Positive expiratory pressure (PEP) therapy
By GAtherton

The aim of physiotherapy for chest clearance is to remove the excess secretions which are produced by the lungs in response to infection, virus or toxins from fungal stimulus. Regular maintenance treatment is important to keep a clear chest and reduce the need for repeated courses of antibiotics.

Three Aims of Chest Clearance are to optimise the muco-cilary escalator,  maintain open airways reducing wheeze, and generate air flow in the airways, getting air behind the phlegm to help push it upwards from the small airways towards the mouth. The aim of physiotherapy is to do all of these things in the most energy and time efficient way possible.  This is not as  complicated sounds and your physiotherapist will help you build a personalised plan to work best with your lungs, an example of a maintenance chest physiotherapy treatment plan  is shown below.


  1. Optimise the mucocilary escalator: Hypertonic Saline(See below), increase oral  hydration and fluid intake.
  2. Maintain open airways to allow the upward movement sputum: Bronchodilators / inhalers will help relax and open the small airways and reduce wheeze, and the Pari O-PEP will splint them open also as you blow out through the PEP device.
  3. Generate air flow in the airways: Deep breathing exercises gets air in behind the sputum to push if from lower in the airways to higher up in the chest, oscillations from the OPEP device helps by adding to turbulence in airways.


Example Patient’s Physiotherapy Treatment Plan

Seretide 250 Evohaler
(Tiotropium) Spiriva Respimat 2.5 mg
Salbutamol (Ventolin) inhaler MDI As required
(Use as required for tightness/wheeze; remember to leave 30 seconds between each puff).

Inhaled Bronchodilator therapies help to open up and relax the airways prior to clearing the phlegm from your chest.


Hypertonic Saline 7% nebuliser via side stream with a mouthpiece
Mucolytics can help to loosen and unstick phlegm from the airways in order to make it easier to move and clear from the chest.

Airway Clearance Techniques: Pari OPEP

The aim of airway clearance is to gather as much phlegm as possible and cough it out in a controlled and energy efficient way. The aim is to clear your chest so you can breathe more freely and still have energy to do the activities you like afterwards.


Step 1: Start off your airway clearance by doing some long, slow, deep breaths in and out while sat up. Sigh and ‘actively’ let go of the breath – do approx. 5 breaths before moving on to step two.  


Then try lying on your side

Step 2; Pari OPEP Try to take a SLOW deep breath in through your nose, filling your lungs as much as possible. Blow out a long, slow breath through your OPEP; try to make the duration of the breath in and out last as long as you can, blow out as far as you can without coughing. Try to keep your cheeks stiff and feel the vibrations deep into your chest. Repeat several of these large breaths to fill your lungs then move on to try some smaller breaths. You can do this by doing a SMALL slow breath in, then blow out through your OPEP device, a low force, long breath out– blow out as far as you can without coughing. Take a small or half sized breath in and continue to blow out as far as you can without coughing.

The Pari O-PEP helps to splint open the smaller airways during your breath out, making the diameter of the airway bigger, allowing  for more space and stopping the phlegm from getting trapped in the smaller airways. The O-PEP also creates oscillations or vibrations which create turbulence inside the airways, these shearing forces unstick the phlegm and drag it up to the larger airways where it can be coughed up and out of chest.  

Step 3: Clearing   As you feel the sputum move up try a little huff and a cough. To huff take a breath in and then blow out a forceful, short and fast breath, out through an open mouth. Try a long slow ‘garlic breath’ huff or a short, sharp fast huff.


Postural Drainage; Repeat the cycle above on the opposite side.

Once your breathing has recovered repeat step 2 and 3 until your chest feels clear. 

Remember-  Try to control your cough- control your breath in after your cough so it is not a fast, sharp breath in.


Excessive coughing can lead to increased airway irritability and increase wheeze or chest tightness, if you don’t cough anything up after one or two coughs you should return to more breathing exercises to move the phlegm a little higher before trying to cough again.


Repeat your appropriate inhaler, nebulisers and airway clearance twice each day, once in the morning and once in the

evening as discussed at your appointment.

Remember to wash your OPEP and nebuliser equipment in hot soapy water and leave to air dry.

  • Remember to boil in water for 5 minutes at least once per week. Please do not hesitate to get in contact with us here at the
    National Aspergillosis Centre(NAC) should you need any ongoing advice.


Hypertonic Saline is a drug taken through a nebuliser that you inhale, it has a high salt concentration which acts on the layers of mucus in your airways. It is a mucolytic which means it helps you to clear the phlegm out of your chest, you may have already tried it if you have done a sputum induction procedure with the physiotherapists in clinic. Mucolytics disrupt the structure of the mucus gel, thereby reducing its viscosity and elasticity. The intention of mucolytic therapy is therefore to make the viscoelasticity of the airway secretions better to help their clearance from the airways.


7% Hypertonic Saline Nebusal video: https://youtu.be/wTOpTnhA6no (Other concentrations and brands are available)


The Pari O-PEP device is an Oscillating Positive Expiratory Pressure device which helps with airway clearance, there are several types of adjuncts and breathing techniques which can help you clear your chest. Your physiotherapist will take into account your how much sputum you have, how your airways react to huffing and coughing and your chest xrays and CT reports when deciding which airway clearance technique should work best for you. There are techniques such as the Active Cycle of Breathing Techniques, Autogenic Drainage, Postural Drainage and other devices such as the Aerobika or Acapella Choice.

Aerobika Airway Clearance Adjunct Video: https://youtu.be/iy2oYadhF9Q


Research studies have shown that regular chest clearance treatment assisted with hypertonic saline will make your sputum (phlegm) easier to cough up. This means:

• you may have fewer flare ups of your chest

• you may have fewer admissions to hospital

• your symptoms may improve

• your lungs may stay healthier for longer

• maintain or improve your lung function

Your physiotherapist can help make you a personalised chest maintenance routine to optimise your chest clearance. Do not hesitate to ask the team if you wish to speak with the physiotherapy team at your clinic next appointment.