Positive Expiratory Pressure Device Research Articles

Use of positive expiratory pressure during six-minute walk test: results in patients with moderate to severe chronic obstructive pulmonary disease

Background: The six-minute walk test (6MWT) is widely used because it is both simple and reliable as a measure of exercise capacity. Individuals with chronic obstructive pulmonary disease (COPD) usually show a limited capacity to perform exercise.
 Methods: Our study is a prospective, randomized controlled trial which uses the 6MWT in one hundred consecutive in and out- patients with moderate to severe COPD to assess the benefit of a simple positive expiratory pressure (PEP) device. PEP device consisted of a PEP valve 5 cmH2O connected to 1-meter tube and a mouthpiece. All the enrolled patients performed a 6MWT before randomization. The following day PEP group patients performed the 6MWT using PEP device. Control group patients performed the 6MWT without this device. The primary outcome was the difference in distance (meters) walked.
 Results: Functional capacity assessed by the distance covered during 6MWT improved in the PEP group more than in the control group. The difference was statistically significant (p < 0.001).Oxygen saturation improved to a statistically significant level during 6MWT (p < 0.01). Heart rate was also reduced (p < 0.03).
 Conclusions: There are few studies demonstrating that PEP devices enhance exercise capacity in COPD patients. Our results has been obtained using only a low positive expiratory pressure (5 cmH2O). In our opinion the strength of this study is the simplicity and the lower cost when compared to other devices and approaches.
 The study was registered as Chi CTR-ORC-12002173 at www.chictr.org.

Adherence to Airway Clearance Therapies by Adult Cystic Fibrosis Patients

Airway clearance therapy (ACT) is critical in cystic fibrosis (CF). To determine rates of self-reported adherence to ACT by patients treated in an adult CF program, to identify patient characteristics associated with poor adherence, to typify adherence according to ACT technique, and to indicate reasons for poor adherence. Our cross-sectional study included CF subjects age 16 years and older. Enrollees were evaluated via general structured questionnaire, adherence questionnaire, clinical assessment, spirometry, and S(pO(2)) values. Each was stratified by self-reporting protocol as high, moderate, or poor adherence to ACT. Concordance between physiotherapist recommended ACT technique and self-reported subject adherence was subjected to agreement analysis. Of the 63 subjects studied, 38 (60%) qualified as high adherence, 12 (19%) as moderate adherence, and 13 (21%) as poor adherence. Logistic regression identified education level (less than high school) as an independent factor associated with poor adherence (odds ratio 10.2, 95% CI 1.23-84.7, P = .03). Positive expiratory pressure (κ = 0.87) and flutter device (κ = 0.63) usage both corresponded with a high level of agreement, while active cycle of breathing technique (κ = 0.40) and autogenic drainage (κ = 0.39) each showed moderate agreement. Agreement was low for percussion and postural drainage (κ = 0.23). Reasons given most frequently for poor adherence to ACT were "not enough time to do ACT" (28%), "cannot be bothered" (16%), and "do not enjoy ACT technique" (8%). Many (32%) provided no reason. Study outcomes showed a high rate of ACT adherence in adult CF subjects. Lower level of education was the most important factor in poor adherence to ACT. Self-reported adherence and treatment recommendations were in best agreement with positive expiratory pressure and flutter device techniques.

Deep Breathing Exercises Performed 2 Months Following Cardiac Surgery

Postoperative breathing exercises are recommended to cardiac surgery patients. Instructions concerning how long patients should continue exercises after discharge vary, and the significance of treatment needs to be determined. Our aim was to assess the effects of home-based deep breathing exercises performed with a positive expiratory pressure device for 2 months following cardiac surgery. The study design was a prospective, single-blinded, parallel-group, randomized trial. Patients performing breathing exercises 2 months after cardiac surgery (n = 159) were compared with a control group (n = 154) performing no breathing exercises after discharge. The intervention consisted of 30 slow deep breaths performed with a positive expiratory pressure device (10-15 cm H2O), 5 times a day, during the first 2 months after surgery. The outcomes were lung function measurements, oxygen saturation, thoracic excursion mobility, subjective perception of breathing and pain, patient-perceived quality of recovery (40-Item Quality of Recovery score), health-related quality of life (36-Item Short Form Health Survey), and self-reported respiratory tract infection/pneumonia and antibiotic treatment. Two months postoperatively, the patients had significantly reduced lung function, with a mean decrease in forced expiratory volume in 1 second to 93 ± 12% (P< .001) of preoperative values. Oxygenation had returned to preoperative values, and 5 of 8 aspects in the 36-Item Short Form Health Survey were improved compared with preoperative values (P< .01). There were no significant differences between the groups in any of the measured outcomes. No significant differences in lung function, subjective perceptions, or quality of life were found between patients performing home-based deep breathing exercises and control patients 2 months after cardiac surgery.

