Positive Expiratory Pressure (PEP) Devices: Difference between revisions

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'''Original Editor '''- Fatemah Ali Fairouz  
'''Original Editor '''- [[User:Fatemah Ali Fairouz| Fatemah Ali Fairouz]]


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  &nbsp;   
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  &nbsp;   
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[[File:Acapella.jpg|thumb|Acapella PEP Device<ref>http://www.acapella-pep.com/Acapella-Choice-Easy-to-Clean-PEP-Device_p_14.html</ref>]]
==Introduction==
[[File:Acapella.jpg|thumb|Acapella PEP Device<ref>http://www.acapella-pep.com/Acapella-Choice-Easy-to-Clean-PEP-Device_p_14.html</ref>]]One of the most frequently prescribed airway clearance therapy (ACT) options for patients with [[Chronic Disease|chronic]] lung conditions or decreased [[Lung Volumes|lung volumes]] are positive expiratory pressure therapy (PEP) devices.


==Introduction''' ==
During PEP therapy, the patient exhales against a fixed-orifice resistor, generating pressures during expiration that usually range from 10 to 20 cm H2O.(14-24) PEP does not require a pressurized external gas source<ref>RC Use of Positive Airway Pressure Adjuncts to Bronchial Hygiene Therapy Journal Available from: http://www.rcjournal.com/cpgs/papcpg.html (last accessed 25.9.2020)</ref>.
Positive Expiratory Pressure (PEP) is breathing against resistance, which can be performed either through a device or against pursed lips<ref name=":0">Fagevik Olsén M, Lannefors L, Westerdahl E. Positive expiratory pressure e Common clinical applications and physiological effects.Respiratory Medicine.2015;105(3):297- 307.</ref> .


====Mechanism of PEP''' ====
The therapy, which is administered by breathing through a special device helps:
The increase in pressure is transmitted to airways creating back pressure stenting them during exhalation <ref name=":1">Frownfelter DL, Dean E. Cadiovascular and Pulmonary Physical Therapy: Evidence and Practice 4th ed.St. Louis, Mo. : Mosby/Elsevier, 2006.</ref>, therefore preventing premature airway closure thus reducing gas trapping <ref name=":2">Darbee JC, Ohtake PJ, Grant BJ, Cerny FJ. Physiologic evidence for the efficacy of positive expiratory pressure as an airway clearance technique in patients with cystic fibrosis. Phys Ther. 2004;84(6):524-37. </ref>. It promotes '''''collateral ventilation''''', allowing pressure to build up distal to the obstruction<ref name=":1" /> . Not only does PEP retains airways from collapsing and prolongs expiratory flow, it is effective airway clearance promoting movement of mucus proximally <ref name=":2" />.Collateral ventilation is a phenomenon found in the human lungs where alveolar structures are ventilated through channels that bypass normal airways<ref>Cetti EJ, Moore AJ, Geddes DM. Collateral ventilation.Thorax. 2006;61(5):371-373 </ref>
* Air get behind the mucus
====Types of PEP''' ====
* Move mucus from [[Lung Anatomy|lung]] and airway walls
Some literature has described PEP as two types varying in pressure range low and high pressure PEP. Low pressure PEP ranges from 5-20cm H<sub>2</sub>O at mid-expiration, whereas high-pressure PEP ranges from 26-102cm H<sub>2</sub>O which is achieved by maximal inspiration followed by performing forced expiratory maneuver into PEP mask<ref>Myers TR. Positive Expiratory Pressure and Oscillatory Positive Expiratory Pressure Therapies. Respiratory Care. 2007;52(1):1308-1327.</ref>. Other sources have described PEP as a three airways techniques that has been developed based on expiratory resistance:- PEP, High Positive Expiratory Pressure (HiPEP), and Oscillatory Positive Expiratory Pressure (OscPEP)<ref name=":0" />.
* To hold the airways open for longer<ref>RT [https://rtmagazine.com/products-treatment/monitoring-treatment/therapy-devices/look-positive-expiratory-pressure-devices/ PEP devices] Available from:https://rtmagazine.com/products-treatment/monitoring-treatment/therapy-devices/look-positive-expiratory-pressure-devices/ (last accessed 25.9.2020)</ref>
* PEP
Increased [[Older People Introduction|geriatric]] population coupled with higher incidences of chronic conditions drive the PEP devices market growth.  
** Involves breathing against expiratory resistance to temporarily increase [https://en.wikipedia.org/wiki/Functional_residual_capacity Functional Residual Capacity (FRC)]and [https://en.wikipedia.org/wiki/Tidal_volume Tidal Volume (VT)]accompanied by clearance techniques such as [http://bronchiectasis.com.au/physiotherapy/techniques/forced-expiration-technique Forced Expiratory Technique (FET), huffing, and or coughing]<ref name=":0" />.
* Increasing prevalence of [[COPD (Chronic Obstructive Pulmonary Disease)|chronic obstructive pulmonary disease (COPD)]] along with [[asthma]] is one of the major driving factors for the industry.
* eg.according to CDC (the Centres for Disease Control and Prevention), in 2018, around 9 million adults were diagnosed with [[Chronic Bronchitis|chronic bronchitis]] which eventually leads to higher requirements for PEP devices, fueling the market.<ref>Business Wire Worldwide Oscillating Positive Expiratory Pressure Devices Industry to 2025 - North America Dominates the Market - ResearchAndMarkets.com
Available from:https://www.businesswire.com/news/home/20200826005648/en/Worldwide-Oscillating-Positive-Expiratory-Pressure-Devices-Industry (last accessed 25.9.2020)
</ref>  
This page takes a look at some of the latest PEP devices available on the market.


