exceeding 25-30 mL in adults, indicating significant retention that standard coughing cannot manage. It is applied in acute settings, such as post-operative recovery from thoracic or abdominal surgeries to prevent atelectasis, or in ventilator-associated pneumonia to clear secretions around artificial airways. In chronic management, it supports home-based therapy for ongoing conditions like cystic fibrosis or bronchiectasis, promoting consistent mucus removal. Patient criteria for its use include an ineffective cough mechanism, presence of artificial airways such as endotracheal tubes, or aspiration of foreign bodies, where gravity-assisted drainage becomes essential.^[5]^[1]^[15] Therapeutic benefits encompass enhanced mucus clearance through gravity-dependent positioning, which mobilizes secretions toward central airways for expulsion, thereby improving ventilation-perfusion matching and arterial oxygenation. This leads to better gas exchange, as cleared airways reduce hypoxia risks, and supports overall lung function, with evidence showing improvements in forced expiratory volume in one second (FEV1) and vital capacity in responsive patients. Additionally, regular application decreases the frequency of respiratory infections by minimizing bacterial colonization in retained mucus and reduces hospitalization rates, particularly in cystic fibrosis cohorts and select neuromuscular cases with appropriate adjuncts. These outcomes contribute to enhanced quality of life, including easier breathing and greater tolerance for daily activities.^[1]^[5]^[15]^[16]

Patient Assessment

Patient assessment for postural drainage begins with a comprehensive review of the patient's medical history to identify conditions associated with excessive mucus production or impaired clearance, such as chronic respiratory diseases, followed by a physical examination that includes auscultation to detect adventitious sounds like crackles indicative of secretion load, and evaluation of vital signs for stability.^[5] Diagnostic tests, including chest X-ray to visualize atelectasis or mucus plugging and measurement of sputum volume (typically >25-30 mL per day in adults signaling need), are essential to quantify secretion burden and confirm the presence of retained mucus. In neuromuscular disorders, assess vital capacity and peak cough flow (e.g., <270 L/min may necessitate adjuncts).^[5]^[1] Tools and criteria for determining suitability include scoring systems like the Bronchiectasis Severity Index (BSI), which integrates factors such as age, body mass index, forced expiratory volume in one second, exacerbation history, and radiological extent to predict disease severity and guide the initiation of airway clearance techniques like postural drainage. Daily sputum quantification and assessment of cough effectiveness, often via peak cough flow measurement, further help identify patients who may benefit, with reassessment recommended every 48 hours in critical care settings or every 72 hours in acute care, and every 3 months in chronic or domiciliary management to evaluate response and adjust therapy.^[5]^[17] Tailoring postural drainage requires consideration of age-specific factors, such as modified positions for infants and neonates to avoid physiological stress or for elderly patients to accommodate reduced tolerance to Trendelenburg positioning, alongside evaluation of mobility status to select feasible postures and conduct tolerance testing through initial trial sessions monitoring for fatigue or discomfort.^[5]^[1] Frequency of sessions is determined based on clinical response, typically 2-4 times daily during acute phases to optimize secretion clearance, then reduced to once or twice daily in stable chronic conditions, with ongoing monitoring of sputum characteristics and lung function to guide adjustments.^[5]^[17]

