ArticlePDF Available

The role of positive expiratory pressure (PEP) in physiotherapy of patients with cystic fibrosis. Comparison with oscillatin positive expiratory pressure (OPEP)

Authors:

Abstract

Physiotherapy plays a very important role in cystic fibrosis. Its basic aim is to regularly clear bronchial passages of mucus which is responsible for exacerbation of bronchoalveolar symptoms. Positive Expiratory Pressure (PEP) and Oscillating Positive Expiratory Pressure (OPEP) are among the most commonly used bronchi clearance methods. It is not entirely clear which technique should be applied in what situations and whether these techniques are similar to other drainage techniques in terms of effectiveness. The aim of this study is to review the literature and analyse the effectiveness of both techniques, to summarise the existing evidence and to point to gaps in the knowledge about this issue.
The role of positive expiratory pressure (PEP)
in physiotherapy of patients with cystic brosis.
Comparison with oscillatin positive expiratory
pressure (OPEP)
Rola podwyższonego ciśnienia wydechowego (PEP)
w zjoterapii chorych na mukowiscydozę. Studium
porównawcze z PEP generującym oscylacje (OPEP)
Teresa Orlik A,E, F
, Anna Wyka-Wojeńska A,D
Rehabilitation Department, Institute of Mother and Child, Warsaw, Poland,
Zakład Usprawniania Leczniczego, Instytut Matki i Dziecka, Warszawa, Polska
Abstract
Physiotherapy plays a very important role in cystic brosis. Its basic aim is to
regularly clear bronchial passages of mucus which is responsible for exacerbation of
bronchoalveolar symptoms. Positive Expiratory Pressure (PEP) and Oscillating Positive
Expiratory Pressure (OPEP) are among the most commonly used bronchi clearance
methods. It is not entirely clear which technique should be applied in what situations and
whether these techniques are similar to other drainage techniques in terms of eectiveness.
The aim of this study is to review the literature and analyse the eectiveness of both
techniques, to summarise the existing evidence and to point to gaps in the knowledge
about this issue.
PEP, OPEP, physiotherapy, cystic brosis
Streszczenie
Fizjoterapia odgrywa bardzo istotną rolę w mukowiscydozie. Jej podstawowym ce-
lem jest systematyczne oczyszczanie oskrzeli z zalegającej wydzieliny odpowiedzial-
nej za rozwój choroby oskrzelowo-płucnej. Do jednych z częściej stosowanych metod
oczyszczania oskrzeli należą technika podwyższonego ciśnienia wydechowego (Positi-
ve Expiratory Pressure – PEP) i oscylacyjnego podwyższonego ciśnienia wydechowe-
go (Oscillatory Positive Expiratory Pressure OPEP). Nie do końca jest jasne, którą
z technik powinno się stosować i w jakich sytuacjach oraz, czy wymienione techniki są
porównywalne pod względem efektywności z innymi technikami drenażowymi. Celem
niniejszej pracy jest przegląd piśmiennictwa i na tej podstawie analiza skuteczności obu
technik, podsumowanie istniejących dowodów, a także podkreślenie luk w funkcjonują-
cej wiedzy na ten temat.
PEP, OPEP, zjoterapia, mukowiscydoza.
email: teresa.orlik@imid.med.pl
The study was not nanced from any resources.
Badanie nie było nansowane z żadnych źródeł.
Słowa kluczowe:
Rehabilitation Advances in Rehabilitation/Postępy Rehabilitacji (1), 39 – 45, 2018
A – preparing concepts
(opracowanie
koncepcji i założeń)
B – formulating methods
(opracowanie metod)
C – conducting research
(przeprowadzenie
badań)
D – processing results
(opracowanie
wyników)
E – interpretation and
conclusions (interpre-
tacja i wnioski)
F – editing the nal
version (redakcja
ostatecznej wersji)
Key words:
40 Teresa Orlik, Anna Wyka-Wojeńska
Introduction
Cystic brosis (CF) is an inherited autosomal
recessive genetic disease of white race. It is caused
by mutations of the gene located on the long arm of
chromosome 7, i.e. Cystic Fibrosis Transmembrane
Conductance Regulator (CFTR), which serves as
a chloride channel. The damaged function of CFTR
resulting from the mutation leads to disorders of
the transport of C1 ions through cell membranes of
respiratory epithelium and excessive absorption of
Na+ and water in a cell. This, in turn, leads to lower
hydration and thickness of cilia of the epithelium,
production of thick and sticky mucus and to
disorders of mucociliary clearance, particularly
in the respiratory system [1]. Cystic brosis is
a chronic progressive disease with various clinical
symptoms. Changes in the respiratory system
usually determine the development of the disease as
well as the quality and length of life.
Physiotherapy plays a very important role
in cystic brosis. Its aim is to regularly clear
bronchial passages of thick, sticky mucus which
accumulates in air passages. It was proved that
regular physiotherapeutic procedures, commonly
known as drainage procedures, reduce the number
of exacerbations of bronchoalveolar symptoms,
and, in this manner, help to slow down the disease
progression and to maintain proper lung function
for as long as possible [2,3]. For many years, it has
been highlighted that better prognosis and quality
of life of patients with cystic brosis depend on
the improvement of complex treatment methods,
including more and more ecient physiotherapy
procedures [4-6].
