PEP Therapy offers the advantages of low-cost simplicity, effective secretion removal, and ease of use and self-administration by patients.

A primary challenge facing respiratory care practitioners is the timely and uncomplicated removal of bronchial secretions associated with surgery, cystic fibrosis, chronic bronchitis, bronchiectasis, and other conditions. Chest physiotherapy (CPT) has been the traditional method for secretion clearance in the United States. In addition, the CPT technique may produce an uncontrolled cough, resulting in bronchospasm or dynamic airway collapse.

In contrast, the positive expiratory pressure (PEP) technique was developed in Denmark in the 1970s, and in 1991 was introduced by Louise Lanafours from Sweden. The PEP technique offers the advantages of low cost, simplicity, effective secretion removal, and, in particular, ease of use and patient self-administration.

To employ the PEP technique, patients use controlled, diaphragmatic breathing to inspire volumes of air that exceed their baseline tidal volumes; they then exhale through a fixed-orifice resistor at an expiratory pressure of 10 to 20 cm H2O until they reach their functional residual capacities. PEP splints airways open and promotes collateral ventilation so that the patient can expectorate secretions from upper airways using a huffing maneuver.

It is important to note that huffing, often misconstrued as a forceful expiratory technique, is actually a gentle maneuver that keeps airways open and stable, averting the bronchospasm and airway collapse often associated with forceful, unproductive coughing. Huffing, performed correctly, promotes upward movement of secretions so that coughs, when they occur, can successfully expel them.

Case 1
An 18-year-old white male with Duchenne muscular dystrophy and severe scoliosis was admitted to the Children’s Hospital Medical University of South Carolina, Charleston, for spinal rod replacement surgery. The patient was essentially quadriplegic, and he had a poor ability to cough due to muscular dystrophy.

This patient had previously undergone anterior spinal rod fixation surgery during which one lung became compressed, necessitating tracheal intubation. Following surgery, one lung was seriously atelectatic. To relieve this condition, conventional CPT was attempted, but it had little success because the patient’s chest was misshapen and twisted. The patient responded well to active cycle of breathing (ACB) treatment and reintubation was not necessary. PEP therapy was not available in the United States at the time of this surgery.

Prior to the second surgery, ACB and incentive spirometry were used to promote airway secretion removal. When PEP therapy was added to the regimen, the patient’s tidal volume dramatically increased from 300 to 700 ccs (as measured using incentive spirometry) and breath sounds improved significantly. This was due, in part, to the collateral ventilation achieved by sustaining positive air pressure in the patient’s lungs.

The patient underwent replacement surgery with difficulty. Because his airway was so tortuous, intubation was impossible, and it was necessary to perform a cricothyrotomy. In spite of this trauma, the patient’s post-operative course was significantly better than it had been following the initial fixation surgery, perhaps because of the availablity of PEP therapy to ventilate the airways more effectively.

The patient was discharged and now receives frequent 5-minute PEP treatments during the day.

Case 2
A 7-year-old white female was admitted to the facility with an undefined progressive neurogenic disorder. The patient was very weak, and she used a wheelchair. She was breathing with difficulty and was unable to generate a cough. Because she could not clear her airway secretions, she was in danger of developing pneumonia.

Prior to admission, the patient had used the Flutter to clear secretions. She was too weak to use this device without her mother’s assistance. The patient was admitted primarily to relieve her mother’s anxiety and frustration.

PEP therapy was tried to help clear this patient’s airways. The patient successfully expectorated secretions by huffing after using PEP therapy. Breath sounds improved significantly, and the patient was discharged.

This little girl, who depended on her mother to meet so many of her needs, was highly elated because, even with limited use of her hands, she could hold the PEP therapy device in her mouth by herself. Her elation was so pronounced that, on one occasion, she drove her electric wheelchair down the hospital halls while performing PEP therapy.

Case 3
A 5-year-old white male was admitted to the hospital with injuries resulting from a motor vehicle accident. He had multiple contusions, right tibial-fibular and rib fractures, and contralateral atelectasis. Breath sounds included coarse rhonchi on the left side, suggesting that the atelectasis was caused by mucous plugging.

The patient, afraid to cough or take deep breaths because of his severe pain, was unable to clear away secretions. He also had a history of asthma. The use of conventional CPT was not possible because of the patient’s broken ribs and chest contusions.

The patient was treated using a combination of 2.5 mg albuterol (delivered every 3 hours via handheld nebulizer) and ACB. PEP therapy was added to his treatment regimen. Prior to treatment, the patient’s respiratory rate was 60 breaths per minute, and his heart rate was 138 beats per minute. His oxygen saturation as measured using pulse oximetry (Spo2) was 92 percent while he was being given supplemental oxygen via nasal cannula at a flow rate of 3 L/min.

The patient was given gentle guidance in diaphragmatic breathing as part of the ACB technique. He hesitated at first because of his chest pain. He was gradually taught to huff without pain. PEP therapy was introduced, and the patient was pleasantly surprised when he made the cylinder move in the pressure indicator. The airflow setting was gradually increased as the patient became stronger.

The patient’s breath sounds increased significantly following treatment. He was able to clear a large amount of thick sputum and blood from his contused lung. His heart rate increased to 120 beats per minute, his Spo2 level rose to 98 percent, and his respiratory rate decreased to 32 breaths per minute. The patient continued to improve and was discharged. The combination of PEP therapy and huffing contributed significantly to the patient’s ability to clear his airways without pain.

PEP therapy significantly improved the removal of bronchial secretions in these three cases of each patient studied. Alternative therapies would probably have been more expensive, less effective, and more difficult (or impossible) to perform. In case 1, traditional CPT was unsuccessful because of the patient’s severe scoliosis. PEP therapy improved his postoperative course despite the additional trauma of a cricothyrotomy. Cases 2 and 3 demonstrate how the simplicity and ease of use of PEP therapy resulted in effective airway clearance for pediatric patients whose weakness or severe pain obviated the use of other secretion-mobilization techniques.

PEP therapy is an extremely effective and inexpensive method for removing pulmonary secretions, especially for handicapped and pediatric patients.

Richard Wilson, BA, RCP, is a cystic fibrosis and pediatric therapist at the Medical University of South Carolina, Charleston.