The active cycle of breathing technique: a systematic review and meta-analysis

Blunt mechanism chest wall injury: initial patient assessment and acute care priorities

Blunt mechanism chest wall injury (CWI) is commonly seen in the emergency department (ED), since it is present in around 15% of trauma patients. The thoracic cage protects the heart, lungs and trachea, thereby supporting respiration and circulation, so injury to the thorax can induce potentially life-threatening complications. Systematic care pathways have been shown to improve outcomes for patients presenting with blunt mechanism CWI, but care is not consistent across the UK. Emergency nurses have a crucial role in assessing and treating patients who present to the ED with blunt mechanism CWI. This article discusses the initial assessment and acute care priorities for this patient group. It also presents a prognostic model for predicting the probability of in-hospital complications following blunt mechanism CWI.

Effects of Physical Therapy on a Patient With Lemierre's Syndrome Who Had Atelectasis and Limited Range of Motion in the Neck

Lemierre's syndrome (LS) is a severe infectious disease that can lead to the formation of neck abscesses and thrombosis. LS may be an indication for surgery; however, there are few reports on the physical therapy approaches used in patients with LS. A male patient in his 20s reported atelectasis and limited range of motion in the neck after resection of a deep neck abscess on the left side of the neck caused by LS. Thrombophlebitis was also observed around the neck lesion, indicating the risk of pulmonary embolism. Physical therapy was initiated with low-load, deep breathing exercises. Additional breathing exercises, such as respiratory assistance and positive pressure loading, were initiated after the administration of anticoagulants. Although the therapeutic intervention was delayed due to the unstable wound with partially resected muscle, it was assumed that the impairment of the range of motion in the neck was unlikely to persist as the patient was young. No critical adverse events were observed, and the range of motion was recovered such that the patient was able to resume playing baseball. The presence of a venous thrombus and inflammation may affect physical therapy; however, careful management of the exercise load could aid in the safe and effective treatment of LS without the incidence of complications, even in the early postoperative period.

Comparative efficacy of different combinations of acapella, active cycle of breathing technique, and external diaphragmatic pacing in perioperative patients with lung cancer: a randomised controlled trial

BACKGROUND

Acapella plus active cycle of breathing technique (ACBT), external diaphragm pacemaker (EDP) plus ACBT have been shown to facilitate the recovery of functional capacity and lung function in patients suffering from airway obstruction but the efficacy in perioperative patients with lung cancer has not been proven.

METHODS

We conducted a three-arm, prospective, randomized, assessor-blinded, controlled trial in patients with lung cancer who underwent thoracoscopic lobectomy or segmentectomy in the department of thoracic surgery, China. Patients were randomly assigned (1:1:1) to receive Acapella plus ACBT, EDP plus ACBT, or ACBT group (control group) using SAS software. The primary outcome was functional capacity, measured by the 6-minute walk test (6MWT).

RESULTS

We recruited 363 participants over 17 months: 123 assigned to the Acapella plus ACBT group, 119 to the EDP plus ACBT group, and 121 to the ACBT group. Statistically significant differences were noted for functional capacity between the EDP plus ACBT and control groups at each follow-up time (1-week follow-up: difference = 47.25 m, 95% CI, 31.56-62.93; P < 0.001; and 1-month follow-up: difference = 49.72 m, 95% CI, 34.04-65.41; P < 0.001), between the Acapella plus ACBT and control groups at postoperative week 1 (difference = 35.23 m, 95% CI, 19.30-51.16; P < 0.001) and postoperative month 1 (difference = 34.96 m, 95% CI, 19.03-50.89; P < 0.001), and between the EDP plus ACBT and Acapella plus ACBT groups at 1-month follow-up (difference = 14.76 m, 95% CI, 1.34-28.19; P = 0.0316).

CONCLUSION

EDP plus ACBT and Acapella plus ACBT significantly improved functional capacity and lung function in perioperative patients with lung cancer, compared with single-model ACBT, and the effects of EDP plus ACBT were clearly superior to those of other programs.

TRIAL REGISTRATION

The study was registered in the clinical trial database (clinicaltrials.gov) on June 4, 2021 (No. NCT04914624).

