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Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support

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Authors

Judith L Hough1, Vicki Flenady2, Leanne Johnston3, Paul G Woodgate4

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


1Physiotherapy Department, Mater Hospital, South Brisbane, Australia [top]
2Centre for Clinical Studies-Women's and Children's Health, Women's and Children's Health Service, South Brisbane, Australia [top]
3School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, Australia [top]
4Dept of Neonatology, Mater Mothers Hospital, South Brisbane, Australia [top]

Citation example: Hough JL, Flenady V, Johnston L, Woodgate PG. Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006445. DOI: 10.1002/14651858.CD006445.pub2.

Contact person

Judith L Hough

Physiotherapy Department
Mater Hospital
Raymond Terrace
South Brisbane
Queensland
4101
Australia

E-mail: judyhough@optusnet.com.au

Dates

Assessed as Up-to-date: 28 November 2007
Date of Search: 30 June 2007
Next Stage Expected: 28 November 2009
Protocol First Published: Issue 2, 2007
Review First Published: Issue 3, 2008
Last Citation Issue: Issue 3, 2008

What's new

Date / Event Description
18 February 2008
Amended

Converted to new review format.

History

Date / Event Description

Abstract

Background

Chest physiotherapy (CPT) has been used in many neonatal nurseries around the world to improve airway clearance and treat lung collapse; however, the evidence to support its use has been conflicting. Despite the large number of studies there is very little evidence of sufficiently good quality on which to base current practice.

Objectives

To assess the effects of active CPT techniques, such as percussion and vibration followed by suction compared with suction alone, on the respiratory system in infants receiving mechanical ventilation. Additionally, differences between types of active CPT techniques were assessed.

Search methods

Our search included The Cochrane Library (Issue 2, 2007), MEDLINE (1966 to 2007), EMBASE (1988 to 2007), CINAHL, Science Citation Index, previous reviews including cross-references, abstracts, conference proceedings and grey literature.

Selection criteria

Trials in which ventilated newborn infants up to four weeks of age were randomly or quasi-randomly assigned to receive active CPT or suction alone. Infants receiving CPT for the extubation period were excluded.

Data collection and analysis

Two review authors independently conducted quality assessments and data extraction for included trials. We analysed data for individual trial results using relative risk (RR) and mean difference (MD). Results are presented with 95% confidence intervals (CI). Due to insufficient data, we could not undertake meta-analysis.

Results

Three trials involving 106 infants were included in this review. In one trial (n = 20) CPT was no better than standard care in clearing secretions. No increase in the risk of intraventricular haemorrhage was noted. Two trials compared different types of active CPT. One trial (n = 56) showed that non-resolved atelectasis was reduced in more neonates receiving the lung squeezing technique (LST) when compared to postural drainage, percussion and vibration (PDPV) (RR 0.25; 95% CI 0.11 to 0.57). No difference in secretion clearance or in the rate of intraventricular haemorrhage or periventricular leucomalacia was demonstrated. The other trial (n = 30) showed that the use of percussion or 'cupping' resulted in an increased incidence of hypoxaemia (RR 0.53; 95% CI 0.28 to 0.99) and increased oxygen requirements (MD -9.68; 95% CI -14.16 to -5.20) when compared with contact heel percussion. There was insufficient information to adequately assess important short and longer-term outcomes, including adverse effects.

Authors' conclusions

The results of this review do not provide sufficient evidence on which to base clinical practice. There is a need for larger randomised controlled trials to address these issues.

Plain language summary

Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support

There is not enough evidence to determine whether active chest physiotherapy is of benefit to neonates on mechanical ventilation. Babies who require mechanical ventilation are at risk of lung collapse from increased secretions. Chest physiotherapy (patting or vibrating the chest) is used to improve clearance of secretions from the airway to try to prevent lung collapse. This review found no clear overall benefit or harm from chest physiotherapy. Some individual chest physiotherapy techniques were more beneficial than others in resolving atelectasis and maintaining oxygenation. These results do not support one technique over another. Due to the limited number, poor quality and age of trials in this review, there is not enough evidence to determine whether or not chest physiotherapy is beneficial or harmful in the treatment of infants being ventilated in today's intensive care units. Further good quality trials are needed to address this issue.

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Background

Approximately two to three per cent of all babies born in Australia and New Zealand require admission to a level three neonatal intensive care unit (NICU) (ANZNN 2005). In this group of high-risk infants, 89% require assisted ventilation. Chest physiotherapy (CPT) techniques are used in many NICUs throughout the world to improve airway clearance and treat lung collapse in infants on ventilatory support.

The application of CPT in airway management of mechanically ventilated adults has been shown to improve total lung/thoracic compliance and cardiorespiratory function (Mackenzie 1985); however, little is known about its effect on neonates. Acute lobar atelectasis is a common problem in infants receiving mechanical ventilation. Atelectasis contributes to morbidity in the neonatal nursery, necessitating prolongation of oxygen administration (Ehrlich 1972). Although CPT has been shown to be effective in the treatment of both non-ventilated children (Zach 1987) and intubated adults (Stiller 1990) with acute lobar collapse, studies of the effectiveness in the neonatal population are conflicting. In the neonatal population, CPT is used to prevent and treat lung collapse and consolidation. Some studies in the neonatal population have shown positive effects of CPT, including improved oxygenation (Finer 1978; Curran 1979) and increased removal of secretions (Etches 1978). However, the use of CPT has also received much criticism, largely as a result of reports of adverse outcomes. Documented adverse outcomes include hypoxaemia (Fox 1978), bruising, rib fractures (Purohit 1975; Dabezies 1997) and intracranial lesions such as intraventricular haemorrhage (Raval 1987) and porencephalic cysts (Cross 1992; Harding 1998).

CPT in the preterm infant consists of a variety of techniques that include positioning, active techniques such as percussion and vibration, and suction. Percussion involves a rhythmical cupping action applied to the chest wall performed with a full cupped hand, tented fingers, or by using an infant resuscitation face mask (cupping). The technique of vibration can be performed manually by using the fingers to cause a fine shaking motion of the chest wall. Alternatively, an electric toothbrush or other vibrating device can be used.

The use of these techniques, in varying combinations and frequencies, has become standard treatment for a variety of pulmonary conditions. Since there are many combinations of treatments that constitute CPT, it is difficult to determine the exact effects of any particular treatment technique. There has been some attempt in the past to ascertain which techniques produced the most clinically relevant results, but the results are equivocal. One study found percussion to be better than vibration (Tudehope 1980), while another has found the opposite to be the case (Curran 1979). A third study found that there was no difference between the techniques (Hartrick 1982). In clinical practice, percussion and vibration are rarely used in isolation; most often percussion and vibration are given in combination with positioning, postural drainage and airway suction. Therefore, it is difficult to assess separately the efficacy of each treatment component.

