Positive Expiratory Pressure (PEP) Devices

Introduction

Acapella PEP Device[1]

One of the most commonly used airway clearance therapy (ACT) options for patients with chronic lung disease or reduced lung volumes is a positive expiratory pressure therapy (PEP) device.

During PEP therapy, the patient exhales against a fixed orifice resistor, typically at a pressure between 10 and 20 cm H2O. (14-24) PEP does not require a pressurized external air supply [2].

Treatment with breathing through special equipment helps to:

• Air get behind the mucus
• clears mucus from the lungs and airway walls
• To hold the airways open for longer[3]

Rising geriatric population coupled with rising incidence of chronic diseases is driving the growth of the PEP devices market.

• Rising prevalence of Chronic Obstructive Pulmonary Disease (COPD) and Asthma is one of the major driving factors for the industry.
• For instance, according to the CDC (Centers for Disease Control and Prevention), approximately 9 million adults were diagnosed with chronic bronchitis in 2018, which ultimately led to higher requirements for PEP devices driving the market. [4]

This page introduces some of the newest PEP equipment on the market.

Mechanism of PEP

The increase in pressure is transmitted to the airway, creating a backpressure brace during exhalation [5], preventing premature airway closure and reducing gas trapping [6].

• Promotes collateral ventilation so that pressure builds up distal to the obstruction [5] (collateral ventilation is a phenomenon found in the human lungs where alveolar structures ventilate by bypassing the normal airways). [7]
• Prevents airway collapse and prolongs expiratory flow
• Effective airway clearance promotes proximal movement of mucus [6].

Types of PEP

The two types of airway clearing devices are positive expiratory pressure (PEP) and oscillating positive pressure.

1. PEP devices increase resistance to expiratory airflow to facilitate mucus clearance by preventing airway closure and increasing collateral ventilation.

• Examples of such devices include TheraPEP® Resistex PEP Mask and Pari RC Cornet Mucus Clearing DeviceTM.

2. Oscillating (or vibrating) positive expiratory pressure (OscPEP) devices are a form of PEP that combine high-frequency airflow oscillations with positive expiratory pressure. The man was blown out multiple times through a device [8]. Under its brand name (Flutter® Acapella® AerobikA® and RC-Cornet®) These types of oscillating PEP devices work in two ways.

• They use resistance like non-oscillating PEP devices to make it harder to exhale.
• Vibrations are also generated when the patient exhales. Vibration dislodges mucus from airway surfaces. After blowing several times through the device, the person clears mucus from the lungs by breathing and coughing [8].

Indications for PEP

• Surgery-induced acute and chronic respiratory failure [8]
• Neurological or musculoskeletal dysfunction [8], such as MND
• Old age and immobility[8]
• Increased lung volume by increasing FRC and VT [8]
• Reduction of hyperinflation[8]/air trapping[9] e.g. emphysema bronchitis asthma[9]
• Improve airway clearance [8]; cystic fibrosis (over 4 years); chronic bronchitis; bronchiectasis; bronchiolitis obliterans [9]
• Maximizing bronchodilator delivery in patients receiving bronchial hygiene therapy [9]

Relative Contraindications for PEP

• Untreated pneumothorax [9]
• Intracranial pressure > 20mm Hg[9]
• Active haemoptysis [9]
• Recent craniofacial or esophageal trauma or surgery [9]
• Patients with acute asthma exacerbations or acute exacerbations of chronic obstructive pulmonary disease (COPD) who cannot tolerate increased work of breathing [9]
• Acute sinusitis or epistaxis [9]
• Ruptured tympanic membrane or other known or suspected inner ear pathology [9]
• Nausea [9]

There are no absolute contraindications to PEP mentioned in the literature

Physiology of PEP

1. Increased lung volume FRC and VT

• When increasing PEP[8], a gradual temporal increase in FRC has been found to be proportional to
• The increase in FRC is achieved through a change in the breathing pattern, which is the product of a decrease in expiratory flow and an increase in expiratory time leading to a decrease in expiratory volume [8].
• Increased lung volume is achieved by altering the breathing pattern to increase VT and decrease respiratory rate due to increased muscle activity of the inspiratory and expiratory muscles [8].
• Improved gas exchange is the result of prolonged breathing with normalized lung volumes [8].

2. Reduction of hyperinflation

• Hyperinflation is the result of air trapping causing the lungs to overinflate. It is caused by muscle spasm, mucosal inflammation, excessive secretion, destruction of lung parenchyma, and decreased lung elasticity. If left untreated, inspiratory muscle failure, decreased ventilation, and dyspnea may result Gas exchange [8].
• PEP reduces expiratory flow, thereby reducing downward pressure on the airway walls, thereby reducing collapse [8]
• The increase in pressure within the airway concentrates the delivery of EPP into a stable airway, so it is implanted in a stent. Reduction of airway collapse increases expiratory volume, leading to additional emptying of lung volume, thereby reducing FRC and improving ventilation distribution and gas exchange [8].

