Policy Number:

xx.xx

Section:

Respiratory

Title:

Positive Expiratory
Pressure (PEP)
Therapy

Original Date
Issued:
Date Reviewed:
Date Revised:

Regulatory Agency:

I. POLICY: Positive Expiratory Pressure (PEP) Therapy is a bronchial hygiene

technique used to improve secretion mobilization and clearance. This mode of
therapy increases intrathoracic pressure on expiration, thereby reducing small
airway closure. PEP therapy is performed by a licensed patient caregiver and
requires a physicians/designee's order.
A. SETTINGS:
1
2
3
4
5

Critical care
Acute care inpatient
Extended-care and transitional-care facilities
Home care
Outpatient

B. INDICATIONS:
1To reduce air trapping in asthma and COPD
2To aid in mobilization of retained secretions (in cystic fibrosis and chronic
bronchitis)
3To prevent or reverse atelectasis
4To optimize delivery of bronchodilators in patients receiving bronchial
hygiene therapy
C. CONTRAINDICATIONS:
Although no absolute contraindications to the use of PEP therapy have been
reported, the following should be carefully evaluated before a decision is made
to initiate PEP mask therapy.
1 Patients unable to tolerate the increased work of breathing (acute
asthma, COPD)
2 Intracranial pressure (ICP) > 20 mm Hg
3 Hemodynamic instability
4Recent facial, oral, or skull surgery or trauma4

5 Acute sinusitis
6 Epistaxis
7 Esophageal surgery
8Active hemoptysis
9 Nausea
10 Known or suspected tympanic membrane rupture or other middle ear
pathology
11 Untreated pneumothorax
D. HAZARDS/COMPLICATIONS:
1 Increased work of breathing that may lead to hypoventilation and
hypercarbia
2 Increased intracranial pressure
3 Cardiovascular compromise
3.1 myocardial ischemia
3.2 decreased venous return
4 Air swallowing, with increased likelihood of vomiting and aspiration
5 Claustrophobia
6 Skin break down and discomfort from mask
7 Pulmonary barotrauma
E. LIMITATIONS OF METHOD:
1 PEP therapies for bronchial hygiene require spontaneously breathing
patients.
F. ASSESSMENT OF NEED:
The following should be assessed together to establish a need for Threshold PEP
therapy:
1 Sputum retention not responsive to spontaneous or directed coughing
2 History of pulmonary problems treated successfully with postural
drainage therapy
3 Decreased breath sounds or adventitious sounds suggesting secretions
in the airway
4 Change in vital signs-increase in breathing frequency, tachycardia
5 Abnormal chest radiograph consistent with atelectasis, mucus plugging,
or infiltrates
6 Deterioration in arterial blood gas values or oxygen saturation

II. PROCEDURE:
A. Threshold PEP Hyperinflation Therapy:
1. Gather equipment:
a. Soft, transparent hand ventilation mask or patient
mouthpiece with nose clips.
b. Threshold PEP device
c. Nebulizer with tee (if needed)
d. Adapters for supplemental oxygen (if needed)
e. Sputum Basin and paper towels
2. Perform hand hygiene and put on personal protective
equipment.
3. Assess heart rate, respiratory rate, bilateral breath sounds,
and work of breathing before, during, and after treatment.
4. Have developmentally able patient sit or stand upright with
mask applied tightly but comfortably over nose and mouth.
Position infants and other patients not able to sit, in a
position that will provide the most effective treatment. When
using a mouthpiece have patient grasp mouthpiece tightly
between the lips. Gently apply nose clips.
5. Instruct patient to take a deep breath and exhale, but not
forcefully, maintaining a positive expiratory pressure as per
physician order. Exhalation should be 2-3 times longer than
inspiration.
6. Repeat step 5 around 20 times or as patient tolerates.
7. If using the Threshold PEP during a nebulizer treatment;
connect the mouthpiece end of the Threshold PEP to the
nebulizers tee via a 22x22 adaptor, or directly to the end of
the 6 inch wide bore tubing. Attach the mouth piece to the
opposite end of the tee.
8. Instruct the patient to take a deep breath in during the
nebulization process and exhale, but not forcefully,
maintaining a positive expiratory pressure as per physician
order. Exhalation should be 2-3 times longer than inspiration.
9. The Threshold PEP device can be used throughout the entire
neb treatment. The patient may be instructed to exhale
normally, not prolonged, if they become fatigued or dizzy
during treatment.

B. Threshold PEP Mucous Clearance Therapy:

1. Follow steps A (1-6 or 1-9) above.
2. Have developmentally able patient sit or stand upright with
mask applied tightly but comfortably over nose and mouth. .
Position infants and other patients not able to sit, in a
position that will provide the most effective treatment. When
using a mouthpiece have patient grasp mouthpiece tightly
between the lips. Gently apply nose clips.
3. Increase the pressure setting on the Threshold PEP to 1820cmH2O
4. Instruct patient to inhale to an almost full lung capacity.
5. Have patient hold their breath for 2-3 seconds.
6. Instruct patient to exhale quickly and forcefully, like
performing a peak flow maneuver or blowing an air dart gun.
7. Instruct patient to cough.
8. Repeat steps B (2-7) above as needed.

III. CHARTING:
Document using current charting format.
IV. REFERENCES:
Threshold PEP package insert
AARC PEP Clinical Practice Guideline http://www.rcjournal.com/cpgs/papcpg.html