Chest physiotherapy for reducing respiratory morbidity in

infants requiring ventilatory support (Protocol)

Hough JL, Flenady VJ, Woodgate PG

This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane
Library 2007, Issue 4

http://www.thecochranelibrary.com

Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol) 1
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
 TABLE OF CONTENTS
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . . 2
SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . . 3
METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol) i
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Chest physiotherapy for reducing respiratory morbidity in
infants requiring ventilatory support (Protocol)

Hough JL, Flenady VJ, Woodgate PG

This record should be cited as:

Hough JL, Flenady VJ, Woodgate PG. Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support.
(Protocol) Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD006445. DOI: 10.1002/14651858.CD006445.

This version first published online: 18 April 2007 in Issue 2, 2007.

Date of most recent substantive amendment: 01 December 2006

ABSTRACT
This is the protocol for a review and there is no abstract. The objectives are as follows:
1. To determine the effects of active chest physiotherapy, including percussion and vibrations, compared to nonactive techniques, such
as suction with or without the addition of positioning, in newborn infants receiving mechanical ventilation:
• electively for the prevention of atelectasis, consolidation, or other respiratory morbidity
• 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: 4 hours or less; > 4 hours

BACKGROUND tal nursery, necessitating prolongation of oxygen administration

(Ehrlich 1972). Although CPT has been shown to be effective in
Approximately two to three per cent of all babies born in Australia the treatment of both nonventilated children (Zach 1987) and
and New Zealand require admission to a level three neonatal in- intubated adults (Stiller 1990) with acute lobar collapse, studies
tensive care unit (NICU) (ANZNN 2005). In this group of high of the effectiveness in the neonatal population are conflicting. In
risk infants, 89% require assisted ventilation. Chest physiother- the neonatal population, CPT is used both as a prophylactic mea-
apy (CPT) techniques are used in many NICU’s throughout the sure (by removing secretions) and also as a treatment technique
world to improve airway clearance in these infants on ventilatory for lung collapse and consolidation. Some studies in the neona-
support. tal population have shown positive effects of CPT, including im-
proved oxygenation (Finer 1978; Curran 1979) and increased re-
The application of CPT in airway management of mechanically moval of secretions (Etches 1978). However, the use of CPT has
ventilated adults has been shown to improve total lung/thoracic also received much criticism, largely as a result of reports of ad-
compliance and cardiorespiratory function (Mackenzie 1985); verse outcomes. Documented adverse outcomes include hypox-
however, little is known about its effect on neonates. Acute lo- aemia (Holloway 1966; Fox 1978), bruising, rib fractures (Puro-
bar atelectasis is a common problem in infants receiving mechan- hit 1975; Dabezies 1997), and intracranial pathology such as in-
ical ventilation. Atelectasis contributes to morbidity in the neona-
Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol) 1
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
traventricular haemorrhage (Raval 1987) and porencephalic cysts
(Harding 1998; Cross 1992).
Chest physiotherapy in the preterm infant consists of a variety of
techniques that include positioning, active techniques such as per-
cussion and vibrations, and suction. Percussion involves a rhyth-
mical cupping action applied to the chest wall performed with
a full cupped hand, tented fingers, or by using an infant resus-
citation face mask (cupping). The technique of vibration can be
performed manually by using the fingers to cause a fine shaking
motion of the chest wall. Alternatively, an electric toothbrush or
other vibrating device can be used.
The use of these techniques, in varying combinations and frequen-
cies, has become standard treatment for a variety of pulmonary
conditions. As there are many combinations of treatments that
constitute CPT, it is difficult to determine the exact effect 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. Some studies have
found percussion to be better than vibrations (Crane 1978; Tude-
hope 1980), while another has found the opposite to be the case
(Curran 1979) and yet another has found that there was no differ-
ence between the techniques (Hartrick 1982). In clinical practice,
percussion and vibrations are rarely used in isolation; most often,
percussion and vibration are given in combination with position-
ing, postural drainage and airway suction. Therefore, it is difficult
to assess the efficacy of each treatment component separately.
Previous Cochrane reviews have investigated the positioning
(Balaguer 2006) and suctioning (Pritchard 2004; Spence 2004;
Woodgate 2004) components of CPT. Only one review has as-
sessed the effect of active chest physiotherapy techniques on
preterm infants, and this has been in the population of infants be-
ing extubated (Flenady 2004). This review could not recommend
guidelines for clinical practice, due to small numbers of infants
studied and insufficient information on outcomes other than the
