Oscillating Positive Expiratory Pressure Therapy

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Oscillating Positive Expiratory Pressure Therapy 2017-04-27T04:42:55+00:00

Oscillating positive expiratory pressure devices on this page:

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PARI O-PEP®, Flutter®, Turboforte®
Acapella®
Bottle PEP
Other oscillating PEP devices

Oscillating Positive Expiratory Pressure (PEP) therapy

Oscillating PEP (OscPEP) therapy provides the combination of positive expiratory pressure with high frequency oscillations. It involves breathing with a slightly active expiration against an expiratory resistance through a device. It is used for:

  • clearance of excess secretions from the lungs
  • reducing gas trapping and improving ventilation of the lungs

Physiology – the PEP component encourages airflow behind secretions. The oscillations induce vibrations within the airway wall to displace secretions into the airway lumen and decrease the viscosity of tenacious secretions. The repeated accelerations of expiratory airflow favour movement of secretions from the peripheral to the central airways.

There are clinical precautions which may influence the choice of OscPEP. It is therefore important that it is taught to the patient by a physiotherapist trained in this technique.

Clinical precautions for OscPEP therapy

Undrained pneumothorax or drained pneumothorax, due to risk of air leak

Post-lung lobectomy or lung transplantation, due to the risk of pneumothorax or compromise to the anastomosis

Haemodynamic instability or severe cardiovascular disease due to the application of positive pressure to the thorax, although with low pressure PEP, the risk is minimal compared to a cough

Undrained empyema or lung abscess (due to the risk of sudden release of large volume of loculated fluid)

Active haemoptysis due to the risk of inducing excessive bleeding with the technique

Inability to tolerate due to increased work of breathing

Sinusitis

Middle ear infection, due to the risk of increased pressure within the Eustachian tubes during the technique

Increased risk of early, uncontrolled coughing with patients with hyper-reactive airways

 

There are many devices used to provide oscillating PEP:

PARI O-PEP®, Flutter®, TurboForte®

Acapella®

Bottle PEP

Aerobika®

RC-Cornet®

When this technique is taught in the sitting position, the importance of the correct posture should be explained to the patient.

Instruct them to sit in a well-supported chair with a neutral lumbar spine. This enhances the function of the diaphragm and the pelvic floor and minimises musculoskeletal stress (Fig. 1)

Posture 2

Fig. 1 Sitting posture

Oscillating PEP using the PARI O PEP®, Flutter® and TurboForte®

Pari O PEP Video (Flutter / Turboforte)

This small pipe-shaped hand-held device has a mouthpiece and a perforated cover which encases a stainless steel ball resting in a circular cone (Fig 2).

           Oscillating PEP                           flutter picture

Fig. 2 Oscillating PEP using the PARI O PEP®, Flutter® and TurboForte®

Application of this device has 2 components.

Breathing (inhalation and slightly forced exhalation)

Huffing/coughing

Breathing

The individual is instructed to inspire slowly to a volume slightly greater than tidal volume and perform an end inspiratory breath hold for 2 to 3 seconds. Inhalation occurs through the nose or through the mouth by breathing around the mouthpiece.

Physiology – Inspiration should be slow, with the inspiratory hold encouraging homogenous ventilation.

Following the breath hold, the individual is instructed to breathe out through the device, with enough flow velocity, against a slight expiratory resistance, using their abdominal muscles at a slightly faster rate than normal.

Individuals may stabilise their cheeks (buccal muscles) with their other hand during expiration, if necessary, to ensure better airflow reaches the lungs.  This is repeated consecutively for the prescribed number of breaths.

  • When the Flutter is tilted a little more down there is a lower pressure and frequency to mobilise phlegm from the distal airways
  • When the Flutter is tilted a little more up there is a higher pressure and frequency to mobilise the phlegm form the proximal airways

Physiology – During expiration, the stainless steel ball rolls up and down the cone, creating interruptions in expiratory flow and generating a positive expiration pressure (PEP) within the range of 18 to 35cmH20. An oscillatory vibration of the air within the airways is also generated which shear secretions from the airways and reduces their viscoelasticity. The mid-range frequency of oscillations mimic cilial beat frequency and are determined by the angle at which the device is held.

Optimal oscillation frequency and flow are those which give reinforcement of airway resonance/vibration in the lower chest and upper abdominal region. Individuals are generally taught to recognise this tactile feedback and use this to adapt their technique.

