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Physical training for bronchiectasis (Review)
Bradley JM, Moran F, Greenstone M
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published inThe Cochrane Library
2002, Issue 2
http://www.thecochranelibrary.com
Physical training for bronchiectasis (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
http://www.thecochranelibrary.com/http://www.thecochranelibrary.com/7/26/2019 Bradley 1996
2/21
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Inspiratory Muscle Training versus Sham or no intervention (change from baseline), Outcome
1 Endurance (metres). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Analysis 1.2. Comparison 1 Inspiratory Muscle Training versus Sham or no intervention (change from baseline), Outcome
2 Incremental shuttle walking test (metres). . . . . . . . . . . . . . . . . . . . . . . . 11
Analysis 1.3. Comparison 1 Inspiratory Muscle Training versus Sham or no intervention (change from baseline), Outcome3 Health Status (CRDQ score). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Analysis 1.4. Comparison 1 Inspiratory Muscle Training versus Sham or no intervention (change from baseline), Outcome
4 Pi Max (cms of water). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Analysis 2.1. Comparison 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results), Outcome 1
Endurance (metres). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Analysis 2.2. Comparison 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results), Outcome 2
Incremental shuttle walking test (metres). . . . . . . . . . . . . . . . . . . . . . . . . 15
Analysis 2.3. Comparison 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results), Outcome 3
Health Status (CRDQ score). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Analysis 2.4. Comparison 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results), Outcome 4 Pi
Max (cms of water). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
17WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iPhysical training for bronchiectasis (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
7/26/2019 Bradley 1996
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[Intervention Review]
Physical training for bronchiectasis
Judy M Bradley1, Fidelma Moran2 , Michael Greenstone3
1Rehabilitation Sciences Research Institute School, University of Ulster and Belfast City Hospital, Newtownabbey, UK. 2Room 14J07,
School of Health Sciences, University of Ulster, Newtownabbey, UK.3 Castle Hill Hospital, Cottingham, UK
Contact address: Judy M Bradley, Rehabilitation Sciences Research Institute School, University of Ulster and Belfast City Hospital,
University of Ulster, Shore Road, Newtownabbey, Northern Ireland, BT37 0QB, [email protected].
Editorial group:Cochrane Airways Group.
Publication status and date:Edited (no change to conclusions), published in Issue 1, 2009.
Review content assessed as up-to-date: 9 February 2005.
Citation: Bradley JM, Moran F, Greenstone M. Physical training for bronchiectasis.Cochrane Database of Systematic Reviews2002,
Issue 2. Art. No.: CD002166. DOI: 10.1002/14651858.CD002166.
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
The pathophysiology of bronchiectasis may result in the development of dyspnoea and decreased exercise tolerance, both of which can
impact on a patients quality of life and ability to perform activities of daily living. There is little information regarding the benefits of
physical training in bronchiectasis: however it is probable that thebenefits of physical training in bronchiectasisare at least comparable to
benefits demonstrated in other respiratory conditions. There is also no information regarding the effects of non-adherence to prescribed
physical training in bronchiectasis. However as in patients with COPD non-adherence may contribute to a deterioration in the patients
condition and conceivably the long term prognosis.
Objectives
The objective of this review is to determine whether a prescribed regime of physical training produces improvements or prevents
deterioration in physiological and clinical outcomes in bronchiectasis compared to no physical training.
Search methods
We searched the Cochrane Airways Group trials register and the Cochrane Central Register of Controlled Trials.
Selection criteria
Randomised or quasi randomised controlled trials in whicha prescribed regimen of physical training is compared to no physical training
in patients with bronchiectasis.
Data collection and analysis
We identified three studies. One was did not meet the inclusion criteria and two appeared in abstract form only. More comprehensivedata will be incorporated into this review once data from those two trials are published, and when further data is made available to the
authors of this review. An update search in February 2005 identified one excluded study.
Main results
Results from the two studies published in abstract showed that inspiratory muscle training compared to sham or no inspiratory
muscle training improved endurance exercise capacity: Weighted Mean Difference (WMD) 264 metres (95% CI 16.4 to 512 metres).
Maximum inspiratory pressure (PiMax) improved: WMD 25 cms H20 (95% CI 11.6 to 38.4 cms H2O ) as did quality of life measured
with the CRQ: WMD 12.4 units (95% CI 2.4 to 22.5 units).
1Physical training for bronchiectasis (Review)
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Authors conclusions
This review only provides evidence of the benefits of inspiratory muscle training and provides no evidence of the effect of other types
of physical training (including pulmonary rehabilitation) in bronchiectasis.
P L A I N L A N G U A G E S U M M A R Y
Physical training for bronchiectasis
A search for controlled trials of physical training in bronchiectasis only identified two early reports (abstracts) including 43 patients in
total. These suggest some benefits of inspiratory muscle training on exercise capacity, quality of life and respiratory muscle function at
eight weeks, but further research is needed to confirm these findings in larger numbers of people with bronchiectasis. Further research
is also needed to assess the benefit of other types of physical training and pulmonary rehabilitation in bronchiectasis.