Safety Considerations

Contraindications

Postural drainage is contraindicated in certain conditions to avoid exacerbating underlying health issues or causing new complications due to the physical positioning and manipulation involved. These contraindications are categorized as absolute, where the technique should not be performed under any circumstances, and relative, where use may be considered only after careful evaluation of risks versus benefits.^[1]^[5] Absolute contraindications include untreated pneumothorax, which risks further lung collapse from pressure changes; active hemoptysis, as positioning could worsen bleeding; recent neurosurgery or head injury, since head-down positions can elevate intracranial pressure and lead to complications; unstable hemodynamics (e.g., hypotension or shock), potentially causing cardiovascular strain; recent spinal surgery or acute spinal cord injury, to prevent disruption of healing or further neurological damage; and conditions predisposing to increased intracranial pressure, like acute respiratory distress syndrome, where positioning exacerbates cerebral strain.^[1]^[5]^[18] Relative contraindications encompass recent or unstable rib fractures (with or without flail chest), severe osteoporosis, high bleeding risk such as from anticoagulant use, pulmonary edema, recent hemoptysis, recent vertebral fractures, and conditions like hiatus hernia or recent eye surgery that may worsen with head-down positioning. For instance, rib fractures or osteoporosis increase the likelihood of fracture aggravation from chest wall pressure, while high bleeding risk heightens hemorrhage potential during manipulation; pulmonary edema or hiatus hernia can be intensified by fluid shifts in Trendelenburg positions, and eye surgery contraindicates head-down tilts due to pressure on surgical sites. Additional relative factors include large pleural effusions, pulmonary embolism, distended abdomen, uncontrolled airway at risk for aspiration, bronchopleural fistula, empyema, suspected pulmonary tuberculosis, lung contusion, subcutaneous emphysema, recent epidural spinal infusion, burns or open wounds on the thorax, and patient intolerance such as in aged, confused, or anxious individuals.^[1]^[5]^[18] In borderline cases, clinical decision-making involves weighing the potential benefits of mucus clearance against these risks, often requiring multidisciplinary consultation to modify or avoid the technique as needed.^[5]^[1]

Risks and Complications

Postural drainage, while generally safe, carries potential risks of orthostatic hypotension, which can lead to dizziness upon position changes due to shifts in blood flow.^[5] Increased intracranial pressure is another common concern, especially in head-down positions that may elevate pressure in the cerebral vasculature.^[19] Vomiting or aspiration risks arise in these inverted postures, particularly if gastric contents reflux into the airways.^[15] Additionally, prolonged or awkward positioning can result in musculoskeletal strain, causing pain or injury to muscles, ribs, or the spine.^[1] Less frequently, postural drainage may trigger bronchospasm in patients with reactive airways, leading to wheezing or shortness of breath.^[5] Exacerbation of hemoptysis can occur, worsening bleeding in those with underlying vascular fragility, though this overlaps with established contraindications such as active hemoptysis.^[1] Barotrauma, including pneumothorax, represents a rare but serious risk in patients with compromised lung structures, potentially due to pressure changes during the procedure.^[1] Fatigue may also develop from extended sessions, contributing to patient discomfort and reduced compliance.^[1] Effective monitoring is essential to minimize these adverse effects, including regular checks of vital signs such as blood pressure, heart rate, and oxygen saturation before and after each session.^[5] Continuous observation for signs of distress, including pallor, nausea, or altered mental status, allows for prompt intervention, with the procedure halted immediately if symptoms emerge.^[5] The overall incidence of serious complications remains low in appropriately selected patients, though rates may be higher in acute care environments where underlying instabilities amplify vulnerabilities.^[20]