Forced Expiration Technique

Cycles of  breaths are followed by the forced expiration technique (FET), then coughing to further mobilise secretions. The performance of FET is outlined in the FET and ACBT  sections.

Prescription

This form of OscPEP therapy using a mouthpiece OscPEP device is generally performed in an upright seated position (Fig 3). It can be applied in other positions, provided that effective oscillation is still achieved.

             Lady with flutter

             Fig. 3 Mouthpiece OscPEP

A typical cycle of OscPEP therapy consists of:

The number of breaths through the device may vary from 6 to 10 (one cycle). This will depend on the individual’s sputum volume, fatigue and dyspnoea levels

The forced expiration technique (huffing followed by breathing control) is repeated 1 to 3 times depending on the clinical status of the patient, either through or outside of the device

Each treatment session should consist of 6 to 10 cycles

Depending on the daily secretion production, this type of OscPEP therapy may be applied daily, or twice daily in a stable clinical state. During an acute infection, the frequency, the number of breaths per cycle and the number of cycles may alter. In paediatric patients, it may also depend on other factors as discussed in conjunction with the therapist and family.

The patient should be given written instructions including the technique, prescription and cleaning of the device.

Clinical application and evidence for this device

In bronchiectasis, the Flutter® improved secretion transport and reduced viscosity more than PEP therapy (Ramos et al 2009, Tambascio et al 2011). It was also found to reduce hyperinflation more effectively than postural drainage and slow expiration (Guimaraes 2012). When compared to ACBT with or without postural drainage in patients with non-CF bronchiectasis, Flutter® was as well tolerated and offered similar benefits when used over a four week duration as the other techniques (Eaton et al 2007, Thompson et al 2002) and was preferred by patients (Eaton et al 2007).

In children with CF, a longer term study by Orlik et al (2001) comparing ACBT, PD with percussion +/- vibration and the Flutter found that both the ACBT and Flutter improved FEV1 and FVC values.  Another study over a one year period, carried out with a group of children with CF compared the Flutter with PEP (McIlwaine et al 2001). The PEP group maintained or improved their pulmonary function whereas the Flutter group showed a significant decline and were also shown to have increased antibiotic use and hospitalisations.

See Oscillating PEP therapy for clinical precautions.

Products:

Pari kit

PARI O-PEP

For information on PARI O-PEP device go to the  Technipro Pulmomed website: http://www.pulmomed.com.au/pari_opep.html

Instructions for using Pari O-PEP

               flutter

Flutter

For information on Flutter go to the Airliquide healthcare website: http://www.vitalaire.com.au/Site/pages/items/COPD/FlutterMucous.php

 

turbforte

Turboforte

For information on the Turboforte device go to the WyMedical website: Turboforte

How to use a Turboforte

 

Oscillating PEP using the Acapella

Acapella Video

The Acapella® is also a flow-operated oscillatory device, which uses a counterweighted plug and magnet to create airflow oscillations. The frequency/resistance dial allows adjustments to the expiratory pressure and the frequency of oscillations.  It has the option of adjusting the flow pressure and frequency of the oscillations for each individual patient and may be used with a mouthpiece or mask or with a nebulizer in-situ (Fig. 4). Compared to the Flutter®, the Acapella® produces more effective oscillations at lower airflows and a wider range of PEP.

Application of the Acapella has 2 components.

Breathing (inhalation and slightly forced exhalation)

Huffing/coughing

Breathing

The individual is instructed to inspire slowly to a volume slightly greater than tidal volume through the mouthpiece and perform an inspiratory breath hold for 2 to 3 seconds.

Physiology – Inspiration should be slow, with the inspiratory hold encouraging homogenous ventilation.

Following the breath hold, the individual is instructed to expire against a slight expiratory resistance through the Acapella, at a slightly faster rate than normal. This is repeated consecutively for the prescribed number of breaths.

Physiology – During expiration, the exhaled air passes through a cone, which is intermittently occluded by a counterweighted plug attached to a lever, to produce airflow oscillations. In addition, the proximity between the counterweighted plug and a magnet can be adjusted to alter the vibration frequency and amplitude and the positive expiratory pressure, with 5 settings available. The frequency of oscillations generally range between 11 and 15Hz.

Optimal oscillation frequency and flow are those which give reinforcement of airway resonance/vibration in the lower chest and upper abdominal region. Individuals are generally taught to recognise this tactile feedback and use this to adapt their technique.

