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Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation

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Authors

Vicki Flenady1, Peter H Gray2

Background - Methods - Results - Characteristics of Included Studies - References - Data Tables & Graphs


1Mater Medical Research Institute, Mater Health Services, Wooloongabba, Australia [top]
2Newborn Services, University of Queensland, South Brisbane, Australia [top]

Citation example: Flenady V, Gray PH. Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000283. DOI: 10.1002/14651858.CD000283.

Contact person

Vicki Flenady

Mater Medical Research Institute
Mater Health Services
Level 2 Quarters Building
Annerley Road
Wooloongabba
Queensland
4102
Australia

E-mail: vicki.flenady@mater.org.au

Dates

Assessed as Up-to-date: 10 November 2009
Date of Search: 11 February 2009
Next Stage Expected: 04 August 2009
Protocol First Published: Issue 1, 1997
Review First Published: Issue 1, 1998
Last Citation Issue: Issue 2, 2002

What's new

Date / Event Description
07 September 2010
Amended

Reference to included study Bagley CEupdated from Abstract to full publication.

History

Date / Event Description
10 November 2009
Updated

This review updates the existing review "Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation" published in the Cochrane Database of Systematic Reviews (Flenady 2002).

Updated search found no new trials.

No changes to conclusions.

13 February 2009
Amended

Updated contact details

16 October 2008
Amended

Converted to new review format.

28 January 2005
Updated

This is an update of the existing review "Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation" published in The Cochrane Library, Issue 1, 1998 and updated in Issue 2, 2002 (Flenady 2002).

No new trials were identified in the search updated to January 2005, and as a result no substantive changes were made to the review.

31 January 2002
New citation: conclusions changed

Substantive amendment

Abstract

Background

Chest physiotherapy has been used to clear secretions and help lung ventilation in newborns who have needed mechanical ventilation for respiratory problems. However, there are concerns about the safety of some forms of chest physiotherapy.

Objectives

To determine the effects of active chest physiotherapy on infants being extubated from mechanical ventilation for respiratory failure.

Search methods

The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of electronic databases: Oxford Database of Perinatal Trials; Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2005); MEDLINE (1966 to February 2009); CINAHL (1982 to February 2009); and EMBASE (2006 to February 2009), previous reviews including cross references, abstracts, conferences, symposia proceedings, expert informants and journal hand searching.

Selection criteria

All trials utilising random or quasi-random patient allocation, in which active chest physiotherapy was compared with non-active techniques (e.g. positioning and suction alone) or no intervention in the peri-extubation period.

Data collection and analysis

Assessment of methodological quality and extraction of data for each included trial was undertaken independently by the authors. Subgroup analysis was performed on different treatment frequencies and gestational age less than 32 weeks. Meta-analysis was conducted using a fixed effects model. Results are presented as relative risk (RR), risk difference (RD) and number needed to treat (NNT) for categorical data and mean difference (MD) for data measured on a continuous scale. All outcomes are reported with the use of 95% confidence intervals.

Results

In this review of four trials, two of which were carried out 15 and 23 years ago, no clear benefit of peri-extubation active chest physiotherapy can be seen. Active chest physiotherapy did not significantly reduce the rate of postextubation lobar collapse [typical RR 0.80 (95% CI 0.49, 1.29)], though a reduction in the use of reintubation was shown in the overall analysis [typical RR 0.32 (95% CI 0.13, 0.82); typical RD -7% (95% CI-13, -2); NNT 14 (95% CI 8, 50)]. There is insufficient information to adequately assess important short and longer term outcomes, including adverse effects.

Authors' conclusions

Caution is required when interpreting the possible positive effects of chest physiotherapy of a reduction in the use of reintubation and the trend for decreased post-extubation atelectasis as the numbers of babies studied are small, the results are not consistent across trials, data on safety are insufficient, and applicability to current practice may be limited.

Plain language summary

Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation

Active chest physiotherapy may not be helpful for all babies being taken off mechanical breathing support. Mechanical ventilation (machine-assisted breathing) increases a baby's lung secretions. Chest physiotherapy (tapping or vibrating on the chest) is thought to clear the baby's lungs, and is often done when taking the baby off the ventilator (extubation). Although this review found a benefit for physiotherapy in terms of less babies needing to go back on the ventilator, no other benefits were shown. Also, this benefit was mainly due to the results of studies conducted a long time ago before advances such as better humidification systems to moisten the air the baby breaths and the drug surfactant. These advances may have reduced the risk of complications around the time of extubation so these results may not apply to babies in today's neonatal nurseries. This review did not show any evidence of harm for babies receiving a short course of chest physiotherapy following extubation.

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Background

Description of the condition

Endotracheal intubation and mechanical ventilation cause trauma and inflammation to the airways and increase secretions in the lungs. These effects may contribute to respiratory complications following cessation of mechanical ventilation and extubation. Postextubation complications range from problematic secretion build up causing discomfort, agitation and distress (necessitating frequent suctioning) to obstruction of major airways with resultant lung collapse. The presence of lung collapse may require increased support such as additional oxygen and occasionally reintubation for further mechanical ventilation. These complications potentially prolong the recovery phase and may impact on long term outcomes.

The neonate is particularly at risk of respiratory complications due to immaturity of the respiratory system. Decreasing birth weight (Odita 1993), increasing duration of mechanical ventilation, high oxygen concentrations, multiple intubations (Wyman 1977), presence of disease states such as sepsis and patent ductus arteriosus (Odita 1993) and nasal intubation (Roper 1976; Spitzer 1982) have been identified as risk factors for postextubation lobar collapse (PEC). The incidence of neonatal PEC has been reported at between 11 and 50% over the past decade (Halliday 1992; Odita 1993), with reintubation required in 10-30% of cases (Halliday 1992).

Description of the intervention

Respiratory physiotherapy techniques include chest percussion and vibrations (often referred to as active chest physiotherapy).