Gram Stain and Culture of Sputum Samples Detect Only Few Pathogens in Community-Acquired Lower Respiratory Tract Infections: Secondary Analysis of a Randomized Controlled Trial

Identification of the bacterial etiology of lower respiratory tract infections (LRTI) is crucial to ensure a narrow-spectrum, targeted antibiotic treatment. However, Gram stain and culture results are often difficult to interpret as they depend strongly on sputum sample quality. We aimed to investigate the diagnostic yield of Gram stain and culture from respiratory samples collected by tracheal suction and expiratory technique from adults admitted with suspected community-acquired LRTI (CA-LRTI). In this secondary analysis of a randomized controlled trial, 177 (62%) samples were collected by tracheal suction, and 108 (38%) by expiratory technique. We detected few pathogenic microorganisms, and regardless of sputum quality, there were no significant differences between the sample types. Common pathogens of CA-LRTI were identified by culture in 19 (7%) samples, with a significant difference between patients with or without prior antibiotic treatment (p = 0.007). The clinical value of sputum Gram stain and culture in CA-LRTI is therefore questionable, especially in patients treated with antibiotics.

Active cycle of breathing technique versus oscillating PEP therapy versus walking with huffing during an acute exacerbation of bronchiectasis: a randomised, controlled trial protocol

BACKGROUND

Airway clearance techniques (ACTs) for individuals with bronchiectasis are routinely prescribed in clinical practice and recommended by international guidelines, especially during an acute exacerbation. However, there is limited evidence of the efficacy of these techniques during an exacerbation to improve sputum expectoration, health-related quality-of-life (HRQOL) or exercise tolerance. The primary aim of this study is to compare the effects of the active cycle of breathing technique (ACBT), oscillating positive expiratory pressure (O-PEP) therapy, and walking with huffing on sputum expectoration for adults hospitalised with an acute exacerbation of bronchiectasis. Secondary aims are to compare the effects of these interventions on HRQOL, health status, exacerbation rates and hospital admissions in a six-month period following hospital discharge.

METHODS

This multi-centre randomised controlled trial will recruit adults with an acute exacerbation of bronchiectasis requiring hospital admission. Participants will be randomised to receive one of three interventions: ACBT, O-PEP therapy, and walking with huffing. Outcome measures including sputum volume during and 1-h post ACT session, and 24-h sputum, as well as health status, HRQOL and exercise capacity will be completed during inpatient stay on day 2 and day 6 of admission, and within 24 h of hospital discharge. Time to first exacerbation, and time to first hospitalisation will be monitored via monthly phone calls for six months post hospital discharge. Health status and HRQOL will be assessed after discharge at two and six months, and exercise capacity will be assessed at six months post hospital discharge.

DISCUSSION

Despite recommendations regarding the importance of ACT for individuals with bronchiectasis during an acute exacerbation, there is a gap in the literature regarding effectiveness of ACT when undertaken by individuals in this clinical state. This study will add to the evidence base regarding the effectiveness of commonly implemented ACTs during a hospital admission with an exacerbation of bronchiectasis. Additionally, it will contribute to knowledge of the long term effects on important and patient-centred outcomes, including incidence of future exacerbations, and HRQOL, which has not been previously established. Trial registration Registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12621000428864).

Expiratory Technique versus Tracheal Suction to Obtain Good-Quality Sputum from Patients with Suspected Lower Respiratory Tract Infection: A Randomized Controlled Trial

Microbiological diagnostics of good-quality sputum samples are fundamental for infection control and targeted treatment of lower respiratory tract infections (LRTI). This study aims to compare the expiratory technique and tracheal suction on the quality of sputa from adults acutely hospitalized with suspected LRTI. We performed an open-label, randomized controlled trial. Patients were randomized to sputum sampling by tracheal suction (standard care) or the expiratory technique. The primary outcome was quality of sputum evaluated by microscopy and was analysed in the intention-to-treat population. The secondary outcomes were adverse events and patients experience. In total, 280 patients were assigned to tracheal suction (n = 141, 50.4%) or the expiratory technique (n = 139, 49.6%). Sputum samples were collected from 122 (86.5%) patients with tracheal suction and 67 (48.2%) patients with expiratory technique. Good-quality sputa were obtained more often with tracheal suction than with expiratory technique (odds ratio 1.83 [95% CI 1.05 to 3.19]; p = 0.035). There was no statistical difference in adverse events (IRR 1.21 [95% CI, 0.94 to 1.66]; p = 0.136), but patient experience was better in the expiratory technique group (p < 0.0001). In conclusion, tracheal suction should be considered a routine procedure in emergency departments for patients with suspected LRTI.

