Cystic Fibrosis (CF) Treatment: Positive Expiratory Pressure (PEP)

Cystic Fibrosis Center

Cystic Fibrosis (CF) Treatment: Positive Expiratory Pressure (PEP)

CF Information from Kids Health

For Parents

For Teens

For Kids

Positive expiratory pressure (PEP) therapy is an airway clearance technique for Cystic Fibrosis (CF) patients.

By breathing out with a moderate force through a resistance, a positive pressure is generated in the airways, helping to keep them open. This positive pressure allows airflow to get beneath the areas of mucus obstruction and move the mucus toward the larger airways, where it can be coughed out. Positive expiratory pressure therapy can also help deliver medication deeper into the lungs when done with nebulized bronchodilator therapy.

PEP techniques:

The PEP Valve

PEP valve
PEP valve

The PEP valve (pictured, left) has a mouthpiece that allows you to draw air in through a one way valve and blow air out through a hole or resistance. The resistance should be set so you feel as if your lungs are getting a workout. A pressure manometer is included to help you see the level of pressure that you want to maintain when you are blowing the air out.

Positive expiratory pressure therapy is best done sitting upright. You need to make a tight seal around the mouthpiece with your lips to prevent leaking. Take a deep breath in naturally but breathe out slowly with a moderate force for as long as you can. You will feel a sense of resistance when breathing out because the air is flowing through a small hole. This resistance is positive pressure being created in your airways and may make you feel the urge to cough.

After taking 20 deep breaths through the PEP valve you need to do two to three huff coughs. A huff cough is done by taking a deep breath in and holding it for one to three seconds. Then force the air out of your lungs and say the word huff at the same time.

Continue to repeat the breathing and coughing for 20 minutes. Positive expiratory pressure therapy can be self administered. Children may need some coaching from their parents as it is easy to lose concentration. Clean the PEP valve once a week in hot soapy water, rinse with hot water and let it air dry over night.

Flutter (Oscillating PEP)

Flutter device
Flutter (oscillating PEP) device

Flutter is also known as oscillating PEP. The pocket device looks like a fat pipe (pictured, left). Inside the pipe is a plastic cone cradling a steel ball sealed with a perforated cover. Its aim is to improve ventilation and mucus production.

Begin by placing your lips around the mouthpiece and taking a breath in through your nose. Then exhale through your mouth with a moderate force. This will cause the ball to oscillate in the pipe. Oscillation is transmitted throughout the airways, loosening secretions. The force of exhalation will help mobilize secretions. After 20 deep breaths, the huff cough is done. This sequence is repeated for 20 minutes or until there is no sputum production.

By changing the angle at which you hold the device you can change the oscillation. Clean the device weekly by disassembling the flutter, wash the pieces in a mild dish soap, rinse with clean tap water and air dry over night.

This device is great for those who are able to do therapy on their own. The individual must be compliant, responsible and able to tell at what angle of the flutter do they feel the most oscillation inside their lungs. If the technique is not done correctly, it is not as effective as manual chest physiotherapy.


Acapella device
Acapella valve

Acapella combines two different types of therapy into one: high frequency oscillation and positive expiratory pressure (PEP).

A lever with a magnet on the end is inside the Acapella. The magnet helps to intermittently interrupt the air flow across the lever, which causes a vibration in the lungs. A dial at one end of the acapella adjusts the amount of resistance. When air is blown out of the lungs through the Acapella valve, the air flow moves the lever back and forth. The number and size of lever movements or frequency is based on the resistance of the air flow.

The acapella comes in two colors. Green is for those who have at least 15 L/min of expiratory flow. Blue are for those who have less than 15 L/min of expiratory flow. The acapella does have an adapter to combine nebulizer therapy. Talk to your doctor to see if this combination is right for you.

The acapella treatment:

  • Make sure that the adjustment dial is set to the correct range identified by your health care provider.
  • Sit with your elbows resting comfortable on the table or sit upright.
  • Make a tight seal around the mouthpiece with your mouth. If you are using a mask, apply the mask tightly but comfortably over your nose and mouth.
  • Breathe in naturally, taking a deep breath.
  • Hold your breath for two to three seconds. This allows the air to move evenly throughout the lungs.
  • Breathe out slowly and forcefully into the Acapella. Keep your cheeks hard and flat while you are breathing out.
  • During the time that you are breathing out, you will feel a "fluttering" sensation in your neck and lungs. If you put your hand on your chest while you are exhaling, you should be able to feel the vibrations. If you do not feel vibrations on your chest, you should blow out with more force.
  • You should breathe out three to four times as long as you breathe in.
  • Continue taking slow deep breaths while breathing out through your flutter valve for about five minutes or 20 breaths.
  • Remove the mouthpiece or mask and perform a "huff cough."
  • A huff cough is performed by taking a deep breath and holding it for one to three seconds. Then force the air out of your lungs with your mouth open like you would do if you were trying to fog a mirror.
  • Continue the above steps for a total of 20 minutes or as prescribed by your doctor.

Note: It is very important to pace yourself as you breathe out into the Acapella device. Pause for a few seconds between breaths. If you feel dizzy or get a headache while using the Acapella, you may be breathing too fast. If you develop these symptoms, stop using the Acapella for a few minutes and breathe normally. When you begin to use the Acapella again, take more time between breaths.

Cleaning the Acapella

The Acapella should be cleaned twice weekly or more often if it is visibly soiled. One of two methods can be used to clean your Acapella.

Method 1:

  1. Remove the mouthpiece or mask from the Acapella.
  2. Place both pieces of the Acapella on the top shelf of the dishwasher and wash with your normal dishwasher soap.

Method 2:

  1. Wash both parts of the Acapella in warm soapy dishwater for five minutes.
  2. Rinse all of the parts and then place them in a bowl with enough rubbing alcohol (isopropyl alcohol) to cover the Acapella. Soak the Acapella device in the alcohol for five minutes.
  3. Remove the Acapella from the alcohol and rinse with sterile water. Do not use water from the faucet or bottled or distilled water. You can make water sterile by boiling it for five minutes. Use this water once and then throw it out.
  4. Drain the Acapella by turning it upside down.
  5. Place the Acapella on a clean paper towel to dry.

Return Clinic Visits or Hospitalizations

It is best to bring your Acapella long with you to clinic or if you are hospitalized to have the respiratory therapist review your technique.