How the intervention might work

Respiratory physiotherapy techniques such as chest percussion and vibrations (often referred to as active chest physiotherapy) are thought to reduce respiratory complications by promoting clearance of secretions (Etches 1978), thus improving ventilation of the lungs. Improvement in oxygenation following active physiotherapy has been reported (Tudehope 1980). However, reports on the effects of the different methods of active physiotherapy show conflicting results (Crane 1978; Curran 1979; Tudehope 1980). Safety in terms of stability of intracranial blood flow during suction (Paratz 1994), no increase in the rate of cerebral lesions (Beeby 1998), and benefit in terms of reducing hypoxaemia during suction (Bradbury-Hough 1995) has been reported. However, concerns have also been expressed regarding the safety of this intervention. Reports of adverse effects include hypoxaemia (Holloway 1969; Fox 1978), rib fractures (Purohit 1975) and associated brain lesions (Raval 1987; Cross 1992; Ramsay 1995; Coney 1995; Harding 1998).

Following the publication of a small trial in 1979 (Finer 1979), the use of active chest physiotherapy techniques for the prevention of postextubation lung collapse became a part of routine care in many neonatal nurseries. However, a growing body of conflicting literature on the effects of active chest physiotherapy has resulted in differences of opinion about the risk/benefit ratio of many neonatal physiotherapy techniques, and also differences in practice (Lewis 1992; Flenady 1997).

Why it is important to do this review

This review updates the existing review "Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation" published in the Cochrane Database of Systematic Reviews Flenady 2002.

Objectives

To determine the effects of active chest physiotherapy on infants being extubated from mechanical ventilation for neonatal respiratory failure on outcomes of post-extubation lobar collapse, the use of reintubation and adverse effects such as bradycardia, hypoxaemia and the incidence of intracranial lesions.

A priori sub-group analyses:

Different treatment intervals - frequent (one and two hourly) versus four hourly.
Different treatment methods - vibrations versus percussion.
Preterm < 28 weeks gestation or < 1000 g birthweight.
Preterm < 32 weeks gestation or < 1500 g birthweight.

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Methods

Criteria for considering studies for this review

Types of studies

All trials utilising random or quasi-random patient allocation, in which active chest physiotherapy was compared with non-active techniques (e.g. positioning and suction alone) or no intervention in the peri-extubation period.

Types of participants

All infants being extubated following a period of mechanical ventilation for neonatal respiratory failure.

Types of interventions

Active chest physiotherapy techniques including the use of vibrations or percussion with or without the use of devices such as face masks and electric vibrators.

Types of outcome measures

Primary outcomes

Lobar collapse of the lung shortly after extubation.
Use of reintubation.
Hypoxaemic episodes.
Bradycardia.
Duration of oxygen therapy.
Intracranial haemorrhage.
Cerebral cystic lesions (Periventricular leukomalacia, porencephalic cysts).
Long term neurosensory impairment.
Death prior to hospital discharge.

Secondary outcomes

Pulmonary air leak.
Duration of mechanical ventilation (days).
Duration of nasopharyngeal CPAP (days).
Chronic lung disease: oxygen use at 28 days of age; oxygen use at 36 weeks postmenstrual age.
Frequency of suctioning and handling.
Duration of neonatal intensive care unit stay (days).
Duration of hospital stay (days).

Search methods for identification of studies

The standard search strategy for the Cochrane Neonatal Review Group was used.

Electronic searches

We searched the following electronic databases for published manuscripts: Oxford Database of Perinatal Trials; Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2005); MEDLINE (1966 to January 2005); and CINAHL (1982 to January 2005) using MeSH term infant-newborn and text terms extubat*; atelectasis; lung collapse; lobar collapse; chest physiotherapy; respiratory therapy, chest physical therapy.

In 2009, the search was updated as follows: MEDLINE (search via PubMed), CINAHL, EMBASE and The Cochrane Librarywere search from 2006 to 2009.
Search terms: extubat* OR atelectasis OR lung collapse OR lobar collapse OR chest physiotherapy OR respiratory therapy OR chest physical therap. Limits: human, newborn infant and clinical trial.
No language restrictions were applied. The bibliography cited in each publication obtained was searched in order to identify additional relevant articles.

Searching other resources

In addition we searched previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants, journal hand searching in the English language.

Clinical trials registries were also searched for ongoing or recently completed trials (ClinicalTrials.gov, Controlled-Trials.com External Web Site Policy, and WHO International Clinical Trials Registry Platform (ICTRP) External Web Site Policy).

Data collection and analysis

The standard methods of the Cochrane Collaboration and its Neonatal Review Group were used.

Selection of studies

All randomised and quasi-randomized controlled trials fulfilling the selection criteria described in the previous section were included. The authors reviewed the results of the search and separately selected the studies for inclusion. The review authors resolved any disagreement by discussion.

Data extraction and management

Each author independently extracted data then compared and resolved differences. For the 2002 update, extraction of data from the previously included trials was conducted for the additional outcomes specified.

Additional data on neonatal morbidity were sought from the investigators of three trials (V- Beresford 1987; Al-Alaiyan 1996; Bagley 2005). One trial (Bagley 2005) provided additional data. Data were received on outcomes for one infant excluded following randomisation in Al-Alaiyan 1996. In Bagley 2005, there were four post randomisation exclusions for the outcome of postextubation collapse (PEC), two for intraventricular haemorrhage (IVH) and one for the outcome of duration of oxygen therapy. In this review, all infants randomised into this trial were included in the denominator for the outcomes of PEC and IVH. Bagley 2005 also provided additional data on the outcome of cerebral cystic lesions at six weeks of age; however, due to large number of losses to follow-up (20 and 30% in the two groups), this outcome has not been included in the review. Data for the outcomes of the duration of mechanical ventilation, oxygen therapy, CPAP and neonatal intensive care stay came from one trial (Bagley 2005). In this trial, these outcomes were calculated for the period from admission to the nursery (not from the time of random allocation) to discharge from hospital.

Two trials included study groups of differing treatment frequencies (Al-Alaiyan 1996; V- Beresford 1987). In the analysis, the hourly, two hourly and four hourly physiotherapy groups in V- Beresford 1987 and the two hourly and four hourly groups in Al-Alaiyan 1996 were combined for the overall comparison.

Assessment of risk of bias in included studies

All included studies were assessed for blinding of randomisation, blinding of intervention, completeness of follow-up, and blinding of outcome assessment. The authors independently undertook this assessment and assigned a rating of either Yes (Adequate), Can't Tell (Unclear), or No (Inadequate) for each. Differences were resolved by discussion. Information was also sought and received on methods of random allocation for two trials (V- Beresford 1987; Al-Alaiyan 1996). This information was added to the table 'Characteristics of Included Studies'.