reduction in post extubation atelectasis (Flenady 2004). In light
of the results of this review and the amount of conflicting infor-
mation from other studies, it is important to investigate the wider
use of the techniques of percussion and vibration in the preterm
population.
As the issue of the effectiveness of physiotherapy is still a contro-
versial topic, it is anticipated that this review will provide guide-
lines on the provision of the respiratory physiotherapy techniques
of percussion and vibrations in the infant on ventilatory support.
OBJECTIVES
1. To determine the effects of active chest physiotherapy, includ-
ing percussion and vibrations, compared to nonactive techniques,
such as suction with or without the addition of positioning, in
newborn infants receiving mechanical ventilation:
Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
• electively for the prevention of atelectasis, consolidation, or
other respiratory morbidity
• 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: 4 hours or less; > 4 hours
CRITERIA FOR CONSIDERING
STUDIES FOR THIS REVIEW
Types of studies
All trials utilising random or quasi-random patient allocation.
Types of participants
All newborn infants receiving mechanical ventilation for neonatal
respiratory disease with the intervention initiated in the first four
weeks of life. Infants receiving prophylactic chest physiotherapy
for the extubation period will be excluded (Flenady 2004).
Types of intervention
Active chest physiotherapy techniques (vibrations or percussion
with or without the use of devices such as face masks and electric
vibrators) compared with standard care (suction with or without
positioning).
Studies comparing two or more methods of chest physiotherapy
intervention will be 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
2
• incidence of atelectasis or consolidation (for prophylactic
group)
• resolution or extension of atelectasis or consolidation (for treat-
ment group)
Oxygenation
• incidence of hypoxaemia (SaO2 < 90% or TcPO2 < 50 mmHg)
during intervention
• per cent change PaCO2 and PaO2 pre and post intervention
• per cent change inspired oxygen received (FiO2) pre and post
intervention
Secretion clearance
• sputum weight (g) post intervention
• sputum volume (ml) post intervention
Rates and type of intracranial lesions diagnosed by ultrasound scan
• intraventricular haemorrhage (IVH) (any IVH, grade 3 - 4)
(Papile 1978)
• periventricular leucomalacia (PVL) [any grade, and severe
(grades 3-4)] (Papile 1978)
Bradycardia (change in heart rate < 30% of baseline or < 100 beats
per minute) during intervention
SEARCH METHODS FOR
IDENTIFICATION OF STUDIES
See: methods used in reviews.
See Neonatal Collaborative Review Group search strategy.
The standard search strategy for the Cochrane Neonatal Review
Group as outlined in The Cochrane Library will be used. This
will include searches of the following electronic databases: The
Cochrane Central Register of Controlled Trials (CENTRAL,
The Cochrane Library, current issue), PubMed/MEDLINE
(1966 - current), EMBASE (1988 - current), CINAHL (1982
- current), PEDro (1929 - present), Web of Science using the
MeSH headings Infant, Newborn, Neonate, Respiratory, Lung,
Chest, physiotherapy, physical therapy. No language restrictions
will be applied.
The search will also include searches of the Oxford Database
of Perinatal Trials, previous reviews including cross references,
abstracts, conference and symposia proceedings, expert
informants, journal handsearching restricted to the English
language. Conference Proceedings of the Society for Pediatric
Research (SPR) (1967- present), the European Society for
Pediatric Research (ESPR) (1970) will be hand searched for
unpublished work.
Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
METHODS OF THE REVIEW
The standard methods of the Neonatal Review Group of the
Cochrane Collaboration will be used. Two review authors will
work independently to search for and assess trials for inclusion
and methodological quality. Eligible studies will be assessed using
the following key criteria: allocation concealment (blinding of
randomisation), blinding of intervention, completeness of follow
up and blinding of outcome measurement. Each of these will
be graded as yes, no, cant tell. Two review authors will extract
data independently. Differences will be resolved by discussion. An
attempt will be made to contact study investigators for additional
information or data as required.
Data analysis
At least two review authors will independently extract data using
prepared data extraction forms. Any discrepancies will be resolved
by discussion.
The Review Manager Software (RevMan 4.2.7) will be used for
statistical analyses. Categorical data will be analysed using relative
risk (RR), risk difference (RD) and number needed to treat (NNT)
where appropriate. A fixed effects model will be used to pool
results. Weighted mean differences (WMD) will be used for data
measured on a continuous scale. 95% confidence intervals (CI)
will be reported for all estimates. Sensitivity analyses to evaluate
the effect of the trial quality (excluding quasi-randomised trials
and considering trials with minimal bias) will be performed.
Heterogeneity will be assessed 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: 4 hours or less; > 4 hours
POTENTIAL CONFLICT OF
INTEREST
JH will be chief investigator in a trial investigating the effect of
chest physiotherapy techniques on lung function in the preterm
infant for her PhD thesis (2005-2007).
3
SOURCES OF SUPPORT

External sources of support

• Queensland Health AUSTRALIA

Internal sources of support
• Mater Hospital, South Brisbane AUSTRALIA
• University of Queensland AUSTRALIA

REFERENCES

Additional references
ANZNN 2005
Samanthi Abeywardana. The report of the Australian and New Zealand
Network, 2003. Sydney: ANZNN, 2005.
Bagley 2005
Bagley CE, Gray PH, Tudehope DI, Flenady V, Shearman AD, Lam-
ont A. Routine neonatal postextubation chest physiotherapy: a ran-
domized controlled trial. Journal of Paediatric and Child Health 2005;
41:592–7.
Balaguer 2006
Balaguer A, Escribano J, Roque M. Infant position in neonates
receiving mechanical ventilation. The Cochrane Database of Sys-
tematic Reviews 2006, Issue 4. Art. No.: CD003668. DOI:
10.1002/14651858.CD003668.pub2.
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, Durbin GM. Postnatal encephaloclastic porencephaly--a new
lesion?. Archives of Disease in Childhood 1992;67:307–11.
Curran 1979
Curran CL, Kachoyeanos MK. The effects on neonates of two meth-
ods of chest physical therapy. MCN American Journal of Maternal
Child Nursing 1979;4:309–13.
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.
Etches 1978
Etches PC, Scott B. Chest physiotherapy in the newborn: effect on
secretions removed. Pediatrics 1978;62:713–5.
Finer 1978
Finer NN, Boyd J. Chest physiotherapy in the neonate: a controlled
study. Pediatrics 1978;61:282–5.
Flenady 2004
Flenady VJ, Gray PH. Chest physiotherapy for preventing morbidity
in babies being extubated from mechanical ventilation. The Cochrane
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Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000283.
DOI:10.1002/14651858.CD000283.
Fox 1978
Fox WW, Schwartz JG, Shaffer TH. Pulmonary physiotherapy in
neonates: physiologic changes and respiratory management. Journal
of Pediatrics 1978;92:977–81.
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(3 Pt 1):440–4.
Hartrick 1982
Hartrick J, Fluit L, Parrott J, Yu VYH. A controlled-study of chest
physiotherapy methods in the newborn-infant. Australian Paediatric
Journal 1982;18:141.
Higgins 2002
Higgins J, Thompson S. Quantifying heterogeneity in meta-analysis.
Statistics in medicine 2002;21:1539–58.
Holloway 1966
Holloway R, Desai SD, Kelly SD, Thambiran AK, Strydom SE,
Adams EB. The effect of chest physiotherapy on the arterial oxygena-
tion of neonates during treatment of tetanus by intermittent positive-
pressure respiration. Sour African Medical Journal 1966;40:445–7.
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(4):529–4.
Pritchard 2004
Pritchard M, Flenady V, Woodgate P. Preoxygenation for tracheal
suctioning in intubated, ventilated newborn infants. The 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. [Med-
Line: medline; neonatal; physiotherapy].
4
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. J Perinatol 1987;7:301–4.
Spence 2004
Spence K, Gillies D, Waterworth L. Deep versus shallow suction of
endotracheal tubes in ventilated neonates and young infants. The
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.
Woodgate 2004
Woodgate PG, Flenady V. Tracheal suctioning without disconnection
in intubated ventilated neonates. The Cochrane Library 2001, Issue
2. Art. No.: CD003065. DOI:10.1002/14651858.CD003065.
Zach 1987
Zach MS, Oberwaldner B. Chest physiotherapy--the mechanical ap-
proach to antiinfective therapy in cystic fibrosis. Infection 1987;15:
381–4.

COVER SHEET
Title Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory
support
Authors Hough JL, Flenady VJ, Woodgate PG
Contribution of author(s) Judy Hough - wrote protocol
Vicki Flenady - edited protocol
Paul Woodgate - edited protocol
Issue protocol first published 2007/2
Date of most recent amendment 05 February 2007
Date of most recent 01 December 2006
SUBSTANTIVE amendment
What’s New Information not supplied by author
Contact address Ms Judith Hough
Physiotherapist/PhD candidate
Physiotherapy Department
Mater Hospital
Raymond Terrace
South Brisbane
Queensland
4101
AUSTRALIA
E-mail: judyhough@optusnet.com.au
DOI 10.1002/14651858.CD006445
Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol) 5
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Cochrane Library number CD006445
Editorial group Cochrane Neonatal Group
Editorial group code HM-NEONATAL

Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol) 6
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd