Positive Expiratory
Pressure Therapy
PEP Overview
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What is PEP?
History of PEP
Current PEP Devices
Clinical Evaluation
Conclusion
What is PEP?
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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 oneway valve against a variable flow resistor.
In modern PEP devices, flow resistance can be
manipulated to adjust for a desired pressure.
What does PEP do?
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Enhances secretion mobilization and removal
Helps prevent infections
Helps mitigate atelectasis
Improved pulmonary mechanics and gas exchange
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How does PEP accomplish this?
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2 ways:
1. Filling under-inflated or collapsed alveoli via collateral
ventilation (pores of Kohn, Canals of Lambert).*
2. Helping to stint the airways open during expiration.
History of PEP
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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 1970’s PEP devices were developed in Denmark, as a means to aid the
patient’s airway clearance with an effective, self-administered low-pressure device
(mouth piece @ 5-20 cm H20).
-High-pressure PEP therapy was developed in Austria (face mask @ 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.
Current PEP Devices
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Airway Oscillation Devices (AOD)
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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
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Current PEP Devices
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Flutter Valve
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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 1025 cm H20.
Gravity dependent
Current PEP Devices
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TheraPEP
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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
Current PEP Devices
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Acapella
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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:
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Low flow ( < 15 L/min, adjustable resistance)
High flow ( > 15 L/min, adjustable resistance)
Choice (any flow, adjustable frequency)
What’s so great about PEP?
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Readily accepted by patients
Shorter treatment time compared to CPT
Independent use
Inexpensive (Acapella $32.00 @ Amazon)
Portable
BUT…is it as effective as other methods of bronchial
hygiene?
VS
What does the research say?
Cystic Fibrosis – Standard PEP
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Mortensen et al: PEP vs. PD&P
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Darbee et al: PEP vs. HFCWC
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Both showed the same increase in FVC, FEV1, and sputum clearance.
McIlWaine et al: PEP vs. PD&P
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Equally effective in secretion clearance
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. PD&P
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PEP produced a significantly greater sputum volume, expiratory flow rate, and
decreased hyperinflation compared to PD&P.
Summary:
These studies show conflicting results. At the least, we can
conclude that standard PEP is just as effective as PD&P and
HFCWC for CF patients.
What does the research say?
Chronic Bronchitis – Standard PEP
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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.
What does the research say?
Cystic Fibrosis – OPEP
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Newhouse et al: Flutter vs. IPPV
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Hominick et al: Flutter vs. PD&P
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Equally effective in sputum clearance
Flutter was more effective at increasing FEV1 and FVC
Konstan et al: Flutter vs. PD&P
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Equally effective in sputum production, and increasing expiratory flows.
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. PD&P
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Flutter showed significant improvement in FVC compared to PD&P
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.
What does the research say?
Chronic Bronchitis – OPEP
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Bellone et al: Flutter vs. PD&P
 Flutter had superior sputum production / clearance.
Research Conclusions
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What conclusions can be drawn from the research?
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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.
Conclusion
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PEP devices such as the Acapella are small, portable,
cost effective, and patient preferred.
PEP devices haven’t 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.
References
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Diomou G., Hristara-Papadopoulou A., Papadopoulou O., and Tsanakas, J. Current devices
of respiratory physiotherapy. Hippokratia 2008 Oct-Dec;12(4):211–220.
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Kacmarek, R.M., Stoller, J.K., Wilkins, R.L. (2009). Egan’s Fundamentals of Respiratory Care
(9th ed.). St. Louis, MO: Mosby Inc.
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Myers, Timothy R. "Positive expiratory pressure and oscillatory positive expiratory pressure
therapies." Respiratory Care Oct. 2007: 1308+. Academic OneFile. Web. 25 Nov. 2011.
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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_1115126486611.html
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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
References
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Bellone A, Lascioli R, Raschi S, Guzzi L, Adone R. Chest physical therapy in patients with acute exacerbation
of chronic bronchitis: effectiveness of three methods. Arch Phys Med Rehabil 2000;81(5): 558-560.
Christensen EF, Nedergaard T, Dahl R. Long-term treatment of chronic bronchitis with positive expiratory
pressure mask and chest physiotherapy. Chest 1990;97(3):645-650.
Darbee JC, Kanga JF, Ohtake PJ. Physiologic evidence for high-frequency chest wall oscillation and breathing
in hospitalized subjects with cystic fibrosis. Phys Ther 2005;85(12):1278-1289.
Gondor M, Nixon PA, Mutich R, Rebovich P, Orenstein DM. Comparison of flutter device and chest physical
therapy in the treatment of cystic fibrosis pulmonary exacerbation. Pediatr Pulmonol 1999; 28(4):255260.
Homnick DN, Anderson K, Marks JH. Comparison of the flutter device to standard chest
physiotherapy in hospitalized patients with cystic fibrosis. A pilot study. Chest 1998;114(4):993-997.
Konstan MW, Stern RC, Doershuk CF. Efficacy of the Flutter device for airway mucus clearance in patients
with cystic fibrosis. J Pediatr 1994;124(5 Pt 1):689-693.
McIlwaine PM, Wong LT, Peacock D, Davidson AG. Long-term comparative trial of conventional postural
drainage and percussion versus positive expiratory pressure physiotherapy in the treatment of cystic
fibrosis. J Pediatr 1997;131(4):570-574.
Mortensen J, Falk M, Groth S, Jensen C. The effects of postural drainage and positive expiratory pressure
physiotherapy on tracheobronchial clearance in cystic fibrosis. Chest 1991;100(5):1350-1357.
Myers, Timothy R. "Positive expiratory pressure and oscillatory positive expiratory pressure therapies."
Respiratory Care Oct. 2007: 1308+. Academic OneFile. Web. 22 Nov. 2011.
Newhouse PA, White F, Marks JH, Homnick DN. The intrapulmonary percussive ventilator and flutter device
compared to standard chest physiotherapy in patients with cystic fibrosis. Clin Pediatr (Phila)
1998;37(7):427-432.
Oberwaldner B, Evans JC, Zach MS. Forced expirations against a variable resistance: a new chest
physiotherapy method in cystic fibrosis. Pediatr Pulmonol 1986;2(6):358-367.