B A C K G R O U N D
Bronchiectasis can be defined as a disease that results in an ab-
normal dilatation of one or more bronchi. The primary cause of
bronchiectasis is an insult to the respiratory tract e.g. severe pneu-
monia, viral infection or aspiration of a foreign body. Genetic dis-
eases such as cystic fibrosis (CF), primary ciliary dyskinesia (in-
cluding Kartageners syndrome) and immunodeficiency can also
result in bronchiectasis. Any one of these conditions predisposes
the airways to lower respiratory colonisation by bacteria such as
Haemophilus influenzae or Pseudomonas aeruginosa.
Although infection and obstruction are implicated in the devel-opment of bronchiectasis , the inflammatory response may also
be important in disease progression: the hosts response to infec-
tion may fail to completely eradicate the infecting organism and
chronic colonisation is established . A vicious cycle of microbial
colonisation/ infection has been proposed whereby bacteria elabo-
rate substances toxic to the mucociliary escalator and perpetuates
the failure to eliminate the organisms. The inflammatory response
leads to furtherdamage of thebronchial tree andlung parenchyma
and is usually associated with excessive secretions and the devel-
opment of airflow obstruction.
The consequences of this may include the development of chronic
respiratory symptoms including cough, excessive purulent spu-tum, haemoptysis, breathlessness and decreased exercise tolerance.
The causes of breathlessness and decreased exercise tolerance are
multifactorial and may include altered pulmonary mechanics, in-
efficient gas exchange, decreased muscle bulk and confounding
psychological morbidity. All of these factors initiate a cyclical phe-
nomenon whereby decreasedexercisetoleranceleadsto progressive
detraining which in turn results in further reductions in exercise
tolerance.
Physical training is defined as participation in a programme of reg-
ular vigorous physical activity designed to improve physical per-
formance, and/or cardiovascular function and/or muscle strength
(Shepherd 1994). Physical training has been shown to improve
exercise tolerance and reduce symptoms of breathlessness in many
patient populations including CF and chronic obstructive pul-
monary disease (COPD). A meta-analysis of randomised trials
examining the role of physical training in COPD conducted by
Smith 1992, indicated a small non-significant trend in favour of
respiratory muscle training for most outcomes. There is little in-
formation regarding the benefits of physical training in bronchiec-
tasis: however it is probable that the benefits of physical trainingin bronchiectasis are at least comparable to benefits demonstrated
in other respiratory conditions (Morgan 1997). There is also no
information regarding the effects of non-adherence to prescribed
physical training in bronchiectasis. However as in patients with
COPD non-adherence may contribute to a deterioration in the
patients condition and conceivably the long term prognosis.
This review will aim to determine the evidence base benefit for
the use of physical training programmes in the management of
patients with bronchiectasis.
O B J E C T I V E S
The objective of this review is to determine whether a prescribed
regime of physical training in bronchiectasis produces improve-
ments or prevents deterioration in physiological and clinical out-
comes in bronchiectasis compared to no physical training.
M E T H O D S
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Criteria for considering studies for this review
Types of studies
Only randomised or quasi -randomised controlled trials in which
a prescribed regimen of physical training is compared to no phys-ical training in patients with bronchiectasis will be considered for
this review. Single blind and open studies will be considered for
inclusion.
Types of participants
We will include patients (adults and children) with stable
bronchiectasis. Patients with cystic fibrosis will be excluded. Diag-
nosis will be based on symptoms and appropriate imaging (bron-
chography or high resolution CT scanning).
Types of interventionsWe will consider any type of prescribed physical training including
pulmonary rehabilitation. We will record, wherever possible, the
precise nature of the training (intensity, frequency and duration)
will be recorded. We will exclued any studies which do not include
a prescribed physical training component. Important alterations
in patient management such as airway clearance techniques or
medication must be controlled for.
Types of outcome measures
The most appropriate outcome measure in bronchiectasis has not
been defined. The assessment of impairment, disability and hand-
icap is necessary to provide a comprehensive evaluation of treat-ment outcome.
Primary outcomes
Exercise tolerance: Objective change in exercise tolerance (maxi-
mal oxygen uptake (VO2 max), peak oxygen uptake (VO2 peak),
maximal ventilation (Ve max), heart rate, subjective assessment of
dyspnoea) as measured during formalexercisetests or field exercise
tests.
Secondary outcomes
1. Measures of specific indices of respiratory muscle strength:
peak inspiratory pressure (PImax), peak expiratory strength
(PEMax). Other measures of muscle strength, mass, effort and
general fatigue will be included.
2. Pulmonary function tests: forced expiratory volume in one
second (FEV1), forced vital capacity (FVC), forced expiratory
flow at 25 to 75% of FVC (FEF25-75), peak expiratory flow
(PEF), total lung capacity (TLC) and fixed respiratory capacity
(FRC): change in % predicted or and absolute change from
baseline compared to control will be assessed. Peak inspiratory If
other parameters are used, they will be considered.
3. Dyspnoea: All measures of dyspnoea used will be
considered.
4. Quality of life: Change in quality of life as measured bygeneric or disease - specific quality of life instruments, or by
subjective perception of well-being. All quality of life
instruments used will be considered.
5. Weight: Absolute weight change, change in % ideal body
weight, or weight standard deviation score or change in body
composition will be assessed.
