POSITIVE EXPIRATORY PRESSURE THERAPY

PEP is used to mobilize secretions & treat atelectasis. Cough & other airway
clearance techniques are essentials components when the therapy is intended
to mobilize secretions.
 The theoretical benefit of PEP therapy is the ability to enhance & promote
mucus clearance by either preventing airway collapse by stenting the airways
or increasing intrathoracic pressure distal to retained secretions, by collateral
ventilation or by increasing functional residual capacity.

History of PEP
ORIGIN
 Traditional CPT with manual percussion, postural drainage & vibration was
first introduced in 1901 to assist airway clearance in children with
bronchiectasis.
 In the 1970’s PEP device were developed in Denmark, as means to aid the px
airway clearance with an effective, self-administered low-pressure device
 High-pressure PEP therapy was developed in Austria
 In US it was introduced by Louise Lanafours from Sweden
 Since 1991 PEP devices have been modified & improved upon which have
produced devices such as the TheraPEP & Acapella
 What does PEP do?
 Enhances secretion mobilization & removal
 Helps prevent infections
 Improved pulmonary mechanisms & gas exchange
How does PEP accomplish this?
2 WAYS
1) Filling under inflated or collapsed alveoli via collateral ventilation
2) Helping to stint the airways open during expiration
 Positive Expiratory Pressure (PEP) therapy can be used as a therapeutic tool for
numerous pulmonary conditions, including:
 COPD
 Asthma
 Emphysema
 Chronic Bronchitis
 Cystic Fibrosis
 Primary Cilliary Dyskinesia
 Respiratory infection and Pneumonia
 Seasonal respiratory influenza
 Pulmonary rehab and case management
 Current PEP devices:
 Airway Oscillation Devices
1) Provide standard PEP with the added benefit of oscillating pressure
within the airway
2) Oscillations reduce the viscoelasticity of mucus
3) Oscillations provide short bursts of increased expiratory to help with
secretions mobilizations
 Flutter valve
 TheraPEP
 Acapella
Application
 Flutter device must be used in the sitting or supine lying position.
 The patient is instructed to inhale deeply and hold his breath for 2 to 3 sec.
Expiration should be slow through the Flutter valve, causing oscillations of the
steel ball inside the cone of the Flutter.
 Patients apply repeated exhalations through the Flutter valve. Routinely, three
sets of 15 exhalations are performed over 12–20 min. After each series of
exhalations, patients were instructed to "huff" and cough, thereby aiding
expectoration.
 SOURCE: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2580042/
 The frequency of the oscillations can be modulated by changing the inclination
of the Flutter device slightly up or down from its horizontal position.
 The patient selects the position that results in the best transmission of
vibration to chest wall, optimizing the mobilization of mucus.
 Effective use of the Flutter device requires training, concentration, and
appropriate positioning of the mouthpiece. The Flutter device is simple to use
inexpensive and easily portable and once the patient and his family are
instructed in its use it does not require the assistance of a caregiver.
 Additionally, patients with severe obstruction may not be able to generate
sufficient airflow to cause vibration of the steel ball housed in the pipe–like
extension of the Flutter valve, thus limiting the effectiveness of this device in
these patients.

Indications:
 Atelectasis
 Bronchitis
 Bronchiectasis
 Cystic Fibrosis
 COPD
 Asthma or other conditions producing retained secretions

Contraindications:
 Flutter device must not be used in patients with:
 Right-sided heart failure
 Pneumothorax
 TB or Hemoptysis
 Mucus Loosening and Mucus Mobilization
 Instruct the patient to slowly inhale to approx. ¾ of a full breath.
 Perform a 2 to 3 sec. breath hold. This allows the inhaled air to be evenly
distributed throughout the lungs.
 Have the patient repeat this breathing technique for another 5 to 10 breaths to
loosen and mobilize as much mucus as possible.

