Download Positive Expiratory Pressure (PEP)

Positive Expiratory Pressure (PEP), Acapella and Flutter Guidelines for Practice
Version: This replaces the PEP, Acapella and Flutter guideline for practice, March 2015
Review Date: September 2018
Contact: Sarah Millward, Senior Physiotherapist or Fiona Haynes Clinical Specialist
Physiotherapist / Ext: 75022
Disclaimer
This guideline has been registered with the Nottingham University Hospitals Trust. However,
clinical guidelines are guidelines only. The interpretation and application of clinical
guidelines will remain the responsibility of the individual clinician. If in any doubt regarding
this procedure, contact a senior colleague. Caution is advised when using guidelines after
the review date. Please contact the named above with any comments / feedback.
Introduction/Indications for Use
This guideline describes the use of the small hand held devices that have the resistive
features of Positive Expiratory Pressure (PEP) and or the vibratory features of a flutter
valve. A resistive pressure device works by using a pressurised breath to splint open the
airways. Vibratory pressure devices work by using oscillating vibrations that travel to the
lungs, shaking mucus that the patient can then expectorate. These devices are indicated to
mobilise retained secretions, prevent or reverse atelectasis. For example in patients with
Cystic fibrosis, Bronchiectasis and Pneumonia
Precautions/Contraindications
There are no absolute contraindications to the use of PEP, Flutter or Acapella.
However, the following are precautions to consider before the commencement of therapy:
- Patient tolerance of increased work of breathing
- Intracranial pressure >20mmHg
- Haemodynamic instability
- Recent facial, oral, or skull surgery or trauma
- Acute sinusitis
- Epistaxis (nose bleeding)
- Oesophageal surgery
- Active Haemoptysis
- Nausea
- Known or suspected tympanic membrane rupture or other middle ear pathology
- Untreated pneumothorax
Best Practice Points
Consider PEP or an oscillating PEP device when recommending an airway clearance
technique for adults with Cystic Fibrosis or for patients with non-cystic fibrosis related
bronchiectasis
PEP/Acapella/Flutter Clinical Guidelines 2015
Acapella Procedure
Action
Explain the device to the patient and gain
consent
Select the appropriate device for the
patient
Position the patient to optimise secretion
clearance
On first use ensure that the resistance
dial is turned counter clockwise to the
lowest resistance setting
Instruct the patient to place the
mouthpiece lightly in the mouth;
maintaining a tight seal on the
mouthpiece during inspiration. A nose
clip can be used if necessary
Instruct the patient to relax and perform
diaphragmatic breathing. The patient
should be instructed to inspire slightly
deeper than normal but not take a full
deep breath in
Instruct the patient to hold their breath
for 2-3 seconds
Ask the patient to exhale actively but not
forcibly or fully through the acapella
device
Encourage an active exhalation for 3-4
seconds while the acapella vibrates
If the patient cannot maintain exhalation
for this length of time adjust the dial
clockwise
Adjust the dial so that the patient feels
the ‘optimal’ vibratory pressure
Perform 10-12 breaths in this manner
Ask the patient to perform 2-3 ‘huffs’ this
may be performed through the device to
assist mobilization of secretions
Repeat as necessary
Document treatment session
PEP/Acapella/Flutter Clinical Guidelines 2015
Rationale
Educates the patient and achieves patient
consent for treatment
The Green acapella is for patients
able to maintain an expiratory flow of
15 Litres Per Minute or greater for 3 seconds
(suitable for most patients)
The blue acapella is for patients
not capable of 15 Litres Per Minute for 3
seconds
The acapella can be used in any position
including postural drainage positions (see
Gravity Assisted positioning guidelines)
Selecting the correct resistance range produces
the desired I:E ratio of 1:3 to 1:4
To provide a seal around the acapella device
and encourage the patient to mouth breath
To develop a relaxed diaphragmatic breathing
pattern, utilise collateral ventilation
To optimize airflow through the collateral
channels
The expiration should be active but not forced
and the patient should not exhale to functional
residual capacity (FRC)
To optimize the vibratory effects of the acapella
to assist secretion clearance
Clockwise adjustment increases the resistance
of the vibrating orifice, which will allow the
patient to exhale at a lower flow rate
To achieve to maximal effect
To mobilise secretions
To enable the expectoration of any secretions
that have been mobilised
To optimize secretion clearance
Legal requirement
Cleaning of the Acapella
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Clean the device after each use to remove moisture and mucus
Disassemble and rinse the components with water, wipe and air dry before reassembling., store in a clean dry location.
Every 2 days disassemble and clean the equipment in a solution of mild soap or
detergent, do not use products that contain chlorine bleach
Flutter Procedure
Action
Explain the device to the patient and gain
consent to treat
Sit the patient in a chair so that their back is
straight and their head slightly tilted up. Or
have the patient seated with their elbows
resting on a table at a comfortable level and
head tilted slightly upwards
Ask the patient to hold the flutter so that the
stem is horizontal to the floor, placing the
cone at a slight tilt
The angle of the flutter device should then be
adjusted by moving the flutter up or down to
achieve the maximum fluttering effect in the
airways
Place one hand on the patients back and the
other on the patients chest
The patient should be asked maintain the
angle of the device to achieve maximum effect
To mobilize and loosen secretions ask the
patient to inhale to ¾ of a full breath and then
place the flutter in the mouth with their lips
firmly around the stem, positioning the flutter
at the optimal angle and perform a 3 second
breath hold
Instruct the patient to exhale through the
flutter at a reasonably fast rate but not too
forcefully, keeping the cheeks stiff &
suppressing the urge to cough. If the patient
is unable to keep their cheeks stiff a mirror
may provide visual in-put to assist this, or use
one hand to stabilize the cheeks.
