Pep devices

Application of PEP devices in Cardiorespiratory physiotherapy.
It includes types of PEP devices and their uses in physiotherapy..
It stands for positive expiratory pressure.
It includes spirometry, flutter, rc cornet, acapella, etc.
useful in various cardiorespiratory disorders like COPD, asthma , cystic fibrosis, respiratory failure etc.

1. Positive expiratory pressure The development of the positive expiratory pressure (PEP) breathing came abou 1980s in Denmark. Several devices deliver PEP in either oscillatory or smooth flow method. Positive expiratory pressure includes one way breathing valve and an adjustable level of expiratory resistance that create back pressure to stent the airways opening during exhalation.

2. PEP therapy involves active expiration against a fixed orifice flow resistor or variable orifice threshold resistor capable of developing pressure of 10-20cm H 2 O. A patient uses PEP in cycle of about 10 breaths at tidal volume with slightly active expiration followed huffing and coughing.

3. Theory PEP breathing reinflates collapsed alveoli by allowing air to be redistributed through collateral channels- the pores of Kohn, and the Lambert canals- allowing pressure to build up distal to the obstruction and promoting the movement of secretion toward the larger airways.

4. Low pressure PEP The resistance is regulated to achieve 10-20cm H 2 O during slightly active expiration. The appropriate resistor provide a flow volume curve, demonstrating a maximal forced vital capacity, good plateau and no curvilinearity .

5. High pressure PEP It use the same principle but at much higher levels of pressure (50-120cm H 2 O). Inspiration is performed to total lung capacity, followed by a forced expiratory maneuver against the PEP mask, which is connected to the spirometer . The equipment consist of ventilation mask, one way valve and various resistor.

6. Spirometery is used to determine the appropriate resistance for each individual patients. 1 ½mm resistor:- infants 2 ½ to 3mm:- older children 3 ½mm:- adults

7. Indications of positive expiratory pressure Improve airway clearance Cystic fibrosis Bronchiectasis COPD Acute and chronic respiratory failure Improve lung function Post operative atelectasis

8. Contraindication of positive expiratory pressure Untreated pneumothorax Acute hemoptysis Recent trauma or surgery Acute sinuitis or epistaxis Increased intracranial pressure

9. Uses of PEP Improve ventilation and gas exchange Help in airway clearance Prevent post operative atelectasis Reduce pulmonary hyperinflation

10. TheraPEP It consist of mouth piece expiratory resistor that can accommodate many levels of expiratory flow. It come with a detachable pressure monitoring part and indicator to show 10-20cm H 2 O. It can accommodate mask of different sizes.

11. Uses of TheraPEP mobilize secretions chronic respiratory diseases Cystic Fibrosis (CF), prevent atelectasis , Post operative patients

12. Bubble PEP A system that incorporates a column of water ( to the level of PEP required:- 10-12cm H 2 O ) and asking the child to blow through the column of water via flexible straw or tubing. Adding a little liquid detergent to the water, on exhalation produce stream of bubbles. It is important that the child is instructed to only exhale through the tubing and never inhale.

13. Oscillating PEP It provide rapid fluctuation in airway as the patient exhales. The frequency of the vibration range from 10-30Hz with amplitude ranging from 20 to 100 torr at flow of 10-25L/min. It provide positive expiratory pressure, oscillation of the airway and accelerated expiratory flow rate to loose secretion and move secretion centrally.

14. Patient must be able to take deep breath (>10-12 mL /kg) to generate adequate pressure, oscillation and prolonged exhalation. Commonly used devices:- Flutter R-C cornet Acapella

15. Flutter

16. This is a pipe like device consist of a steel ball, a plastic cone , a perforated cover and a mouth piece. Exhaled air cause the steel ball to roll up and down the cone causing airflow vibration. The PEP maintained by the flutter (5-35cm H 2 O) prevent dynamic airway compression and improve airway acceleration. Movement of the flutter Upward:- increase pressure and frequency Downward:- lower pressure and frequency

17. Uses of flutter loosening mucus facilitating movement of mucus up the airways prevent the alveoli from collapsing Effective in cystic fibrosis and COPD pt.

18. R-C cornet Mouth piece Valve hose Outer hard plastic Sound damper

19. Consist of a curved hard plastic outer tube, mouth piece and flexible iatex free inner tube. The flow, pressure and frequency of the oscillation can be adjusted to suit the individual and it can be used in any position. It is independent of gravitational forces. It can be used for 10-15 min.

20. Uses of R-C cornet Airway clearance Effective in:- COPD Cystic fibrosis Pulmonary disease Bronchiectasis

21. Acapella

22. Acapella consist of a mouth piece attached to the body of the unit that uses a counterweighted plug and magnet to create airflow oscillation and a dial for expiratory resistance at the other end. It comes in several models such as: Green:- maintain expiratory flow rate of 15L/min or more Blue:- expiratory flow rate is less than 15L/min

23. Uses of acapella Effective in: Cystic fibrosis COPD Bronchiectasis Asthma Mucociliary disorders

24. References Dean E, Frownfelter DL. Cardiovascular and pulmonary physical therapy: Evidence and practice. Mosby; 2006. Kacmarek RM, Stoller JK, Heuer A. Egan's Fundamentals of Respiratory Care. Elsevier Health Sciences; 2016 Feb 5. Pryor JA, Prasad AS. Physiotherapy for respiratory and cardiac problems: adults and paediatrics . Elsevier Health Sciences; 2008 Mar 6.

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