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Manos J. Current and Emerging Therapies to Combat Cystic Fibrosis Lung Infections. Microorganisms 2021; 9:1874. [PMID: 34576767 PMCID: PMC8466233 DOI: 10.3390/microorganisms9091874] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/26/2021] [Accepted: 08/30/2021] [Indexed: 11/30/2022] Open
Abstract
The ultimate aim of any antimicrobial treatment is a better infection outcome for the patient. Here, we review the current state of treatment for bacterial infections in cystic fibrosis (CF) lung while also investigating potential new treatments being developed to see how they may change the dynamics of antimicrobial therapy. Treatment with antibiotics coupled with regular physical therapy has been shown to reduce exacerbations and may eradicate some strains. Therapies such as hypertonic saline and inhaled PulmozymeTM (DNase-I) improve mucus clearance, while modifier drugs, singly and more successfully in combination, re-open certain mutant forms of the cystic fibrosis transmembrane conductance regulator (CFTR) to enable ion passage. No current method, however, completely eradicates infection, mainly due to bacterial survival within biofilm aggregates. Lung transplants increase lifespan, but reinfection is a continuing problem. CFTR modifiers normalise ion transport for the affected mutations, but there is conflicting evidence on bacterial clearance. Emerging treatments combine antibiotics with novel compounds including quorum-sensing inhibitors, antioxidants, and enzymes, or with bacteriophages, aiming to disrupt the biofilm matrix and improve antibiotic access. Other treatments involve bacteriophages that target, infect and kill bacteria. These novel therapeutic approaches are showing good promise in vitro, and a few have made the leap to in vivo testing.
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Affiliation(s)
- Jim Manos
- Infection, Immunity and Inflammation, Faculty of Medicine and Health, School of Medical Sciences, The University of Sydney, Sydney 2006, Australia
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Braverman JM. Increasing the Quantity of Lungs for Transplantation Using High-Frequency Chest Wall Oscillation: A Proposal. Prog Transplant 2016; 12:266-74. [PMID: 12593065 DOI: 10.1177/152692480201200406] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The use of chest physiotherapy in donor patient management occupies an established place in most lung procurement protocols. Although its merits remain controversial and uncorroborated by direct data, some studies support the efficacy of chest physiotherapy in a variety of pulmonary patient populations. Comparative studies have shown that an airway clearance technology utilizing high-frequency chest wall oscillation clears pulmonary secretions as well as or better than chest physiotherapy, but has few of its contraindications and disadvantages. The implementation of high-frequency chest wall oscillation as part of the donor lung procurement protocol may increase rates of successful lung recovery by providing effective clearance of obstructing pulmonary secretions containing destructive by-products of inflammation and entrapped pathogens. High-frequency chest wall oscillation may also improve arterial blood gas values, a critical factor in increasing lung procurement rates. Although speculative, the benefits of high-frequency chest wall oscillation on donor lungs might improve perfusion and oxygenation of other organs for possible transplantation.