* HiPEP
==Mechanism of PEP==
** Involves breathing against resistance by augmenting expiratory flow using FVC<ref name=":0" />.
The increase in pressure is transmitted to airways creating back pressure stenting them during exhalation <ref name=":1">Frownfelter DL, Dean E. Cadiovascular and Pulmonary Physical Therapy: Evidence and Practice 4th ed.St. Louis, Mo. : Mosby/Elsevier, 2006.</ref>, preventing premature airway closure and reducing gas trapping <ref name=":2">Darbee JC, Ohtake PJ, Grant BJ, Cerny FJ. Physiologic evidence for the efficacy of positive expiratory pressure as an airway clearance technique in patients with cystic fibrosis. Phys Ther. 2004;84(6):524-37. </ref>.
* Promotes collateral ventilation, allowing pressure to build up distal to the obstruction<ref name=":1" />(collateral ventilation is a phenomenon found in the human lungs where alveolar structures are ventilated through channels that bypass normal airways).<ref>Cetti EJ, Moore AJ, Geddes DM. Collateral ventilation.Thorax. 2006;61(5):371-373 </ref>
* Retains airways from collapsing and prolongs expiratory flow
* Effective airway clearance promotes movement of mucus proximally <ref name=":2" />.


* Oscillating PEP
== Types of PEP ==
** Oscillating PEP is an airway clearance technique, where the person blows all the way out many times through a device<ref name=":0" />. Commonly known by their brand names (Flutter®, Acapella®, AerobikA®, and RC-Cornet®), these types of oscillating PEP devices work in two ways. Firstly, they use resistance to make it more difficult during the breath out, like non-oscillating PEP devices. Oscillating PEP devices also create vibrations when a patient breathes out. The vibrations move mucus from the surface of the airways. After blowing through the device several times, the person will huff and cough to clear the mucus from the lungs.
Two types of airway clearance devices are the positive expiratory pressure device (PEP) and the oscillating positive pressure device.
====Indications for PEP''' ====
# A PEP device increases resistance to expiratory airflow to promote mucus clearance by preventing airway closure and increasing collateral ventilation.
* Examples of this type of device include the TheraPEP®, Resistex PEP Mask, and the Pari RC Cornet Mucus Clearing DeviceTM.
2. An oscillating (or vibratory) positive expiratory pressure (OscPEP) device is a form of PEP that combines high-frequency air flow oscillations with positive expiratory. The person blows all the way out many times through a device<ref name=":0">Fagevik Olsén M, Lannefors L, Westerdahl E. Positive expiratory pressure e Common clinical applications and physiological effects.Respiratory Medicine.2015;105(3):297- 307.</ref>. Commonly known by their brand names (Flutter®, Acapella®, AerobikA®, and RC-Cornet®), these types of oscillating PEP devices work in two ways.  
* They use resistance to make it more difficult during the breath out, like non-oscillating PEP devices.  
* Also create vibrations when a patient breathes out. The vibrations move mucus from the surface of the airways. After blowing through the device several times, the person will huff and cough to clear the mucus from the lungs<ref name=":0" />.
 
==Indications for PEP==
* [[Respiratory Failure|Acute and chronic respiratory failure]] for reasons of surgery <ref name=":0" />
* [[Respiratory Failure|Acute and chronic respiratory failure]] for reasons of surgery <ref name=":0" />
* Neurological or musculoskeletal dysfunction<ref name=":0" />
* Neurological or musculoskeletal dysfunction<ref name=":0" />eg MND
* Old age and immobility<ref name=":0" />
* [[Older People - An Introduction|Old age]] and immobility<ref name=":0" />
* To increase lung volume by increasing FRC and VT<ref name=":0" />
* To increase lung volume by increasing FRC and VT<ref name=":0" />
* Reduce hyperinflation<ref name=":0" />/ Air trapping <ref name=":5">Sills JR. Airway Clearance Therapy.The Comprehensive Respiratory Therapist Exam Review. 6th ed. St. Louis, Missouri : Elsevier, 2016</ref> in patient's with [[emphysema]], [[bronchitis]], and [[asthma]]<ref name=":5" />
* Reduce hyperinflation<ref name=":0" />/ Air trapping <ref name=":5">Sills JR. Airway Clearance Therapy.The Comprehensive Respiratory Therapist Exam Review. 6th ed. St. Louis, Missouri : Elsevier, 2016</ref> in eg : [[emphysema]], [[bronchitis]], [[asthma]]<ref name=":5" />
* Improve [[Active cycle of breathing technique|airway clearance]]<ref name=":0" /> in patient's older than 4 years old who have [[Cystic Fibrosis|cystic fibrosis]], chronic bronchitis, [[bronchiectasis]], or bronchiolitis obliterans <ref name=":5" />
* Improve [[Active Cycle of Breathing Technique|airway clearance]]<ref name=":0" /> in; [[Cystic Fibrosis|cystic fibrosis]] (over 4 y.o); chronic bronchitis; [[bronchiectasis]]; bronchiolitis obliterans <ref name=":5" />
* To maximise the delivery of bronchodilators in patient's receiving bronchial hygiene therapy<ref name=":5" />  
* To maximise the delivery of [[Respiratory Medication|bronchodilators]] in patient's receiving bronchial hygiene therapy<ref name=":5" />  


