A reduction in pulmonary exacerbations in CF with PEP device
Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis (CF). Positive expiratory pressure (PEP) devices provide back pressure to the airways during expiration. This may improve clearance by building up gas behind mucus via collateral ventilation and by temporarily increasing functional residual capacity. Given the widespread use of PEP devices, this review determines the evidence for their effect, including 26 studies.
The most important outcome parameters were change in FEV1 and number of respiratory exacerbations.
Conclusion: despite poor quality and comparability of studies, PEP was significantly effective in reducing exacerbations, most notable in long term studies, > 1 year of intervention. Patient preference pointed towards PEP too. However, each patient needs to be considered individually for selection of optimal treatment regimen, short and long term, throughout life.
CF affects approximately one in 3000 Caucasians and causes frequent infection. Physiotherapists are intensively involved in airway clearance, exercise management, and teaching self care strategies.
This review included 26 studies (733 patients, 6-47 years) comparing PEP to postural drainage and percussion (PD), active cycle of breathing techniques (ACBT), oscillating PEP devices (flutter and acapella), thoracic oscillating devices (the “Vest”, HFCWO), bilevel positive airway pressure (BiPaP) and exercise.
A number of PEP devices are available, some with a mask, and some with a mouthpiece.
Outcome measurements were change in FEV1 and number of exacerbations. Several studies also assessed a direct measure of mucus clearance (weight of expectorated secretions), other pulmonary function parameters, exercise tolerance, ventilation/perfusion scans and adherence to treatment.
Overall methodological quality was poor, with 10 studies only reporting a single treatment.
Reduction of flare-ups was significant in application of PEP devices as compared to HFCWO, based on the a meta-analysis of a few studies.
It is important to note, however, that there may be individual preferences with respect to airway clearance techniques and that each patient needs to be considered individually for the selection of their optimal treatment regimen in the short and long term, throughout life, as circumstances including developmental stages, pulmonary symptoms and lung function change over time.
Read the European Cystic Fibrosis Society guideline for Physiotherapy in people with Cystic Fibrosis here.
What do you consider most important in the management of your young CF patients?
> From: McIlwaine et al., Cochrane Database Syst Rev (2015) (Epub ahead of print). All rights reserved to The Cochrane Collaboration. Click here for the Pubmed summary.