Likely to Be Effective

Positive Expiratory Pressure and Self-Monitoring

for Prevention of Infection: General

Positive expiratory pressure involves breathing against an airway resistance provided by a flute-like device. This approach has been used for lung training and to open and clear airways. This intervention, along with patient self-monitoring of forced expiratory volume in 1 second (FEV1), was evaluated for its effect on the development of pneumonia in high-risk patients with cancer. FEV1 monitoring was used for early detection of pulmonary deterioration, enabling early diagnostic testing and interventions as needed.

Research Evidence Summaries

Moller, T., Moser, C., Adamsen, L., Rugaard, G., Jarden, M., Botcher, T.S., . . . Kjeldsen, L. (2016). Early warning and prevention of pneumonia in acute leukemia by patient education, spirometry, and positive expiratory pressure: A randomized controlled trial. American Journal of Hematology, 91, 271–276. 

Study Purpose

To evaluate the feasibility and effectiveness of a patient-performed daily spirometry as an early warning tool and the use of a positive expiratory pressure (PEP) flute device to prevent pneumonia among outpatients undergoing treatment for acute myeloid leukemia (AML)

Intervention Characteristics/Basic Study Process

All patients received a 45-minute face-to-face educational session about pneumonia prevention and assessing for early signs, plus instructions on how to use a spirometer and record findings daily. The intervention group received PEP flutes and instructions for use. All patients received instructions for contacting a healthcare provider if symptoms occurred. The primary outcome was occurrences of pneumonia.

Sample Characteristics

  • N = 80 (40 per group)   
  • MEAN AGE = 56 years (both groups)
  • MALES: 63.75%, FEMALES: 36.25%
  • CURRENT TREATMENT: Chemotherapy
  • KEY DISEASE CHARACTERISTICS: AML

Setting

  • SITE: Multi-site   
  • SETTING TYPE: Multiple settings    
  • LOCATION: Copenhagen, Denmark

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active antitumor treatment

Study Design

  • Randomized, controlled trial

Measurement Instruments/Methods

  • Adherence to the PEP flute was measured by patient feedback at weekly meetings (unclear if verbal or written).
  • Pneumonia was measured by x-ray verification of infiltrates, bronchoalveolar lavage or sputum cultures, and electronic transfer of data from the spirometer to show adherence.

Results

The prevalence of pneumonia throughout 5,420 days of observation was 28.75%. Six cases of pneumonia occurred in the intervention group compared to 17 in the control group (p = 0.007). Cultures were correlated with x-rays in eight patients with pneumonia diagnosed by x-ray infiltrates. A decline in FEV1 (spirometry) was an early predictor of pneumonia in 43% of cases using an 85% individual threshold for FEV1 decline.

Conclusions

The use of FEV1 to monitor for early onset pneumonia can be effective. The use of the PEP flute significantly decreases the occurrence of pneumonia.

Limitations

  • Small sample (< 100)
  • The findings were reported on a total of 80 patients, although three dropped out in the beginning of the study, seven during induction chemotherapy, and another eight because of distress.
  • Table II reported on pneumonia findings in all 80 patients.
  • Statistical considerations for missing data were unclear.
  • An adjustment was made for the FEV1 analysis (10 patients removed because of comorbidities and/or very poor lung capacity, 4 of whom had cases of pneumonia).

Nursing Implications

Direct patient education on the use of spirometry to evaluate FEV1 and PEP flutes is effective. FEV1 findings can potentially aid with early pneumonia diagnosis, and the use of the PEP flutes can help prevent pneumonia.

Print