====Relative Contraindications for PEP''' ====
==Relative Contraindications for PEP==
* Untreated [[pneumothorax]] <ref name=":5" />
* Untreated [[pneumothorax]] <ref name=":5" />
* Intracranial pressure > 20mm Hg<ref name=":5" />
* Intracranial pressure > 20mm Hg<ref name=":5" />
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* Tympanic membrane rupture or other known or suspected inner ear pathology<ref name=":5" />  
* Tympanic membrane rupture or other known or suspected inner ear pathology<ref name=":5" />  
* Nausea <ref name=":5" />
* Nausea <ref name=":5" />
'''''There are no absolute contraindications to PEP that have been noted by literature'''''
There are no absolute contraindications to PEP that have been noted by literature  


=='''Physiology of PEP'''==
==Physiology of PEP==
Literature has stated theoretical explanations that discuss the physiology behind PEP therapy and its effects on cardiopulmonary status. The theories are:-
# Increasing [[Lung Volumes|lung volume]] FRC and VT
 
====Increasing [[Lung Volumes|lung volume]] FRC and VT''' ====
* A progressively temporary increase in FRC has been found to be proportionally correlated when increasing PEP<ref name=":0" />
* A progressively temporary increase in FRC has been found to be proportionally correlated when increasing PEP<ref name=":0" />
* An increase in FRC is attained by alteration of breathing pattern that is a product of a decrease in expiratory flow and an increase in expiratory time leading to exhalation of smaller volumes<ref name=":0" />.
* An increase in FRC is attained by alteration of breathing pattern that is a product of a decrease in expiratory flow and an increase in expiratory time leading to exhalation of smaller volumes<ref name=":0" />.
* lung volume increase is achieved by altering breathing pattern, thereby increasing VT and decreasing respiratory frequency, which is due to an increase in muscle activity of inspiratory and expiratory muscles<ref name=":0" />.
* lung volume increase is achieved by altering breathing pattern, thereby increasing VT and decreasing respiratory frequency, which is due to an increase in muscle activity of inspiratory and expiratory muscles<ref name=":0" />.
* Improved gas exchange is a result of breathing during a prolonged period with normalized lung volumes<ref name=":0" />.
* Improved gas exchange is a result of breathing during a prolonged period with normalized lung volumes<ref name=":0" />.
 
2. Reduction of hyperinflation
====Reduction of hyperinflation''' ====
* Hyperinflation is a result of air entrapment causing the lungs to over inflate. It is caused by muscle spasm, mucosal inflammation, hyper-secretions, reduced lung elasticity due to destruction of lung parenchyma. If Untreated may lead to inspiratory muscle exhaustion, decreased ventilation, and deficient gas exchange<ref name=":0" />.
* Hyperinflation is a result of air entrapment causing the lungs to over inflate. It is caused by muscle spasm, mucosal inflammation, hyper-secretions, reduced lung elasticity due to destruction of lung parenchyma. If Untreated may lead to inspiratory muscle exhaustion, decreased ventilation, and deficient gas exchange<ref name=":0" />.
* PEP reduces expiratory flow, which in return decreases the declining pressure across the airway wall thereby reducing collapse<ref name=":0" />
* PEP reduces expiratory flow, which in return decreases the declining pressure across the airway wall thereby reducing collapse<ref name=":0" />
* Increasing pressure within airways transports EPP centrally and in stable airways therefore stenting them. Reduction of airway collapse increases expired volume leading to additional emptying of lung volume thus lowering FRC and improving ventilation distribution and gas exchange<ref name=":0" />.
* Increasing pressure within airways transports EPP centrally and in stable airways therefore stenting them. Reduction of airway collapse increases expired volume leading to additional emptying of lung volume thus lowering FRC and improving ventilation distribution and gas exchange<ref name=":0" />.
3. Airway Clearance


====Airway Clearance''' ====
When using HiPEP
When using HiPEP
* It homogenously mobilize secretions in collapsed airways. It aims towards increasing FRC by recruiting collapsed lung volumes and uses resistance to obtain progressive homogenization emptying of the lungs<ref name=":0" />.
* It homogenously mobilize secretions in collapsed airways. It aims towards increasing FRC by recruiting collapsed lung volumes and uses resistance to obtain progressive homogenization emptying of the lungs<ref name=":0" />.
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* The oscillating property is achieved by bursts and turbulent expiratory airflow due to the opening and closing of the valve. Oscillations during expiration decreases the viscoelasticity properties of mucus, effecting its movement which depends on the oscillating frequency. OscPEP is equally as effective as other Airway Clearance Technique (ACT) as PEP and [[Active Cycle of Breathing Technique|Active Cycle Breathing Technique (ACBT)]]<ref name=":0" />.
* The oscillating property is achieved by bursts and turbulent expiratory airflow due to the opening and closing of the valve. Oscillations during expiration decreases the viscoelasticity properties of mucus, effecting its movement which depends on the oscillating frequency. OscPEP is equally as effective as other Airway Clearance Technique (ACT) as PEP and [[Active Cycle of Breathing Technique|Active Cycle Breathing Technique (ACBT)]]<ref name=":0" />.


