+

Group 4 - Magkilat, Hans

- Hubilla, Jhoesua
- Inciong, Geraldine
- Isidro, Carlem
-Lopez, Eunice
-Macapagal, Maribel
- Mariano, Allysa Marie
- Mendoza, Meryll
- Montero, Marimar
+ POSITIVE EXPIRATORY PRESSURE
THERAPY

 PEP is used to mobilize secretions & treat atelectasis. Cough &

other airway clearance techniques are essentials components
when the therapy is intended to mobilize secretions.

 The theoretical benefit of PEP therapy is the ability to enhance &

promote mucus clearance by either preventing airway collapse by
stenting the airways or increasing intrathoracic pressure distal to
retained secretions, by collateral ventilation or by increasing
functional residual capacity.
+
History of PEP

 ORIGIN

 Traditional CPT with manual percussion, postural drainage & vibration was
first introduced in 1901 to assist airway clearance in children with
bronchiectasis.

 In the 1970’s PEP device were developed in Denmark, as means to aid the px
airway clearance with an effective, self-administered low-pressure device

 High-pressure PEP therapy was developed in Austria

 In US it was introduced by Louise Lanafours from Sweden

 Since 1991 PEP devices have been modified & improved upon which have
produced devices such as the TheraPEP & Acapella
+
What does PEP do?
 Enhances secretion mobilization & removal
 Helps prevent infections
 Improved pulmonary mechanisms & gas exchange

How does PEP accomplish this?

 2 WAYS
1) Filling under inflated or collapsed alveoli via collateral ventilation

2) Helping to stint the airways open during expiration

+ Positive Expiratory Pressure (PEP) therapy
can be used as a therapeutic tool for
numerous pulmonary conditions, including:
 COPD

 Asthma

 Emphysema

 Chronic Bronchitis

 Cystic Fibrosis

 Primary Cilliary Dyskinesia

 Respiratory infection and Pneumonia

 Seasonal respiratory influenza

 Pulmonary rehab and case management

+
Current PEP devices:

 Airway Oscillation Devices

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

 Oscillations reduce the viscoelasticity of mucus

 Oscillations provide short bursts of increased expiratory to

help with secretions mobilizations
 Flutter
valve
 TheraPEP
 Acapella
+
 The concept of “flutter” mucus clearance therapy was first
introduced by Freitag. The appeal for this device
undoubtedly is influenced by its simplicity of design and by
the fact that it is relatively easy for patients to use. The flatter
valve consists of a pipe-shaped apparatus with a steel ball in
a bowl covered by a perforated cap. The steel ball creates a
PEP (similar to PEP device) that helps prevent early airway
closure, and the internal dimensions of the pipe allow the
steel ball to “flutter” resulting in the creation of a series of
high-frequency oscillations that are transmitted to the lungs
through the airway opening.

SOURCE: Mosby’s Respiratory Care Equipment

+

Anumber of studies have demonstrated

that this therapy is a viable alternative to
standard CPT techniques in select patient
groups. Further in vivo studies involving
greater numbers and more diverse patient
groups are required to better determine the
effectiveness of Flutter valve therapy
devices compared with other airway
clearance techniques involving PAP.
+ PROTOCOL FOR
ADMINISTERING
FLUTTER VALVE
THERAPY
 Assess whether flutter valve therapy is indicated and design a treatment
program.
1) Bring the equipment to the bedside and provide initial therapy, adjusting the
pressure settings to meet the px’s needs.
2) After the initial treatment or px training, communicate the treatment plan to the
px physician and nurse and provide instructions to the nursing staff, if
required.

 Explain that flutter therapy is used to reexpand lung tissue and help
mobilize secretions. Px should be taught to huff cough.

 SOURCE: Mosby’s Respiratory Care Equipment

+ Instruct the px to:
① Sit comfortably.
② Take a deep breath that is larger than normal
but does not fill the lungs completely
③ Seal the lips firmly around the flutter device
mouthpiece & exhale actively but not forcefully,
holding the flutter valve at an angle that
produces maximum oscillation.
④ Perform 10 to 20 breaths
⑤ Remove the flutter mouthpiece & perform 2 to
3 huff coughs and then rest as needed.
⑥ Repeat this cycle 4 to 8 times not to exceed
20mns.
SOURCE: Mosby’s Respiratory Care Equipment
+ Evaluate the px for the ability to self-administer the therapy.
When appropriate, teach the px to self-administer flutter therapy.
Observe the px conduct the self-administer on several occasions
to ensure proper Flutter techniques before allowing the pc to self-
administer without supervision.

 When the px are also receiving bronchodilator aerosol,

administer in conjunction with flutter therapy by administering
the bronchodilator immediately before the flutter breaths.

 If the flutter device becomes visibly oiled, rinse it with sterile

water & shake & air-dry. Leave the device within reach at the px
bedside.

 Send the flutter device home with the px.

 In the px medical record, document the procedures performed

(device, no. of breaths per treatment & frequency), the px
response to therapy, the px teaching provided & the px ability to
self-administer the treatment.
+
Application

 Flutter device must be used in the sitting or supine lying position.

 The patient is instructed to inhale deeply and hold his breath for 2
to 3 sec. Expiration should be slow through the Flutter valve,
causing oscillations of the steel ball inside the cone of the Flutter.

 Patients apply repeated exhalations through the Flutter valve.

Routinely, three sets of 15 exhalations are performed over 12–20
min. After each series of exhalations, patients were instructed to
"huff" and cough, thereby aiding expectoration.
+
 The frequency of the oscillations can be modulated by changing the
inclination of the Flutter device slightly up or down from its horizontal
position.

 The patient selects the position that results in the best transmission of
vibration to chest wall, optimizing the mobilization of mucus.

 Effective use of the Flutter device requires training, concentration, and

appropriate positioning of the mouthpiece. The Flutter device is
simple to use inexpensive and easily portable and once the patient
and his family are instructed in its use it does not require the
assistance of a caregiver.

 Additionally, patients with severe obstruction may not be able to

generate sufficient airflow to cause vibration of the steel ball housed in
the pipe–like extension of the Flutter valve, thus limiting the
effectiveness of this device in these patients.

SOURCE:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2580042/
+
Indications: Contraindications:

 Atelectasis  Flutter device must not be

used in patients with:
 Bronchitis

 Bronchiectasis
 Right-sided heart failure
 Cystic Fibrosis

 COPD  Pneumothorax

 Asthma or other conditions  TB or Hemoptysis

producing retained
secretions
+
Mucus Loosening and Mucus
Mobilization

 Instruct the patient to slowly inhale to approx. ¾ of a full

breath.

 Perform a 2 to 3 sec. breath hold. This allows the inhaled air

to be evenly distributed throughout the lungs.

 Have the patient repeat this breathing technique for another

5 to 10 breaths to loosen and mobilize as much mucus as
possible.
+ Acapella device
 The Acapella is a handheld airway clearance device that operates on the
same principle as the Flutter.

( i.e. a valve interrupting expiratory flow generating oscillating PEP.)

 Utilizing a counterweighted plug and magnet to achieve valve closure, the

Acapella is not gravity dependent like the Flutter. The Acapella comes in
three models, a low flow (<15 L/min), high flow (>15 L/min) and the
Acapella Choice.

 The high and low flow models have a dial to set expiratory resistance while
the Choice model has a numeric dial to adjust frequency. All models can be
used with a mask or mouthpiece and can be used in line with a nebulizer.

 While these attributes may offer the Acapella some advantage over the
Flutter, no long–term studies have been done in CF patients. A bench study
of the performance characteristics of the two devices showed a slight
advantage for the Acapella, with more stable wave form and a wider range
of PEP at low air flow.
Acapella

 Uses a counterweighted plug & magnet to create the expiratory

resistance. Unlike the Flutter valve, which the px must use while seated
upright or standing, the Acapella can be used in the upright or supine
position, according to the manufacturer.

SOURCE: Mosby’s Respiratory Care Equipment

+
Cornet Device

 The Cornet device consists of a semi–circular tube containing a

flexible latex– free hose . Expiration through the Cornet causes
the hose to flex, buckle and unbuckle, causing oscillating
positive pressure in the airways which fluctuates many times per
second.

 The mouthpiece can be adjusted to produce the optimal effect.

 Operating principle and use are similar to the Flutter valve,

although the Cornet is not gravity dependent and can be used in
any position.

 Like the Flutter, the Cornet cannot be used in line with a

nebulizer.

 No studies showing the long–term effectiveness of the Cornet in

CF patients are available yet.
+
CORNET
DEVICE
+ Quake

 Consist of two barrels with matching slots that fit snugly over each
other.

 When these slots are aligned, the patient can inhale and exhale
freely through the device.

 When the slots are not aligned, back pressure is created because
the px continuous breath is prevented from escaping.

 This design allows the px to create the ideal frequency and

percussive pressure by manually rotating the outer barrel at the
ideal rate while breathing through the device.

 The faster a px rotates the handle, the greater the frequency and
lower the pressure; the slower the handle rotation, the lower the
frequency
SOURCE: Mosby’s Respiratory Care Equipment
+

QUAKE
+
High –
frequency
chest wall
oscillation
devices
+
High-Frequency Compression/
Oscillation
 As applied to airway clearance, oscillation refers to the rapid
vibratory movement of small volumes of air back and forth in
the respiratory tract.

