Positive Expiratory Pressure in Patients with Chronic Obstructive Pulmonary Disease – A Systematic Review

Abstract

Background: Breathing exercises against a resistance during expiration are often used as treatment for patients with chronic obstructive pulmonary disease (COPD). Controversy still exists regarding the clinical application and efficacy. Objectives: The aim of this systematic review was to determine the effects of chest physiotherapy techniques with positive expiratory pressure (PEP) for the prevention and treatment of pulmonary impairment in adults with COPD. Methods: The review was conducted on randomised, controlled clinical trials in which breathing exercises with positive expiratory pressure were compared with other chest physical therapy techniques or with no treatment, in adult patients with COPD. A computer-assisted literature search of available databases from 1970 to January 2008 was performed. Two reviewers extracted data independently and assessed the trials systematically with an instrument for measuring methodological quality. Results: In total, 11 trials met the inclusion criteria, of which 5 reached an adequate level of internal validity. Several kinds of PEP techniques with a diversity of intensities and durations of treatment have been evaluated with different outcome measures and follow-up periods. Benefits of PEP were found in isolated outcome measures in separate studies with a follow-up period <1 month. Concerning long-term effects, the results are contradictory. Conclusion: Prior to widespread prescription of long-term PEP treatment, more research is required to establish the benefit of the technique in patients with COPD.

Evaluation of Pressure Generated by Resistors From Different Positive Expiratory Pressure Devices

“…In a review evaluating evidence on PEP training for subjects with COPD, only 3 of 11 articles registered adverse effects. 2 Reported effects were complaints about the mask, dizziness caused by hyperventilation, and the treatment in general. The risk of adverse effects is minor, but it is a challenge to prescribe the optimal treatment.…”

“…[1][2][3] The use of PEP is standard care in many hospitals for patients with pulmonary disease or neurological disorders or those undergoing surgery, especially in the Nordic countries. [1][2][3] PEP can be created by a patient by breathing through pursed lips, with the size of the opening and the expiratory flow determining the pressure, 4,5 and when an expiratory pressure with an average of 5 cm H 2 O is reached. 6 An inexpensive and often-used application is the blow bottle, where resistance is created by a tube submerged in water.…”

“…[1][2][3] In pressure-regulated devices, resistors with varying diameters are used to create the resistance. Even though the diameter of the lumen on the resistor is reported to be the same, there are other components of the design, such as the length and shape of the tube, that may affect the resistance.…”

Effects of Expiratory Positive Airway Pressure on Dynamic Hyperinflation During Exercise in Patients With COPD

“…Both increases and decreases of pulmonary volumes have been described in COPD patients. 10 This may be one of the explanations why pursed-lip breathing, a type of breathing resulting in positive expiratory pressure and thought to have similarities with EPAP, is spontaneously adopted by many patients. 11 Theoretically, EPAP could alleviate dynamic compression on expiration, attenuating expiratory air-flow limitation 11 and reduce the inspiratory threshold load of hyperinflated lungs in COPD patients, promoting an enhancement in neuromuscular coupling.…”

Current best practice in pulmonary rehabilitation for chronic obstructive pulmonary disease

“…The value of this therapy in patients with stable COPD and with acute COPD exacerbation is uncertain. Nonetheless, for patients who produce more than 30 ml of sputum every 24 h or who have difficulties with sputum elimination, chest physical therapy combined with postural drainage and effective coughing techniques enhance sputum expectoration; the actual benefit, however, has not been determined [Fagevik and Westerdahl, 2009]. Nowadays, chest physiotherapy represents a nonessential component of PR, to be used in a small percentage of patients with chronic respiratory disease who are affected by a marked hypersecretory component [de Blasio, 2009].…”