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Burtin C, Hebestreit H. Rehabilitation in Patients with Chronic Respiratory Disease Other than Chronic Obstructive Pulmonary Disease: Exercise and Physical Activity Interventions in Cystic Fibrosis and Non-Cystic Fibrosis Bronchiectasis. Respiration 2015; 89:181-9. [DOI: 10.1159/000375170] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Mulholland C, Lennon S, Graham R. Does prone positioning improve oxygen saturation in a patient with cystic fibrosis? An alternating-treatment single case design. Physiother Theory Pract 2009. [DOI: 10.3109/09593989409036401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Jones AYM, Hutchinson RC, Oh TE. Chest physiotherapy practice in intensive care units in Australia, the UK and Hong Kong. Physiother Theory Pract 2009. [DOI: 10.3109/09593989209108078] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lagerkvist AL, Sten G, Westerberg B, Ericsson-Sagsjö A, Bjure J. Positive expiratory pressure (PEP) treatment in children with multiple severe disabilities. Acta Paediatr 2005; 94:538-42. [PMID: 16188740 DOI: 10.1111/j.1651-2227.2005.tb01935.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Children with multiple severe disabilities cannot be spontaneously physically active and therefore lack the ventilatory stimulation of physical activity. They often produce large quantities of airway mucus, which they have difficulty to evacuate on their own. The accumulation of mucus may lead to respiratory insufficiency. AIM To investigate whether chest physiotherapy with positive expiratory pressure (PEP) could improve the blood oxygen tension (PO(2)) and/or decrease carbon dioxide tension (PCO(2)) in severely disabled children with airway mucus accumulation. METHODS Eighteen disabled children (mean age 7.5 y, SD 4.3, range 1.7-17.8 y) participated in the study. Transcutaneous (tc) PO(2), tcPCO(2) and respiratory rate (RR) were recorded before and after PEP treatment. The reproducibility of the effect of the treatment was tested by repeating the recordings. RESULTS The mean tcPO(2) increased 1.0 kPa (range -0.2 to 3.4 kPa) immediately after PEP treatment (p=0.0001). No significant changes in tcPCO(2) or RR were noted. The reproducibility of the effect of PEP treatment was good, with a significant increase in tcPO(2) at all retests. All children accepted the treatment well. CONCLUSION PEP increases blood oxygen tension immediately after treatment in severely disabled children with airway mucus accumulation. Long-term effects remain to be proven.
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Affiliation(s)
- Anna-Lena Lagerkvist
- Department of Physiotherapy, The Queen Silvia Children's Hospital, Göteborg, Sweden.
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Braverman JM. Increasing the quantity of lungs for transplantation using high-frequency chest wall oscillation: a proposal. Prog Transplant 2002. [PMID: 12593065 DOI: 10.7182/prtr.12.4.l66540265q64067j] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The use of chest physiotherapy in donor patient management occupies an established place in most lung procurement protocols. Although its merits remain controversial and uncorroborated by direct data, some studies support the efficacy of chest physiotherapy in a variety of pulmonary patient populations. Comparative studies have shown that an airway clearance technology utilizing high-frequency chest wall oscillation clears pulmonary secretions as well as or better than chest physiotherapy, but has few of its contraindications and disadvantages. The implementation of high-frequency chest wall oscillation as part of the donor lung procurement protocol may increase rates of successful lung recovery by providing effective clearance of obstructing pulmonary secretions containing destructive by-products of inflammation and entrapped pathogens. High-frequency chest wall oscillation may also improve arterial blood gas values, a critical factor in increasing lung procurement rates. Although speculative, the benefits of high-frequency chest wall oscillation on donor lungs might improve perfusion and oxygenation of other organs for possible transplantation.
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Nicholas KJ, Dhouieb MO, Marshall TG, Edmunds AT, Grant MB. An Evaluation of Chest Physiotherapy in the Management of Acute Bronchiolitis. Physiotherapy 1999. [DOI: 10.1016/s0031-9406(05)61230-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Irwin RS, Boulet LP, Cloutier MM, Fuller R, Gold PM, Hoffstein V, Ing AJ, McCool FD, O'Byrne P, Poe RH, Prakash UB, Pratter MR, Rubin BK. Managing cough as a defense mechanism and as a symptom. A consensus panel report of the American College of Chest Physicians. Chest 1998; 114:133S-181S. [PMID: 9725800 DOI: 10.1378/chest.114.2_supplement.133s] [Citation(s) in RCA: 367] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Alexander E, Weingarten S, Mohsenifar Z. Clinical strategies to reduce utilization of chest physiotherapy without compromising patient care. Chest 1996; 110:430-2. [PMID: 8697846 DOI: 10.1378/chest.110.2.430] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There is widespread interest in the evaluation of clinical strategies that safely reduce health-care costs. Elimination of inappropriate chest physiotherapy may represent one of those strategies. SETTING An academic community hospital. METHODS One-hundred one patients receiving chest physiotherapy were prospectively randomized to continue their chest physiotherapy or to inform their physicians that the order for the chest physiotherapy may have been inappropriate. RESULTS Patients who were randomized to have their chest physiotherapy discontinued received 45% fewer chest physiotherapy treatments than control patients (p < 0.01). There was no increase in the mortality rate or length of hospital stay associated with the reduction in chest physiotherapy in carefully selected patients. The estimated cost savings would be $319,000, which is 50 times greater than the cost associated with the intervention. CONCLUSION Chest physiotherapy is frequently provided to patients for inappropriate indications. Reducing chest physiotherapy for these patients may significantly reduce respiratory therapy costs without increasing length of stay or mortality rates.