Intensive development of physiotherapy in cystic
brosis was mainly connected with developing
and modifying methods of clearing airways which
would serve as an alternative to postural drainage
(also known as gravity assissted drainage) with
manual chest percussion or vibration. In the 1960s
and 1970s, this type of drainage was a popular
method of clearing bronchi in Europe. Owing to
multidirectional scientic research, traditional
bronchi clearance methods were gradually replaced
with modern, more ecient methods in which
various tools supporting airway clearance were
used. The research which exerted the greatest
inuence on the development of physiotherapy in
cystic brosis mainly regarded negative eects of
gastroesophageal reux on the respiratory system
and the fact that reux was stimulated during
postural drainage [7-9]. Getting to know a key
role of mobilisation of mucus in eective bronchi
clearance and identifying the meaning of autotherapy
for patients’ independence as well as assessing the
eects of this process were also signicant [10].
The majority of tools, including the ones available
on the Polish market, work in the system of Positive
Expiratory Pressure (PEP) and Oscillating Positive
Expiratory Pressure (OPEP). The application of
PEP improves ventilation in broncholi, reduces the
symptom called “bubble trap” and increases the
Functional Residual Capacity (FRC) [2,11-13]. In
turn, vibrations lead to easier clearance of thick,
sticky mucus from bronchial wall, and expirations
made by the device increase the expiratory ow for
a short time, which makes it easier to push mucus
towards central bronchi [14,15].
Despite the fact that PEP and OPEP have been
in use for over 30 years, it is still not entirely clear
which technique should be used in what situations,
and whether these techniques are similar to other
drainage techniques in terms of eectiveness. The
aim of this study is to review the literature and
analyse the eectiveness of both techniques on
the basis of this review, to summarise the existing
evidence and to point to gaps in the knowledge
about this issue.
Do PEP and OPEP produce measureable
therapeutic eects compared to other drainage
techniques?
PEP
In a cross-over study on 9 patients in a stable
state, Lannefors et al. applied 3 dierent methods
of clearing bronchi [16]. These methods included:
1) postural drainage with thoracic expansion
exercises and Forced Expiration Technique (FET),
2) PEP mask and FET, 3) physical exercise on
a cycloergometer and FET. While assessing the
eectiveness of these techniques on the basis of
the amount of mucus cleared, the authors did not
nd any statistically signicant dierences between
these regimes. A similar study was conducted by
Mortensen et al. [17]. The authors concluded that
postural drainage with FET was as eective as PEP
with FET in tracheobronchial clearance in patients
with cystic brosis.
Advances in Rehabilitation/Postępy Rehabilitacji (1), 39 – 45, 2018 41
In the study by Darbee et al. [18], two methods were
compared, i.e. PEP and High-Frequency Chest Wall
Oscillation (HFCWO). The eects of both techniques
on arterial blood oxyhemoglobin saturation (SaO2)
and selected spirometric indices were assessed. The
authors revealed that HFCWO and PEP were equally
eective. As far as SaO2 is concerned, the results
were unequivocal. In several patients with respiratory
failure and low values of SaO2, an unacceptable
decrease in SaO2 levels was noted during the therapy
with HFCWO. The authors concluded that the patients
may benet more from PEP during an acute phase of
the pulmonary exacerbation.
McIlwaine et al. carried out research in which
they compared out-patients treated with PEP
technique with those who underwent postural
drainage with chest percussion technique [19]. The
study participants were paired on the basis of similar
values of forced expiratory volume in 1 second
(FEV1%N – up to 15% dierence), gender and age
(up to 3-year dierence). Patients who performed
less than 85% of the recommendations (assessment
based on the questionnaire) were excluded from the
study. Thirty-six patients participated in the whole
study that lasted 1 year. A signicant increase in
forced expiratory volume in 1 second (FEV1) and
forced vital capacity (FVC) was noted in the PEP
group. McIlwaine et al. concluded that PEP is
a better method for maintaining lung function in
patients with cystic brosis compared to postural
drainage with chest percussion.
OPEP
The majority of studies on the eectiveness of
OPEP were conducted with the use of Flutter VRP1.
Orlik carried out a comparative analysis of the
eectiveness of selected physiotherapeutic methods
in 21 in-patients [6]. She compared 5 airway
clearance techniques, i.e. postural drainage with
chest percussion, postural drainage with percussion
and squeezing, Active Cycle of Breathing Technique
(ACBT), Flutter as well as Flutter with relaxation.
It was revealed that the largest amount of mucus
was removed by coughing in patients undergoing
ACBT and Flutter with relaxation technique. No
statistically signicant dierences were found
between the values of peak expiratory ow (PEF)
and SaO2 measured before and after the application
of any drainage technique.
In their randomised crossover study, Pryor et al.
compared OPEP with Flutter and ACBT [20]. The
authors did not note a signicant improvement
in lung function or oxygenation in the examined
patients. A signicant increase in the amount of
mucus cleared was noted in the study participants
who underwent ACBT. The authors concluded that
there were no signicant dierences between the
application of Flutter and ACBT.
App et al. carried out research that focused on
the eectiveness of autogenic drainage compared
to OPEP with Flutter [21]. The study included
17 patients with cystic brosis. No signicant
dierences were noted between the values of FVC
and FEV1 and the amount of mucus cleared during
the study. However, thickness and stickiness of
mucus were reduced more with the use of Flutter
than during autogenic drainage. The authors
concluded that the vibrations applied with certain
frequency produced by Flutter may reduce the
stickiness of mucus to the bronchial wall.
