Chestphysiotherapyforreducingrespiratorymorbidityin ...223715/UQ223715_OA.pdf · to improve airway clearance and treat lung collapse in infants on ... Although CPT has been shown

Cochrane Database of Systematic Reviews

Chest physiotherapy for reducing respiratory morbidity in

infants requiring ventilatory support (Review)

Hough JL, Flenady V, Johnston L, Woodgate PG

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.

www.cochranelibrary.com

Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Review)

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.cochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 1 Weight of secretions

cleared per procedure per day (g). . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Analysis 1.2. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 2 Intraventricular

haemorrhage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Analysis 1.3. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 3 IVH grade 3 or 4. 21

Analysis 2.1. Comparison 2 Comparison of active chest physiotherapy techniques (percussion vs cupping), Outcome 1

Hypoxaemia per procedure per baby. . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Analysis 2.2. Comparison 2 Comparison of active chest physiotherapy techniques (percussion vs cupping), Outcome 2 %

change in FiO2 per procedure per baby. . . . . . . . . . . . . . . . . . . . . . . . . . 22

Analysis 3.1. Comparison 3 Comparison of active chest physiotherapy techniques (LST vs PDPV), Outcome 1 Non-

resolution of atelectasis after initial intervention. . . . . . . . . . . . . . . . . . . . . . . 22

Analysis 3.2. Comparison 3 Comparison of active chest physiotherapy techniques (LST vs PDPV), Outcome 2 Secretions

cleared (<0.2 ml) per procedure per baby. . . . . . . . . . . . . . . . . . . . . . . . . 23

Analysis 3.3. Comparison 3 Comparison of active chest physiotherapy techniques (LST vs PDPV), Outcome 3 IVH grade

3 or 4 after commencement of CPT. . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Analysis 3.4. Comparison 3 Comparison of active chest physiotherapy techniques (LST vs PDPV), Outcome 4

Periventricular leucomalacia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

24WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iChest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Review)


[Intervention Review]

Chest physiotherapy for reducing respiratory morbidity ininfants requiring ventilatory support

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

1Physiotherapy Department, Mater Hospital, South Brisbane, Australia. 2Centre for Clinical Studies-Women’s and Children’s Health,

Women’s and Children’s Health Service, South Brisbane, Australia. 3School of Health and Rehabilitation Sciences, University of

Queensland, St Lucia, Australia. 4Department of Neonatology, Mater Mother’s Hospital, Brisbane, Australia

Contact address: Judith L Hough, Physiotherapy Department, Mater Hospital, Raymond Terrace, South Brisbane, Queensland, 4101,

Australia. [email protected].

Editorial group: Cochrane Neonatal Group.

Publication status and date: New, published in Issue 1, 2010.

Review content assessed as up-to-date: 27 November 2007.

Citation: 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.


A B S T R A C T

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.

1Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Review)


mailto:[email protected]

Main 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.

P L A I N L A N G U A G E S U M M A R Y

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.

B A C K G R O U N D

Approximately two to three per cent of all babies born in Australia

and New Zealand require admission to a level three neonatal in-

tensive 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 lo-

bar atelectasis is a common problem in infants receiving mechan-

ical ventilation. Atelectasis contributes to morbidity in the neona-

tal 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 popu-

lation 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 re-

ceived much criticism, largely as a result of reports of adverse out-

comes. 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 vi-

bration, and suction. Percussion involves a rhythmical cupping ac-

tion applied to the chest wall performed with a full cupped hand,

tented fingers, or by using an infant resuscitation face mask (cup-



ping). 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 frequen-

cies, 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 an-

other 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 air-

way suction. Therefore, it is difficult to assess separately the effi-

cacy 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 in-

volved 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 insuffi-

cient 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 tech-

niques of percussion and vibration in the preterm population.

Since the issue of the effectiveness of physiotherapy is still a con-

troversial topic, it is anticipated that this review will provide evi-

dence on which to base guidelines regarding the provision of the

chest physiotherapy techniques of percussion and vibration in the

infant on ventilatory support.

O B J E C T I V E S

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:

a) electively for the prevention of atelectasis, consolidation or other

respiratory morbidity

b) 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:

• 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

M E T H O D S

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 suc-

tion compared with standard care (suction with or without posi-

tioning).