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Affiliation(s)
- E Alexander
- Department of Medicine, Cedars-Sinai Medical Center, UCLA School of Medicine, USA
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Williams MT. Chest physiotherapy and cystic fibrosis. Why is the most effective form of treatment still unclear? Chest 1994; 106:1872-82. [PMID: 7988215 DOI: 10.1378/chest.106.6.1872] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- M T Williams
- School of Physiotherapy, Faculty of Health and Biomedical Science, University of South Australia, Adelaide
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Olséni L, Midgren B, Hörnblad Y, Wollmer P. Chest physiotherapy in chronic obstructive pulmonary disease: forced expiratory technique combined with either postural drainage or positive expiratory pressure breathing. Respir Med 1994; 88:435-40. [PMID: 7938794 DOI: 10.1016/s0954-6111(05)80046-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The aim of this study was to measure the short-term effects on mucus clearance after forced expiratory technique (FET) combined with either postural drainage (PD) or positive expiratory pressure breathing (PEP) on two different days. We also wanted to assess the patient's preference to the two methods. We measured mucociliary clearance at rest and during physiotherapy in 14 patients with chronic obstructive pulmonary disease. The subjects inhaled an aerosol containing 99mTc-labelled albumin colloid. Five sets of scintigraphic images were obtained with 22-min intervals. Lung retention of radioactivity was quantified using a gamma camera and the clearance of particles from the lungs calculated for each 22-min period. The first image was obtained directly after inhalation, the second after a period of 22 min rest, the third after physiotherapy and the fourth and fifth images after further periods of rest. Clearance from the whole lung and from central and peripheral regions were much greater after physiotherapy than at rest. Clearance during PD+FET was significantly higher than during PEP+FET in the total lung field (P < 0.05) and in the peripheral region (P < 0.004). The patients found the two methods equally efficient but most of the patients preferred PEP as a treatment.
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Affiliation(s)
- L Olséni
- Department of Physical Therapy, University of Lund, Sweden
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Baldwin DR, Hill AL, Peckham DG, Knox AJ. Effect of addition of exercise to chest physiotherapy on sputum expectoration and lung function in adults with cystic fibrosis. Respir Med 1994; 88:49-53. [PMID: 8029514 DOI: 10.1016/0954-6111(94)90174-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Promotion of sputum expectoration by chest physiotherapy is an essential part of cystic fibrosis management. The role of exercise in improving sputum expectoration and lung function in these patients is more contentious. We therefore investigated the effect of adding an exercise programme to conventional chest physiotherapy in eight adult subjects (four male) with cystic fibrosis. Subjects were treated on two non-consecutive days of the second week of a course of in-patient antibiotic therapy in a cross-over fashion. On the exercise and physiotherapy day, subjects exercised 60 min before physiotherapy. On the physiotherapy alone day, subjects rested for 60 min instead of exercising. Physiotherapy was administered on both study days (postural drainage, percussion, deep breathing, vibrations, forced expiratory technique and coughing). Lung function tests were performed at baseline, after exercise or rest and again immediately and 30 min after physiotherapy. Sputum weights were measured in the 60 min of exercise or rest (period A) and for the 60 min physiotherapy period and 30 min after physiotherapy (period B). Mean total sputum expectoration (period A and B) was 14 g on physiotherapy alone and 21.5 g (4.8) on exercise and physiotherapy (mean difference 7.5 g, 95% CI 1.4-13.6 g, P = 0.02). Mean sputum weights during period A (i.e. rest vs. exercise) on physiotherapy alone and exercise and physiotherapy were 2.6 and 7 g respectively (mean difference 4.4 g, 95% CI-0.07-8.8 g, P = 0.053).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D R Baldwin
