Active cycle of breathing technique for cystic fibrosis

Occupational therapy interventions in pulmonary rehabilitation – an update in the COVID-19 ERA

Background. As symptoms of COVID-19 infection are varying in severity and type, the long-term disability is yet to be established due to a short time-window since the pandemic started. Most survivors will have persistent pulmonary symptoms even after the infection, which raises the awareness of the importance of pulmonary rehabilitation in these patients, as they are mostly young, with severely diminished quality of life as they are unable to perform their basic activities of daily living as before. Occupational therapy is a form of rehabilitation treatment aimed at maximizing functionality and independence in performing activities of daily living, improvement of the patient’s autonomy and prevention of further functional decline. Objective. The purpose of the current work is to review the most important occupational therapy interventions applicable during a pulmonary rehabilitation program for chronic pulmonary pathologies, that can also be applied in COVID-19 survivors with persistent respiratory symptoms. Discussion. The main objectives of occupational therapy in pulmonary rehabilitation are training using breathing techniques at rest and during task performance, upper limbs training to increase exercise tolerance, programming and simplifying daily activities, informing patients of the importance of asking for help, planning the day/week, organizing the environment, educating the patient. All these objectives can be achieved in a simple way and at low-cost. Conclusions. Occupational therapy intervention during comprehensive pulmonary rehabilitation must be promoted to specifically evaluate and solve problems related to respiratory disability. Occupational tasks should be related to symptoms occurring during specific activities. Standardized protocols and definition of outcomes during occupational therapy intervention are lacking. Keywords: occupational therapy, pulmonary rehabilitation, COVID-19, activities of daily living, quality of life,

Standard (head-down tilt) versus modified (without head-down tilt) postural drainage in infants and young children with cystic fibrosis

BACKGROUND

Postural drainage is used primarily in infants with cystic fibrosis from diagnosis up to the moment when they are mature enough to actively participate in self-administered treatments. However, there is a risk of gastroesophageal reflux associated with this technique.

OBJECTIVES

To compare the effects of standard postural drainage (greater (30° to 45° head-down tilt) and lesser (15° to 20° head-down tilt)) with modified postural drainage (greater (30º head-up tilt) or lesser (15º to 20º head-up tilt)) with regard to gastroesophageal reflux in infants and young children up to six years old with cystic fibrosis in terms of safety and efficacy.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register. We also searched the reference lists of relevant articles and reviews. Additional searches were conducted on ClinicalTrials.gov and on the WHO International Clinical Trials Registry Platform for any planned, ongoing and unpublished studies.The date of the most recent literature searches: 20 January 2015.

SELECTION CRITERIA

We included randomised controlled studies that compared two postural drainage regimens (standard and modified postural drainage) with regard to gastroesophageal reflux in infants and young children (up to and including six years old) with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies to be included in the review, assessed their risk of bias and extracted data.

MAIN RESULTS

Two studies, including 40 participants, were eligible for inclusion in the review. The studies were different in terms of the age of participants, the angle of tilt, the reported outcomes, the number of sessions and the study duration. The following outcomes were measured: appearance or exacerbation of gastroesophageal reflux episodes; percentage of peripheral oxygen saturation; number of exacerbations of upper respiratory tract symptoms; number of days on antibiotics for acute exacerbations; chest X-ray scores; and pulmonary function tests. One study reported that postural drainage with a 20° head-down position did not appear to exacerbate gastroesophageal reflux. However, the majority of the reflux episodes reached the upper oesophagus. The second included study reported that modified postural drainage (30º head-up tilt) was associated with fewer number of gastroesophageal reflux episodes and fewer respiratory complications than standard postural drainage (30º head-down tilt). The included studies had an overall low risk of bias. Data were not able to be pooled by meta-analysis due to differences in the statistical presentation of the data.

AUTHORS' CONCLUSIONS

The available evidence regarding the comparison between the two regimens of postural drainage is still weak due to the small number of included studies, the small number of participants assessed, the inability to perform any meta-analyses and some methodological issues with the studies. However, it may be inferred that the use of a postural regimen with a 30° head-up tilt is associated with a lower number of gastroesophageal reflux episodes and fewer respiratory complications in the long term. The 20º head-down postural drainage position was not found to be significantly different from the 20º head-up tilt modified position. Nevertheless, the fact that the majority of reflux episodes reached the upper oesophagus should make physiotherapists carefully consider their treatment strategy.

Chest physiotherapy for pneumonia in children

BACKGROUND

Pneumonia is an inflammatory lung disease and it is the greatest cause of deaths in children younger than five years of age worldwide. Chest physiotherapy is widely used in the treatment of pneumonia because it can help to eliminate inflammatory exudates and tracheobronchial secretions, remove airway obstructions, reduce airway resistance, enhance gas exchange and reduce the work of breathing. Thus, chest physiotherapy may contribute to patient recovery as an adjuvant treatment even though its indication remains controversial.

OBJECTIVES

To assess the effectiveness of chest physiotherapy in relation to time until clinical resolution in children (from birth up to 18 years old) of either gender with any type of pneumonia.

SEARCH METHODS

We searched CENTRAL 2013, Issue 4; MEDLINE (1946 to May week 4, 2013); EMBASE (1974 to May 2013); CINAHL (1981 to May 2013); LILACS (1982 to May 2013); Web of Science (1950 to May 2013); and PEDro (1950 to May 2013).We consulted the ClinicalTrials.gov and the WHO ICTRP registers to identify planned, ongoing and unpublished trials. We consulted the reference lists of relevant articles found by the electronic searches for additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared chest physiotherapy of any type with no chest physiotherapy in children with pneumonia.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies to be included in the review, assessed trial quality and extracted data.

MAIN RESULTS

Three RCTs involving 255 inpatient children are included in the review. They addressed conventional chest physiotherapy, positive expiratory pressure and continuous positive airway pressure. The following outcomes were measured: duration of hospital stay, time to clinical resolution (observing the following parameters: fever, chest indrawing, nasal flaring, tachypnoea and peripheral oxygen saturation levels), change in adventitious sounds, change in chest X-ray and duration of cough in days. Two of the included studies found a significant improvement in respiratory rate and oxygen saturation whereas the other included study failed to show that standardised respiratory physiotherapy and positive expiratory pressure decrease the time to clinical resolution and the duration of hospital stay. No adverse effects related to the interventions were described. Due to the different characteristics of the trials, such as the duration of treatment, levels of severity, types of pneumonia and the techniques used in children with pneumonia, as well as differences in their statistical presentation, we were not able to pool data. Two included studies had an overall low risk of bias whereas one included study had an overall unclear risk of bias.

AUTHORS' CONCLUSIONS

Our review does not provide conclusive evidence to justify the use of chest physiotherapy in children with pneumonia due to a lack of data. The number of included studies is small and they differed in their statistical presentation.