6. Expectorated secretions: Dry or wet weight or volume.
7. Changes in physical symptoms such as cough and wheeze
8. Number of acute exacerbations, duration, hospitalisation,
IV antibiotic courses and time off work will be considered.
9. Oxygen saturation measured by pulsed or transcutaneous
oximetry.
10. Compliance with physical training will be recorded indetail.
11. Compliance with other treatment, such as airway clearance
techniques, nutritional regimes if measured. Methods of
assessing compliance will be recorded in detail.
12. Adverse effects including fractures, skeletal muscle injuries
and death will be recorded.
13. Cost evaluation.
If outcomes have been measured more than once in a study, we
will record the outcome measured most distant from the com-
mencement of physical training.
Search methods for identification of studies
We carried out a search using the Cochrane Airways Group trials
register and the Cochrane Central Register of Controlled Trials.
This database is comprised of systematic MEDLINE, CINAHL
and EMBASE searches.
We searched these registers using the search terms;
Bronchiectasis AND training OR physical training OR physical
fitness OR physical activity OR physical rehabilitation OR phys-
ical therapy OR exercise training OR exercise rehabilitation OR
exercise therapy OR exercise OR pulmonary rehabilitation OR
physiotherapy
We searched the reference lists of each RCT for additional stud-
ies. We also contacted authors of RCTs for information on otherpublished and unpublished studies.
Data collection and analysis
Two reviewers (JB, FM) independently selected the trials to be
included in the review using a proforma capturing the main in-
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clusion criteria listed above. Each reviewer assessed the method-
ological quality of each included trial.
The methodological quality of the RCTs was assessed using the
modified version of the five point instrument proposed byJadad
1996and the system for assessing treatment allocation conceal-
ment used by the Cochrane Collaboration.JADAD FIVE POINT SYSTEM:
(1) Was the study described as randomised (1 = yes; 0 = no)?
(2) Was the study described as being double blind (1 = yes; 0 =
no)?
(3) Was there a description of withdrawals and dropouts (1 = yes;
0 = no)?
(4) Was the method of randomisation well described and appro-
priate (1 = yes; 0 = no)?
(5) Was the method of double blinding well described and appro-
priate (1 = yes; 0 = no)?
(6) Deduct 1 point if methods for randomisation or blinding were
inappropriate.
Concealment system:A - adequate concealment
B - uncertain
C - clearly inadequate
We resolved disagreements by consensus.
For binary outcome measures, we sought data on the number of
participants with each outcome event, by allocated treated group,
(irrespective of compliance or subsequent eligibility) to allow an
intention-to-treat analysis. For continuous outcomes, we aimed to
record either mean change from baseline for each group or mean
post treatment / intervention values and the standard deviation
(SD) or standard error (standard error will be converted to SD).
For binary outcomes, we aimed to calculate a pooled estimate of
the treatment effect for each outcome across studies, (the odds ofan outcome amongtreatment allocated patientsto the correspond-
ing odds among controls). For continuous outcomes we aimed to
calculate a pooled estimate of treatment effect by calculating the
weighted mean difference.
R E S U L T S
Description of studies
See: Characteristics of includedstudies; Characteristics of excluded
studies.
Electronic searches yielded a total of 38 references. Three of these
were identified as potentially relevant. One was excluded (Choe
1996), for details see Excluded studies table. The other two ful-
filled the inclusion criteria for the review but have been published
in abstract form only. In spite of efforts to obtain complete data
from these trials none has been made available to the authors of
this review. It is anticipated that more complete data will be avail-
able at a later date and will be incorporated into updated versions
of this review. An update searchconducted in February 2005 iden-
tified one excluded study (Kellett 2005).
Both studies are describedbelow, butwillbe subject to amendment
upon their full journal publication.Newall 2000a was a randomised controlled eight week study.
NIneteen participants were involved (10 in the inspiratory mus-
cle training group, nine in the control group). Inspiratory muscle
training was carried out using a pressure threshold device. The
control group had no intervention. Concealment of allocation was
unclear and no drop outs were reported.
Newall 2000bwas a randomised controlled study, conducted over
an eight week period. 33 patients were randomised to receive either
inspiratory muscle training(using a pressure threshold device) plus
pulmonary rehabilitation (education, exercise training) or sham
inspiratory muscle training plus pulmonary rehabilitation or no
intervention. Twelve participants were in the active inspiratory
muscle training group, 12 in the sham inspiratory muscle traininggroup and nine in the control group. No data was available for the
control group in this study.
Risk of bias in included studies
In the two trials in this review, we ranked the method of con-
cealment unclear (Grade B). Both studies achieved a score of 1/
5 on the Jadad scale however both studies are only available in
abstract form and this score may change when the full text studies
are published. We will, therefore, provide a clearer indication of
study quality when more data becomes available.
Effects of interventions
A limited amount of data was reported in abstract form on 43
participants with bronchiectasis from the two included studies
(Newall 2000a;Newall 2000b). No data was available for the con-
trol group inNewall 2000b, therefore no comparison has been
made between pulmonary rehabilitation and no pulmonary re-
habilitation. There were considerable baseline difference between
groups in the studies. Therefore the results have been presented
using changes from baseline, but the absolute post treatment re-
sults are also shown as a second comparison.
