The Oscillatory Positive Expiratory Pressure Device (Acapella)

Don’t forget to read the basics of airway clearance techniques for full application of this tool!

What is an Acapella Device?

  • Provides Positive Expiratory Pressure (PEP) to exhalation
  • Used for pulmonary hygiene to increase/maintain secretion mobility, increases  sputum production
  • Promotes increased lung volumes due to re-inflation of collapsed airways
  • Changes focus to Exhalation instead of Inhalation!
  • Improves the efficacy of inhaled medications! See this post for more information!
  • Improves amount of time someone can participate in exercise and reduces the amount of time they need to recover dyspnea after exercise (see more about that here!).

Patients who can benefit from Acapella use:

Pneumonia (viral or bacterial, COVID-19)          
Cystic Fibrosis
Chronic Bronchitis               
Pulmonary Edema
Congestive Heart Failure       
Pre/Post Lung Transplant

Why use an Acapella device?

  • Less forceful than coughing, less irritating to pulmonary tissues (Leith, D.)
  • Increased FEV1 (marker of lung function)
  • Increased sputum production decreases bacterial load and decreases infection risk

How to Use an Acapella:

No evidence-based protocols, use alone or with other interventions.
You can also combine it with postural drainage.

Use in Active Cycle of Breathing, especially if your patient can’t huff well.

You need to tell your patient that this will make them cough! That way, they don’t STOP using it because it made them cough! Getting them to cough is the whole point. They may not tolerate this will at first, so you may need to instruct them to spread out performance over the course of the day to increase tolerance.

Goal: maintain secretion mobility, produce cough, expel secretions

Other common PEP-type devices:

The Aerobika. Although useful and better than nothing, this device doesn’t function if turned upside down so using it in conjunction with postural drainage positions is challenging. However, it will still give the patient some resistance to exhalation with some oscillation to assist in loosening secretion as long as they are upright.

Duet Devices. Allow for all the benefits of a regular PEP device with the addition of the ability to run nebulizer medications through the device at the same time. Read more about that here! This is the standard, but there are other options.

Here is an article that outlines the very basics of different types of devices including PEPs, flutter valves, cough-assists, and more.

How do you like to combine your pulmonary interventions? Let me know in the comments!

More from the Pulmonary Rehab Toolbox…


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  • Olsen, et al. (2015) Respiratory Medicine Positive expiratory pressure – Common clinical applications and physiological effects. Resp Med: 109, 297-307;
  • Gastaldi AC (2016) Flutter Device Review: Effects on Secretion and Pulmonary Function. J Nov Physiother 6: 292. doi:10.4172/2165-7025.1000292.

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The Dangers of Providing Necessary Care

We know the doctors, nurses, respiratory therapists, anesthetists, and all those other incredible people caring for patients in the ICU and ED are risking their lives every moment. But there is another side of this pandemic: the side that stays home.

Patients that stay home or are sent home still require care. Many may have comorbidities that require higher level skills (like pulmonary hygiene interventions or medication management) that can’t be performed virtually. So someone HAS to go to them instead.

The definition of “home bound” has completely changed. This is a term home health care providers are extremely familiar with. It is often a reason we have to deny services or discharge services: a patient has recovered to a point where they are no longer home bound. And most payers will NOT reimburse care provided in the home for those who are not home bound. However, due to the recent implementation of “shelter-in-place” orders across the country, EVERYONE IS HOME BOUND.

This means that the utilization of home health care based services will exponentially grow in accordance with the growth of COVID-19 cases. It is understandable. If you can’t go out because you are at high risk or you risk infecting others, then health care has to come to you. But what does that mean for the providers who go from house to house?

The number of health care workers who are infected climbs every day. Some are recovering, some are not. This isn’t meant to spread fear, it’s just the truth. We, as health care workers, are carriers just like everyone else if we have somehow been exposed.

Home care providers are at very high risk for infection due to the inability to maintain social distances from their patients, the manual interventions that require close contact, and the inability to ensure a clean and sanitary environment in which to practice. And that’s only the risk to us!

We also pose a significant risk to our patients! We go from house to house and are out in the world risking exposure and bringing it in with us. In to the homes of the MOST fragile, the homes of the very sick, and even group homes where we could infect many people at once.

But Physical Therapy is STILL a necessary service that many patients will require, not just to recover from COVID-19 or keep them of of ventilators, but to keep them out of the hospital for other conditions like vertigo, back pain, and injuries due to a fall.

If you are a home health care worker and you are feeling the strain of this, you are not alone. Many home health care therapists and other providers are sharing their concerns:

Home health workers fear spreading COVID-19

The APTA has given some guidance on this:

“….our profession plays a crucial role in the health of our society, and there are people in our communities whose health will be significantly impacted by disruptions to care.

[Physical Therapists should] use their professional judgment in the best interests of their patients and clients and their local communities – including rescheduling non urgent care if that is the best approach, or making other adjustments when the risk of exposure to COVID-19 outweighs the benefits of immediate treatment.”

-APTA representative (link)

So the question comes down to this: What care is truly necessary to be performed face-to-face? Are you implementing any virtual visit platforms to complete care that doesn’t have to be done face-to-face? How are you prioritizing your patient care?

If you are a home health care therapist, let me know what you think in the comments! Or share your tips with others!

Primary Care PT

PTs primarily treating diabetes shouldn’t be a far cry from the future, it should be today! Read this for more!

More Than Just A Respiratory Disease: The COVID-19 Toolbox

Isn’t COVID-19 just a respiratory disease? If only that was true. We are good at treating respiratory infections. We have lots of drugs for viral, bacterial, parasitic, and fungal infections of the lungs. Most of them work really well! We also have several backup treatments, inhaled medications, and adjuvant therapies (like rehab!) that make primaryContinue reading “More Than Just A Respiratory Disease: The COVID-19 Toolbox”


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We’ve never had a better reason…

…to brush up on our respiratory intervention skills. These are my bread and butter. In the six years that I practiced in home healthcare, I learned to love these skills I never thought I’d need. And the more I grew to love them, the more I loved using them. But that means seeing the patients that are the most medically complex.

This brought me to heart and lung transplant care. That may seem scary for some people: providing aerobic exercise and respiratory interventions for patients who have just had their organs removed and replaced with someone else’s. But it is my passion. And that passion led me to get involved with the heart and lung transplant education team at my hospital system. I started providing the education courses for other PTs, OTs, and SLPs, so they could also provide these interventions and care for these patients with confident competence.

I can promise you, the patients being treated before or after transplant are just as scared as the ones being treated for COVID-19. No one knows what their outcomes will be. In lung transplant, we say “50% will live 5 years”. That may not sound like much, but many of these people are literally DAYS away from suffocating to death. It’s a chance they are willing to take.

With COVID-19, I imagine the feelings are the same. We don’t even know how long 50% of the hospitalized patients will live. We hope they return to the majority that recover, but not everyone will. Some will fall into that percentage that require extended hospitalization. The others will get the red tag.

I have taken a patient through YEARS of pulmonary pre-hab for a double lung transplant and many months of rehab after. She was on her way to visit family to say her final good-bye, trucking along her 10 L/min supply, when she got her phone call. The lungs were available. She knew what that meant, but she also knew she had to accept that reality quickly and get to the hospital. Thankfully, the family she was visiting lived nearby.

She had some rough road after her transplant, but it turned out to be successful. She had a beautiful two years of life after transplant. She returned to gardening, spending time outside, and welcomed a new grand-niece in to the world. So what kept her going?


Seriously, years of PT.

Obviously, you can’t do that in every setting. But, we spent our time strengthening her diaphragm using a Threshold IMT for progressive resistive exercise, diaphragmatic breathing activities with PNF-based manual inputs, practicing breathing with activity, PEP for airway clearance, active cycle of breathing, huffing, postural drainage, percussion, and even METs for rib mobility. She was in desperate need of cough efficiency planning because she had so little reserve.

I utilized auscultation and active pulse oximetry prior to and after interventions to demonstrate progress and instructed her in high-intensity interval training. Yes, even someone with advanced COPD, pulmonary hypertension, and an indwelling pulmonary catheter on 10 L/min of oxygen can do high-intensity interval training.

You can read more about this story here and see some beautiful pictures of respiratory interventions taking place. But more importantly, you can see the happiness that beams from her, even though she can hardly breathe.

If you’ve checked out the World Confederation of Physical Therapy’s Guidelines for PT Treatment of COVID-19 in Acute Care, you’ve seen these types of interventions listed. Patients who have COVID-19 need respiratory interventions from a skilled PT before they end up on a ventilator, during their ventilated time, and after they are removed from the ventilator. Active interventions should always be given priority over passive ones (aka EXERCISE!) but you do what you can. And don’t forget about contraindications for some interventions.

To perform these interventions properly for patients with COVID-19, the WCPT recommends that PTs who are already skilled and experienced in providing them be the ones to do so. However, that doesn’t mean you won’t see these patients outside of acute care. It’s time to brush up. It’s time to take back this part of our practice. We are the most skilled in providing physical interventions to improve cardiopulmonary function. If you haven’t done this stuff in a while, you can find online courses everywhere (or here!). We need more people providing these interventions because the demand is going to be high.

Image credit: Chris Clark, 2016

Do you think it’s time to brush up on your CV/P skills? Let me know what you feel like you need to most brushing up on in the comments!

