Many Physicians and Physiotherapists talk about the benefits of combining aerosol medication like Ventolin with pressure support ventilation, PEP and OPEP device. The outcomes of the following 5 medical studies and helpful information is truly surprising.

Since finding these studies a month ago, AirPhysio has talked to a number of physicians. These physicians has a similar understanding as the physicians who started 4 of these studies. They started these studies to test their theory that PEP and OPEP devices should be used before the use of a reliever, believing that the PEP and OPEP devices would help clear the mucus and this would result in better distribution and effectiveness of the aerosol medication. So when the results were correlated, they were surprised by what they found.

Before I go into these studies, I first need to explain the properties of PEP and OPEP devices. As a part of the PEP or positive expiratory pressure therapy, when you blow into the devices, they have 2 major properties:

  1. Mucus Clearance – The PEP helps to clear mucus from the lungs by assisting the natural mucus clearance process of the body by helping to push and pull the mucus up to the throat.
  2. Lung Expansion – When blowing into the device, the positive pressure or back pressure created in the lungs helps to inflate or as mentioned in medical terms, splint open the airways, assiting to open up closed, semi-closed airways and loosen any blockages in the airways like mucus plugs.

 The 1st study:

In the 1st study [1], 2 doctors started their study with 54 bronchial asthmatics in 2001 found the following:

  1. Use of the PEP device after nebulization showed significant improvement of lung function,
  2. Use of the PEP device before nebulization showed no obvious improvement of lung function at all.

It was concluded that the use of PEP device after the use of aerosol medication showed a significant enhanced effect of reduction of inflammation in patients with an FEV1 below 85% FVC, over aerosol medication by itself.

This went against what they initially believed and they put this down to the mucus clearance properties of the PEP device.

 The 2nd study:

The 2nd study [2], 8 doctors performed the aerosol medication with 2 different gases (Heliox and Oxygen) to test out the 1st study mentioned above and to test the effects of aerosol medication with each gas independently and with a PEP device.

Their findings correlated those in the 1st study mentioned above and they found that in both groups using PEP therapy in conjuction with the delivery of the aerosol medication showed a higher distribution and effectiveness over either of the gases by themselves aerosol medication when used alone.

They put this down to the fact that PEP prevents airway collapse during expiration, decreasing resistance when breathing out, and showed a significant increase in how much air can be blown out in 1 second (FEV1) was observed in the Heliox + PEP group, which did not occur in other groups.

Heliox is a combination of Helium and Oxygen which is thicker and therefore has less turbulence in the lungs to provide better distribution

The 3rd and 4th studies:

The 3rd and 4th studies [3,4], used an adrenaline based aerosol reliever called Terbutaline and their findings correlated those of the first 2 studies with 1 minor difference. In the 4th study, it was found that  when using Terbutaline with a PEP device, on lower doses the combination of PEP with or without Terbutaline had an influence on airway resistance and FRC, but once the dosage of Terbutaline reached a certain level, there was no significant difference to the effect of the PEP device.

The 3rd study had the same conclusions as the 1st and 2nd study otherwise.

The 5th study:

The 5th study was the most interesting as it showed a visible difference in distribution and effectiveness of aerosol medication from a nebulizer with 18 children diagnosed with cystic fibrosis. As shown to the right on the top 2 images A and B.

  1. Shows aerosol distribution and absorption without Pressure Support
  2. Shows aerosol distribution and absorption with Pressure Support

The study used a process called pressure support ventilation which is purely about keeping the airways open and has no mucus clearance properties. They used a nebulizer with a tiny amount of radioactive particles and then used a perfusion scan to see what effects the distribution and absorption was with and without pressure support.

Pressure support is similar to the lung expansion properties of PEP and OPEP devices and this further supports the findings of the 4 studies above and in particular the 2nd studies point that PEP prevents airway collapse during expiration, decreasing resistance when breathing out.

Some other very interesting findings as follows:

  1. The quantity of radioactive particles absorbed by the lungs was 30% greater after they scanned the children who had used pressure support and nebulizer,
  2. The efficacy (as a percentage of nebulizer output) was significantly better during the pressure support session (30% better)
  3. They also found that the best means of medication delivery was through slow, deep breaths during nebulisation to improve distribution and absorption
  4. They also concluded that a longer exhalation time may have an important effect on aerosol droplet being deposited and absorbed into the airways

They concluded that pressure support ventilation enhances lung aerosol deposition without increasing particle impact in the airways.


The best way to use PEP and OPEP devices in conjunction with aerosol medication are as follows:

  1. Use the medication 1st
  2. Use with a spacer to improve distribution into the lungs
  3. Use slow deep breaths to breath in when administering the medication to improve distribution and effectiveness of the medication
  4. Use the PEP or OPEP device 2nd
  5. Breath out slowly over a longer period into the PEP or OPEP device to improve deposition and absorption of the particles

It is the lung expansion properties of PEP and OPEP devices which assists in the improved distribution and effectiveness, not the mucus clearance properties which have the most effect.

For the individual studies and medical summaries, please visit -


  1. Tsai CF1, Tsai, JJ, Effectiveness of a positive expiratory pressure device in conjunction with beta2-agonist nebulization therapy for bronchial asthma, Published by Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi 34(2):92-6 · July 2001
  2. Alcoforado L1, Brandão S, Rattes C, Brandão D, Lima V, Ferreira Lima G, Fink JB, Dornelas de Andrade A, Evaluation of lung function and deposition of aerosolized bronchodilators carried by heliox associated with positive expiratory pressure in stable asthmatics: a randomized clinical trial. Published by Elsevier Inc. August 2013 Volume 107, Issue 8, Pages 1178–1185
  3. Frischknecht-Christensen E1, Nørregaard O, Dahl R. Treatment of bronchial asthma with terbutaline inhaled by conespacer combined with positive expiratory pressure mask. Published by Elsevier Inc. Volume 100, Issue 2, August 1991, Pages 317–321
  4. Christensen EF1, Nørregaard O, Jensen LW, Dahl R. Inhaled beta 2-agonist and positive expiratory pressure in bronchial asthma. Influence on airway resistance and functional residual capacity.Published by Journal
  5. Fauroux B1, Itti E, Pigeot J, Isabey D, Meignan M, Ferry G, Lofaso F, Willemot JM, Clément A, Harf A. Optimization of aerosol deposition by pressure support in children with cystic fibrosis: an experimental and clinical study. Article in American Journal of Respiratory and Critical Care Medicine 162(6):2265-71 · December 2000
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