EXERCISE TOLERANCE
The pooled results of the two studies show significant increase
from baseline in the inspiratory muscletraininggroup versussham
or no inspiratory muscle training in endurance (method of as-
sessment not detailed), Weighted Mean Difference (WMD) 264
metres (95% CI 16.4 to 512 metres). Maximal exercise capacity
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(incremental shuttle walking test) did not show a significant in-
crease from baseline, WMD 54 metres (95% CI -34 to 142 me-
tres). The post treatment results showed bigger treatment effects,
but also introduced heterogeneity. The baseline endurance in the
treatment group was 160 m less (500 m versus 661 m) in the
treatment group inNewall 2000aand 328 m more (732 m versus404 m) inNewall 2000b.
QUALITY OF LIFE
The pooled results of the two studies indicate an increase in the
quality of life following treatment compared to baseline in the
inspiratory muscle training group versus sham or no inspiratory
muscletrainingWMD 12.4 units on the CRQ scale (95% CI 2.38
to 22.48). Again the larger treatment effects shown in the post
treatment scores relate to the higher baseline quality of life in the
treatment groups.
PULMONARY FUNCTION
Pooled results from the two trials showed significant increases
in maximal inspiratory pressure (PiMax) from baseline following
treatment compared to baseline in the inspiratory muscle training
group versus sham or no inspiratory muscle training WMD 25
cms of water (95% CI 11.6 to 38.4 cms). Post treatment analysis
showed similar results.
At present there is no evidence from randomised control trials
to indicate whether physical training in bronchiectasis has an ef-
fect on peripheral muscle strength, mass, effort and general fa-
tigue; dyspnoea; weight; expectorated secretions; physical symp-
toms; number of and treatment of acute exacerbations; duration,
hospitalisation, IV antibiotic courses and time off work ; oxygen
saturation of thehaemoglobin of arterial blood (SaO2); bone min-
eral density and diabetes; compliance; nutritional regimes; adverse
effects and cost.
D I S C U S S I O N
Thissystematic review examined the effectiveness of physical train-
ing in the management of bronchiectasis. This was in order to
determine whether a prescribed regimen of physical training in
bronchiectasis produces improvements or prevents deterioration,in physiological and clinical outcomes in bronchiectasis compared
to no physical training.
Despite an exhaustive review of available literature, we only iden-
tified two relevant primary trials. Both of these trials investigated
the efficacy of inspiratory muscle training in bronchiectasis. As
there are only two studies the results should be viewed in the con-
text of possible publication bias.
Neither study was reported to be double blinded however this
quality issue must be considered in the context of the difficulty
of blinding any type of physical training study. Both studies used
random allocation, however neither provideddetailson the specific
procedures used. This maybe dueto thefact that both studies were
reported in abstract form only. In both studies the randomisationused was not successful in ensuring the groups were balanced at
baseline in all measures. These quality issues effect the internal
validity of the studies and justify the low Jadad scores reported.
The primary outcome measure in this review was exercise toler-
ance. Secondary outcome measures included pulmonary function
tests and quality of life. Analyses of the two studies suggest that
there is some evidence of the effect of inspiratory muscle training
on endurance exercise capacity, lung function and quality of life
but didnot show any benefitin terms of maximal exercise capacity.
Baseline differences make it difficult to be sure of the size of the
treatment effect, and the standard deviation of the changes from
baseline is not reported so has been assumed to be similar to the
standard deviation of the post treatment results (this is likely to bea conservative estimate).
A U T H O R S C O N C L U S I O N S
Implications for practice
It has been suggested that the magnitude of improvement from
physical training programmes in patients with bronchiectasis
should at least be comparable to the improvements demonstrated
in otherrespiratory disease populations. Theseclaims arebased pri-
marilyon expert opinion of thebenefits of training in bronchiecta-
sis, albeit supported by a sound physiological rationale. Thisreviewonly provides evidence of the benefits of inspiratory muscle train-
ingand provides no evidence of the effectof other types of physical
training (including pulmonary rehabilitation) in bronchiectasis.
Implications for research
This review has identified that there are no trials assessing the ef-
fect of physical training in bronchiectasis. There is a need for well
designed, adequately powered, randomised controlled clinical tri-
als to assess the net benefit (positive effects and side effects) of
adherence to different forms of prescribed physical training pro-
grammes, in patients with bronchiectasis. As it is likely that the
benefits and side effects of adherence to different types of physical
training differs in patients with mild, moderate and severe disease,
the influence of disease severity should be considered in the de-
sign of any future trial. The full benefit of any prescribed physical
training is unlikely to be demonstrated in programmes that are of
insufficient length or intensity. Therefore any future trial should
be of sufficient duration, intensity and frequency to assess the net
benefit of training on measures of disease impairment, disability
and handicap. Further research shouldalso consider whetherphys-
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ical training programmes delivered within the context of a pul-
monary rehabilitation program offers any additional advantages
to physical training alone.
A C K N O W L E D G E M E N T S
We gratefully thank ClaireAllen for assistancewith the preparation
of the synopsis and Kirsty Olsen who copy edited this review.