In addition, following issues were evaluated and entered into the Risk of Bias Table:

  1. Sequence generation: Was the allocation sequence adequately generated?
  2. Allocation concealment: Was allocation adequately concealed?
  3. Blinding of participants, personnel and outcome assessors: Was knowledge of the allocated intervention adequately prevented during the study? At study entry? At the time of outcome assessment?
  4. Incomplete outcome data: Were incomplete outcome data adequately addressed?
  5. Selective outcome reporting: Are reports of the study free of suggestion of selective outcome reporting?
  6. Other sources of bias: Was the study apparently free of other problems that could put it at a high risk of bias?.

Measures of treatment effect

Statistical analyses were performed using Review Manager software. Categorical data were analyzed using relative risk (RR), risk difference (RD) and the number needed to treat (NNT). Continuous data were analyzed using weighted mean difference (WMD). The 95% Confidence interval (CI) was reported on all estimates.

Assessment of heterogeneity

We estimated the treatment effects of individual trials and examined heterogeneity between trials by inspecting the forest plots and quantifying the impact of heterogeneity using the I2statistic. If we detected statistical heterogeneity, we explored the possible causes using the subgroups noted below.

Assessment of reporting biases

Reporting bias was investigated by examining the degree of asymmetry of the funnel plot. Information was also sought and received on methods of random allocation for two trials (V- Beresford 1987; Al-Alaiyan 1996).

Data synthesis

Meta-analysis was performed using Review Manager software (RevMan 5) supplied by the Cochrane Collaboration. Meta-analysis was conducted using the fixed effect model. Mean Differences (MD) were used for outcome data measured on a continuous scale and relative risk, risk difference and number needed to treat as appropriate for categorical data. 95% Confidence Intervals (CI) are presented for all reported outcomes.

Subgroup analysis and investigation of heterogeneity

Different treatment intervals: frequent (one and two hourly) versus four hourly.
Different treatment methods: vibrations versus percussion.
Preterm < 28 weeks gestation or < 1000 g birthweight.
Preterm < 32 weeks gestation or < 1500 g birthweight.

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Results

Description of studies

Results of the search

Four randomised trials addressing the issue of active chest physiotherapy in the peri-extubation period were identified and included in this review (Finer 1979; V- Beresford 1987; Al-Alaiyan 1996; Bagley 2005). A full description of each is included in the table, Characteristics of Included Studies.

Included studies

Participants

The participants of the four trials differed somewhat with respect to primary diagnosis and gestational ages. The groups in Finer 1979 and Al-Alaiyan 1996 were more mature than in V- Beresford 1987 and Bagley 2005. Mean gestational age in was 35 weeks in Finer 1979, 33-35 weeks across the groups in Al-Alaiyan 1996, 29-32 weeks in V- Beresford 1987 and 30 weeks in Bagley 2005. Nine babies had multiple intubations (maximum of three) prior to enrolment in Finer 1979. Two trials randomised infants undergoing extubation from a primary course of ventilation only (V- Beresford 1987; Bagley 2005). The number of courses of mechanical ventilation prior to randomisation is unknown for infants in Al-Alaiyan 1996. The main diagnosis of babies enrolled in the four trials was respiratory distress syndrome, however Al-Alaiyan 1996 enrolled a higher proportion of babies with thoracoabdominal surgery (30%) and only Finer 1979 included infants with meconium aspiration and bacterial pneumonia.

Intervention

The intervention differed in that Finer 1979 and Al-Alaiyan 1996 used vibrations whereas V- Beresford 1987 and Bagley 2005 used percussion. Al-Alaiyan 1996 used an electric vibrator to deliver the chest wall vibrations. The frequency of treatments differed among the three trials. Al-Alaiyan 1996 and V- Beresford 1987 enrolled babies into groups of differing treatment frequencies. V- Beresford 1987 and Finer 1979 commenced active physiotherapy 1 hour prior to extubation whereas Al-Alaiyan 1996 and Bagley 2005 commenced the treatments following extubation.

Outcomes

The outcomes of postextubation lobar collapse and the use of endotracheal reintubation within 24 hours of extubation were assessed in all trials. Adverse effects were assessed in Bagley 2005 (short term neonatal morbidity and mortality) and V- Beresford 1987 (bradycardia only). Bagley 2005 reported on duration of respiratory support (mechanical ventilation, oxygen therapy and CPAP) and also for neonatal intensive care and hospital stay for the period from admission to the nursery to the initial discharge from hospital.

Excluded studies

  • None noted.

Risk of bias in included studies

Details of each study appear in the table, Characteristics of Included Studies.

Allocation

Concealment of allocation:
All of the included trials assigned babies to study groups by random allocation. Adequate concealment of treatment allocation by the use of sealed envelopes was undertaken in three trials (Finer 1979; Al-Alaiyan 1996; Bagley 2005). Concealment of treatment allocation was not achieved in V- Beresford 1987. In this trial, four treatment allocations (one for each of the four groups) were included in one sealed envelope.

Blinding

Blinding of the intervention: Blinding of the intervention was not possible.

Blinding of outcome: Diagnosis of post-extubation collapse was performed by an assessor blinded to the treatment allocation in all included trials.

Incomplete outcome data

Completeness of follow-up:

Finer 1979 and V- Beresford 1987 reported on outcomes for all randomised babies. In the Al-Alaiyan 1996 trial one baby who failed extubation was excluded; this baby has been included in this review following personal communication with the investigator. Bagley 2005 excluded four infants for the outcome of post extubation collapse as chest radiography was not performed, and two infants for the outcome of intraventricular haemorrhage as head ultrasonography was not performed; greater than 20% loss to follow-up was reported for the outcome of cerebral cystic lesions at six weeks.

Effects of interventions

Active chest physiotherapy vs. no active chest physiotherapy (Comparison 1):

Primary outcomes:

Post extubation collapse (PEC) and reintubation were the only outcomes reported in all of the included trials. The overall analysis shows a trend towards a reduction in the rate of PEC with active chest physiotherapy which is not statistically significant [(typical RR 0.80 (95% CI 0.49, 1.29)]. A significant reduction in the use of reintubation within 24 hours of extubation was shown for babies receiving active chest physiotherapy [(typical RR 0.32 (95% CI 0.13, 0.82); typical RD -7% (95% CI -13, -2)]. Thus, number needed to treat (NNT) to expect to prevent one baby receiving reintubation is 14 (95% CI 8, 50). There was insufficient information to adequately assess the outcomes of bradycardia, duration of oxygen therapy, cerebral haemorrhage, cerebral cystic lesions, long term neurosensory impairment or death.