Procedure

Positioning Techniques

Postural drainage relies on specific body positions to leverage gravity for clearing secretions from the bronchial tree, targeting the 19 lung segments divided among the upper, middle, and lower lobes. The general setup requires a firm surface such as a bed or treatment table, with the foot end elevated 14 to 18 inches using blocks or an adjustable mechanism to achieve a 15- to 30-degree tilt for lower lobe positions.^[21] Pillows or rolled towels provide support to maintain alignment and comfort, preventing strain during the procedure.^[5] Sessions typically involve holding each position for 3 to 15 minutes, allowing time for deep breathing and huffing to mobilize secretions, with total treatment lasting 20 to 40 minutes depending on the number of positions used.^[5]^[21] Positions for the upper lobes focus on upright or semi-recumbent orientations to drain the apical, posterior, and anterior segments bilaterally. For the apical segments, the patient sits upright or leans back slightly at a 30-degree angle with arms relaxed at the sides.^[21] Posterior segments are addressed by leaning forward over a pillow at 30 degrees, promoting drainage toward the central airways.^[21] Anterior segments involve a supine position flat on the back, with a small pillow under the head if needed for neutral alignment.^[21] The middle lobe on the right and lingula on the left require side-lying positions with a modest head-down tilt to direct secretions from these anterior-inferior segments. The patient lies on the right side with the head lowered 15 degrees and the body rotated a quarter turn backward for lingula drainage, or mirrored on the left side for the middle lobe.^[21] Hips may be slightly elevated with a pillow to enhance gravitational pull without discomfort.^[1] Lower lobe positions incorporate greater tilts to access the posterior basal, anterior basal, lateral basal, and superior segments, often using prone or side-lying setups. For posterior basal segments, the patient lies prone with hips elevated on two pillows and the head down 30 degrees in Trendelenburg position.^[21] Anterior basal segments are targeted in side-lying with a 30-degree head-down tilt and a quarter turn forward.^[21] Lateral basal segments use side-lying with the upper leg straight and head down 30 degrees, while superior segments involve prone positioning with hips raised on pillows but minimal or no tilt.^[21] Variations accommodate patient limitations, such as bedridden individuals who use adjustable hospital beds or wedge-shaped pillows to replicate tilts without full mobility.^[1] For pediatric patients, durations are shortened to 3 to 5 minutes per position to match tolerance, with infants often positioned on a caregiver's lap in adapted upright or side-lying holds.^[21] The sequence of positions typically begins with upper lobe orientations, progressing to middle and then lower lobes, allowing gradual mobilization of secretions from less dependent to more dependent areas based on clinical assessment and patient response.^[6] This approach is re-evaluated every 48 to 72 hours to optimize efficacy.^[5]

Implementation and Adjuncts

Postural drainage sessions are typically conducted for a total duration of 20 to 40 minutes, involving multiple positions held for 3 to 15 minutes each depending on the targeted lung segments and patient tolerance.^[5]^[21] In acute care settings, these sessions are performed 2 to 4 times daily to optimize secretion clearance, while in critical care environments, such as for mechanically ventilated patients, they occur every 4 to 6 hours with reassessment every 48 hours.^[5]^[22] Each session concludes with encouraged coughing or huffing techniques to facilitate the expulsion of mobilized secretions, enhancing overall airway clearance.^[1] Adjunct techniques are integral to postural drainage to loosen and mobilize mucus, including manual percussion, which involves rhythmic clapping with cupped hands over specific lung segments for 2 to 3 minutes per area, and vibration, consisting of firm, rhythmic pressure applied during exhalation to promote shear forces on secretions.^[5]^[1] Breathing exercises, such as deep thoracic expansions or controlled huffing, are often incorporated to augment airflow and mucus movement.^[1] For self-administration, particularly in home settings, mechanical percussors or vibratory devices allow patients to replicate these manual methods independently.^[5] Implementation varies between clinical and home environments to accommodate patient needs and resources. In clinical settings, sessions are supervised and adapted frequently, with reevaluation every 72 hours or upon status changes in acute care.^[22] Domiciliary or home-based postural drainage emphasizes patient training for autonomy, with periodic reassessment every 3 months or as clinical changes occur to ensure ongoing efficacy.^[5]^[22] Respiratory therapists play a central role in overseeing postural drainage, verifying correct positioning and technique application, delivering patient education on adjunct methods and self-management, and facilitating progression toward independent performance to support long-term adherence.^[1]^[5]

