Not enough strong evidence about the effects of positive expiratory pressure (PEP) devices for chest physiotherapy for people with cystic fibrosis

Elkins M, Jones A, van der Schans CP

Published Online:

January 21, 2009

Cystic fibrosis (CF) causes frequent respiratory infection and blocks the airways with mucus secretions. Chest physiotherapy is frequently used to try to clear these secretions out of the lungs. Positive expiratory pressure (PEP) devices provide pressure behind the mucus to try to push it out of the lungs. The review of studies found only weak evidence about the effects of PEP. The evidence does not show that PEP is more effective than other methods of chest physiotherapy. There was some evidence that people with CF may prefer PEP to other chest physiotherapy methods, but more research is needed.

Abstract (click to read)

Background:

Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis (CF). Positive expiratory pressure (PEP) devices provide constant back pressure to the airways during expiration. This may improve clearance by building up gas behind mucus via collateral ventilation. Given the widespread use of PEP devices, there is a need to determine the evidence for their effect.

Objectives:

To determine the effectiveness and acceptability of PEP devices compared to other forms of physiotherapy as a means of improving mucus clearance and other outcomes in people with CF.

Search strategy:

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. The electronic database CINAHL was also searched from 1982 to 2001.

Most recent search of the Group's register: February 2006.

Selection criteria:

Randomised controlled studies in which PEP was compared with any other form of physiotherapy in people with CF.

Data collection and analysis:

Two authors independently applied the inclusion and exclusion criteria to publications and assessed the quality of the included studies.

Main results:

Forty studies were identified and twenty-five studies involving 507 participants met the review inclusion criteria. Most included studies had low scores on a scale of study quality. Twenty of these studies involving 300 participants were cross-over in design. Data were not published in sufficient detail in most of these studies to perform meta-analysis.

Forced expiratory volume in one second (FEV1) was the most frequently measured outcome. Single interventions or series of treatments continued for up to three months demonstrated no significant difference in effect between PEP and other methods of airway clearance on FEV1. Long-term studies had equivocal or conflicting results regarding the effect on FEV1. Participant preference was reported in nine studies. In all studies with an intervention period of at least one month, measures of participant preference were in favour of PEP. The results for the remaining outcome measures were not examined or reported in sufficient detail to provide any high level evidence.

Authors' conclusions:

There was no clear evidence that PEP was a more or less effective intervention overall than other forms of physiotherapy. There was limited evidence that PEP was preferred by participants compared to other techniques, but this finding is from studies of low quality.

This record should be cited as:

Elkins M, Jones A, van der Schans CP. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD003147. DOI: 10.1002/14651858.CD003147.pub3

Assessed as up to date:

February 22, 2006

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Primary Review Group:

Cystic Fibrosis and Genetic Disorders Group

Health topics:

Genetic disorders > Cystic fibrosis > Physiotherapy & exercise

Lungs & airways > Cystic fibrosis > Physiotherapy & exercise

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Not enough strong evidence about the effects of positive expiratory pressure (PEP) devices for chest physiotherapy for people with cystic fibrosis

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