FLUTTER AND OTHER DEVICES

 A number of studies have demonstrated that this therapy is a viable alternative
to standard CPT techniques in select patient groups. Further in vivo studies
involving greater numbers and more diverse patient groups are required to
better determine the effectiveness of Flutter valve therapy devices compared
with other airway clearance techniques involving PAP.
 PROTOCOL FOR ADMINISTERING FLUTTER VALVE THERAPY
 Assess whether flutter valve therapy is indicated and design a treatment
program.
1) Bring the equipment to the bedside and provide initial therapy,
adjusting the pressure settings to meet the px’s needs.
2) After the initial treatment or px training, communicate the treatment
plan to the px physician and nurse and provide instructions to the
nursing staff, if required.
 Explain that flutter therapy is used to reexpand lung tissue and help mobilize
secretions. Px should be taught to huff cough.

SOURCE: Mosby’s Respiratory Care Equipment

 Instruct the px to:

① Sit comfortably.
② Take a deep breath that is larger than normal but does not fill the
lungs completely
 ③ Seal the lips firmly around the flutter device mouthpiece & exhale
actively but not forcefully, holding the flutter valve at an angle that
produces maximum oscillation.
④ Perform 10 to 20 breaths
⑤ Remove the flutter mouthpiece & perform 2 to 3 huff coughs and
then rest as needed.
⑥ Repeat this cycle 4 to 8 times not to exceed 20mns.

 Evaluate the px for the ability to self-administer the therapy. When

appropriate, teach the px to self-administer flutter therapy. Observe the px
conduct the self-administer on several occasions to ensure proper Flutter
techniques before allowing the pc to self-administer without supervision.
 When the px are also receiving bronchodilator aerosol, administer in
conjunction with flutter therapy by administering the bronchodilator
immediately before the flutter breaths.
 If the flutter device becomes visibly oiled, rinse it with sterile water & shake &
air-dry. Leave the device within reach at the px bedside.
 Send the flutter device home with the px.
 In the px medical record, document the procedures performed (device, no. of
breaths per treatment & frequency), the px response to therapy, the px
teaching provided & the px ability to self-administer the treatment.

Acapella device
 The Acapella is a handheld airway clearance device that operates on the same
principle as the Flutter.
( i.e. a valve interrupting expiratory flow generating oscillating PEP.)
 Utilizing a counterweighted plug and magnet to achieve valve closure, the
Acapella is not gravity dependent like the Flutter. The Acapella comes in three
models, a low flow (<15 L/min), high flow (>15 L/min) and the Acapella Choice.
 The high and low flow models have a dial to set expiratory resistance while the
Choice model has a numeric dial to adjust frequency. All models can be used
with a mask or mouthpiece and can be used in line with a nebulizer.
 While these attributes may offer the Acapella some advantage over the Flutter,
no long–term studies have been done in CF patients. A bench study of the
performance characteristics of the two devices showed a slight advantage for
the Acapella, with more stable wave form and a wider range of PEP at low air
flow.

Cornet Device
 The Cornet device consists of a semi–circular tube containing a flexible latex–
free hose . Expiration through the Cornet causes the hose to flex, buckle and
unbuckle, causing oscillating positive pressure in the airways which fluctuates
many times per second.
 The mouthpiece can be adjusted to produce the optimal effect.
 Operating principle and use are similar to the Flutter valve, although the
Cornet is not gravity dependent and can be used in any position.
 Like the Flutter, the Cornet cannot be used in line with a nebulizer.
 No studies showing the long–term effectiveness of the Cornet in CF patients
are available yet.
 Quake
 High –frequency chest wall oscillation devices