In the study by Konstan et al. [22], the mass of
sputum expectorated after the application of Flutter
was compared to the mass of sputum expectorated
in forced cough and during postural drainage with
percussions and vibrations. During the session
with Flutter, all the study participants coughed up
signicantly more mucus (p<0.001) than during
postural drainage and forced cough technique. The
authors concluded that Flutter is more eective
in helping to cough up mucus than traditional
techniques of clearing airways in patients with
cystic brosis.
In her 7-month study, Orlik assessed the
eectiveness of selected physiotherapeutic methods
in 80 patients divided into 4 subgroups [23]. In each
group, a dierent airway clearance technique was
applied, i.e. postural drainage with chest percussion,
postural drainage with percussion and squeezing,
ACBT and OPEP with Flutter. The author noted
a statistically signicant increase in the values of
all the examined spirometric indices in the ACBT
group. In the OPEP group, an increase in FEV1
(statistically insignicant dierences) and FVC
(statistically signicant dierences) was noted. The
author concluded that forced breathing with Flutter
led to an increase in lung obturation in patients with
bronchial hyperresponsiveness.
42 Teresa Orlik, Anna Wyka-Wojeńska
Comparison of PEP and OPEP
The crossover study by Lagerkvist et al. included
15 patients with cystic brosis [24]. The aim of the
study was to assess the eects of PEP and OPEP
(Flutter) on the values of gas tensions in blood. The
authors concluded that OPEP led to more favourable
changes in the values of PaO2 and PaCO2 compared
to PEP; however, these changes disappeared very
quickly, i.e. within less than 10 minutes. Neither PEP
nor OPEP brought about dierences in spirometric
values.
In their study that lasted 1 year, McIlwain et
al. compared the eectiveness of PEP and OPEP
(Flutter) [25]. Forty patients with cystic brosis
were randomly assigned to one of the assessed
therapies. Patients who performed less than 80% of
the recommended sessions per month (assessed on
the basis of the questionnaire) were excluded from
the study. Thirty-two patients completed the study.
The authors did not reveal statistically signicant
dierences in lung function of patients who were
treated with PEP. In turn, in the case of patients
who were using Flutter, a decrease in the values
of lung function indices was noted after one year,
while FVC dierence was statistically signicant
compared to PEP.
Van Winden et al. conducted a two-week
randomised crossover study in which they compared
OPEP with Flutter method and PEP mask method
applied in clinically stable children with cystic
brosis [26]. The PEF was measured before and
after a morning physiotherapy session and patients
completed a questionnaire regarding day and
night cough, production of sputum and diculty
breathing. No signicant dierences were found
between the PEF in both groups. Moreover, no
dierences were revealed concerning oxygenation
before, during and 30 minutes after the session
of clearing airways. There were no signicant
dierences in the assessment of symptoms included
in the questionnaire for either of the two therapies.
The crossover study by Borka et al. included 10
patients with cystic brosis [27]. Within the study,
260 procedures were performed aimed at measuring
the mass of sputum expectorated. The authors
concluded that PEP was more ecient than Flutter.
Flutter is a useful additional tool.
Discussion
In the presented publications, the authors obtained
considerably dierent research results. It regarded
both the comparisons of PEP and OPEP with other
drainage techniques and the comparisons of both
methods with each other. The only exception was the
comparison of PEP and OPEP with postural drainage
with percussion which is treated as a conventional
physiotherapy method of clearing bronchi. In 4 of
the presented studies on the eectiveness of the
aforementioned methods, statistically signicant
dierences regarding the values of FEV1, FVC and
mass of sputum expectorated were noted, where PEP
and OPEP produced better outcomes [6,21,24,25].
The application of various research procedures by
dierent authors, e.g. comparing PEP and OPEP with
various therapeutic methods (a dierent method in
every study), and the application of dierent indices
to assess therapy eects bring about unquestionable
diculties in drawing unanimous conclusions on
measurable therapeutic eects of PEP and OPEP in
patients with cystic brosis. The studies also diered
in the length of observation periods, which lasted
from one week to one year. In one work, the number
of performed procedures was given instead of the
length of observation period [27]. The majority of
the examined groups had small populations.
Homogeneity of research groups is a signicant
criterion in the assessment of the eectiveness of
airway clearance techniques that is often neglected
in the research methodology and in the analysis
of results. Due to a progressive character of cystic
brosis, the research should include groups of
patients at similar stages of the disease. Changes in
lungs and bronchi in patients with cystic brosis at
an advanced stage are so big that physiotherapy is
less eective. These patients should not be included
in the same study as patients with less advanced
changes in lungs. For instance, in her study, Orlik
suggested that while assessing the eectiveness
of physiotherapeutic methods, patients with the
diagnosed bronchial hyperresponsiveness should
be analysed separately [23]. An interesting solution
concerning the methodology of assigning patients
to groups was put forward by McIlwaine et al.
Patients were paired on the basis of similar values of
FEV1%N taking into account 15% dierence [20].