Previous Cochrane reviews have investigated the positioning (Balaguer 2006) and suctioning (Pritchard 2001; Woodgate 2001; Spence 2003) components of CPT. Only one review has assessed the effect of active CPT on preterm infants, and this study involved a population of infants who were being extubated (Flenady 2002). This review could not recommend guidelines for clinical practice due to small numbers of infants studied and the insufficient information on outcomes other than the reduction in post-extubation atelectasis (Flenady 2002). In light of the results of this review and the amount of conflicting information from other studies, it is important to investigate the wider use of the techniques of percussion and vibration in the preterm population.

Since the issue of the effectiveness of physiotherapy is still a controversial topic, it is anticipated that this review will provide evidence on which to base guidelines regarding the provision of the chest physiotherapy techniques of percussion and vibration in the infant on ventilatory support.

Objectives

  1. To determine the effects of active CPT, such as percussion and vibration followed by suction, compared to nonactive techniques, such as suction with or without the addition of positioning, in newborn infants receiving mechanical ventilation:
    1. electively for the prevention of atelectasis, consolidation or other respiratory morbidity
    2. therapeutically for the treatment of atelectasis or consolidation
  2. To determine the effects of the different types of active CPT.

The following subgroup analyses are planned:

  1. Population:
    1. Gestational age: < 30 weeks; < 37 weeks; 37 weeks and over
    2. Birth weight : < 1500 grams; < 2500 grams; 2500 grams and ove
    3. Underlying pulmonary disorder: respiratory distress syndrome (RDS), aspiration, infection or chronic lung disease (CLD)
  2. Intervention - techniques:
    1. Type of technique: percussion (including cupping with a face mask, contact heel percussion and finger percussion); vibration (with fingers or mechanical vibrator)
    2. Frequency: four hours or less; > four hours

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Methods

Criteria for considering studies for this review

Types of studies

All trials utilising random or quasi-random patient allocation that met the inclusion criteria for types of participants, interventions and at least one outcome were included. Cross-over trials were included.

Types of participants

All newborn infants receiving mechanical ventilation for neonatal respiratory disease with the intervention initiated in the first four weeks of life. We excluded infants receiving prophylactic CPT for the extubation period as this intervention is addressed in another Cochrane review (Flenady 2002).

Types of interventions

Active CPT (vibration or percussion, with or without the use of devices such as face masks and electric vibrators) followed by suction compared with standard care (suction with or without positioning).

Studies comparing two or more methods of CPT intervention were eligible.

Types of outcome measures

Primary outcomes
  • Duration of mechanical ventilation (MV) (days)
  • Duration of supplemental oxygen after intervention (days)
  • Duration of hospital stay (days)
Secondary outcomes

Atelectasis or consolidation based on pre/post radiographs:

  • incidence of atelectasis or consolidation (for prophylactic group)
  • resolution or extension of atelectasis or consolidation (for treatment group)
Oxygenation:
  • incidence of hypoxaemia (SaO2 < 90% or TcPO2 < 50 mmHg) during a single intervention
  • per cent change PaCO2 and PaO2 pre and post a single intervention
  • per cent change inspired oxygen received (FiO2) pre and post a single intervention
Secretion clearance:
  • sputum weight (g) post a single intervention
  • sputum volume (ml) post a single intervention
Rates and type of intracranial lesions diagnosed by ultrasound scan:
  • intraventricular haemorrhage (IVH) (any IVH, grade 3 and 4) (Papile 1978)
  • periventricular leucomalacia (PVL) [any grade, and severe (grades 3 and 4)] (Papile 1978)

Bradycardia (change in heart rate < 30% of baseline or < 100 beats per minute) during intervention

Search methods for identification of studies

We used the standard search strategy for the Cochrane Neonatal Review Group (see: Cochrane Neonatal Review Group, search strategy for Specialised Register in The Cochrane Library). The review authors undertook a comprehensive search which included searches of the following electronic databases: The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 to June 2007), EMBASE (1988 to June 2007), CINAHL (1982 to June 2007), PEDro (1929 to June 2007) and Web of Science. The review authors cross-referenced relevant literature including identified trials and review articles.

Searches of the electronic databases were based on the following search strategy:

  1. physiotherapy OR physical therapy, AND
  2. infant OR neonate OR newborn, AND
  3. chest OR lung OR respiratory
  4. NOT cystic fibrosis

The search also included searches of previous reviews including cross-references, abstracts, conference and symposia proceedings, expert informants and journal hand searching restricted to the English language. We handsearched conference Proceedings of the Society for Pediatric Research (SPR) (1967 to 2007), the European Society for Pediatric Research (ESPR) (2005), Pediatric Academic Societies Abstracts 2006, Australasian Physiotherapy conference abstracts (2003 to 2006), theses and dissertation lists, The Chartered Society of Physiotherapists (1988 to 2005) and trial registries (Australia, UK, USA) for unpublished work. No other language restrictions were applied.

We examined the title and abstract of each retrieved study to assess eligibility. If there was uncertainty, we examined the full paper.

Data collection and analysis

We used the standard methods of the Neonatal Review Group of the Cochrane Collaboration.Two review authors searched for and considered trials for inclusion, evaluated methodological quality and extracted data independently. Differences in interpretation were resolved by discussion with a third review author.
Where necessary, we contacted investigators of identified trials for additional information regarding trial methodology or outcome data (Crane 1978; Etches 1978; Finer 1978; Curran 1979; Tudehope 1980; Hartrick 1982; Peters 1983; Fiser 1985; Leung 1998; Main 2001). Since many of these studies were performed quite a few years ago some of the authors either no longer had the data available (Etches 1978; Finer 1978; Curran 1979; Tudehope 1980) or could not be contacted (Crane 1978; Hartrick 1982). At the time of this review, additional data had been received from Peters 1983, and was included in this review.

Quality assessment

We conducted quality assessment according to the methods described in section six of the Cochrane Handbook for Systematic Reviews of Interventions (Handbook 2007). We considered four major sources of potential bias and methods of avoidance when assessing the trial quality:

  1. selection bias - blinding of randomisation;
  2. performance bias - blinding of intervention;
  3. attrition bias - complete follow-up;
  4. detection bias - blinding of outcome assessment.

A quality rating was assigned to each trial for the criterion of blinding of randomisation as follows: (A) adequate, (B) unclear, (C) inadequate, or (D) not used. A quality rating of (A) yes, (B) can't tell, or (C) no, was assigned to the other quality components (completeness of follow-up and blinding of outcome assessment). High quality trials were defined as those receiving an A rating for blinding of randomisation (central computerised randomisation service or sealed opaque envelopes). The quality assessment rating included in the Table of 'Characteristics of Included Studies' refers to blinding of randomisation (allocation concealment) only.

Data analysis

Two review authors independently extracted data using prepared data extraction forms. We resolved any discrepancies by discussion with a third review author.

We used the Review Manager software (RevMan 4.2.7) (RevMan 2003) for statistical analyses. In the cross-over trial (Peters 1983) investigators provided individual patient data for each intervention on oxygenation. From this data the authors derived the group means and standard deviations for per cent change in oxygenation. The numbers of infants who experienced one or more hypoxaemic episode during each intervention were included for the outcome of hypoxaemia.