Evidence and Practice

Clinical Evidence

Early observational studies from the 1930s and 1950s established the foundational role of postural drainage in promoting secretion clearance from the lungs in patients with bronchopulmonary conditions such as cystic fibrosis and chronic bronchitis.^[1] These investigations, including early descriptions by clinicians like Nelson in 1934, demonstrated that gravity-assisted positioning mobilized mucus toward central airways, facilitating expectoration and improving ventilation-perfusion matching, though the evidence was primarily descriptive and lacked rigorous controls.^[10] In the 1990s, randomized controlled trials in cystic fibrosis patients provided stronger support for postural drainage during acute pulmonary exacerbations. A crossover randomized study involving hospitalized children compared postural drainage with percussion to other regimens and found significant improvements in forced expiratory volume in one second (FEV1), with gains of approximately 10-15% post-treatment across groups, alongside reduced exacerbation severity through enhanced mucus clearance. Long-term application in these trials also correlated with fewer exacerbations, as regular use maintained better lung function and decreased infection frequency over 6-12 months. Modern evidence from meta-analyses underscores moderate efficacy for postural drainage in mucus mobilization, particularly in bronchiectasis. The 2015 Cochrane review of airway clearance techniques, including postural drainage, analyzed seven trials and reported limited evidence of short-term improvements in sputum expectoration (mean difference 4.7 g wet weight, 95% CI -2.7 to 12.0) with no significant FEV1 gains, but noted no clear superiority over alternatives due to limited high-quality data.^[23] In the 2020s, studies on chronic obstructive pulmonary disease (COPD) during acute exacerbations have shown benefits, such as enhanced sputum clearance and reduced hospitalization duration, in patients with high mucus burden, though results vary by protocol.^[1] Clinical trials on postural drainage face notable limitations, including small sample sizes (often under 50 participants), heterogeneity in positioning techniques and adjuncts, and difficulties in blinding due to the physical nature of interventions, which can introduce bias in subjective outcomes like symptom relief. Despite these challenges, positive outcomes are more consistent in pediatric populations with cystic fibrosis and high sputum loads, where trials report reliable increases in expectorated volume.^[24] Quantitative insights from controlled studies indicate variable increases in expectorated sputum volume post-session, typically ranging from 4 to 15 g wet weight, with benefits more pronounced in patients with high sputum loads.^[25] As of 2024, systematic reviews continue to support moderate short-term benefits in mucus clearance for conditions like cystic fibrosis and bronchiectasis, though long-term impacts remain understudied.^[1]

Guidelines and Recommendations

The American Association for Respiratory Care (AARC) recommends postural drainage therapy for patients producing more than 25-30 mL of sputum per day in adults, particularly those with conditions such as cystic fibrosis, bronchiectasis, or atelectasis due to mucus plugging, as this indicates difficulty in clearing secretions.^[5] The European Respiratory Society (ERS) guidelines for bronchiectasis management endorse airway clearance techniques, including gravity-assisted postural drainage, for symptomatic adult patients to improve sputum expectoration and health-related quality of life, though evidence is stronger when combined with other methods like active cycle of breathing techniques. The Cystic Fibrosis Foundation (CFF) incorporates postural drainage as an effective component of multi-modal airway clearance regimens for all patients with cystic fibrosis, emphasizing its role in sputum clearance and lung function maintenance alongside techniques such as positive expiratory pressure devices, with no single method deemed superior.^[26] Recent ERS statements, including the 2023 consensus on airway clearance in bronchiectasis, prioritize individualized application of postural drainage based on patient preferences, tolerance, and clinical status over routine use, recommending respiratory physiotherapists guide selection among options like autogenic drainage or oscillating positive expiratory pressure to enhance adherence and outcomes. In intensive care unit protocols for mechanically ventilated patients, the AARC advises performing postural drainage every 4 to 6 hours as indicated to mobilize secretions and improve ventilation-perfusion matching, integrated with turning and percussion.^[5] Best practices include combining postural drainage with patient assessment tools such as auscultation and sputum volume measurement, alongside continuous monitoring of oxygen saturation via pulse oximetry, vital signs, and breath sounds to detect desaturation or distress during sessions.^[5] Positions should be held for 3-15 minutes per segment, adjusted for tolerance, and therapy discontinued if adverse effects occur or if there is no observed increase in sputum clearance or clinical improvement after initial trials.^[5] In low-resource settings, postural drainage is endorsed as a non-invasive, low-cost element of pulmonary rehabilitation for post-tuberculosis lung disease management to aid secretion evacuation and prevent complications.^[27]