While analysing patients with cystic brosis, it
is important to take into consideration an individual
Advances in Rehabilitation/Postępy Rehabilitacji (1), 39 – 45, 2018 43
reaction of a patient to a particular drainage
technique. An individual reaction depends to
a large extent on motivation and good knowledge
of the drainage technique application. Each of
the techniques can be adapted with regard to
the position in which drainage is performed,
number of cycles, duration of drainage, number
of expirations in a cycle, length of expirations and
length of intervals between cycles. Moreover, high
awareness of parents or adult patients concerning
the role of physiotherapy in treating cystic brosis
is signicant as it allows to control the progress
of a physiotherapeutic session. An interesting
and objective study assessing the cooperation of
a patient while applying the recommended drainage
techniques and performing all the physiotherapeutic
sessions per day was conducted by McIlwaine et
al. They used a questionnaire assessing to what
extent the patients followed the recommendations.
The patients who performed less than 80% of the
recommended sessions per month were excluded
from the study [20,25].
The application of oscillation aimed at making
mucus less thick and sticky, and helping to clear
the airways is a signicant issue in physiotherapy
of patients with cystic brosis. In this context,
the application of OPEP in everyday practice is
perceived as more eective than other airway
clearance techniques and physiotherapeutic
methods. In the aforementioned studies as well
as in other PubMed publications, the authors
obtained extremely dierent results regarding the
eectiveness and role of oscillation in clearing the
airways. Several authors indicated a favourable
inuence of oscillation by Flutter on lung function
in patients with cystic brosis compared to other
techniques of clearing the airways [28,29,30]. Other
authors did not note any inuence of Flutter therapy
on lung function [21,22,23,31]. There was also one
study which revealed that lung function in patients
with cystic brosis worsened after the application
of the therapy with the use of Flutter [20].
The reviews of Cochrane Database Syst. Rev.
published in 2014, 2015 and 2017 did not provide a
unanimous conclusion regarding higher eectiveness
of PEP and OPEP compared to other physiotherapy
techniques applied in the therapy of patients with
cystic brosis. Only McIlwaine et al. revealed that
in the studies in which the disease advancement was
a basic assessment criterion, a signicant decrease
in the frequency of exacerbations of bronchalveolar
symptoms was noted in patients applying PEP
compared to those using HFCWO (The Vest) [32].
Moreover, no evidence was found that one device
was better than the other [15, 32,33,].
Summary
Performing homogeneous, high-quality research
assessing physiotherapeutic techniques in patients
with cystic brosis is very dicult. Cystic brosis
is a disease with a very changeable clinical
progress with periods of stability and periods of
various-intensity exacerbations of bronchoalveolar
symptoms. Therefore, recruiting study participants
is very hard. Moreover, physiotherapy is a standard
way of treating patients so conducting a blind study
is impossible. This is the reason why short-term
and crossover studies are the dominating types of
studies assessing the eects of physiotherapy on
various indices in patients with cystic brosis. It has
to be highlighted that in the case of cystic brosis,
which is regarded as a rare disease, carrying out
high-quality studies will be often connected with the
fact that the number of participants is insucient to
draw any statistical conclusions.
In the light of the fact that there are many airway
clearance techniques and similar research results
regarding their eectiveness, the question arises
about preferable criteria of selecting a particular
technique for a patient with cystic brosis. More
and more attention is drawn to the fact that factors
other than eectiveness should be taken into account
while selecting a technique. The signicance of
patients’ independence in performing the procedures
and following the rules of physiotherapy as well
as patients’ preferences regarding the applied
techniques are more and more often stressed.
The preferences may be connected with lifestyle,
patients’ beliefs concerning the best eectiveness or
easy application of a given technique, or possibilities
to shorten the duration of a physiotherapy session.
In Poland, there are no current studies which would
assess the preferences of patients or the frequency
of applying particular drainage techniques. Such
multi-centre research was conducted in 2000 and the
results were published in Standardy Medyczne [34].
The research revealed that Flutter was applied by
44% of the patients over 18 years of age in Poland.
Taking into account my own experience as well as
the diversity and easier availability of devices on
44 Teresa Orlik, Anna Wyka-Wojeńska
the Polish market compared to PEP devices, we
may conclude that currently, the number of Polish
patients using OPEP is higher. The British research
revealed that the frequency of using particular
airway clearing techniques diers signicantly
depending on a country and ranges from 6% to 23%
in the case of OPEP and from 10% to 40% in the
case of PEP [35].
While selecting a particular drainage device,
a nancial aspect is also very important. The costs
of PEP and OPEP devices are comparable and
range from 200 PLN to 500 PLN, while the Polish
National Health Service refunds 200 PLN once in
two years. Compared to the costs of The Vest, i.e. 32
000 PLN to 36 000 PLN, OPEP is more nancially
attractive for patients with cystic brosis.
OPEP is a method which enables patients to be
independent from their guardians. It takes less time
to achieve similar therapeutic eects than other
methods and is aordable. Despite contradictory
research results, it can be assumed that in the near
future, this method will dominate physiotherapy of
patients with cystic brosis in Poland.
References
1. Walkowiak J, Pogorzelski A, Sands D, Skorupa W, Milanowski A, Orlik T, et al. Zasady rozpoznawania i leczenia mukowi-
scydozy. Standardy Medyczne/pediatria 2009;3(6).
