Breathing with a new positive expiratory pressure device during exercise increases exercise endurance in patients with chronic obstructive pulmonary disease: Preliminary study

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Malipond Pukdeechat Chatchai Phimphasak Chulee Jones


 Dynamic hyperinflation (DH) during exercise or physical activity is a major cause of dyspnea in COPD patients which progressively increasing severity with time during exercise. This leads to exercise intolerance and poor physical activity. Previous studies reveal that breathing with positive expiratory pressure (PEP) can reduce dyspnea at rest and breathing with Conical-PEP device (C-PEP) during exercise can increase exercise endurance. However, the device is not practical to be used during exercise with mobility and daily life. We, therefore, has developed a new PEP device, C-PEP mask, and aimed to evaluate the effects of breathing with C-PEP mask during exercise on exercise tolerance exertional dyspnea and cardiorespiratory function in moderate to severe COPD patients. A randomized cross-over trial was conducted in 9 COPD participants with an average age of 67.3 ± 3.9 years. The participants performed Spot Marching exercise test at the average speed of 90±15 step/min with (C-PEP) and without C-PEP mask (control) until symptom limited by severe dyspnea or heart rate (HR) reaching 80%HRmax. Exercise duration was recorded. Dyspnea HR, respiratory rate (RR), end tidal carbondioxide pressure (PETCO2), pulse oxygen saturation (SpO2), arrhythmia and blood pressure were examined at pre- , during,  immediate post  and 10 minute of recovery except BP was not measured during exercise. The results showed that the participants could exercise 4 minutes longer in C-PEP than Control (12.2 ± 5.8  v.s  8.3 ± 2.1 minutes; p< 0.05) whilst they  stopped the exercise at similar levels of dyspnea and HR (80% HRmax) in both conditions (RPB 4.6 ± 2.7/10  vs 4.1 ± 1.8 /10unit and HR at 106.2 ± 8.4  vs 108.5 ± 11.7 bpm (in C-PEP and control condition respectively) RR was slower in C-PEP than Control during the exercise (AUC median IQR 25-75 in CPEP vs Control respectively p= 0.26)  At the end of exercise, RR slower and VT greater in C-PEP vs Control (24.0±6.0 vs     28.0± 3.0breaths/min  and 1017.8±189.0  vs 974.4±279.1 ml  respectively p = 0.42). No arrhythmia was observed and PETCO2 and SpO2 were normal during exercise in both conditions. RR returned to rest in C-PEP but not in Control and HR and BP were still higher than resting in both conditions at the end of the 10 min recovery period. We conclude that using a C-PEP mask during exercise is safe, reduces exertional dyspnea increases exercise tolerance and promotes recovery of lung function in COPD. Therefore, C-PEP mask could be used during exercise training in pulmonary rehabilitation and physical activity in moderate to severe COPD. 


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Pukdeechat M, Phimphasak C, Jones C. Breathing with a new positive expiratory pressure device during exercise increases exercise endurance in patients with chronic obstructive pulmonary disease: Preliminary study. Thai Journal of Physical Therapy [Internet]. 16Dec.2017 [cited 26Apr.2018];39(3):97-10. Available from:
Research Articles


Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management and prevention of COPD. [Online] 2015 [cited 2015 May 21]. Available from uploads/users/files/GOLD_Report_2015.pdf.

O’Donnell DE, Banzett RB, Carrieri-Kohlman V, Casaburi R, Davenport PW, Gandevia SC. Pathophysiology of Dyspnea in Chronic Obstructive Pulmonary Disease. Proc Am Thorac Soc 2007; 4: 145–68.

Calverley PMA. Exercise and dyspnoea in COPD. EurRespir Rev 2006; 15(100): 72–9.

Cooper CB. The connection between chronic obstructive pulmonary disease symptoms and hyperinflation and its impact on exercise and function. Am J Med 2006; 119(10): 21-31.

Sridhar SA, Vaishali K, Alaparthi GK, Krishnan S, Zulfeequer, Anand R. Effect of Threshold Positive Expiratory Pressure on Dynamic Hyperinflation & Dyspnea in COPD: A Randomized Cross Over Trial. Journal of Health Sciences & Research 2012; 2(5): 7-16.

Saetta M, Turato G, Baraldo S, Zanin A, Braccioni F, Mapp CE, et al: Goblet cell hyperplasia and epithelial inflammation in peripheral airways of smokers with both symptoms of chronic bronchitis and chronic airflow limitation. Am J Respir Crit Care Med 2000; 161: 1016–21.

Padkao T, Boonsawat W, Jones CU. Conical-PEP is safe, reduces lung hyperinflation and contributes to improved exercise endurance in patients with COPD: a randomized cross-over trial. J Physiother 2010; 56(1): 33-39.

Wibmer T, Rudiger S, Heitner C, Kropf- Sanchen C, Blanta L, Stoibe KM, et al. Effects of Nasal Positive Expiratory Pressure on Dynamic Hyperinflation and Six Minute Walk Test in Patients with COPD. Resp care 2013; 174: 1-27.

Olsen MF, Lannefors L, Westerdahl E. Positive expiratory pressure-common clinical applications and physiological effects. Respir Med 2015; 109: 297-307.

Myers RT. Positive Expiratory Pressure and Oscillatory Positive Expiratory Pressure Therapies. Resp care 2007; 50(10): 1308-27

Mughal MM, Culver AD, Minai AO, Arroliga AC. Auto-positive end-expiratory pressure: Mechanisms and treatment. Cleveland Clinical journal of medicine 2014; 72(9): 801-9Marini JJ. Dynamic Hyperinflation and Auto–Positive End-Expiratory Pressure. Am J Respir Crit Care Med 2011; 184: 756-62.

Pongpanit K, Boonsawat W, Jones DA, and Jones CU. Positive expiratory pressure breathing increases the recovery of dyspnea in patients with COPD. Thai Journal of Physical Therapy 2015; 37(1): 41-53.