Effects of the use of respiratory physiotherapy in children admitted with acute viral bronchiolitis

Effects and safety of hypertonic saline combined with airway clearance in non-hospitalized children with recurrent wheezing

Background

The International Study of Wheezing in Infants defines recurrent wheezing as the presence of three or more medically documented episodes of wheezing within one year. To date, there is no evidence on the use of hypertonic saline (HS) combined with airway clearance techniques (ACT) for children with recurrent wheezing treated in an outpatient setting. Therefore, this is the first study to explore the use of such interventions in infants with recurrent wheezing.

Objectives

To evaluate the effects and safety of a three-month protocol including HS and ACT for non-hospitalized infants with recurrent wheezing.

Methods

Randomized, double-blind, controlled trial, including outpatient infants with recurrent wheezing. Children were randomized to either 3% HS or 0.9% saline groups and were treated with bronchodilator and nebulized with the respective solutions before ACT. The primary outcome was the Wang score. Secondary outcomes included the number of hospitalizations and respiratory crisis, need for rescue medication, and school absences. All variables were measured during the three previous months from inclusion and during intervention period. The study protocol was registered at ClinicalTrials.gov (NCT04331496) on March, 31, 2020.

Results

Forty children were included. Regarding immediate effects, significant differences (p < 0 . 001 ) were found for time, but not for group or interaction (group × time), in all outcome variables (increase in SpO2, decrease in heart and respiratory rate, wheezing episodes, retraction, and Wang score). Comparing the previous three months with the study period, there were significant differences in both groups for the severity of crisis (p < 0 . 001 ) and medication steps (p = 0 . 002 ).

Conclusion

A three-month protocol including HS and ACT for outpatient infants with recurrent wheezing was safe and reduced morbidity. No differences were found between the use of HS and 0.9% saline.

Frequent body position changes and physical activity as effective as standard care for infants hospitalised with acute respiratory infections - a randomised controlled trial

Background

No definite consensus has been reached yet on the best treatment strategy for the large group of infants hospitalised with bronchiolitis or pneumonia. Minimal handling is often recommended, although not evaluated scientifically. There is a need to evaluate the management, as the infants often are critically affected, and the costs for society are high. The aim of this RCT was to evaluate the most common physiotherapy intervention in Sweden for this patient group, including frequent changes in body position and stimulation of physical activity, compared to standard care.

Methods

Infants 0-24 months old, without previous cardiac or respiratory diagnoses and born in gestational week 35+, were recruited in two Swedish hospitals. The participants (n=109) were randomised to either interventions in addition to standard care (intervention group) or to standard care alone (control group). The primary outcome measure was time to improvement. The secondary outcomes were immediate changes in oxygen saturation, heart rate and respiratory rate, time to improved general condition (parents' assessment), and lung complications.

Results

The median time to improvement was 6 hours in both groups (p=0.54). The result was similar when we adjusted for age in months, sex, tobacco smoke exposure, heredity for asthma/atopic disease, and early stage of the infection (for those with RSV), p=0.69. Analyses of the immediate changes showed no significant differences either (p=0.49-0.89). Time to improved general condition was median 3 hours in the intervention group and 6 hours in the control group, p=0.76. No lung complications occurred.

Conclusions

No statistically significant differences in outcomes were detected between the intervention group and the control group. Both strategies were found to be equally effective and safe, indicating that the current recommendation of minimal handling for these infants should be reconsidered. Furthermore, the findings suggest that this treatment can be safely continued.

Physiotherapy interventions encouraging frequent changes of the body position and physical activity for infants hospitalised with bronchiolitis: an internal feasibility study of a randomised control trial

Background

The effect of a treatment that includes frequent changes of the body position for infants with bronchiolitis has not been evaluated, although it is often used in Swedish hospitals. Because of this, a randomised control trial (RCT) has begun with the aim to evaluate this treatment, comparing the effect of an individualised physiotherapy intervention, a non-individualised intervention, and standard care in a control group. The objective of this internal pilot study was to address uncertainties concerning the ongoing RCT and to determine whether the trial is feasible or not, possibly with adjustments to the protocol.

Methods

Descriptive analyses of the recruitment, retention, data supply for the primary end point, and the usability of the primary outcome measure in the full RCT were performed. A safety analysis was conducted by an independent analysis group.

Results

Ninety-one infants were included, 33 (36.3%), 28 (30.8%), and 30 (33.0%) in the respective allocation groups. Fifty-nine (64.8%) were boys. The median age was 2.5 (min–max 0.2–23.7) months. They remained in the study for a median of 46 hours (min–max 2–159). The recruitment rate was 19%. The data supply for the primary end point and for the primary outcome measure was lower than anticipated in the original sample size calculation. Difficulties concerning utilising the primary outcome measure were identified. The safety analysis detected no risks of harm related to participation in the study.

Conclusions

It is feasible to continue the RCT with modifications of the analysis plan. Participation in the study was not associated with any safety risks.

Trial registration

ClinicalTrials.gov NCT03575091. Registered 2 July 2018. Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01030-2.

Safety of airway clearance combined with bronchodilator and hypertonic saline in non-hospitalized infants with acute bronchiolitis

BACKGROUND

Acute viral bronchiolitis (AVB) is associated with significant morbidity and no study has addressed the safety of airway clearance techniques (ACT) for non-hospitalized infants. This study aimed to evaluate the safety of the use of ACT combined with bronchodilator and hypertonic saline in non-hospitalized children with the first episode of AVB.

METHODS

A quasi-experimental study of infants aged 2-12 months, with a clinical diagnosis of AVB (mild to moderate), was performed. The Wang score, breathing frequency, oxygen saturation (SpO₂), heart rate (HR), and the presence of adverse events were evaluated before, 10 and 20 min after the application of a protocol including ACT (nasal irrigation, prolonged slow expiration, and provoked cough), bronchodilator and hypertonic saline inhalation. A total of 265 infants, mean age 6.86±3.01 months, were included.

RESULTS

A reduction (p<0.001) in the Wang score and in the breathing frequency as well as an increase in SpO₂ were found. There was also a transient HR increment at 10 min followed by a reduction at 20 min (p<0.05). The proportion of patients presenting with chest retraction and wheezing decreased (p<0.001) after treatment. Most of the children (88.3%) did not experience adverse events. A post-treatment increment (p<0.001) of patients classified as having normal values, as well as a decrease in those with mild and moderate AVB, was found for the Wang score levels.

CONCLUSION

The use of ACT combined with bronchodilator and hypertonic saline was safe, immediately after treatment, for non-hospitalized children with mild to moderate AVB. No clinically important deterioration or adverse events were identified in the follow-up period.

Impacto da fisioterapia nos diferentes tipos de bronquiolite, pacientes e locais de atendimento: revisão sistemática

RESUMO A bronquiolite é definida como um episódio agudo de sibilâncias que ocorre no contexto de um quadro respiratório, de origem normalmente viral, com elevada incidência nas crianças com menos de 2 anos. Considerando que o papel da Fisioterapia tem sido questionado nesse contexto, é extremamente importante esclarecer e diferenciar o impacto das diversas técnicas de fisioterapia empregadas em cada tipo de bronquiolite, paciente e local de atendimento. Foi realizada uma revisão sistemática, com busca nas bases de dados ScienceDirect, MEDLINE/PubMed e SciELO, sobre as técnicas de fisioterapia em crianças de até 2 anos de idade com episódio de bronquiolite. Foram incluídos seis estudos observacionais, cinco experimentais sem grupo de controle e 15 com grupo de controle, envolvendo 3.339 indivíduos. São 14 os estudos com amostras em internamento, seis em internamento e unidade de cuidados intensivos (UCI) e seis em ambulatório. Dentre as técnicas de fisioterapia respiratória mais utilizadas, destacam-se a técnica de expiração lenta e prolongada (ELPr) associada à tosse provocada (TP), a aumento do fluxo expiratório (AFE), a desobstrução rinofaríngea retrógrada (DRR) e a drenagem postural (DP). Encontraram-se resultados positivos em relação às técnicas de fisioterapia respiratória, nomeadamente DRR, ELPr e AFE ou TP, na permeabilização das vias aéreas, promoção da higiene brônquica, dias de hospitalização, saturação de oxigênio, pontuação clínica, frequência cardíaca, frequência respiratória e necessidade de oxigenoterapia. Como limitações do estudo, destaca-se o fato de não haver estudos suficientes com metodologias robustas e comparáveis que permitam chegar a conclusões com maior certeza, em especial em relação às diferentes severidades da patologia, e fundamentar assim a personalização e adequação das intervenções na prática clínica.

A Quality Improvement Approach to Influence Value-based Mucolytic Use in the PICU

INTRODUCTION

High-cost medication administration, despite lacking evidence for use, results in poor healthcare value. This work aimed to reduce dornase-alfa utilization in critically ill mechanically ventilated children.