2. Pryor JA, Webber BA. Physiotherapy for cystic brosis – which technique? Physiotherapy 1992;78(2):105-8.
3. Pryor JA, Webber BA, Hodson ME. Eect of chest physiotherapy on oxygen saturation in patients with cystic brosis. Thorax
1990;45(1):77.
4. Reisman JJ, Rivington-Law B, Corey M, Marcotte J, Wannamaker E, Harcourt D, et al. Role of conventional physiotherapy in
cystic brosis. J Pediatr 1988; 113:632-6.
5. Orlik T. Współczesne techniki zjoterapii klatki piersiowej stosowane w leczeniu chorych na mukowiscydozę. Med Wieku
Roz 1997; 1(3):397-406.
6. Orlik T. Ocena efektywności wybranych metod zjoterapii klatki piersiowej stosowanej w leczeniu chorych na mukowiscy-
dozę. Med Wieku Roz 2000;4(3):233-46.
7. Orenstein SR, Whitngton PF. Positioning for prevention of infant gastroesophageal reux. J Pediatr 1983;103:534-7.
8. Vandenplast Y, Diericx A, Blecker U, Lanciers S, Deneyer M. Esophagel pH monitoring data during chest physiotherapy.
J Ped Gastroenterol Nutr 1991;13:23-6.
9. Button BM, Heine R, Catto-Smith A, Phelan P, Olinsky A. Postural drainage techniques and gastro-oesophageal reux in
infants with cystic brosis. Eur Resp J 1999; 14:1456.
10. Orlik T. Ocena metod autodrenażu w wybranej grupie chorych na mukowiscydozę z uwzględnieniem czynnika środowisko-
wego. Med Wieku Roz 2000; 4(3):247-59.
11. Falk M, Kelstrup M, Andersen JB, Kinoshita T, Falk P, Stovring S, et al. Improving the ketchup bottle method with positive
expiratory pressure, PEP, in cystic brosis. Eur J Respir Dis 1984;65(6):423-32.
12. Hofmeyr JL, Webber BA, Hodson M E. Ewaluation of positive expiratory pressure as an adjunct to chest physiotherapy in the
treatment of cystic brosis. Thorax 1986;41(12):951-4.
13. Andersen JB, Qvist J, Kann T. Recruiting collapsed lung through collateral channels with positive and expiratory pressure.
Scan J Res Dis 1979;60:260-6.
14. McIlwaine M. Physiotherapy and airway clearance techniques and devices. Pediatr Respir Rev 2006;7(suppl):220-2.
15. Morrison L, Agnew J. Oscillating devices for airway clearance in people with cystic brosis. Cochrane Database Syst 2014
doi: 10 1002/14651858 CD006842 pub3
16. Lannefors L, Wollmer P. Mucus clearance with three chest physiotherapy regimes in cystic brosis: a comparison between
postural drainage, PEP and physical exercise. Eur Respir J 1992;5(6):748-53.
17. Mortensen J, Falk M, Groth S, Jensen C. The eects of postural drainage and positive expiratory pressure physiotherapy on
tracheobronchial clearance in cystic brosis. Chest 1991;100(5):1350-57.
18. Darbee JC, Kanga JF, Ohtake PJ. Physiologic evidence for high frequency chest wall oscillation and positive airway clearance
technique in patients with cystic brosis. Phys Ther 2004;84(6):524-37.
19. McIlwaine PM, Wong LT, Peacok D, Davidson AG. Long-term comparative trial of conventional postural drainage and per-
cussion versus positive expiratory pressure physiotherapy in the treatment of cystic brosis. J Pediatr 1997;131(4):570-4.
20. Pryor JA, Webber BA, Hodson ME. The Flutter VRP1 as an adjunct to chest physiotherapy in cystic brosis. Respir Med
1994;88(9):677-81.
21. App EM, Kieselmann R, Reinhardt D, Lindemann H, Dasgupta B, King M, et al. Sputum rheology changes in cystic brosis
lung disease following two dierent types of physiotherapy: utter vs autogenic drainage. Chest 1998;114(1):171-7.
Advances in Rehabilitation/Postępy Rehabilitacji (1), 39 – 45, 2018 45
22. Konstan MW, Stern RC, Doershuk CF. Ecacy of the Flutter device for airway mucus clearance in patients with cystic bro-
sis. J Pediatr 1994;124(5):689-93.
23. Orlik T, Sands D. Długofalowa ocena skuteczności wybranych metod zjoterapii klatki piersiowej stosowanych w leczeniu
chorych na mukowiscydozę. Med Wieku Roz 2001;5(3): 245- 57.
24. Lagerkvist AL, Sten GM, Redfors SB, Lindblad AG, Hjalmarson O. Immediate changes in blood gas tensions during chest
physiotherapy pressure in patients with cystic brosis. Respir Care 2006;51(10):1154-61.
25. McIlwaine PM, Webber BA, Hodson ME. Long-term comparative trial of positive expiratory pressure versus oscillating po-
sitive expiratory pressure (utter) physiotherapy in the treatment of cystic brosis. J Pediatr 2001;138(6):845-50.
26. Van Winden CM, Visser A, Hop W, Sterk PJ, Becker S, de Jongste JC. Eects of utter and PEP mask physiotherapy on symp-
toms and lung function in children with cystic brosis. Eur Respir J 1998;12(1):143-7.