==Different PEP devices''' ==
==Different PEP devices==
'''PEP''' therapy may be applied through:
!. OscPEP - applied with a threshold-dependent mechanism with a high density steel "movable ball" that is interposed on a funnel or circular cone between the exhalation tract of the device causing a vibration that is transmitted to the lungs, examples are:  
 
* Aerobika OPEP - Monaghan Medical’s Aerobika oscillating positive expiratory pressure (OPEP) device assists mucociliary clearance and helps prevent COPD progression, according to the company.
Face mask with a one-way valve to which expiratory resistors are attached or face-mask connected to a plastic ring drilled by holes of different caliber that act as resistors. Both devices could be suited to mouthpiece application if necessary. These systems are considered to be ''flux-dependent''.
* Flutter - The Flutter mucus clearance device, manufactured by Aptalis Pharma US Inc, provides PEP therapy for patients with atelectasis, bronchitis, bronchiectasis, cystic fibrosis, COPD, asthma or other conditions producing retained secretions, according to the company
 
* Pari O-PEP - Coming soon to the US market is Pari O-PEP, an oscillating positive expiratory pressure device manufactured by Pari Respiratory. The device is designed to mobilize secretions in the lower respiratory tract, strengthen the respiratory tract and alleviate shortness of breath for patients five and older.
[https://www.pari.com/uk-en/products/pari-pep-systems/pari-pep-s-system-1/ '''PARI S-System'''] <ref name=":3">PARI PEP S-System. Available from:  https://www.pari.com/uk-en/products/pari-pep-systems/pari-pep-s-system-1/<nowiki/>(accessed 5 June 2019)</ref>    <ref name=":6">TheraPEP® PEP Therapy System. Available from: https://www.smiths-medical.com/products/respiratory/bronchial-hygiene/therapep-pep-therapy-system (accessed 5 June 2019).
'''2. PEP''' therapy may be applied through e.g.[[File:Bubble PEP.jpg|alt=Cincinnati Childrens- https://www.cincinnatichildrens.org/health/b/Bubble-PEP|[https://www.cincinnatichildrens.org/health/b/Bubble-PEP Bubble PEP] |right|frameless]]
</ref>                                                                                                         
* Face mask with a one-way valve to which expiratory resistors are attached or face-mask connected to a plastic ring drilled by holes of different caliber that act as resistors. Both devices could be suited to mouthpiece application if necessary. These systems are considered to be ''flux-dependent''.
 
''[https://www.pari.com/fileadmin/user_upload/PARI.com_UK/Doc/IFU/018D4000-E-de-en-IFU-PARI-PEP-S.pdf Instructions]''<ref name=":3" /> ''- [https://www.pari.com/fileadmin/user_upload/PARI.com_UK/Doc/Docs/018D4008-EN-UK-PARI-PEP-S-short-ifu.pdf Brochure]''<ref name=":3" /> ''- [http://bronchiectasis.com.au/resources/videos/positive-expiratory-pressure-therapy-using-pari-pep Video]''<ref>Positive Expiratory Pressure Therapy using PARI PEP. Available from:http://bronchiectasis.com.au/resources/videos/positive-expiratory-pressure-therapy-using-pari-pep (accessed 5 June 2019).</ref>                                                                                                 
[[File:PARI PEP S-System.jpg|alt=PARI S-System|thumb|[https://www.pari.com/uk-en/products/pari-pep-systems/pari-pep-s-system-1/ PARI S-System] |none]]
 
[https://www.smiths-medical.com/products/respiratory/bronchial-hygiene/therapep-pep-therapy-system '''TheraPEP''']<ref name=":6" />
 
[http://bronchiectasis.com.au/resources/videos/positive-expiratory-pressure-therapy-using-thera-pep ''Video'']<ref>Positive Expiratory Pressure Therapy using Thera PEP. Available from:http://bronchiectasis.com.au/resources/videos/positive-expiratory-pressure-therapy-using-thera-pep (accessed 5 June 2019)</ref>[[File:TheraPEP.png|alt=Smiths Medical- TheraPEP|thumb|261x261px|[https://www.smiths-medical.com/products/respiratory/bronchial-hygiene/therapep-pep-therapy-system Smiths Medical] TheraPEP |none]] 
 
A very common ''threshold-dependent'' system is "PEP Bottle" or bubble PEP that consists of a bottle filled with a predetermined quantity of water in which a tube that draws from the bottom. Patient blows into the tube and has to overcome the pressure opposed by the level of water until bubbles are produced.
 
[https://www.cincinnatichildrens.org/health/b/Bubble-PEP '''PEP Bottle''']<ref name=":4">Bubble PEP (Positive Expiratory Pressure). Cincinnati Children's. Available from:https://www.cincinnatichildrens.org/health/b/Bubble-PEP<nowiki/>(accessed 5 June 2019).
</ref> [https://www.cincinnatichildrens.org/health/b/Bubble-PEP ''(Instructions)'']
 
A very common ''threshold-dependent'' system is "PEP Bottle" or bubble PEP that consists of a bottle filled with a predetermined quantity of water in which a tube that draws from the bottom. Patient blows into the tube and has to overcome the pressure opposed by the level of water until bubbles are produced.
[[File:Bubble PEP.jpg|alt=Cincinnati Childrens- https://www.cincinnatichildrens.org/health/b/Bubble-PEP|thumb|[https://www.cincinnatichildrens.org/health/b/Bubble-PEP Bubble PEP] |left]]      
 
PEP may also be applied tighter with vibrations with oscillating PEP (OscPEP) devices .  


