Positive Expiratory Pressure (PEP) therapy, developed in the 1980s, involves using devices that provide either low or high pressure (10-20cm H2O or 50-120cm H2O) to facilitate airway clearance and improve lung function in patients with conditions like cystic fibrosis and COPD. PEP operates through mechanisms such as oscillation and positive pressure to mobilize secretions and prevent postoperative atelectasis. Various devices, including flutter, r-c cornet, and acapella, are utilized to deliver PEP therapy tailored to individual patient needs.

1. Positive expiratory pressure
• The development of the positive expiratory
pressure (PEP) breathing came abou 1980s in
Denmark.
• Several devices deliver PEP in either oscillatory or
smooth flow method.
• Positive expiratory pressure includes one way
breathing valve and an adjustable level of
expiratory resistance that create back pressure to
stent the airways opening during exhalation.

2. • PEP therapy involves active expiration against
a fixed orifice flow resistor or variable orifice
threshold resistor capable of developing
pressure of 10-20cm H2O.
• A patient uses PEP in cycle of about 10
breaths at tidal volume with slightly active
expiration followed huffing and coughing.

3. Theory
• PEP breathing reinflates collapsed alveoli by
allowing air to be redistributed through
collateral channels- the pores of Kohn, and the
Lambert canals- allowing pressure to build up
distal to the obstruction and promoting the
movement of secretion toward the larger
airways.

4. Low pressure PEP
• The resistance is regulated to achieve 10-
20cm H2O during slightly active expiration.
• The appropriate resistor provide a flow
volume curve, demonstrating a maximal
forced vital capacity, good plateau and no
curvilinearity.

5. High pressure PEP
• It use the same principle but at much higher
levels of pressure (50-120cm H2O).
• Inspiration is performed to total lung capacity,
followed by a forced expiratory maneuver against
the PEP mask, which is connected to the
spirometer.
• The equipment consist of ventilation mask, one
way valve and various resistor.

7. • Spirometery is used to determine the
appropriate resistance for each individual
patients.
• 1 ½mm resistor:- infants
• 2 ½ to 3mm:- older children
• 3 ½mm:- adults

8. Indications of positive expiratory
pressure
• Improve airway clearance
• Cystic fibrosis
• Bronchiectasis
• COPD
• Acute and chronic respiratory failure
• Improve lung function
• Post operative atelectasis

9. Contraindication of positive expiratory
pressure
• Untreated pneumothorax
• Acute hemoptysis
• Recent trauma or surgery
• Acute sinuitis or epistaxis
• Increased intracranial pressure

10. Uses of PEP
• Improve ventilation and gas exchange
• Help in airway clearance
• Prevent post operative atelectasis
• Reduce pulmonary hyperinflation

11. TheraPEP
• It consist of mouth piece expiratory resistor that
can accommodate many levels of expiratory
flow.
• It come with a detachable pressure monitoring
part and indicator to show 10-20cm H2O.
• It can accommodate mask of different sizes.

13. Uses of TheraPEP
• mobilize secretions
• chronic respiratory diseases
• Cystic Fibrosis (CF),
• prevent atelectasis,
• Post operative patients

14. Bubble PEP
• A system that incorporates a column of water ( to
the level of PEP required:- 10-12cm H2O ) and
asking the child to blow through the column of
water via flexible straw or tubing.
• Adding a little liquid detergent to the water, on
exhalation produce stream of bubbles.
• It is important that the child is instructed to only
exhale through the tubing and never inhale.

16. Oscillating PEP
• It provide rapid fluctuation in airway as the
patient exhales.
• The frequency of the vibration range from 10-
30Hz with amplitude ranging from 20 to 100 torr
at flow of 10-25L/min.
• It provide positive expiratory pressure, oscillation
of the airway and accelerated expiratory flow rate
to loose secretion and move secretion centrally.

18. • Patient must be able to take deep breath (>10-
12 mL/kg) to generate adequate pressure,
oscillation and prolonged exhalation.
• Commonly used devices:-
1. Flutter
2. R-C cornet
3. Acapella

19. Flutter

20. • This is a pipe like device consist of a steel ball, a
plastic cone , a perforated cover and a mouth
piece.
• Exhaled air cause the steel ball to roll up and
down the cone causing airflow vibration.
• The PEP maintained by the flutter (5-35cm H2O)
prevent dynamic airway compression and
improve airway acceleration.
• Movement of the flutter
Upward:- increase pressure and frequency
Downward:- lower pressure and frequency

21. Uses of flutter
• loosening mucus
• facilitating movement of mucus up the
airways
• prevent the alveoli from collapsing
• Effective in cystic fibrosis and COPD pt.

22. R-C cornet
Mouth piece
Valve hose
Outer hard plastic
Sound damper

23. • Consist of a curved hard plastic outer tube,
mouth piece and flexible iatex free inner tube.
• The flow, pressure and frequency of the
oscillation can be adjusted to suit the
individual and it can be used in any position.
• It is independent of gravitational forces.
• It can be used for 10-15 min.

24. Uses of R-C cornet
• Airway clearance
• Effective in:-
COPD
 Cystic fibrosis
Pulmonary disease
Bronchiectasis

25. Acapella

26. • Acapella consist of a mouth piece attached to the
body of the unit that uses a counterweighted plug
and magnet to create airflow oscillation and a dial
for expiratory resistance at the other end.
• It comes in several models such as:
Green:- maintain expiratory flow rate of 15L/min
or more
Blue:- expiratory flow rate is less than 15L/min

27. Uses of acapella
• Effective in:
Cystic fibrosis
COPD
Bronchiectasis
Asthma
Mucociliary disorders

28. References
• Dean E, Frownfelter DL. Cardiovascular and
pulmonary physical therapy: Evidence and
practice. Mosby; 2006.
• Kacmarek RM, Stoller JK, Heuer A. Egan's
Fundamentals of Respiratory Care. Elsevier
Health Sciences; 2016 Feb 5.
• Pryor JA, Prasad AS. Physiotherapy for respiratory
and cardiac problems: adults and paediatrics.
Elsevier Health Sciences; 2008 Mar 6.

29. THANK YOU