ACAPELLA

PEP therapy is an alternative to CPT and may be used to improve bronchial hygiene and aid in optimizing pulmonary status. The PEP® device and the Flutter® device both provide positive expiratory pressure (PEP) therapy.
The Acapella PEP® device entails active expiration against a variable-flow resistance device, thus creating positive pressure during exhalation. This promotes airflow to the small airways, increases the movement of air under retained secretions, and prevents early closure of the small airways.

Clinical Benefits
The clinical benefits of PEP therapy include:

Preventing or reversing atelectasis
Improving airway patency
Improving lung function
Improving mobilization and removal of secretions
Facilitating movement of secretions to large airways where they can be more easily cleared
Promoting airflow to previously obstructed areas
Enhancing collateral ventilation by enhancing air movement to fill under-aerated and non-aerated lung segments
Preventing airway collapse via positive back-pressure during exhalation
Improved bronchodilation when used in conjunction with bronchodilating medications
Promoting effective breathing patterns and improving gas exchange & distribution of ventilation

General Description

The Acapella PEP® device consists of a removable mouthpiece (or, optionally, a mask). The device includes an expiratory resistance/frequency adjustment dial and a one-way inspiratory valve. There is also an optional pressure measurement port.

Principals of Operation

The Acapella PEP® device directs exhaled air through an opening, which is closed periodically by a pivoting cone. The result is a vibration and a positive expiratory pressure during exhalation. The frequency of oscillations ranges from 0 to 30 Hz. The frequency of the vibrations, and the resistance of the opening, are adjusted by rotating the dial. Higher frequencies create a higher resistance.

The Acapella PEP® device comes in 2 colors: green for high flow and blue for low flow. The green device is recommended for patients who are able to maintain an expiratory flow of 15 L/min or greater for 3 seconds. The blue is recommended for patients with an expiratory flow less than 15 L/min.

Directions for Use
Obtain a physician's order prior to beginning PEP therapy and ensure that a licensed practitioner instructs the patient in the proper use of the device. Begin the initial session of PEP therapy using the lowest frequency setting, and adjusting the setting according to the individual patient's response. Turn the frequency adjustment dial counter-clockwise to decrease frequency and resistance, and clockwise to increase frequency and resistance. The goal is to obtain a positive expiratory pressure of +10 to +20 cm H2O.

Instruct the patient to sit in a high Fowler's position. The elbows may rest on a table and noseclips may be used. There is also a port to attach a nebulizer if bronchodilator medication is indicated. The nebulizer can be given in conjunction with the PEP therapy.

Have the patient perform diaphragmatic breathing and inhale through the resistor. An effective breath is larger than the normal tidal volume, but not as large as the total lung capacity. Hold the breath for 2 to 3 seconds. Make a good seal with the mouthpiece or mask and exhale actively, but not forcefully, until the lungs feel empty. The patient should be able to exhale while feeling the vibratory effects for a minimum of 3 to 4 seconds. If the patient is unable to maintain an exhalation for this length of time, increase the resistance by turning the dial clockwise. This increased resistance allows the patient to exhale at a lower flow rate. The patient can also be instructed to exhale faster or slower to optimize the vibrating pressure felt. Make adjustments to the settings until reaching the desirable I:E ratio of 1:3 or 1:4. Achieving this goal may take several trials.

Frequency and Duration
Have the patient perform 10 to 20 PEP breaths followed by 2 or 3 coughs. Instruct the patient on effective cough techniques, including the "huff" cough. The patient should then expectorate secretions. The entire session of 10 to 20 PEP breaths, followed by 2 to 3 coughs, can be repeated as necessary. The usual duration of the entire treatment is 10 to 20 minutes. PEP therapy treatments are performed 2 to 4 times per day, depending on the patient's condition and response to therapy.

Indications
Positive expiratory pressure (PEP) therapy is indicated for patients with the following conditions:

· Chronic obstructive pulmonary diseases (COPD) including asthma,bronchitis,bronchiectasis, and cystic fibrosis
· Pneumonia
· Atelectasis
· Post-operative
· Prolonged bedrest
· Ineffective cough
· Ciliary dysfunction
· Accumulated or retained secretions

Contraindications

· Pneumothorax
· Overt right-sided heart failure

Precautions

· Hemoptysis
· Nausea
· Hemodynamic instability
· Epistaxis
· Inability to tolerate increased work of breathing.
· Moderate or severe dyspnea
· Unstable medical or respiratory status
· Increased intracranial pressure (ICP) >20 mm Hg
· Recent trauma or surgery, especially to the upper body

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