Aerobika® , Acapella®, VibraPEP®, vPEP® are flux-dependent plastic-made devices with a general mechanism of opening and vibrating.  
* PEP Bottle<ref name=":4">Bubble PEP (Positive Expiratory Pressure). Cincinnati Children's. Available from:https://www.cincinnatichildrens.org/health/b/Bubble-PEP<nowiki/>(accessed 5 June 2019).
</ref> - A very common threshold-dependent system is "PEP Bottle" or bubble PEP that consists of a bottle filled with a predetermined quantity of water in which a tube that draws from the bottom. Patient blows into the tube and has to overcome the pressure opposed by the level of water until bubbles are produced.


OscPEP can also be applied with a threshold-dependent mechanism with a high density steel "movable ball" that is interposed on a funnel or circular cone between the exhalation tract of the device causing a vibration that is transmitted to the lungs (examples are PARI O PEP®, Flutter® , TurboForte®, PEPE).
== Instructions for the use of PEP devices ==
Physiotherapist will set device to the amount of pressure needed (Can be used as an adjunct to [[Active Cycle of Breathing Technique]])


==Instructions for the use of PEP devices'''  ==
Intructions
# Treatment can be carried out in sitting or any postural drainage position (where possible).
# Relax your stomach muscles and take a few normal breaths before using the PEP device.
# Close your lips around the mouthpiece of the PEP device, making sure there is a good seal.
# Take a slightly bigger breath in through your nose and then blow out through the PEP device. You may feel vibrations on your chest wall.
# Repeat eight to 10 times.
# Following this you should put the PEP device down and do huffing and coughing to clear any sputum. You should then have a period of relaxed breathing before continuing.
This cycle should continue for 10-20 minutes or until you have cleared all your sputum.


Instructions for PEP devices may vary. Please see manufacturers instructions.
Repeat below steps at least 5 times to make 1 cycle. Repeat the following steps as many times as directed to complete 1 cycle:


==Scientific literature about PEP'''  ==
Loosen mucus:
'''"Using positive expiratory pressure physiotherapy to clear the airways of people with [[Cystic Fibrosis|cystic fibrosis]]" - Cochrane review'''<ref>McIlwaine M, Button B, Dwan K. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2015; (6): CD003147. DOI: 10.1002/14651858.CD003147.pub4</ref>
* Sit up with your back straight and your chin slightly up. This position allows your throat to be open so air can move easily without blockage.
* Following meta-analyses of the effects of PEP versus other <abbr>airway</abbr> clearance techniques on lung function and patient preference a cochrane review demonstrated that there was a significant reduction in <abbr>pulmonary</abbr> exacerbations in people using PEP where exacerbation rate was a primary <abbr>outcome</abbr> measure. 
* You may need to put your elbows on a table. This may keep you from slouching and blocking air from moving freely.
* Take a deep breath and hold it for 2 to 3 seconds.
* While you hold your breath, place the mouthpiece in your mouth or the mask over your mouth and nose.
* Breathe out at a steady rate for 4 to 6 seconds or as long as you can. Keep your cheeks as flat as possible. You may have to use your fingers to hold your cheeks down. Try not to cough.
* You may be able to keep the mouthpiece in, or your mask on, as you repeat. Take a deep breath in through your nose.
Cough and bring up mucus:
* Remove the mouthpiece from your mouth or the mask from your face.
* Do 2 to 3 huff coughs. Take a deep breath in. Use your stomach muscles to breathe out 3 quick, forceful breaths. Make a ha, ha, ha sound.
* Then cough hard to bring up mucus. Spit the mucus out. Do not swallow the mucus.
* You may need to rest for 1 to 2 minutes.
* This cycle should continue for 10-20 minutes or until you have cleared all your sputum.
* Instructions for PEP devices may vary. Please see manufacturers instructions.


'''"PEP therapy in [[bronchiectasis]]" - Cochrane review'''<ref>Lee AL, Burge AT, Holland AE. Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis. Cochrane Database of Systematic Reviews 2017;(9): CD011699. DOI: 10.1002/14651858.CD011699.pub2</ref>
== Scientific literature about PEP ==
* PEP <abbr>therapy</abbr> appears to have similar effects on health related quality of life, symptoms of breathlessness, <abbr>sputum</abbr> expectoration, and lung volumes compared to other ACTs when prescribed within a stable clinical state or during an <abbr>acute</abbr> exacerbation.
* Following meta-analyses of the effects of PEP versus other <abbr>airway</abbr> clearance techniques on lung function and patient preference, a cochrane review demonstrated that there was a significant reduction in <abbr>pulmonary</abbr> exacerbations in people using PEP where exacerbation rate was a primary <abbr>outcome</abbr> measure.<ref>McIlwaine M, Button B, Dwan K. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2015; (6): CD003147. DOI: 10.1002/14651858.CD003147.pub4</ref> 


