Positive

Expiratory Pressure Therapy

PEP Overview
What is PEP?
History of PEP
Current PEP Devices
Clinical Evaluation
Conclusion

What is PEP?
PEP is a form of bronchial hygiene,
and is one of the 3 adjuncts of
positive airway pressure (PEP, CPAP,
and EPAP).
PEP involves active expiration
through a one-way valve against a
variable flow resistor.
In modern PEP devices, flow
resistance can be manipulated to
adjust for a desired pressure.

What does PEP do?

Enhances secretion mobilization and

removal
Helps prevent infections
Helps mitigate atelectasis
Improved pulmonary mechanics and gas
exchange
How does PEP accomplish this?
2 ways:
1. Filling under-inflated or collapsed alveoli via

collateral ventilation (pores of Kohn, Canals of

Lambert).*
2. Helping to stint the airways open during expiration.

History of PEP
Origin of PEP
-Traditional CPT with manual percussion, postural drainage, and vibration
was first introduced in 1901 to assist airway clearance in children with
bronchiectasis.
-In the 1970s PEP devices were developed in Denmark, as a means to aid
the patients airway clearance with an effective, self-administered lowpressure device (mouth piece @ 5-20 cm H20).
-High-pressure PEP therapy was developed in Austria (face mask @ 26-102
cm H20).
-In 1991, PEP was introduced in the U.S. by Louise Lanafours from Sweden.
-Since 1991, PEP devices have been modified and improved upon, which
have produced devices such as the TheraPEP and Acapella.

Current PEP Devices

Airway Oscillation Devices (AOD)
Provide standard PEP with the added benefit of
oscillating pressure within the airway
Oscillations reduce the viscoelasticity of mucus
Oscillations provide short bursts of increased
expiratory airflow to help with secretion
mobilization
Flutter Valve
TheraPEP
Acapella

Current PEP Devices

Flutter Valve
Developed in

Switzerland
Pipe-shaped AOD
with a steel ball
resting in an angled
bowl.
On exhalation, the
ball oscillates at
approximately 15 Hz,
and provides 10-25
cm H20.
Gravity dependent

Current PEP Devices

TheraPEP
Designed by Smiths

Medical Company
Standard low-flow PEP
device
Built in pressure indicator
Can be used with a mask
or mouthpiece
Has a 22mm OD which
allows it to be docked
with a nebulizer
Inspiratory and
expiratory valves
Provides 10-20 cm H20

Current PEP Devices

Acapella
Designed by Smiths Medical

Company
Similar to the flutter valve but with
greater functionality (AOD)
Utilizes a counterweighted plug and
magnet to achieve valve closure (not
gravity dependent)
3 Models:
Low flow ( < 15 L/min, adjustable

resistance)
High flow ( > 15 L/min, adjustable
resistance)
Choice (any flow, adjustable frequency)

Whats so great about PEP?

Readily accepted by patients
Shorter treatment time compared to CPT
Independent use
Portable

VS

What does the research say?

Cystic Fibrosis Standard PEP
Mortensen et al: PEP vs. PD&P
Equally effective in secretion clearance

Darbee et al: PEP vs. HFCWC

Both showed the same increase in FVC, FEV1, and sputum

clearance.

McIlWaine et al: PEP vs. PD&P

PEP had greater improvement in FEV1 and FVC
Patients preferred PEP because they felt it was more effective,

required less time, independent, and easier.

Oberwaldner et al: PEP vs. PD&P

PEP produced a significantly greater sputum volume, expiratory

flow rate, and decreased hyperinflation compared to PD&P.

Summary: These studies show conflicting results. At the

least, we can
conclude that standard PEP is just as

What does the research say?

Chronic Bronchitis Standard PEP
Christensen et al: Diaphragmatic breathing

/FET vs. PEP/FET

PEP group had greater secretion clearance,
lower exacerbation rate, lower rate of
mucolytic and antibiotic use, and an increase
in FEV1.

What does the research say?

Cystic Fibrosis
Newhouse et al: Flutter vs. IPPV
Equally effective in sputum production, and increasing expiratory flows.

Hominick et al: Flutter vs. PD&P

Equally effective in sputum clearance
Flutter was more effective at increasing FEV1 and FVC

Konstan et al: Flutter vs. PD&P

Flutter produced significantly more sputum.
Flutter was assessed to be safe, cost effective, easy to use, and with

greater patient adherence.

Gondor et al: Flutter vs. PD&P

Flutter showed significant improvement in FVC compared to PD&P
No difference in length of hospital stay

What does the research say?

Chronic Bronchitis OPEP
Bellone et al: Flutter vs. PD&P
Flutter had superior sputum production /

clearance.

Research Conclusions
What conclusions can be drawn from

the research?
The majority of the research regarding the

efficacy of PEP has been conducted on CF

patients.
In some studies, PEP and OPEP have been shown
to have superior secretion clearance and
improvements in pulmonary function than
traditional methods of CPT. However, other
research clearly refutes these results, placing PEP
as only as effective as traditional methods.
Thus, the choice to utilize PEP as a primary
method of bronchial hygiene therapy should be
made on the basis of other criteria, such as cost
and patient compliance.

Conclusion
PEP devices such as the Acapella are

small, portable, cost effective, and

patient preferred.
PEP devices havent been shown to be
superior to other forms of CPT, but they
haven been proven inferior either.
Continued research on the efficacy of
PEP devices needs to be conducted.
At this time, the effectiveness of PEP
devices has been shown to be equal or
better than traditional methods of
bronchial hygiene, and the decision to
use PEP devices should be made on the
basis of other factors, such as cost
effectiveness.

Flutter

Flutter