R E F E R E N C E S
References to studies included in this review
Newall 2000a{published data only}
Newall C, Henson M, McConnell AK, Stockley RA, Hill
SL. The effect of inspiratory muscle training (IMT) on
pulmonary function, exercise tolerance, and quality of life
in patients with bronchiectasis (BE). European Respiratory
Society. 2000; Vol. August September:1.
Newall 2000b {published data only}
Newall C, Henson M, McConnell AK, Stockley RA, Hill
SL. The effects of pulmonary rehabilitation (PR ) in patients
with bronchiectasis (BE). European Respiratory Society.
2000; Vol. AugustSept:3.
References to studies excluded from this review
Choe 1996 {published data only}
Choe KH Park YJ, et al.The effect of pulmonary
rehabilitation in patients with chronic lung disease.
Tuberculosis and respiratory diseases1996;43(5):73645.
Kellett 2005 {published data only} Kellett F, Redfern J, Niven RMcL. Evaluation of nebulised
hypertonic saline (7%) as an adjunct to physiotherapy in
patients with stable bronchiectasis. Respiratory Medicine
2005;99(1):2731.
Additional references
Jadad 1996
Jadad A, Moore RA, Carroll D, Jenkinson C, Reynolds
JM, Gavaghan DJ, et al.Assessing the quality of reports
of randomised controlled trials: is blinding necessary?.
Controlled Clinical Trials1996;17(1):112.
Morgan 1997
Morgan M, Singh S.Practical Pulmonary Rehabilitation. 1st
Edition. London: Chapman and Hall Medical, 1997.
Revill 1999
Revill SM, Morgan MDL, Singh SJ, Williams J, Hardman
AE. The endurance shuttle walk: A new field test for the
assessment of endurance capacity in chronic obstructive
pulmonary disease. Thorax1999;54(3):21322.
Shepherd 1994
Shephard RJ.Aerobic Fitness and Health. Leeds, England:
Human Kinetic Publishers, 1994.
Smith 1992
Smith K, Cook D, Guyatt G, Madhavan J, Oxman A.Respiratory Muscle Training in Chronic Airflow Limitation:
A Meta-Analysis. American Review of Respiratory Disease
1992;145(3):5339. Indicates the major publication for the study
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C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Newall 2000a
Methods 8 week study; concealment unclear; no dropouts specified; groups not similar at baseline
Participants 19 patients with bronchiectasis (IMT group, n = 10. Mean age 62.4 +/- 16.53); (control group, n = 9.
Mean age 62.8 +/- 11.6)
Interventions 8 weeks IMT using a pressure threshold device
control no intervention
Outcomes Included in this study were PImax; VC; RV; TLC; endurance; ISWT; CRDQ
Notes Jadad = 1
Risk of bias
Item Authors judgement Description
Allocation concealment? Unclear Information not available (Cochrane Grade B)
Newall 2000b
Methods 8 week study concealment unclear; no dropouts specified; groups not similar at baseline
Participants 33 patients with bronchiectasis(IMT plus PR: n = 12; mean age 56.8 +/- 7.8 years)
(sham IMT plus PR: n = 12 mean age 63 +/- 8.9)
(control: n = 9 mean age 62 +/- 11.6)
Interventions IMT using a pressure threshold device plus PR (education and exercise training)
sham IMT plus PR
control- no intervention
Outcomes Included in this study were PImax; endurance; ISWT; CRDQ
Notes Jadad = 1
Risk of bias
Item Authors judgement Description
Allocation concealment? Unclear Information not available (Cochrane Grade B)
CRDQ: Chronic respiratory disease questionnaire
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IMT: Inspiratory muscle training
ISWT: Incremental shuttle walking test
PImax: Peak inspiratory pressure (cmH2O)
PR: pulmonary rehabilitation (education, exercise training)
RV: Residual Volume (L)
TLC: Total Lung Capacity (L)VC: Vital Capacity (L)
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Choe 1996 Inappropriate patient population (only 1 patient had bronchiectasis) and no randomisation
Kellett 2005 Assessment of the addition of hypertonic saline to breathing technique. In the absence of an inactive control we
excluded the study
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D A T A A N D A N A L Y S E S
Comparison 1. Inspiratory Muscle Training versus Sham or no intervention (change from baseline)
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Endurance (metres) 2 43 Mean Difference (IV, Fixed, 95% CI) 264.21 [16.40, 512.
02]
1.1 Compared to no
intervention
1 19 Mean Difference (IV, Fixed, 95% CI) 204.60 [-374.01,
783.21]
1.2 Compared to sham
(both groups had Pulmonary
Rehabilitation)
1 24 Mean Difference (IV, Fixed, 95% CI) 277.60 [3.36, 551.
84]
2 Incremental shuttle walking test
(metres)
2 43 Mean Difference (IV, Fixed, 95% CI) 54.01 [-33.98, 142.
01]
2.1 Compared to no
intervention
1 19 Mean Difference (IV, Fixed, 95% CI) 46.8 [-129.87, 223.
47]
2.2 Compared to sham
(both groups had Pulmonary
Rehabilitation)
1 24 Mean Difference (IV, Fixed, 95% CI) 56.39 [-45.09, 157.
