POSITIVE EXPIRATORY PRESSURE

Positive Expiratory Pressure therapy is a method of

airway clearance. PEP creates a back pressure to stent the airways open during exhalation and promotes collateral ventilation, allowing pressure to buildup distal to obstruction. PEP eases the mobilization of secretion from the periphery toward the central airways

INTRODUCTION
The main components of the PEP device consist of a one way valve connected to either a small-exit orifice or an adjustable expiratory resistor. Sometimes a disposable manometer is incorporated to measure the expiratory pressure. Low pressure PEP devices typically generate a pressure range of 1020 cm H2O at mid-expiration. IT AIMS To reduce air trapping and optimize delivery of bronchodilators (e.g. in asthma and COPD), Enhance secretion mobilization (e.g. in cystic fibrosis, chronic bronchitis and bronchiectasis) Treat atelectasis, thus preventing recurring infection and disease progression. It promotes mucus clearance by either preventing airway collapse through stenting the airways 3 or by increasing intra thoracic pressure distal to retained secretions through collateral ventilation or by increasing functional residual capacity.

PATIENT INSTRUCTIONS FOR PEP THERAPY

1. The patient should sit comfortably and upright while holding the mask firmly over the nose and mouth or the mouthpiece tightly between the lips. 2. Adjust the expiratory resistor dial to the prescribed setting. 3. Have the patient breathe from the diaphragm, taking in a larger than normal tidal breath, but not to total lung capacity. 4. Have the patient gently exhale, maintaining a prescribed pressure of 520 cm H2O. 5. Exhalation time should last approximately 3 times longer than inhalation. 6. Patient should perform 1020 PEP breaths, then perform 23 forced exhalation maneuvers or huffs. 7. Repeat steps 36 until secretions are cleared, or until the predetermined treatment period has elapsed PEP positive expiratory pressure.

FLUTTER & PEP MASK

OPEP THERAPY
Oscillatory PEP Therapy OPEP therapy was first developed and described in Switzerland, as an adjunct or supplement to traditional airway clearance methods. OPEP combines the purported benefits previously described for PEP with airway vibrations or oscillations. The theoretical benefits of oscillations have been described as a 2-fold effect in airway clearance. Oscillations reportedly decrease the viscoelastic properties of mucus, which makes it easier to mobilize mucus up the airways, and create short bursts of increased expiratory airflow that assist in mobilizing secretions up the airways. Secretion removal is then facilitated by the patient forcing deep exhalations through the device or with subsequent coughing and/or huffing techniques.

OPEP DEVICES
Three OPEP devices are currently available in the United States: 1. Acapella 2.Quake 3.Flutter

FLUTTER
The basic operation of the Flutter occurs when

expiratory flow through the mouthpiece causes the ball to rise and fall within the cone, which creates a PEP between 5 cm H2O and 35 cm H2O. The vibrations, which are typically in the range 826 Hz, create airflow pulsations throughout the airways. The Flutter can be tilted (frequently referred to as tuning) slightly upward or downward to change the vibration frequency.

PEP THERAPY
ADVANTAGES
Easy method Easy to learn Less expensive Portable device

DISADVANTAGES
Risk of pneumothorax with

high pressure pep Special care in case of acute sinusitis, oral or facial surgery Fullest cooperation o the pt. Precaution for airway hyperreactivity.