'''"Chest physiotherapy with positive expiratory pressure breathing after abdominal and thoracic surgery: a systematic review"'''<ref>Örman J, Westerdahl E. Chest physiotherapy with positive expiratory pressure breathing after abdominal and thoracic surgery: a systematic review. Acta Anaesthesiologica Scandinavica. 2010; 54(3): 261-267.</ref>
* Another '''Cochrane review'''<ref>Lee AL, Burge AT, Holland AE. Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis. Cochrane Database of Systematic Reviews 2017;(9): CD011699. DOI: 10.1002/14651858.CD011699.pub2</ref> suggests that PEP <abbr>therapy</abbr> appears to have similar effects on health-related quality of life, symptoms of breathlessness, <abbr>sputum</abbr> expectoration, and lung volumes compared to other ACTs when prescribed within a stable clinical state or during an <abbr>acute</abbr> exacerbation.
* This review has investigated the effect of PEP breathing after an open upper abdominal or thoracic surgery.
* '''A systematic review"'''<ref>Örman J, Westerdahl E. Chest physiotherapy with positive expiratory pressure breathing after abdominal and thoracic surgery: a systematic review. Acta Anaesthesiologica Scandinavica. 2010; 54(3): 261-267.</ref> investigated the effect of PEP breathing after an open upper abdominal or thoracic surgery. Questionable quality standards, different protocols and PEP devices used among the six RCTs included concur to uncertainty about PEP effect. It is not possible to assume that a prophylactic chest physiotherapy treatment is superior to a PEP device protocol in preventing within five-days postoperative complications.
* Questionable quality standards, different protocols and PEP devices used among the six RCTs included concur to uncertainty about PEP effect. It is not possible to assume that a prophylactic chest physiotherapy treatment is superior to a PEP device protocol in preventing within five-days postoperative complications.
* A single-arm pilot study analyzing the impact of a specific Oscillating positive expiratory pressure (oPEP) - Aerobika® device in COPD patients' lung dynamics and drug deposition suggests that the Aerobika® device usage led to an improved airflow causing a shift in internal airflow distribution and impacted the drug deposition patterns of the medication in patients with COPD<ref>Leemans G, Belmans D, Van Holsbeke C, Kushnarev V, Sugget J, Ides K, Vissers D, De Backer W. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280059/ A Functional Respiratory Imaging Approach to the Effect of an Oscillating Positive Expiratory Pressure Device in Chronic Obstructive Pulmonary Disease.] International Journal of Chronic Obstructive Pulmonary Disease. 2020 Jun 4;15:1261-8.</ref>.


== References  ==
== References  ==
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[[Category:Respiratory]]   
[[Category:Respiratory]]   
[[Category:Cardiopulmonary]]
[[Category:Cardiopulmonary]]
[[Category:Interventions - Respiratory Disease]]  
[[Category:Respiratory Disease - Interventions]]  
[[Category:Respiratory Disease - Interventions]]
[[Category:Respiratory Disease - Interventions]]

Latest revision as of 23:21, 25 April 2021

Original Editor - Fatemah Ali Fairouz

Top Contributors - Lucinda hampton, Fatemah Ali Fairouz, Kim Jackson, Uchechukwu Chukwuemeka, Riccardo Guarise, Adam Vallely Farrell, Vidya Acharya, Merinda Rodseth and Amanda Ager  

Introduction[edit | edit source]

Acapella PEP Device[1]

One of the most frequently prescribed airway clearance therapy (ACT) options for patients with chronic lung conditions or decreased lung volumes are positive expiratory pressure therapy (PEP) devices.

During PEP therapy, the patient exhales against a fixed-orifice resistor, generating pressures during expiration that usually range from 10 to 20 cm H2O.(14-24) PEP does not require a pressurized external gas source[2].

The therapy, which is administered by breathing through a special device helps:

  • Air get behind the mucus
  • Move mucus from lung and airway walls
  • To hold the airways open for longer[3]

Increased geriatric population coupled with higher incidences of chronic conditions drive the PEP devices market growth.

  • Increasing prevalence of chronic obstructive pulmonary disease (COPD) along with asthma is one of the major driving factors for the industry.
  • eg.according to CDC (the Centres for Disease Control and Prevention), in 2018, around 9 million adults were diagnosed with chronic bronchitis which eventually leads to higher requirements for PEP devices, fueling the market.[4]

This page takes a look at some of the latest PEP devices available on the market.

Mechanism of PEP[edit | edit source]

The increase in pressure is transmitted to airways creating back pressure stenting them during exhalation [5], preventing premature airway closure and reducing gas trapping [6].

  • Promotes collateral ventilation, allowing pressure to build up distal to the obstruction[5](collateral ventilation is a phenomenon found in the human lungs where alveolar structures are ventilated through channels that bypass normal airways).[7]
  • Retains airways from collapsing and prolongs expiratory flow
  • Effective airway clearance promotes movement of mucus proximally [6].

Types of PEP[edit | edit source]

Two types of airway clearance devices are the positive expiratory pressure device (PEP) and the oscillating positive pressure device.

  1. A PEP device increases resistance to expiratory airflow to promote mucus clearance by preventing airway closure and increasing collateral ventilation.
  • Examples of this type of device include the TheraPEP®, Resistex PEP Mask, and the Pari RC Cornet Mucus Clearing DeviceTM.

2. An oscillating (or vibratory) positive expiratory pressure (OscPEP) device is a form of PEP that combines high-frequency air flow oscillations with positive expiratory. The person blows all the way out many times through a device[8]. Commonly known by their brand names (Flutter®, Acapella®, AerobikA®, and RC-Cornet®), these types of oscillating PEP devices work in two ways.

  • They use resistance to make it more difficult during the breath out, like non-oscillating PEP devices.
  • Also create vibrations when a patient breathes out. The vibrations move mucus from the surface of the airways. After blowing through the device several times, the person will huff and cough to clear the mucus from the lungs[8].

