RESPONSE OF EXPIRATORY MUSCLES TRAINING TO POSITIVE END EXPIRATORY PRESSURE IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE

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Int J Physiother Res 2017;5(5):2344-48. ISSN 2321-1822 2344
Original Research Article
RESPONSE OF EXPIRATORY MUSCLES TRAINING TO POSITIVE END
EXPIRATORY PRESSURE IN CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
Mohamed Sh. Mosa *
1
, Azza A. El Aziz
2
, Amany R. Mohamed
3
, Marwa M. Shaban
4
.
*1 MSc Physical Therapy Student, Faculty of Physical Therapy, Cairo University, Egypt.
2 Professor of Physical Therapy for Cardiovascular/Respiratory Disorder and Geriatrics, Faculty of
Physical Therapy, Cairo University, Egypt.
3 Consultant (Professor) of Physical Therapy, Critical Care Department, Cairo University Hospitals,
Egypt.
4 Assistant Professor of Chest Diseases, Faculty of Medicine, Cairo University, Egypt.
Introduction: Although expiratory muscles have been little studied it is known that expiratory muscle strength is
impaired in most patients with significant chronic obstructive pulmonary disease (COPD), the expiratory muscles
partake in the generalized muscle weakness that is observed in those patients. The decreased expiratory muscle
strength was associated with reduced patient’s exercise capacity. There is need to find an alternate cost effective,
easy technique which can help strength the expiratory muscles and improve the exercise capacity. An interven-
tion like applying positive end expiratory pressure (PEEP) training could help in strengthening of expiratory
muscles and improving the exercise capacity in patient with COPD.
Procedure: Forty COPD male patients were assigned into two equal groups: Group A consisted of 20 males whom
received PEEP (10-20 cm H2o, 15 minutes session, once daily for 4 weeks) plus standard chest physiotherapy.
Group B consisted of 20 males received standard chest physiotherapy only. Maximum Expiratory pressure (MEP)
and Six-minute walk distance (6MWD) were measured for each patient before and after treatment.
Results: There was a significant difference (p= 0.041) between study and control group patients in MEP post
treatment (84.35 ± 9.73 vs 77 ± 12.11 cm H2o). There was significant difference (p= 0.045) between study and
control group patients in 6MWT post treatment (339.7 ± 54.126 vs 301.65 ± 61.78).
Conclusion: Positive expiratory pressure therapy is efficient in improving the expiratory muscle strength and
exercises capacity and helps COPD patients to improve their active life.
KEY WORD: COPD, PEEP, Expiratory muscles, MEP, 6MWT.
ABSTRACT
INTRODUCTION
Address for correspondence: Mr. Mohamed Sh. Mosa, MSc Physical Therapy Student, Faculty of
Physical Therapy, Cairo University, Egypt. E-Mail: mohamed.s.mosa@gmail.com
International Journal of Physiotherapy and Research,
Int J Physiother Res 2017, Vol 5(5):2344-48. ISSN 2321-1822
DOI: https://dx.doi.org/10.16965/ijpr.2017.207
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International Journal of Physiotherapy and Research
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DOI: 10.16965/ijpr.2017.207
Received: 31-07-2017
Peer Review: 31-07-2017
Revised: None
Accepted: 16-08-2017
Published (O): 11-09-2017
Published (P): 11-10-2017
the focus of intense research because of its
persistently increasing prevalence, mortality [1].
COPD is a preventable and treatable disease
that characterized by Reduction in oxygenation,
pulmonary functions, and respiratory muscle
strength, as well as radiological changes such
(COPD) is a syndrome characterized and defined
by a single physiological parameter: limitation
of expiratory airflow. COPD has gained interest
as a major public health concern and is currently

Int J Physiother Res 2017;5(5):2344-48. ISSN 2321-1822 2345
as atelectasis and air flow limitation which is
not fully reversible. associated with an abnor-
mal inflammatory response of the lung to
cigarette smoke and other noxious particles or
gases [1].
