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Positive Expiratory Pressure

Question 9:

In the child hospitalized with an asthma exacerbation, should positive expiratory pressure (PEP) therapy be used?


Inpatient Asthma team recommendation: Based on very low quality evidence the Asthma Inpatient CPG team makes a weak recommendation that PEP therapy may be used in the treatment of children hospitalized with asthma. Due to the lack of evidence on this therapy, a strong quality project or research study should be done to understand the efficacy of the treatment. Other alternatives may be equally reasonable. Further research (if performed) is likely to have an important influence on our confidence in the estimate of the effect and is likely to change the estimate.

Literature (Appendix E): The literature was searched since the publication of EPR-3 (2007). Two studies were identified. The studies are reported individually because the comparisons and outcomes differ for each study. Christensen, Norregaard, Jensen, & Dahl 1993) compared β2-agonists and PEP with functional residual capacity (FRC) and airway resistance (RAW). Frischknecht-Christensen, Norregaard, & Dahl (1991) used the same comparison but measured peak expiratory flow (PEF) and forced expired volume (FEV). Neither study showed improvement in the measured outcomes using PEP therapy. Clinical experience at Children’s Mercy has shown the usefulness of PEP therapy in children with asthma. Texas Children’s Hospital and Denver Children’s Hospital were contacted regarding the use of PEP therapy in hospitalized children with asthma. Texas Children’s does not use PEP routinely and Denver Children’s uses EzPAP, not PEP, due to the lack of evidence. 

Forest plot comparisons

Figure 5. PEP versus Terbutaline, Outcome Symptom Score

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.