3. Airway Clearance

When using HiPEP

• It evenly moves secretions in collapsed airways. It aims to increase the FRC by recruiting collapsed lung volume and uses resistance to obtain a progressive homogenized emptying of the lung [8].
• Homogenization is achieved by promoting movement of the EPP peripherally during expiration to avoid trapped air and atelectasis in collapsed airways. This results in a decrease in respiratory flow and an increase in expiratory flow with an increase in FRC. doing so mobilizes secretions In areas where the lungs are closed or collapsed and cannot be reached. HiPEP has been shown to be an equally or more effective airway clearance technique than PEP [8].

When using OscPEP

• Due to the opening and closing of the valve, the burst and turbulence of the expiratory flow achieves an oscillatory character. Oscillations during exhalation reduce the viscoelasticity of mucus, affecting its movement, depending on the oscillation frequency. OscPEP is equivalent to As effective as other airway clearance techniques (ACTs) such as PEP and active cycle breathing technique (ACBT) [8].

Different PEP devices

! . OscPEP – Applies a Threshold Dependent Mechanism where a movable ball of high density steel is inserted over the funnel or cone between the expiratory passages of the device causing vibrations to be transmitted to the lungs Examples are:

• Aerobika OPEP – Monaghan Medical’s Aerobika Oscillatory Positive Expiratory Pressure (OPEP) device helps clear mucocilia and helps prevent COPD progression, according to the company.
• Flutter – The Flutter Mucus Clearance Device, manufactured by Aptalis Pharma US Inc, provides PEP therapy for patients with atelectasis, bronchitis, bronchiectasis, cystic fibrosis, COPD, asthma, or other conditions that produce retained secretions
• Pari O-PEP – Coming soon to the US market is the Pari O-PEP, an oscillating positive expiratory pressure device manufactured by Pari Respiratory. The device is designed to mobilize secretions from the lower airway, strengthen the airway, and relieve shortness of breath in patients Over five years old.

2. PEP therapy can be used by e.g.

• A face mask consisting of a one-way valve to which expiratory resistors are attached or a face-mask attached to a plastic ring with holes of different shapes acting as resistors moved. Both devices could be eligible to use solutions if needed. These systems are considered to be flow-based.
• PEP Bottle[10] – The most common threshold-based system is the PEP Bottle or bubble PEP which is a bottle filled with a predetermined amount of water inside with a tube that drains from the bottom. Patient blows into the tube and must overcome the pressure of the opposing fluid volume to bubbles are formed.

Instructions for the use of PEP devices

Physiotherapist will set the machine to the level of pressure needed (Can be used as a component of Active Cycle of Breathing Technique)

Intructions

Repeat the steps below at least 5 times to complete cycle 1. Repeat the following steps the indicated number of times to complete cycle 1:

Loosen mucus:

• Sit with your back straight and chin slightly up. This position keeps your throat open so that air can flow easily without getting blocked.
• You may need to put your elbows on the table. This may keep you from sinking and preventing airflow.
• Take a deep breath and hold it for 2 to 3 seconds.
• While holding your breath place the solution in your mouth or place the mask over your mouth and nose.
• Take steady breaths for 4 to 6 minutes or as long as you can. Keep your jaw as flat as possible. You may have to use your fingers to hold your cheeks together. Try not to cough.
• You may be able to apply the solution or apply your mask when you repeat. Breathe deeply through your nose.

Cough and bring up mucus:

• Remove the mouthpiece from your mouth or the mask from your face.
• Perform a huff cough 2 to 3. Take deep breaths Use your abdominal muscles for 3 quick, powerful breaths. Make a ha ha ha sound.
• Then he coughs violently to produce mucus. Strain off the cold water. Do not swallow the liquid.
• You may need to rest for 1 to 2 minutes.
• This cycle should continue for 10-20 minutes or until you have drained all your urine.
• Instructions for PEP devices may vary. Please refer to the manufacturers instructions.

Scientific literature about PEP

• In addition to meta-analyses of the effects of PEP and other airway clearances on lung function and patient preference, a cochrane review revealed a significant reduction in the severity of pneumonia in people who use of PEP and severity level was a primary outcome kisses.[11]
• Another Cochrane review[12] suggests that PEP therapy appears to have similar effects on health-related quality-of-life symptoms of dyspnea and comparable sputum levels of other ACTs when prescribed in a critical clinical setting or during an acute exacerbation.
• A systematic review[13] investigated the effects of PEP inhalation after upper abdominal or open thoracic surgery. Questionable quality standards protocols and PEP devices used in the six included RCTs are consistent with uncertainty about PEP effects. It is impossible to assume that a prophylactic chest physiotherapy treatment was superior to PEP mechanical protocol in preventing postoperative complications within five days.
• A single-arm study investigating the effect of a specific Oscillating positive expiratory pressure (oPEP) – Aerobika® device on lung capacity and drug clearance in COPD patients shows that the use of Aerobika® devices resulted in ventilation the penetration improved leading to changes in the airflow distribution and influenced the drug release rate in patients with COPD[14].