Positive Expiratory pressure (PEP), Acapella and Flutter Full Title of Guideline: Author (include email and role): Division & Speciality: Version: 3 Ratified by: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): Positive Expiratory Pressure (PEP), Acapella and Flutter Guidelines for Practice Sarah Millward, Senior Physiotherapist, sarah.millward@nuh.nhs.uk Clinical Support, Physiotherapy Senior Physiotherapists at NUH Trust wide physiotherapists September, 2021 Primarily this includes patients with Cystic Fibrosis and Bronchiectasis, but may include any patient with a respiratory disease that requires the assistance of a device to assist chest clearance. Review of research, minor changes to wording, grammar and spelling errors corrected. At least one randomised controlled trial. Well designed nonexperimental descriptive studies (ie comparative / correlation Summary of evidence base this and case studies). Expert committee reports or opinions and / guideline has been created from: or clinical experiences of respected authorities. Recommended best practise based on the clinical experience of the guideline developer This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust.
Positive Expiratory Pressure (PEP), Acapella and Flutter Guidelines for Practice Version: This replaces the PEP, Acapella and Flutter guideline for practice, September 2018 Review Date: September 2021 Contact: Sarah Millward, Senior Physiotherapist or Fiona Haynes Clinical Specialist Physiotherapist / Ext: 53522 Disclaimer This guideline has been registered with the Nottingham University Hospitals Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in any doubt regarding this procedure, contact a senior colleague. Caution is advised when using guidelines after the review date. Please contact the named above with any comments / feedback. Introduction/Indications for Use This guideline describes the use of the small hand held devices that have the resistive features of Positive Expiratory Pressure (PEP) and/ or the vibratory features of a flutter valve. A resistive pressure device works by using a pressurised breath to splint open the airways. Vibratory pressure devices work by using oscillating vibrations that travel to the lungs, shaking mucus that the patient can then expectorate. These devices are indicated to mobilise retained secretions, prevent or reverse atelectasis. For example in patients with Cystic fibrosis, Bronchiectasis and Pneumonia. Precautions/Contraindications There are no absolute contraindications to the use of PEP, Flutter or Acapella. However, the following are precautions to consider before the commencement of therapy: - Patient tolerance of increased work of breathing - Intracranial pressure >20mmHg - Haemodynamic instability - Recent facial, oral, or skull surgery or trauma - Acute sinusitis - Epistaxis (nose bleeding) - Oesophageal surgery - Active Haemoptysis - Nausea - Known or suspected tympanic membrane rupture or other middle ear pathology - Untreated pneumothorax Best Practice Points Consider PEP or an oscillating PEP device when recommending an airway clearance technique for adults with Cystic Fibrosis or for patients with non-cystic fibrosis related bronchiectasis
Acapella Procedure Action Explain the device to the patient and gain consent Select the appropriate device for the patient Position the patient to optimise secretion clearance On first use ensure that the resistance dial is turned counter clockwise to the lowest resistance setting Instruct the patient to place the mouthpiece lightly in the mouth; maintaining a tight seal on the mouthpiece during inspiration. A nose clip can be used if necessary Instruct the patient to relax and perform diaphragmatic breathing. The patient should be instructed to inspire slightly deeper than normal but not take a full deep breath in Instruct the patient to hold their breath for 2-3 seconds Ask the patient to exhale actively but not forcibly or fully through the acapella device Encourage an active exhalation for 3-4 seconds while the acapella vibrates If the patient cannot maintain exhalation for this length of time adjust the dial clockwise Adjust the dial so that the patient feels the optimal vibratory pressure Perform 10-12 breaths in this manner Ask the patient to perform 2-3 huffs this may be performed through the device to assist mobilization of secretions Repeat as necessary Document treatment session Rationale Educates the patient and achieves patient consent for treatment The Green acapella is for patients able to maintain an expiratory flow of 15 Litres Per Minute or greater for 3 seconds (suitable for most patients) The blue acapella is for patients not capable of 15 Litres Per Minute for 3 seconds The acapella can be used in any position including postural drainage positions (see Gravity Assisted Positioning guidelines 2018) Selecting the correct resistance range produces the desired Insufflation:Exsufflation ratio of 1:3 to 1:4 To provide a seal around the acapella device and encourage the patient to mouth breath To develop a relaxed diaphragmatic breathing pattern, utilise collateral ventilation To optimize airflow through the collateral channels The expiration should be active but not forced and the patient should not exhale to functional residual capacity (FRC) To optimize the vibratory effects of the acapella to assist secretion clearance Clockwise adjustment increases the resistance of the vibrating orifice, which will allow the patient to exhale at a lower flow rate To achieve to maximal effect To mobilise secretions To enable the expectoration of any secretions that have been mobilised To optimize secretion clearance Legal requirement