27. Borka P, Gyurkovits K, Bódis J. Comparative study of PEP mask and Flutter on expectoration in cystic brosis patients. Acta
Physiol Hung 2012 Sep;99(3):324-31. doi: 10.1556/APhysiol.99.2012.3.9.
28. Homnick DN, Anderson K, Marks JH. Comparison of the utter device to standard chest physiotherapy in hospitalized pa-
tients with cystic brosis: a pilot study. Chest 1998;114:993-7.
29. Newhouse PA, White F, Marks JH. The intrapulmonary percussive ventilator and utter device compared to standard chest
physiotherapy in patients with cystic brosis. Clin Pediatr 1998;37:427-32.
30. Gondor M, Nixon PA, Mutich R, Rebovich P, Orenstein DM. Comparison of Flutter device and chest physical therapy in the
treatment of cystic brosis pulmonary exacerbation. Pediatr Pulmo 1999;28:255-60.
31. Oermann CM, Sockrider MM, Gilles D, Sontag MK, Accurso FJ, Castile RG. Comparison of high-frequency chest wall
oscillation and oscillating positive expiratory pressure in the home management of cystic brosis: a pilot study. Pediatr Pulmo
2001;32:372-7.
32. McIlwaine M, Button B, Dwan K. Positive expiratory pressure physiotherapy for airway clearance in people with cystic bro-
sis. Cochrane Database Syst Rev 2015 Jun 17;(6):CD003147. doi: 10.1002/14651858.CD003147.pub4.
33. Morrison L, Innes S, Oscillating devices for airway clearance in people with cystic brosis. Cochrane Database Syst Rev 2017
May 4;5; doi: 10 1002/14651858 CD006842 pub4.
34. Orlik T, Milanowski A, Skorupa W, Kluba L, Korzeniewska A, Majka L i wsp. Długofalowy model postępowania zjoterapeu-
tycznego w mukowiscydozie. Standardy Medyczne 2003;10 (48):1306-1314.
35. Hoo ZH, Daniels T, Wildman M, Teare MD, Bradley JM. Airway clearance techniques used by people with cystic brosis in
the UK. Physiotherapy 2015;101(4):340-8. doi: 10.1016/j.physio.2015.01.008. Epub 2015 Mar 14.
ResearchGate has not been able to resolve any citations for this publication.
Article
Background: Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis. Oscillating devices generate intra- or extra-thoracic oscillations orally or external to the chest wall. Internally they create variable resistances within the airways, generating controlled oscillating positive pressure which mobilises mucus. Extra-thoracic oscillations are generated by forces outside the respiratory system, e.g. high frequency chest wall oscillation. This is an update of a previously published review. Objectives: To identify whether oscillatory devices, oral or chest wall, are effective for mucociliary clearance and whether they are equivalent or superior to other forms of airway clearance in the successful management of secretions in people with cystic fibrosis. Search methods: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. Latest search of the Cystic Fibrosis Trials Register: 27 April 2017.In addition we searched the trials databases ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. Latest search of trials databases: 26 April 2017. Selection criteria: Randomised controlled studies and controlled clinical studies of oscillating devices compared with any other form of physiotherapy in people with cystic fibrosis. Single-treatment interventions (therapy technique used only once in the comparison) were excluded. Data collection and analysis: Two authors independently applied the inclusion criteria to publications and assessed the quality of the included studies. Main results: The searches identified 76 studies (302 references); 35 studies (total of 1138 participants) met the inclusion criteria. Studies varied in duration from up to one week to one year; 20 of the studies were cross-over in design. The studies also varied in type of intervention and the outcomes measured, data were not published in sufficient detail in most of these studies, so meta-analysis was limited. Few studies were considered to have a low risk of bias in any domain. It is not possible to blind participants and clinicians to physiotherapy interventions, but 11 studies did blind the outcome assessors.Forced expiratory volume in one second was the most frequently measured outcome. One long-term study (seven months) compared oscillatory devices with either conventional physiotherapy or breathing techniques and found statistically significant differences in some lung function parameters in favour of oscillating devices. One study identified an increase in frequency of exacerbations requiring antibiotics whilst using high frequency chest wall oscillation when compared to positive expiratory pressure. There were some small but significant changes in secondary outcome variables such as sputum volume or weight, but not wholly in favour of oscillating devices. Participant satisfaction was reported in 15 studies but this was not specifically in favour of an oscillating device, as some participants preferred breathing techniques or techniques used prior to the study interventions. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high level evidence. Authors' conclusions: There was no clear evidence that oscillation was a more or less effective intervention overall than other forms of physiotherapy; furthermore there was no evidence that one device is superior to another. The findings from one study showing an increase in frequency of exacerbations requiring antibiotics whilst using an oscillating device compared to positive expiratory pressure may have significant resource implications. More adequately-powered long-term randomised controlled trials are necessary and outcomes measured should include frequency of exacerbations, individual preference, adherence to therapy and general satisfaction with treatment. Increased adherence to therapy may then lead to improvements in other parameters, such as exercise tolerance and respiratory function. Additional evidence is needed to evaluate whether oscillating devices combined with other forms of airway clearance is efficacious in people with cystic fibrosis.There may also be a requirement to consider the cost implication of devices over other forms of equally advantageous airway clearance techniques. Using the GRADE method to assess the quality of the evidence, we judged this to be low or very low quality, which suggests that further research is very likely to have an impact on confidence in any estimate of effect generated by future interventions.