- Respiratory Medicine Unit, City Hospital, Nottingham, U.K
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Conway JH, Fleming JS, Perring S, Holgate ST. Humidification as an adjunct to chest physiotherapy in aiding tracheo-bronchial clearance in patients with bronchiectasis. Respir Med 1992; 86:109-14. [PMID: 1615175 DOI: 10.1016/s0954-6111(06)80225-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Humidification of inspired air or oxygen is frequently utilized by respiratory physiotherapists to relieve sputum retention. Cold water, jet nebulizing humidifiers are in widespread use but there has been no previous attempt to investigate the efficacy of this treatment. We have performed a single-blind, cross-over study to quantify the effect of humidification as an adjunct to chest physiotherapy. Seven patients with bronchiectasis completed the trial, with a mean (range) age of 51 years (41-64 years) and mean (range) percent of predicted FEV1 of 46% (29-76%). On 2 days, separated by 1 week, subjects were randomly allocated to humidification or no humidification as a precursor to an optimal chest physiotherapy regimen. A radio-aerosol of human serum albumin millimicrospheres labelled with 99mTechnetium was used to measure sputum clearance by serial gamma camera images. Serial measurements of sputum weight and FEV1 were also recorded. Humidification (30 min) was followed by postural drainage (20 min) with the subject using the forced expiration technique to assist clearance. When humidification was combined with physiotherapy there was a significant increase in total wet weight of sputum (P less than 0.05) with a median (range) increase of 6 g (-9-15.5 g); and a significant increase in total radiolabel clearance (P less than 0.05) with a median (range) increase of 8.7% (1-13%), compared to physiotherapy alone. This study demonstrates that the use of cold water, jet nebulizing humidifiers significantly increases tracheo-bronchial clearance above that of an optimal physiotherapy regimen alone in bronchiectasis.(ABSTRACT TRUNCATED AT 250 WORDS)
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Paratz J. Haemodynamic stability of the ventilated intensive care patient: A review. ACTA ACUST UNITED AC 1992; 38:167-72. [DOI: 10.1016/s0004-9514(14)60559-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mortensen J, Jensen C, Groth S, Lange P. The effect of forced expirations on mucociliary clearance in patients with chronic bronchitis and in healthy subjects. CLINICAL PHYSIOLOGY (OXFORD, ENGLAND) 1991; 11:439-50. [PMID: 1934940 DOI: 10.1111/j.1475-097x.1991.tb00816.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Animal studies have shown that frequent coughing may damage the mucociliary apparatus in flow-limiting segments of the central airways. To determine whether mucociliary clearance in humans is affected by repeated dynamic compression associated with forced expirations, we measured pulmonary deposition and mucociliary clearance for 2 h of inhaled [99Tcm]albumin. The subjects inhaled [99Tcm]albumin on 2 study days (randomized) using (A) slow inspirations and forced expirations, while inhalation using (B) forced inspirations and slow expirations served as control. The study was conducted using 10 patients with chronic hypersecretory/obstructive bronchitis and six normal subjects. We found that inhalation of [99Tcm]albumin by the two manoeuvres (A and B) resulted in similar patterns of aerosol deposition. There was no significant difference in retention of radioactivity in the central lung region at 1 h in the patients with chronic bronchitis after inhalation with manoeuvre A (102%) and with manoeuvre B (91.5%), or in the healthy subjects after manoeuvre A (74%) and manoeuvre B (77%). There was also no difference in the retention at 2 h or in overall mucociliary clearance in any of the groups. We conclude that dynamic compression in the central airways associated with forced expiration does not affect bronchial clearance in the airways of healthy subjects or in patients with chronic bronchitis.
