2 PEP Overview What is PEP? History of PEP Current PEP Devices Clinical EvaluationConclusion
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 infectionsHelps mitigate atelectasisImproved pulmonary mechanics and gas exchangeHow 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 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 5-20 cm H20).-High-pressure PEP therapy was developed in Austria (face 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 airwayOscillations reduce the viscoelasticity of mucusOscillations provide short bursts of increased expiratory airflow to help with secretion mobilizationFlutter ValveTheraPEPAcapella
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 cm H20.Gravity dependent
8 Current PEP Devices TheraPEP Designed by Smiths Medical Company Standard low-flow PEP deviceBuilt in pressure indicatorCan be used with a mask or mouthpieceHas a 22mm OD which allows it to be docked with a nebulizerInspiratory and expiratory valvesProvides 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 ( < 15 L/min, adjustable resistance)High flow ( > 15 L/min, adjustable resistance)Choice (any flow, adjustable frequency)
10 What’s so great about PEP? Readily accepted by patientsShorter treatment time compared to CPTIndependent useInexpensive (Acapella Amazon)PortableBUT…is it as effective as other methods of bronchial hygiene?VS
11 What does the research say? Cystic Fibrosis – Standard PEPMortensen et al: PEP vs. PD&PEqually effective in secretion clearanceDarbee et al: PEP vs. HFCWCBoth showed the same increase in FVC, FEV1, and sputum clearance.McIlWaine et al: PEP vs. PD&PPEP had greater improvement in FEV1 and FVCPatients preferred PEP because they felt it was more effective, required less time, independent, and easier.Oberwaldner et al: PEP vs. PD&PPEP 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.
12 What does the research say? Chronic Bronchitis – Standard PEPChristensen et al: Diaphragmatic breathing /FET vs. PEP/FETPEP 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 – OPEPNewhouse et al: Flutter vs. IPPVEqually effective in sputum production, and increasing expiratory flows.Hominick et al: Flutter vs. PD&PEqually effective in sputum clearanceFlutter was more effective at increasing FEV1 and FVCKonstan et al: Flutter vs. PD&PFlutter 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&PFlutter showed significant improvement in FVC compared to PD&PNo difference in length of hospital staySummary: 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 – OPEPBellone et al: Flutter vs. PD&PFlutter 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 ConclusionPEP 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.
17 ReferencesDiomou G., Hristara-Papadopoulou A., Papadopoulou O., and Tsanakas, J. Current devices of respiratory physiotherapy. Hippokratia 2008 Oct-Dec;12(4):211–220.Kacmarek, R.M., Stoller, J.K., Wilkins, R.L. (2009). Egan’s 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: Academic OneFile. Web. 25 NovUniversity of Wisconsin-Madison. (2011). Health Informatin: TheraPEP [Data file]. Retrieved from HEALTH_IN FORMATION-FlexMember-Show_Public_HFFY_ htmlWilson, Richard., (Feb-March 1999) Positive Expiratory Pressure Therapy: The Key to Effective, Low-Cost Removal of Bronchial Secretions. RT Magazine. Retrieved from
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