A positive experience from use of PEP

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

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.   

World Continence Week 2019

This week is World Continence Week, an annual event designed to raise awareness of bladder weakness and pelvic health. These are very common problems – bladder weakness alone affects 1 in 3 people – but there still remains a stigma which needs to be tackled. Due to chronic coughing, many aspergillosis patients will face stress incontinence (loss of urine due to pressure put on the bladder), which can impact on airway clearance techniques and life in general. Unfortunately, incontinence is seen as part and parcel of ageing (or illness, pregnancy etc.), so many don’t access the help they need. However, incontinence can be helped, and in many cases cured, with exercises, surgery or medication. World Continence Week aims to educate people on how common pelvic health issues are, reduce the stigma surrounding them and link people with the help they may need.

For more information:

Love your lungs week 2019

This week is the British Lung Foundation’s Love Your Lungs Week, a chance to raise awareness about breathlessness and lung disease. As many aspergillosis sufferers will know, lung disease can be difficult to diagnose and can have a significant impact on quality of life. The BLF are raising awareness of their online breath test – a quick and easy way to check whether or not your level of breathlessness is something you should be concerned about. Often people put off mentioning breathlessness to their doctors because they’re not sure it’s something they should be worried about, or they’re worried that their doctors will be disapproving about their lifestyle or smoking habit. However, breathlessness is a serious symptom and can be indicative of severe lung conditions, such as lung cancer, COPD and rarer diseases like aspergillosis. Breathlessness needs to be checked out so that people can access the treatment they need to prevent their quality of life diminishing. Even if breathlessness isn’t due to a health condition, your GP can help you with advice on improving fitness levels and stopping smoking.

You can help by raising awareness about the significance of breathlessness and lung health online and in your communities. Lung disease affects 1 in 5 people, which means you may know several people whose lives could be changed by taking the BLF breathlessness test.


Carers Week 2019

The 10th-16th June is national carers week in the UK, and this year’s theme is “help build carer friendly communities”. Though most people wouldn’t identify themselves as a carer (instead just calling themselves a partner/parent/child/friend etc.), there are millions of people around the UK providing unpaid care and support to a family member or friend. Caring for someone can be hugely rewarding, but can also impact on many aspects of life – carers need the help and support available to be able to look after their own wellbeing too.

Isolation and loneliness are major problems faced by carers; time and financial pressures can prevent them from reaching out to friends and family and participating in activities for their own interest. Also, despite contributing massively to society, carers are far less likely than the rest of the population to consider what they do as worthwhile. So… clearly as a society we need to change this and do more to help care for our carers!

The theme “help build carer friendly communities” aims to help link carers with the information and support they need so that they can care for others, and look after themselves. Raising awareness of carers in the media, in work and in communities helps link carers to the available support, whilst making the rest of us aware of the amazing jobs they do!

For information on support and resources available for carers, click here.

Click here to read a touching carers week blog by Jill, an aspergillosis patient.

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