Positive Positive Expiratory Expiratory

Pressure TherapyPressure Therapy

PEP OverviewPEP Overview

What is PEP?What is PEP? History of PEPHistory of PEP Current PEP Current PEP

DevicesDevices Clinical Clinical

EvaluationEvaluation ConclusionConclusion

What is PEP?What is PEP? PEP is a form of bronchial hygiene, and is PEP is a form of bronchial hygiene, and is

one of the 3 adjuncts of positive airway one of the 3 adjuncts of positive airway pressure (PEP, CPAP, and EPAP).pressure (PEP, CPAP, and EPAP).

PEP involves active expiration through a PEP involves active expiration through a one-way valve against a variable flow one-way valve against a variable flow resistor.resistor.

In modern PEP devices, flow resistance can In modern PEP devices, flow resistance can be manipulated to adjust for a desired be manipulated to adjust for a desired pressure.pressure.

What does PEP do?What does PEP do? Enhances secretion mobilization and removalEnhances secretion mobilization and removal Helps prevent infectionsHelps prevent infections Helps mitigate atelectasisHelps mitigate atelectasis Improved pulmonary mechanics and gas Improved pulmonary mechanics and gas

exchangeexchange

How does PEP accomplish this?How does PEP accomplish this? 2 ways:2 ways:

1.1.Filling under-inflated or collapsed alveoli via Filling under-inflated or collapsed alveoli via collateral ventilation (pores of Kohn, Canals of collateral ventilation (pores of Kohn, Canals of Lambert).*Lambert).*

2.2.Helping to stint the airways open during expiration.Helping to stint the airways open during expiration.

History of PEPHistory of PEP Origin of PEPOrigin of PEP

-Traditional CPT with manual percussion, postural drainage, and -Traditional CPT with manual percussion, postural drainage, and vibration was first introduced in 1901 to assist airway clearance in vibration was first introduced in 1901 to assist airway clearance in children with bronchiectasis.children with bronchiectasis.

-In the 1970’s PEP devices were developed in Denmark, as a means to -In the 1970’s PEP devices were developed in Denmark, as a means to aid the patient’s airway clearance with an effective, self-administered aid the patient’s airway clearance with an effective, self-administered low-pressure device (mouth piece @ 5-20 cm H20).low-pressure device (mouth piece @ 5-20 cm H20).

-High-pressure PEP therapy was developed in Austria (face mask @ 26--High-pressure PEP therapy was developed in Austria (face mask @ 26-102 cm H20).102 cm H20).

-In 1991, PEP was introduced in the U.S. by Louise Lanafours from -In 1991, PEP was introduced in the U.S. by Louise Lanafours from Sweden.Sweden.

-Since 1991, PEP devices have been modified and improved upon, -Since 1991, PEP devices have been modified and improved upon, which have produced devices such as the TheraPEP and Acapella.which have produced devices such as the TheraPEP and Acapella.

Current PEP DevicesCurrent PEP Devices

Airway Oscillation Devices (AOD)Airway Oscillation Devices (AOD) Provide standard PEP with the added benefit of Provide standard PEP with the added benefit of

oscillating pressure within the airwayoscillating pressure within the airway Oscillations reduce the viscoelasticity of mucusOscillations reduce the viscoelasticity of mucus Oscillations provide short bursts of increased Oscillations provide short bursts of increased

expiratory airflow to help with secretion expiratory airflow to help with secretion mobilizationmobilization

Flutter ValveFlutter Valve TheraPEPTheraPEP AcapellaAcapella

Current PEP DevicesCurrent PEP Devices

Flutter ValveFlutter Valve Developed in Developed in

SwitzerlandSwitzerland Pipe-shaped AOD with Pipe-shaped AOD with

a steel ball resting in a steel ball resting in an angled bowl.an angled bowl.

On exhalation, the On exhalation, the ball oscillates at ball oscillates at approximately 15 Hz, approximately 15 Hz, and provides 10-25 and provides 10-25 cm H20.cm H20.

Gravity dependentGravity dependent

Current PEP DevicesCurrent PEP Devices

TheraPEPTheraPEP Designed by Smiths Designed by Smiths

Medical CompanyMedical Company Standard low-flow PEP Standard low-flow PEP

devicedevice Built in pressure Built in pressure

indicatorindicator Can be used with a Can be used with a

mask or mouthpiecemask or mouthpiece Has a 22mm OD which Has a 22mm OD which

allows it to be docked allows it to be docked with a nebulizerwith a nebulizer

Inspiratory and Inspiratory and expiratory valvesexpiratory valves

Provides 10-20 cm H20Provides 10-20 cm H20

Current PEP DevicesCurrent PEP Devices

AcapellaAcapella Designed by Smiths Medical CompanyDesigned by Smiths Medical Company Similar to the flutter valve but with Similar to the flutter valve but with

greater functionality (AOD)greater functionality (AOD) Utilizes a counterweighted plug and Utilizes a counterweighted plug and

magnet to achieve valve closure (not magnet to achieve valve closure (not gravity dependent)gravity dependent)

3 Models: 3 Models: Low flow ( < 15 L/min, adjustable Low flow ( < 15 L/min, adjustable

resistance)resistance) High flow ( > 15 L/min, adjustable High flow ( > 15 L/min, adjustable

resistance)resistance) Choice (any flow, adjustable frequency)Choice (any flow, adjustable frequency)

What’s so great about What’s so great about PEP?PEP?

Readily accepted by patientsReadily accepted by patients Shorter treatment time compared to CPTShorter treatment time compared to CPT Independent useIndependent use Inexpensive (Acapella $32.00 @ Amazon)Inexpensive (Acapella $32.00 @ Amazon) PortablePortable BUT…is it as effective as other methods of BUT…is it as effective as other methods of

bronchial hygiene?bronchial hygiene?

