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Positive Expiratory Pressure Therapy

a form of bronchial hygiene

one of the 3 adjuncts of positive airway pressure (PEP, CPAP, and EPAP).

involves active expiration through a one-way valve against a variable flow


In modern PEP devices, flow resistance can be manipulated to adjust for a

desired pressure.

Enhances secretion mobilization and removal

Helps prevent infections

Helps mitigate atelectasis

Improved pulmonary mechanics and gas exchange

Filling under-inflated or collapsed alveoli via collateral ventilation

Helping to stint the airways open during expiration.

A subsequent huff or FET maneuver allows the patient to generate the flows
needed to expel mucus from blocked airways

Advantages: self-administered, cost effective

Disadvantage: cannot be used among children <3 years old

During acute exacerbations, therapy should be performed at decreased intervals

Aerosol drug therapy may be added to PEP therapy through an in-line hand-held
nebulizer or MDI

PEP is achieved by having the patient exhale through a mask or mouthpiece with
a resistance valve which creates a back pressure into the patients airway.

Resistors are used to adjust the level of PEP

PEP levels of 10 to 20 cmH2O are used

If pressure being used appears to be ineffective, PEP levels may be increased to

3-5 cmH2O

Prevents expiratory airway collapse and aids in the mobilization of secretions

Airway Oscillation Devices (AOD)

o Provide standard PEP with the added benefit of oscillating
pressure within the airway

o Oscillations reduce the viscoelasticity of mucus

o Oscillations provide short bursts of increased expiratory

airflow to help with secretion mobilization

Flutter Valve



High Frequency Oscillation


-refers to the vibratory movement of small volumes of air back and forth the
respiratory tract

-act as physical mucolytic at high frequencies (12 to 25 Hz)

1. Chestwall application

2. Airway application -flutter valve and intrapulmonary percussive


High Frequency Chest Wall Oscillation

Small gas volumes are alternately injected into and withdrawn from the vest
by air-pulse generator at a fast-rate creating an oscillatory motion against the
patients thorax

Frequencies between 5 Hz to 25 Hz

Flutter Valve

Pipe-shaped AOD with a steel ball resting in an angled bowl.

On exhalation, the ball oscillates at approximately 15 Hz, and
provides 10-25 cm H20.
Gravity dependent
Combines techniques of EPAP with high-frequency oscillation at the
airway opening
When the patient exhales, into the pipe, the ball creates a positive
expiratory pressure between 10 to 25 cmH2O
The pipe angle causes the ball to flutter back and forth at about 15
Intrapulmonary Percussive Ventilation

Uses a pneumatic device to deliver a series of pressurized gas

minibursts at rates of 100 to 225 cycles per minute (1.6 to 3.75 Hz)

Duration of percussive cycle is manually controlled by the patient

May incorporate pneumatic nebulization

Well tolerated by stable patients


o Similar to the flutter valve but with greater functionality (AOD)

o Utilizes a counterweighted plug and magnet to achieve valve

closure (not gravity dependent)

o 3 Models:

Low flow ( < 15 L/min, adjustable resistance)

High flow ( > 15 L/min, adjustable resistance)

Choice (any flow, adjustable frequency)

ADVANTAGE: Frequency and flow resistance may be

adjusted; may be used in any posture

Cabaron, Mary Gwen Frosi

Petalcorin, Marie Fraulein