Article
Background: Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis. Positive expiratory pressure (PEP) devices provide back pressure to the airways during expiration. This may improve clearance by building up gas behind mucus via collateral ventilation and by temporarily increasing functional residual capacity. Given the widespread use of PEP devices, there is a need to determine the evidence for their effect. This is an update of a previously published review. Objectives: To determine the effectiveness and acceptability of PEP devices compared to other forms of physiotherapy as a means of improving mucus clearance and other outcomes in people with cystic fibrosis. Search methods: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. The electronic database CINAHL was also searched from 1982 to 2013.Most recent search of the Group's Cystic Fibrosis Trial Register: 02 December 2014. Selection criteria: Randomised controlled studies in which PEP was compared with any other form of physiotherapy in people with cystic fibrosis. This included, postural drainage and percussion, active cycle of breathing techniques, oscillating PEP devices, thoracic oscillating devices, bilevel positive airway pressure (BiPaP) and exercise. Studies also had to include one or more of the following outcomes: change in forced expiratory volume in one second; number of respiratory exacerbations; a direct measure of mucus clearance; weight of expectorated secretions; other pulmonary function parameters; a measure of exercise tolerance; ventilation scans; cost of intervention; and adherence to treatment. Data collection and analysis: Three authors independently applied the inclusion and exclusion criteria to publications and assessed the risk of bias of the included studies. Main results: A total of 26 studies (involving 733 participants) were included in the review. Eighteen studies involving 296 participants were cross-over in design. Data were not published in sufficient detail in most of these studies to perform any meta-analysis. These studies compared PEP to active cycle of breathing techniques (ACBT), autogenic drainage (AD), oral oscillating PEP devices, high frequency chest wall oscillation (HFCWO) and Bi level PEP devices (BiPaP) and exercise.Forced expiratory volume in one second was the review's primary outcome and the most frequently reported outcome in the studies. Single interventions or series of treatments that continued for up to three months demonstrated no significant difference in effect between PEP and other methods of airway clearance on this outcome. However, long-term studies had equivocal or conflicting results regarding the effect on this outcome. A second primary outcome was the number of respiratory exacerbations. There was a lower exacerbation rate in participants using PEP compared to other techniques when used with a mask for at least one year. Participant preference was reported in 10 studies; and in all studies with an intervention period of at least one month, this was in favour of PEP. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high-level evidence. The only reported adverse event was in a study where infants performing either PEP or postural drainage with percussion experienced some gastro-oesophageal reflux. This was more severe in the postural drainage with percussion group. Many studies had a risk of bias as they did not report how the randomisation sequence was either generated or concealed. Most studies reported the number of dropouts and also reported on all planned outcome measures. Authors' conclusions: Following meta-analyses of the effects of PEP versus other airway clearance techniques on lung function and patient preference, this Cochrane review demonstrated that there was a significant reduction in pulmonary exacerbations in people using PEP compared to those using HFCWO in the study where exacerbation rate was a primary outcome measure. It is important to note, however, that there may be individual preferences with respect to airway clearance techniques and that each patient needs to be considered individually for the selection of their optimal treatment regimen in the short and long term, throughout life, as circumstances including developmental stages, pulmonary symptoms and lung function change over time. This also applies as conditions vary between baseline function and pulmonary exacerbations.However, meta-analysis in this Cochrane review has shown a significant reduction in pulmonary exacerbations in people using PEP in the few studies where exacerbation rate was a primary outcome measure.
Article
To describe the current use of airway clearance techniques among people with cystic fibrosis (CF) in the UK, and the baseline characteristics for users of different airway clearance techniques. Analysis of the UK CF Registry 2011 data. All people with CF in the UK aged ≥11 years (n=6372). Of the 6372 people on the UK CF registry in 2011, 89% used airway clearance techniques. The most commonly used primary techniques were forced expiratory techniques (28%) and oscillating positive expiratory pressure (PEP) (23%). Postural drainage and high-frequency chest wall oscillation were used by 4% and 1% of people with CF, respectively. The male:female ratio of individuals who used exercise as their primary airway clearance technique was 2:1, compared with 1:1 for other techniques. Individuals with more severe lung disease tended to use devices such as non-invasive ventilation or high-frequency chest wall oscillation. Forced expiratory techniques and oscillating PEP are the most common airway clearance techniques used by people with CF in the UK, and postural drainage and high-frequency chest wall oscillation are the least common techniques. This is significant in terms of planning airway clearance technique trials, where postural drainage has been used traditionally as the comparator. The use of airway clearance techniques varies between countries, but the reasons for these differences are unknown. Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.
Article
The objective of the study was to investigate the effect of positive expiratory pressure (PEP) and Flutter on expectoration in cystic fibrosis (CF) patients. Data was gathered through 260 treatments with 10 patients (5 female; 19.2 years; BMI: 18.0). Two methods were used alternately, first the patients started with Flutter and proceeded with PEP, and the next occasion they exercised in the reverse order, starting with PEP then continuing with Flutter. During each phase, 5 sets of 10 exhalations were performed. Sputum weight was measured after the use of the first device, and at the end of the treatment. During sessions starting with Flutter 4.0 ± 4.0 g sputum was expectorated, continuing with PEP, an additional 5.2 ± 5.0 g was produced, altogether 9.2 ± 8.2 g. At sessions starting with PEP 7.4 ± 3.7 g was expectorated, continuing with Flutter an additional 0.8 ± 1.4 g, that is 8.2 ± 4.1 g. Comparing the two devices by themselves, PEP proved to be significantly more efficient then Flutter. Comparing the two treatment types it is statistically not proven, which one is preferable using both devices. Conclusively, PEP is significantly more efficient than the Flutter in sputum expectoration among CF patients. The Flutter is a useful supplementary device.