Breathing Exercises with Positive Expiratory Pressure after Abdominal Surgery–The Current Physical Therapy Practice in Sweden

Objectives: In Sweden breathing exercises with Positive Expiratory Pressure (PEP) are commonly recommended for the prevention of pulmonary complications after abdominal surgery. Scientific documentation of the effects of PEP treatment is limited. The aim of this national survey was to describe the current physical therapy practice of PEP treatment after abdominal surgery in Sweden. Methods: A questionnaire was sent by e-mail to the 45 physical therapists who work with abdominal surgery patients in all seven university hospitals in Sweden. The questionnaire contained questions about the usage of PEP after abdominal surgery. Results: In total, 24 (54%) of the physical therapists answered the questionnaire. All reported using PEP as a treatment option after abdominal surgery. The most commonly used PEP device was the Blow bottle system and the PEP ventil system connected to a mouthpiece. Recommendations regarding treatment frequency and implementation varied significantly across respondents. The number of breaths per treatment varied considerably. Conclusion: All respondentsreported using PEP as a postoperative treatment on abdominal surgery wards. The treatment is most often recommended hourly during the first postoperative days. The common first-choice PEP devices were the Blow bottle system, Pep/Rmt set with mouthpiece or mask, Breathing exerciser/PEP valve system 22, and the Mini-PEP.

Comparing Performance of Three Oscillating Positive Expiratory Pressure Devices at Similar Amplitude and Frequencies of Oscillations on Displacement of Mucus Inside Trachea During Cough

Performance of Flutter® (Axcan Scandipharm Inc, Birmingham, AL), Acapella® (Smiths Medicals Inc, Rockland, MA) and Quake® (Thayer Medical, Tucson, AZ) were compared at similar frequencies and amplitudes of oscillations at nine angles of the device in clearing simulated mucus inside a tracheal model (trachea) oriented at three angles with or without simulated constrictions in airway upstream of trachea. Displacement of 0.4mL of simulated mucus prepared with viscoelastic properties similar to healthy individuals (syrup-like) or patients with COPD (gel-like) using locust bean gum(LBG) solution (0.38g LBG in 100mL water) cross-linked with 3mL or 12mL borax solution (0.02 molar), respectively were measured inside trachea during coughs of 300ms at low cough velocity (15±0.5m/s) generated using a computer controlled solenoid valve. Oscillations were superimposed on cough by connecting the oscillator device to the outlet of the trachea. Frequency and amplitude of oscillations generated by Quake and Acapella and resulting mucus displacement were independent of angle of oscillator, while amplitude of oscillations and resulting mucus displacement generated by Flutter, increased up to 30o upward and 20o downward angles of Flutter from horizontal but decreased significantly thereafter. Displacement with Quake increased significantly with frequencies of oscillations up to 25 Hz and decreased thereafter but increased with amplitudes of oscillations up to 22±4.7 m/s. Quake showed significantly larger displacements than Flutter and Acapella at equal frequencies and amplitudes (p<0.05). Displacements were significantly larger with trachea positioned 30o upwards than horizontal or 20o downwards (p<0.0001). Displacement was the greatest for gel-like mucus than syrup-like (p<0.0001). Airway constrictions upstream resulted in enhanced displacement of mucus (p<0.0001). Mucus clearance can be significantly enhanced by coughing through oscillating positive expiratory devices that generate high amplitude oscillations at moderate frequencies, increasing frontal depths of mucus facing airflow and slightly increasing resistance to airflow in airways in COPD patients.