Forced Expiration Technique

Cycles of breaths are followed by the forced expiration technique (FET), then coughing to further mobilise secretions. The performance of FET is outlined in the FET and ACBT sections.

Prescription

This form of oscillating PEP therapy can be performed in either an upright seated position (Fig. 4) or a gravity assisted drainage position.

151203 Bronchiectasis-8acapella-duet-nebulizer-amp-vibratory-pep-therapy-dd3

Fig. 4 Oscillating PEP with an Acapella – mouthpiece, mask and nebuliser attached to Acapella Duet

A typical cycle of oscillating PEP with an Acapella consists of:

The number of breaths through the device may vary from 6 to 10. This will depend on the individual’s sputum volume, fatigue and dyspnoea levels, which will vary according to the clinical status.

The forced expiration technique (huffing followed by breathing control) is repeated 1 to 3 times depending on the clinical status of the patient, either through or outside of the device

The total number of cycles may range from 6 to 10. This will depend on individuals’ symptoms and sputum volume, which will vary according to the clinical status.

Depending on the daily secretion production, this type of OscPEP therapy may be applied daily or twice daily in a stable clinical state. During an acute infection, the frequency, the number of breaths per cycle and the number of cycles may alter.

The patient should be given written instructions including the technique, prescription and cleaning of the device.

There are several Acapella devices:

Acapella Blue – produces a lower amplitude of vibrations compared to Acapella Green or Acapella Choice. Acapella blue is generally used for individuals with a flow rate of < 15L/min. For this reason, it may be more useful than other oscillating PEP devices, as it can be applied in those with lower expiratory flows, due to severe airflow obstruction or airway instability, age or size. (Volsko et al 2003).

Acapella Green – used for flow rates of > 15L/min.

Acapella Choice – used for flow rates of  > 15L/min. It is able to be taken apart and thoroughly cleaned.

Acapella Duet – It is able to be taken apart and thoroughly cleaned and has a dedicated nebuliser port

                   4 acapella's

Evidence for clinical application of the Acapella®

In patients with non-CF bronchiectasis, a three month trial of regular Acapella® was associated with improvement in sputum volume and patient reported outcomes of cough and health-related quality of life and exercise capacity compared to no treatment (Murray et al 2009). In this same patient group, it offers comparable benefit compared to ACBT or other airway clearance techniques in those in a stable disease state (Patterson et al 2005) and when acutely unwell (Patterson et al 2007). Sputum expectoration was greater with the Acapella® compared to a threshold inspiratory muscle training applied as an airway clearance technique, suggesting that the oscillatory effect of the Acapella® and enhanced expiratory flow are of significant benefit (Naraparaju et al 2010). In children, a study has shown that the resistor set at 4 is an optimal setting for secretion mobilisation as it has a similar beat frequency to the cilia (Mueller et al 2014).

See Oscillating PEP therapy for clinical precautions.

For information on the Acapella devices go to the Smiths Medical website:

http://www.smiths-medical.com/catalog/bronchial-hygiene/acapella/acapella.html

 

Oscillating PEP using Bottle PEP

Bottle PEP Video

Bottle PEP is prescribed for single patient use only.

Bottle PEP (Fig. 5) is a simple and inexpensive method of administering low pressure PEP. In the paediatric setting, it is frequently called Bubble PEP as the creation of bubbles (by the addition of liquid detergent and food colouring to the water) is enticing for young children.

This method of PEP therapy is generally used in the following circumstances:

To ascertain if oscillating PEP therapy is effective for the patient

The patient cannot afford any other device

PEP therapy is only required for an in-patient exacerbation

Other equipment is not available

This method of PEP therapy is not appropriate and or necessary when:

The patient doesn’t have the cognitive ability to use the device without inhaling the water

They are not able to sit to do their airway clearance

It is likely that the device will not be cleaned

They obtain effective airway clearance without using a device – eg ACBT

The resistance with this apparatus is created by a water seal. Tubing of > or = 10 mm inner diameter (such as suction tubing), is placed in the bottle with the bottom of the tubing resting on the base of the bottle. With tubing > or = 10 mm inner diameter there are no significant PEP-pressure differences with any of the tubing lengths or flow rates, which indicates a threshold-resistor system.   An escape orifice of less than 8mm inner diameter significantly increases the PEP pressure (Mestriner et al 2009).

