Positive-Expiratory-Pressure-Therapy-PEP-Overview呼氣末正壓治療PEP概述課件

PositiveExpiratoryPressureTherapyPositiveExpiratoryPressureTPEPOverviewWhatisPEP?HistoryofPEPCurrentPEPDevicesClinicalEvaluationConclusionPEPOverviewWhatisPEP?WhatisPEP?PEPisaformofbronchialhygiene,andisoneofthe3adjunctsofpositiveairwaypressure(PEP,CPAP,andEPAP).PEPinvolvesactiveexpirationthroughaone-wayvalveagainstavariableflowresistor.InmodernPEPdevices,flowresistancecanbemanipulatedtoadjustforadesiredpressure.WhatisPEP?PEPisaformofbWhatdoesPEPdo?EnhancessecretionmobilizationandremovalHelpspreventinfectionsHelpsmitigateatelectasisImprovedpulmonarymechanicsandgasexchangeHowdoesPEPaccomplishthis?2ways:Fillingunder-inflatedorcollapsedalveoliviacollateralventilation(poresofKohn,CanalsofLambert).*Helpingtostinttheairwaysopenduringexpiration.WhatdoesPEPdo?EnhancessecrHistoryofPEPOriginofPEP

-TraditionalCPTwithmanualpercussion,posturaldrainage,andvibrationwasfirstintroducedin1901toassistairwayclearanceinchildrenwithbronchiectasis.

-Inthe1970’sPEPdevicesweredevelopedinDenmark,asameanstoaidthepatient’sairwayclearancewithaneffective,self-administeredlow-pressuredevice(mouthpiece@5-20cmH20). -High-pressurePEPtherapywasdevelopedinAustria(facemask@26-102cmH20). -In1991,PEPwasintroducedintheU.S.byLouiseLanafoursfromSweden.

-Since1991,PEPdeviceshavebeenmodifiedandimprovedupon,whichhaveproduceddevicessuchastheTheraPEPandAcapella.

HistoryofPEPOriginofPEPCurrentPEPDevicesAirwayOscillationDevices(AOD)ProvidestandardPEPwiththeaddedbenefitofoscillatingpressurewithintheairwayOscillationsreducetheviscoelasticityofmucusOscillationsprovideshortburstsofincreasedexpiratoryairflowtohelpwithsecretionmobilizationFlutterValveTheraPEPAcapellaCurrentPEPDevicesAirwayOsciCurrentPEPDevicesFlutterValveDevelopedinSwitzerlandPipe-shapedAODwithasteelballrestinginanangledbowl.Onexhalation,theballoscillatesatapproximately15Hz,andprovides10-25cmH20.GravitydependentCurrentPEPDevicesFlutterValCurrentPEPDevicesTheraPEPDesignedbySmithsMedicalCompanyStandardlow-flowPEPdeviceBuiltinpressureindicatorCanbeusedwithamaskormouthpieceHasa22mmODwhichallowsittobedockedwithanebulizerInspiratoryandexpiratoryvalvesProvides10-20cmH20CurrentPEPDevicesTheraPEPCurrentPEPDevicesAcapellaDesignedbySmithsMedicalCompanySimilartothefluttervalvebutwithgreaterfunctionality(AOD)Utilizesacounterweightedplugandmagnettoachievevalveclosure(notgravitydependent)3Models:Lowflow(<15L/min,adjustableresistance)Highflow(>15L/min,adjustableresistance)Choice(anyflow,adjustablefrequency)CurrentPEPDevicesAcapellaWhat’ssogreataboutPEP?ReadilyacceptedbypatientsShortertreatmenttimecomparedtoCPTIndependentuseInexpensive(Acapella$32.00@Amazon)PortableBUT…isitaseffectiveasothermethodsofbronchialhygiene?