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 Neona-

tal Review Group (see: Cochrane Neonatal Review Group, search

strategy for Specialised Register in The Cochrane Library). The re-

view authors undertook a comprehensive search which included

searches of the following electronic databases: The Cochrane Cen-

tral Register of Controlled Trials (CENTRAL, The Cochrane Li-

brary, 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 En-

glish 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 Char-

tered 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 out-

come 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 de-

scribed 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 sensi-

tivity 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

R E S U L T S

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 re-

ported or could be obtained from the authors.

(For further details on excluded studies see the table of ’Charac-

teristics 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 pre-

mature neonates with a gestational age of 28 to 32 weeks. Infants

who were intubated and ventilated for respiratory distress syn-

drome (RDS) were randomly assigned to two groups. The inter-

vention 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 suc-

tioning 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 instilla-

tion of saline, suction and percussion consisting of cupping with a

Bennett face mask (Bennett percussion) followed by Boyd percus-

sion (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 in-

clusion 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, per-

cussion and vibration (PDPV). Therapy sessions were performed

twice daily at specified times until resolution of atelectasis oc-

curred. Re-expansion of atelectasis, recurrence of atelectasis, dura-

tion 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 intuba-

tion. 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 at-

electasis. In the third study, the diagnoses included hyaline mem-

brane 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, meco-

nium aspiration syndrome, congenital heart defects, pneumonia

presenting with generalised patchy consolidation, post-cardiotho-

racic 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, vi-

bration 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 com-

pared individual techniques of percussion with a face mask (cup-

ping) 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 in-

cluded from one cross-over trial (Peters 1983). In this trial, tran-

scutaneous oxygenation, changes in oxygen requirements and hy-

poxic episodes were measured 10 minutes pre and post-interven-

tion. Although Peters 1983 measured PaCO2, we could not in-

clude this data in the analyses as the standard deviation data could

not be obtained from the author. In the trial by Raval 1987, oxy-

genation 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 mea-

sure 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 mea-

sured the amounts of secretions collected over a 24-hour period

and reported average secretion per procedure. Rates of intracra-

nial 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 venti-

lation, duration of oxygen dependency and bronchopulmonary

dysplasia, and the presence of atelectasis on chest radiographs.

(For further details on included studies see the table, ’Character-

istics 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 ven-

tilation (CMV)]. The other two reported randomly assigning par-

ticipants 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 inter-

vention 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); how-

ever, 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 (Com-

parison 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 out-

come 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.




Peters 1983 did not address any of the preplanned primary out-

come 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 cup-

ping 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.




Wong 2003 did not address any of the preplanned primary out-

come 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 anal-

yses could not be undertaken.

D I S C U S S I O N

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) re-

sulted in a decrease in the number of infants with non-resolution

of atelectasis after the first treatment; however, LST did not re-

sult 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-ex-

pand (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 cup-

ping. 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 method-

ological 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 ex-

cluded. 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 oxy-

genation 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. Applicabil-

ity of the results to present day practice may be compromised due

to changes in population characteristics and interventions includ-

ing: 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 me-

chanical ventilation, duration of supplemental oxygen, and dura-

tion 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

A U T H O R S ’ C O N C L U S I O N S

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 interven-

tion cautiously.



Implications for research

Further well-designed trials are required to assess the risks and ben-

efits 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 pop-

ulation of infants < 30 weeks gestation. Clinically important out-

comes 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 re-

main unmeasured by current research are likely to require a very

large sample size, therefore, a large multicentre trial would be rec-

ommended.

A C K N O W L E D G E M E N T S

The authors would like acknowledge Dr K Peters, Assistant Pro-

fessor, 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.

R E F E R E N C E S

References to studies included in this review

Peters 1983 {published and unpublished data}

Peters, K. Neonatal unit - research studies. AARN News

Letter 1983;39:14–6.

Raval 1987 {published data only}

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 {published data only}

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.

References to studies excluded from this review

Andersen 1991 {published data only}

Andersen JB, Falk M. Chest physiotherapy in the pediatric

age group. Respiratory Care 1991;36:546–54.

Beaudoin 1973 {published data only}

Beaudoin J, Remondiere R. Chest therapy for newborn

children. Physiotherapy Canada 1973;25:152–4.

Becroft 1998 {published data only}

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.

Proceedings of the 1996 National Physiotherapy Congress.

1996:199–200.

Cabero 1987 {published data only}

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 {published data only}

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 {published data only}

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 {published data only}

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 {published data only}

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 {published data only}

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 {published data only}

Fox WW, Schwartz JG, Shaffer TH. Pulmonary

physiotherapy in neonates: Physiologic changes and

respiratory management. Journal of Pediatrics 1978;92:

977–81.

Gajdosik 1985 {published data only}

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 {published data only}

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 {published data only}

Hartsell MB. Chest physiotherapy and mechanical

vibration. Journal of Pediatric Nursing 1987;2:135–7.

Hough 1991 {published data only}

Hough A. Positioning vs vibrations in chest physiotherapy.

Chest 1991;100:1741.

James 1970 {published data only}

James J. The use of a mechanical vibrator during chest

physiotherapy. Physiotherapy 1970;56:31–2.

Kanarek 1980 {published data only}

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 {published data only}

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. The effect of physiotherapy on respiratory

function in ventilated children. PhD thesis, University

College, London 2001.

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.

Meier 1979 {published data only}

Meier P. CPT - which method, if any?. MCN American

Journal of Maternal Child Nursing 1979;4:310–1.

Meyer 1984 {published data only}

Meyer CL. Chest physiotherapy in infants requiring

ventilatory assistance. Respiratory Therapy 1984;14:27-9,

32-4.

Murai 1994 {published data only}

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 {published data only}

Parker AE. Chest physiotherapy in the neonatal intensive

care unit. Physiotherapy 1985;71:63–5.

Remondiere 1976 {published data only}

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 {published data only}

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 {published data only}

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 {published data only}

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 {published data only}

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 {published data only}

Warner A. Does chest physiotherapy move airway secretions?

. American Review of Respiratory Disease 1984;130:701–2.

Warwick 2004 {published data only}

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 {published data only}

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.

References to 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.

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. [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, issue 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; 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 [Computer program]

The Nordic Cochrane Centre, The Cochrane Collaboration.

Review Manager (RevMan). 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.∗ Indicates the major publication for the study



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]

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

Bias Authors’ judgement Support for judgement

Allocation concealment? Unclear risk B - Unclear

Raval 1987

Methods Blinding of randomisation - Unclear. Randomly assigned to 2 groups



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



Raval 1987 (Continued)


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


Allocation concealment? Unclear risk 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 outcome measure - Yes

Participants 56 neonates who required mechanical ventilation were randomised - 2 withdrawals due to critical condi-

tions (1 from each group)

Main diagnosis: atelectasis (segmental or lobar collapse)

Gestational age: 22 to 36 weeks


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



Wong 2003 (Continued)

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


Mortality rate

Notes

Risk of bias


Allocation concealment? Low risk A - Adequate

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Andersen 1991 Not a randomised trial - review article

Beaudoin 1973 Not a randomised trial - review article

Becroft 1998 Not a randomised trial

Bradbury 1996 Babies on nasopharyngeal CPAP - not mechanically ventilated

Cabero 1987 Not a randomised trial

Coradello 1979 Not a randomised trial

Coradello 1982 Not a randomised trial - cross-over study

Crane 1978 Abstract only - unable to contact author for further information

Crane 1986 Not a randomised trial - review article

Curran 1979 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 Not a randomised trial - case control study



(Continued)

Etches 1978 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 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 Eligible for inclusion but despite contacting primary author no further data were supplied

Fitzpatrick 1988 Not a randomised trial - case control study

Fox 1978 Not a randomised trial - case control study

Gajdosik 1985 Not a randomised trial - case report

Greisen 1985 Not a randomised trial - case control study

Not assessing respiratory outcome measures

Hartrick 1982 Abstract only - unable to contact author for further information

Hartsell 1987 Not newborn infants - children and adults with cystic fibrosis and bronchiectasis