Secondary outcomes:

No statistically significant differences were shown in any other short term outcomes (duration of CPAP and mechanical ventilation, duration of neonatal intensive care) reported by one trial (Bagley 2005).

Subgroup analysis by gestation age (Comparison 2):

No significant effect of chest physiotherapy on the following outcomes was shown in sub-group analyses of infants born less than 32 weeks gestation reported by one trial (Bagley 2005): postextubation collapse, use of reintubation, duration of oxygen therapy, cerebral haemorrhage, bradycardia, duration of CPAP and mechanical ventilation, duration of neonatal intensive care stay and death. Although no trend to a reduction in PEC was shown as for the overall analysis [RR 1.09 (95% CI 0.45, 2.63)], the trend to a reduction in reintubation remained [RR 0.64 (95% CI 0.11, 3.72)].

Sub-group analyses of differing treatment frequencies (Comparison 3):

Four trials contributed to the comparison of more frequent treatment (one and two hourly groups combined) with no treatment. In keeping with the overall analysis, there was a non significant reduction in the rate of PEC [typical RR 0.76 (95% CI 0.47, 1.24)] and a significant reduction in the use of reintubation [typical RR 0.24 (95% CI 0.08, 0.72); typical RD -8% (95% CI -14, -3); NNT 13 (95% CI 7, 33)]. Less frequent treatment (4 hourly) was compared to no treatment. Two trials were included in this analysis (V- Beresford 1987; Al-Alaiyan 1996), which showed an increase in PEC with active physiotherapy which is not statistically significant [(typical RR 1.45; (95% CI 0.51, 4.09)]. The reduction in the use of reintubation is also not statistically significant [(typical RR 0.80; 95% CI 0.21, 2.99)].

Discussion

Summary of main results

This review identified several important limitations of the presently available evidence from randomised trials:

Small sample sizes

Due to small numbers of infants in the four included trials, all estimates of effect are imprecise resulting in the inability to adequately assess the effects of this intervention.

Inconsistency of results

Some of the effects, particularly the effect on postextubation alveolar collapse, are inconsistent across trials. In the case of PEC, there is some evidence of a secular trend in that the rates in the control groups of the different trials fell from 38% (Finer 1979) to 25% (V- Beresford 1987) to 13% (Al-Alaiyan 1996) and 20% in Bagley 2005. The size and the direction of treatment effect varies with control event rate, so that the point estimates for risk difference are -38% (Finer 1979), -13% (V- Beresford 1987), +16% (Al-Alaiyan 1996) and -2% (Bagley 2005). Thus, a source of the heterogeneity of treatment effect on PEC may be the level of risk for PEC in the absence of chest physiotherapy. A similar trend across time, again correlated with size of treatment effect, is shown for reintubation. The rate of reintubation and the risk difference in the control groups are as follows: Finer 1979 33% (RD -33%), V- Beresford 1987 25% (RD -21%), Al-Alaiyan 1996 8.7% (RD -1.4%) and Bagley 2005 3.4% (RD -1.1%).

Overall completeness and applicability of evidence

Lack of safety data

Over the past decade, concerns regarding the safety of chest physiotherapy, particularly in the small preterm infant, have been reported. Information on possible adverse effects was inadequate in these trials to allow assessment of safety.

Although no difference was found in the number of infants with bradycardia following extubation reported by two trials, the numbers of infants studied are too small to be confident about this outcome or other more important adverse short term outcomes such as hypoxaemia and cerebral haemorrhage or cysts. None of the included trials reported measures of the important longer term outcome of neurodevelopmental impairment.

Quality of the evidence

Applicability to present day practice

Two of the four trials were conducted 15 and 23 years ago. Applicability of the results of the review to current practice may be compromised due to advancements in neonatal care which have occurred over the interval since the earlier trials were performed. Relevant improvements in neonatal care include better techniques for humidification of inspired gases, introduction of exogenous surfactant, strategies to reduce trauma during endotracheal suctioning (less frequent suctioning and the use of measured smaller bore catheters) and the use of prophylactic post-extubation nasal continuous positive airway pressure (NCPAP). These innovations may well have changed the nature of post-extubation complications considerably. For example, the use of prophylactic post-extubation NCPAP has been shown to reduce the rate of post-extubation complications (Davis 2001). Only one trial (Bagley 2005) used routine post-extubation NCPAP prophylactically for preterm infants. Therefore, the results of this review may overestimate the rates of PEC and reintubation in nurseries where prophylactic post-extubation NCPAP is now being used.

Potential biases in the review process

Caution is required in interpreting the results of this review and applying them to current practice. Although the number needed to treat of 14 to avoid reintubation shown in the overall analysis of this review suggests that active chest physiotherapy in this situation may be a worthwhile intervention, this finding was heavily weighted by the two trials conducted some time ago (Finer 1979; V- Beresford 1987) and was not supported by the results of the two more recent trials in this review. No benefit for chest physiotherapy was shown in one trial (Bagley 2005) in terms of the duration of mechanical ventilation, NCPAP, oxygen therapy or neonatal intensive care nursery stay. However, adequate assessment of the effects of chest physiotherapy on these outcomes is difficult due to insufficient data and also as the outcomes were measured from admission to the nursery not from randomisation and institution of the allocated treatment.

Agreements and disagreements with other studies or reviews

Although data in this review are insufficient to permit adequate assessment of this intervention, the lack of clear benefit for postextubation active chest physiotherapy shown is supported by other recent reports. A similar rate of PEC and no evidence for benefit of postextubation physiotherapy in terms of PEC was reported in a recent before-and-after study assessing active postextubation physiotherapy (Bloomfield 1998). Furthermore, the low risk of postextubation complications (PEC and reintubation) evident in the more recent trials in this review (Al-Alaiyan 1996; Bagley 2005) is also supported by a recent retrospective study. Davies 1998 reported a very low risk of PEC with no requirement for reintubation in these infants. Bagley 2005 reported no use of reintubation for any infant with PEC (unpublished data).

