Oscillating positive expiratory pressure devices
Topic Status Complete
Oscillating positive expiratory pressure devices for airway clearance in chronic hypersecretory lung conditions.
Outcome of the appraisal
HTW undertook an evidence review to address the following question: are oscillating positive expiratory pressure (OPEP) devices more clinically and cost-effective than other techniques for airway clearance in chronic hypersecretory lung conditions?
A significant amount of evidence was identified on the effectiveness of OPEP in a range of different type of hypersecretory lung conditions. The way in which OPEP devices were used, and what outcomes were used to measure their effectiveness, differed considerably between different sources of evidence.
Stakeholders indicated that, in Wales, there is a clear, patient-dependent decision making process in place to determine who uses OPEP, and this process is subject to change in the future. Any recommendation would be temporary and little value would be added by the production of guidance at this time. Therefore, HTW’s Assessment Group concluded that this topic should not progress to Appraisal Panel and will not receive HTW Guidance recommendations.
Why was this topic appraised?
Positive expiratory pressure devices are often used as a form of chest physiotherapy to clear mucus from the lungs of individuals with hypersecretory conditions. OPEP devices seek to interrupt expiratory airflow by providing resistance during exhalation, causing the airways to vibrate and loosen the mucus. OPEP devices are already available through NHS prescribing and several devices are available in Wales. Feedback from clinical experts suggests that they are used as an option for patients alongside traditional airway clearance techniques where the patient is unable to undergo conventional types of physiotherapy. The review focused on use of the OPEP devices in people with hypersecretory conditions, including cystic fibrosis, chronic obstructive pulmonary disease, and bronchiectasis.
Plain language summary
Hypersecretory lung conditions, where an excess of mucus is produced, include conditions such as cystic fibrosis, chronic obstructive pulmonary disease (COPD), and bronchiectasis. In cystic fibrosis (CF), a genetic defect results in abnormal mucus production in the airways, which can cause obstruction and mucus plugging. It can also make it easy to get an infection, which in turn produces more mucus. COPD is an airflow obstruction which is not fully reversible. These obstructions to the small airways can cause increased mucus production, which in turn further narrows the airway. Lastly, bronchiectasis is a condition where the airways of the lungs become abnormally widened. This widening leads to a build-up of excess mucus that can make the lungs more vulnerable to infection. In all of these conditions, it becomes necessary to clear the airway and lungs of the excess build-up of mucus.
Mucus is traditionally cleared from the airways and lungs through the use of positive expiratory pressure (PEP) devices. When exhaling through a PEP mouthpiece, the device gives resistance that make it more difficult to breathe out. This helps to loosen and move mucus out of the lungs. After using the PEP device, the user huff coughs to help clear the mucus from the body. Oscillatory positive expiratory pressure devices combine PEP devices with high frequency oscillations, or fast movements back and forth in a regular rhythm, to provide resistance. These can be used in two ways; inside (intra-thoracic) or outside of the body (extra-thoracic). Intra-thoracic devices are usually placed in the mouth and provide resistance when breathing out, which causes the airways to vibrate and loosen the mucus. Extra-thoracic devices are placed outside the body.
HTW’s report found evidence on how effective OPEP devices are across a range of conditions. The way in which the devices were used, and the way their effectiveness was measured, varied across different conditions, making it difficult to recommend them for any particular group of patients. There is a clear, patient-dependent decision making process in place to determine who uses OPEP, and this process is subject to change in the future. HTW’s Assessment Group therefore concluded that any recommendation would be temporary and little value would be added by the production of guidance at this time.