The patient should repeat 5-10 breaths
through the flutter
PEP/Acapella/Flutter Clinical Guidelines 2015
Rationale
Educates the patient and achieves patient
consent for treatment
So that the upper airway is open and the
air can flow freely from the lungs and out
through the flutter
This tilt ensures that the ball not only
bounces but also rolls during exhalation
The combined rolling and bouncing of the
ball produces the vibrations that dislodges
the mucus
The vibrations should be palpable through
the lungs and this determines that the
patient has achieved the fluttering effect
The patient has now established a
comfortable position and selected the
proper tilt of the flutter device to begin
therapy
This allows the inhaled air to be evenly
distributed throughout the lungs
This should produce vibrations through the
patients airways and not allow the
vibrations to be wasted in the patients
cheeks
To loosen as much mucus as possible. The
mucus moves further up the airways with
each exhalation
To assist mucus elimination the patient should
perform 1 or 2 additional breaths through the
flutter as previous but. This time the breath
should be exhaled forcefully through the
flutter as completely as possible
Repeat until no more mucus can be cleared
Document treatment and outcome
The forceful exhalation moves the mucus
to a level where it can be expectorated
To clear the lungs of secretions
Legal requirement
Cleaning the Flutter
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The flutter is single patient use
It should be cleaned after each use to remove moisture/mucus
Disassemble and rinse all the components in water, wipe with a clean towel and air
dry before reassembling and storing in a clean dry location
Every two days the flutter should be disassembled and cleaned in a solution of mild
soap or detergent
Bleach and other chlorine - containing products should not be used
Once a month the device should be boiled to clean it, as per manufacturers
instructions
Troubleshooting
Problems
No oscillation felt
Reasons
Poor technique
Cheeks wobbling
Flow rate to fast/ slow
Low flow on expiration
Ball sticking in Flutter/
magnet sticking in Acapella
Solutions
Hold device in teeth and reteach
Hold cheeks with hand
Flutter angle not effective
Experiment with breathing
pattern
Alter Flutter angle
Closing glottis
Keep Glottis open
Bronchospasm / airway
collapse
Trying too hard / breathing
out too far
Practice relaxed breathing
Glottis closing
Condensation
Keep Glottis open
Ensure device is cleaned
after each use and left
dismantled to allow to dry
completely
PEP/Acapella/Flutter Clinical Guidelines 2015
Use tissue to practice
breathing technique
PEP Procedure
Action
Explain the device to the patient and gain
consent
Position the patient so that they are sitting
with their elbows resting on a table
Allow the patient to breathe through the PEP
mask without any resistance
Ask them to breathe through the mask with
each of the resistors from the largest to the
smallest
Allow the patient at least 30 seconds with
each resistor. The smallest diameter resistor
which the patient can use effortlessly for 2
minutes is the correct one
Choose the correct resistor by watching the
pressures achieved on the manometer
Do not allow the patient to see the
manometer during this test period
Chose the correct resistor and then show the
patient the manometer
Ask the patient to perform 8-12 breaths
through the mask with a slightly active
expiration
Remove the mask for huffing and breathing
control
Rationale
Educates the patient and achieves patient
consent for treatment
This allows the patient to hold the mask
tightly over their face and create a tight seal
To become comfortable & familiar with its
use
To establish the correct resistance for the
patient
To establish a smooth, steady breathing
pattern
A pressure of 10-20cmH20 should be
achieved at mid expiration to optimize PEP
Most people will alter their breathing pattern
to reach the required pressures with all the
resistors
Showing the patient the manometer may
now help them to achieve a smooth, steady
breathing pattern. Once established the
patient may not need the manometer to
perform the treatment
To mobilise secretions
To expectorate secretions and allow relaxed
breathing in between PEP breaths
Continue until the patients chest is clear or
they fatigue
To loosen as much mucus as possible. The
mucus moves further up the airways with
each exhalation
Document treatment and outcome
Legal requirement
Troubleshooting
Problems
No secretions heard
Incorrect pressure
Mask not sealing
Reasons
Trying too hard
Solutions
Practice relaxed breathing
Flow rate too fast
Try with large resistor on
inspiratory valve to slow
insp. flow rate down
Practice relaxed breathing
Use manometer to monitor
pressure (10-20cms H2)
Try mouthpiece and nose clip
Chang to new mask regularly
Flow rate too slow
Trying too hard
Flow rate too fast
Flow rate too slow
Wrong size
Damaged mask
PEP/Acapella/Flutter Clinical Guidelines 2015
Poor cleaning
Cuff not sufficiently inflated
Inflate rubber seal of mask
Poor contact between mask
and face
Several parts to disconnect
and re-assemble
Check leaning into mask
when using
Ensure clear instructions are
given for cleaning and drying
Cleaning the PEP Mask
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It should be cleaned after each use to remove moisture/mucus
Disassemble and rinse all the components in water, wipe with a clean towel,
reassemble and store in a clean dry location
Every two days the PEP components should be disassembled and cleaned in a
solution of mild soap or detergent
Bleach and other chlorine -containing products should not be used
Once a month the device should be boiled to clean it, as per manufacturers
instruction
References
Association of chartered Physiotherapists in CF (2007) Practical Guidelines for Cystic
Fibrosis Care
Bott J et al (2009)Guidelines for the physiotherapy management of the adult, medical,
spontaneously breathing patient. Thorax 64: (Suppl 1)ii-i151
Hough, A. (2001) Physiotherapy in Respiratory Care, Nelson Thornes, UK
Mullen, A (June 2009) Using the Acapella Coice, National Jewish health, Denver US
PEP/Acapella/Flutter Clinical Guidelines 2015