Care providers need to consider the role of active postextubation chest physiotherapy in the light of the lack of clear evidence for benefit, recent reports of severe adverse outcome associated with active chest physiotherapy in some situations (Ramsay 1995; Harding 1998) and the need to avoid unnecessary distress in the care of sick newborn infants from interventions which may not be beneficial. There are challenges in obtaining robust evidence for physiotherapy interventions due to the difficulties with blinding the intervention, and defining and measuring clinically meaningful outcomes (Wallis 1999).

Authors' conclusions

Implications for practice

The results of this review do not give a clear direction for the role of active chest physiotherapy for infants being extubated from mechanical ventilation in today's neonatal intensive care settings. Evidence for benefit of this intervention is conflicting and it was not possible to identify subgroups of babies who may benefit. No benefit for more vs. less frequent treatment is evident.

Concerns regarding the safety of active chest physiotherapy for preterm neonates have been reported. Information on adverse effects is inadequate in the trials included in this review to allow assessment of safety. In view of this and the lack of clear evidence for benefit, it would seem wise to use this intervention cautiously.

Implications for research

Further randomised controlled trials addressing the role of prophylactic active chest physiotherapy for neonates in the postextubation period may be unwarranted.

Acknowledgements

The authors would like to acknowledge Catherine Bagley, Physiotherapy Department, Mater Hospital, Brisbane, Australia; Dr Saleh Al-Alaiyan, Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia and Ann Vivian-Beresford, Children's Rehabilitation Centre, St John's, Newfoundland, Canada for providing further information regarding their trials.

We would also like to acknowledge Katie Welsh for assistance with literature searching and formatting the review.

Contributions of authors

Vicki Flenady prepared the protocol for the review, initial review and subsequent updates. Peter Gray provided comment.

Vicki Flenady (VF) wrote the original review and updated the review in 2002 and 2006.

The 2009 update was conducted centrally by the Cochrane Neonatal Review Group staff (Yolanda Montagne, Roger Soll, Diane Haughton) and reviewed and approved by VF.

Declarations of interest

The authors were investigators on the trial Bagley 2005.

Differences between protocol and review

  • None noted.

Additional tables

  • None noted.

Potential conflict of interest

  • None noted.

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Characteristics of studies

Characteristics of Included Studies

Al-Alaiyan 1996

Methods

Blinding of randomisation: yes
Blinding of intervention: no
Complete follow-up: yes
Blinding of outcome measure: yes for primary outcome (PEC)

Participants

Electively extubated infants who were intubated for more than 24 hours.
Exclusions were atelectasis prior to extubation, meconium aspiration or pneumonia.
Main diagnoses were respiratory distress syndrome (52%) and thoracoabdominal surgery (30%).
Mean gestational age across the groups was 33 - 35 weeks.
Duration of MV at randomisation:
Physio groups: 11.2 (16.7), and 11.4 (13.8)
Control group: 8.3 (11.2)
Mean (SD) days

Interventions

Active chest physio n=41: Postural drainage(lateral decubitus) and bilateral chest wall vibration (using a neo-cussor) were commenced immediately following extubation and continued for a 24 hour period. Two active chest physio groups: a 2 hourly and a 4 hourly treatment frequency group.
All treatments were performed by a physiotherapist.
Controls n=23: No active chest physiotherapy.

Outcomes

Atelectasis on chest radiography performed at 24 hours post-extubation, the use of reintubation and nasopharyngeal CPAP up to 24 hours postextubation.

Notes

All infants enrolled received active chest physiotherapy for postextubation collapse detected on the chest radiography at 24 hrs postextubation. Additional outcome data were received from the author for one infant excluded following randomisation.

Risk of bias table
Item Judgement Description
Adequate sequence generation? Unclear

Uncertain method of randomisation

Allocation concealment? Yes

Blinding of randomisation: yes

Blinding? No

Blinding of intervention: no

Blinding of outcome measure: yes for primary outcome (PEC)

Incomplete outcome data addressed? Yes

Complete follow-up: yes

Free of selective reporting? Yes

Additional information received from author

Free of other bias? Unclear

Insufficient information

Bagley 2005

Methods

Blinding of randomisation: yes
Blinding of intervention: no
Complete follow-up: no
Blinding of outcome measure: yes for primary outcome (PEC)

Participants

177 infants receiving a primary course of MV deemed ready for extubation. Exclusions: MV < 24 hrs, unstable infants, infants with GA < 28 weeks in the first week of life. Main diagnosis was RDS (94%).
97% of extubations were elective.
At randomisation:
Duration of MV (days): physio-7.3 (7.7) Control- 6.5 (8.5)
Postnatal age (days):
Physio: 8.7 (8.6)
Control: 7.2 (7.8)
GA (weeks):
Physio- 30.1 (3.4), Controls- 30.5 (3.69) [mean(SD)]

Interventions

Active chest physio n= 88: Percussion with a Laerdal or Bennetts face mask 2nd hourly for 6 hrs starting 2 hrs post extubation
Majority of physio performed by physiotherapists.
Controls n=89: No active chest physiotherapy Positioning and suctioning program as for the physio group.

Outcomes

Lobar collapse on chest radiography performed at 6 and 24 hrs post- extubation, reintubation and bradycardia within 24 hrs of extubation, total episodes of MV, duration of MV, oxygen treatment and NICU stay, IVH, intracranial haemorrhage, other cerebral lesions, hypoxia measured by continuous pulse oximetry (subgroup only).

Notes

Routine nursery practice included: oropharyngeal intubation, 4 hourly & prn ETT suction using 6 gauge catheter,
prophylactic post extubation NCPAP for GA < 32 weeks.
Infants remained in the original study group for each subsequent extubation episode. The outcomes of PEC and reintubation for the initial extubation episode only were included in the analysis
Additional data to that in the published abstract were included for Bagley 2005 as follows: durations of mechanical ventilation, oxygen therapy, CPAP, neonatal intensive care and hospital stay.
Sample size calculation: 430 needed to detect a 50% reduction in PEC from 40% in control group. Trial stopped at interim analysis due to no difference in the rates of PEC.