Chest physiotherapy for pneumonia in adults

BACKGROUND

Despite conflicting evidence, chest physiotherapy has been widely used as an adjunctive treatment for adults with pneumonia. This is an update of a review first published in 2010 and updated in 2013.

OBJECTIVES

To assess the effectiveness and safety of chest physiotherapy for pneumonia in adults.

SEARCH METHODS

We updated our searches in the following databases to May 2022: the Cochrane Central Register of Controlled Trials (CENTRAL) via OvidSP, MEDLINE via OvidSP (from 1966), Embase via embase.com (from 1974), Physiotherapy Evidence Database (PEDro) (from 1929), CINAHL via EBSCO (from 2009), and the Chinese Biomedical Literature Database (CBM) (from 1978).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs assessing the efficacy of chest physiotherapy for treating pneumonia in adults.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included two new trials in this update (540 participants), for a total of eight RCTs (974 participants). Four RCTs were conducted in the United States, two in Sweden, one in China, and one in the United Kingdom. The studies looked at five types of chest physiotherapy: conventional chest physiotherapy; osteopathic manipulative treatment (OMT, which includes paraspinal inhibition, rib raising, and myofascial release); active cycle of breathing techniques (which includes active breathing control, thoracic expansion exercises, and forced expiration techniques); positive expiratory pressure; and high-frequency chest wall oscillation. We assessed four trials as at unclear risk of bias and four trials as at high risk of bias. Conventional chest physiotherapy (versus no physiotherapy) may have little to no effect on improving mortality, but the certainty of evidence is very low (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.15 to 7.13; 2 trials, 225 participants; I² = 0%). OMT (versus placebo) may have little to no effect on improving mortality, but the certainty of evidence is very low (RR 0.43, 95% CI 0.12 to 1.50; 3 trials, 327 participants; I² = 0%). Similarly, high-frequency chest wall oscillation (versus no physiotherapy) may also have little to no effect on improving mortality, but the certainty of evidence is very low (RR 0.75, 95% CI 0.17 to 3.29; 1 trial, 286 participants). Conventional chest physiotherapy (versus no physiotherapy) may have little to no effect on improving cure rate, but the certainty of evidence is very low (RR 0.93, 95% CI 0.56 to 1.55; 2 trials, 225 participants; I² = 85%). Active cycle of breathing techniques (versus no physiotherapy) may have little to no effect on improving cure rate, but the certainty of evidence is very low (RR 0.60, 95% CI 0.29 to 1.23; 1 trial, 32 participants). OMT (versus placebo) may improve cure rate, but the certainty of evidence is very low (RR 1.59, 95% CI 1.01 to 2.51; 2 trials, 79 participants; I² = 0%). OMT (versus placebo) may have little to no effect on mean duration of hospital stay, but the certainty of evidence is very low (mean difference (MD) -1.08 days, 95% CI -2.39 to 0.23; 3 trials, 333 participants; I² = 50%). Conventional chest physiotherapy (versus no physiotherapy, MD 0.7 days, 95% CI -1.39 to 2.79; 1 trial, 54 participants) and active cycle of breathing techniques (versus no physiotherapy, MD 1.4 days, 95% CI -0.69 to 3.49; 1 trial, 32 participants) may also have little to no effect on duration of hospital stay, but the certainty of evidence is very low. Positive expiratory pressure (versus no physiotherapy) may reduce the mean duration of hospital stay by 1.4 days, but the certainty of evidence is very low (MD -1.4 days, 95% CI -2.77 to -0.03; 1 trial, 98 participants). Positive expiratory pressure (versus no physiotherapy) may reduce the duration of fever by 0.7 days, but the certainty of evidence is very low (MD -0.7 days, 95% CI -1.36 to -0.04; 1 trial, 98 participants). Conventional chest physiotherapy (versus no physiotherapy, MD 0.4 days, 95% CI -1.01 to 1.81; 1 trial, 54 participants) and OMT (versus placebo, MD 0.6 days, 95% CI -1.60 to 2.80; 1 trial, 21 participants) may have little to no effect on duration of fever, but the certainty of evidence is very low. OMT (versus placebo) may have little to no effect on the mean duration of total antibiotic therapy, but the certainty of evidence is very low (MD -1.07 days, 95% CI -2.37 to 0.23; 3 trials, 333 participants; I² = 61%). Active cycle of breathing techniques (versus no physiotherapy) may have little to no effect on duration of total antibiotic therapy, but the certainty of evidence is very low (MD 0.2 days, 95% CI -4.39 to 4.69; 1 trial, 32 participants). High-frequency chest wall oscillation plus fibrobronchoscope alveolar lavage (versus fibrobronchoscope alveolar lavage alone) may reduce the MD of intensive care unit (ICU) stay by 3.8 days (MD -3.8 days, 95% CI -5.00 to -2.60; 1 trial, 286 participants) and the MD of mechanical ventilation by three days (MD -3 days, 95% CI -3.68 to -2.32; 1 trial, 286 participants), but the certainty of evidence is very low. One trial reported transient muscle tenderness emerging after OMT in two participants. In another trial, three serious adverse events led to early withdrawal after OMT. One trial reported no adverse events after positive expiratory pressure treatment. Limitations of this review were the small sample size and unclear or high risk of bias of the included trials.

