Positive expiratory pressure treatment: Efficacy in pulmonary diseases

Abstract

We read with interest the report by McIlwaine et al1McIlwaine PM Wong LT Peacock D Davidson AGF 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: 570-574Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar in which the authors highlighted that positive expiratory pressure (PEP) physiotherapy effectively resulted in improvement of pulmonary function (PF) in cystic fibrosis. On the contrary, in patients continuing conventional physiotherapy, pulmonary function significantly declined over the study period despite the use of inhaled bronchodilators and steroids. These results are undoubtedly convincing, and we agree with the comment in the related editorial2Coates AL Chest physiotherapy in cystic fibrosis: spare the hand and spoil the cough?.J Pediatr. 1997; 131: 506-508PubMed Google Scholar that the results of a study are reliable only if demonstrated in the long-term rather than in the short-term period. However, any improvement or decline of PF in pulmonary diseases requiring a comprehensive treatment and high individual compliance rates should be examined with criticism. We recently evaluated the effect of treatment with PEP on PF and on regional lung ventilation (LV) assessed by radioaerosol labeled with 99-Technetium diethylentriamine pentacetic acid in 6 children with cystic fibrosis (median age 9.8 years) and in 6 children with bronchiectasis of unknown origin (median age 8 years). The study protocol was as follows. (1) Assessment of baseline LV and PF. (2) Eight weeks of prestudy physiotherapy with postural drainage and percussion (PDP) twice daily. (3) Reassessment of LV and PF. (4) Eight weeks of treatment twice daily with PEP according to Falk et al3Falk M Kelstrup M Anderson JB Kinoshita T Falk P Stovring S et al.Improving the ketchup bottle method with positive expiratory pressure (PEP).Eur J Respir Dis. 1984; 65: 423-432PubMed Google Scholar and no other physiotherapy. (5) Reassessment of LV and PF. Results of LV were expressed as penetration index (PI) of the radioaerosol, which was calculated as the ratio of counts per minute per pixel of the peripheral region to the central region of each lung. During the study period the patients had no exacerbations and did not receive any pulmonary drug. Results, expressed as mean ± SEM, showed that LV did not significantly improve after PDP (PI in the right lung: 0.40 ± 0.06 vs 0.44 ± 0.07, P = .3; PI in the left lung: 0.48 ± 0.03 vs 0.50 ± 0.09, P = .4, respectively), whereas PEP resulted in significantly improved LV (PI in the right lung: 0.44 ± 0.07 vs 0.57 ± 0.09, P < .05; PI in the left lung: 0.50 ± 0.09 vs 0.60 ± 0.06, P < .05, respectively). Conversely, neither PDP nor PEP treatment resulted in significant changes of FEV1 % predicted (pre-PDP 84% ± 5% vs post-PDP 86% ± 4%, P = .4; pre-PEP 86% ± 4% vs post-PEP 88% ± 4%, P = .5, respectively). Findings of LV and PF were confirmed when patients with cystic fibrosis and subjects with bronchiectasis of unknown origin were considered as a group. Despite the absence of significant changes in PF, these results have been taken by us to confirm the great superiority of PEP in improving lung ventilation. Patients with pulmonary diseases necessitating improved clearance of secretions should be treated early with the PEP method, even before irreversible functional impairment becomes evident.