High-Frequency Compression/ Oscillation

 As applied to airway clearance, oscillation refers to the rapid vibratory
movement of small volumes of air back and forth in the respiratory tract.
Two general approaches to oscillation:
 External application /high-frequency chest wall compression (HFCWC)
 Airway application/intrapulmonary percussive ventilation
 High-frequency chest wall oscillation is accomplished by using a
two-part system :
 A variable air-pulse generator
 Non-stretch inflatable vest that covers the patient’s entire torso
 The Vest and Hayek RTX Oscillator can be used to deliver high-frequency
external chest wall oscillations.
 Vest was developed by Warwick and colleagues. It consists of non-stretchable,
inflatable vest that extends over the entire torso area down to the iliac crest.
 Chest wall vibrations are delivered to the vest through a series of pressure
pulses produced by an air compressor connected to the vest by a vacuum hose.
 A remote control switch is also available to stop & start the device.
 The px can adjust the intensify and frequency of the pressure pulses to
achieve pressures ranging from approx. 25-40 mmHg over a frequency range of
5-25 Hz, respectively.

Lung Flute
 It is a device used to help loosen, mobilize, and eliminate secretions from your
airways.
How the Lung Flute Works?
 Mucus congestion clogs the lungs and is difficult to cough up.
  When the patient blows out through the Lung Flute, (as if blowing out
candle) his/her breathe moves the reed inside.
This causes acoustic vibrations that thin and loosen secretions deep in
the lungs and results in the secretions moving progressively up the
patient’s airway until they collect at the back of the throat.
Patient is able to cough up thinned mucus so the lungs clear and
symptoms ease.

Two types of lung flute:

 Therapeutic Advantages
 Reusable, drug-free device, provides an economical therapeutic option to
meet patients changing needs.
 Offers better results than standard vibration or PEP Therapy- mobilizes
secretions from deep within the lungs.
 Diagnostic Advantages
 Minimally invasive technology produces reliable results.
 Rapid and convenient for practitioners and patients.
Lung Flute for Home Care
It is indicated for Positive Expiratory Pressure (PEP) therapy.
PEP therapy, when combined with “huff” coughing, will help remove
secretions from airways , reduce the amount of air that may be trapped
in airways.
 Keep airways open and clear secretions and improve delivery of
bronchodilator medication.

Lung Flute for Home Care

 It is indicated for Positive Expiratory Pressure (PEP) therapy.
 PEP therapy, when combined with “huff” coughing, will help remove secretions
from airways , reduce the amount of air that may be trapped in airways.
 Keep airways open and clear secretions and improve delivery of bronchodilator
medication.

Lung flute for hospitals & clinics

 The lung flute for hospitals and clinics is indicated for the collection of sputum
samples for laboratory analysis and pathologic examinations.
 Clinical studies have shown that sputum induction with the lung flute for
hospitals and clinics is safe for patients with COPD, including very severe
COPD.
  Sputum samples induced by the Lung Flute for hospitals & clinics can be used
to diagnose multiple pulmonary disease such as:
 Pneumonia
 Chronic Bronchitis
 Asthma
 Emphysema
 Cystic Fibrosis
 Lung Cancer
 Tuberculosis

Secretion Loosening and Mobilization (Stage 1)

 The patient should hold the lung flute pointing down.
 Inhale a little deeper than normal, place his/her lips completely around the
mouthpiece, and gently blow out through the lung flute as if trying to blow out
a candle.
 As the patient blows, he/she will hear the reed inside the lung flute make a
fluttering noise as it moves.
 Next, the patient should remove the mouthpiece from his/her mouth, quickly
inhale again, put the mouthpiece back in his/her mouth and blow gently
through the lung flute.

Secretion Elimination (Stage 2)

 Once you have worked up to the required number of 2 blow repetitions, the
lung flute will thin and loosen secretions.
 The patient should wait five minutes after the session for secretions to collect
at the back of the throat.
 Several minutes of coughing should bring up most of the secretions.
 FLUTTER
AND OTHER
DEVICES
Group 4

Hubilla, Jhoesua
Inciong, Geraldine
Isidro, Carlem
Lopez, Eunice
Macapagal, Maribel
Magkilat, Hans
Mariano, Allysa Marie
Mendoza, Meryll
Montero, Marimar