AUTHORS' CONCLUSIONS

The inclusion of two new trials in this update did not change the main conclusions of the original review. The current evidence is very uncertain about the effect of chest physiotherapy on improving mortality and cure rate in adults with pneumonia. Some physiotherapies may slightly shorten hospital stays, fever duration, and ICU stays, as well as mechanical ventilation. However, all of these findings are based on very low certainty evidence and need to be further validated.

Prehabilitation in high-risk patients scheduled for major abdominal cancer surgery: a feasibility study

Background

Patients presenting for major surgery with low cardiorespiratory fitness (deconditioning) and other modifiable risk factors are at increased risk of postoperative complications. This study investigated the feasibility of delivering prehabilitation in high-risk patients scheduled for major abdominal cancer surgery.

Methods

Eligible patients in this single-center cohort study included patients with poor fitness (objectively assessed by cardiopulmonary exercise testing, CPET) scheduled for elective major abdominal cancer surgery. Patients were recruited to participate in a prehabilitation program that spanned up to 6 weeks pre-operatively and comprised aerobic and resistance exercise training, breathing exercise, and nutritional support. The primary outcome assessed pre-specified feasibility targets: recruitment >70%, retention >85%, and intervention adherence >70%. Secondary outcomes were assessed for improved pre-operative functional status and health-related quality of life and for postoperative complications.

Results

Eighty-two (34%) out of 238 patients screened between April 2018 and December 2019 were eligible for recruitment. Fifty (61%) patients (52% males) with a median age of 71 (IQR, 63–77) years participated in the study. Baseline oxygen consumption the at anaerobic threshold and at peak exercise (mean±SD: 9.8±1.8 and 14.0±2.9 mL/kg/min, respectively) confirmed the deconditioned state of the study cohort. The retention rate within the prehabilitation program was 84%, with 42 participants returning for repeat CPET testing. While >60% of participants preferred to do home-based prehabilitation, adherence to the intervention was low—with only 12 (28%) and 15 (35%) of patients having self-reported compliance >70% with their exercise prescriptions.

Conclusion

Our prehabilitation program in high-risk cancer surgery patients did not achieve pre-specified targets for recruitment, retention, and self-reported program adherence. These findings underpin the importance of implementation research and strategies for the prehabilitation programs in major surgery.

Trial registration

Australian New Zealand Clinical Trials Registry (ACTRN12620000073909) retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-022-00263-2.

