ORIGINAL ARTICLE The effect of positive expiratory pressure (PEP) therapy on symptoms, quality of life and incidence of re-exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease: a multicentre, randomised controlled trial Christian R Osadnik, 1,2 Christine F McDonald, 2,3 Belinda R Miller, 4 Catherine J Hill, 2,5 Ben Tarrant, 6 Ranjana Steward, 6 Caroline Chao, 5 Nicole Stodden, 5 Cristino C Oliveira, 1 Nadia Gagliardi, 3 Anne E Holland 1,2,6 1 School of Physiotherapy, La Trobe University, Melbourne, Victoria, Australia 2 Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria, Australia 3 Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia 4 Department of Allergy, Immunology and Respiratory Medicine, Alfred Health, Melbourne, Victoria, Australia 5 Department of Physiotherapy, Austin Health, Melbourne, Victoria, Australia 6 Department of Physiotherapy, Alfred Health, Melbourne, Victoria, Australia Correspondence to Christian Robert Osadnik, La Trobe University, Alfred Clinical School, Level 4, The Alfred Centre, Commercial Road, Prahran, Melbourne, VIC 3181, Australia; christian.osadnik@monash.edu Received 13 February 2013 Revised 13 August 2013 Accepted 15 August 2013 Published Online First 4 September 2013 To cite: Osadnik CR, McDonald CF, Miller BR, et al. Thorax 2014;69: 137–143. ABSTRACT Background Positive expiratory pressure (PEP) is a technique used to enhance sputum clearance during acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The impact of PEP therapy during acute exacerbations on clinically important outcomes is not clear. This study sought to determine the effect of PEP therapy on symptoms, quality of life and future exacerbations in patients with AECOPD. Methods 90 inpatients (58 men; mean age 68.6 years, FEV 1 40.8% predicted) with AECOPD and sputum expectoration were randomised to receive usual care (including physical exercise)±PEP therapy. The Breathlessness, Cough and Sputum Scale (BCSS), St George’s Respiratory Questionnaire (SGRQ) and BODE index (Body mass index, airflow Obstruction, Dyspnoea, Exercise tolerance) were measured at discharge, 8 weeks and 6 months following discharge, and analysed via linear mixed models. Exacerbations and hospitalisations were recorded using home diaries. Results There were no significant between-group differences over time for BCSS score [mean (SE) at discharge 5.2 (0.4) vs 5.0 (0.4) for PEP and control group, respectively; p=0.978] or SGRQ total score [41.6 (2.6) vs 40.8 (2.8) at 8 weeks, p=0.872]. Dyspnoea improved more rapidly in the PEP group over the first 8 weeks (p=0.006), however these benefits were not observed at 6 months. Exacerbations (p=0.986) and hospitalisations (p=0.359) did not differ between groups. Conclusions We found no evidence that PEP therapy during AECOPD improves important short-term or long- term outcomes. There does not appear to be a routine role for PEP therapy in the management of such individuals. INTRODUCTION Acute exacerbations of chronic obstructive pulmon- ary disease (AECOPD) are clinically important events known to accelerate lung function decline, 12 decrease quality of life (QOL) 3 and increase the risk of mortality. 4 They are a common cause of hospital admission and are associated with recurrent exacer- bations, 5 thereby contributing significantly to the total healthcare burden of chronic obstructive pul- monary disease (COPD). Airway clearance techniques (ACT) involve the application of external forces and manipulation of lung volumes, pulmonary pressures and gas flow in order to shear sputum from the airway lumen towards the mouth. 6 Physiotherapists frequently prescribe ACTs during AECOPDs and perceive their role to be important, 7 however, their clinical impact appears small. 8 Positive expiratory pressure (PEP) therapy involves exhaling against a mild resistance, with the aim of shifting the equal pres- sure point peripherally to maximise airflow behind sputum and protect against dynamic airway col- lapse. It appears to confer greater short-term benefit than other ACTs 8 such as a reduced need for and duration of ventilatory assistance, 9 10 and have been recommended for patients with an AECOPD. 11 The increased expiratory time Key messages What is the key question? ▸ Does performance of airway clearance therapy via positive expiratory pressure (PEP) during an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) improve symptoms, quality of life and incidence of future exacerbations? What is the bottom line? ▸ PEP therapy conferred no additional benefit to usual care on key clinical outcomes, suggesting this form of therapy is unlikely to be routinely indicated for individuals with an AECOPD. Why read on? ▸ This large randomised and controlled multicentre study provides some of the first high-quality evidence regarding the efficacy of airway clearance therapy via PEP therapy and, in doing so, highlights an area of practice that may need careful consideration of its clinical efficacy. Osadnik CR, et al. Thorax 2014;69:137–143. doi:10.1136/thoraxjnl-2013-203425 137 Chronic obstructive pulmonary disease on June 11, 2020 by guest. Protected by copyright. http://thorax.bmj.com/ Thorax: first published as 10.1136/thoraxjnl-2013-203425 on 4 September 2013. Downloaded from