Positive Expiratory Pressure Therapy

1
Positive Expiratory Pressure Therapy
2
PEP Overview

• What is PEP?
• History of PEP
• Current PEP Devices
• Clinical Evaluation
• Conclusion

3
What is PEP?

• PEP is a form of bronchial hygiene, and is one of
  the 3 adjuncts of positive airway pressure (PEP,
  CPAP, and EPAP).
• PEP involves active expiration through a one-way
  valve against a variable flow resistor.
• In modern PEP devices, flow resistance can be
  manipulated to adjust for a desired pressure.

4
What does PEP do?

• Enhances secretion mobilization and removal
• Helps prevent infections
• Helps mitigate atelectasis
• Improved pulmonary mechanics and gas exchange
• How does PEP accomplish this?
• 2 ways
• Filling under-inflated or collapsed alveoli via
  collateral ventilation (pores of Kohn, Canals of
  Lambert).
• Helping to stint the airways open during
  expiration.

5
History of PEP

• Origin of PEP
• -Traditional CPT with manual percussion,
  postural drainage, and vibration was first
  introduced in 1901 to assist airway clearance in
  children with bronchiectasis.
• -In the 1970s PEP devices were developed in
  Denmark, as a means to aid the patients airway
  clearance with an effective, self-administered
  low-pressure device (mouth piece _at_ 5-20 cm H20).
• -High-pressure PEP therapy was developed in
  Austria (face mask _at_ 26-102 cm H20).
• -In 1991, PEP was introduced in the U.S. by
  Louise Lanafours from Sweden.
• -Since 1991, PEP devices have been modified and
  improved upon, which have produced devices such
  as the TheraPEP and Acapella.

6
Current PEP Devices

• Airway Oscillation Devices (AOD)
• Provide standard PEP with the added benefit of
  oscillating pressure within the airway
• Oscillations reduce the viscoelasticity of mucus
• Oscillations provide short bursts of increased
  expiratory airflow to help with secretion
  mobilization
• Flutter Valve
• TheraPEP
• Acapella

7
Current PEP Devices

• Flutter Valve
• Developed in Switzerland
• Pipe-shaped AOD with a steel ball resting in an
  angled bowl.
• On exhalation, the ball oscillates at
  approximately 15 Hz, and provides 10-25 cm H20.
• Gravity dependent

8
Current PEP Devices

• TheraPEP
• Designed by Smiths Medical Company
• Standard low-flow PEP device
• Built in pressure indicator
• Can be used with a mask or mouthpiece
• Has a 22mm OD which allows it to be docked with a
  nebulizer
• Inspiratory and expiratory valves
• Provides 10-20 cm H20

9
Current PEP Devices

• Acapella
• Designed by Smiths Medical Company
• Similar to the flutter valve but with greater
  functionality (AOD)
• Utilizes a counterweighted plug and magnet to
  achieve valve closure (not gravity dependent)
• 3 Models
• Low flow ( lt 15 L/min, adjustable resistance)
• High flow ( gt 15 L/min, adjustable resistance)
• Choice (any flow, adjustable frequency)

10
Whats so great about PEP?

• Readily accepted by patients
• Shorter treatment time compared to CPT
• Independent use
• Inexpensive (Acapella 32.00 _at_ Amazon)
• Portable
• BUTis it as effective as other methods of
  bronchial hygiene?
• VS

11
What does the research say?

• Cystic Fibrosis Standard PEP
• Mortensen et al PEP vs. PDP
• Equally effective in secretion clearance
• Darbee et al PEP vs. HFCWC
• Both showed the same increase in FVC, FEV1, and
  sputum clearance.
• McIlWaine et al PEP vs. PDP
• PEP had greater improvement in FEV1 and FVC
• Patients preferred PEP because they felt it was
  more effective, required less time, independent,
  and easier.
• Oberwaldner et al PEP vs. PDP
• PEP produced a significantly greater sputum
  volume, expiratory flow rate, and decreased
  hyperinflation compared to PDP.
• Summary These studies show conflicting results.
  At the least, we can conclude that standard PEP
  is just as effective as PDP and HFCWC for CF
  patients.

12
What does the research say?

• Chronic Bronchitis Standard PEP
• Christensen et al Diaphragmatic breathing /FET
  vs. PEP/FET
• PEP group had greater secretion clearance, lower
  exacerbation rate, lower rate of mucolytic and
  antibiotic use, and an increase in FEV1.

13
What does the research say?

• Cystic Fibrosis OPEP
• Newhouse et al Flutter vs. IPPV
• Equally effective in sputum production, and
  increasing expiratory flows.
• Hominick et al Flutter vs. PDP
• Equally effective in sputum clearance
• Flutter was more effective at increasing FEV1 and
  FVC
• Konstan et al Flutter vs. PDP
• Flutter produced significantly more sputum.
• Flutter was assessed to be safe, cost effective,
  easy to use, and with greater patient adherence.
• Gondor et al Flutter vs. PDP
• Flutter showed significant improvement in FVC
  compared to PDP
• No difference in length of hospital stay
• Summary Again, these studies show conflicting
  results, but at the least OPEP is shown to be
  just as effective as traditional methods of CPT
  for CF patients.

14
What does the research say?

• Chronic Bronchitis OPEP
• Bellone et al Flutter vs. PDP
• Flutter had superior sputum production /
  clearance.

15
Research Conclusions

• What conclusions can be drawn from the research?
• The majority of the research regarding the
  efficacy of PEP has been conducted on CF
  patients.
• In some studies, PEP and OPEP have been shown to
  have superior secretion clearance and
  improvements in pulmonary function than
  traditional methods of CPT. However, other
  research clearly refutes these results, placing
  PEP as only as effective as traditional methods.
  
• Thus, the choice to utilize PEP as a primary
  method of bronchial hygiene therapy should be
  made on the basis of other criteria, such as cost
  and patient compliance.

16
Conclusion

• PEP devices such as the Acapella are small,
  portable, cost effective, and patient preferred.
• PEP devices havent been shown to be superior to
  other forms of CPT, but they haven been proven
  inferior either.
• Continued research on the efficacy of PEP devices
  needs to be conducted.
• At this time, the effectiveness of PEP devices
  has been shown to be equal or better than
  traditional methods of bronchial hygiene, and the
  decision to use PEP devices should be made on the
  basis of other factors, such as cost
  effectiveness.

17
References

• Diomou G., Hristara-Papadopoulou A., Papadopoulou
  O., and Tsanakas, J. Current devices of
  respiratory physiotherapy. Hippokratia 2008
  Oct-Dec12(4)211220.
• Kacmarek, R.M., Stoller, J.K., Wilkins, R.L.
  (2009). Egans Fundamentals of Respiratory Care
  (9th ed.). St. Louis, MO Mosby Inc.
• Myers, Timothy R. "Positive expiratory pressure
  and oscillatory positive expiratory pressure
  therapies." Respiratory Care Oct. 2007 1308.
  Academic OneFile. Web. 25 Nov. 2011.
• University of Wisconsin-Madison. (2011). Health
  Informatin TheraPEP Data file. Retrieved from
  http//www.uwhealth.org/healthfacts/B_EXTRANET
  HEALTH_IN FORMATION-FlexMember-Show_Public_HFFY_11
  15126486611.html
• Wilson, Richard., (Feb-March 1999) Positive
  Expiratory Pressure Therapy The Key to
  Effective, Low-Cost Removal of Bronchial
  Secretions. RT Magazine. Retrieved from
  http//www.rtmagazine.com/issues/articles/1999-02
  _08.asp

18
References

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