COVID and Clotting: How to Identify, Assess, and Treat Clotting Disorders in COVID-19 Survivors

Treating patients with acute and chronic clotting conditions is not new to rehabilitation professionals. We even have clinical practice guidelines around how to do so safely. However, what is new is the increased risk of newly acquired clotting conditions among post-COVID-19 patients. Those of us practicing in acute, subacute, emergency, and outpatient settings are uniquely tasked withContinue reading “COVID and Clotting: How to Identify, Assess, and Treat Clotting Disorders in COVID-19 Survivors”


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The Why

Hey everyone,

I continue to receive numerous texts, emails, phone calls, and messages asking how the heck PTs are supposed to keep practicing amidst the trials of COVID-19. The laws are changing constantly, states are laying down practice restrictions, and payers are opening up and expanding, but amidst all that, many of us feel lost.

I’ve held leadership roles in our profession, but I definitely am no COVID-19 expert. What I can tell you is that Physical Therapists are incredibly strong, smart, undaunted, and resourceful. We have jumped at the chance to respond to pretty much every epidemic, pandemic, and natural disaster around the world since the inception of our profession. COVID-19 shouldn’t and won’t be any different.

Our sense of altruism is too strong. That’s why most of us are TERRIBLE at marketing ourselves. Our values are deeply engrained. That’s why we keep wondering how we can help.

I had the idea to start this site years ago, but the inundation of communication I’ve received related specifically to the current situation pushed me to open this up sooner than I had planned. I never imagined that I would be launching this site in response to a pandemic that has left my colleagues providing chauffeur services for other healthcare providers, or being a greeter at the front door of an urgent care, or applying to work at Costco. Yes, these are all things our fellow PTs are currently doing. And It’s killing me.

I, like Liam Neeson, have a very particular set of skills. I am a physical therapist who specializes in the management of advanced chronic disease. I do that by providing skilled interventions targeted at the cardiovascular, pulmonary, and neurological systems in the geriatric population. I spend most of my days treating end stage COPD, ESRD, or CHF, and I love it. As a PT, I want to see more people in our profession utilizing these types of skillsets. We all have them to some extent. We all learned this stuff somewhere along the way. I just kept learning it and never looked back. My goal is to help all of you relearn it, too. I want you to feel comfortable with the skillsets you will need to treat patients with advanced heart and lung diseases, like COVID-19. I want to teach what interventions you’ll need in your toolbox. Most of all, I want you to be able to keep doing your job because you are valuable and I want you to be able to prove it.

If you are an outpatient orthopedics therapist who doesn’t really remember much from cardiopulmonary class, this is for you. If you are a new grad who just wants to know everything you don’t know, this is for you. If you have been practicing in skilled nursing for 25 years and want an update, this is for you. If you don’t care at all about cardiopulmonary physical therapy services, but you know you need them right now, this is for you (but we should talk more later).

I want you all to feel confident in the competence you have in these skills. I want you to know that someone else is out there fighting for you and with you through all this crazy. I want you to know that there is somewhere you can go to brush up on all this stuff quickly and without cost so you can go right back to work tomorrow and DO these things. I want you to feel valuable and give value to your patients.

I hope you can find some help here. And once this passes, if it passes, I hope to re-focus on other practice issues.

Stay safe and stay healthy, because we can’t stay home.

Doctor B


More Reads…


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Coronavirus Is Our Future | Alanna Shaikh | TEDxSMU

Check out this TEDx video from Alanna Shaikh, a global health expert.

What do you think about Alanna’s perspective? Let me know in the comments!

It’s Getting Hot in Here: Body Temperature

How many times have you had your temperature taken lately? I think I’ve had my temperature taken thousands of times in the last few months. We are seeing the increased use of forehead scanning thermometers and temporal scanners, all the non-contact forms of temperature assessment, to screen folks for COVID-19 symptoms upon entry to anyContinue reading “It’s Getting Hot in Here: Body Temperature”


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The Best We Can Do (So Far)…

We finally have enough research and enough answers and enough patients and enough confirmed cases that have received care. We can start making some recommendations and have at least a minimal amount of evidence for some guidelines on treatment.

The World Confederation of Physical Therapy has published acute care guidelines for care of patients with COVID-19 specific to PTs. There are plenty of guidelines for physicians and nurses right now, most with a fiar amount of evidence, but not PT. We haven’t gotten much to guide us.

My favorite part of these guidelines is that it makes recommendations for who should and should NOT be seen for PT in a critical care setting. I feel like these recommendations for service triage will be modified for application to other settings. So many therapists are reaching out right now because they are struggling with the lack of definition of “essential” and this could be the answer. Some states (like Michigan) have taken it upon themselves to define “essential” as life-saving or life-sustaining care.

How do you feel your employers are doing with utilizing the term “essential” when it comes to patient triage? Take a look at these guidelines for triage and treatment.