Due to insufficient data it was not possible to conduct a meta-analysis. For individual trials, where possible, mean differences and 95% confidence intervals (CI) are reported for data measured on a continuous scale. For categorical outcomes, relative risk and 95% confidence intervals are reported.

Methods for future updates of this review

We did not implement all of the methods outlined in the protocol as there were insufficient data.

For future updates of the review, we will analyse categorical data using relative risk (RR), risk difference (RD) and number needed to treat (NNT) where appropriate. We will use a fixed-effect model to pool results. We will use weighted mean differences (WMD) for data measured on a continuous scale. We will report the 95% confidence intervals (CI) for all estimates. We will perform sensitivity analyses to evaluate the effect of the trial quality (excluding quasi-randomised trials and considering trials with minimal bias). We will assess heterogeneity by visual inspection of the outcomes tables and by using an I-squared test of heterogeneity (Higgins 2002). Where statistical heterogeneity is found, the review authors will look for an explanation using prespecified subgroup analyses.

The following subgroup analyses will be performed:

  1. Population
    • Gestational age: < 30 weeks; < 37 weeks; 37 weeks and over
    • Birth weight : < 1500 grams, < 2500 grams, 2500 grams and over
    • Underlying pulmonary disorder: respiratory distress syndrome (RDS), aspiration, infection or chronic lung disease (CLD)
  2. Intervention - techniques
    • Type of technique: percussion (including cupping with a face mask, contact heel percussion and finger percussion); vibration (with fingers or mechanical vibrator)
    • Frequency: four hours or less; > four hours

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Results

Description of studies

The search strategy initially retrieved 2036 references of which 1993 publications were excluded based upon title and abstract. We identified the remaining 43 publications as potentially eligible for inclusion in this review and requiring more detailed examination. After examination of the publications, we excluded 40 publications from the review. Thirty-one publications were excluded as they did not fulfil the inclusion criteria. Of these 31, we excluded 23 trials as they were not randomised or quasi-randomised controlled trials, six trials because the participants were not newborn infants with respiratory disease in the first four weeks of life, one because the participants were not mechanically ventilated, and a further one trial because the intervention was not a physiotherapy technique. We excluded a further four trials (Crane 1978; Hartrick 1982; Fiser 1985; Leung 1998) as the publications were in the form of conference abstracts and despite attempts to do so no further data could be obtained from the authors.
We excluded another five trials (Etches 1978; Finer 1978; Curran 1979; Tudehope 1980; Main 2001) as no useable data were reported or could be obtained from the authors.

(For further details on excluded studies see the table of 'Characteristics of Excluded Studies').

One ongoing trial was identified (Hough 2007) (See table of 'Characteristics of Ongoing Studies').

Three trials were included in the review.

The study by Raval 1987 compared the effects of CPT in 20 premature neonates with a gestational age of 28 to 32 weeks. Infants who were intubated and ventilated for respiratory distress syndrome (RDS) were randomly assigned to two groups. The intervention in the CPT group (n = 10) consisted of postural drainage in the head up and head down position, percussion, vibration and suction. The control group (n = 10) procedure consisted of suctioning only. Each of these procedures was performed every two to three hours in the first 24 hours of life. Outcomes measured used were continuous TcPO2 monitoring, arterial blood gas (ABG) sampling, weight of sputum cleared, mortality rate and rates of intracranial lesions.

Peters 1983 evaluated the responses of critically ill neonates to two different techniques of CPT administration. Thirty neonates (25 to 42 weeks gestational age) who were 28 days old or younger were randomised in a two-period cross-over design to one of two groups. Group 1 received postural drainage, endotracheal instillation of saline, suction and percussion consisting of cupping with a Bennett face mask (Bennett percussion) followed by Boyd percussion (contact heel percussion) an hour later. Group 2 received the same interventions in the reverse order. The neonates' responses for heart rate, mean arterial pressure (MAP), intracranial pressure (ICP), TcPO2 and TcPCO2 were recorded during the pre-CPT, postural drainage, percussion, ETT instillation and suctioning, and immediately post-CPT phases.

Wong 2003 enrolled 56 neonates who were aged less than 37 weeks gestation and required mechanical ventilation if they met the inclusion criteria of the presence of a segmental or lobar collapse confirmed on chest x-ray. Lung squeezing technique (LST), a form of manual chest wall compression, was compared in a group of 26 neonates with conventional treatment of postural drainage, percussion and vibration (PDPV). Therapy sessions were performed twice daily at specified times until resolution of atelectasis occurred. Re-expansion of atelectasis, recurrence of atelectasis, duration of ventilation, duration of oxygen dependency, occurrence of bronchopulmonary dysplasia (BPD), rates of intracranial lesions and mortality rate were the outcomes measured in this study.

Types of participants

A total of 106 infants were randomised in the three included trials investigating CPT in neonates.
Participant recruitment and inclusion criteria varied between the three trials; Raval 1987 included preterm infants with a birth weight less than 2000 grams, Wong 2003 recruited mechanically ventilated infants with a gestational age of less than 37 weeks, and Peters 1983 included any newborn infant requiring intubation. Gestational ages varied from between 28 to 32 weeks (Raval 1987), 22 to 36 weeks (Wong 2003) and 25 to 42 weeks (Peters 1983). Birth weights varied correspondingly with one study not stating birth weight (Raval 1987), the second ranging from 540 to 2900 grams (Wong 2003), and in third the study (Peters 1983) the infants tending to be heavier (ranging in weight from 750 to 4030 grams). Postnatal age at the time of the study varied from 1 to 12 hours of age (Raval 1987) to 1 to 10 days (Peters 1983). In the trial by Wong 2003, the postnatal age was not stated. The primary diagnosis for enrolled infants in Raval 1987 was RDS, whereas for the study by Wong 2003 the main diagnosis was atelectasis. In the third study, the diagnoses included hyaline membrane disease (HMD), pneumonia and transient tachypnoea of the newborn (Peters 1983). All three studies included only infants who were mechanically ventilated. Only two of the studies stated exclusion criteria. Peters 1983 included infants requiring sedation for irritability and/or restlessness, while Wong 2003 stated their exclusion criteria as persistent pulmonary hypertension, meconium aspiration syndrome, congenital heart defects, pneumonia presenting with generalised patchy consolidation, post-cardiothoracic surgery, pleural effusion and pneumothorax.

Types of interventions

The types of interventions assessed differed across the included studies. Raval 1987 compared CPT comprising postural drainage in the head up and in the head down positions, percussion, vibration and suctioning (PDPV) with a control group receiving standard care. Each of these procedures was performed every two to three hours throughout the first 24 hours of life. Wong 2003 also used the PDPV technique combination but compared this with another CPT technique called the lung squeezing technique (LST) until resolution of atelectasis. The remaining study compared individual techniques of percussion with a face mask (cupping) and contact heel percussion using a cross-over design (Peters 1983). Each infant received each technique once in a randomised order over approximately a three hour period.

