title: Positive expiratory pressure to enhance cough effectiveness in tracheomalacia.
abstract: OBJECTIVE
  To determine the effectiveness of increasing levels of Positive Expiratory Pressure (PEP) during coughing to enhance expiratory flow and improve efficiency of the cough.
  
  
  METHODS
  Forty children aged 8 to 18 years, with repaired tracheo-oespohageal fistula (TOF) and twenty-one age matched controls performed spirometry followed by cough spirometry with PEP of 0, 5, 10, 15 and 20 cmH2O using an adjustable PEP valve. Cough expiratory flow between 75 and 25% of vital capacity (CEF25-75) for each curve was calculated to represent the effectiveness of cough at mid-lung volume, the region of the flow volume curve most vulnerable in tracheomalacia.
  
  
  RESULTS
  In the TOF group, CEF25-75 increased by a mean (95% CI) of 18.8% (4.4, 33.2), 1.7% (-2.6, 26.0) and 0.5% (-13.7, 14.7) at PEP of 5, 10 and 15 cmH2O respectively, but decreased by 2.4% (-13.4, 8.5) at PEP of 20 cmH2O. In the control group the CEF25-75 decreased. The values were -3.1% (-16.7, 10.4), -6.3%(-18.1, 5.6), -22.2% (-33, -11.5) and -19% (-29.3, -8.7) at PEP of 5, 10, 15 and 20cmH2O respectively.
  
  
  CONCLUSIONS
  The use of a simple adjustable PEP valve increases CEF25-75 during cough spirometry and may provide a useful adjunct to chest physiotherapy in children with tracheomalacia.
authors.affiliation: Department of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand. sanitras@hotmail.com
authors.forename: Sanitra
authors.initials: S
authors.lastname: Sirithangkul
authors.forename: Sarath
authors.initials: S
authors.lastname: Ranganathan
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Robinson
authors.forename: Colin F
authors.initials: CF
authors.lastname: Robertson
mesh_terms: D000293:Adolescent; D002648:Child; D003371:Cough / Q000503:physiopathology*; D004933:Esophageal Atresia / Q000150:complications; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D026741:Physical Therapy Modalities; D011175:Positive-Pressure Respiration; D011312:Pressure; D013147:Spirometry; D013785:Thailand; D014138:Tracheoesophageal Fistula / Q000150:complications; D055090:Tracheomalacia / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D016896:Treatment Outcome; D014797:Vital Capacity