Conical-PEP is safe, reduces lung hyperinflation and contributes to improved exercise endurance in patients with COPD: a randomised cross-over trial

Does a new positive expiratory pressure device (conical-PEP) decrease lung hyperinflation during exercise in patients with chronic obstructive pulmonary disease compared to normal breathing? Does it increase the duration of exercise? A randomised, cross-over trial with concealed allocation. Thirteen patients with moderate to severe chronic obstructive pulmonary disease (mean FEV1 61% predicted). THE experimental intervention was conical-PEP breathing with a positive expiratory pressure of 4-20 cmH2O during 30% of 1 RM alternate knee extension exercise at 70% age-predicted HRmax to fatigue. The control intervention was normal breathing. Total lung capacity (inspiratory capacity and slow vital capacity), breathlessness, and leg discomfort were measured pre and post exercise. Cardiorespiratory function was measured pre and during the last 30 s of exercise. Duration of exercise was recorded. After the experimental intervention, inspiratory capacity increased 200 ml (95% CI 0 to 400) and slow vital capacity increased 200 ml (95% CI 0 to 400) more than the control intervention. Participants exercised for 107 s (95% CI -23 to 238) more during the experimental intervention than the control intervention. Conical-PEP breathing during exercise resulted in 6.1 fewer breaths/min (95% CI 1.4 to 10.8) than normal breathing; it did not have any adverse effects on CO2 retention or oxygen saturation. The novel conical-PEP device decreases lung hyperinflation, is safe to use, and tends to increase the duration of exercise. NCT00741832.

Positive expiratory pressure techniques in respiratory patients: old evidence and new insights

Educational aims To describe the rationale for the use of positive expiratory pressure (PEP) techniques as a means of chest physiotherapy in respiratory patients. To compare both the effectiveness and problems of the most popular PEP devices in clinical practice. To introduce the impact and potential interest of temporary PEP (TPEP) techniques in this field. Summary In recent years, a large number of PEP devices, used to assist in airway clearance or, at the very least, to allow for effective self-administered physiotherapy, have been developed. A secondary clinically relevant objective of these devices is to prevent recurring infections and atelectasis, or to improve pulmonary mechanics and facilitate gas exchange, thus lowering the impact of disease progression. The use of PEP devices in this field has become widely accepted for two main reasons: 1) their clinical efficacy, which is as great as that of conventional chest physiotherapy practice, and 2) the high level of acceptance and compliance by patients, which makes PEP devices very useful in the domiciliary environment. The functional and clinical response of any specific PEP device, with or without vibration effect, may vary according to a specific diagnostic group. Ultimately, the choice of airway clearance strategy may be the one that is clinically effective, cost-effective and preferred by the patient and which, therefore, supports adherence. Recent technology has enabled the development of a new machine, which is able to apply a TPEP at a level several times lower than that applied with previous devices; thus, at least potentially, it is able to reduce the risk of mechanical stress injury to the bronchial tree and lung parenchyma. In this review, we will discuss the rationale for the use of PEP devices and compare both their effectiveness and problems in clinical practice. Finally, we will introduce the application and potential interest of TPEP as a new means for treating patients with hypersecretion.

A randomised crossover trial of chest physiotherapy in non-cystic fibrosis bronchiectasis

Regular chest physiotherapy is advocated in non-cystic fibrosis bronchiectasis despite little evidence supporting its routine use. This study aimed to establish the efficacy of regular chest physiotherapy in non-cystic fibrosis bronchiectasis compared with no regular chest physiotherapy. 20 patients not practising regular chest physiotherapy were enrolled in a randomised crossover trial of 3 months of twice daily chest physiotherapy using an oscillatory positive expiratory pressure device compared with 3 months of no chest physiotherapy. The primary end-point was the Leicester Cough Questionnaire (LCQ). Additional outcomes included 24-h sputum volume, forced expiratory volume in 1 s (FEV(1)), forced vital capacity (FVC), forced expiratory flow at 25-75% of FVC (FEF(25-75%)), maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), exercise capacity, sputum microbiology and St George's Respiratory Questionnaire (SGRQ). The treatment effect was estimated using the differences of the pairs of observations from each patient. There was a significant improvement in all domains and total LCQ score with regular chest physiotherapy (median (interquartile range) total score improvement 1.3 (-0.17-3.25) units; p = 0.002). 24-h sputum volume increased significantly with regular chest physiotherapy (2 (0-6) mL; p = 0.02), as did exercise capacity (40 (15-80) m; p = 0.001) and SGRQ total score (7.77 (-0.99-14.5) unit improvement; p = 0.004). No significant differences were seen in sputum bacteriology, FEV(1), FVC, FEF(25-75%), MIP or MEP. Regular chest physiotherapy in non-cystic fibrosis bronchiectasis has small, but significant benefits.

Airway clearance physiotherapy improves quality of life in people with bronchiectasis

Does regular airway clearance using an oscillating positive expiratory pressure (PEP) device improve quality of life, sputum volume, respiratory function, and exercise capacity in people with bronchiectasis? Randomised, crossover, controlled trial with 3-month intervention periods separated by a 1-month washout period. Acute teaching hospital in Scotland. 20 adults with radiologically diagnosed bronchiectasis and chronic sputum expectoration, who were not performing regular physiotherapy for airway clearance. Smoking, asthma, emphysema, and cystic fibrosis were exclusion criteria. While in the intervention arm, participants performed 20–30 minutes of airway clearance twice daily. Each session consisted of three cycles of 10 breaths through an oscillating positive expiratory pressure (PEP) device called the Acapella, followed by the forced expiratory technique and coughing. Each participant's technique was reviewed by a physiotherapist monthly during the intervention arm. During the control arm, the device was retained by the investigators and participants performed no physiotherapy for airway clearance. Throughout the study, both groups received all other standard management including antibiotics when exacerbation criteria were met. Any changes to the participants’ usual medication regimen were noted. The primary outcome was the Leicester Cough Questionnaire (LCQ) – a 19-point, patient-reported measure of the impact of cough severity on quality of life with three domains (physical, psychological, and social). Secondary outcomes included the St George's Respiratory Questionnaire (SGRQ), 24-hour sputum volume, lung function, maximum respiratory pressures, and the incremental shuttle walk test, measured at the end of each intervention arm. All participants completed the study with no adverse events during airway clearance. During the 3-month intervention period, the total LCQ score showed significantly greater improvement than during the control period: difference in medians for total LCQ score 1.3 points, p = 0.002. Each of the three domains within the LCQ also showed significant benefits. Other outcomes that showed significantly greater improvements due to the airway clearance intervention were the SGRQ (difference in medians 8.5 points, p = 0.005), 24-hr sputum volume (difference in medians 3 ml, p = 0.02), and the incremental shuttle walk distance (difference in medians 40 m, p = 0.001). The groups did not differ significantly on the remaining secondary outcomes. Regular airway clearance with oscillating PEP improves diseaserelated quality of life and exercise capacity in people with bronchiectasis.

Change in physiotherapy management of children with cystic fibrosis in a large urban hospital

A retrospective audit was conducted in 1998 and 2000 to review the physiotherapy management of hospitalized children with cystic fibrosis (CF) at the Brisbane Royal Children's Hospital (RCH). The objective was to detect and explore possible changes in patient management in this time period and investigate whether these changes reflected changes in the current theory of CF management. All children over two years of age with CF admitted during 1998 and 2000 with pulmonary manifestation and who satisfied set criteria were included (n = 249). Relative frequency of each of six treatment modalities used were examined on two occasions, revealing some degree of change in practice reflecting the changes in current theory. There was a significant decrease in the frequency of usage of postural drainage with head-down tilt (p < 0.001), and autogenic drainage (p < 0.001) between 1998 and 2000. Modified postural drainage without head-down tilt (p < 0.001), and positive expiratory pressure devices (p < 0.001) were used more frequently in 2000 (p < 0.001). No significant changes were identified in the use of Flutter VRP1 (p = 0.145) and exercise (p = 0.763). No significant differences were found in population demographics or occurrence of concomitant factors that may influence patient management.

Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis.

Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis (CF). Positive expiratory pressure (PEP) devices provide constant back pressure to the airways during expiration. This may improve clearance by building up gas behind mucus via collateral ventilation. Given the widespread use of PEP devices, there is a need to determine the evidence for their effect. To determine the effectiveness and acceptability of PEP devices compared to other forms of physiotherapy as a means of improving mucus clearance and other outcomes in people with CF. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group trials register comprising of references identified from comprehensive electronic database searches and handsearching of relevant journals and abstract books of conference proceedings. The electronic database CINAHL was also searched from 1982 to 2001. Most recent search of the Group's register: November 2003. Randomised controlled trials in which PEP was compared with any other form of physiotherapy in people with CF. Two reviewers independently applied the inclusion and exclusion criteria to publications and assessed the quality of the included studies. Thirty-three studies were identified and twenty studies involving 429 participants met review inclusion criteria. Most included studies had low scores on a scale of study quality. Sixteen of these studies involving 257 participants were cross-over in design. Data were not published in sufficient detail in these studies to perform meta-analysis.Forced expiratory volume in one second (FEV1) was the most frequently measured outcome. Single interventions or series of treatments continued for up to one month demonstrated no significant difference in effect between PEP and other methods of airway clearance on FEV1. Long-term studies had equivocal or conflicting results regarding the effect on FEV1. Patient preference was reported in nine studies. In all studies with an intervention period of at least one month, measures of patient preference were in favour of PEP. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high level evidence. There was no clear evidence that PEP was a more or less effective intervention overall than other forms of physiotherapy. There was limited evidence that PEP was preferred by participants compared to other techniques but this finding is from studies of low quality.