87]
3 Health Status (CRDQ score) 2 43 Mean Difference (IV, Fixed, 95% CI) 12.40 [2.38, 22.43]
3.1 Compared to no
intervention
1 19 Mean Difference (IV, Fixed, 95% CI) 1.90 [-13.52, 17.32]
3.2 Compared to sham
(both groups had Pulmonary
Rehabilitation)
1 24 Mean Difference (IV, Fixed, 95% CI) 20.1 [6.90, 33.30]
4 Pi Max (cms of water) 2 43 Mean Difference (IV, Fixed, 95% CI) 25.03 [11.63, 38.44]
4.1 Compared to nointervention
1 19 Mean Difference (IV, Fixed, 95% CI) 32.4 [6.09, 58.71]
4.2 Compared to sham
(both groups had Pulmonary
Rehabilitation)
1 24 Mean Difference (IV, Fixed, 95% CI) 22.45 [6.87, 38.03]
Comparison 2. Inspiratory Muscle Training v Sham or no intervention (post treatment results)
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Endurance (metres) 2 43 Mean Difference (IV, Fixed, 95% CI) 502.48 [254.67,
750.30]
1.1 Compared to no
intervention
1 19 Mean Difference (IV, Fixed, 95% CI) 43.90 [-534.71, 622.
51]
1.2 Compared to sham
(both groups had Pulmonary
Rehabilitation)
1 24 Mean Difference (IV, Fixed, 95% CI) 605.5 [331.26, 879.
74]
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2 Incremental shuttle walking test
(metres)
2 43 Mean Difference (IV, Fixed, 95% CI) 148.96 [60.96, 236.
95]
2.1 Compared to no
intervention
1 19 Mean Difference (IV, Fixed, 95% CI) -14.20 [-190.87,
162.47]
2.2 Compared to sham
(both groups had PulmonaryRehabilitation)
1 24 Mean Difference (IV, Fixed, 95% CI) 202.79 [101.31,
304.27]
3 Health Status (CRDQ score) 2 43 Mean Difference (IV, Fixed, 95% CI) 22.89 [12.87, 32.92]
3.1 Compared to no
intervention
1 19 Mean Difference (IV, Fixed, 95% CI) 17.70 [2.28, 33.12]
3.2 Compared to sham
(both groups had Pulmonary
Rehabilitation)
1 24 Mean Difference (IV, Fixed, 95% CI) 26.70 [13.50, 39.90]
4 Pi Max (cms of water) 2 43 Mean Difference (IV, Fixed, 95% CI) 25.77 [12.36, 39.18]
4.1 Compared to no
intervention
1 19 Mean Difference (IV, Fixed, 95% CI) 24.40 [-1.91, 50.71]
4.2 Compared to sham
(both groups had Pulmonary
Rehabilitation)
1 24 Mean Difference (IV, Fixed, 95% CI) 26.25 [10.67, 41.83]
Analysis 1.1. Comparison 1 Inspiratory Muscle Training versus Sham or no intervention (change from
baseline), Outcome 1 Endurance (metres).
Review: Physical training for bronchiectasis
Comparison: 1 Inspiratory Muscle Training versus Sham or no intervention (change from baseline)
Outcome: 1 Endurance (metres)
Study or subgroup IMT ControlMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Compared to no intervention
Newall 2000a 10 271.4 (651.2) 9 66.8 (634.6) 18.3 % 204.60 [ -374.01, 783.21 ]
Subtotal (95% CI) 10 9 18.3 % 204.60 [ -374.01, 783.21 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.69 (P = 0.49)
2 Compared to sham (both groups had Pulmonary Rehabilitation)
Newall 2000b 12 678.3 (400.3) 12 400.7 (273.3) 81.7 % 277.60 [ 3.36, 551.84 ]
Subtotal (95% CI) 12 12 81.7 % 277.60 [ 3.36, 551.84 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.98 (P = 0.047)
Total (95% CI) 22 21 100.0 % 264.21 [ 16.40, 512.02 ]
Heterogeneity: Chi2 = 0.05, df = 1 (P = 0.82); I2 =0.0%
Test for overall effect: Z = 2.09 (P = 0.037)
Test for subgroup differences: Chi2 = 0.05, df = 1 (P = 0.82), I2 =0.0%
-1000 -500 0 500 1000
Favours control Favours IMT
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Analysis 1.2. Comparison 1 Inspiratory Muscle Training versus Sham or no intervention (change from
baseline), Outcome 2 Incremental shuttle walking test (metres).
Review: Physical training for bronchiectasis
Comparison: 1 Inspiratory Muscle Training versus Sham or no intervention (change from baseline)
Outcome: 2 Incremental shuttle walking test (metres)
Study or subgroup IMT ControlMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Compared to no intervention
Newall 2000a 10 57.8 (162.9) 9 11 (221.9) 24.8 % 46.80 [ -129.87, 223.47 ]
Subtotal (95% CI) 10 9 24.8 % 46.80 [ -129.87, 223.47 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.52 (P = 0.60)
2 Compared to sham (both groups had Pulmonary Rehabilitation)
Newall 2000b 12 110.89 (134.9) 12 54.5 (118.2) 75.2 % 56.39 [ -45.09, 157.87 ]
Subtotal (95% CI) 12 12 75.2 % 56.39 [ -45.09, 157.87 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.09 (P = 0.28)
Total (95% CI) 22 21 100.0 % 54.01 [ -33.98, 142.01 ]
Heterogeneity: Chi2 = 0.01, df = 1 (P = 0.93); I2 =0.0%
Test for overall effect: Z = 1.20 (P = 0.23)
Test for subgroup differences: Chi2 = 0.01, df = 1 (P = 0.93), I2 =0.0%
-1000 -500 0 500 1000
Favours control Favours IMT
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Analysis 1.3. Comparison 1 Inspiratory Muscle Training versus Sham or no intervention (change from
baseline), Outcome 3 Health Status (CRDQ score).