It is more likely that expiratory muscles of COPD
patients, which persistently work under the
overloads of increased airway resistance and
decreased lung elastic recoil, would develop
muscle dysfunction. It should be recognized,
however, that the intensity of expiratory muscle
dysfunction appears to be relatively low if
compared with weakness shown by COPD
patients in peripheral or inspiratory muscles [2].
(PEEP) therapy involves the application of a
resistance to expiration in order to produce
positive airway pressure. It is thought to stabi-
lize airways, prevent premature airway closure
improve ventilation and reduce gas trapping.
It has been used, and is recommended, as
component of respiratory physiotherapy man-
agement for varying groups including those with
cystic fibrosis acute and chronic respiratory dis-
ease and in the post-operative setting. Improve-
ments in secretion clearance, functional residual
capacity and oxygenation have been demon-
strated with the use of positive expiratory pres-
sure therapy [3].
However, there is little information about the
actual clinical usage of( the technique, there is
little definition of the patient groups most com-
monly prescribed PEEP therapy, the methods of
administration [3].
Since muscle weakness might be improved
through different mechanisms by training. These
problems arouse our interest to investigate the
response of expiratory muscle training to PEEP
on COPD patients.
This study was designed to respond to the rela-
tive lack of information about the impact of us-
ing PEEP therapy on expiratory muscle strength
measured by maximum expiratory pressure MEP
and exercise capacity measured by six-minute
walking test (6MWT).
differences (p >0.05) between both groups in
age. They were selected from the chest depart-
ment , faculty of Medicine, Kasr Al Einy hospi-
tal.
Inclusion criteria: All Patients included in this
study were diagnosed as mild to severe COPD,on
optimized medical therapy all over the study,
clinically stable (not suffering from recent res-
piratory tract infection 3 weeks before the study),
they are willing to participate in the study.
Materials Used: 1. peep device (Astra Tech AB,
Export, Sweden). 2. Micro Respiratory Pressure
Meter (Micro RPM) from Micro Medical Ltd. 3.
Stopwatch 4.an expiratory airway pressure indi-
cator. 5. Pen and paper.
Forty COPD male patients were assigned into
two equal groups: Group A consisted of 20 males
with received (PEEP) (10-20 cm H2o, 15 minutes
session, 1times per day-daily for 4 weeks) plus
standard chest physiotherapy (postural drainage,
percussion, vibration, and breathing exercises).
Group B consisted of 20 males received stan-
dard chest physiotherapy only. Maximum Expi-
ratory pressure (MEP) and Six-minute walk dis-
tance (6MWD) was measured for each patient
before and after treatment
Procedures: A verbal explanation about the
importance of this study procedure, main aims
and conceptual approach was explained to ev-
ery patient. an informed written consent was
taken from them.
The procedures of this study divided into two
main procedures: subjects in group A use (PEEP)
device with one session daily for 4 consecutive
weeks the patients had to breath in, but not to
total lung capacity then exhale gently, the pres-
sure detected by an expiratory airway pressure
indicator is inserted into the system to pressure
range from 10–20 cm H2O. Exhalation time
lasted approximately 3 times longer than inha-
lation. One minute of PEEP breathing was fol-
lowed by 2-3 forced expirations or huffs, a short
period of relaxation and controlled breathing.
Then repeat for 15 minutes (should stop if they
experience breathlessness or any severe dis-
comfort).
In both groups MEP (cm H2o) to measure the
expiratory muscles strength and 6MWT (meter)
to measure the exercise capacity was taken pre
MATERIALS AND METHODS
Subjects:
Forty COPD male patients, their ages ranged
from 45 to 65 years. There were no significance
Mohamed Sh. Mosa, Azza A. El Aziz, Amany R. Mohamed, Marwa M. Shaban. RESPONSE OF EXPIRATORY MUSCLES TRAINING TO POSITIVE
END EXPIRATORY PRESSURE IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE.

