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Meta-Analysis
. 2019 Nov 27;2019(11):CD003147.
doi: 10.1002/14651858.CD003147.pub5.

Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis

Maggie McIlwaine  1 , Brenda Button  2 , Sarah J Nevitt  3
Affiliations
Meta-Analysis

Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis

Maggie McIlwaine et al. Cochrane Database Syst Rev. .

Abstract

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 back pressure to the airways during expiration. This may improve clearance by building up gas behind mucus via collateral ventilation and by temporarily increasing functional residual capacity. The developers of the PEP technique recommend using PEP with a mask in order to avoid air leaks via the upper airways and mouth. In addition, increasing forced residual capacity (FRC) has not been demonstrated using mouthpiece PEP. Given the widespread use of PEP devices, there is a need to determine the evidence for their effect. This is an update of a previously published review.

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 methods: 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 2017. Most recent search of the Group's CF Trials Register: 20 February 2019.

Selection criteria: Randomised controlled studies in which PEP was compared with any other form of physiotherapy in people with CF. This included, postural drainage and percussion (PDPV), active cycle of breathing techniques (ACBT), oscillating PEP devices, thoracic oscillating devices, bilevel positive airway pressure (BiPaP) and exercise.

Data collection and analysis: Three authors independently applied the inclusion and exclusion criteria to publications, assessed the risk of bias of the included studies and assessed the quality of the evidence using the GRADE recommendations.

Main results: A total of 28 studies (involving 788 children and adults) were included in the review; 18 studies involving 296 participants were cross-over in design. Data were not published in sufficient detail in most of these studies to perform any meta-analysis. In 22 of the 28 studies the PEP technique was performed using a mask, in three of the studies a mouthpiece was used with nose clips and in three studies it was unclear whether a mask or mouthpiece was used. These studies compared PEP to ACBT, autogenic drainage (AD), oral oscillating PEP devices, high-frequency chest wall oscillation (HFCWO) and BiPaP and exercise. Forced expiratory volume in one second was the review's primary outcome and the most frequently reported outcome in the studies (24 studies, 716 participants). Single interventions or series of treatments that continued for up to three months demonstrated little or no difference in effect between PEP and other methods of airway clearance on this outcome (low- to moderate-quality evidence). However, long-term studies had equivocal or conflicting results regarding the effect on this outcome (low- to moderate-quality evidence). A second primary outcome was the number of respiratory exacerbations. There was a lower exacerbation rate in participants using PEP compared to other techniques when used with a mask for at least one year (five studies, 232 participants; moderate- to high-quality evidence). In one of the included studies which used PEP with a mouthpiece, it was reported (personal communication) that there was no difference in the number of respiratory exacerbations (66 participants, low-quality evidence). Participant preference was reported in 10 studies; and in all studies with an intervention period of at least one month, this was in favour of PEP. The results for the remaining outcome measures (including our third primary outcome of mucus clearance) were not examined or reported in sufficient detail to provide any high-quality evidence; only very low- to moderate-quality evidence was available for other outcomes. There was limited evidence reported on adverse events; these were measured in five studies, two of which found no events. In a study where infants performing either PEP or PDPV experienced some gastro-oesophageal reflux , this was more severe in the PDPV group (26 infants, low-quality evidence). In PEP versus oscillating PEP, adverse events were only reported in the flutter group (five participants complained of dizziness, which improved after further instructions on device use was provided) (22 participants, low-quality evidence). In PEP versus HFCWO, from one long-term high-quality study (107 participants) there was little or no difference in terms of number of adverse events; however, those in the PEP group had fewer adverse events related to the lower airways when compared to HFCWO (high-certainty evidence). Many studies had a risk of bias as they did not report how the randomisation sequence was either generated or concealed. Most studies reported the number of dropouts and also reported on all planned outcome measures.

Authors' conclusions: The evidence provided by this review is of variable quality, but suggests that all techniques and devices described may have a place in the clinical treatment of people with CF. Following meta-analyses of the effects of PEP versus other airway clearance techniques on lung function and patient preference, this Cochrane Review demonstrated that there was high-quality evidence that showed a significant reduction in pulmonary exacerbations when PEP using a mask was compared with HFCWO. It is important to note that airway clearance techniques should be individualised throughout life according to developmental stages, patient preferences, pulmonary symptoms and lung function. This also applies as conditions vary between baseline function and pulmonary exacerbations.

PubMed Disclaimer

Conflict of interest statement

Maggie McIlwaine is the Principal Investigator for four of the included studies. These studies were independently assessed by the other review authors.

Brenda Button declares no potential conflict of interest.

Sarah Nevitt declares no potential conflict of interest.