Risk of bias table
Item Judgement Description
Adequate sequence generation? Unclear

Uncertain method of randomisation

Allocation concealment? Yes

Blinding of randomisation: yes

Blinding? No

Blinding of intervention: no
Blinding of outcome measure: yes for primary outcome (PEC)

Incomplete outcome data addressed? No

Complete follow-up: no

Free of selective reporting? Yes
Free of other bias? Yes

Finer 1979

Methods

Blinding of randomisation: yes
Blinding of intervention: no
Complete follow-up: yes
Blinding of outcome measure: yes for primary outcome (PEC)

Participants

Mechanically ventilated for greater than 24 hours. Exclusion criteria are not mentioned.
The mean gestational age was 35 weeks.
Respiratory Distress Syndrome was the most common diagnosis (60%); other diagnoses included meconium aspiration, bacterial pneumonia, asphyxia, thoracoabdominal surgery and apnoea.
Duration of MV at randomisation (mean days):
Physio: 6
Controls: 6

Interventions

Active chest physio n=21: Postural drainage and chest wall vibrations commenced one hour prior to extubation and continued for a period of 48 hours as follows:
Hourly for 8 hours, 2 hourly for a further 16 hrs and 3 hourly until 48 hrs postextubation. A physiotherapist performed all the treatments for the first 8 hours and nurses for the remainder.
Controls n=21: Hourly positioning program for upper lobe drainage.

Outcomes

Atelectasis on chest radiographs performed at 8 or 24 hours post-extubation.

Notes

All infants enrolled received active chest physiotherapy for postextubation collapse detected on the chest radiography at 8 or 24 hrs postextubation.

Risk of bias table
Item Judgement Description
Adequate sequence generation? Unclear

Uncertain method of randomisation

Allocation concealment? Yes

Blinding of randomisation: yes

Blinding? No

Blinding of intervention: no
Blinding of outcome measure: yes for primary outcome (PEC)

Incomplete outcome data addressed? Yes

Complete follow-up: yes

Free of selective reporting? Unclear

Insufficient information

Free of other bias? Unclear

Insufficient information

V- Beresford 1987

Methods

Blinding of randomisation: no
Blinding of intervention: no
Complete follow-up: yes
Blinding of outcome measurement: yes for primary outcome (PEC)

Participants

Preterm infants with Respiratory Distress Syndrome undergoing a planned extubation from a primary course of extubation were eligible. Exclusions were babies with severe pulmonary oedema, apnoea or bradycardia, tachycardia or other signs of distress. Additional diagnoses were transient tachypnoea and pneumonia.
Mean gestational age across the groups was 29 - 32 weeks.
Duration of MV at randomisation (days):
Physio groups: 7, 9 and 16.
Control group: 16
Mean (SD) days

Interventions

Active chest physio n=24: Chest wall percussion was given in three study groups of different frequency: 4 hourly, 2 hourly and 1 hourly. Commencing at one hour pre-extubation until 24 hrs post-extubation. The treatments were carried out by either physiotherapists or nurses.
Controls n=8: No active chest physiotherapy. Similar positioning program as for intervention.

Outcomes

Atelectasis (detected on chest radiographs at 24 hours post-extubation), pneumonia, bradycardia, respiratory distress and intolerance of treatment up to 24 hours post-extubation.

Notes

Sample size calculation required 60 babies in total; 15 in each arm. Sample size not achieved due to poor recruitment rate.

Risk of bias table
Item Judgement Description
Adequate sequence generation? Unclear

Uncertain method of randomisation

Allocation concealment? No

Blinding of randomisation: no

Blinding? No

Blinding of intervention: no

Blinding of outcome measurement: yes for primary outcome (PEC)

Incomplete outcome data addressed? Yes

Complete follow-up: yes

Free of selective reporting? Unclear

Insufficient information

Free of other bias? Unclear

Insufficient information

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References to studies

Included studies

Al-Alaiyan 1996

Al-Alaiyan S, Dyer D, Khan B. Chest physiotherapy and post-extubation atelectasis in infants. Pediatric Pulmonology 1996;21:227-30.

Bagley 2005

Bagley C, Flenady V, Tudehope D, Gray P. The role of postextubation chest physiotherapy: A randomised controlled trial. In: Proceedings of the Perinatal Society of Australia and New Zealand 4th Annual Congress. Brisbane, 1999.

Bagley CE, Gray PH, Tudehope DI, Flenady V, Shearman AD, Lamont A. Routine neonatal postextubation chest physiotherapy: a randomized controlled trial. Journal of Paediatrics and Child Health 2005;41(11):592-7.

Finer 1979

Finer N, Moriartey R, Boyd J, Phillips H, Stewart A, Ulan O. Post-extubation atelectasis: A retrospective review and a prospective controlled study. Journal of Pediatrics 1979;94:110-3.

V- Beresford 1987

Vivian-Beresford A, King C, Macauley H. Neonatal post-extubation complications: the preventive role of physiotherapy. Physiotherapy Canada 1987;39:184-90.

References to excluded studies

  • None noted.

Studies awaiting classification

  • None noted.

Ongoing studies

  • None noted.

Other references

Additional references

Beeby 1998

Beeby PJ, Henderson-Smart DJ, Lacey JL, Rieger I. Short- and long-term neurological outcomes following neonatal chest physiotherapy. Journal of Paediatrics and Child Health 1998;34:60-2.

Bloomfield 1998

Bloomfield FH, Teele RL, Voss M, Knight DB, Harding J. The role of neonatal chest physiotherapy in preventing postextubation atelectasis. Journal of Pediatrics 1998;133:269-71.

Bradbury-Hough 1995

Bradbury-Hough JB. Cupping: The effect of this respiratory physiotherapy technique on the cardiorespiratory function of the neonate with idiopathic respiratory distress syndrome [Masters of Physiotherapy thesis]. Australia: University of Queensland, 1995.

Coney 1995

Coney S. Physiotherapy technique banned in Auckland. Lancet 1995;345:510.

Crane 1978

Crane LD, Zombek M, Krauss AN, Auld PAM. Comparison of chest physiotherapy techniques in infants with HMD. Pediatric Research 1978;12:559.

Cross 1992

Cross JH, Harrison CJ, Preston PR, Rushton DI, Newell SJ, Morgan MEI, et al. Postnatal encephaloclastic porencephaly - a new lesion? Archives of Disease in Childhood 1992;67:307-11.