METHODS

The project employed an observational pre-post design to develop a value-based clinical pathway to guide provider choice in mucolytic utilization in a quaternary pediatric intensive care unit. This pathway was designed to continue using low-cost mucolytic aerosols (hypertonic saline, N-acetylcysteine) but decrease new starts and total doses per 100 patient days (P100PD) dornase-alfa among patients for whom there is little to no supporting evidence. Interventions included a departmental journal club for fellow and attending physicians and a rolling introduction of the pathway to residents and respiratory therapists. Control charts serially tracked ordering changes and location-specific dornase alfa orders.

RESULTS

New dornase-alfa starts P100PD decreased by 53% (1.17-0.55), and total doses P100PD decreased by 75% (16-4). N-acetylcysteine ordering more than doubled; however, total doses of P100PD remained unchanged after the intervention. The use of 3% sodium chloride increased significantly from 0.28 to 4.15 new starts and 4.37 to 38.84 total doses P100PD. Mechanical ventilation days P100PD decreased, suggesting there were no measured adverse effects of pathway implementation. The reduction in dornase-alfa utilization resulted in a cumulative and sustained 59% mucolytic cost reduction ($2183.08-$885.77 P100PD).

CONCLUSION

A clinical pathway prioritizing pharmacoeconomics when evidence for use is lacking can improve health care value without adversely affecting patient outcomes.

Effectiveness of chest physiotherapy using passive slow expiratory techniques in dogs with airway fluid accumulation: A randomized controlled trial

BACKGROUND

Prolonged slow expiration (PSE) and assisted cough (AC) are airway clearance techniques feasible and well tolerated in dogs.

OBJECTIVES

To evaluate the effectiveness of PSE and AC as chest physiotherapy (CP) techniques in dogs with airway fluid accumulation.

ANIMALS

Thirty-one client-owned dogs hospitalized in an intensive care unit from October 2014 to May 2018.

METHODS

Prospective randomized controlled trial. Dogs presented with or developing acute dyspnea during hospitalization associated with airway fluid accumulation were assigned to CP group (medical treatment and CP, 15 dogs) or control group (medical treatment alone, 16 dogs). The arterial partial pressure of oxygen (PaO2 ) to fraction of inspired oxygen (FiO2 ) ratio (P/F ratio; PaO2 /FiO2 × 100) was calculated daily for the 1st 48 hours of hospitalization and using the last arterial blood gas performed before discharge or death. The ratio of days of hospitalization with oxygen/total number of hospitalization days (ratio of oxygen-free-days [O2 Free]) was calculated.

RESULTS

During the 1st 48 hours, the P/F ratio increased significantly in the CP group compared to the control group (+ 35.1 mm Hg/day; 95% confidence interval [CI] = 0.4-57.5; P = .03). The (median; 1st quartile to 3rd quartile) difference between the P/F ratio at discharge and inclusion was significantly higher in the CP group (178 mm Hg; 123-241) than in the control group (54 mm Hg; -19 - 109; P = .001). Mean O2 Free increased by 46.4% in the CP group compared with control group (95% CI = 16-59; P = .001). Mortality was 13% (2/15) in the CP group and 44% (7/16) in the control group (P = .07).

CONCLUSIONS AND CLINICAL IMPORTANCE

Prolonged slow expiration and AC improved P/F ratio within 48 hours and decreased need for oxygenation in dyspneic dogs with acute airway fluid accumulation.

Ambulatory chest physiotherapy in mild-to-moderate acute bronchiolitis in children under two years of age - A randomized control trial

Objective

The aim of this study was to compare the role of a chest physiotherapy (CP) intervention to no intervention on the respiratory status of children under two years of age, with mild-to-moderate bronchiolitis.

Methods

Out of 80 eligible children observed in the Emergency Room, 45 children completed the study with 28 randomized to the intervention group and 17 to the control group. The intervention protocol, applied in an ambulatory setting, consisted of combined techniques of passive prolonged slow expiration, rhinopharyngeal clearance and provoked cough. The control group was assessed with no chest physiotherapy intervention. The efficacy of chest physiotherapy was assessed using the Kristjansson Respiratory Score at the admission and discharge of the visit to the Emergency Room and during clinical visits at day 7 and day 15.

Results

There was a significant improvement in the Kristjansson Respiratory Score in the intervention group compared to the control group at day 15 [1.2 (1.5) versus 0.3 (0.5); p -value = 0 . 005 , in the control and intervention groups, respectively], with a mean difference (95% CI) of - 0 . 9 ( - 1 . 6 to - 0 . 3 ).

Conclusion

Chest physiotherapy had a positive impact on the respiratory status of children with mild-to-moderate bronchiolitis.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT04260919.

Effect of nurse-led, goal-directed lung physiotherapy on prognosis of patients with sepsis caused by Acinetobacter baumannii pulmonary infection

OBJECTIVES

To investigate the role of nurse-led, goal-directed lung physiotherapy on the prognosis of patients with sepsis caused by Acinetobacter baumannii pulmonary infection.

METHODS

Patients with sepsis caused by A. baumannii pulmonary infection were recruited and divided into a control group (phase 1) and a treatment group (phase 2). Both groups received standard therapy for sepsis, and patients in phase 2 also received nurse-led, goal-directed lung physiotherapy. The primary outcome measure was 28-day mortality.

RESULTS

Among 742 patients with sepsis, 201 were diagnosed with A. baumannii pulmonary infection. Compared with patients in phase 1, patients in phase 2 had a significantly shorter duration of mechanical ventilation {median 4 (interquartile range (IQR) 3-5] vs 5 (IQR 3-12) days; P = 0.004}, lower intensive care unit (ICU) mortality [13.6% (18/132) vs 27.5% (19/69); P = 0.016] and lower 28-day mortality [21.2% (28/132) vs 37.7% (26/69); P = 0.012]. As a protective factor, nurse-led, goal-directed lung physiotherapy (odds ratio 0.341, 95% confidence interval 0.155-0.751; P = 0.008) was an independent risk factor for 28-day mortality.

CONCLUSIONS

Nurse-led, goal-directed lung physiotherapy shortened the duration of mechanical ventilation and ICU stay, and decreased ICU mortality and 28-day mortality in patients with sepsis caused by A. baumannii pulmonary infection.

Potential Prophylactic and Therapeutic Effects of Respiratory Physiotherapy for COVID-19

New coronavirus disease 2019 (COVID-19) has succeeded in surprising the world with infecting more than 12 million people and claiming 560,000 lives in only six months. COVID-19 is associated with a spectrum of respiratory symptoms, especially dyspnea. Patients who progress to severe or critical condition display peripheral and posterior lung lesions bilaterally. These patients require admission to the intensive care unit (ICU); therefore, they are prone to ICU-related complications during disease and after recovery. Respiratory physiotherapy techniques, in particular, active techniques, might help the improvement of airway clearance and lung capacity in addition to the reduction of breathing effort during the active disease. In parallel, it might lead to the prevention of disabilities, resulting from infection and extended hospitalization in patients who recovered from COVID-19. This supports physiotherapy both as a prophylactic and therapeutic strategy for COVID-19.

The effect of physiotherapy including frequent changes of body position and stimulation to physical activity for infants hospitalised with acute airway infections. Study protocol for a randomised controlled trial

Background

Every year, many infants are infected with the respiratory syncytial virus (RSV) or other agents and need hospitalisation due to bronchiolitis. The disease causes much suffering and high costs. Thus, it is important that the treatment methods are both effective and cost-efficient. The use of different physiotherapy treatment methods is debated, and not all methods are evaluated scientifically. The clinical praxis in Sweden that includes frequent changes of body position and stimulation to physical activity has not previously been evaluated. The aim of this clinical study is to evaluate this praxis.

Methods

This study is a clinical two-centre individually randomised controlled trial (RCT) with three parallel groups. The participants will be randomly assigned to an individualised physiotherapy intervention, a non-individualised intervention, or a control group. All three groups will receive the standard care at the ward, and the two intervention groups will receive additional treatment, including different movements of the body. The primary outcome measure is a clinical index based on determinants for hospitalisation. Baseline assessments will be compared with the assessments after 24 h. The secondary outcome measures include vital signs, the parents’ observations, time spent at the hospital ward, and referrals to an intensive care unit. We also want see if there is any immediate effect of the first intervention, after 20 min.

Discussion

This study will add knowledge about the effect of two physiotherapy interventions that are commonly in use in Swedish hospitals for infants with bronchiolitis or other acute lower respiratory tract infections.

Trial registration

ClinicalTrials.gov NCT03575091. Registered July 2, 2018—retrospectively registered.