Cleaning of the Acapella Clean the device after each use to remove moisture and mucus Disassemble and rinse the components with sterile water and air dry before reassembling, store in a clean, dry location. Every 2 days disassemble and clean the equipment in a solution of mild soap or detergent, do not use products that contain chlorine bleach Once a month the acapella should be boiled to clean it, as per manufacturer s instruction. Flutter Procedure Action Explain the device to the patient and gain consent to treat Sit the patient in a chair so that their back is straight and their head slightly tilted up. Or have the patient seated with their elbows resting on a table at a comfortable level and head tilted slightly upwards Ask the patient to hold the flutter so that the stem is horizontal to the floor, placing the cone at a slight tilt The angle of the flutter device should then be adjusted by moving the flutter up or down to achieve the maximum fluttering effect in the airways Place one hand on the patients back and the other on the patients chest The patient should be asked maintain the angle of the device to achieve maximum effect To mobilize and loosen secretions ask the patient to inhale to ¾ of a full breath and then place the flutter in the mouth with their lips firmly around the stem, positioning the flutter at the optimal angle and perform a 3 second breath hold Instruct the patient to exhale through the flutter at a reasonably fast rate but not too forcefully, keeping the cheeks stiff & suppressing the urge to cough. If the patient is unable to keep their cheeks stiff a mirror may provide visual in-put to assist this, or use one hand to stabilize the cheeks. The patient should repeat 5-10 breaths through the flutter Rationale Educates the patient and achieves patient consent for treatment So that the upper airway is open and the air can flow freely from the lungs and out through the flutter This tilt ensures that the ball not only bounces but also rolls during exhalation The combined rolling and bouncing of the ball produces the vibrations that dislodges the mucus The vibrations should be palpable through the lungs and this determines that the patient has achieved the fluttering effect The patient has now established a comfortable position and selected the proper tilt of the flutter device to begin therapy This allows the inhaled air to be evenly distributed throughout the lungs This should produce vibrations through the patients airways and not allow the vibrations to be wasted in the patients cheeks To loosen as much mucus as possible. The mucus moves further up the airways with each exhalation
To assist mucus elimination the patient should perform 1 or 2 additional breaths through the flutter as previously, but this time the breath should be exhaled forcefully through the flutter as completely as possible Repeat until no more mucus can be cleared Document treatment and outcome The forceful exhalation moves the mucus to a level where it can be expectorated To clear the lungs of secretions Legal requirement Cleaning the Flutter The flutter is single patient use It should be cleaned after each use to remove moisture/mucus Disassemble and rinse all the components in sterile water and air dry before reassembling and storing in a clean dry location Every two days the flutter should be disassembled and cleaned in a solution of mild soap or detergent Bleach and other chlorine - containing products should not be used Once a month the device should be boiled to clean it, as per manufacturers instructions Troubleshooting Problems Reasons Solutions No oscillation felt Poor technique Hold device in teeth and reteach Cheeks wobbling Hold cheeks with hand Low flow on expiration Ball sticking in Flutter/ magnet sticking in Acapella Flow rate to fast/ slow Flutter angle not effective Closing glottis Bronchospasm / airway collapse Trying too hard / breathing out too far Glottis closing Condensation Experiment with breathing pattern Alter Flutter angle Keep Glottis open Practice relaxed breathing Use tissue to practice breathing technique Keep Glottis open Ensure device is cleaned after each use and left dismantled to allow to dry completely
PEP Procedure Action Explain the device to the patient and gain consent Position the patient so that they are sitting with their elbows resting on a table Allow the patient to breathe through the PEP mask without any resistance Ask them to breathe through the mask with each of the resistors from the largest to the smallest Allow the patient at least 30 seconds with each resistor. The smallest diameter resistor which the patient can use effortlessly for 2 minutes is the correct one Choose the correct resistor by watching the pressures achieved on the manometer Do not allow the patient to see the manometer during this test period Chose the correct resistor and then show the patient the manometer Ask the patient to perform 8-12 breaths through the mask with a slightly active expiration Remove the mask for huffing and breathing control Rationale Educates the patient and achieves patient consent for treatment This allows the patient to hold the mask tightly over their face and create a tight seal To become comfortable & familiar with its use To establish the correct resistance for the patient To establish a smooth, steady breathing pattern A pressure of 10-20cmH 2 0 should be achieved at mid expiration to optimize PEP Most people will alter their breathing pattern to reach the required pressures with all the resistors Showing the patient the manometer may now help them to achieve a smooth, steady breathing pattern. Once established the patient may not need the manometer to perform the treatment To mobilise secretions To expectorate secretions and allow relaxed breathing in between PEP breaths Continue until the patients chest is clear or they fatigue Document treatment and outcome To loosen as much mucus as possible. The mucus moves further up the airways with each exhalation Legal requirement Troubleshooting Problems Reasons Solutions No secretions heard Trying too hard Practice relaxed breathing Incorrect pressure Mask not sealing Flow rate too fast Flow rate too slow Trying too hard Flow rate too fast Flow rate too slow Wrong size Damaged mask Try with large resistor on inspiratory valve to slow insp. flow rate down Practice relaxed breathing Use manometer to monitor pressure (10-20cms H2O) Try mouthpiece and nose clip Change to new mask
Poor cleaning Cuff not sufficiently inflated Poor contact between mask and face Several parts to disconnect and re-assemble Inflate rubber seal of mask Check leaning into mask when using Ensure clear instructions are given for cleaning and drying Cleaning the PEP Mask It should be cleaned after each use to remove moisture/mucus Disassemble and rinse all the components in sterile water, air dry, reassemble and store in a clean dry location Every two days the PEP components should be disassembled and cleaned in a solution of mild soap or detergent Bleach and other chlorine -containing products should not be used Once a month the device should be boiled to clean it, as per manufacturer s instruction References Association of chartered Physiotherapists in CF (2007) Practical Guidelines for Cystic Fibrosis Care Bott J et al (2009)Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. Thorax 64: (Suppl 1)ii-i151 Hough, A. (2001) Physiotherapy in Respiratory Care, Nelson Thornes, UK Mullen, A (June 2009) Using the Acapella Coice, National Jewish health, Denver US