Figures

1.1
1.1. Analysis
Comparison 1 PEP compared with PDPV, Outcome 1 Change in FEV1 (% predicted).
1.2
1.2. Analysis
Comparison 1 PEP compared with PDPV, Outcome 2 Change in FVC (% predicted).
1.3
1.3. Analysis
Comparison 1 PEP compared with PDPV, Outcome 3 Change in FEF25‐75 (% predicted).
1.4
1.4. Analysis
Comparison 1 PEP compared with PDPV, Outcome 4 TLC.
1.5
1.5. Analysis
Comparison 1 PEP compared with PDPV, Outcome 5 Radiological imaging: increased bronchial markings.
1.6
1.6. Analysis
Comparison 1 PEP compared with PDPV, Outcome 6 Radiological imaging: change in Brasfield score.
1.7
1.7. Analysis
Comparison 1 PEP compared with PDPV, Outcome 7 Adverse events.
2.1
2.1. Analysis
Comparison 2 PEP compared with oscillating PEP (Acapella, Flutter and Cornet)), Outcome 1 Change in FEV1 (% predicted).
2.2
2.2. Analysis
Comparison 2 PEP compared with oscillating PEP (Acapella, Flutter and Cornet)), Outcome 2 Hospitalisations for respiratory exacerbation (number per participant).
2.3
2.3. Analysis
Comparison 2 PEP compared with oscillating PEP (Acapella, Flutter and Cornet)), Outcome 3 Change in FVC (% predicted).
2.4
2.4. Analysis
Comparison 2 PEP compared with oscillating PEP (Acapella, Flutter and Cornet)), Outcome 4 Change in FEF25‐75 (% predicted).
2.5
2.5. Analysis
Comparison 2 PEP compared with oscillating PEP (Acapella, Flutter and Cornet)), Outcome 5 Exercise performance (percentage change).
2.6
2.6. Analysis
Comparison 2 PEP compared with oscillating PEP (Acapella, Flutter and Cornet)), Outcome 6 LCI.
2.7
2.7. Analysis
Comparison 2 PEP compared with oscillating PEP (Acapella, Flutter and Cornet)), Outcome 7 User satisfaction (patient satisfaction survey).
2.8
2.8. Analysis
Comparison 2 PEP compared with oscillating PEP (Acapella, Flutter and Cornet)), Outcome 8 Adherence: at least 85% of prescribed treatments performed.
2.9
2.9. Analysis
Comparison 2 PEP compared with oscillating PEP (Acapella, Flutter and Cornet)), Outcome 9 Participant preference: self‐withdrawal due to lack of perceived effectiveness.
3.1
3.1. Analysis
Comparison 3 PEP compared with HFCWO, Outcome 1 Change in FEV1 (% predicted).
3.2
3.2. Analysis
Comparison 3 PEP compared with HFCWO, Outcome 2 Participants experiencing a respiratory exacerbation.
3.3
3.3. Analysis
Comparison 3 PEP compared with HFCWO, Outcome 3 Change in FVC (% predicted).
3.4
3.4. Analysis
Comparison 3 PEP compared with HFCWO, Outcome 4 Change in FEF25‐75 (% predicted).
See this image and copyright information in PMC