What are you doing for patients who have COVID-19? Let me know in the comments.

More Reads…

Rule of 2’s

To go along with our Chronic Disease Management Series, here is some bonus content of managing patients with heart failure!


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Your Mission, Should You Choose to Accept It…

Depending on your setting and expertise, you may or may not be asked to take on a special role during this time. There are some resources to assist you from the World Confederation of Physical Therapy. But don’t feel like you have to do everything. We have such a varied skill set as a profession that we fall all across the board when it comes to crisis response. Here are some thoughts on roles you can play.

The big one that most people think of is trauma triage.

Most people think of a physical therapist as someone they see after a broken leg or an ankle sprain or a surgery.

So the natural next step would be to triage injuries so that doctors and nurses can provide medical treatment for very serious life-threatening injuries, and then PTs can take over for the non-life-threatening injuries that just need training, education, or exercise.

PTs can easily provide medical screenings of patients and nonpatients.
And we don’t have to be limited to virus screenings, either. PTs can screen visitors and other providers for symptoms and provide education on quarantine guidelines. We can also screen people for secondary issues that will determine their course of care, like fall risk, and pneumonia risk. PTs can also check and monitor vitals to ensure people stay safe.

Something people probably don’t see PTs do often is chronic condition management, but there are some PT’s who provide this type of care everyday.
Like care for COPD, CHF, Diabetes, Gout, RA, and anything else that sticks with you for the long term. In times of crisis, PTs can assess these patients for acute and non-acute needs and provide basic and advanced interventions as part of their normal scope of practice. Of course this would include taking medical histories and determining the needs of each patient which most of us do pretty much every day, anyway.
This would also include wound care. At the very minimum, PTs can provide basic first aid and treat minor to moderate wounds, but some PTs actually specialize in wound treatment and can treat advanced, complicated, and chronic wounds easily.

PTs can also play a natural role in Accessibility Consultation. Sometimes, people have to be relocated because of a disaster affecting their home. PTs can help search out, extract, and move people whether they are injured or not.  And once we get them out, we can assess what accessibility needs they will have at the new location. PTs can determine if they will need medical equipment like walkers or crutches and teach people how to use them. And if there aren’t enough PTs to do the people moving, we can train others how to safely move people so they don’t get hurt in the process.

PTs can also take on administrative roles to reduce the burden on others. This can include simple tasks like inventorying, stocking, recommending, and moving supplies and coordinating other services like dieticians, social workers, and nonclinical help. PTs are also prime coordinators when it comes to people management. Our expertise is human movement, so when it comes to moving large masses, we can take control and do this safely.

For people who are already under medical care, PTs can provide assessment of rehabilitation potential during field (on site) or facility triage phases and facilitation of discharge by assisting patients to functionally recover enough to return home or to another level of care like a rehab unit.

Outpatient therapists are currently working on seeing patients virtually as much as possible. However, the overarching goal of outpatient therapists will likely soon transition to offloading primary care physicians, emergency departments, and urgent cares from orthopedic injuries and pain management concerns. Some Outpatient Orthopedic clinics have already transitioned to urgent orthopedic care centers utilizing direct access rights!

And, of course, PTs are all trained in minimum emergency response, or what we call Basic Life Support. This means we can participate in Code Teams and provide CPR/AED support. Some PTs are trained in Advanced Cardiac Life Support and are able to provide even further care in these situations.

Looking at this list, I’m betting lots of people don’t know we do all of these things!

People like the general public or your hospital administrators. Even people like your community emergency response team (CERT). And they will never know unless you tell them.
We are SO much more than greeters or chauffeurs (yes, that is how PTs are being utilized right now), but we HAVE to educate others.

Join the international team of PTs responding to COVID-19!

Are you taking on an unexpected role due to COVID-19? Let me know in the comments!

Sternal Precautions

“Patients exchanging habits of activity for complete rest are likely to become rapidly worse.” This quote fuels my everyday. These words have informed nonsurgical and surgical rehabilitation and its evolution from handing out bed rest like Oprah hands out cars to getting people moving early and keeping them moving often. Here’s the crazy thing: ThisContinue reading “Sternal Precautions”


Gosh, this is a fine line… Especially in the patients I regularly see. A colleague and I often say, “If you have any more water, you’ll die. If you don’t have any more water, you’ll die.” This is actually a frequent education topic that I cover with patients. Scary? Yes, but true. So, why isContinue reading “Dehydration”

Diaphragmatic Breathing

Let’s talk about this super simple technique that can change everything. Diaphragmatic breathing is really just how we are all supposed to be breathing most of the time. The purpose of the diaphragm is to facilitate breathing. Diaphragmatic breathing improves gas exchange and increases lung volumes. These are all really good things if we need toContinue reading “Diaphragmatic Breathing”


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