Enhance Aerosol Therapy
with Positive Expiratory Pressure (PEP) Therapy
Aerosol therapy, normally administered to open the airways and/or relieve congestion, may be enhanced with positive expiratory pressure. Expiratory resistance mimics pursed lip breathing which helps to keep the airways open during exhalation to mobilize mucus towards the larger airways for easier expectoration. And, the Breather's inspiratory resistance creates a low-flow, sustained, maximal inspiration, commonly referred to as Incentive Spirometry. This slow inspiration also enhances medication deposition. Inspiratory resistance also strengthens the diaphragm and helps the patient to better understand and practice diaphragmatic breathing.
1. Connect the Breather to a nebulizer as illustrated.
2. Set inhalation resistance to #1 and exhalation resistance to setting #1.
3. Instruct the patient to inhale slowly and deeply focusing on expanding the stomach; pause approximately 1 second, then exhale with enough force in order to feel the stomach muscles contract. Note A: The patient should maintain a tight seal with lips around the mouth piece. Note B: If the patient is also practicing resistive breathing training and is on more intense levels of resistances, please remember to decrease resistances to the number one settings to prevent fatigue during treatment.
4. Instruct the patient in the less tiring "huff cough" maneuver. Note A: A huff cough is a slow, deep breath in, then a flap of the arms up and down as the patient exhales 2 to 3 smaller bursts of air creating a huffing sound. This is demonstrated on the new "Patient Instructional DVD." Note B: Some patients may become too fatigued to complete an entire treatment with PEP therapy; therefore, simply remove the Breather and continue the aerosol treatment for a few minutes. Then reattach the Breather for a few minutes. Continue taking the Breather on and off until all the medication is gone. Note C: Often a patient requires only 1 to 2 PEP therapy treatments per day (morning and evening), in order to relieve congestion.
Note: The Breather may not be adaptable for all nebulizers. Simply administer the treatment; then instruct the patient in the use of the Breather for 1 to 3 minutes before performing 2 to 3 "huff cough" maneuvers as in step 4 above. Continue to encourage the patient to use the Breather in 1 to 3 minute intervals until mucus is expectorated, allowing adequate time for huff coughing between use of the Breather.
For enhanced aerosol therapy with PEP, one of the following suggested criteria should be met:
1. acute obstructive airway disease
2. COPD characterized by air flow obstruction
3. pneumonia / congestion / atelectasis
4. post-op abnominal surgery / poor expiratory air flow following thoracic surgery
5. respiratory distress with poor air flow
Possible contraindications and special considerations: Although no absolute contraindications to the use of PEP therapy have been reported, the following should be carefully evaluated before the initiation of therapy: active hemoptysis, untreated pneumothorax, esophageal surgery, intracranial pressure > 20 mm Hg, recent facial, oral, or skull surgery or trauma, acute sinusitis, epistaxis, hemodynamic instability, bolus emphysema, extreme nausea, and suspected tympanic membrane rupture or other middle ear pathology.
Medical documentation supporting PEP Therapy: "Positive-expiratory-pressure (PEP) therapy is a bronchial hygiene technique that may serve as an effective alternative to CPT (chest-physiotherapy) in mobilizing secretions. Developed in Denmark in the late 1970s, PEP therapy is more effective than incentive spirometry and intermittent positive-pressure breathing (IPPB) in the management of postoperative atelectasis, and as an adjunct to enhance the befefits of aerosol bronchodilator delivery." - M. Mahlmeister, et al., Respiratory Care, 1991; Vol 36(11)1218-1229. (Please click on medical abstracts for more documentation.)