Update of

Comment in

References

References to studies included in this review

Braggion 1995 {published data only}
    1. Braggion C, Cappelletti LM, Cornacchia M, Zanolla L, Mastella G. Short‐term effects of three chest physiotherapy regimens in patients hospitalized for pulmonary exacerbations of cystic fibrosis: a cross‐over study. Pediatric Pulmonology 1995;19(1):16‐22. [CFGD Register: PE26b] - PubMed
    1. Cappelletti LM, Cornacchia M, Braggion C, Zanolla L, Mastella G. Short‐term effects of 3 physiotherapy (CPT) regimens in cystic fibrosis (CF) patients hospitalized for a pulmonary exacerbation: a cross‐over randomized trial. 18th European Cystic Fibrosis Conference; 1993 May 21‐26; Madrid. 1993:W9.3. [CFGD Register: PE26a] - PubMed
    1. Cappelletti LM, Cornacchia M, Braggion C, Zanolla L, Mastella G. Short‐term effects of three chest physiotherapy regimens on patients with cystic fibrosis hospitalized for pulmonary exacerbation: a crossover randomized study. Excerpta Medica International Congress Series 1993;1034:239‐46. [CFGD Register: PE26c]
Costantini 2001 {published data only (unpublished sought but not used)}
    1. Costantini D, Brivio A, Brusa D, Delfino R, Fredella C, Russo, et al. PEP‐mask versus postural drainage in CF infants a long‐term comparative trial. 24th European Cystic Fibrosis Conference; 2001. Vienna, 2001:100. [CFGD Register: PE94b]
    1. Costantini D, Brivio A, Brusa D, Delfino R, Fredella C, Russo, et al. PEP‐mask versus postural drainage in CF infants a long‐term comparative trial. Pediatric Pulmonology 2001;Suppl 22:308. [CFGD Register: PE94c]
    1. Costantini D, Brivio A, Delfino R, Sguera A, Brusa D, Padoan R, et al. PEP mask versus postural drainage in CF infants. Pediatric Pulmonology 1998;Suppl 17:342. [CFGD Register: PE94a]
Darbee 1990 {published and unpublished data}
    1. Dadparvar S, Darbee J, Jehan A, Bensel K, Slizofski WJ, Holsclaw D. Tc‐DTPA aerosol ventilation evaluates the effectiveness of PEP mask in the treatment of cystic fibrosis. European Respiratory Journal 1995;8 Suppl 19:177s.
    1. Darbee J, Dadparvar S, Bensel K, Jehan A, Watkins M, Holsclaw D. Radionuclide assessment of the comparative effects of chest physical therapy and positive expiratory pressure mask in cystic fibrosis. Pediatric Pulmonology 1990;Suppl 5:251.
Darbee 2004 {published data only}
    1. Darbee JC, Grant BJ, Ohtake PJ, Cerny FC. Positive expiratory pressure breathing and gas distribution in cystic fibrosis. Pediatric Pulmonology 2000;Suppl 20:304.
    1. Darbee JC, Ohtake PJ, Grant BJB, Cerny FJ. Physiologic evidence for the efficacy of positive expiratory pressure as an airway clearance technique in patients with cystic fibrosis. Physical Therapy 2004;84(6):524‐37. - PubMed
Darbee 2005 {published data only}
    1. Darbee JC, Kanga JF, Ohtake PJ. Physiological evidence for high‐frequency chest wall oscillation and positive expiratory breathing in hospitalized subjects with cystic fibrosis. Physical Therapy 2005;85(12):1278‐89. - PubMed
    1. Darbee JC, KangaJF, Ohtake PJ. Physiological evidence for high frequency chest wall oscillation and positive expiratory breathing in hospitalized patients with cystic fibrosis. Pediatric Pulmonology 2005;40 Suppl 21:322. - PubMed
Fainardi 2011 {published data only}
    1. Fainardi V, Longo F, Faverzani S, Tripodi MC, Chetta A, Pisi G. Short‐term effects of high‐frequency chest compressions and positive expiratory pressure in patients with cystic fibrosis. Journal of Clinical Medicine Research 2011;3(6):279‐84. - PMC - PubMed
Falk 1984 {published data only}
    1. Falk M, Kelstrup M, Andersen JB, Kinoshita T, Falk P, Stovring S, et al. Improving the ketchup bottle method with positive expiratory pressure, PEP, in cystic fibrosis. European Journal of Respiratory Diseases 1984;65(6):423‐32. - PubMed
Falk 1993 {published data only}
    1. Falk M, Mortensen J, Kelstrup M, Lanng S, Larsen L, Ulrik CS. Short‐term effects of positive expiratory pressure and the forced expiration technique on mucus clearance and lung function in CF. Pediatric Pulmonology 1993;Suppl 9:241.
    1. Larsen L, Mortensen J, Falk M, Kelstrup M, Lanng S, Ulrik CS. Radiolabelled mucus clearance in patients with cystic fibrosis is improved by physiotherapy with positive expiratory pressure and the forced expiration technique. Clinical Physiology 1994;14:365.
    1. Mortensen J, Falk M, Kelstrup M, Lanng S, Ulrik CS. Effect of positive expiratory pressure and the forced expiration technique on mucus clearance in patients with cystic fibrosis. European Respiratory Journal 1993;6(Suppl 17):409S.
Gaskin 1998 {published and unpublished data}
    1. Gaskin L. [personal communication]. Conversation with: M McIlwaine before 11 November 2019.
    1. Gaskin L, Corey M, Shin J, Reisman JJ, Thomas J, Tullis DE. Long term trial of conventional postural drainage and percussion vs. positive expiratory pressure. Pediatric Pulmonology 1998;Suppl 17:345.
Hofmeyr 1986 {published data only}
    1. Hofmeyr JL, Webber BA, Hodson ME. Evaluation of positive expiratory pressure as an adjunct to chest physiotherapy in the treatment of cystic fibrosis. Thorax 1986;41(12):951‐4. - PMC - PubMed
    1. Webber BA, Hofmeyer JL, Hodson ME, Batten JC. Evaluation of positive expiratory pressure as an adjunct to postural drainage. 13th Annual Meeting of the European Working Group for Cystic Fibrosis; 1985 Nov 3‐8; Jerusalem. 1985:95.
Kofler 1998 {published data only}
    1. Kofler AM, Carlesi A, Cutrera R, Leone P, Lucidi V, Rosati S, et al. BiPAP versus PEP as chest physiotherapy in patients with cystic fibrosis. Pediatric Pulmonology 1998;Suppl 17:344.
Lagerkvist 2006 {published data only}
    1. Lagerkvist AL, Sten G, Lindblad A, Redfors S. Chest physiotherapy with positive expiratory pressure (PEP) and oscillating positive expiratory pressure (flutter) in patients with cystic fibrosis ‐ a comparative study. 21st European Cystic Fibrosis Conference 1997 June 1‐6. 1997:132.
    1. Lagerkvist AL, Sten GM, Redfors SB, Lindblad AG, Hjalmarson O. Immediate changes in blood‐gas tensions during chest physiotherapy with positive expiratory pressure and oscillating positive expiratory pressure in patients with cystic fibrosis. Respiratory Care 2006;51(10):1154‐61. - PubMed
Lannefors 1992 {published data only}
    1. Lannefors L, Wollmer P. Mucus clearance in cystic fibrosis (CF) ‐ a comparison between postural drainage, PEP‐mask and physical exercise. 11th International Cystic Fibrosis Congress; 1992; Dublin, Ireland. 1992:AHP31. - PubMed
    1. Lannefors L, Wollmer P. Mucus clearance with three chest physiotherapy regimes in cystic fibrosis: a comparison between postural drainage, PEP and physical exercise. European Respiratory Journal 1992;5(6):748‐53. - PubMed
McIlwaine 1991 {published and unpublished data}
    1. Davidson AGF, McIlwaine PM, Wong TK, Nakielna EM, Pirie GE. A comparative trial of positive expiratory pressure, autogenic drainage and conventional percussion and drainage techniques. Pediatric Pulmonology 1988;Suppl 2:137. [CFGD Register: PE44a]
    1. McIlwaine PM, Davidson AGF. Comparison of positive expiratory pressure and autogenic drainage with conventional percussion and drainage therapy in the treatment of CF. 17th European Cystic Fibrosis Conference; 1991 Jun 18‐21; Copenhagen. 1991:S8.4. [CFGD Register: PE44c]
    1. McIlwaine PM, Davidson QGF, Wong LTK, Pirie GE, Nakielna EM. Comparison of positive expiratory pressure and autogenic drainage with conventional percussion and drainage therapy in the treatment of CF. 10th International Cystic Fibrosis Congress; Mar 5‐10; Sydney. 1988; Vol. 74:3. [CFGD Register: PE44b]
    1. McIlwaine PM, Wong LT, Pirie GE, Davidson AG. Comparison of positive expiratory pressure and autogenic drainage therapy in the treatment of cystic fibrosis (as supplied 21 July 2003). Data on file. [CFGD Register: PE44d]
McIlwaine 1997 {published and unpublished data}
    1. Button B, Herbert R, Maher C. Positive expiratory pressure therapy better maintains pulmonary function than postural drainage and percussion in patients with cystic fibrosis. Australian Journal of Physiotherapy 1998;44(4):285‐6.
    1. McIlwaine PM, Wong LT, Peacock D, Davidson AG. Long‐term comparative trial of conventional postural drainage and percussion versus positive expiratory pressure physiotherapy in the treatment of cystic fibrosis. 12th International Cystic Fibrosis Conference; 1996 Jun 16‐21; Jerusalem. 1996:S193. - PubMed
    1. McIlwaine PM, Wong LT, Peacock D, Davidson AG. Long‐term comparative trial of conventional postural drainage and percussion versus positive expiratory pressure physiotherapy in the treatment of cystic fibrosis. Journal of Pediatrics 1997;131(4):570‐4. - PubMed
    1. McIlwaine PM, Wong LT, Peacock D, Davidson AG. Long‐term comparative trial of conventional postural drainage and percussion versus positive expiratory pressure physiotherapy in the treatment of cystic fibrosis. Pediatric Pulmonology 1995;Suppl 12:268. - PubMed
McIlwaine 2001 {published data only}
    1. Davidson AG, McIlwaine PM, Wong LT, Peacock D. "Flutter versus PEP": A long‐term comparative trial of positive expiratory pressure (PEP) versus oscillating positive pressure (Flutter) physiotherapy techniques. 22nd European Cystic Fibrosis Conference; 1998 Jun 13‐19; Berlin. 1998:71.
    1. McIlwaine PM, Wong LT, Peacock D, Davidson AG. Long‐term comparative trial of positive expiratory pressure versus oscillating positive expiratory pressure (flutter) physiotherapy in the treatment of cystic fibrosis. Journal of Pediatrics 2001;138(6):845‐50. - PubMed
    1. McIlwaine PM, Wong LTK, Peacock D, Davidson AGF. "Flutter versus PEP": A long‐term comparative trial of positive expiratory pressure (PEP) versus oscillating positive expiratory pressure (Flutter) physiotherapy techniques. Pediatric Pulmonology 1997;Suppl 14:299.
McIlwaine 2013 {published data only}
    1. Alarie N, Agnew JL, McIlwaine M, Ratjen F, Davidson G, Lands LC. Canadian National Airway Clearance Study: how physically active are CF patients?. Pediatric Pulmonology 2012;47(S35):367. [CENTRAL: 875004; CFGD Regsiter: PE187e; CRS: 5500125000000032]
    1. Alarie N, Agnew LL, McIlwaine MP, Ratjen F, Davidson GF, Milner R, et al. Evaluation of physical activity using the habitual activity estimation scale (HAES) questionnaire in a multicenter study. Journal of Cystic Fibrosis 2013;12 Suppl 1:S28. [CENTRAL: 875001; CFGD Register: PE187f; CRS: 5500100000011657]
    1. McIlwaine M, Agnew J, Alarie N, Ratjen F, Lands L, Milner R, et al. Canadian national airway clearance study: patient satisfaction with positive expiratory pressure versus high frequency chest wall oscillation. Pediatric Pulmonology 2012;47 Suppl 35:367. [CFGD Register: PE187b]
    1. McIlwaine M, Agnew JL, Alarie N, Lands L, Ratjen F, Milner R, et al. Canadian national airway clearance study: positive expiratory pressure mask versus high frequency chest wall oscillation. Journal of Cystic Fibrosis 2012;11 Suppl 1:S23. [CFGD Register: PE187a]
    1. McIlwaine MP, Alarie N, Davidson GF, Lands LC, Ratjen F, Milner R, et al. Long‐term multicentre randomised controlled study of high frequency chest wall. Thorax 2013;68(8):746‐51. [CFGD Register: PE187c; ] - PubMed
Mortensen 1991 {published data only}
    1. Falk M, Mortensen J, Jensen C, Groth S, Jensen T. Postural drainage or PEP: effects on tracheobronchial clearance in cystic fibrosis. Pediatric Pulmonology 1990;Suppl 5:226.
    1. Mortensen J, Falk M, Groth S, Jensen C. The effects of postural drainage and positive expiratory pressure physiotherapy on tracheobronchial clearance in cystic fibrosis. Chest 1991;100(5):1350‐7. - PubMed
    1. Mortensen J, Groth S, Falk M, Jensen C, Jensen T. Assessment of tracheobronchial clearance by sputum expectorated during chest physiotherapy in cystic fibrosis. European Respiratory Journal 1990;3 Suppl 10:260s‐61s.
Newbold 2005 {published data only}
    1. Newbold ME, Brooks D, Tullis DE, Ross BG. Effectiveness of the flutter device versus the PEP mask in the treatment of adult cystic fibrosis. Pediatric Pulmonology 2000;Suppl 20:304.
    1. Newbold ME, Tullis E, Corey M, Ross B, Brooks D. The flutter device versus the PEP mask in the treatment of adults with cystic fibrosis. Physiotherapy Canada 2005;57(3):199‐207.
Pfleger 1992 {published data only}
    1. Pfleger A, Theissl B, Oberwaldner B, Zach MS. Self‐administered chest physiotherapy in cystic fibrosis: a comparative study of high‐pressure PEP and autogenic drainage. Lung 1992;170(6):323‐30. - PubMed
    1. Theissl B, Pfleger A, Oberwaldner B, Zach M. Chest physiotherapy (PT) in cystic fibrosis (CF) ‐ a comparative study of high‐pressure PEP and autogenic drainage. Pediatric Pulmonology 1990;Suppl 5:256. - PubMed
Pryor 2010 {published data only}
    1. Pryor JA, Tannenbaum E, Cramer D, Scott SF, Burgess J, Gyi K, et al. A comparison of five airway clearance techniques in the treatment of people with cystic fibrosis. Journal of Cystic Fibrosis 2006;5 Suppl 1:S76. - PubMed
    1. Pryor JA, Tannenbaum E, Scott SF, Burgess J, Cramer D, Gyi K, et al. Beyond postural drainage and percussion: Airway clearance in people with cystic fibrosis. Journal of Cystic Fibrosis 2010;9(3):187‐92. - PubMed
Rodriguez 2016 {published data only}
    1. Rodriguez Hortal MC, Hjelte L. Non invasive ventilation as airway clearance technique compared to PEP in adult patients with cystic fibrosis. Journal of Cystic Fibrosis 2013;12 Suppl 1:S18. [Abstract no: WS9.4; CENTRAL: 875000; CRS: 5500100000011654]
    1. Rodriguez Hortal MC, Nygen‐Bonnier M, Hjelte L. Non‐invasive ventilation as airway clearance technique in cystic fibrosis. Phyiotherapy Research International 2016;22(3):1‐9. - PubMed
Steen 1991 {published data only}
    1. Steen HJ, Redmond AO, O'Neill D, Beattie F. Evaluation of the PEP mask in cystic fibrosis. Acta Paediatrica Scandinavica 1991;80(1):51‐6. - PubMed
    1. Steen HJ, Redmond AO, O'Neill D, Beattie F. Has the PEP mask a role in the management of teenage patients?. 13th Annual Meeting of the European Working Group for Cystic Fibrosis; 1985 Nov. 3‐8; Jerusalem. 1985:94.
Tannenbaum 2005 {published data only}
    1. Main E, Tannenbaum E, Stanojevic S, Scrase E, Prasad A. The effects of positive expiratory pressure (PEP) or oscillatory positive pressure (RC Cornet®) on FEV1 and lung clearance index over a twelve month period in children with CF. Pediatric Pulmonology 2006;41 Suppl 29:351.
    1. Prasad A, Tannenbaum E, Bryon M, Main E. One year trial of two airway clearance techniques in children with cystic fibrosis: Limitations of the quality of well‐being scale. Pediatric Pulmonology 2005;Suppl 28:323.
    1. Tannenbaum E, Prasad SA, Main. E, Scrase E. Long term effects of positive expiratory pressure (PEP) or oscillatory positive pressure (RC Cornet®) on FEV1 and perceived health in children with CF. 28th European Cystic Fibrosis Conference; 2005 Jun 22‐25; Crete, Greece. 2005:S100.
Tyrrell 1986 {published and unpublished data}
    1. Tyrrell JC, Hiller EJ, Martin J. Face mask physiotherapy in cystic fibrosis. Archives of Disease in Childhood 1986;61(6):598‐600. - PMC - PubMed
    1. Tyrrell JC, Martin J, Hiller EJ. 'PEP' mask physiotherapy in cystic fibrosis. 13th Annual Meeting of the European Working Group for Cystic FIbrosis; 1985 Nov 3‐8; Jerusalem. 1985:23.
van Asperen 1987 {published and unpublished data}
    1. Asperen PP, Jackson L, Hennessy P, Brown J. Comparison of a positive expiratory pressure (PEP) mask with postural drainage in patients with cystic fibrosis. Australian Journal of Paediatrics 1987;23(5):283‐4. - PubMed
van Winden 1998 {published data only}
    1. Winden CM, Visser A, Hop W, Sterk PJ, Beckers S, Jongste JC. Effects of Flutter and PEP‐MASK on expectoration and lung function in cystic fibrosis. 12th International Cystic Fibrosis Conference; 1996 Jun 16‐21; Jerusalem, Israel. 1996:S275.
    1. Winden CM, Visser A, Hop W, Sterk PJ, Beckers S, Jongste JC. Effects of flutter and PEP mask physiotherapy on symptoms and lung function in children with cystic fibrosis. European Respiratory Journal 1998;12(1):143‐7. - PubMed
West 2010 {published data only}
    1. West K, Wallen M, Follett J. Acapella vs. PEP mask therapy: a randomised trial in children with cystic fibrosis during respiratory exacerbation. Physiotherapy Theory and Practice 2010;26(3):143‐9. [CENTRAL: 753270; CRS: 5500050000000049; PUBMED: 20331370] - PubMed

References to studies excluded from this review

Aquino 2006 {published data only}
    1. Aquino A, Balestri E, Dall 'Ara S, Lami I, Gobbi F, Ambroni M, et al. Efficacy of physical exercise playing a video game for mucus clearance in patients with Cystic Fibrosis. Journal of Cystic Fibrosis 2006;5 Suppl:S83.
Aquino 2012 {published data only}
    1. Aquino ES, Shimura F, Santos AS, Goto DM, Coelho CC, Fucciiio MB, et al. CPAP has no effect on clearance, sputum properties or expectorated volume in cystic fibrosis. Respiratory Care 2012;57(11):1914‐9. - PubMed
Aubriot 2016 {unpublished data only}
    1. Aubriot A, Lebecque P, Teresinha L, Liistro G, Reychler G. Evaluation of the combination of positive expiratory pressure and nebulization with cystic fibrosis patients. Paediatric Pulmonology 2016;51 Suppl 45:371. [Abstract no.: 468]
Balestri 2004 {published data only}
    1. Balestri E, Ambroni M, Dall'Ara S, Miano A. Efficacy of physical exercise for mucus clearance in patients with cystic fibrosis (CF). Pediatric Pulmonology 2004;Suppl 27:316.
Battistini 2001 {published data only}
    1. Battistini R, Balestri E, Ambroni M, Miano A. Efficacy of underwater positive expiratory pressure therapy (UPEP) for mucus clearance in patients with cystic fibrosis. 24th European Cystic Fibrosis Conference; 2001 Jun 6‐9; Vienna. 2001:P104.
Bishop 2011 {published data only}
    1. Middleton PG, Bishop J. Dornase alpha and physiotherapy ‐ which should be first? A randomised, double‐blind, placebo‐controlled trial in CF adults. Pediatric Pulmonology 2001;32 Suppl 22:310. [CFGD Register: BD102c]
Borka 2012 {published data only}
    1. Borka P, Gyurkovits K, Bodis J. Comparative study of PEP mask and Flutter on expectoration in cystic fibrosis patients. Acta Physiologica Hungarica 2012; Vol. 99, issue 3:324‐31. [] - PubMed
Castle 1994 {published data only}
    1. Castle T, Metcalfe C, Knox A. A comparison between the active cycle of breathing technique (A.C.B.T.) and positive expiratory pressure (PEP) mask plus A.C.B.T. on sputum production and lung volumes in adults with Cystic Fibrosis. 19th European Cystic Fibrosis Conference; 1994 May 29‐Jun 3. 1994:O17.
Dosman 2003 {published data only}
    1. Dosman CF, Zuberbuhler PC, Tabak JI, Jones RL. Effects of positive end‐expiratory pressure on oscillated volume during high frequency chest compression in children with cystic fibrosis. Canadian Respiratory Journal 2003;10(2):94‐8. - PubMed
Falk 1988 {published data only}
    1. Falk M, Kelstrup M, Andersen JB, Pedersen SS, Rossing I, Dirksen H. PEP treatment or physical exercise. Effects on secretions expectorated and indices of central and peripheral airway function. A controlled study. 10th International Cystic Fibrosis Conference; 1988 Mar 5‐10; Sydney. 1988.
Fitzgerald 2001 {published data only}
    1. Fitzgerald DA, Hilton J, Jepson B, Smith L. A crossover, randomized, controlled trial of dornase alfa before versus after physiotherapy in cystic fibrosis. Pediatrics 2005;116(4):e549. [CFGD Register: BD102b] - PubMed
    1. Fitzgerald DA, Hilton J, Smith L, Jepson B. Is dornase alfa (Pulmozyme) more effective before or after physiotherapy? A cross‐over, randomised, placebo‐controlled trial. Pediatric Pulmonology 2001; Vol. 32 Suppl 22:309‐10. [CFGD Register: BD102a; ]
Gotz 1995 {published data only}
    1. Gotz M, Wolkerstorfer A. Physiotherapy in cystic fibrosis: intrapulmonary percussive ventilation (IPV) versus positive expiratory pressure (PEP). Pediatric Pulmonology 1995;Suppl 12:267.
Kraemer 1996 {published data only}
    1. Kraemer D, Liedtke C, Casaulta AC. Bronchodilator inhalation (BD) treatment in sequence with flutter VRP1 chest physiotherapy (CPT) in patients with cystic fibrosis. Israel Journal of Medical Sciences 1996;32 Suppl:S192.
Laube 2000 {published data only}
    1. Laube BL, Geller DE, Lin TC, Dalby RN, Diener‐West M, Zeitlin PL. Positive expiratory pressure changes aerosol distribution in patients with cystic fibrosis. Respiratory Care 2005;50(11):1438‐44. - PubMed
    1. Laube BL, Lin T, Geller D, Dalby R, Zeitlin P. Positive expiratory pressure alters aerosol distribution in CF. Pediatric Pulmonology 2000;Suppl 20:247.
Liedtke 1996 {published data only}
    1. Liedtke D, Castaulta AC, Martin N, Schibler A, Kraemer R. Mucociliar clearance (MCC) in patients with cystic fibrosis (CF)‐Efficacy of beta 2‐inhalation therapy ( beta 2) in combination with respiratory physiotherapy. Schweizerische Medizinische Wochenschrift 1996;126 Suppl 78:29s.
Marks 1998 {published data only}
    1. Marks JH, Fooy C, Anderson K, Homnick DN. Nebulized albuterol delivered with positive expiratory pressure (PEP) and the flutter device in patients with cystic fibrosis: an assessment of bronchodilator response compared to standard nebulizer therapy. American Journal of Respiratory and Critical Care Medicine 1998; Vol. 157, issue 3 Suppl:A130. []
McCarren 2006 {published data only}
    1. McCarren B, Alison JA. Comparison of vibration to other physiotherapy interventions for secretion clearance. European Respiratory Journal 2005;26 Suppl 49:497s. []
    1. McCarren B, Alison JA. Physiological effects of vibration in subjects with cystic fibrosis. European Respiratory Journal 2006; Vol. 27, issue 6:1204‐9. [] - PubMed
Munro 2007 {published data only}
    1. Munro P, Button B, Bailey M, Ellis S, Whitford H, Snell G. A prospective randomized trial comparing airway clearance strategies following lung transplant. Journal of Cystic Fibrosis 2007;6 Suppl 1:S62.
    1. Munro PE, Button B, Bailey M, Whitford H, Ellis S, Snell G. A prospective randomized trial comparing airway clearance strategies following lung transplantation. Pediatric Pulmonology 2007;42 Suppl 30:352.
Oermann 2001 {published data only}
    1. Oermann CM, Sockrider MM, Giles D, Sontag MK, Accurso FJ, Castile RG. Comparison of high‐frequency chest wall oscillation and oscillating positive expiratory pressure in the home management of cystic fibrosis: a pilot study. Pediatric Pulmonology 2001;32(5):372‐7. - PubMed
Orlik 2000 {published data only}
    1. Orlik T. Evaluation of autodrainage methods in a selected group of cystic fibrosis patients with home environment factors taken into consideration. Medycyna Wieku Rozwojowego 2000;4(3):247‐59. - PubMed
Orlik 2015 {published data only}
    1. Orlik T, Sands D. Application of positive expiratory pressure PEP in cystic fibrosis patient inhalations. Developmenyal Period Medicine 2015;19(1):50‐9. - PubMed
Padman 1999 {published data only}
    1. Padman R, Geouque DM, Engelhardt MT. Effects of the flutter device on pulmonary function studies among pediatric cystic fibrosis patients. Delaware Medical Journal 1999;71(1):13‐8. - PubMed
Patel 2013 {published data only}
    1. Patel P, Fukushima L, Balekian A, Chou W, Lu A, Gali V, et al. Is Metaneb comparable to high frequency chest compression in the setting of a severe pulmonary exacerbation in adults with cystic fibrosis. Pediatric Pulmonology 2013;48 Suppl 36:359. [Abstract No.: 420; CENTRAL: 887112; CRS: 5500125000000289]
Placidi 2001 {published data only}
    1. Placidi G, Cornacchia M, Cappelletti LM, Mastella G, Assael BM, Braggion C. Short‐term effects of positive airway pressure on sputum clearance by directed coughing: A cross‐over, randomized study. Pediatric Pulmonology 2001;32 Suppl 22:313‐4.
    1. Placidi G, Cornacchia M, Polese G, Zanolla L, Assael BM, Braggion C. Chest physiotherapy with positive airway pressure: a pilot study of short‐term effects on sputum clearance in patients with cystic fibrosis and severe airway obstruction. Respiratory Care 2006;51(10):1145‐53. - PubMed
Reychler 2015 {published data only}
    1. Reychler G, Jacques L, Arnold D, Scheers I, Smets F, Sokal E, et al. Influence of chest physiotherapy on gastro‐oesophagael reflux in children. Revue des Maladies Respiratories 2015;32(5):493‐9. - PubMed
Richmond 2016 {unpublished data only}
    1. Richmond M, Lee Son N, Chilvers M, McIlwaine M. Use of technology to measure adherence to and quality of airway clearance techniques. Paediatric Pulmonology 2016;51 Suppl 45:371. [Abstract no.: 467; CFGD Register: MH47]
Roos 1987 {published data only}
    1. Roos S, Birrer P, Rudeberg A, Kraemer R. First experience with intrapulmonary percussive ventilation (IPV) in the treatment of patients with cystic fibrosis. 15th Annual Meeting of the European Working Group for Cystic Fibrosis; 1987; Oslo. 1987.
Sanchez Riera 1999 {published data only}
    1. Sanchez Riera H, Dapena Fernandez FJ, Gomez Dominguez F, Ortega Ruiz F, Elias Hernandez T, Montemayor Rubio T, et al. Comparative study of the efficacy of 2 respiratory physiotherapy protocols for patients with cystic fibrosis [Estudio comparativo de la eficacia de dos protocolos de fisioterapia respiratoria en pacientes con fibrosis quistica.]. Archivos de Bronconeumologia 1999;35(6):275‐9. - PubMed
    1. Toral J, Sanchez H, Ortega F, Elfas T, Castillo D, Montemayor T. Comparative study of two treatments of respiratory physiotherapy for cystic fibrosis [Estudio comparativo de dos tratamientos de fisioterapia respiratoria en la fibrosis qufstica]. Archivos de Bronconeumologia 1997;33:39.
van der Schans 1991 {published data only}
    1. Schans CP, Mark TW, Vries G, Piers DA, Beekhuis H, Dankert‐Roelse JE, et al. Effect of positive expiratory pressure breathing in patients with cystic fibrosis. Thorax 1991;46(4):252‐6. - PMC - PubMed
van Hengstum 1987 {published data only}
    1. Hengstum M, Festen J, Beurskens C, Hankel M, Broek W, Buijs W, et al. The effect of positive expiratory pressure (PEP) versus forced expiration technique (FET) on tracheobronchial clearance in chronic bronchitics. 15th Annual Meeting of the European Working Group for Cystic Fibrosis; 1987; Oslo. 1987.
Wettstein 2014 {published data only}
    1. Wettstein M, Radlinger L, Riedel T. Effect of different breathing aids on ventilation distribution in adults with cystic fibrosis. PLoS One 2014;9(9):1‐5. - PMC - PubMed
Wilson 2015 {unpublished data only}
    1. Wilson P, Lambert C, Nwokoro C. Safety of nebulised hypertonic saline via Pari eFlow with Pari positive expiratory pressure (PEP) device in circuit for paediatric cystic fibrosis patients. Journal of Cystic Fibrosis 2015;14 Suppl 1. [Abstract no.: 170]
Znotina 2000 {published data only}
    1. Znotina I, Svabe V. The effectiveness of physiotherapy for children with cystic fibrosis. 13th International Cystic Fibrosis Congress; 2000 Jun 4‐8; Stockholm. 2000:152.

References to studies awaiting assessment

Elkins 2005 {published data only}
    1. Elkins MR, Eberl S, Constable C, White J, Robinson M, Daviskas E, et al. The effect of manual chest physiotherapy, positive expiratory pressure (PEP), and oscillating PEP on mucociliary clearance in subjects with cystic fibrosis. Pediatric Pulmonology 2005; Vol. 40 Suppl 28:321. []
Grzincich 2008 {published data only}
    1. Grzincich GL, Longon F, Faverzani S, Chetta A, Spaggiari C, Pisi G. Short‐term effects of high‐frequency chest compression (HFCC) and positive expiratory pressure (PEP) in adults with cystic fibrosis. European Respiratory Society Annual Congress; 2008 Oct 4‐8; Berlin, Germany. 2008:502s. []
Kofler 1994 {published data only}
    1. Kofler AM, Belluscio M, Bressan T, Carlesi A, Leone P, Lucidi V, et al. PEP‐mask and active cycle of breathing techniques. What is better in children with cystic fibrosis. 19th European Cystic Fibrosis Conference; 1994 May 29‐Jun 3; Paris. 1994:066.
Parreira 2008 {published data only}
    1. Parreira V, Pires S, Sulmonett N, Camargos P, Haddad J, Britto R. Positive expiratory pressure and lung function in cystic fibrosis patients. European Respiratory Society Annual Congress; 2008 Oct 4‐8; Berlin, Germany. 2008:E1779. [CENTRAL: 679902; CRS: 5500050000000051]
Radtke 2018 {published data only}
    1. Radtke T, Boni L, Bohnacker P, Fischer P, Benden C, Dressel H. The many ways sputum flows ‐ Dealing with high within‐subject variability in cystic fibrosis sputum rheology. Respiratory Physiology & Neurobiology 2018;254:36‐9. [CFGD Register: PE255c] - PubMed
    1. Radtke T, Boni L, Bohnacker P, Maggi‐Beba M, Fischer P, Kriemler S, et al. Acute effects of combined exercise and oscillatory positive expiratory pressure therapy on sputum properties and lung diffusing capacity in cystic fibrosis: a randomized, controlled, crossover trial. BMC Pulmonary Medicine 2018;18(1):99. [CFGD Register: PE255a] - PMC - PubMed
    1. Radtke T, Boni L, Bohnacker P, Maggi‐Bebba M, Fischer P, Kriemler S, et al. Acute effects of combined exercise and oscillatory positive expiratory pressure therapy on sputum properties and lung diffusing capacity in cystic fibrosis: a randomised, controlled, crossover trial. Journal of Cystic Fibrosis 2018;17 Suppl 3:S15. [CFGD Register: PE255b] - PMC - PubMed
Tonnesen 1982 {published data only}
    1. Tonnesen P, Kelstrup M. Self‐administered positive end expiratory pressure (PEEP) using a face mask as an alternative to conventional lung physiotherapy [Selvadministeret positivt sluteksspiratorisk tryk (PEEP) pa maske som alternativ til konventionel lungefysioterapi.]. Ugeskr Laeger 1982;144(21):1532‐6. - PubMed
Vendrusculo 2019 {published data only}
    1. Vendrusculo FM, Johnstone Z, Dhouieb E, Donadio MVF, Cunningham S, Urquhart DS. Airway clearance physiotherapy can reduce dead space and lead to improvements in ventilatory inhomogeniety during exercise in patients with cystic fibrosis: a pilot study. Journal of Cystic Fibrosis 2017;16 Suppl 1:S8. [Abstract no.: WS04.6; CFGD Register: PE250a]
    1. Vendrusculo FM, Johnstone Z, Dhouieb E, Donadio MVF, Cunningham S, Urquhart DS. Airway clearance physiotherapy improves ventilatory dynamics during exercise in patients with cystic fibrosis: a pilot study. Archives of Disease in Childhood 2019;104(1):37‐42. [CFGD Register: PE250b] - PubMed
Ward 2018 {published data only}
    1. Ward N, Stiller K, Rowe H, Morrow S, Morton J, Greville H, et al. Airway clearance by exercising in mild cystic fibrosis (ACE‐CF): a feasibility study. Respiratory Medicine 2018;142:23‐8. [CFGD Register: PE257b] - PubMed
    1. Ward N, Stiller K, Rowe H, Morrow S, Morton J, Greville H, et al. Airway clearance by exercising in mild cystic fibrosis: clinical outcomes. Respirology 2018;23(Suppl 1):140. [CFGD Register: PE257a] - PubMed
Wong 2000 {published data only}
    1. Wong LT, McIlwaine PM, Davidson AG. Gastroesophageal reflux during chest physiotherapy: a comparison of positive expiratory pressure and postural drainage with percussion. 13th International Cystic Fibrosis Congress; 2000 June 4‐8; Stockholm. 2000:130.
    1. Wong LT, McIlwaine PM, Davidson AG. Gastroesophageal reflux during chest physiotherapy: a comparison of positive expiratory pressure and postural drainage with percussion. Pediatric Pulmonology 1999;Suppl 19:288.

Additional references

Andersen 1979
    1. Andersen JB, Qvist H, Kann T. Recruiting collapsed lung through collateral channels with positive end‐expiratory pressure. Scandinavian Journal of Respiratory Disease 1979;60:260‐266. - PubMed
Cantin 1995
    1. Cantin A. Cystic fibrosis lung inflammation: Early, sustained, and severe. American Journal of Respiratory and Critical Care Medicine 1995;151(4):939‐41. - PubMed
Elbourne 2002
    1. Elbourne DR, Altman DG, Higgins JP, Curtin F, Worthington HV, Vail A. Meta‐analysis involving cross‐over trials: methodological issues. International Journal of Epidemiology 2002;31(1):140‐9. - PubMed
Groth 1985
    1. Groth S, Stafanger G, Dirksen H, Andersen JB, Falk M, Kelstrup M. Positive expiratory pressure (PEP‐Mask) physiotherapy improves ventilation and reduces volume of trapped gas in cystic fibrosis. Bulletin Europeen de Physiopathologie Respiratoire 1985;21(4):339‐43. - PubMed
Higgins 2003
    1. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta‐analyses. BMJ 2003;327(7414):557‐60. - PMC - PubMed
Konstan 1997
    1. Konstan MW, Berger M. Curent understanding of the inflammatory process in cystic fibrosis: onset and etiology. Pediatric Pulmonology 1997;24(2):137‐42. - PubMed
Liou 2001
    1. Liou TG, Adler FR, Fitzsimmons SC, Cahill BC, Hibbs JR, Marshall BC. Predictive 5‐year survivorship model of cystic fibrosis. American Journal of Epidemiology 2001;153(4):345‐52. - PMC - PubMed
Main 2005
    1. Main E, Prasad A, Schans C. Conventional chest physiotherapy compared to other airway clearance techniques for cystic fibrosis. Cochrane Database of Systematic Reviews 2005, Issue Issue 1. [DOI: 10.1002/14651858.CD002011.pub2] - DOI - PMC - PubMed
McIlwaine 1996
    1. McIlwaine MP, Davidson AG. Airway clearance techniques in the treatment of cystic fibrosis. Current Opinion in Pulmonary Medicine 1996;2(6):447‐51. [MEDLINE: ] - PubMed
Oberwaldner 1986
    1. Oberwaldner B, Evans JC, Zach MS. Forced expirations against a variable resistance: a new chest physiotherapy method in cystic fibrosis. Pediatric Pulmonology 1986;2:358‐267. - PubMed
Prasad 1993
    1. Prasad SA. Current concepts in physiotherapy. Journal of the Royal Society of Medicine 1993;86(Suppl 20):23‐9. [MEDLINE: ] - PMC - PubMed
Prasad 2000
    1. Prasad SA, Tannenbaum EL, Mikelsons C. Physiotherapy in cystic fibrosis. Journal of the Royal Society of Medicine 2000;93(Suppl 38):27‐36. [MEDLINE: ] - PMC - PubMed
Review Manager 2014 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Southern 2003
    1. Southern KW, Smyth RL. Design of clinical trials in cystic fibrosis. Lancet 2003;361(9354):349‐50. - PubMed
Warnock 2013
    1. Warnock L, Gates A, Schans CP. Chest physiotherapy compared to no chest physiotherapy for cystic fibrosis. Cochrane Database of Systematic Reviews 2013, Issue 9. [DOI: 10.1002/14651858.CD001401.pub2] - DOI - PubMed
Williams 1994
    1. Williams MT. Chest physiotherapy and cystic fibrosis. Why is the most effective form of treatment still unclear?. Chest 1994;106(6):1872‐82. - PubMed
Zach 1987
    1. Zach MS, Oberwaldner B. Chest physiotherapy: the mechanical approach to antiinfective therapy in cystic fibrosis. Infection 1987;15(5):381‐4. [MEDLINE: ] - PubMed
Zach 1990
    1. Zach MS. Lung disease in cystic fibrosis ‐ an updated concept. Pediatric Pulmonology 1990;8(3):188‐202. - PubMed

References to other published versions of this review

Elkins 2004
    1. Elkins MR, Jones A, Schans C. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2004, Issue 1. [DOI: 10.1002/14651858.CD003147.pub2] - DOI - PubMed
Elkins 2006
    1. Elkins M, Jones A, Schans CP. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2006, Issue 2. [DOI: 10.1002/14651858.CD003147.pub3] - DOI - PubMed
McIlwaine 2015
    1. McIlwaine M, Button B, Dwan K. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. Cochrane Database of Systematic Reviews 2015, Issue 6. [DOI: 10.1002/14651858.CD003147.pub4] - DOI - PubMed

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