Use of flutter VRP1 in the management of patients with steroid-dependent asthma.

We have assessed a new positive expiratory pressure device, the Flutter VRP1, in 20 patients with moderately severe asthma. Patients were studied for an initial 1-week 'run-in' period, followed by 2 weeks of the flutter device in one of which the ball-bearing was removed from the bowl. Peak expiratory flow rates, salbutamol inhaler requirements and visual analogue scores were recorded daily. Ease of sputum expectoration showed a significant improvement after 6 days of the flutter device, but there were no differences in objective measurements of lung function nor in salbutamol use. The device may be a useful adjunct to asthma therapy.

Long-Term Treatment of Chronic Bronchitis with Positive Expiratory Pressure Mask and Chest Physiotherapy

Long-term treatment of chronic bronchitis with chest physiotherapy with or without positive expiratory pressure (PEP) by mask was studied in 43 patients randomly allocated to PEP treatment (PEP group, 20 patients) and conventional chest physiotherapy (control group, 23 patients). After instruction, the treatments were self-administered twice daily for 12 months (34 patients) and 5 months (9 patients). Twice weekly, patients filled in a diary concerning symptoms. The PEP group had significantly less cough and less mucus production. The number of acute exacerbations were calculated from the diaries and were lower in the PEP group compared to the control group, and 85 percent of the patients in the PEP group were free from acute exacerbations versus 48 percent in the control group. The PEP group also used less antibiotics and mucolytics. The PEP group had a small increase in FEV1 of mean 62 ml compared to a small decrease of 43 ml for the control group. Treatment with a simple PEP device can reduce morbidity in patients with chronic bronchitis and may preserve lung function from a more rapid decline.

Pancreatic scanning.

<h3>BACKGROUND:</h3> Air-flow oscillations generated by exhaling through oscillatory positive expiratory pressure (OPEP) devices favor airway clearance. Variations in mechanical properties between different devices may influence therapeutic efficacy. The objective of this study was to assess mechanical properties in vitro and to compare the performance of 6 OPEP devices at different resistance levels under active expiratory flow patterns. <h3>METHODS:</h3> 4 gravity-dependent OPEP devices (ie, Flutter, Gelomuc, Pari O-PEP, Shaker Medic Plus) and 2 gravity-independent OPEP devices (ie, Acapella Choice and Aerobika) were each tested at low, medium, and high resistance settings. All devices were independently connected to a pulmonary waveform generator that reproduced active exhalation flows. Expiratory flow-volume curves were retrieved from 4 subjects with different stages of obstruction severity and were scaled according to either peak expiratory flow (4, 6, and 8 L/s) or volumes (2, 3 and 4 L), thus amounting to 24 active exhalations. Resulting waveforms were divided into 4 parts and the 2 middle parts were used to extract the following mechanical data: positive expiratory pressure (PEP), maximum expiratory pressure (P_peak), oscillation frequency, and flow oscillation amplitude. The percentage of tests achieving oscillation frequencies ≥ 12 Hz and PEP ≥ 10 cm H₂O was calculated for each device. <h3>RESULTS:</h3> Mechanistic effects of the Acapella, Aerobika, and Shaker devices were not comparable. The Flutter, Gelomuc, and Pari devices behaved similarly and achieved more tests with optimum oscillation frequency and PEP values than the other devices. These 3 devices also produced the highest oscillation amplitudes at the low-resistance level, whereas the Aerobika elicited higher and consistent oscillation amplitudes at medium and high resistance settings. <h3>CONCLUSIONS:</h3> Operational parameters differed between and within devices, yet the Flutter, Gelomuc, and Pari devices were similar in many aspects. Therapeutic efficacy may depend on the selected OPEP device and set resistance.