Review: Physical training for bronchiectasis
Comparison: 1 Inspiratory Muscle Training versus Sham or no intervention (change from baseline)
Outcome: 3 Health Status (CRDQ score)
Study or subgroup IMT ControlMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Compared to no intervention
Newall 2000a 10 7.3 (10.7) 9 5.4 (21.3) 42.3 % 1.90 [ -13.52, 17.32 ]
Subtotal (95% CI) 10 9 42.3 % 1.90 [ -13.52, 17.32 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.24 (P = 0.81)
2 Compared to sham (both groups had Pulmonary Rehabilitation)
Newall 2000b 12 10.5 (19.5) 12 -9.6 (12.8) 57.7 % 20.10 [ 6.90, 33.30 ]
Subtotal (95% CI) 12 12 57.7 % 20.10 [ 6.90, 33.30 ]
Heterogeneity: not applicable
Test for overall effect: Z = 2.99 (P = 0.0028)
Total (95% CI) 22 21 100.0 % 12.40 [ 2.38, 22.43 ]
Heterogeneity: Chi2 = 3.09, df = 1 (P = 0.08); I2 =68%
Test for overall effect: Z = 2.42 (P = 0.015)
Test for subgroup differences: Chi2 = 3.09, df = 1 (P = 0.08), I2 =68%
-100 -50 0 50 100
Favours control Favours IMT
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Analysis 1.4. Comparison 1 Inspiratory Muscle Training versus Sham or no intervention (change from
baseline), Outcome 4 Pi Max (cms of water).
Review: Physical training for bronchiectasis
Comparison: 1 Inspiratory Muscle Training versus Sham or no intervention (change from baseline)
Outcome: 4 Pi Max (cms of water)
Study or subgroup IMT ControlMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Compared to no intervention
Newall 2000a 10 30.8 (31.6) 9 -1.6 (26.9) 26.0 % 32.40 [ 6.09, 58.71 ]
Subtotal (95% CI) 10 9 26.0 % 32.40 [ 6.09, 58.71 ]
Heterogeneity: not applicable
Test for overall effect: Z = 2.41 (P = 0.016)
2 Compared to sham (both groups had Pulmonary Rehabilitation)
Newall 2000b 12 28.25 (25.7) 12 5.8 (9.9) 74.0 % 22.45 [ 6.87, 38.03 ]
Subtotal (95% CI) 12 12 74.0 % 22.45 [ 6.87, 38.03 ]
Heterogeneity: not applicable
Test for overall effect: Z = 2.82 (P = 0.0047)
Total (95% CI) 22 21 100.0 % 25.03 [ 11.63, 38.44 ]
Heterogeneity: Chi2 = 0.41, df = 1 (P = 0.52); I2 =0.0%
Test for overall effect: Z = 3.66 (P = 0.00025)
Test for subgroup differences: Chi2 = 0.41, df = 1 (P = 0.52), I2 =0.0%
-100 -50 0 50 100
Favours control Favours IMT
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Analysis 2.1. Comparison 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results),
Outcome 1 Endurance (metres).
Review: Physical training for bronchiectasis
Comparison: 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results)
Outcome: 1 Endurance (metres)
Study or subgroup IMT ControlMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Compared to no intervention
Newall 2000a 10 772.1 (651.2) 9 728.2 (634.6) 18.3 % 43.90 [ -534.71, 622.51 ]
Subtotal (95% CI) 10 9 18.3 % 43.90 [ -534.71, 622.51 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.15 (P = 0.88)
2 Compared to sham (both groups had Pulmonary Rehabilitation)
Newall 2000b 12 1410 (400.3) 12 804.5 (273.3) 81.7 % 605.50 [ 331.26, 879.74 ]
Subtotal (95% CI) 12 12 81.7 % 605.50 [ 331.26, 879.74 ]
Heterogeneity: not applicable
Test for overall effect: Z = 4.33 (P = 0.000015)
Total (95% CI) 22 21 100.0 % 502.48 [ 254.67, 750.30 ]
Heterogeneity: Chi2 = 2.96, df = 1 (P = 0.09); I2 =66%
Test for overall effect: Z = 3.97 (P = 0.000071)
Test for subgroup differences: Chi2 = 2.96, df = 1 (P = 0.09), I2 =66%
-1000 -500 0 500 1000
Favours control Favours IMT
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Analysis 2.2. Comparison 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results),
Outcome 2 Incremental shuttle walking test (metres).