Depending on the desired effect of the technique and the flow rate of the patient, the column of water is generally 10 – 13cm in depth in a bottle of at least one litre. The level of PEP generated with this device is generally between 10 and 20cmH2O. Increasing the water depth will increase the pressure and decrease oscillations during expiration. Conversely, decreasing the water depth will increase oscillations and decrease the pressure during expiration. To check the expiratory pressure, and as a teaching tool, it is advisable to attach a manometer to the circuit, as shown in the diagram below.

     Bottle PEP 1.jpg                     Bottle PEP 2.jpg.png

Fig. 5 Bottle PEP

Sitting with the bottle resting on a table, the patient is instructed to breathe in through their nose. If this isn’t possible, they are instructed to take their lips off the tubing and breathe in through their mouth (see bottle PEP video).

Breathing

The breath in should be a little more than tidal volume and, with the lips sealed around the tubing, expiration needs to be active with longer than normal expiratory flow.

The airflow and pressure generates bubbles within the water. As the water may flow out of the top of the bottle during expiration, it is important to stress to patients that they must not seal off the top of the bottle as this will increase the pressure which may be a contraindication for some patients. A towel can be placed under the bottle to catch any excess water.

Forced Expiration Technique

Cycles of breaths are followed by the forced expiration technique (FET), then coughing to further mobilise secretions. The performance of FET is outlined in the FET and ACBT sections.

It is imperative that the water in the bottle is emptied and that the bottle and tubing are thoroughly cleaned after each use with warm soapy water. To assist with drying the tubing, it can be hung up.

Prescription

The number of breaths may vary from 6 to 10. This will depend on the individual’s sputum volume, fatigue and dyspnoea levels, which will vary according to the clinical status.

Approximately 2-3 forced expiratory technique (huffing) is generally performed after breathing.

The total number of cycles may range from 6 to 10. This, and the frequency of treatment will depend on individuals’ symptoms and sputum volume, which will vary according to the clinical status.

The patient should be given written instructions including the technique, prescription and cleaning of the device.

See Oscillating PEP therapy for clinical precautions.

Evidence for the clinical application of Bottle PEP.

There is no current and relevant literature on the use of Bottle PEP in the paediatric or adult population. A recent study has evaluated that the height of the water in the bottle should be 5 cm for optimal mucus mobilisation (Mueller et al, 2014).

The alternative option is a Therabubble (Fig. 6).

              Therabubble               Therabubble update       

                                                           Fig. 6   Therabubble device                                                                       

The Therabubble has recently been updated to enable two set up options:

  1. Original set up – not threshold PEP. The pressures generated are listed in the instruction booklet and are similar to Flutter and Acapella
  2. Threshold PEP – the water level equals the pressure generated. Therabubble recommend the prescribing therapist to do a full risk assessment before using this option as the valve is removed during use.  The instruction booklet that comes with each device describes how to do the risk assessment.

For information:  Therabubble

Other oscillating PEP devices

Aerobika device

The Aerobika* Oscillating Positive Expiratory Pressure Therapy System (OPEP) (Fig. 7a) is designed to aid in the loosening and removal of excess secretions. With the correct attachment it can also be used with the Aeroeclipse breath actuated nebuliser (Fig 7b).

See Oscillating PEP therapy for clinical precautions.

aerobika                   Aerobika with Compressor_0

Fig. 7a Oscillating PEP via an Aerobika                   Fig. 7b Aerobika attached to Aeroeclipse nebuliser

For information regarding the Aerobika device  – www.airliquidehealthcare.com.au

See video link for how to use the Aerobika – Instruction video

Aerobika Instructions for Use – pamphlet

 

Cornet device

The cornet (Fig. 8) uses low frequency acoustic wave technology to facilitate secretion clearance.

It consists of a mouthpiece, a curved tube, a valve hose and a sound damper.

Expiration through the tube creates an increasing pressure within the hose until it is sufficient to cause the hose end to open, allowing air to flow through the device, creating a positive expiratory pressure and oscillatory vibrations within the airways.

The pressure and flow rate can be adjusted by rotating the mouthpiece in the tube.

It has the advantage of being able to be used in any position with the flow, pressure and frequency of oscillations adjusted to the patients’ needs.

The disadvantage is that it is not easy to effectively clean.

 

cornet                                           man with cornet

Fig. 8 The cornet device

For information regarding the Cornet device – http://www.curaplex.com/rc_cornet.asp

See Oscillating PEP therapy for clinical precautions.

References