Complementary Therapies

Integration with Other Methods

Postural drainage is frequently integrated with active cycle of breathing techniques (ACBT), positive expiratory pressure (PEP) devices, and high-frequency chest wall oscillation (HFCWO) to achieve synergistic effects in mucus mobilization, particularly in conditions like cystic fibrosis where retained secretions impair lung function.^[26] These combinations leverage gravity-assisted drainage to initially loosen secretions, followed by breathing exercises or mechanical aids to facilitate their expulsion, enhancing overall airway clearance efficacy.^[28] For instance, ACBT incorporates thoracic expansion and forced expiration phases that complement postural positions, while PEP devices maintain airway patency during exhalation, and HFCWO applies external vibrations to dislodge mucus without requiring specific positioning.^[1] In clinical protocols for cystic fibrosis, postural drainage is often combined with PEP therapy, with sessions tailored to individual needs, typically lasting 10-20 minutes each and performed 1-2 times daily.^[29] This approach is adapted within interprofessional teams, where physiotherapists demonstrate techniques, pulmonologists monitor lung function, and respiratory therapists ensure proper device use during inpatient or outpatient care.^[26] For home management, protocols emphasize portable PEP devices or lightweight HFCWO vests, allowing patients to perform bundled sessions independently while maintaining consistency with supervised routines.^[28] Bundling postural drainage with these adjuncts has been associated with improved patient adherence in chronic respiratory conditions, as individualized combinations align with preferences and reduce treatment burden, leading to better long-term mucus clearance and quality of life.^[26] Such integrated strategies foster greater engagement, particularly when patients select familiar devices, resulting in sustained efficacy for ongoing airway management.^[1]

Comparisons and Alternatives

Postural drainage, a passive technique relying on gravity to facilitate mucus clearance from the airways, contrasts with several active and mechanical alternatives in airway clearance therapy (ACT). Autogenic drainage involves self-controlled breathing to adjust airflow and mobilize secretions without positional changes or equipment, making it suitable for independent use in sitting positions. Studies indicate autogenic drainage is clinically equivalent to postural drainage in sputum expectoration and lung function improvement for patients with cystic fibrosis (CF).^[30] Similarly, the active cycle of breathing technique (ACBT) requires patient effort through phases of breathing control, thoracic expansion, and forced expiration (huffing), offering comparable efficacy to postural drainage in clearing secretions for conditions like bronchiectasis and CF, but with greater tolerability for mobile individuals.^[31]^[30] Mechanical alternatives include intrapulmonary percussive ventilation (IPV), which delivers high-frequency mini-bursts of air to loosen and propel mucus, and high-frequency chest wall oscillation (HFCWO) using an inflatable vest to vibrate the thorax. IPV demonstrates similar sputum production to postural drainage in CF but may be more effective for atelectasis resolution in intubated patients, while HFCWO matches postural drainage's clearance rates in home settings for CF without requiring caregiver assistance.^[31]^[32]^[33] Mechanical insufflation-exsufflation (MI-E) simulates cough via alternating positive and negative pressure, proving superior to autogenic drainage in sputum volume for neuromuscular disorders and particularly beneficial for immobile patients unable to perform active techniques. Non-invasive options like exercise promote airway clearance through increased ventilation and shear forces, serving as a viable alternative for mobile patients with mild secretions in CF, where it yields outcomes akin to postural drainage and percussion.^[31]^[32]^[33] Key differences lie in passivity versus activity: postural drainage demands no patient effort but often requires assistance and specific positioning, whereas active methods like ACBT or autogenic drainage empower patient participation, potentially enhancing adherence in cooperative individuals. For immobile or weak patients, postural drainage proves less suitable due to positioning challenges, favoring mechanical aids like HFCWO vests or MI-E, which can be applied supine without gravity reliance. Positive expiratory pressure (PEP) therapy, involving exhalation against resistance to stent airways open, differs by preventing collapse during expiration; it shows no short-term superiority over postural drainage but offers long-term lung function benefits in pediatric CF.^[1]^[30]^[34] Alternatives are preferred in cases of contraindications to postural drainage, such as severe osteoporosis where head-down positions risk fractures, or recent spinal surgery increasing intracranial pressure; here, device-based options like MI-E or IPV allow clearance without tilting. In evidence gaps, such as in chronic obstructive pulmonary disease (COPD) where evidence for postural drainage is limited, alternatives like PEP may be preferred for ease of use. A 2023 Cochrane review confirms no significant differences in efficacy among various ACTs, including postural drainage, for CF, supporting patient-centered selection.^[6]^[1]^[34]^[35]

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