Types of outcome measures

Short-term physiological outcomes of oxygenation could be included from one cross-over trial (Peters 1983). In this trial, transcutaneous oxygenation, changes in oxygen requirements and hypoxic episodes were measured 10 minutes pre and post-intervention. Although Peters 1983 measured PaCO2, we could not include this data in the analyses as the standard deviation data could not be obtained from the author. In the trial by Raval 1987, oxygenation was reported in figure format and as the authors could not be contacted, we could not include the data on oxygenation in the review. Secretion clearance was also used as an outcome measure in two of the studies (Raval 1987; Wong 2003). Wong 2003 defined the secretions as obvious if the amount collected during a single intervention was greater than 0.2 ml. Raval 1987 measured the amounts of secretions collected over a 24-hour period and reported average secretion per procedure. Rates of intracranial lesions diagnosed by ultrasound scan and mortality rate were measured in the two parallel group studies. Ultrasound scans were done at three to five days of postnatal life in one trial (Raval 1987) and for three consecutive days after the first intervention in the other (Wong 2003). For the purposes of this review the highest grade of haemorrhage was included. Although the study by Peters 1983 did not include ultrasound findings, they did report changes in intracranial pressure and mean arterial pressure; however, these measurements were not included in our pre-specified outcomes. Wong 2003 was the only study to document duration of ventilation, duration of oxygen dependency and bronchopulmonary dysplasia, and the presence of atelectasis on chest radiographs.

(For further details on included studies see the table, 'Characteristics of Included Studies').

Risk of bias in included studies

Concealment of allocation

Of the three included studies, only one reported an adequate method of allocation concealment (Wong 2003). This study used a computerised random number allocation placed in sealed opaque envelopes, and stratified by mode of ventilation [high frequency oscillatory ventilation (HFOV) or conventional mechanical ventilation (CMV)]. The other two reported randomly assigning participants to groups but did not report on the method of allocation concealment (Peters 1983; Raval 1987).

Blinding of intervention

Due to the nature of the intervention of CPT, blinding of intervention was not employed in any of the included studies.

Completeness of follow-up

There was no loss to follow-up reported in any of the included studies. Only one study reported withdrawals (Wong 2003); however, outcomes for these infants were included in the analysis.

Blinding of outcome measures

In summary, only one study was of a high methodological quality (Wong 2003). It is difficult to determine adequately the quality of the remaining two trials (Peters 1983; Raval 1987) due to lack of information in the reported studies and the inability to obtain clarification from the authors.

Effects of interventions

The results of three trials are included in this review (Peters 1983; Raval 1987; Wong 2003).

Active CPT versus nonactive techniques/standard care (Comparison 1)

One trial (Raval 1987) with a total of 20 infants compared active CPT in the form of postural drainage, percussion and vibration (PDPV) with the nonactive technique of suction alone.

Primary outcome measures

(Duration of mechanical ventilation, duration of supplemental oxygen, duration of hospital stay):
Raval 1987 did not address any of the preplanned primary outcome measures.

Secondary outcomes
Weight of secretions cleared per procedure per day (Outcome 1.1)

There was no statistical difference in the amount of sputum cleared with CPT as compared to the amount cleared with suction alone (MD 0.01 g; 95% CI -0.10 to 0.12).

Rates of IVH (Outcomes 1.2 - 1.3)

No statistically significant difference was found for either the rate of any intraventricular haemorrhage (RR 2.33; 95% CI 0.83 to 6.54) or for the rate of a grade 3-4 IVH (RR 11.00; 95% CI 0.69 to 175.86).

Comparison of active CPT techniques (Comparison 2)

One trial (Peters 1983) (n = 30) reported change in oxygenation comparing the techniques of percussion versus cupping.

Primary outcome measures

(Duration of mechanical ventilation, duration of supplemental oxygen, duration of hospital stay):
Peters 1983 did not address any of the preplanned primary outcome measures.

Secondary outcomes measures
Change in oxygenation per procedure per baby (Outcome 2.1 - 2.2)

An increase in the incidence of hypoxaemia was shown with cupping when compared to contact heel percussion (RR 0.53; 95% CI 0.28 to 0.99) and an associated increase in oxygen requirement (MD -9.68; 95% CI -14.16 to -5.20).

Comparison of LST and PDPV (Comparison 3)

One trial (Wong 2003) (n = 56) compared the techniques of LST and PDPV.

Primary outcome measures

(Duration of mechanical ventilation, duration of supplemental oxygen, duration of hospital stay):
Wong 2003 did not address any of the preplanned primary outcome measures.

Secondary outcomes
Non-resolution of atelectasis after initial intervention (Outcome 3.1)

When compared with PDPV, LST resulted in a reduction in the numbers of infants with non resolution of atelectasis (RR 0.25; 95% CI 0.11 to 0.57).

Secretion clearance per procedure per baby (Outcome 3.2)

There was no statistically significant difference between the LST and PDPV groups in the numbers of infants who had less than 0.2 ml of secretions removed post-treatment (RR 0.96; 95% CI 0.62 to 1.49).

Rates of IVH grade 3-4 (Outcome 3.3)

There was no difference in the rate of progression of IVH to grade 3-4 when LST was compared to PDPV (RR 0.87; 95% CI 0.35 to 2.17).

Rates of any PVL (Outcome 3.4)

There was no difference in the rate of PVL (RR 0.87; 95% CI 0.21 to 3.52) between the techniques of LST and PDPV.

Due to small numbers, meta-analyses and planned subgroup analyses could not be undertaken.

Discussion

This review includes the results of three trials that studied 106 infants. Due to insufficient data and differences in reporting of outcome measures meta-analysis could not be undertaken.

Primary outcomes

The pre-specified primary outcomes of duration of mechanical ventilation, duration of supplemental oxygen after intervention, and duration of hospital stay were not reported in any of the three trials included in this review.

Secondary outcomes

Data from one trial (Raval 1987) comparing active CPT (postural drainage, percussion and vibration (PDPV)) with standard care did not show any difference in the outcome of weight of secretions cleared.

The remaining two studies compared different types of active CPT techniques. In one trial, the lung squeezing technique (LST) resulted in a decrease in the number of infants with non-resolution of atelectasis after the first treatment; however, LST did not result in a corresponding improvement in secretion clearance (Wong 2003). This study also reported that LST took significantly fewer therapy sessions to attain full re-expansion of the atelectatic lung than the PDPV group (p < 0.001). Despite LST being superior to PDPV in attaining lung re-expansion, the rate of recurrence of lung atelectasis was similar in both groups (p = 0.8) and there was no difference in the number of infants whose lungs failed to re-expand (p = 0.7). In the analyses on change in oxygenation, cupping resulted in more hypoxaemia and increased oxygen requirements compared with contact heel percussion.

The results of this review indicate that although there was no clear benefit for the use of CPT over standard care, LST was superior to PDPV for the treatment of atelectasis, and neonates were kept better oxygenated with contact heel percussion compared to cupping. LST, although reportedly used in Asia, does not appear to be used extensively throughout other parts of the world. Further research is required to better understand the indications for and outcomes of this technique.

CPT has come under much criticism due to adverse events such as intracranial lesions (Harding 1998) and rib fractures (Purohit 1975). This review found that there was no difference in the risk of developing intracranial lesions, either between active CPT and standard care or between types of techniques. However, the analysis between active CPT and standard care did approach significance and therefore raises some concern as to whether this finding is clinically significant. Practices described in the trial by Raval 1987 comparing active CPT and standard care are very different to those currently used in most neonatal nurseries. Although there was no evidence of adverse events or harm, the small numbers of infants included in the review meant that important outcomes could not be assessed. Due to insufficient data, planned subgroup analyses of infants < 30 weeks gestation who are potentially more at risk could not be undertaken.

The findings of this review highlight the limitations of the evidence presently available from randomised trials.
These limitations include:

Methodological quality of included studies

Only one trial was considered to be of relatively high methodological quality (Wong 2003). As only one trial reported blinded allocation to treatment, no trials blinded the intervention, and it is unknown whether there was blinded assessment of outcome, the potential for a high risk of bias in these studies cannot be excluded. Blinding of intervention is important when blinding of outcome is not undertaken. This is an inherent problem in trials investigating CPT (Wallis 1999).

Small numbers

Due to the small numbers of infants enrolled in the included trials, all estimates of effect are imprecise resulting in the inability to assess adequately the effects of this intervention. Subgroup analyses of high risk infants (< 30 weeks) could not be undertaken. This is an important deficiency in the evidence currently available.

Inconsistency in study design

The included trials employed different interventions and outcome measures and, therefore, could not be combined. Even when oxygenation was the outcome measured, the three studies defined it in slightly different ways, precluding the ability to combine the results. Other factors which may have had an impact on the results obtained could be differences in inclusion criteria and technique delivery.

Applicability to present day practice

Two of these studies were conducted over 20 years ago. Applicability of the results to present day practice may be compromised due to changes in population characteristics and interventions including: exogenous surfactant, changes in modes of ventilation, and changes in how CPT is delivered. Importantly, two of the trials included a head down tip for postural drainage, which is not used today as it has been shown to increase the risk of IVH (Emery 1983; Cowan 1985). Since continuous positive airway pressure (CPAP) is being used more frequently, the effect of CPT in infants on CPAP should also be included in future reviews.

Absence of primary outcome measures in included studies

Clinically relevant long-term outcomes such as duration of mechanical ventilation, duration of supplemental oxygen, and duration of hospital stay have not been reported in any of the included trials.

These limitations all highlight the need for further good quality randomised trials. Due to insufficient data there is not enough reliable evidence to support or refute the use of CPT

Authors' conclusions

Implications for practice

The results of this review do not provide sufficient evidence to guide clinical practice on the use of CPT techniques in infants on ventilatory support in today's neonatal intensive care settings. Although concern for the safety of active CPT in preterm infants has been reported, possible adverse effects of CPT could not be evaluated due to insufficient data. 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 well-designed trials are required to assess the risks and benefits of CPT in the treatment of respiratory diseases in ventilated neonates. Future trials should be adequately powered to address clinically important outcomes, particularly for the high risk population of infants < 30 weeks gestation. Clinically important outcomes which should be assessed include duration of ventilation, duration of oxygen therapy, length of hospital stay, and presence of intracranial lesions. Shorter-term outcomes such as resolution of atelectasis, oxygenation, and other lung function variables such as ventilation distribution should also be included. Costs also need to be considered.

Some of the important clinical and economic outcomes that remain unmeasured by current research are likely to require a very large sample size, therefore, a large multicentre trial would be recommended.

Acknowledgements

The authors would like acknowledge Dr K Peters, Assistant Professor, Faculty of Nursing/Perinatal Research Centre, University of Alberta, Edmonton, Alberta for providing further information regarding her trial.
Although Dr C Curran, Dr P Etches, Dr N Finer and Dr D Tudehope could not provide more data from their trials, we would like to acknowledge their attempt to do so.
We would also like to thank Karen New for providing assistance with the completion of this review.

Contributions of authors

Judy Hough - wrote the protocol and review, searched the literature, retrieved papers, reviewed all possible trials for inclusion, appraised paper quality, extracted details of the studies' methods and results, wrote to authors and entered data into RevMan for analysis.
Leanne Johnston - searched the literature, reviewed all possible trials for inclusion, appraised paper quality, extracted details of the studies' methods and results, entered data into RevMan for analysis and contributed to all versions of the review.
Vicki Flenady - contributed to the development of the protocol, the review of included trials, the synthesis of the results and to all versions of the review.
Paul Woodgate - development of protocol

Declarations of interest

JH and LJ are co-investigators in a trial investigating the effect of CPT techniques on lung function in the preterm infant for JH's PhD thesis (2005 to 2007).

Potential conflict of interest

  • None noted.

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Characteristics of studies

Characteristics of Included Studies

Peters 1983

Methods

Blinding of randomisation - Unclear
Blinding of intervention - No
Blinding of outcome measure - Can't tell
Complete follow-up - Yes

Participants

30 newborn infants who required intubation
Main diagnosis: 16 infants had HMD; the remainder had a variety of diagnoses
Gestational age: 25 to 42 weeks
Birth weight: 750 to 4030 grams
Postnatal age: 1 to 10 days
Conducted in Edmonton, Canada

Interventions

Two period cross-over design with 2 CPT groups:
Bennett face mask
Contact heel percussion

Each technique was performed once only during postural drainage of both the upper and lower lobes and was followed by saline instillation and suction of the ETT

Outcomes

Heart rate
Mean arterial pressure (MAP)
Intracranial pressure (ICP)
TcpO2
TcpCO2
All taken pre and post CPT as well as post postural drainage, saline instillation and suctioning

Notes
Risk of bias table
Item Judgement Description
Allocation concealment? Unclear

B - Unclear

Raval 1987

Methods

Blinding of randomisation - Unclear. Randomly assigned to 2 groups
Blinding of intervention - No
Complete follow-up - Yes
Blinding of outcome measure - No

Participants

20 preterm infants who required endotracheal intubation and assisted ventilation
Main diagnosis: all infants had RDS
Gestation age: 28 to 32 weeks
Birth weight: 680 to 1870 grams
Postnatal age at study: 1 to 12 hours
Conducted in Chicago, USA

Interventions

2 arms - intervention, control
CPT group (n = 10): postural drainage with head up and head down, percussion, vibration and suctioning
All procedures performed every 2 to 3 hours in the first 24 hours of life
Control (n = 10): suctioning only

Outcomes

Oxygenation: continuous TcPO2 monitoring, ABG samples
Secretion clearance: sputum weight per procedure
Rates of intracranial lesions by ultrasound scan
Mortality rate

Notes
Risk of bias table
Item Judgement Description
Allocation concealment? Unclear

B - Unclear

Wong 2003

Methods

Blinding of randomisation - Yes. Computerised random number allocation in sealed opaque envelopes, stratified by mode of ventilation (HFOV or CMV)
Blinding of intervention - No
Complete follow-up - Yes
Blinding of outcome measure - Yes

Participants

56 neonates who required mechanical ventilation were randomised - 2 withdrawals due to critical conditions (1 from each group)
Main diagnosis: atelectasis (segmental or lobar collapse)
Gestational age: 22 to 36 weeks
Birth weight: 540 to 2900 grams
Exclusions: persistent pulmonary hypertension, meconium aspiration syndrome, congenital heart defects, pneumonia presenting with generalised patchy consolidation, post-cardiothoracic surgery, pleural effusion and pneumothorax
Conducted in Shatin, Hong Kong

Interventions

2 arms - 2 intervention groups:
Lung squeezing technique (LST) (n = 26) - 3 or 4 sustained chest compressions lasting for about 5 seconds followed by a slow gentle release in the supine position with bed flat
Postural drainage, percussion, vibration (PDPV) (n = 30) - performed in alternate side lying with bed flat

Both techniques were proceeded by endotracheal suctioning
Sessions were performed twice daily

Outcomes

Re-expansion of atelectasis
Recurrence of atelectasis
Duration of ventilation
Duration of oxygen dependency
Oxygenation: oxygen saturation
Secretion clearance: sputum volume per procedure per baby
Rates of intracranial lesions by ultrasound scan
Mortality rate

Notes
Risk of bias table
Item Judgement Description
Allocation concealment? Yes

A - Adequate

Characteristics of excluded studies

Andersen 1991

Reason for exclusion

Not a randomised trial - review article

Beaudoin 1973

Reason for exclusion

Not a randomised trial - review article

Becroft 1998

Reason for exclusion

Not a randomised trial

Bradbury 1996

Reason for exclusion

Babies on nasopharyngeal CPAP - not mechanically ventilated

Cabero 1987

Reason for exclusion

Not a randomised trial

Coradello 1979

Reason for exclusion

Not a randomised trial

Coradello 1982

Reason for exclusion

Not a randomised trial - cross-over study

Crane 1978

Reason for exclusion

Abstract only - unable to contact author for further information

Crane 1986

Reason for exclusion

Not a randomised trial - review article

Curran 1979

Reason for exclusion

Eligible for inclusion but did not have sufficient data to enable outcomes to be calculated. Primary author was contacted but was unable to supply the information required.

Duara 1983

Reason for exclusion

Not a randomised trial - case control study

Etches 1978

Reason for exclusion

Eligible for inclusion but did have have standard deviations to enable outcomes to be calculated. Primary author was contacted but was unable to supply the information required.

Finer 1978

Reason for exclusion

Eligible for inclusion but data supplied was combined for ventilated infants and infants on CPAP. Primary author was contacted but was unable to supply the information required.

Fiser 1985

Reason for exclusion

Eligible for inclusion but despite contacting primary author no further data were supplied

Fitzpatrick 1988

Reason for exclusion

Not a randomised trial - case control study

Fox 1978

Reason for exclusion

Not a randomised trial - case control study

Gajdosik 1985

Reason for exclusion

Not a randomised trial - case report

Greisen 1985

Reason for exclusion

Not a randomised trial - case control study
Not assessing respiratory outcome measures

Hartrick 1982

Reason for exclusion

Abstract only - unable to contact author for further information

Hartsell 1987

Reason for exclusion

Not newborn infants - children and adults with cystic fibrosis and bronchiectasis

Hough 1991

Reason for exclusion

Not a randomised trial or newborn infants

James 1970

Reason for exclusion

Not a randomised trial - report on technique

Kanarek 1980

Reason for exclusion

Not a randomised trial - case control study

Leung 1998

Reason for exclusion

Eligible for inclusion but despite contacting primary author no further data were supplied

Luther 1981

Reason for exclusion

Not a randomised trial - case reports

Main 2001

Reason for exclusion

Not newborn infants with respiratory distress - any studied newborns had cardiac conditions

Meier 1979

Reason for exclusion

Not a randomised trial - a letter

Meyer 1984

Reason for exclusion

Not a randomised trial - review article

Murai 1994

Reason for exclusion

Intervention not physiotherapy - postural therapy

Paratz 1994

Reason for exclusion

Not a randomised trial - case control study

Parker 1985

Reason for exclusion

Not a randomised trial - review article

Remondiere 1976

Reason for exclusion

Not a randomised trial - case report

Schultz 2005

Reason for exclusion

Not newborn infants - greater than 8 months of age

Stiller 1996

Reason for exclusion

Not newborn infants - adult population

Storni 2003

Reason for exclusion

Not newborn infants with neonatal respiratory disease - infants had cystic fibrosis

Tudehope 1980

Reason for exclusion

Eligible for inclusion but did not have have enough data for outcomes to be calculated. Primary author was contacted but was unable to supply the information required.

Unoki 2005

Reason for exclusion

Not newborn infants

Warner 1984

Reason for exclusion

Not a randomised trial - review article

Warwick 2004

Reason for exclusion

Not newborn infants

Wong 2006

Reason for exclusion

Not a randomised trial - cohort study

Characteristics of ongoing studies

Hough 2007

Study name

The effect of chest physiotherapy on lung function in the preterm infant

Methods

Blinding of randomisation - Yes. Computerised random number allocation in sealed opaque envelopes.
Blinding of intervention - No
Blinding of outcomes measures - Yes
Complete follow-up - Yes

Participants

Ventilated preterm infants in whom active CPT is indicated
Main diagnosis: atelectasis
Gestation age: < 34 weeks
Birth weight: > 750 grams
Conducted in Brisbane, Australia

Interventions

Cross-over design with 2 CPT groups:
Cupping with face mask
Vibration
Techniques performed 4 hours apart
After CPT, saline instillation and suction to be performed

Outcomes

Ventilation distribution: measured by electrical impedance tomography
Oxygenation: saturation monitoring
Rates of intracranial lesions by ultrasound scan

Starting date

October 2006

Contact information

judyhough@optusnet.com.au

Notes

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References to studies

Included studies

  • None noted.

Peters 1983

Published and unpublished data

Peters, K. Neonatal unit - research studies. AARN News Letter 1983;39:14-6.

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.

Wong 2003

Wong I, Fok TF. Randomized comparison of two physiotherapy regimens for correcting atelectasis in ventilated pre-term neonates. Hong Kong Physiotherapy Journal 2003;21:43-50.

Excluded studies

Andersen 1991

Andersen JB, Falk M. Chest physiotherapy in the pediatric age group. Respiratory Care 1991;36:546-54.

Beaudoin 1973

Beaudoin J, Remondiere R. Chest therapy for newborn children. Physiotherapy Canada 1973;25:152-4.

Becroft 1998

Becroft DM, Chan Y, Harding JE. Chest physiotherapy is associated with encephaloclastic porencephaly in extremely premature babies. Modern Pathology 1998;11:1P.