VSWhat’ssogreataboutPEP?ReadWhatdoestheresearchsay?CysticFibrosis–StandardPEPMortensenetal:PEPvs.PD&PEquallyeffectiveinsecretionclearanceDarbeeetal:PEPvs.HFCWCBothshowedthesameincreaseinFVC,FEV1,andsputumclearance.McIlWaineetal:PEPvs.PD&PPEPhadgreaterimprovementinFEV1andFVCPatientspreferredPEPbecausetheyfeltitwasmoreeffective,requiredlesstime,independent,andeasier.Oberwaldneretal:PEPvs.PD&PPEPproducedasignificantlygreatersputumvolume,expiratoryflowrate,anddecreasedhyperinflationcomparedtoPD&P.Summary: Thesestudiesshowconflictingresults.Attheleast,wecan concludethatstandardPEPisjustaseffectiveasPD&Pand HFCWCforCFpatients.Whatdoestheresearchsay?CysWhatdoestheresearchsay?ChronicBronchitis–StandardPEPChristensenetal:

Diaphragmaticbreathing/FETvs.PEP/FETPEPgrouphadgreatersecretionclearance,lowerexacerbationrate,lowerrateofmucolyticandantibioticuse,andanincreaseinFEV1.Whatdoestheresearchsay?ChrWhatdoestheresearchsay?CysticFibrosis–OPEPNewhouseetal:Fluttervs.IPPVEquallyeffectiveinsputumproduction,andincreasingexpiratoryflows.Hominicketal:Fluttervs.PD&PEquallyeffectiveinsputumclearanceFlutterwasmoreeffectiveatincreasingFEV1andFVCKonstanetal:Fluttervs.PD&PFlutterproducedsignificantlymoresputum.Flutterwasassessedtobesafe,costeffective,easytouse,andwithgreaterpatientadherence.Gondoretal:Fluttervs.PD&PFluttershowedsignificantimprovementinFVCcomparedtoPD&PNodifferenceinlengthofhospitalstaySummary: Again,thesestudiesshowconflictingresults,butat theleastOPEPisshowntobejustaseffectiveas traditionalmethodsofCPTforCFpatients.Whatdoestheresearchsay?Whatdoestheresearchsay?ChronicBronchitis–OPEPBelloneetal:Fluttervs.PD&PFlutterhadsuperiorsputumproduction/clearance.Whatdoestheresearchsay?ChrResearchConclusionsWhatconclusionscanbedrawnfromtheresearch?ThemajorityoftheresearchregardingtheefficacyofPEPhasbeenconductedonCFpatients.Insomestudies,PEPandOPEPhavebeenshowntohavesuperiorsecretionclearanceandimprovementsinpulmonaryfunctionthantraditionalmethodsofCPT.However,otherresearchclearlyrefutestheseresults,placingPEPasonlyaseffectiveastraditionalmethods.Thus,thechoicetoutilizePEPasaprimarymethodofbronchialhygienetherapyshouldbemadeonthebasisofothercriteria,suchascostandpatientcompliance.ResearchConclusionsWhatconclConclusionPEPdevicessuchastheAcapellaaresmall,portable,costeffective,andpatientpreferred.PEPdeviceshaven’tbeenshowntobesuperiortootherformsofCPT,buttheyhaven’beenproveninferioreither.ContinuedresearchontheefficacyofPEPdevicesneedstobeconducted.Atthistime,theeffectivenessofPEPdeviceshasbeenshowntobeequalorbetterthantraditionalmethodsofbronchialhygiene,andthedecisiontousePEPdevicesshouldbemadeonthebasisofotherfactors,suchascosteffectiveness.ConclusionPEPdevicessuchasReferencesDiomouG.,Hristara-PapadopoulouA.,PapadopoulouO.,andTsanakas,J.Currentdevices ofrespiratoryphysiotherapy.Hippokratia2008Oct-Dec;12(4):211–220.Kacmarek,R.M.,Stoller,J.K.,Wilkins,R.L.(2009).Egan’sFundamentalsofRespiratory Care (9thed.).St.Louis,MO:MosbyInc.Myers,TimothyR."Positiveexpiratorypressureandoscillatorypositiveexpiratorypressure therapies."RespiratoryCareOct.2007:1308+.AcademicOneFile.Web.25Nov.2011.UniversityofWisconsin-Madison.