Indications for PEP[edit | edit source]

Relative Contraindications for PEP[edit | edit source]

  • Untreated pneumothorax [9]
  • Intracranial pressure > 20mm Hg[9]
  • Active haemoptysis [9]
  • Recent trauma or surgery to skull, face, mouth, or oesophagus[9]
  • Patient with acute asthma attack or acute worsening of Chronic Obstructive Pulmonary Disease (COPD) unable to tolerate increased work of breathing [9]
  • Acute sinusitis or epistaxis [9]
  • Tympanic membrane rupture or other known or suspected inner ear pathology[9]
  • Nausea [9]

There are no absolute contraindications to PEP that have been noted by literature

Physiology of PEP[edit | edit source]

  1. Increasing lung volume FRC and VT
  • A progressively temporary increase in FRC has been found to be proportionally correlated when increasing PEP[8]
  • An increase in FRC is attained by alteration of breathing pattern that is a product of a decrease in expiratory flow and an increase in expiratory time leading to exhalation of smaller volumes[8].
  • lung volume increase is achieved by altering breathing pattern, thereby increasing VT and decreasing respiratory frequency, which is due to an increase in muscle activity of inspiratory and expiratory muscles[8].
  • Improved gas exchange is a result of breathing during a prolonged period with normalized lung volumes[8].

2. Reduction of hyperinflation

  • Hyperinflation is a result of air entrapment causing the lungs to over inflate. It is caused by muscle spasm, mucosal inflammation, hyper-secretions, reduced lung elasticity due to destruction of lung parenchyma. If Untreated may lead to inspiratory muscle exhaustion, decreased ventilation, and deficient gas exchange[8].
  • PEP reduces expiratory flow, which in return decreases the declining pressure across the airway wall thereby reducing collapse[8]
  • Increasing pressure within airways transports EPP centrally and in stable airways therefore stenting them. Reduction of airway collapse increases expired volume leading to additional emptying of lung volume thus lowering FRC and improving ventilation distribution and gas exchange[8].

3. Airway Clearance

When using HiPEP

  • It homogenously mobilize secretions in collapsed airways. It aims towards increasing FRC by recruiting collapsed lung volumes and uses resistance to obtain progressive homogenization emptying of the lungs[8].
  • Homogenization is achieved by the facilitation of EPP to move peripherally during expiration avoiding collapsed airways, trapped gas, and atelectasis. This results in reduction of respiratory flow and an increase in expiratory flow combined with an increase in FRC. In doing so secretion is mobilized in closed or collapsed and unreachable parts of the lungs. HiPEP is proven to be an airway clearance technique equally or more effective than PEP[8].

When using OscPEP

  • The oscillating property is achieved by bursts and turbulent expiratory airflow due to the opening and closing of the valve. Oscillations during expiration decreases the viscoelasticity properties of mucus, effecting its movement which depends on the oscillating frequency. OscPEP is equally as effective as other Airway Clearance Technique (ACT) as PEP and Active Cycle Breathing Technique (ACBT)[8].

Different PEP devices[edit | edit source]

!. OscPEP - applied with a threshold-dependent mechanism with a high density steel "movable ball" that is interposed on a funnel or circular cone between the exhalation tract of the device causing a vibration that is transmitted to the lungs, examples are:

  • Aerobika OPEP - Monaghan Medical’s Aerobika oscillating positive expiratory pressure (OPEP) device assists mucociliary clearance and helps prevent COPD progression, according to the company.
  • Flutter - The Flutter mucus clearance device, manufactured by Aptalis Pharma US Inc, provides PEP therapy for patients with atelectasis, bronchitis, bronchiectasis, cystic fibrosis, COPD, asthma or other conditions producing retained secretions, according to the company
  • Pari O-PEP - Coming soon to the US market is Pari O-PEP, an oscillating positive expiratory pressure device manufactured by Pari Respiratory. The device is designed to mobilize secretions in the lower respiratory tract, strengthen the respiratory tract and alleviate shortness of breath for patients five and older.

2. PEP therapy may be applied through e.g.

Cincinnati Childrens- https://www.cincinnatichildrens.org/health/b/Bubble-PEP
  • Face mask with a one-way valve to which expiratory resistors are attached or face-mask connected to a plastic ring drilled by holes of different caliber that act as resistors. Both devices could be suited to mouthpiece application if necessary. These systems are considered to be flux-dependent.
  • PEP Bottle[10] - A very common threshold-dependent system is "PEP Bottle" or bubble PEP that consists of a bottle filled with a predetermined quantity of water in which a tube that draws from the bottom. Patient blows into the tube and has to overcome the pressure opposed by the level of water until bubbles are produced.

Instructions for the use of PEP devices[edit | edit source]

Physiotherapist will set device to the amount of pressure needed (Can be used as an adjunct to Active Cycle of Breathing Technique)

Intructions

Repeat below steps at least 5 times to make 1 cycle. Repeat the following steps as many times as directed to complete 1 cycle:

Loosen mucus:

  • Sit up with your back straight and your chin slightly up. This position allows your throat to be open so air can move easily without blockage.
  • You may need to put your elbows on a table. This may keep you from slouching and blocking air from moving freely.
  • Take a deep breath and hold it for 2 to 3 seconds.
  • While you hold your breath, place the mouthpiece in your mouth or the mask over your mouth and nose.
  • Breathe out at a steady rate for 4 to 6 seconds or as long as you can. Keep your cheeks as flat as possible. You may have to use your fingers to hold your cheeks down. Try not to cough.
  • You may be able to keep the mouthpiece in, or your mask on, as you repeat. Take a deep breath in through your nose.

Cough and bring up mucus:

  • Remove the mouthpiece from your mouth or the mask from your face.
  • Do 2 to 3 huff coughs. Take a deep breath in. Use your stomach muscles to breathe out 3 quick, forceful breaths. Make a ha, ha, ha sound.
  • Then cough hard to bring up mucus. Spit the mucus out. Do not swallow the mucus.
  • You may need to rest for 1 to 2 minutes.
  • This cycle should continue for 10-20 minutes or until you have cleared all your sputum.
  • Instructions for PEP devices may vary. Please see manufacturers instructions.

Scientific literature about PEP[edit | edit source]

  • Following meta-analyses of the effects of PEP versus other airway clearance techniques on lung function and patient preference, a cochrane review demonstrated that there was a significant reduction in pulmonary exacerbations in people using PEP where exacerbation rate was a primary outcome measure.[11] 
  • Another Cochrane review[12] suggests that PEP therapy appears to have similar effects on health-related quality of life, symptoms of breathlessness, sputum expectoration, and lung volumes compared to other ACTs when prescribed within a stable clinical state or during an acute exacerbation.
  • A systematic review"[13] investigated the effect of PEP breathing after an open upper abdominal or thoracic surgery. Questionable quality standards, different protocols and PEP devices used among the six RCTs included concur to uncertainty about PEP effect. It is not possible to assume that a prophylactic chest physiotherapy treatment is superior to a PEP device protocol in preventing within five-days postoperative complications.
  • A single-arm pilot study analyzing the impact of a specific Oscillating positive expiratory pressure (oPEP) - Aerobika® device in COPD patients' lung dynamics and drug deposition suggests that the Aerobika® device usage led to an improved airflow causing a shift in internal airflow distribution and impacted the drug deposition patterns of the medication in patients with COPD[14].

References[edit | edit source]

  1. ↑ http://www.acapella-pep.com/Acapella-Choice-Easy-to-Clean-PEP-Device_p_14.html
  2. ↑ RC Use of Positive Airway Pressure Adjuncts to Bronchial Hygiene Therapy Journal Available from: http://www.rcjournal.com/cpgs/papcpg.html (last accessed 25.9.2020)
  3. ↑ RT PEP devices Available from:https://rtmagazine.com/products-treatment/monitoring-treatment/therapy-devices/look-positive-expiratory-pressure-devices/ (last accessed 25.9.2020)
  4. ↑ Business Wire Worldwide Oscillating Positive Expiratory Pressure Devices Industry to 2025 - North America Dominates the Market - ResearchAndMarkets.com Available from:https://www.businesswire.com/news/home/20200826005648/en/Worldwide-Oscillating-Positive-Expiratory-Pressure-Devices-Industry (last accessed 25.9.2020)
  5. ↑ 5.0 5.1 Frownfelter DL, Dean E. Cadiovascular and Pulmonary Physical Therapy: Evidence and Practice 4th ed.St. Louis, Mo. : Mosby/Elsevier, 2006.
  6. ↑ 6.0 6.1 Darbee JC, Ohtake PJ, Grant BJ, Cerny FJ. Physiologic evidence for the efficacy of positive expiratory pressure as an airway clearance technique in patients with cystic fibrosis. Phys Ther. 2004;84(6):524-37.
  7. ↑ Cetti EJ, Moore AJ, Geddes DM. Collateral ventilation.Thorax. 2006;61(5):371-373
  8. ↑ 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 8.13 8.14 8.15 8.16 8.17 Fagevik Olsén M, Lannefors L, Westerdahl E. Positive expiratory pressure e Common clinical applications and physiological effects.Respiratory Medicine.2015;105(3):297- 307.
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 Sills JR. Airway Clearance Therapy.The Comprehensive Respiratory Therapist Exam Review. 6th ed. St. Louis, Missouri : Elsevier, 2016
  10. ↑ Bubble PEP (Positive Expiratory Pressure). Cincinnati Children's. Available from:https://www.cincinnatichildrens.org/health/b/Bubble-PEP(accessed 5 June 2019).
  11. ↑ McIlwaine M, Button B, Dwan K. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2015; (6): CD003147. DOI: 10.1002/14651858.CD003147.pub4
  12. ↑ Lee AL, Burge AT, Holland AE. Positive expiratory pressure therapy versus other airway clearance techniques for bronchiectasis. Cochrane Database of Systematic Reviews 2017;(9): CD011699. DOI: 10.1002/14651858.CD011699.pub2
  13. ↑ Örman J, Westerdahl E. Chest physiotherapy with positive expiratory pressure breathing after abdominal and thoracic surgery: a systematic review. Acta Anaesthesiologica Scandinavica. 2010; 54(3): 261-267.
  14. ↑ Leemans G, Belmans D, Van Holsbeke C, Kushnarev V, Sugget J, Ides K, Vissers D, De Backer W. A Functional Respiratory Imaging Approach to the Effect of an Oscillating Positive Expiratory Pressure Device in Chronic Obstructive Pulmonary Disease. International Journal of Chronic Obstructive Pulmonary Disease. 2020 Jun 4;15:1261-8.
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