Curran 1979

Curran LC, Kachoyeanos MK. The effects on neonates of two methods of chest physical therapy. Mothercraft Nursing 1979;4:309-13.

Davies 1998

Davies MW, Cartwright DW. Postextubation chest X-rays in neonates: A routine no longer necessary. Journal of Paediatrcs and Child Health 1998;34:147-50.

Davis 2001

Davis PG, Henderson-Smart DJ. Prophylactic post-extubation nasal CPAP in preterm infants. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD000143. DOI: 10.1002/14651858.CD000143 .

Duara 1983

Duara S, Bessard K, Keszier L, Artes D, Batzer K. Evaluation of different percussion time intervals of chest physiotherapy on neonatal pulmonary function parameters [abstract]. Pediatric Research 1983;17:310A.

Etches 1978

Etches PC, Scott B. Chest physiotherapy in the newborn: Effects on secretions removed. Pediatrics 1978;62:713-5.

Finer 1978

Finer NN, Boyd DPT. Chest physiotherapy in the neonate: A controlled study. Pediatrics 1978;61:282-5.

Flenady 1997

Flenady VJ, Bagley C, Tudehope DT. Active chest physiotherapy practices in neonatal intensive care: A survey of units in Australia and New Zealand. In: Proceedings of the Perinatal Society of Australia and New Zealand Congress. Fremantle, 1997.

Fox 1978

Fox WH, Schwartz JG, Shaffer TH. Pulmonary physiotherapy in neonates: Physiologic changes and respiratory management. Journal of Pediatrics 1978;92:977-81.

Halliday 1992

Halliday HL. Other acute lung disorders. In: Sinclair JC, Bracken MB, editor(s). Effective Care of the Newborn Infant. Oxford: Oxford University Press, 1992:359-384.

Harding 1998

Harding JE, Miles FKI, Becroft DMO, Allen BC, Knight DB. Chest physiotherapy may be associated with brain damage in extremely premature babies. Journal of Pediatrics 1998;132:440-4.

Higgins 2008

Higgins JPT, Green S, editors. Cochrane Handbook for Systemic Reviews of Interventions Version 5.0.0 [updated February 2008]. The Cochrane Collaboration, 2008. Available from www.cochrane-handbook.org.

Holloway 1969

Holloway R, Adams EB, Desai SD, Thambian AK. Effect of chest physiotherapy on blood gases of neonates treated by intermittent positive pressure respiration. Thorax 1969;24:421-6.

Lewis 1992

Lewis JA, Lacey JL, Henderson-Smart DJ. A review of chest physiotherapy in neonatal intensive care units in Australia. Journal of Paediatrics and Child Health 1992;28:297-303.

Odita 1993

Odita JC, Kayyali M, Ammari A. Post-extubation atelectasis in newborn infants. Pediatric Radiology 1993;23:183-5.

Paratz 1994

Paratz JD. The effect of respiratory physiotherapy on intracranial dynamics in preterm and term infants [Doctor of Philosophy thesis]. Australia: University of Queensland, 1994.

Purohit 1975

Purohit DM, Caldwell C, Levkoff AH. Multiple rib fractures due to physiotherapy in a neonate with hyaline membrane disease. American Journal of Disease of Children 1975;129:1103-4.

Ramsay 1995

Ramsay S. The Birmingham experience. Lancet 1995;345:510.

Raval 1987

Raval D, Yeh TF, Mora A, Cuevas D, Pyati S, Pildes RS. Chest physiotherapy in preterm infants with RDS in the first 24 hours of life. Journal of Perinatology 1987;7:301-4.

Roper 1976

Roper PC, Vonwiller JB, Fisk GC, Gupta JM. Lobar atelectasis after nasotracheal intubation in newborn infants. Australian Paediatric Journal 1976;12:272-5.

Spitzer 1982

Spitzer AR, Fox WW. Post-extubation atelectasis - the role of oral versus nasal endotracheal tubes. Journal of Pediatrics 1982;100:806-10.

Tudehope 1980

Tudehope DI, Bagley C. Techniques of physiotherapy in intubated babies with respiratory distress syndrome. Australian Paediatric Journal 1980;16:226-8.

Wallis 1999

Wallis C, Prasad A. Who needs chest physiotherapy? Moving from anecdote to evidence. Archives of Disease in Childhood 1999;80:393-7.

Wyman 1977

Wyman L, Kuhns L. Lobar opacification of the lung after tracheal extubation in neonates. Journal of Pediatrics 1977;91:109-12.

Other published versions of this review

Flenady 1998

Flenady VJ, Gray PH. Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation. Cochrane Database of Systematic Reviews 1998, Issue 1. Art. No.: CD000283. DOI: 10.1002/14651858.CD000283.

Flenady 2002

Flenady VJ, Gray PH. Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000283. DOI: 10.1002/14651858.CD000283.

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Data and analyses

1 Active chest physiotherapy vs no active chest physiotherapy

Outcome or Subgroup Studies Participants Statistical Method Effect Estimate
1.1 Postextubation lobar collapse 4 315 Risk Ratio (M-H, Fixed, 95% CI) 0.80 [0.49, 1.29]
1.2 Reintubation within 24hrs 4 315 Risk Ratio (M-H, Fixed, 95% CI) 0.32 [0.13, 0.82]
1.3 Pneumonia 1 32 Risk Ratio (M-H, Fixed, 95% CI) 1.00 [0.12, 8.31]
1.4 Bradycardia 2 209 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.66, 1.53]
1.5 Intraventricular haemorrhage-all grades 1 177 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.58, 1.78]
1.6 Intraventricular haemorrhage - Grades 3 and 4 1 177 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
1.7 Death prior to discharge 1 177 Risk Ratio (M-H, Fixed, 95% CI) 0.25 [0.03, 2.22]
1.8 Duration of mechanical ventilation (days) 1 177 Mean Difference (IV, Fixed, 95% CI) 1.74 [-1.26, 4.74]
1.9 Duration of nasopharyngeal CPAP( days) 1 177 Mean Difference (IV, Fixed, 95% CI) 1.83 [-0.54, 4.20]
1.10 Duration of supplemental oxygen (days) 1 176 Mean Difference (IV, Fixed, 95% CI) 9.73 [-0.69, 20.15]
1.11 Duration of neonatal intensive care stay (days) 1 177 Mean Difference (IV, Fixed, 95% CI) 3.91 [-2.85, 10.67]