[Respiratory physiotherapy in pediatric practice]

Congestion of the upper (URT) and lower respiratory tracts (LRT) is a common symptom in several acute and chronic respiratory diseases that occur in childhood. To eliminate these secretions, airway clearance techniques (ACT) directed to the URT and LRT are frequently prescribed. The rationale for the application of these techniques is the same as in adults, but they need to be adapted to be transposed to children. The physiotherapist will be able to choose among a wide range of techniques, of which the most adequate will depend not only on the age of the child and the indication, but also on the basis of his preferences or habits, as well as those of the child. Upper airway clearance, including nasal irrigation, is now recommended for acute and chronic rhinosinusitis in children. It is also one of the symptomatic treatments recommended for infants with acute bronchiolitis. For LRT clearance, several indications, such as cystic fibrosis, primary ciliary dyskinesia and neuromuscular disease, are now widely advocated. Conversely, other indications, such as for infants with acute viral bronchiolitis, are highly controversial. Thoughtful application of these techniques is lacking in robust and precise tools to objectively assess the presence of bronchial congestion, and to treat it accordingly. Similarly, no precise and reliable evaluation of the effectiveness of these ACTs is available to date. This review is designed to explore the ACTs used by physiotherapists, to provide an overview of their current indications, and to consider complementary approaches.

The effectiveness of the active cycle of breathing technique in patients with chronic respiratory diseases: A systematic review

BACKGROUND

Active cycle breathing technique (ACBT), which includes cycle of breathing control, thoracic expansion exercises and forced expiratory technique (FET), appears to have beneficial effects in patients with a variety of respiratory diseases. This systematic review provides an update on the new related studies, expanding the evidence base through the last 12 years and specifically evaluating the effectiveness of ACBT on pulmonary function-related outcome variables in patients with chronic respiratory diseases.

METHODS

MEDLINE/Pubmed, PEDro, and Cochrane Library for Randomized Controlled Trials were searched between September 2008 and December 2021, in continuance of a previous systematic review, to identify randomized clinical trials and/or crossover studies comparing ACBT to other respiratory treatment techniques in patients with chronic obstructive pulmonary diseases, cystic fibrosis, or bronchiectasis.

RESULTS

Eleven studies were included and the quality of most of them was moderate to good. The outcomes most frequently assessed were forced expiratory volume in 1 s (FEV₁), sputum wet weight, forced vital capacity (FVC), and peak expiratory flow rate. Secondary outcomes were quality of life and dyspnea. Various comparators were identified and most of them assessed the ACBT as an effective method in comparison with other respiratory treatment modalities. Most studies revealed that ACBT/FET had at least an equally beneficial short-term effect on sputum wet weight, FEV₁ and FVC compared to other treatment methods.

CONCLUSION

The results of this updating review reinforced the data of a previous systematic review regarding the beneficial impact of ACBT for the short-term improvement in respiratory tract secretions clearance and pulmonary function. ACBT is effective in increasing the expectorated sputum volume, in reducing viscoelasticity of the secretion and in relieving symptoms such as dyspnea.

Physiotherapy for large airway collapse: an ABC approach

Large airway collapse (LAC) describes the phenomenon of excessive, abnormal, inward movement of the large airways (i.e. trachea and/or main bronchi and/or bronchus intermedius) occurring during the expiratory phase of the respiratory cycle. It is an increasingly well-recognised problem and a prevalent comorbidity in other chronic respiratory conditions (e.g. COPD and asthma). LAC is associated with pervasive respiratory features such as a barking cough, exertional dyspnoea and an increased propensity to lower respiratory tract infection. These symptoms are unpleasant, and patients are often limited in their daily life and their function. The pathophysiology of this condition impairs airway clearance and can cause breathlessness and exercise intolerance, due to a loss of airway patency during expiratory flow. Dysfunctional adaptations to breathing and coughing may further amplify symptoms. This article provides, for the first time, clinically focused physiotherapeutic intervention advice based on our understanding of the pathophysiology of LAC, to support conservative management. It uses the available evidence from LAC, transferable evidence from other conditions and knowledge based on clinical experience. It proposes a practical "ABC model" to ensure physiotherapy assessment and treatments are centred around optimising three key clinical areas: Airways, including airway clearance and cough; Breathing, including breathlessness and breathing pattern; and Capacity for exercise, including an assessment of functional exercise ability.