Int J Physiother Res 2017;5(5):2344-48. ISSN 2321-1822 2346
and post the study for each patient [4,5,6].
Statistical procedures: Statistics were analyzed
using SPSS software package. Results are shown
as the mean ± SD. Both t-tests were used to
assess significance of differences within each
group and between the two groups. Significance
was accepted as P-value < 0.05.
In study group the mean values ± SD of maxi-
mum expiratory pressure increased from 70.3±
8.7 to 84.35 ± 9.76 cm H2o after applying Posi-
tive End Expiratory Pressure (PEEP). The mean
difference was -14.05. Which is highly signifi-
cance (P=0.000).
In control group the mean values ± SD of maxi-
mum expiratory pressure before the experiment
was 76.6 ± 13.22 cm H2o while after the experi-
ment was 77 ± 12.118 cm H2o. The mean differ-
ence was - 0.4. which is statistically insignifi-
cant (P=0.438).
RESULTS
Table 1: MEP before and after treatment for the study
group.
Table 2: MEP before and after treatment for the control
group.
Table 3: 6MWT before and after treatment for the study
group.
was -48.35. Which is highly significant (P=0.000).
In control group the mean values ± SD of 6
minutes’ walk test before the experiment was
298.95 ± 62.27 while after the experiment was
301.65 ± 61.27. The mean difference was -21.2
Which is statistically insignificant (P=0.142).
Table 4: 6MWT before and after treatment for the control
group.
In study group the mean values ± SD of 6
minutes’ walk test increased from 291.35 ±58.86
to 339.7 ± 54.126 after applying Positive End
Expiratory Pressure (PEEP). The mean difference
DISCUSSION
There is much less data related to the expira-
tory muscles in COPD patients, However the
expiratory muscle strength is impaired in most
patients with significant COPD., the expiratory
muscles partake in the generalized muscle weak-
ness that is observed in patients with COPD. The
decreased expiratory muscle strength was
associated with reduced exercise capacity and
reduced quality of life [7].
This study was designed to respond to the
relative lack of information about the impact of
using peep on expiratory muscle strength
measured by MEP and submaximal exercise
capacity measured by (6MWT).
The result of our study revealed statistically
significant improvement in expiratory muscle
strength (MEP), and exercise capacity (6MWT)
after using the PEEP. as expiratory muscles can
be trained similarly to the peripheral muscles
with inexpensive devices that increase the
resistive or threshold expiratory load on the
expiratory muscles.
While decreased expiratory muscle strength was
associated with reduced patient’s exercise
capacity [8] then wherever the expiratory muscle
become stronger the patient significantly
improved in their exercise capacity measures as
the result of our study. And consequently,
suggest a causative role for the former mechan-
ism(PEEP).
Our findings are consistent with the results of
the Study done by Nicolini A et al., 2014, Re-
sults supporting the use and the effectiveness
of PEEP in (COPD) patients.
The difference that the study was three groups
of intermittent positive pressure breathing(IPPB)
temporary positive expiratory pressure(TPEP)
and a group with pharmacological therapy alone,
mean age was relatively higher 70±6, The dura-
tion of each treatment was 30 min per session
Mohamed Sh. Mosa, Azza A. El Aziz, Amany R. Mohamed, Marwa M. Shaban. RESPONSE OF EXPIRATORY MUSCLES TRAINING TO POSITIVE
END EXPIRATORY PRESSURE IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE.
±SD Min max
Before 70.3 ± 8.7 54 90
After 84.35 ± 9.76 65 105
Item MEP (cm H2o) MD t-value P-value Sig
-14.1 -8.736 0.000 S
±SD Min max
Before 76.6 ± 13.22 57 105
After 77 ± 12.118 57 100
MEP (cm H2o)
Item MD t -value P-value Sig
-0.4 -0.793 0.438 NS
±SD Min max
Before 291.35 ± 58.86 163 395
After 339.7 ± 54.126 215 439
Item 6MWT (me ter) MD t-value P-value Sig
-48.4 -13.79 0.000 S
±SD Min max
Before 298.95 ± 62.27 190 390
After 3 01.65 ± 61.78 197 403
6MWT (meter)
Item MD t-value P-value Sig
-2.7 -1.532 0.142 NS

Int J Physiother Res 2017;5(5):2344-48. ISSN 2321-1822 2347
and was given twice daily with pressure only1cm
H2O [9].
Our findings are also consistent with the results
of the study in 2013, Nicolini et al., they used
the positive expiratory pressure (PEP) during the
6MWT which found that low threshold PEP of
only 5cmH2O improved the distance walked in
patients with moderate-to-severe COPD [10].
However, Wibmer et al., 2014 investigated the
same kind of patients and found that, with a
flow-dependent PEP in the range of 10–20 cm
H2O, patients walked 30.8m less than the con-
trols without devices [11].
Furthermore, Study by Mascardi V et al.,2016
using Temporary positive expiratory pressure
(T-PEP) a device which applies an expiratory
pressure d”1 cmH2O only two-week treatment
with T-PEP but in this study in hospital and at
home, Result revealed that MEP and 6MWT im-
proved significantly in the two TPEP groups [12].
Also, Study done by Chien-Ling Su et al., 2006
stated that Four-week of positive expiratory pres-
sure (PEP) as an adjunct to forced expiratory
technique (FET) further enhanced 6minute walk
distance(6MWD), and reduced cough difficulty
compared to FET only in COPD patients with
mucus hypersecretion [13].
However, Study done by Russo D et al., 2016 in
patients with severe COPD, the application of
1cmH2O of PEP seems to improve the exercise
tolerance as 10 cmH2O, with similar dyspnea
during 6MWT [14].
Martin et al.,2011 applied two levels of thresh-
old PEP (13.8 and 2 cm H2O) and demonstrated
a significant decrease in dyspnea with the use
of the higher level of PEP after a treadmill
constant load test. the authors applied PEP only
after the conclusion of the exercise test, rather
than before - as our study- or during effort [15].
Weiner et al.,2003 studied the effects of expi-
ratory muscle strength training (EMST) on expi-
ratory muscle strength and, exercise perfor-
mance as the participants of both groups ex-
haled through the expiratory port of the (Thresh-
old Inspiratory Muscle Trainer). The treatment
group, the expiratory load modified from 15 to
60 percent of their MEP, and the sham group
was trained with a low load of 7 cm H2O they
reported statistically significant changes in the
treatment group: an increase (21%) in the MEP
and statistically significant increase (19%) in the
distance walked during 6MWT [7].
Finally, Future studies may lead to a more prac-
tical utilization of positive expiratory therapy.
And further studies needed to test the effects
of different levels PEEP on expiratory muscle
strength and during aerobic and strength train-
ing protocol.
ACKNOWLEDGEMENTS
The authors acknowledge the Cardiovascular/
Respiratory Disorder and Geriatrics department,
Faculty of physical therapy, Cairo University and
Chest Diseases department, Faculty of Medi-
cine, Cairo University for providing resources
that contributed to this study.
Conflicts of interest: None
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How to cite this article:
Mohamed Sh. Mosa, Azza A. El Aziz, Amany R. Mohamed, Marwa M. Shaban.
RESPONSE OF EXPIRATORY MUSCLES TRAINING TO POSITIVE END
EXPIRATORY PRESSURE IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE.
Int J Physiother Res 2017;5(5):2344-2348. DOI: 10.16965/ijpr.2017.207
Mohamed Sh. Mosa, Azza A. El Aziz, Amany R. Mohamed, Marwa M. Shaban. RESPONSE OF EXPIRATORY MUSCLES TRAINING TO POSITIVE
END EXPIRATORY PRESSURE IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE.