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NIHR Signal Chest physiotherapy for acute bronchiolitis is ineffective and may be harmful

Published on 10 May 2016

doi: 10.3310/signal-000235

Chest physiotherapy for acute bronchiolitis in children under two has no benefits and may be harmful, according to a systematic review published by the Cochrane Collaboration.

The research looked at three different types of chest physiotherapy. It found that none of the techniques helped children with bronchiolitis recover more quickly or led to any improvement in their condition. Some types of chest physiotherapy may make breathing and blood-oxygen levels worse.

This review’s findings suggest that chest physiotherapy should not normally be used for children hospitalised with severe bronchiolitis. The findings support current NICE guidance which says that children (who don’t have another condition) should not be given chest physiotherapy on the basis of having bronchiolitis.

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Why was this study needed?

Acute bronchiolitis is a common viral infection in children under two, in which the airways become inflamed and narrowed. About 30% of infants will develop the disease in the first year of life, of which 2 to 3% will need admission to hospital. In severe cases children may have difficulty breathing and suffer lack of oxygen.

Chest physiotherapy is used in many other lung conditions and it has been proposed that it may help clear the airways and make breathing easier in cases of acute bronchiolitis.

The first Cochrane review of the subject was published in 2004 and updated in 2005, 2007 and 2012. All the reviews concluded that chest physiotherapy was ineffective for acute bronchiolitis. However, chest physiotherapy, including new and gentler techniques, is still being used for acute bronchiolitis in some countries.

The latest review assessed the safety and effectiveness of chest physiotherapy, including more recent techniques, in infants aged less than two years with acute bronchiolitis.

What did this study do?

The review compared chest physiotherapy with no intervention or with another type of treatment such as suctioning secretions or applying nasal drops. The 12 included trials (three new to this update) covered 1,249 children with bronchiolitis younger than 24 months who had been admitted to hospital. Two studies were carried out in the UK, the rest were mainly from Europe or Latin America.

The researchers looked at whether vibration and percussion plus postural drainage, or the newer, gentler techniques of slow passive expiration, or forced expiration reduced the severity of the illness and the time it took patients to recover. These were measured using different outcome scores, which could not be combined numerically. Other outcomes included harms associated with physiotherapy.

This Cochrane review was carried out using reliable methods. There was high grade evidence in trials measuring time to recovery for forced expiration techniques, which means we can be confident in findings. However, we can be less certain about other techniques and findings, where the trials were at risk of bias and presented imprecise estimates of any effect.

What did it find?

  • In three trials, forced passive expiratory techniques had no effect on disease severity, measured by the time it took children to recover or to reach a stable condition. These trials were graded as high quality evidence with low risk of bias, so we can be confident in the findings.
  • One high quality trial showed this technique was associated with harm, including increased risk of vomiting (relative risk [RR] 10.2, 95% confidence interval [CI] 1.3 to 78.8) and of a child’s breathing becoming worse (RR 5.4, 95% CI 1.6 to 18.4).
  • In five trials, vibration and percussion plus postural drainage did not reduce the severity of the disease, as measured by patients’ clinical scores. The trials included did not have information on possible harms of percussion and vibration, and had unclear risk of bias due to selective reporting. This means we cannot be sure of the findings for these outcomes in this group.
  • Slow passive expiratory techniques were studied in four trials. Three showed no effect or small, transient improvement in severity of the illness, as measured by patients’ clinical scores. This technique appears to be safe, with no adverse effects reported in two trials. However, all the research on slow passive expiration was unclear in its description of bias reducing our confidence in these findings too.

What does current guidance say on this issue?

Guidance from NICE on managing bronchiolitis in children in hospital was published in 2015. It says that chest physiotherapy should not be performed on children with bronchiolitis who do not have other illnesses affecting the airways, for example, where children cannot clear secretions due to muscle weakness.

NICE advises clinicians to consider requesting a chest physiotherapy assessment in children who have other relevant illness, when there may be additional difficulty clearing lung secretions.

What are the implications?

Updated evidence from this high quality review continues to support 2015 NICE guideline recommendations not to use chest physiotherapy for children with acute bronchiolitis who do not have other reasons for physiotherapy. This guideline warns that chest physiotherapy can be uncomfortable for the child and distressing for the carers. There is also the potential that it can worsen the condition.

Given the strong evidence of lack of health benefits of physiotherapy for this condition, and the more uncertain risk of harmful effects for some types of physiotherapy, this reviews’ findings could help align practice with evidence. The imprecision in estimating the extent of any harm should not deter clinicians from assuming that at least some harm does exist, taking a precautionary approach. Based on this evidence there is the potential to save resources in terms of the cost of treating harms and releasing a physiotherapist’s time for other treatments.

Citation and Funding

Roqué I Figuls M, Giné-Garriga M, Granados Rugeles C, et al. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev. 2016;2:CD004873.

No funding information was provided for this study.

Bibliography

Gajdos V, Katsahian S, Beydon N, et al. Effectiveness of chest physiotherapy in infants hospitalized with acute bronchiolitis: a multicenter, randomized, controlled trial. PLoS Med. 2010;7(9):e1000345.

NHS Choices. Bronchiolitis.  Leeds: NHS Choices; 2015.

NICE. Bronchiolitis in children: diagnosis and management. NG9. London: National Institute for Health and Care Excellence; 2015.

Why was this study needed?

Acute bronchiolitis is a common viral infection in children under two, in which the airways become inflamed and narrowed. About 30% of infants will develop the disease in the first year of life, of which 2 to 3% will need admission to hospital. In severe cases children may have difficulty breathing and suffer lack of oxygen.

Chest physiotherapy is used in many other lung conditions and it has been proposed that it may help clear the airways and make breathing easier in cases of acute bronchiolitis.

The first Cochrane review of the subject was published in 2004 and updated in 2005, 2007 and 2012. All the reviews concluded that chest physiotherapy was ineffective for acute bronchiolitis. However, chest physiotherapy, including new and gentler techniques, is still being used for acute bronchiolitis in some countries.

The latest review assessed the safety and effectiveness of chest physiotherapy, including more recent techniques, in infants aged less than two years with acute bronchiolitis.

What did this study do?

The review compared chest physiotherapy with no intervention or with another type of treatment such as suctioning secretions or applying nasal drops. The 12 included trials (three new to this update) covered 1,249 children with bronchiolitis younger than 24 months who had been admitted to hospital. Two studies were carried out in the UK, the rest were mainly from Europe or Latin America.

The researchers looked at whether vibration and percussion plus postural drainage, or the newer, gentler techniques of slow passive expiration, or forced expiration reduced the severity of the illness and the time it took patients to recover. These were measured using different outcome scores, which could not be combined numerically. Other outcomes included harms associated with physiotherapy.

This Cochrane review was carried out using reliable methods. There was high grade evidence in trials measuring time to recovery for forced expiration techniques, which means we can be confident in findings. However, we can be less certain about other techniques and findings, where the trials were at risk of bias and presented imprecise estimates of any effect.

What did it find?

  • In three trials, forced passive expiratory techniques had no effect on disease severity, measured by the time it took children to recover or to reach a stable condition. These trials were graded as high quality evidence with low risk of bias, so we can be confident in the findings.
  • One high quality trial showed this technique was associated with harm, including increased risk of vomiting (relative risk [RR] 10.2, 95% confidence interval [CI] 1.3 to 78.8) and of a child’s breathing becoming worse (RR 5.4, 95% CI 1.6 to 18.4).
  • In five trials, vibration and percussion plus postural drainage did not reduce the severity of the disease, as measured by patients’ clinical scores. The trials included did not have information on possible harms of percussion and vibration, and had unclear risk of bias due to selective reporting. This means we cannot be sure of the findings for these outcomes in this group.
  • Slow passive expiratory techniques were studied in four trials. Three showed no effect or small, transient improvement in severity of the illness, as measured by patients’ clinical scores. This technique appears to be safe, with no adverse effects reported in two trials. However, all the research on slow passive expiration was unclear in its description of bias reducing our confidence in these findings too.

What does current guidance say on this issue?

Guidance from NICE on managing bronchiolitis in children in hospital was published in 2015. It says that chest physiotherapy should not be performed on children with bronchiolitis who do not have other illnesses affecting the airways, for example, where children cannot clear secretions due to muscle weakness.

NICE advises clinicians to consider requesting a chest physiotherapy assessment in children who have other relevant illness, when there may be additional difficulty clearing lung secretions.

What are the implications?

Updated evidence from this high quality review continues to support 2015 NICE guideline recommendations not to use chest physiotherapy for children with acute bronchiolitis who do not have other reasons for physiotherapy. This guideline warns that chest physiotherapy can be uncomfortable for the child and distressing for the carers. There is also the potential that it can worsen the condition.

Given the strong evidence of lack of health benefits of physiotherapy for this condition, and the more uncertain risk of harmful effects for some types of physiotherapy, this reviews’ findings could help align practice with evidence. The imprecision in estimating the extent of any harm should not deter clinicians from assuming that at least some harm does exist, taking a precautionary approach. Based on this evidence there is the potential to save resources in terms of the cost of treating harms and releasing a physiotherapist’s time for other treatments.

Citation and Funding

Roqué I Figuls M, Giné-Garriga M, Granados Rugeles C, et al. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev. 2016;2:CD004873.

No funding information was provided for this study.

Bibliography

Gajdos V, Katsahian S, Beydon N, et al. Effectiveness of chest physiotherapy in infants hospitalized with acute bronchiolitis: a multicenter, randomized, controlled trial. PLoS Med. 2010;7(9):e1000345.

NHS Choices. Bronchiolitis.  Leeds: NHS Choices; 2015.

NICE. Bronchiolitis in children: diagnosis and management. NG9. London: National Institute for Health and Care Excellence; 2015.

Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old

Published on 3 February 2016

Roque, I. Figuls M.,Gine-Garriga, M.,Granados Rugeles, C.,Perrotta, C.,Vilaro, J.

Cochrane Database Syst Rev Volume 2 , 2016

BACKGROUND: This Cochrane review was first published in 2005 and updated in 2007, 2012 and now 2015. Acute bronchiolitis is the leading cause of medical emergencies during winter in children younger than two years of age. Chest physiotherapy is sometimes used to assist infants in the clearance of secretions in order to decrease ventilatory effort. OBJECTIVES: To determine the efficacy of chest physiotherapy in infants aged less than 24 months old with acute bronchiolitis. A secondary objective was to determine the efficacy of different techniques of chest physiotherapy (for example, vibration and percussion and passive forced exhalation). SEARCH METHODS: We searched CENTRAL (2015, Issue 9) (accessed 8 July 2015), MEDLINE (1966 to July 2015), MEDLINE in-process and other non-indexed citations (July 2015), EMBASE (1990 to July 2015), CINAHL (1982 to July 2015), LILACS (1985 to July 2015), Web of Science (1985 to July 2015) and Pedro (1929 to July 2015). SELECTION CRITERIA: Randomised controlled trials (RCTs) in which chest physiotherapy was compared against no intervention or against another type of physiotherapy in bronchiolitis patients younger than 24 months of age. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data. Primary outcomes were change in the severity status of bronchiolitis and time to recovery. Secondary outcomes were respiratory parameters, duration of oxygen supplementation, length of hospital stay, use of bronchodilators and steroids, adverse events and parents' impression of physiotherapy benefit. No pooling of data was possible. MAIN RESULTS: We included 12 RCTs (1249 participants), three more than the previous Cochrane review, comparing physiotherapy with no intervention. Five trials (246 participants) evaluated conventional techniques (vibration and percussion plus postural drainage), and seven trials (1003 participants) evaluated passive flow-oriented expiratory techniques: slow passive expiratory techniques in four trials, and forced passive expiratory techniques in three trials.Conventional techniques failed to show a benefit in the primary outcome of change in severity status of bronchiolitis measured by means of clinical scores (five trials, 241 participants analysed). Safety of conventional techniques has been studied only anecdotally, with one case of atelectasis, the collapse or closure of the lung resulting in reduced or absent gas exchange, reported in the control arm of one trial.Slow passive expiratory techniques failed to show a benefit in the primary outcomes of severity status of bronchiolitis and in time to recovery (low quality of evidence). Three trials analysing 286 participants measured severity of bronchiolitis through clinical scores, with no significant differences between groups in any of these trials, conducted in patients with moderate and severe disease. Only one trial observed a transient significant small improvement in the Wang clinical score immediately after the intervention in patients with moderate severity of disease. There is very low quality evidence that slow passive expiratory techniques seem to be safe, as two studies (256 participants) reported that no adverse effects were observed.Forced passive expiratory techniques failed to show an effect on severity of bronchiolitis in terms of time to recovery (two trials, 509 participants) and time to clinical stability (one trial, 99 participants analysed). This evidence is of high quality and corresponds to patients with severe bronchiolitis. Furthermore, there is also high quality evidence that these techniques are related to an increased risk of transient respiratory destabilisation (risk ratio (RR) 10.2, 95% confidence interval (CI) 1.3 to 78.8, one trial) and vomiting during the procedure (RR 5.4, 95% CI 1.6 to 18.4, one trial). Results are inconclusive for bradycardia with desaturation (RR 1.0, 95% CI 0.2 to 5.0, one trial) and bradycardia without desaturation (RR 3.6, 95% CI 0.7 to 16.9, one trial), due to the limited precision of estimators. However, in mild to moderate bronchiolitis patients, forced expiration combined with conventional techniques produced an immediate relief of disease severity (one trial, 13 participants). AUTHORS' CONCLUSIONS: None of the chest physiotherapy techniques analysed in this review (conventional, slow passive expiratory techniques or forced expiratory techniques) have demonstrated a reduction in the severity of disease. For these reasons, these techniques cannot be used as standard clinical practice for hospitalised patients with severe bronchiolitis. There is high quality evidence that forced expiratory techniques in severe patients do not improve their health status and can lead to severe adverse events. Slow passive expiratory techniques provide an immediate and transient relief in moderate patients without impact on duration. Future studies should test the potential effect of slow passive expiratory techniques in mild to moderate non-hospitalised patients and patients who are respiratory syncytial virus (RSV) positive. Also, they could explore the combination of chest physiotherapy with salbutamol or hypertonic saline.

