POSITIVE EXPIRATORY PRESSURE

POSITIVE EXPIRATORY PRESSURE

Positive expiratory pressure creates a back pressure to stent the airways open during exhalation and promotes collateral ventilation, allowing pressure build up distal to the obstruction. This method of act prevents collapse of the airways, which eases the mobilization of secretions from the periphery toward the central airways. A mask or mouthpiece apparatus provides a controlled resistance (19 to20 cm water pressure) to exhalation and requires a slightly active expiration; tidal volume in inspiration is unimpeded.

A variation of Positive Expiratory Pressure, known has HIGH-PRESSURE PEP, uses the same mask apparatus but at much higher levels of pressure (50 to 120 cm water pressure). Inspiration is performed to total lung capacity, this is followed by a forced expiratory maneuver against the PEP mask. A form of Intermittent PEP is provided by a device called the FLUTTER. This pipe like device provides 1. Positive Expiratory Pressure, 2. Oscillation of the airways (at frequencies of 6 to 20 Hz) and 3.Accelerated expiratory flow rates to loosen secretions and move them centrally.

EQUIPMENTS
A PEP mask system may be assembled using a soft ventilation mask, a T-piece , a one way valve, and resistors of various sizes or an adjustable resistor valve. A manometer is placed proximal to the resistor in the initial stages of instruction in the use of pep. First, the manometer helps to determine and monitor the appropriate level of resistance needed for the patient to achieve 10 to 20 cm of water pressure throughout exhalation. Secondly, the visual display of the manometer serves as feedback to assist the patient in mastering the technique (Mahlmeister, 1991).

Aerosol medication by Nebulizer- Deposition of medication improves with PEP(Anderson, 1982; frischnecht-christensen, 1991). Supplemental oxygen - Hypoxic.

TREATMENT WITH PEP

The patient should be instructed to breathe in to the mask or mouth piece to tidal volume using the lower chest and abdomen. Exhalation into the mask or mouthpiece should be slightly active but not forced. The patient continues breathing into the mask or mouthpiece for 10 to 15 breaths, using a normal respiratory rate. Initially, the patient and caregiver monitor the effort by means of the manometer, ensuring that a pressure of 10 to 20 cms of water pressure is achieved throughout exhalation. After a series of 10 to 15 breaths, the mask is removed from the face and the patient performs a series of huffs (and coughing if necessary) to expectorate any mucus that has been mobilized.

The series of PEP breaths followed by huffs should be repeated about four to six times. The total treatment lasts about 15 to 20 minutes and should be repeated twice to three times during the day. The frequency and duration of the treatment must be individualized for each patient. During periods of pulmonary exacerbation, patients are encouraged to increase the frequency of PEP treatments, rather than extending the length of individual sessions. (Mahlmeister, 1991). The procedure for use of high pressure PEP differs from that of low pressure PEP. The expiratory pressure used in this method usually ranges between 50 and120 cms of water pressure. The patient breathes in and out through the mask at tidal volume for 6 to 10 breaths, then inspiration is done to total lung capacity and forced expiratory maneuver is performed against the PEP mask. This is repeated until all the mucus is mobilized.(mcilwaine, 1993

FLUTTER
The device is held horizontally with the lips tightly around the mouthpiece. After a deep inspiration through the nose, the breath is held for 2 to 3 seconds before exhaling deeply through the flutter. The cheeks must be kept flat and to use the abdominal muscles for effective exhalation. The vibration of the chest may be palpated by the patient and caregiver to provide feed back as to the optimal angle of the device. A flutter session consists of 10 to 15 breaths followed by huffing. (This may be done into the device.) with a session lasting about 15 to 20 minutes. To avoid dizziness due to hyperventilation, a patient should refrain from forced exhalation. It may by necessary to pause every 5 to 10 exhalations before resuming the session(Althaus, 1993).

PRECAUTIONS
Although rare, Pneumothorax has been reported with high pressure PEP(oberwaldner,1986). A decision to use PEP should be carefullyl evaluated in cases of Acute Sinusitis, Ear Infection, Epistaxis, recent Oral or Facial Surgery or injury(mahlmeister-1991). For PEP therapy to be effective, a patient should be able to cooperate and actively participate with the treatment.

Pfleger(1992) recommends that patients with airway hyperactivity should take a bronchodilator premedication before the use of PEP.

ADVANTAGES
PEP is performed in the upright position and can be used during acute episodes, as well as chronic pulmonary conditions. PEP therapy does not possess some of the limitations of conventional PD and percussion for secretion clearance and is therefore applicable to a wider patient population. It is relatively easy to learn in one or two sessions, and may be applied equally to the pediatric and adult populations. PEP is appropriate for use in hospitalized patients, as well as long term use at home.

The expense of the equipment is minimal and once the patient is competent in the technique, it provides independence (except for small children.). All of the PEP devices are quite portable, making airway clearance easier to perform during travel or when away from home during the day In those patients in whom PEP is an appropriate airway clearance technique, a high degree of acceptance has been shown (Falk, 1984; Steen, 1991). This may translate into better adherence in the long term.