Review: Physical training for bronchiectasis
Comparison: 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results)
Outcome: 2 Incremental shuttle walking test (metres)
Study or subgroup IMT ControlMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Compared to no intervention
Newall 2000a 10 448.8 (162.9) 9 463 (221.9) 24.8 % -14.20 [ -190.87, 162.47 ]
Subtotal (95% CI) 10 9 24.8 % -14.20 [ -190.87, 162.47 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.16 (P = 0.87)
2 Compared to sham (both groups had Pulmonary Rehabilitation)
Newall 2000b 12 579.09 (134.9) 12 376.3 (118.2) 75.2 % 202.79 [ 101.31, 304.27 ]
Subtotal (95% CI) 12 12 75.2 % 202.79 [ 101.31, 304.27 ]
Heterogeneity: not applicable
Test for overall effect: Z = 3.92 (P = 0.000090)
Total (95% CI) 22 21 100.0 % 148.96 [ 60.96, 236.95 ]
Heterogeneity: Chi2 = 4.36, df = 1 (P = 0.04); I2 =77%
Test for overall effect: Z = 3.32 (P = 0.00091)
Test for subgroup differences: Chi2 = 4.36, df = 1 (P = 0.04), I2 =77%
-1000 -500 0 500 1000
Favours control Favours IMT
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Analysis 2.3. Comparison 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results),
Outcome 3 Health Status (CRDQ score).
Review: Physical training for bronchiectasis
Comparison: 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results)
Outcome: 3 Health Status (CRDQ score)
Study or subgroup IMT ControlMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Compared to no intervention
Newall 2000a 10 97.2 (10.7) 9 79.5 (21.3) 42.3 % 17.70 [ 2.28, 33.12 ]
Subtotal (95% CI) 10 9 42.3 % 17.70 [ 2.28, 33.12 ]
Heterogeneity: not applicable
Test for overall effect: Z = 2.25 (P = 0.024)
2 Compared to sham (both groups had Pulmonary Rehabilitation)
Newall 2000b 12 101.5 (19.5) 12 74.8 (12.8) 57.7 % 26.70 [ 13.50, 39.90 ]
Subtotal (95% CI) 12 12 57.7 % 26.70 [ 13.50, 39.90 ]
Heterogeneity: not applicable
Test for overall effect: Z = 3.97 (P = 0.000073)
Total (95% CI) 22 21 100.0 % 22.89 [ 12.87, 32.92 ]
Heterogeneity: Chi2 = 0.76, df = 1 (P = 0.38); I2 =0.0%
Test for overall effect: Z = 4.48 (P < 0.00001)
Test for subgroup differences: Chi2 = 0.76, df = 1 (P = 0.38), I2 =0.0%
-100 -50 0 50 100
Favours control Favours IMT
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Analysis 2.4. Comparison 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results),
Outcome 4 Pi Max (cms of water).
Review: Physical training for bronchiectasis
Comparison: 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results)
Outcome: 4 Pi Max (cms of water)
Study or subgroup IMT ControlMean
Difference WeightMean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Compared to no intervention
Newall 2000a 10 100 (31.6) 9 75.6 (26.9) 26.0 % 24.40 [ -1.91, 50.71 ]
Subtotal (95% CI) 10 9 26.0 % 24.40 [ -1.91, 50.71 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.82 (P = 0.069)
2 Compared to sham (both groups had Pulmonary Rehabilitation)
Newall 2000b 12 100.55 (25.7) 12 74.3 (9.9) 74.0 % 26.25 [ 10.67, 41.83 ]
Subtotal (95% CI) 12 12 74.0 % 26.25 [ 10.67, 41.83 ]
Heterogeneity: not applicable
Test for overall effect: Z = 3.30 (P = 0.00096)
Total (95% CI) 22 21 100.0 % 25.77 [ 12.36, 39.18 ]
Heterogeneity: Chi2 = 0.01, df = 1 (P = 0.91); I2 =0.0%
Test for overall effect: Z = 3.77 (P = 0.00017)
Test for subgroup differences: Chi2 = 0.01, df = 1 (P = 0.91), I2 =0.0%
-100 -50 0 50 100
Favours control Favours IMT
W H A T S N E W
Last assessed as up-to-date: 9 February 2005.
Date Event Description
30 September 2008 Amended Converted to new review format.
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H I S T O R Y
Protocol first published: Issue 1, 2001
Review first published: Issue 2, 2002
Date Event Description
1 February 2002 New citation required and conclusions have changed Substantive amendment
C O N T R I B U T I O N S O F A U T H O R S
The review was conceived by the Cochrane Airways Group and designed by Dr Judy Bradley and Ms Fidelma Moran. Searches for
relevant studies were conducted by Dr Judy Bradley and Ms Fidelma Moran and by the Cochrane Airways Group. Dr Judy Bradley
and Ms Fidelma Moran screened, appraised and abstracted data for review. Data entry was and analysis was performed by Dr Judy
Bradley and Ms Fidelma Moran with advice from the editor, Dr Mike Greenstone and the Cochrane Airways Group
D E C L A R A T I O N S O F I N T E R E S T
None known.
S O U R C E S O F S U P P O R T
Internal sources
NHS Research and Development, UK.
External sources
Garfield Weston Foundation, UK.
I N D E X T E R M S
Medical Subject Headings (MeSH)
Respiratory Muscles; Bronchiectasis [therapy]; Exercise Therapy [methods]; Physical Endurance
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MeSH check words
Humans
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