The types of chest physiotherapy studied in this review are vibration and percussion, forced expiratory techniques and slow passive expiratory techniques.

Vibration and percussion with postural drainage is a common physiotherapy approach for mucus removal. Percussion involves the physiotherapist clapping on the chest or back to help break up secretions. In vibration, the physiotherapist applies light manual pressure, creating a shaking movement on specific areas of the chest wall. The child is held in a position to help drain fluid from the lungs.

In forced expiratory technique, the physiotherapist presses suddenly on the chest or abdomen to increase the breath out and help clear secretions. In slow passive expiratory technique the rib cage and abdominal cavity is gradually and gently compressed from mid breath to the end of the breath out, to help clear secretions.

Expert commentary

Acute bronchiolitis is a common emergency in the first two years of life, and there is no effective treatment. The authors have identified that there is no evidence that chest physiotherapy is useful, nor is this surprising given the pathophysiology of the disease. Also, handling these sick babies may cause acute decompensation, so chest physiotherapy may actually be harmful. The authors call for further studies on physiotherapy combined with hypertonic saline or salbutamol, two other useless therapies for bronchiolitis; I cannot agree with this conclusion.

Andrew Bush, Professor of Paediatrics and Head of Section (Paediatrics), Imperial College; Professor of Paediatric Respirology, National Heart and Lung Institute; Consultant Paediatric Chest Physician, Royal Brompton and Harefield NHS Foundation Trust

Expert commentary

The theoretical rationale for physiotherapy interventions to relieve lung hyperinflation or mucus plugging in acute bronchiolitis is plausible. However, inflammation, tachypnea, paroxysmal cough and critical airway narrowing in small airways, mean that treatments in infants with severe illness are fraught with balancing clinical benefit against the risk of triggering respiratory failure.

This review includes data from 12 studies in 9 countries across the UK, Europe, South America and the Middle East, which represent many heterogeneous therapeutic interventions. There is no persuasive evidence of overall clinical benefit which would justify routine physiotherapy in this vulnerable population. Credible evidence from one European study suggests that the risks of respiratory decline after forced expiratory techniques can be significant for severely affected infants.

Professor Eleanor Main, Programme Director: UCL MSc, Diploma and Certificate in Physiotherapy