Bradbury 1996

Published and unpublished data

Bradbury J. The effect of cupping on the cardiorespiratory status of the neonate with respiratory distress syndrome. In: Proceedings of the 1996 National Physiotherapy Congress. 1996:199-200.

Cabero 1987

Cabero Mendoza M, Farre Rosich T, Garcia-Margallo Paris L, Lorente Lorente MJ, Pla Consuegra M, Rodes Meifren C. Early respiratory physiotherapy in bronchopulmonary dysplasia. Revista de Enfermería 1987;10:52-3.

Coradello 1979

Coradello H, Tauffkirchen E, Baar B. Effect of chest physiotherapy on pO2 and pCO2 in premature and mature babies with respiratory distress syndrome (author's transl). Padiatrie und Padologie 1979;14:37-42.

Coradello 1982

Coradello H, Simbruner G, Baar B. Influence of physical chest therapy in mechanically ventilated newborn infants on the amount of secretions removed from the trachea. Klinische Padiatrie 1982;194:8-10.

Crane 1978

Published data only (unpublished sought but not used)

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

Crane 1986

Crane LD. Cardiorespiratory management of the high-risk neonate: Implications for developmental therapists. Physical and Occupational Therapy in Pediatrics 1986;6:255-81.

Curran 1979

Published data only (unpublished sought but not used)

Curran CL, Kachoyeanos MK. The effects on neonates of two methods of chest physical therapy. MCN. The American Journal of Maternal Child Nursing 1979;4:309-13.

Duara 1983

Duara S, Bessard K, Keszler L, Artes D, Batzer K. Evaluation of different percussion time intervals at chest physiotherapy (CPT) on neonatal pulmonary function parameters. Pediatric Research 1983;17:310A.

Etches 1978

Published data only (unpublished sought but not used)

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

Finer 1978

Published data only (unpublished sought but not used)

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

Finer NN, Grace MG, Boyd J. Chest physiotherapy in the neonate with respiratory distress. Pediatric Research 1977;11:570.

Fiser 1985

Published data only (unpublished sought but not used)

Fiser DH, Kluck W. The effect of chest physiotherapy and tracheal suctioning on PaO2 in infants and children with atelectasis. Chest 1985;88:S22.

Fitzpatrick 1988

Fitzpatrick MP, Bullock MI, Tudehope DI. Chest physiotherapy for intubated infants with hyaline membrane disease. New Zealand Journal of Physiotherapy 1988;16:15-18.

Fox 1978

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

Gajdosik 1985

Gajdosik CG. Transcutaneous monitoring of PO2 during chest physical therapy in a premature infant. Physical and Occupational Therapy in Pediatrics 1985;5:69-75.

Greisen 1985

Greisen G, Frederiksen PS, Hertel J, Christensen NJ. Catecholamine response to chest physiotherapy and endotracheal suctioning in preterm infants. Acta Paediatrica Scandinavica 1985;74:525-9.

Hartrick 1982

Published data only (unpublished sought but not used)

Hartrick J, Fluit L, Parrott J, Yu VY. A controlled-study of chest physiotherapy methods in the newborn-infant. Australian Paediatric Journal 1982;18:141.

Hartsell 1987

Hartsell MB. Chest physiotherapy and mechanical vibration. Journal of Pediatric Nursing 1987;2:135-7.

Hough 1991

Hough A. Positioning vs vibrations in chest physiotherapy. Chest 1991;100:1741.

James 1970

James J. The use of a mechanical vibrator during chest physiotherapy. Physiotherapy 1970;56:31-2.

Kanarek 1980

Kanarek KS, Curran JS, Williams PR, Sidebottom RA, Brown C. Changes in trans-cutaneous PO2 (TcPO2) and transcutaneous PCO2 (TcPCO2) during chest physiotherapy in neonates. Clinical Research 1980;28:A875.

Leung 1998

Published data only (unpublished sought but not used)

Leung A. MSc dissertation abstract session. A study of two different chest physiotherapy percussion techniques on some physiological changes in neonates. Hong Kong Physiotherapy Journal 1988;16:19.

Luther 1981

Luther U, Friedrich H, Schramm D. Physiotherapy in intensive care of premature infants and newborns. Zeitschrift fur Physiotherapie 1981;33:457-61.

Main 2001

Published data only (unpublished sought but not used)

Main E, Castle R, Newham D, Stocks J. Respiratory physiotherapy vs suction: the effects on respiratory function in ventilated infants and children. Intensive Care Medicine 2004;30:1144-51.

Main E, Stocks J. The influence of physiotherapy and suction on respiratory deadspace in ventilated children. Intensive Care Medicine 2004;30:1152-9.

* Main E. The effect of physiotherapy on respiratory function in ventilated children. PhD thesis, University College, London 2001.

Meier 1979

Meier P. CPT - which method, if any? MCN American Journal of Maternal Child Nursing 1979;4:310-1.

Meyer 1984

Meyer CL. Chest physiotherapy in infants requiring ventilatory assistance. Respiratory Therapy 1984;14:27-9, 32-4.

Murai 1994

Murai D, Grant J. Continuous oscillation therapy improves the outcome of intubated newborns: results of a prospective, randomized controlled trial. Neonatal Intensive Care 1995;8:18.

* Murai DT, Grant JW. Continuous oscillation therapy improves the pulmonary outcome of intubated newborns - results of a prospective, randomized, controlled trial. Critical Care Medicine 1994;22:1147-54.

Paratz 1994

Unpublished data only

Paratz J. The effect of respiratory physiotherapy on intracranial dynamics in preterm and term infants. PhD thesis, University of Queensland, Brisbane. 1994.

Parker 1985

Parker AE. Chest physiotherapy in the neonatal intensive care unit. Physiotherapy 1985;71:63-5.

Remondiere 1976

Remondiere R, Relier JP, Esclapez P, Beaudoin J. Value of respiratory physiotherapy in the treatment of hyaline membrane disease in the newborn. Annales de Pediatrie 1976;23:617-23.

Schultz 2005

Schultz TR, Lin R, Francis BA, Hales RL, Colborn S, Napoli LA, et al. Kinetic therapy improves oxygenation in critically ill pediatric patients. Pediatric Critical Care Medicine 2005;6:428-34.

Stiller 1996

Stiller K, Jenkins S, Grant R, Geake T, Taylor J, Hall B. Acute lobar atelectasis: a comparison of five physiotherapy regimens. Physiotherapy Theory and Practice 1996;12:197-209.

Storni 2003

Storni V. Role of respiratory physiotherapy for diagnosed infants. Revue Des Maladies Respiratoires 2003;20:S189-S193.

Tudehope 1980

Published data only (unpublished sought but not used)

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

Unoki 2005

Unoki T, Kawasaki Y, Mizutani T, Fujino Y, Yanagisawa Y, Ishimatsu S, Tet al. Effects of expiratory rib-cage compression on oxygenation, ventilation, and airway-secretion removal in patients receiving mechanical ventilation. Respiratory Care 2005;50:1430-7.

Warner 1984

Warner A. Does chest physiotherapy move airway secretions? American Review of Respiratory Disease 1984;130:701-2.

Warwick 2004

Warwick W, Wielinski C, Hansen L. Comparison of expectorated sputum after manual chest physical therapy and high-frequency chest compression. Biomedical Instrumentation and Technology 2004;38:470-5.

Wong 2006

Wong I, Fok TF. Effects of lung squeezing technique on lung mechanics in mechanically-ventilated preterm infants with respiratory distress syndrome. Hong Kong Physiotherapy Journal 2006;24:39-46.

Studies awaiting classification

  • None noted.

Ongoing studies

Hough 2007

Unpublished data only

Hough J, Johnston L, Brauer S, Woodgate P. The effect of chest physiotherapy on lung function in preterm infants. PhD thesis in progress: University of Queensland, Australia.

Other references

Additional references

ANZNN 2005

Abeywardana S. The report of the Australian and New Zealand Network, 2003. Sydney: ANZNN, 2005.

Balaguer 2006

Balaguer A, Escribano J, Roque M. Infant position in neonates receiving mechanical ventilation. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003668. DOI: 10.1002/14651858.CD003668.pub2.

Cowan 1985

Cowan F, Thoresen M. Changes in superior sagittal sinus blood velocities due to postural alterations and pressure on the head of the newborn infant. Pediatrics 1985;75:1038-47.

Crane 1978

Crane LD, Zombek M, Krauss AN, Auld PAM. Comparison of chest physiotherapy techniques in infants with HMD. Pediatric Research 1978;12:559-9.

Cross 1992

Cross JH, Harrison CJ, Preston PR, Rushton DI, Newell SJ, Morgan ME, et al. Postnatal encephaloclastic porencephaly - a new lesion? Archives of Disease in Childhood 1992;67:307-11. [Other: 1468-2044]

Dabezies 1997

Dabezies EJ, Warren PD. Fractures in very low birth weight infants with rickets. Clinical Orthopaedics Related Research 1997;Feb:233-9.

Ehrlich 1972

Ehrlich R, Arnon RG. The intermittent endotracheal intubation technique for the treatment of recurrent atelectasis. Pediatrics 1972;50:144-7.

Emery 1983

Emery JR, Peabody JL. Head position affects intracranial pressure in newborn infants. Journal of Pediatrics 1983;103:950-3.

Etches 1978

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

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.

Handbook 2007

Higgins JPT, Green S, editors. Assessment of study quality. Cochrane Handbook for Systematic Reviews of Interventions 4.2.6 [updated September 2006]; Section 6. The Cochrane Library 2007;(2).

Harding 1998

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

Higgins 2002

Higgins J, Thompson S. Quantifying heterogeneity in meta-analysis. Statistics in Medicine 2002;21:1539-58.

Mackenzie 1985

Mackenzie CF, Shin B. Cardiorespiratory function before and after chest physiotherapy in mechanically ventilated patients with post-traumatic respiratory failure. Critical Care Medicine 1985;13:483-6.

Papile 1978

Papile L, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1, 500gm. The Journal of Pediatrics 1978;92:529-34.

Pritchard 2001

Pritchard M, Flenady V, Woodgate P. Preoxygenation for tracheal suctioning in intubated, ventilated newborn infants. Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD000427. DOI: 10.1002/14651858.CD000427.

Purohit 1975

Purohit DM, Caldwell C, Levkoff AH. Letter: Multiple rib fractures due to physiotherapy in a neonate with hyaline membrane disease. American Journal of Diseases of Children 1975;129:1103-4. [MEDLINE: medline; neonatal; physiotherapy; Other: 0002-922X]

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.

RevMan 2003

Review Manager (RevMan) [Computer program]. Version 4.2 for Windows. Copenhagan: The Nordic Cochrane Centre, The Cochrane Collaboration, 2003.

Spence 2003

Spence K, Gillies D, Waterworth L. Deep versus shallow suction of endotracheal tubes in ventilated neonates and young infants. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003309. DOI: 10.1002/14651858.CD003309.

Stiller 1990

Stiller K, Geake T, Taylor J, Grant R, Hall B. Acute lobar atelectasis: a comparison of two chest physiotherapy regimens. Chest 1990;98:1336-40.

Tudehope 1980

Tudehope DI, Bagley C. Techniques of physiotherapy in intubated babies with the 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.

Woodgate 2001

Woodgate PG, Flenady V. Tracheal suctioning without disconnection in intubated ventilated neonates. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD003065. DOI: 10.1002/14651858.CD003065.

Zach 1987

Zach MS, Oberwaldner B. Chest physiotherapy - the mechanical approach to antiinfective therapy in cystic fibrosis. Infection 1987;15:381-4.

Other published versions of this review

  • None noted.

Classification pending references

  • None noted.

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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 Weight of secretions cleared per procedure per day (g) 1 20 Mean Difference (IV, Fixed, 95% CI) 0.01 [-0.10, 0.12]
1.2 Intraventricular haemorrhage 1 20 Risk Ratio (M-H, Fixed, 95% CI) 2.33 [0.83, 6.54]
1.3 IVH grade 3 or 4 1 20 Risk Ratio (M-H, Fixed, 95% CI) 11.00 [0.69, 175.86]

2 Comparison of active chest physiotherapy techniques (percussion vs cupping)

Outcome or Subgroup Studies Participants Statistical Method Effect Estimate
2.1 Hypoxaemia per procedure per baby 1 60 Risk Ratio (M-H, Fixed, 95% CI) 0.53 [0.28, 0.99]
2.2 % change in FiO2 per procedure per baby 1 60 Mean Difference (IV, Fixed, 95% CI) -9.68 [-14.16, -5.20]

3 Comparison of active chest physiotherapy techniques (LST vs PDPV)

Outcome or Subgroup Studies Participants Statistical Method Effect Estimate
3.1 Non-resolution of atelectasis after initial intervention 1 56 Risk Ratio (M-H, Fixed, 95% CI) 0.25 [0.11, 0.57]
3.2 Secretions cleared (< 0.2 ml) per procedure per baby 1 56 Risk Ratio (M-H, Fixed, 95% CI) 0.96 [0.62, 1.49]
3.3 IVH grade 3 or 4 after commencement of CPT 1 56 Risk Ratio (M-H, Fixed, 95% CI) 0.87 [0.35, 2.17]
3.4 Periventricular leucomalacia 1 56 Risk Ratio (M-H, Fixed, 95% CI) 0.87 [0.21, 3.52]

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Sources of support

Internal sources

  • Centre for Clinical Studies, Mater Mothers' Hospital, South Brisbane, Queensland, Australia
  • Mater Research Support Centre, Mater Health Services, South Brisbane, Queensland, Australia
  • School of Health and Rehabilitation Studies, University of Queensland, Australia

External sources

  • Evidence Based Practice Grant, Queensland Health, Australia

This review is published as a Cochrane review in The Cochrane Library, Issue 3, 2008 (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.