Positive Expiratory Pressure (PEP) Therapy: Clinical Uses

Positive expiratory pressure, commonly known as PEP therapy, is a respiratory care technique used to improve airway clearance, support lung expansion, and reduce air trapping in selected patients. It works by having the patient exhale against resistance, which creates positive pressure during expiration.

This pressure helps keep small airways open, moves air behind retained secretions, and assists with mucus movement toward larger airways.

PEP therapy is commonly used in patients with cystic fibrosis, bronchiectasis, COPD, asthma with mucus plugging, atelectasis risk, and other conditions involving retained secretions.

What Is Positive Expiratory Pressure Therapy?

Positive expiratory pressure (PEP) therapy is a noninvasive breathing technique in which a patient exhales through a device that provides resistance. This resistance creates positive pressure in the airways during exhalation. The pressure helps stabilize the airways, improve ventilation distribution, and mobilize secretions.

PEP therapy is different from continuous positive airway pressure, or CPAP. CPAP provides positive pressure during both inspiration and expiration. PEP therapy provides positive pressure only during exhalation. This makes PEP simpler, more portable, and easier to use in many hospital, outpatient, and home care settings.

PEP devices are often small and handheld. Some use fixed or adjustable resistors, while others add vibrations or oscillations during exhalation. The patient usually breathes in normally or slightly deeper than normal, then exhales actively through the device. After a series of breaths, the patient performs huff coughing or directed coughing to remove secretions that have been moved toward the larger airways.

PEP therapy is considered a patient-driven therapy because it requires active participation. The patient must understand the instructions, create an adequate seal around the mouthpiece or mask, inhale properly, exhale with the correct effort, and cough or huff effectively afterward. For this reason, patient selection and coaching are important.

How PEP Therapy Works

PEP therapy works by increasing pressure inside the airways during exhalation. This pressure helps prevent small airway collapse, especially in patients with obstructive lung disease or unstable airways. When the airways remain open longer during exhalation, air can move more evenly through the lungs.

One important effect of PEP is improved secretion movement. In many patients with chronic lung disease, mucus becomes trapped in small airways. This can block airflow, worsen ventilation, increase infection risk, and contribute to atelectasis. PEP therapy helps move air behind secretions through collateral ventilation. This means air can reach partially blocked areas through alternate pathways, helping push mucus toward larger central airways.

Once secretions reach the larger airways, the patient can remove them with huff coughing, directed coughing, or suctioning if needed. PEP does not simply “clear mucus” on its own. It mobilizes secretions, but the patient still needs an effective method to expectorate or remove them.

PEP may also improve lung expansion. By increasing expiratory airway pressure, PEP can help increase functional residual capacity, which is the amount of air remaining in the lungs after normal exhalation. This can help recruit poorly ventilated or collapsed alveoli. For patients at risk for atelectasis, especially after surgery, this can be clinically useful.

PEP Therapy and Airway Clearance

One of the most common uses of PEP therapy is airway clearance. Airway clearance therapy includes techniques that help mobilize and remove bronchial secretions. These techniques may include coughing, huff coughing, postural drainage, percussion, vibration, high-frequency chest wall compression, mechanical insufflation-exsufflation, and PEP therapy.

PEP is especially helpful when secretions are present but difficult to clear. This may occur in cystic fibrosis, bronchiectasis, chronic bronchitis, COPD exacerbation, asthma with mucus plugging, and bronchiolitis obliterans. These conditions can involve thick secretions, airway inflammation, mucus plugging, impaired cough, or airflow obstruction.

During PEP therapy, the patient exhales against resistance to create back pressure. This helps splint the airways open and improves airflow behind mucus. As the mucus moves toward larger airways, the patient follows with a huff cough or directed cough. This combination is important because PEP mobilizes secretions, while coughing removes them.

The therapy may be especially practical for patients who need repeated airway clearance treatments. Many PEP devices are portable, easy to clean, and suitable for independent use after proper instruction. This can make PEP useful for home care patients, including some patients with cystic fibrosis or bronchiectasis who need routine secretion clearance.

PEP Therapy and Lung Expansion

PEP therapy may also be used as a lung expansion adjunct. Lung expansion therapy is designed to prevent or reverse atelectasis, which occurs when alveoli collapse or when gas is absorbed beyond an obstructed airway. Atelectasis is common after surgery, especially after thoracic or upper abdominal procedures.

Postoperative patients are at risk for atelectasis because pain, immobility, shallow breathing, and retained secretions can reduce ventilation. If the patient avoids deep breathing or coughing because of pain, the lungs may not expand fully. Secretions can accumulate, small airways may close, and alveoli can collapse.

PEP can help by encouraging controlled breathing, increasing airway pressure during exhalation, improving functional residual capacity, and helping maintain airway patency. It may be chosen when the patient can cooperate and has retained secretions or difficulty with airway clearance. In some cases, it may be used instead of incentive spirometry when sputum production is a major problem.

PEP is not the only option for lung expansion. Other techniques include early mobilization, deep breathing, directed coughing, incentive spirometry, CPAP, intermittent positive pressure breathing, noninvasive ventilation, and high-flow nasal cannula. The best choice depends on the patient’s condition, ability to participate, amount of secretions, oxygenation status, and response to therapy.

Standard PEP Devices

Standard PEP devices provide resistance during exhalation. These devices may use a fixed-orifice flow resistor or a threshold resistor. With a fixed-orifice device, the patient exhales through an opening that creates resistance. The size of the opening can often be changed to adjust the pressure.

With a threshold resistor device, the patient must exhale against a set resistance before airflow occurs. This resistance may be created by a spring-loaded valve, adjustable counterweight, or similar mechanism. The goal is to generate enough pressure to provide therapeutic benefit without causing excessive fatigue or distress.

Standard PEP devices may include a mouthpiece or mask, one-way valves, a pressure manometer, tubing, and adjustable resistors. A manometer is helpful because it allows the therapist and patient to monitor the pressure being generated. The common therapeutic target is about 10 to 20 cm H₂O, although some devices may generate pressures in a broader range.

Note: Standard PEP devices are often simple, lightweight, and easy to teach. They are useful when the main goals are airway splinting, secretion movement, improved ventilation distribution, and atelectasis prevention or treatment.

Oscillating PEP Devices

Oscillating PEP, also called OPEP or vibratory PEP, combines expiratory resistance with airway oscillations. These oscillations create rapid pressure changes during exhalation. The goal is to loosen secretions, reduce mucus adhesion, and help move mucus toward larger airways.

Examples of oscillating PEP devices include the Flutter valve, Acapella, Aerobika, and RC-Cornet. These devices differ in design, but they share the same general purpose: they provide resistance during exhalation while creating vibrations or oscillations in the airways.

The Flutter valve contains a steel ball that rises and falls during exhalation. As the patient exhales, the ball repeatedly interrupts airflow, creating pressure fluctuations and vibrations. The amount of pressure and oscillation can change based on the patient’s expiratory flow and the angle of the device.

The Acapella uses a counterweighted lever and magnet system. As exhaled air passes through the device, airflow is intermittently blocked, creating oscillations. The resistance can usually be adjusted with a dial or knob.

Oscillating PEP may be selected when the patient has retained secretions and can generate adequate expiratory flow. It may be especially useful for patients with chronic mucus-producing disorders, although it is not automatically superior to other airway clearance methods.

Note: The best device depends on the patient’s needs, preference, ability, and clinical response.

Indications for PEP Therapy

PEP therapy may be indicated when the patient has retained secretions and can participate in treatment. It is commonly associated with cystic fibrosis, bronchiectasis, chronic bronchitis, COPD with secretion retention, asthma with mucus plugging, bronchiolitis obliterans, and selected postoperative conditions.

Patients with cystic fibrosis often produce thick secretions that require regular airway clearance. PEP therapy can help mobilize mucus and may be easier for some patients to perform independently compared with manual chest physical therapy. Children who are old enough to follow directions may be able to learn the technique with proper coaching.

Patients with bronchiectasis may also benefit because their airways are chronically dilated and prone to mucus retention. Secretions can pool in the airways, increasing the risk of infection and obstruction. PEP can help move mucus toward larger airways for removal.

In COPD, chronic bronchitis, and emphysema, PEP may help reduce air trapping and improve airway stability during exhalation. Some patients with expiratory airflow limitation may respond well because PEP creates back pressure and helps prevent premature airway collapse. This effect is similar in concept to pursed-lip breathing.

Note: PEP may also be useful for atelectasis prevention or treatment, especially when retained secretions contribute to airway obstruction. In chest trauma or postoperative care, PEP may help improve ventilation, support secretion clearance, and reduce complications when the patient can tolerate the therapy.

Patient Selection

Proper patient selection is essential. PEP therapy requires cooperation, understanding, and active breathing effort. A good candidate should be alert enough to follow instructions and physically able to perform the maneuver.

The patient must be able to inhale adequately, exhale through the device, maintain a seal, and perform coughing or huff coughing afterward. If the patient cannot understand or repeat the instructions, the therapy may not be effective. If the patient is obtunded, severely fatigued, or unable to cooperate, another therapy may be more appropriate.

The patient should also be able to take a deep enough breath to generate useful pressure and airflow. Some references describe the need for a breath greater than about 10 to 12 mL/kg predicted body weight to produce adequate pressure, oscillation, and prolonged exhalation.

Note: Patient comfort matters as well. A therapy that is technically correct but poorly tolerated may not be continued. The therapist should consider the patient’s pain level, anxiety, dyspnea, strength, secretion burden, diagnosis, and preference when selecting a device.

Basic Procedure for PEP Therapy

The basic procedure begins with explanation and demonstration. The therapist should show the device to the patient, explain the purpose of the treatment, and demonstrate how to inhale and exhale through the device.

The patient is usually placed upright or in semi-Fowler’s position. This supports diaphragmatic movement and helps improve ventilation. The abdomen should not be restricted. If the patient cannot tolerate sitting upright, another position may be used based on clinical judgment.

The device is usually started at the lowest resistance setting. The patient inhales a tidal or slightly larger-than-tidal breath, then exhales actively through the device. Exhalation should be controlled, not explosive. The therapist adjusts resistance to reach the desired pressure, commonly about 10 to 20 cm H₂O.

A typical breathing cycle includes 10 to 20 PEP breaths, followed by huff coughing or directed coughing. This cycle may be repeated several times, often four to eight times, with the total treatment lasting about 10 to 20 minutes. The exact schedule depends on the patient’s condition, tolerance, and response.

Note: The patient should not hyperventilate during therapy. If dizziness, tingling, light-headedness, or discomfort occurs, therapy should be paused until symptoms resolve. The therapist should then coach the patient to resume with a slower, more controlled breathing pattern.

Breathing Pattern During PEP Therapy

The breathing pattern used during PEP therapy is important. The patient should inhale slightly deeper than normal but not necessarily to total lung capacity. A short breath hold may be used to improve ventilation distribution. The patient then exhales through the device with active but controlled effort.

The expiratory phase should be longer than the inspiratory phase. A common goal is an inspiratory-to-expiratory ratio near 1:3, although a range of about 1:2 to 1:4 may be acceptable. This means the patient exhales two to four times longer than they inhale.

A slow, controlled exhalation helps maintain airway pressure and reduces the risk of dynamic airway collapse. This is especially important in obstructive lung disease. Exhaling too forcefully may worsen airway narrowing in some patients, while exhaling too weakly may fail to generate enough therapeutic pressure.

Note: The patient can use a manometer when available to monitor pressure. Visual feedback can help the patient learn the correct force and speed of exhalation. With oscillating PEP devices, the therapist may also check whether vibrations are being transmitted to the central airways during exhalation.

Huff Coughing and Directed Coughing

PEP therapy should be paired with an effective airway clearance technique. Huff coughing is commonly used because it helps move secretions while reducing the risk of excessive airway collapse.

During huff coughing, the patient inhales slowly and deeply, holds the breath briefly, then performs a forced exhalation with an open glottis. The sound is similar to saying “huff.” This technique moves mucus from smaller airways toward larger airways and can be less harsh than a forceful closed-glottis cough.

Directed coughing may also be used. The patient is coached to inhale deeply, hold the breath briefly, and cough effectively to clear secretions. The therapist should observe whether the cough is strong enough and whether sputum is produced.

Note: This step is essential because PEP mobilizes secretions but does not remove them completely without an effective cough. If the patient cannot cough effectively, suctioning or another airway clearance method may be needed.

Combining PEP With Aerosol Therapy

PEP therapy can sometimes be combined with aerosolized medications. Some devices allow a small-volume nebulizer or metered-dose inhaler adapter to be attached to the system. This can allow bronchodilators or mucolytic medications to be delivered during airway clearance therapy.

Combining bronchodilator therapy with PEP may be helpful when bronchospasm or airflow obstruction is present. Better airway opening may improve secretion movement and ventilation distribution. Mucolytic agents may also be used in selected patients to help thin or loosen secretions.

However, not every PEP device is designed for aerosol delivery. The therapist should follow manufacturer instructions and institutional policy. Medication response and side effects should also be monitored. For example, bronchodilators may affect heart rate, tremor, or symptoms, while mucolytics may increase coughing or airway irritation in some patients.

Frequency and Duration

The frequency and duration of PEP therapy are not the same for every patient. Treatment should be based on assessment, clinical response, secretion burden, and tolerance.

In acute care or home care, PEP therapy is commonly performed two to four times per day. In some intensive care settings, it may be used more frequently, depending on the patient’s needs. Some patients may require more frequent therapy during acute illness, infection, or increased sputum production.

A typical session may last about 10 to 20 minutes. One common pattern is 10 to 20 breaths followed by huff coughing or directed coughing, repeated several times. The therapist should avoid making the treatment so long or intense that the patient becomes fatigued.

The therapy should be continued only when it is effective. Signs of effectiveness include easier expectoration, increased sputum clearance when appropriate, improved breath sounds, improved oxygenation, reduced dyspnea, and improved radiographic findings when atelectasis or secretion retention is being monitored.

Note: If the patient already produces large amounts of sputum and PEP does not improve clearance, the treatment may not be needed. Respiratory care should be based on response, not routine habit.

Monitoring During PEP Therapy

Monitoring is a key part of safe and effective PEP therapy. Before treatment, the therapist should assess the patient’s breath sounds, respiratory rate, heart rate, blood pressure, oxygen saturation when appropriate, sputum production, pain, dyspnea, and ability to follow instructions.

During therapy, the therapist should watch for signs of intolerance. These may include increased shortness of breath, chest discomfort, dizziness, fatigue, anxiety, oxygen desaturation, abnormal vital sign changes, or worsening distress. The patient’s breathing pattern should be observed to ensure that exhalation is controlled and not too forceful.

After therapy, the therapist should reassess breath sounds, sputum production, patient comfort, oxygenation, and subjective response. Sputum should be evaluated for amount, color, thickness, and odor when clinically appropriate. These findings help determine whether the treatment is helping.

The therapist should also check the device. If the patient cannot exhale through the device, the valve or outlet may be obstructed. If pressure is too high, resistance may be excessive or the outlet may be blocked. If pressure is too low, there may be a leak, poor seal, loose connection, or insufficient expiratory effort.

Contraindications and Precautions

PEP therapy is not appropriate for every patient. Although some sources describe no absolute contraindications for certain positive airway pressure adjuncts, several conditions require caution or avoidance.

PEP should be carefully evaluated in patients with untreated pneumothorax, increased intracranial pressure, hemodynamic instability, active hemoptysis, recent facial surgery or trauma, recent oral or skull surgery, esophageal surgery, acute sinusitis, epistaxis, tympanic membrane rupture, middle ear disease, nausea, or inability to tolerate increased work of breathing.

Untreated pneumothorax is a major concern because positive pressure could worsen the air leak. Increased intracranial pressure is also important because positive pressure and forced breathing maneuvers may increase pressure further. Hemodynamic instability matters because positive pressure can affect venous return and cardiovascular function.

Patients with acute asthma or COPD exacerbation may need careful assessment. PEP can help some patients with airflow limitation, but it also increases the work of breathing. If the patient is severely distressed, fatigued, or unable to tolerate expiratory resistance, PEP may make the situation worse.

Note: The respiratory therapist must use clinical judgment. A therapy that is helpful for one patient may be unsafe or ineffective for another.

Hazards and Complications

Possible hazards of PEP therapy include increased work of breathing, fatigue, pulmonary barotrauma, increased intracranial pressure, decreased venous return, cardiovascular compromise, myocardial ischemia, air swallowing, nausea, vomiting, aspiration, mask discomfort, skin breakdown, and claustrophobia.

Hyperventilation can also occur if the patient breathes too quickly or too deeply during therapy. Symptoms may include dizziness, tingling in the fingers, light-headedness, and discomfort. If this occurs, the patient should stop therapy until symptoms resolve, then resume with a slower breathing pattern if appropriate.

Poor device setup can also cause problems. Excessive resistance may make exhalation difficult and lead to fatigue. Insufficient resistance may fail to generate therapeutic pressure. A blocked outlet can cause unexpectedly high pressure. Leaks around the mouthpiece or mask can prevent adequate pressure generation.

Note: Proper instruction, monitoring, and troubleshooting reduce these risks. PEP therapy may be simple, but it still requires careful application.

Troubleshooting PEP Therapy

Troubleshooting begins with observing the patient and checking the equipment. If the patient cannot exhale through the device, the therapist should check for obstruction. The valve, tubing, outlet port, or resistor may be blocked.

If the device fails to generate pressure, the most likely cause is often a leak. The therapist should check all connections, mouthpiece seal, mask fit, and one-way valves. A loose connection or poor seal can make the therapy ineffective.

If pressure is too high, the resistance may be set too high, the orifice may be too small, or the outlet may be obstructed by bedding, the patient’s hand, or another object. The therapist should reduce resistance or clear the obstruction.

If pressure is too low, the resistance may be too low, the patient may be exhaling too weakly, or there may be a leak. The therapist may need to coach the patient, adjust the resistor, or correct the seal.

Note: If the patient becomes frustrated or unwilling to continue, reeducation may be needed. Sometimes a small setup problem, such as resistance accidentally set to maximum, can make therapy feel impossible. Correcting the issue and explaining the device again can improve cooperation.

Cleaning and Maintenance

PEP devices must be cleaned according to manufacturer recommendations and infection control policy. Since patients exhale through the device and secretions may be present, cleaning is important to reduce contamination.

Many devices can be disassembled, washed with warm soapy water, rinsed thoroughly, and air-dried completely. Some devices may have specific parts that cannot be submerged or require special cleaning procedures. The patient should be taught exactly how to clean, dry, store, and reassemble the device.

Home care patients need clear instructions. They should know how often to clean the device, how to inspect it for damage, and when to replace parts. They should also know who to contact if the device stops working or if symptoms worsen.

Note: Good maintenance supports safe therapy and helps ensure that the device generates the intended pressure and airflow.

PEP Therapy in Exam Preparation

For respiratory therapy students, PEP therapy is a common board-style topic because it connects airway clearance, lung expansion, obstructive lung disease, equipment setup, contraindications, and patient education.

Important exam points include the mechanism of action. PEP helps keep airways open during exhalation, promotes collateral ventilation, moves secretions toward larger airways, and may reduce air trapping. It is often paired with huff coughing or directed coughing.

The target pressure is commonly about 10 to 20 cm H₂O. The patient should exhale longer than they inhale, often with an I:E ratio near 1:3. A typical treatment includes 10 to 20 breaths followed by huff coughing, repeated several times for a session of about 10 to 20 minutes.

Board questions may also focus on contraindications. Untreated pneumothorax, high intracranial pressure, hemodynamic instability, active hemoptysis, inability to tolerate increased work of breathing, facial trauma, sinusitis, epistaxis, and middle ear problems are important warning signs.

Note: Device troubleshooting is also an important topic. If pressure is too low, check for leaks or poor effort. If pressure is too high, check for obstruction or excessive resistance. If the patient cannot exhale, check the valve or outlet.

When PEP Should Be Modified or Discontinued

PEP therapy should not be continued just because it was ordered. It should be continued when it produces measurable or meaningful benefit.

The therapist should modify therapy if the patient is unable to generate the target pressure, becomes fatigued, reports discomfort, or shows signs of worsening distress. Adjustments may include reducing resistance, changing the device, switching from mouthpiece to mask, shortening the session, adding rest periods, or pairing therapy with bronchodilator treatment when appropriate.

PEP should be discontinued or paused if the patient develops significant intolerance, worsening oxygenation, chest pain, severe dyspnea, vomiting, suspected barotrauma, or unstable vital signs. It should also be reconsidered if sputum clearance does not improve and there is no other clear benefit.

Note: The safest and most effective respiratory therapy plan is individualized. PEP may be helpful for one patient and unnecessary for another. Ongoing assessment should guide the decision.

PEP Therapy Practice Questions

1. What does PEP stand for?
PEP stands for positive expiratory pressure.

2. What is positive expiratory pressure therapy?
Positive expiratory pressure therapy is a breathing technique in which the patient exhales against resistance to create positive pressure during expiration.

3. What is the main purpose of PEP therapy?
The main purpose of PEP therapy is to mobilize retained secretions, support lung expansion, improve ventilation, and reduce air trapping.

4. How does PEP therapy help move secretions?
PEP therapy helps keep small airways open during exhalation, allowing air to move behind secretions and push mucus toward larger airways.

5. What must the patient do after PEP mobilizes secretions?
The patient must use huff coughing, directed coughing, or another airway clearance method to remove the secretions.

6. How is PEP therapy different from CPAP?
PEP creates positive pressure only during exhalation, while CPAP provides positive pressure during both inspiration and expiration.

7. Why is PEP considered a patient-driven therapy?
PEP is patient-driven because the patient must actively inhale, exhale through the device, follow instructions, and cough effectively after treatment.

8. What type of patients must be able to participate in PEP therapy?
Patients must be alert, cooperative, able to follow instructions, and able to perform the breathing technique correctly.

9. What pressure range is commonly targeted during PEP therapy?
The common target pressure range for PEP therapy is about 10–20 cm H₂O.

10. What is the usual goal of exhaling against resistance during PEP therapy?
The goal is to create back pressure that helps prevent premature airway collapse and improves secretion movement.