2 Active chest physiotherapy vs no active physiotherapy - < 32 wks gestation

Outcome or Subgroup Studies Participants Statistical Method Effect Estimate
2.1 Postextubation lobar collapse 1 120 Risk Ratio (M-H, Fixed, 95% CI) 1.09 [0.45, 2.63]
2.2 Reintubation within 24hrs 1 120 Risk Ratio (M-H, Fixed, 95% CI) 0.64 [0.11, 3.72]
2.3 Bradycardia 1 120 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.63, 1.64]
2.4 Intraventricular haemorrhage - all grades 1 120 Risk Ratio (M-H, Fixed, 95% CI) 0.91 [0.52, 1.60]
2.5 Intraventricular haemorrhage - Grades 3 and 4 1 120 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
2.6 Death prior to discharge 1 120 Risk Ratio (M-H, Fixed, 95% CI) 0.24 [0.03, 2.10]
2.7 Duration of mechanical ventilation (days) 1 120 Mean Difference (IV, Fixed, 95% CI) 1.50 [-2.59, 5.59]
2.8 Duration of nasopharyngeal CPAP( days) 1 120 Mean Difference (IV, Fixed, 95% CI) 2.20 [-0.91, 5.31]
2.9 Duration of supplemental oxygen (days) 1 119 Mean Difference (IV, Fixed, 95% CI) 9.84 [-3.91, 23.59]
2.10 Duration of neonatal intensive care stay (days) 1 120 Mean Difference (IV, Fixed, 95% CI) 4.79 [-4.02, 13.60]

3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)

>
Outcome or Subgroup Studies Participants Statistical Method Effect Estimate
3.1 Post extubation lobar collapse 4 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1.1 1 and 2 hourly active physiotherapy vs no active physiotherapy 4 285 Risk Ratio (M-H, Fixed, 95% CI) 0.76 [0.47, 1.24]
3.1.2 4 hourly active physiotherapy vs no active physiotherapy 2 61 Risk Ratio (M-H, Fixed, 95% CI) 1.45 [0.51, 4.09]
3.2 Reintubation within 24 hours 4 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.2.1 1 and 2 hourly active physiotherapy vs no active physiotherapy 4 285 Risk Ratio (M-H, Fixed, 95% CI) 0.24 [0.08, 0.72]
3.2.2 4 hourly active physiotherapy vs no active physiotherapy 2 61 Risk Ratio (M-H, Fixed, 95% CI) 0.80 [0.21, 2.99]
3.3 Pneumonia 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.3.1 1 and 2 hourly active physiotherapy vs no active physiotherapy 1 24 Risk Ratio (M-H, Fixed, 95% CI) 2.00 [0.14, 27.99]
3.3.2 4 hourly active physiotherapy vs no active physiotherapy 1 16 Risk Ratio (M-H, Fixed, 95% CI) 2.00 [0.22, 17.89]
3.4 Bradycardia 2 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.4.1 1 and 2 hourly active physiotherapy vs no active physiotherapy 2 201 Risk Ratio (M-H, Fixed, 95% CI) 1.03 [0.67, 1.58]
3.4.2 4 hourly active physiotherapy vs no active physiotherapy 1 16 Risk Ratio (M-H, Fixed, 95% CI) 0.40 [0.11, 1.49]
3.5 Intraventricular haemorrhage- all grades 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.5.1 1 and 2 hourly active physiotherapy vs no active physiotherapy 1 177 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.58, 1.78]
3.5.2 4 hourly active physiotherapy vs no active physiotherapy 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
3.6 Intraventricular haemorrhage - Grades 3 and 4 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.6.1 1 and 2 hourly active physiotherapy vs no active physiotherapy 1 177 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
3.6.2 4 hourly active physiotherapy vs no active physiotherapy 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
3.7 Death prior to discharge 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.7.1 1 and 2 hourly active physiotherapy vs no active physiotherapy 1 177 Risk Ratio (M-H, Fixed, 95% CI) 0.25 [0.03, 2.22]
3.7.2 4 hourly active physiotherapy vs no active physiotherapy 0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
3.8 Duration of mechanical ventilation (days) 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
3.8.1 1 and 2 hourly active physiotherapy vs no active physiotherapy 1 177 Mean Difference (IV, Fixed, 95% CI) 1.74 [-1.26, 4.74]
3.8.2 4 hourly active physiotherapy vs no active physiotherapy 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
3.9 Duration of nasopharyngeal CPAP( days) 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
3.9.1 1 and 2 hourly active physiotherapy vs no active physiotherapy 1 177 Mean Difference (IV, Fixed, 95% CI) 1.83 [-0.54, 4.20]
3.9.2 4 hourly active physiotherapy vs no active physiotherapy 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
3.10 Duration of supplemental oxygen (days) 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
3.10.1 1 and 2 hourly active physiotherapy vs no active physiotherapy 1 176 Mean Difference (IV, Fixed, 95% CI) 9.54 [0.42, 18.66]
3.10.2 4 hourly active physiotherapy vs no active physiotherapy 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
3.11 Duration of neonatal intensive care stay (days) 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
3.11.1 1 and 2 hourly active physiotherapy vs no active physiotherapy 1 177 Mean Difference (IV, Fixed, 95% CI) 3.91 [-2.85, 10.67]
3.11.2 4 hourly active physiotherapy vs no active physiotherapy 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable

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Sources of support

Internal sources

  • JP Kelly Research Foundation, Mater Hospital, Sth Brisbane, Queensland, Australia
  • Mater Mother's Research Centre - Mater Hospital, Sth Brisbane, Queensland, Australia
  • Department of Neonatology, Mater Mothers' Hospital, South Brisbane, Queensland, Australia

External sources

  • Department of Health and Ageing, Commonwealth Government, Canberra, ACT, Australia

This review is published as a Cochrane review in The Cochrane Library, Issue 10, 2010 (see http://www.thecochranelibrary.com External Web Site Policy for information). Cochrane reviews are regularly updated as new evidence emerges and in response to feedback. The Cochrane Library should be consulted for the most recent recent version of the review.