Hough 1991 Not a randomised trial or newborn infants

James 1970 Not a randomised trial - report on technique

Kanarek 1980 Not a randomised trial - case control study

Leung 1998 Eligible for inclusion but despite contacting primary author no further data were supplied

Luther 1981 Not a randomised trial - case reports

Main 2001 Not newborn infants with respiratory distress - any studied newborns had cardiac conditions

Meier 1979 Not a randomised trial - a letter

Meyer 1984 Not a randomised trial - review article

Murai 1994 Intervention not physiotherapy - postural therapy

Paratz 1994 Not a randomised trial - case control study

Parker 1985 Not a randomised trial - review article

Remondiere 1976 Not a randomised trial - case report

Schultz 2005 Not newborn infants - greater than 8 months of age



(Continued)

Stiller 1996 Not newborn infants - adult population

Storni 2003 Not newborn infants with neonatal respiratory disease - infants had cystic fibrosis

Tudehope 1980 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 Not newborn infants

Warner 1984 Not a randomised trial - review article

Warwick 2004 Not newborn infants

Wong 2006 Not a randomised trial - cohort study

Characteristics of ongoing studies [ordered by study ID]

Hough 2007

Trial name or title 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 outcomes measures - 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


Starting date October 2006

Contact information [email protected]



Hough 2007 (Continued)

Notes



D A T A A N D A N A L Y S E S

Comparison 1. Active chest physiotherapy vs no active chest physiotherapy

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Weight of secretions cleared per

procedure per day (g)

1 20 Mean Difference (IV, Fixed, 95% CI) 0.01 [-0.10, 0.12]

2 Intraventricular haemorrhage 1 20 Risk Ratio (M-H, Fixed, 95% CI) 2.33 [0.83, 6.54]

3 IVH grade 3 or 4 1 20 Risk Ratio (M-H, Fixed, 95% CI) 11.0 [0.69, 175.86]

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


studies

No. of


1 Hypoxaemia per procedure per

baby

1 60 Risk Ratio (M-H, Fixed, 95% CI) 0.53 [0.28, 0.99]

2 % change in FiO2 per procedure

per baby

1 60 Mean Difference (IV, Fixed, 95% CI) -9.68 [-14.16, -5.20]

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


studies

No. of


1 Non-resolution of atelectasis

after initial intervention


2 Secretions cleared (<0.2 ml) per

procedure per baby


3 IVH grade 3 or 4 after

commencement of CPT


4 Periventricular leucomalacia 1 56 Risk Ratio (M-H, Fixed, 95% CI) 0.87 [0.21, 3.52]



Analysis 1.1. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 1

Weight of secretions cleared per procedure per day (g).

Review: Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support

Comparison: 1 Active chest physiotherapy vs no active chest physiotherapy

Outcome: 1 Weight of secretions cleared per procedure per day (g)

Study or subgroup CPT Suction onlyMean

Difference WeightMean

Difference

N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Raval 1987 10 0.09 (0.11) 10 0.08 (0.14) 100.0 % 0.01 [ -0.10, 0.12 ]

Total (95% CI) 10 10 100.0 % 0.01 [ -0.10, 0.12 ]

Heterogeneity: not applicable

Test for overall effect: Z = 0.18 (P = 0.86)

Test for subgroup differences: Not applicable

-0.1 -0.05 0 0.05 0.1

Favours suction only Favours CPT

Analysis 1.2. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 2

Intraventricular haemorrhage.



Outcome: 2 Intraventricular haemorrhage

Study or subgroup CPT Suction only Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Raval 1987 7/10 3/10 100.0 % 2.33 [ 0.83, 6.54 ]

Total (95% CI) 10 10 100.0 % 2.33 [ 0.83, 6.54 ]

Total events: 7 (CPT), 3 (Suction only)



0.2 0.5 1 2 5

Favours CPT Favours suction only



Analysis 1.3. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 3 IVH

grade 3 or 4.



Outcome: 3 IVH grade 3 or 4

Study or subgroup CPT Suction only Risk Ratio Weight Risk Ratio


Raval 1987 5/10 0/10 100.0 % 11.00 [ 0.69, 175.86 ]

Total (95% CI) 10 10 100.0 % 11.00 [ 0.69, 175.86 ]

Total events: 5 (CPT), 0 (Suction only)



0.01 0.1 1 10 100

Favours CPT Favours suction only

Analysis 2.1. Comparison 2 Comparison of active chest physiotherapy techniques (percussion vs cupping),

Outcome 1 Hypoxaemia per procedure per baby.


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

Outcome: 1 Hypoxaemia per procedure per baby

Study or subgroup Percussion Cupping Risk Ratio Weight Risk Ratio


Peters 1983 9/30 17/30 100.0 % 0.53 [ 0.28, 0.99 ]

Total (95% CI) 30 30 100.0 % 0.53 [ 0.28, 0.99 ]

Total events: 9 (Percussion), 17 (Cupping)



0.5 0.7 1 1.5 2

Favours percussion Favours cupping



Analysis 2.2. Comparison 2 Comparison of active chest physiotherapy techniques (percussion vs cupping),

Outcome 2 % change in FiO2 per procedure per baby.


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

Outcome: 2 % change in FiO2 per procedure per baby

Study or subgroup Percussion CuppingMean

Difference WeightMean

Difference

N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Peters 1983 30 -6.11 (9.16) 30 3.57 (8.52) 100.0 % -9.68 [ -14.16, -5.20 ]

Total (95% CI) 30 30 100.0 % -9.68 [ -14.16, -5.20 ]



Test for subgroup differences: Not applicable

-10 -5 0 5 10

Favours percussion Favours cupping

Analysis 3.1. Comparison 3 Comparison of active chest physiotherapy techniques (LST vs PDPV), Outcome

1 Non-resolution of atelectasis after initial intervention.


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

Outcome: 1 Non-resolution of atelectasis after initial intervention

Study or subgroup LST PDPV Risk Ratio Weight Risk Ratio


Wong 2003 5/26 23/30 100.0 % 0.25 [ 0.11, 0.57 ]

Total (95% CI) 26 30 100.0 % 0.25 [ 0.11, 0.57 ]

Total events: 5 (LST), 23 (PDPV)



0.2 0.5 1 2 5

Favours LST Favours PDPV




2 Secretions cleared (<0.2 ml) per procedure per baby.



Outcome: 2 Secretions cleared (<0.2 ml) per procedure per baby



Wong 2003 15/26 18/30 100.0 % 0.96 [ 0.62, 1.49 ]

Total (95% CI) 26 30 100.0 % 0.96 [ 0.62, 1.49 ]




0.5 0.7 1 1.5 2



3 IVH grade 3 or 4 after commencement of CPT.



Outcome: 3 IVH grade 3 or 4 after commencement of CPT



Wong 2003 6/26 8/30 100.0 % 0.87 [ 0.35, 2.17 ]

Total (95% CI) 26 30 100.0 % 0.87 [ 0.35, 2.17 ]




0.5 0.7 1 1.5 2





4 Periventricular leucomalacia.



Outcome: 4 Periventricular leucomalacia



Wong 2003 3/26 4/30 100.0 % 0.87 [ 0.21, 3.52 ]

Total (95% CI) 26 30 100.0 % 0.87 [ 0.21, 3.52 ]




0.5 0.7 1 1.5 2


W H A T ’ S N E W

Last assessed as up-to-date: 27 November 2007.

Date Event Description

18 February 2008 Amended Converted to new review format.

C O N T R I B U T I O N S O F A U T H O R S

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



D E C L A R A T I O N S O F I N T E R E S T

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).

S O U R C E S O F S U P P O R T

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.

I N D E X T E R M S

Medical Subject Headings (MeSH)

Mucus [∗secretion]; Percussion [methods]; Pulmonary Atelectasis [∗therapy]; Randomized Controlled Trials as Topic; Respiration,

Artificial [∗adverse effects]; Respiratory Therapy [∗methods]; Suction; Vibration [therapeutic use]

MeSH check words

Humans; Infant; Infant, Newborn



Documents

Chestphysiotherapyforreducingrespiratorymorbidityin ...223715/UQ223715_OA.pdf · to improve airway clearance and treat lung collapse in infants on ... Although CPT has been shown