11. How can PEP therapy help patients with expiratory airflow limitation?
PEP therapy can help by slowing exhalation, creating back pressure, and reducing premature airway collapse.

12. What common breathing technique is PEP similar to in obstructive lung disease?
PEP therapy is similar in concept to pursed-lip breathing.

13. Why may PEP therapy be helpful in COPD?
PEP may help patients with COPD by reducing air trapping, improving airway stability, and assisting secretion clearance.

14. Why may PEP therapy be useful in chronic bronchitis?
PEP may help chronic bronchitis patients mobilize retained secretions and improve airway clearance.

15. Why is PEP therapy commonly used in cystic fibrosis?
PEP therapy is commonly used in cystic fibrosis because it helps mobilize thick secretions and can often be performed independently.

16. Why may patients with bronchiectasis benefit from PEP therapy?
Patients with bronchiectasis may benefit because PEP helps move retained secretions from smaller airways toward larger airways.

17. How can PEP therapy help prevent or reverse atelectasis?
PEP therapy can help improve airway pressure, support lung expansion, increase functional residual capacity, and promote ventilation to poorly expanded areas.

18. Why are postoperative patients at risk for atelectasis?
Postoperative patients are at risk because pain, shallow breathing, immobility, and retained secretions can reduce lung expansion.

19. What role can PEP therapy play after surgery?
PEP therapy may help selected postoperative patients improve ventilation, clear secretions, and reduce the risk of atelectasis.

20. What is functional residual capacity (FRC)?
Functional residual capacity is the volume of air remaining in the lungs after a normal exhalation.

21. How can PEP therapy affect functional residual capacity?
PEP therapy may increase functional residual capacity by helping maintain positive airway pressure during exhalation.

22. What is collateral ventilation?
Collateral ventilation is the movement of air through alternate pathways that can help gas reach areas behind mucus obstruction.

23. How does collateral ventilation relate to PEP therapy?
PEP therapy may improve collateral ventilation, allowing air to move behind secretions and help push them toward larger airways.

24. What is a standard PEP device?
A standard PEP device is a device that provides expiratory resistance without adding airway oscillations.

25. What is an oscillating PEP device?
An oscillating PEP device provides expiratory resistance while also creating rapid pressure fluctuations or vibrations during exhalation.

26. What is another name for oscillating PEP?
Oscillating PEP is also called OPEP or vibratory PEP.

27. How is oscillating PEP different from standard PEP?
Oscillating PEP adds rapid pressure fluctuations or vibrations during exhalation, while standard PEP only provides expiratory resistance.

28. What is the purpose of oscillations during OPEP therapy?
The oscillations are intended to loosen secretions and help move them toward larger airways.

29. What are examples of oscillating PEP devices?
Examples of oscillating PEP devices include the Flutter, Acapella, Aerobika, and RC-Cornet.

30. What is an example of a standard PEP device?
TheraPEP is an example of a standard PEP device.

31. How does a fixed-orifice PEP device work?
A fixed-orifice PEP device creates resistance by having the patient exhale through an opening of a specific size.

32. How can resistance be adjusted in a fixed-orifice PEP device?
Resistance can be adjusted by changing the size of the expiratory orifice.

33. What happens if the expiratory orifice is too small?
If the expiratory orifice is too small, airway pressure may become too high and the patient may become fatigued.

34. What happens if the expiratory orifice is too large?
If the expiratory orifice is too large, pressure may be too low to provide therapeutic benefit.

35. What is the purpose of a manometer during PEP therapy?
A manometer allows the therapist and patient to monitor the pressure generated during exhalation.

36. What position is generally recommended for PEP therapy?
The patient should generally be placed upright, semi-Fowler’s, or Fowler’s position.

37. Why should the patient avoid slouching during PEP therapy?
Slouching can restrict diaphragmatic movement and make the breathing technique less effective.

38. When may supine positioning be used during PEP therapy?
Supine positioning may be used if the patient cannot tolerate an upright or semi-Fowler’s position.

39. How many breaths are commonly performed in one PEP cycle?
A typical PEP cycle includes about 10–20 breaths.

40. What should follow each cycle of PEP breaths?
Each cycle of PEP breaths should be followed by directed coughing or huff coughing.

41. How many times may a PEP breathing cycle be repeated during a session?
The cycle may be repeated about four to eight times during a session.

42. What is a common total treatment time for PEP therapy?
A common total treatment time is about 10–20 minutes.

43. What inspiratory-to-expiratory ratio is often targeted during PEP therapy?
An inspiratory-to-expiratory ratio near 1:3 is often targeted.