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Affiliation(s)
- J Mortensen
- Department of Clinical Physiology, Rigshospitalet, Copenhagen, Denmark
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Abstract
Review of the data shows that chest physiotherapy (CP) is effective in clearing secretions from the lungs of patients with copious secretions (i.e., daily sputum production in excess of 30 ml). Assessment of the various components of CP shows that percussion, vibratory shaking, and breathing exercises have little to offer. Although instructed cough, the back up mucus clearance mechanism, is effective in clearing secretions its effect is less than that achieved with the forced expiration technique (FET). Postural drainage (PD) is on the whole successful in helping to drain secretions in the lungs. The administration of a beta 2-agonist via a nebulizer prior to CP in addition to promoting bronchodilation may also help to alter the physical properties of secretions, rendering them more amenable for clearance by FET/cough. Technology regarding high-frequency oscillations (HFO) has yet to be improved and its efficacy in clearing excess secretions proven prior to its inclusion in a CP treatment regimen. Intermittent positive pressure breathing (IPPB) may have a role to play in those patients where conventional CP is not possible. Data with positive expiratory pressure (PEP) are encouraging and direct evaluation is awaited regarding its effect on mucus clearance. With our present knowledge it seems reasonable to recommend that physiotherapists concentrate their CP treatment on the following: administration of a nebulized beta 2-agonist followed by PD and FET.
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Affiliation(s)
- D Pavia
- Department of Clinical Research, Boehringer Ingelheim (UK) Ltd., Bracknell, Berkshire
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Stiller KR, McEvoy RD. Chest physiotherapy for the medical patient--are current practices effective? AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1990; 20:183-8. [PMID: 2188643 DOI: 10.1111/j.1445-5994.1990.tb01302.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- K R Stiller
- Physiotherapy Department, Royal Adelaide Hospital, SA
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Asher MI, Douglas C, Airy M, Andrews D, Trenholme A. Effects of chest physical therapy on lung function in children recovering from acute severe asthma. Pediatr Pulmonol 1990; 9:146-51. [PMID: 2277735 DOI: 10.1002/ppul.1950090305] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The effects of chest physical therapy in acute severe asthma in children have been studied in 38 children aged 6 to 13 years in a randomized placebo controlled trial. The study began between 6 and 24 hours after admission to hospital; 19 children received chest physical therapy (PT) and 19 children received placebo visits. Each child had 4 treatments over 2 days which were preceded by nebulized salbutamol. Lung volumes and flow rates were measured in a body plethysmograph before salbutamol and before and after either PT or placebo on the first and fourth treatments. Throughout the study standard asthma drug therapy was given. In both groups characteristics such as sex, race, age, height, weight, severity, and baseline lung function were similar. Taking into account the baseline, lung function at the end of the study was similar in both groups. Three 12 year old children in the PT group showed improvements in flows above those seen in any children in the placebo group. We conclude that chest PT, when combined with asthma drug therapy, does not improve lung function in most children in this age group with acute severe asthma.
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Affiliation(s)
- M I Asher
- Department of Paediatrics, University of Auckland, New Zealand
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Hough A. Respir Med 1989; 83:260-261. [DOI: 10.1016/s0954-6111(89)80047-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Tydeman D, Harrison B. Chest physiotherapy: time for reappraisal (1). Respir Med 1989; 83:260-2. [PMID: 2595048 DOI: 10.1016/s0954-6111(89)80046-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Hough A. Chest physiotherapy. West J Med 1989. [DOI: 10.1136/bmj.298.6676.826-b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Chest physiotherapy. West J Med 1989. [DOI: 10.1136/bmj.298.6676.826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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