VSVS

What does the research What does the research say?say?

Cystic Fibrosis – Standard PEPCystic Fibrosis – Standard PEP

Mortensen et al: PEP vs. PD&PMortensen et al: PEP vs. PD&P Equally effective in secretion clearanceEqually effective in secretion clearance

Darbee et al: PEP vs. HFCWCDarbee et al: PEP vs. HFCWC Both showed the same increase in FVC, FEV1, and sputum Both showed the same increase in FVC, FEV1, and sputum

clearance.clearance. McIlWaine et al: PEP vs. PD&PMcIlWaine et al: PEP vs. PD&P

PEP had greater improvement in FEV1 and FVCPEP had greater improvement in FEV1 and FVC Patients preferred PEP because they felt it was more effective, Patients preferred PEP because they felt it was more effective,

required less time, independent, and easier.required less time, independent, and easier. Oberwaldner et al: PEP vs. PD&POberwaldner et al: PEP vs. PD&P

PEP produced a significantly greater sputum volume, PEP produced a significantly greater sputum volume, expiratory flow rate, and decreased hyperinflation compared to expiratory flow rate, and decreased hyperinflation compared to PD&P.PD&P.

SummarySummary:: These studies show conflicting results. At the These studies show conflicting results. At the least, we can least, we can conclude that standard PEP is just as conclude that standard PEP is just as effective as PD&P and effective as PD&P and HFCWC for CF patients.HFCWC for CF patients.

What does the research What does the research say?say?

Chronic Bronchitis – Standard PEPChronic Bronchitis – Standard PEP

Christensen et al:Christensen et al: Diaphragmatic breathing /FET Diaphragmatic breathing /FET vs. PEP/FETvs. PEP/FET PEP group had greater secretion clearance, PEP group had greater secretion clearance,

lower exacerbation rate, lower rate of lower exacerbation rate, lower rate of mucolytic and antibiotic use, and an increase mucolytic and antibiotic use, and an increase in FEV1.in FEV1.

What does the research What does the research say?say?

Cystic Fibrosis – OPEPCystic Fibrosis – OPEP

Newhouse et al: Flutter vs. IPPVNewhouse et al: Flutter vs. IPPV Equally effective in sputum production, and increasing expiratory flows.Equally effective in sputum production, and increasing expiratory flows.

Hominick et al: Flutter vs. PD&PHominick et al: Flutter vs. PD&P Equally effective in sputum clearanceEqually effective in sputum clearance Flutter was more effective at increasing FEV1 and FVCFlutter was more effective at increasing FEV1 and FVC

Konstan et al: Flutter vs. PD&PKonstan et al: Flutter vs. PD&P Flutter produced significantly more sputum.Flutter produced significantly more sputum. Flutter was assessed to be safe, cost effective, easy to use, and with Flutter was assessed to be safe, cost effective, easy to use, and with

greater patient adherence.greater patient adherence. Gondor et al: Flutter vs. PD&PGondor et al: Flutter vs. PD&P

Flutter showed significant improvement in FVC compared to PD&PFlutter showed significant improvement in FVC compared to PD&P No difference in length of hospital stayNo difference in length of hospital stay

SummarySummary:: Again, these studies show conflicting Again, these studies show conflicting results, but at results, but at the least OPEP is shown to the least OPEP is shown to be just as effective as be just as effective as traditional methods traditional methods of CPT for CF patients. of CPT for CF patients.

What does the research What does the research say?say?

Chronic Bronchitis – OPEPChronic Bronchitis – OPEP

Bellone et al: Flutter vs. PD&PBellone et al: Flutter vs. PD&P Flutter had superior sputum production / Flutter had superior sputum production /

clearance.clearance.

Research ConclusionsResearch Conclusions What conclusions can be drawn from the What conclusions can be drawn from the

research?research? The majority of the research regarding the efficacy of The majority of the research regarding the efficacy of

PEP has been conducted on CF patients. PEP has been conducted on CF patients. In some studies, PEP and OPEP have been shown to In some studies, PEP and OPEP have been shown to

have superior secretion clearance and improvements in have superior secretion clearance and improvements in pulmonary function than traditional methods of CPT. pulmonary function than traditional methods of CPT. However, other research clearly refutes these results, However, other research clearly refutes these results, placing PEP as only as effective as traditional methods. placing PEP as only as effective as traditional methods.

Thus, the choice to utilize PEP as a primary method of Thus, the choice to utilize PEP as a primary method of bronchial hygiene therapy should be made on the basis bronchial hygiene therapy should be made on the basis of other criteria, such as cost and patient compliance.of other criteria, such as cost and patient compliance.

ConclusionConclusion PEP devices such as the Acapella are small, PEP devices such as the Acapella are small,

portable, cost effective, and patient preferred.portable, cost effective, and patient preferred. PEP devices haven’t been shown to be PEP devices haven’t been shown to be

superior to other forms of CPT, but they superior to other forms of CPT, but they haven’ been proven inferior either.haven’ been proven inferior either.

Continued research on the efficacy of PEP Continued research on the efficacy of PEP devices needs to be conducted.devices needs to be conducted.

At this time, the effectiveness of PEP devices At this time, the effectiveness of PEP devices has been shown to be equal or better than has been shown to be equal or better than traditional methods of bronchial hygiene, and traditional methods of bronchial hygiene, and the decision to use PEP devices should be the decision to use PEP devices should be made on the basis of other factors, such as made on the basis of other factors, such as cost effectiveness.cost effectiveness.

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