(2011).HealthInformatin:TheraPEP[Datafile]. Retrievedfrom/healthfacts/B_EXTRANETHEALTH_IN FORMATION-FlexMember-Show_Public_HFFY_1115126486611.htmlWilson,Richard.,(Feb-March1999)PositiveExpiratoryPressureTherapy:TheKeyto Effective,Low-CostRemovalofBronchialSecretions.RTMagazine.Retrievedfrom /issues/articles/1999-02_08.aspReferencesDiomouG.,Hristara-ReferencesBelloneA,LascioliR,RaschiS,GuzziL,AdoneR.Chestphysicaltherapyinpatientswithacuteexacerbation ofchronicbronchitis:effectivenessofthreemethods.ArchPhysMedRehabil2000;81(5):558-560.ChristensenEF,NedergaardT,DahlR.Long-termtreatmentofchronicbronchitiswithpositiveexpiratory pressuremaskandchestphysiotherapy.Chest1990;97(3):645-650.DarbeeJC,KangaJF,OhtakePJ.Physiologicevidenceforhigh-frequencychestwalloscillationandbreathing inhospitalizedsubjectswithcysticfibrosis.PhysTher2005;85(12):1278-1289.GondorM,NixonPA,MutichR,RebovichP,OrensteinDM.Comparisonofflutterdeviceandchestphysical therapyinthetreatmentofcysticfibrosispulmonaryexacerbation.PediatrPulmonol1999;28(4):255- 260.HomnickDN,AndersonK,MarksJH.Comparisonoftheflutterdevicetostandardchest physiotherapyinhospitalizedpatientswithcysticfibrosis.Apilotstudy.Chest 1998;114(4):993-997.KonstanMW,SternRC,DoershukCF.EfficacyoftheFlutterdeviceforairwaymucusclearanceinpatients withcysticfibrosis.JPediatr1994;124(5Pt1):689-693.McIlwainePM,WongLT,PeacockD,DavidsonAG.Long-termcomparativetrialofconventionalpostural drainageandpercussionversuspositiveexpiratorypressurephysiotherapyinthetreatmentofcystic fibrosis.JPediatr1997;131(4):570-574.MortensenJ,FalkM,GrothS,JensenC.Theeffectsofposturaldrainageandpositiveexpiratorypressure physiotherapyontracheobronchialclearanceincysticfibrosis.Chest1991;100(5):1350-1357.Myers,TimothyR."Positiveexpiratorypressureandoscillatorypositiveexpiratorypressuretherapies." RespiratoryCareOct.2007:1308+.AcademicOneFile.Web.22Nov.2011.NewhousePA,WhiteF,MarksJH,HomnickDN.Theintrapulmonarypercussiveventilatorandflutterdevice comparedtostandardchestphysiotherapyinpatientswithcysticfibrosis.ClinPediatr(Phila) 1998;37(7):427-432.OberwaldnerB,EvansJC,ZachMS.Forcedexpirationsagainstavariableresistance:a newchest physiotherapymethodincysticfibrosis.PediatrPulmonol1986;2(6):358-367.ReferencesBelloneA,LascioliPositiveExpiratoryPressureTherapyPositiveExpiratoryPressureTPEPOverviewWhatisPEP?HistoryofPEPCurrentPEPDevicesClinicalEvaluationConclusionPEPOverviewWhatisPEP?WhatisPEP?PEPisaformofbronchialhygiene,andisoneofthe3adjunctsofpositiveairwaypressure(PEP,CPAP,andEPAP).PEPinvolvesactiveexpirationthroughaone-wayvalveagainstavariableflowresistor.InmodernPEPdevices,flowresistancecanbemanipulatedtoadjustforadesiredpressure.WhatisPEP?PEPisaformofbWhatdoesPEPdo?EnhancessecretionmobilizationandremovalHelpspreventinfectionsHelpsmitigateatelectasisImprovedpulmonarymechanicsandgasexchangeHowdoesPEPaccomplishthis?2ways:Fillingunder-inflatedorcollapsedalveoliviacollateralventilation(poresofKohn,CanalsofLambert).*Helpingtostinttheairwaysopenduringexpiration.WhatdoesPEPdo?EnhancessecrHistoryofPEPOriginofPEP

-TraditionalCPTwithmanualpercussion,posturaldrainage,andvibrationwasfirstintroducedin1901toassistairwayclearanceinchildrenwithbronchiectasis.