44. What I:E ratio range may be acceptable during PEP therapy?
An I:E ratio of about 1:2 to 1:4 may be acceptable.

45. Why should expiration be longer than inspiration during PEP therapy?
A longer expiration helps maintain airway pressure, promotes secretion movement, and reduces premature airway collapse.

46. Should the patient exhale forcefully during PEP therapy?
The patient should exhale actively but not forcefully, using a controlled breathing pattern.

47. Why should the patient avoid hyperventilating during PEP therapy?
Hyperventilation may cause dizziness, tingling, light-headedness, or discomfort.

48. What should be done if the patient becomes dizzy during PEP therapy?
Therapy should be stopped until symptoms resolve, then resumed with a slower breathing pattern if appropriate.

49. Why is patient coaching important during PEP therapy?
Patient coaching helps ensure the patient uses the correct breath size, expiratory effort, resistance level, and cough technique.

50. What breath size is commonly used before exhaling through a PEP device?
The patient usually inhales a tidal or slightly larger-than-tidal breath before exhaling through the device.

51. What type of exhalation is used during PEP therapy?
The patient uses active, controlled exhalation against resistance.

52. Why is PEP therapy useful for patients with retained secretions?
PEP therapy helps mobilize retained secretions so they can be moved toward larger airways and cleared more effectively.

53. What conditions commonly involve secretion retention that may benefit from PEP?
Conditions include cystic fibrosis, bronchiectasis, chronic bronchitis, COPD, asthma with mucus plugging, and bronchiolitis obliterans.

54. What is the role of PEP therapy in bronchial hygiene?
PEP therapy helps mobilize mucus, improve airway patency, and support effective secretion clearance.

55. How may PEP therapy improve ventilation distribution?
PEP therapy may help keep small airways open and allow air to reach poorly ventilated lung regions.

56. Why may PEP be helpful in patients with asthma and mucus plugging?
PEP may help move air behind mucus plugs and assist with secretion mobilization when the patient can tolerate the therapy.

57. Why should PEP therapy be used cautiously during an acute asthma attack?
PEP increases the work of breathing, which may worsen distress or fatigue in a patient who cannot tolerate added effort.

58. What is a relative contraindication involving the pleural space?
Untreated pneumothorax is a relative contraindication because positive pressure may worsen the air leak.

59. Why is high intracranial pressure a concern with PEP therapy?
Positive pressure and forced expiratory efforts may increase intracranial pressure further.

60. What intracranial pressure value is commonly listed as a caution for PEP therapy?
An intracranial pressure greater than 20 mm Hg is commonly listed as a caution.

61. Why is active hemoptysis a concern during PEP therapy?
Airway clearance maneuvers and pressure changes may worsen bleeding.

62. Why is hemodynamic instability a concern with PEP therapy?
Positive pressure can affect venous return and cardiovascular function, which may worsen instability.

63. Why should recent facial trauma be considered before PEP therapy?
A mask, mouthpiece, or pressure changes may cause pain or disrupt healing tissues.

64. Why is recent oral or skull surgery a concern for PEP therapy?
The pressure and breathing maneuvers may interfere with healing or increase the risk of complications.

65. Why is esophageal surgery a precaution for PEP therapy?
PEP may increase pressure and air swallowing, which may be unsafe after esophageal surgery.

66. Why can acute sinusitis be a concern during PEP therapy?
Pressure changes during PEP may worsen sinus discomfort or symptoms.

67. Why is epistaxis a relative contraindication for PEP therapy?
The pressure changes and mask interface may worsen nasal bleeding.

68. Why are middle ear problems important to assess before PEP therapy?
Pressure changes may worsen middle ear disease or discomfort.

69. Why is tympanic membrane rupture a concern during PEP therapy?
Pressure changes during therapy may worsen ear-related complications or discomfort.

70. Why is nausea a concern during PEP therapy?
PEP may cause air swallowing, which can worsen nausea and increase the risk of vomiting.

71. What is pulmonary barotrauma?
Pulmonary barotrauma is lung injury caused by excessive pressure, which is a possible hazard of positive pressure therapy.

72. How can PEP therapy affect venous return?
Positive pressure may decrease venous return to the heart in some patients.

73. What cardiovascular complication may occur with PEP therapy?
Myocardial ischemia is a possible cardiovascular complication in susceptible patients.

74. What mask-related complications may occur during PEP therapy?
Mask discomfort, skin breakdown, and claustrophobia may occur.

75. Why can increased work of breathing be a hazard of PEP therapy?
PEP requires active exhalation against resistance, which may fatigue some patients or worsen ventilation.

76. What should the therapist assess before starting PEP therapy?
The therapist should assess breath sounds, respiratory rate, heart rate, blood pressure, oxygenation, sputum production, pain, dyspnea, and the patient’s ability to follow instructions.

77. What should be monitored during PEP therapy?
The therapist should monitor dyspnea, pain, chest discomfort, breath sounds, vital signs, oxygenation, breathing pattern, and patient tolerance.

78. How can oxygenation be monitored during PEP therapy?
Oxygenation can be monitored with pulse oximetry, mental clarity, skin color, and the patient’s overall appearance.

79. What sputum characteristics should be assessed during airway clearance therapy?
Sputum should be assessed for amount, color, odor, and thickness.

80. What finding may suggest that PEP therapy is effective?
Easier secretion expectoration may suggest that PEP therapy is effective.

81. What breath sound change may suggest improvement after PEP therapy?
Improved or clearer breath sounds may suggest better secretion clearance or improved ventilation.

82. What radiographic finding may suggest that PEP therapy is helping atelectasis?
Improved radiographic evidence of atelectasis resolution may suggest that PEP therapy is effective.

83. Why should ineffective PEP therapy be discontinued or modified?
Ineffective PEP therapy should be discontinued or modified because treatment should be based on patient response, not routine use.

84. What should be checked if a patient cannot exhale through a PEP device?
The therapist should check the valve, tubing, resistor, and outlet port for obstruction.

85. What is a common cause of low pressure during PEP therapy?
A leak around the mouthpiece, mask, tubing, or device connections is a common cause of low pressure.

86. What should the therapist do if the PEP device fails to generate pressure?
The therapist should check for leaks, tighten connections, improve the mask or mouthpiece seal, and reassess patient effort.

87. What may cause unexpectedly high pressure during PEP therapy?
Unexpectedly high pressure may occur if the resistance is set too high or if the outlet port is obstructed.

88. What should be done if PEP resistance is accidentally set too high?
The therapist should reduce the resistance, reeducate the patient, and reassess comfort and pressure generation.

89. Why are device settings important during PEP therapy?
Device settings determine the amount of expiratory resistance and help ensure therapeutic pressure without causing fatigue.

90. What is the role of the respiratory therapist during PEP therapy?
The respiratory therapist selects appropriate patients, sets up the device, coaches technique, monitors response, and modifies therapy as needed.

91. How can PEP therapy be combined with aerosol therapy?
Some PEP systems allow a nebulizer or metered-dose inhaler adapter to be attached for aerosolized medication delivery.

92. What medications may be used with PEP therapy in selected patients?
Bronchodilators or mucolytic agents may be used with PEP therapy when clinically appropriate.

93. Why may bronchodilator therapy be helpful with PEP?
Bronchodilator therapy may improve airway opening, which can support better ventilation distribution and secretion movement.

94. Why should manufacturer instructions be followed when using PEP with aerosols?
Manufacturer instructions should be followed because not all PEP devices are designed for aerosol medication delivery.

95. What type of interface may be used if a patient cannot use a mouthpiece?
A mask may be used for patients who cannot effectively use a mouthpiece.

96. What types of patients may need a mask instead of a mouthpiece for PEP?
Toddlers, stroke patients, or patients with neuromuscular weakness may need a mask instead of a mouthpiece.

97. Why is cleaning important for PEP devices?
Cleaning is important because patients exhale through the device and secretions can contaminate the equipment.

98. How are many PEP devices cleaned in home care?
Many PEP devices can be disassembled, washed with warm soapy water, rinsed well, and completely air-dried.

99. What should home care patients be taught about PEP devices?
Home care patients should be taught proper use, cleaning, drying, storage, maintenance, and when to seek help.

100. What is the key exam takeaway about PEP therapy?
PEP therapy mobilizes secretions, supports ventilation distribution, may help atelectasis and air trapping, requires patient cooperation, and must be adjusted based on response.

Final Thoughts

Positive expiratory pressure (PEP) therapy is a practical airway clearance and lung expansion technique that can help selected patients mobilize secretions, improve ventilation distribution, reduce air trapping, and prevent or treat atelectasis.

Its success depends on choosing the right patient, selecting the right device, setting the proper resistance, and coaching the patient through the correct breathing pattern. PEP is most useful when the patient can participate actively and clear secretions with huff coughing or directed coughing.

Respiratory therapists must monitor tolerance, troubleshoot equipment problems, and adjust therapy based on response. When used correctly, PEP can be a valuable part of respiratory care.