 Two general approaches to oscillation:

 External application /high-frequency chest wall compression
(HFCWC)
 Airway application/intrapulmonary percussive ventilation

 High-frequency chest wall oscillation is accomplished by

using a two-part system :
 A variable air-pulse generator
 Non-stretch inflatable vest that covers the patient’s entire torso
+ The Vest and Hayek RTX Oscillator can be used to deliver
high-frequency external chest wall oscillations.

 Vest was developed by Warwick and colleagues. It

consists of non-stretchable, inflatable vest that extends over
the entire torso area down to the iliac crest.

 Chest wall vibrations are delivered to the vest through a

series of pressure pulses produced by an air compressor
connected to the vest by a vacuum hose.

 A remote control switch is also available to stop & start the

device.

 The px can adjust the intensify and frequency of the

pressure pulses to achieve pressures ranging from approx.
25-40 mmHg over a frequency range of 5-25 Hz,
respectively.
+
 The Hayek is technically classified as an electrically powered noninvasive
ventilator, high-frequency chest wall oscillator & assist cough device. It
consist of a power unit with CRT screen, control keyboard, & flexible chest
cuirass with disposable foam seal that is applied over the anterior chest
wall and abdomen from the upper part of the sternum to below the
umbilicus.

 It is designed to deliver negative & positive pressures to the chest wall to

control or assist both phases of the respiratory cycle, to provide HFCWO to
px from <1 to 180kg.

 The negative pressure delivered during the inspiratory portion of the

cycle causes the chest wall & lungs to expand while the positive pressure
can produce or assist with expiration.

 The pressure differential bet. The negative and positive pressure settings
used for normal respiratory rates influences the VT delivered.

 The frequency of oscillations, the I:E ratio & inspiratory & expiratory
pressures are controlled by a microprocessor which can be programmed
by the respiratory therapist according to the px’s need.
+ Lung Flute
 It is a device used to help loosen, mobilize, and eliminate secretions from
your airways.

How the Lung Flute Works?

 Mucus congestion clogs the lungs and is difficult to cough up.

 When the patient blows out through the Lung Flute, (as if blowing out
candle) his/her breathe moves the reed inside.
 This causes acoustic vibrations that thin and loosen secretions deep in
the lungs and results in the secretions moving progressively up the
patient’s airway until they collect at the back of the throat.

 Patient is able to cough up thinned mucus so the lungs clear and

symptoms ease.
+
+
+
Types/Uses of lung flute:
1) Therapeutic
2) Diagnostic

Therapeutic Lung Flute

 Is indicated for PEP therapy & is clinically proven to be an
effective method for Mucociliary Clearance.

Features:
 Simple hand held device
 Low pressure operation
 Replaceable reeds
+
Therapeutic Advantages

 Reusable, drug-free device, provides

an economical therapeutic option to
meet patients changing needs.

 Offers better results than standard

vibration or PEP Therapy- mobilizes
secretions from deep within the lungs.
+ Diagnostic Lung Flute

 Is designed to be an alternative to hypertonic saline in the collection of

diagnostic sputum samples for respiratory disease such as cystic
fibrosis, pneumonia, lung cancer, tuberculosis & asthma.

Features:
 Simple hand held disposable device
 Low pressure operation
+
Diagnostic Advantages

Minimally invasive technology

produces reliable results.

Rapid and convenient for

practitioners and patients.
+
Lung Flute for Home Care

 It is indicated for Positive Expiratory Pressure (PEP) therapy.

 PEP therapy, when combined with “huff” coughing, will help

remove secretions from airways , reduce the amount of air
that may be trapped in airways.

 Keep airways open and clear secretions and improve

delivery of bronchodilator medication.
+
Lung flute for hospitals & clinics

 The lung flute for hospitals and clinics is indicated for the
collection of sputum samples for laboratory analysis and
pathologic examinations

 Clinical studies have shown that sputum induction with the

lung flute for hospitals and clinics is safe for patients with
COPD, including very severe COPD.
+ Sputum samples induced by the Lung Flute
for hospitals & clinics can be used to
diagnose multiple pulmonary disease such
as:
 Pneumonia

 Chronic Bronchitis
 Asthma
 Emphysema
 Cystic Fibrosis
 Lung Cancer
 Tuberculosis
+
Secretion Loosening and Mobilization
(Stage 1)
 The patient should hold the lung flute pointing down.

 Inhale a little deeper than normal, place his/her lips completely around
the mouthpiece, and gently blow out through the lung flute as if trying to
blow out a candle.

 As the patient blows, he/she will hear the reed inside the lung flute make
a fluttering noise as it moves.

 Next, the patient should remove the mouthpiece from his/her mouth,
quickly inhale again, put the mouthpiece back in his/her mouth and blow
gently through the lung flute
+

Secretion Elimination (Stage 2)

 Once you have worked up to the required number of 2 blow
repetitions, the lung flute will thin and loosen secretions.

 The patient should wait five minutes after the session for secretions
to collect at the back of the throat.

 Several minutes of coughing should bring up most of the

secretions.