-Inthe1970’sPEPdevicesweredevelopedinDenmark,asameanstoaidthepatient’sairwayclearancewithaneffective,self-administeredlow-pressuredevice(mouthpiece@5-20cmH20). -High-pressurePEPtherapywasdevelopedinAustria(facemask@26-102cmH20). -In1991,PEPwasintroducedintheU.S.byLouiseLanafoursfromSweden.

-Since1991,PEPdeviceshavebeenmodifiedandimprovedupon,whichhaveproduceddevicessuchastheTheraPEPandAcapella.

HistoryofPEPOriginofPEPCurrentPEPDevicesAirwayOscillationDevices(AOD)ProvidestandardPEPwiththeaddedbenefitofoscillatingpressurewithintheairwayOscillationsreducetheviscoelasticityofmucusOscillationsprovideshortburstsofincreasedexpiratoryairflowtohelpwithsecretionmobilizationFlutterValveTheraPEPAcapellaCurrentPEPDevicesAirwayOsciCurrentPEPDevicesFlutterValveDevelopedinSwitzerlandPipe-shapedAODwithasteelballrestinginanangledbowl.Onexhalation,theballoscillatesatapproximately15Hz,andprovides10-25cmH20.GravitydependentCurrentPEPDevicesFlutterValCurrentPEPDevicesTheraPEPDesignedbySmithsMedicalCompanyStandardlow-flowPEPdeviceBuiltinpressureindicatorCanbeusedwithamaskormouthpieceHasa22mmODwhichallowsittobedockedwithanebulizerInspiratoryandexpiratoryvalvesProvides10-20cmH20CurrentPEPDevicesTheraPEPCurrentPEPDevicesAcapellaDesignedbySmithsMedicalCompanySimilartothefluttervalvebutwithgreaterfunctionality(AOD)Utilizesacounterweightedplugandmagnettoachievevalveclosure(notgravitydependent)3Models:Lowflow(<15L/min,adjustableresistance)Highflow(>15L/min,adjustableresistance)Choice(anyflow,adjustablefrequency)CurrentPEPDevicesAcapellaWhat’ssogreataboutPEP?ReadilyacceptedbypatientsShortertreatmenttimecomparedtoCPTIndependentuseInexpensive(Acapella$32.00@Amazon)PortableBUT…isitaseffectiveasothermethodsofbronchialhygiene?

VSWhat’ssogreataboutPEP?ReadWhatdoestheresearchsay?CysticFibrosis–StandardPEPMortensenetal:PEPvs.PD&PEquallyeffectiveinsecretionclearanceDarbeeetal:PEPvs.HFCWCBothshowedthesameincreaseinFVC,FEV1,andsputumclearance.McIlWaineetal:PEPvs.PD&PPEPhadgreaterimprovementinFEV1andFVCPatientspreferredPEPbecausetheyfeltitwasmoreeffective,requiredlesstime,independent,andeasier.Oberwaldneretal:PEPvs.PD&PPEPproducedasignificantlygreatersputumvolume,expiratoryflowrate,anddecreasedhyperinflationcomparedtoPD&P.Summary: Thesestudiesshowconflictingresults.Attheleast,wecan concludethatstandardPEPisjustaseffectiveasPD&Pand HFCWCforCFpatients.Whatdoestheresearchsay?CysWhatdoestheresearchsay?ChronicBronchitis–StandardPEPChristensenetal:

Diaphragmaticbreathing/FETvs.PEP/FETPEPgrouphadgreatersecretionclearance,lowerexacerbationrate,lowerrateofmucolyticandantibioticuse,andanincreaseinFEV1.Whatdoestheresearchsay?ChrWhatdoestheresearchsay?CysticFibrosis–OPEPNewhouseetal:Fluttervs.IPPVEquallyeffectiveinsputumproduction,andincreasingexpiratoryflows.Hominicketal:Fluttervs.PD&PEquallyeffectiveinsputumclearanceFlutterwasmoreeffectiveatincreasingFEV1andFVCKonstanetal:Fluttervs.PD&PFlutterproducedsignificantlymoresputum.Flutterwasassessedtobesafe,costeffective,easytouse,andwithgreaterpatientadherence.Gondoretal:Fluttervs.PD&PFluttershowedsignificantimprovementinFVCcomparedtoPD&PNodifferenceinlengthofhospitalstaySummary: Again,thesestudiesshowconflictingresults,butat theleastOPEPisshowntobejustaseffectiveas traditionalmethodsofCPTforCFpatients.Whatdoestheresearchsay?Whatdoestheresearchsay?ChronicBronchitis–OPEPBelloneetal:Fluttervs.PD&PFlutterhadsuperiorsputumproduction/clearance.Whatdoestheresearchsay?ChrResearchConclusionsWhatconclusionscanbedrawnfromtheresearch?ThemajorityoftheresearchregardingtheefficacyofPEPhasbeenconductedonCFpatients.Insomestudies,PEPandOPEPhavebeenshowntohavesuperiorsecretionclearanceandimprovementsinpulmonaryfunctionthantraditionalmethodsofCPT.However,otherresearchclearlyrefutestheseresults,placingPEPasonlyaseffectiveastraditionalmethods.Thus,thechoicetoutilizePEPasaprimarymethodofbronchialhygienetherapyshouldbemadeonthebasisofothercriteria,suchascostandpatientcompliance.ResearchConclusionsWhatconclConclusionPEPdevicessuchastheAcapellaaresmall,portable,costeffective,andpatientpreferred.PEPdeviceshaven’tbeenshowntobesuperiortootherformsofCPT,buttheyhaven’beenproveninferioreither.ContinuedresearchontheefficacyofPEPdevicesneedstobeconducted.Atthistime,theeffectivenessofPEPdeviceshasbeenshowntobeequalorbetterthantraditionalmethodsofbronchialhygiene,andthedecisiontousePEPdevicesshouldbemadeonthebasisofotherfactors,suchascosteffectiveness.ConclusionPEPdevicessuchasReferencesDiomouG.,Hristara-PapadopoulouA.,PapadopoulouO.,andTsanakas,J.Currentdevices ofrespiratoryphysiotherapy.Hippokratia2008Oct-Dec;12(4):211–220.Kacmarek,R.M.,Stoller,J.K.,Wilkins,R.L.(2009).Egan’sFundamentalsofRespiratory Care (9thed.).St.Louis,MO:MosbyInc.Myers,TimothyR."Positiveexpiratorypressureandoscillatorypositiveexpiratorypressure therapies."RespiratoryCareOct.2007:1308+.AcademicOneFile.Web.25Nov.2011.UniversityofWisconsin-Madison.(2011).HealthInformatin:TheraPEP[Datafile]. Retrievedfrom/healthfacts/B_EXTRANETHEALTH_IN FORMATION-FlexMember-Show_Public_HFFY_1115126486611.htmlWilson,Richard.,(Feb-March1999)PositiveExpiratoryPressureTherapy:TheKeyto Effective,Low-CostRemovalofBronchialSecretions.RTMagazine.Retrievedfrom /issues/articles/1999-02_08.aspReferencesDiomouG.,Hristara-ReferencesBelloneA,LascioliR,RaschiS,GuzziL,AdoneR.Chestphysicaltherapyinpatientswithacuteexacerbation ofchronicbronchitis:effectivenessofthreemethods.ArchPhysMedRehabil2000;81(5):558-560.ChristensenEF,NedergaardT,DahlR.Long-termtreatmentofchronicbronchitiswithp