Article
Different physiotherapy techniques have developed for airway clearance, but are all these techniques effective and efficient?
Article
Background: Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis. Oscillating devices generate intra- or extra-thoracic oscillations orally or external to the chest wall. Internally they create variable resistances within the airways, generating controlled oscillating positive pressure which mobilises mucus. Extra-thoracic oscillations are generated by forces outside the respiratory system, e.g. high frequency chest wall oscillation. Objectives: To identify whether oscillatory devices, oral or chest wall, are effective for mucociliary clearance and whether they are equivalent or superior to other forms of airway clearance in the successful management of secretions in people with cystic fibrosis. Search methods: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. Latest search of the Cystic Fibrosis Trials Register: 13 January 2014. Selection criteria: Randomised controlled studies and controlled clinical studies of oscillating devices compared with any other form of physiotherapy in people with cystic fibrosis. Single-treatment interventions (therapy technique used only once in the comparison) were excluded. Data collection and analysis: Two authors independently applied the inclusion criteria to publications and assessed the quality of the included studies. Main results: The searches identified 68 studies with a total of 288 references; 35 studies (total of 1050 participants) met the inclusion criteria. Studies varied in duration from up to one week to one year; 20 of the studies were cross-over in design. The studies also varied in type of intervention and the outcomes measured, furthermore data were not published in sufficient detail in most of these studies, so meta-analysis was limited. Few studies were considered to have a low risk of bias in any domain. It is not possible to blind participants and clinicians to physiotherapy interventions, but 10 studies did blind the outcome assessors.Forced expiratory volume in one second was the most frequently measured outcome. One long-term study (seven months) compared oscillatory devices with either conventional physiotherapy or breathing techniques and found statistically significant differences in some lung function parameters in favour of oscillating devices. One study identified an increase in frequency of exacerbations requiring antibiotics whilst using high frequency chest wall oscillation when compared to positive expiratory pressure. There were some small but significant changes in secondary outcome variables such as sputum volume or weight, but not wholly in favour of oscillating devices. Participant satisfaction was reported in 15 studies but this was not specifically in favour of an oscillating device, as some participants preferred breathing techniques or techniques used prior to the study interventions. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high level evidence. Authors' conclusions: There was no clear evidence that oscillation was a more or less effective intervention overall than other forms of physiotherapy; furthermore there was no evidence that one device is superior to another. The findings from one study showing an increase in frequency of exacerbations requiring antibiotics whilst using an oscillating device compared to positive expiratory pressure may have significant resource implications. More adequately-powered long-term randomised controlled trials are necessary and outcomes measured should include frequency of exacerbations, patient preference, adherence to therapy and general satisfaction with treatment. Increased adherence to therapy may then lead to improvements in other parameters, such as exercise tolerance and respiratory function. Additional evidence is needed to evaluate whether oscillating devices combined with other forms of airway clearance is efficacious in people with cystic fibrosis.
Article
We studied reinflation of collapsed parts in excised normal human lungs through both the ordinary bronchial route and through collateral channels. A model of atelectasis was made either by simple collapse or by applying a positive pressure to the pleura and a negative to the airway. Five different ventilatory patterns were used for reinflation: simulated normal breathing with and without continuous positive airway pressure (CPAP), simulated deep breathing and mechanical ventilation with and without positive end-expiratory pressure (PEEP). All methods, except normal breathing without CPAP, reinflated the collapsed part with pressures well within the range used clinically. The most effective way of re-expanding collapsed lung was the application of CPAP during simulated normal breathing or PEEP during mechanical ventilation, which required smaller transpulmonary pressure swings than the other methods. A comparison between CPAP and PEEP showed CPAP to be preferable. Collateral reinflation occurred just as readily as normal reinflation and the results suggest that collateral reinflation is the primary choice. This route of reexpansion also has a potential secretion clearing effect in that pressure is built up distal to an obstruction.
Article
The effects of three different regimes of chest physiotherapy were compared in this cross-over study. Mucus clearance was monitored in nine clinically stable cystic fibrosis (CF) patients. The patients performed: 1) postural drainage with thoracic expansion exercises + forced expiration technique (FET) in the left decubitus position; 2) positive expiratory pressure (PEP)-mask breathing + FET; and 3) physical exercise on a bicycle ergometer + FET. All treatments had the same duration and FET was standardized. Mucus clearance was assessed using a technique based on measurement of the elimination of inhaled radiolabelled particles. Mean clearance of tracer from the right lung by postural drainage, PEP and physical exercise was 18% (range 10-29%), 20% (12-43%), 16% (8-25%), respectively, and from the left lung 20% (8-42%), 15% (5-23%) and 13% (5-17%), respectively. The differences were not statistically significant. Surprisingly, postural drainage (PD) was the most effective technique in the left, dependent lung in 7 of the 9 patients.