Cardiac Rehabilitation in Patients with Peripheral Artery Disease-A Literature Review in COVID-19 Era

Cardiac rehabilitation (CR) is an integral part of the management of various cardiovascular disease such as coronary artery disease (CAD), peripheral artery disease (PAD), or chronic heart failure (CHF), with proven morbidity and mortality benefits. This article aims to review and summarize the scientific literature related to cardiac rehabilitation programs for patients with PAD and how they were adapted during the COVID-19 pandemic. The implementation of CR programs has been problematic since the COVID-19 pandemic due to social distancing and work-related restrictions. One of the main challenges for physicians and health systems alike has been the management of PAD patients. COVID-19 predisposes to coagulation disorders that can lead to severe thrombotic events. Home-based walking exercises are more accessible and easier to accept than supervised exercise programs. Cycling or other forms of exercise are more entertaining or challenging alternatives to exercise therapy. Besides treadmill exercises, upper- and lower-extremity ergometry also has great functional benefits, especially regarding walking endurance. Supervised exercise therapy has a positive impact on both functional capacity and also on the quality of life of such patients. The most effective manner to acquire this seems to be by combining revascularization therapy and supervised exercise. Rehabilitation programs proved to be a mandatory part of the integrative approach in these cases, increasing quality of life, and decreasing stress levels, depression, and anxiety.

Active cycle of breathing technique may reduce pulmonary complications after esophagectomy: A randomized clinical trial

BACKGROUND

The purpose of the study was to determine whether the active cycle of breathing technique (ACBT) has an impact on postoperative pulmonary complication (PPC) after esophagectomy.

METHODS

In this prospective randomized trial, patients who were candidates for esophagectomy were randomized into groups, wherein they received either ACBT (n = 146) or conventional chest physiotherapy (control group, n = 145) on postoperative days (POD) 1-3. The primary outcome was PPC. The secondary outcomes included the incidence of anastomotic leakage (AL), efficacy of airway clearance, and postoperative hospital length of stay (LOS).

RESULTS

After esophagectomy, the PPC rate was significantly lower in the ACBT group (15.2%) than in the control group (31.0%) (p = 0.001). The incidences of AL were 5.5% and 12.4% in the ACBT and control groups, respectively (p = 0.042). Mean hospital LOS was 12.3 days for the ACBT group and 16.8 days for the control group (p = 0.008). ACBT significantly increased the mean sputum wet weight (g) on POD 1-3 when compared with conventional therapy (POD 1 9.08 vs. 6.47, POD 2 16.86 vs. 10.92, POD 3 24.65 vs. 13.52, all p < 0.001). Multivariable analysis revealed that ACBT decreased the rates of PPC (odds ratio [OR] 0.403, p = 0.003), AL (OR 0.379，p = 0.038)，arrhythmia (OR 0.397, p = 0.028), and bronchoscopy aspiration (OR 0.362, p = 0.016).

CONCLUSION

ACBT is an effective airway clearance technique that significantly reduces the incidence of PPC after esophagectomy. ACBT could also significantly reduce both AL and LOS.

Effectiveness of expiratory technique and induced sputum in obtaining good quality sputum from patients acutely hospitalized with suspected lower respiratory tract infection: a statistical analysis plan for a randomized controlled trial

Background

Targeted antimicrobial treatment is essential to avoid unnecessary use of broad-spectrum antibiotics and antimicrobial resistance. Targeted treatment relies on a precise microbiological diagnosis — in pneumonia, this poses a challenge as the usefulness of Gram stains and cultures is highly dependent on the quality of the sputum sample.

This study aims to examine adverse effects and quality of sputum samples obtained by expiratory techniques (forced expiratory technique and sputum induction) compared with tracheal suction. The hypothesis is that expiratory techniques are non-inferior to tracheal suction in obtaining samples from the lower respiratory tract. This statistical analysis plan (SAP) describes the study design, method, and data analysis of the trial to increase transparency, avoid reporting bias or data-driven analysis and increase the study’s reproducibility.

Method

The design is a pragmatic, non-inferiority, parallel-arm randomized controlled trial including 280 patients admitted with suspected lower respiratory infection to two emergency departments. Patients are randomized to a usual care group, where sputum samples are collected by tracheal suction or to an intervention group where sputum samples are collected by forced expiratory technique and sputum induction. The statistical analysis will follow an intention-to-treat protocol. This SAP is developed and submitted before the end of recruitment, database closure, and statistical analyses.

Discussion

The results of this study will provide valuable knowledge to clinical practice by comparing adverse effects and sputum sample quality associated with different sample methods.

Trial registration

Clinicaltrials.gov, NCT04595526. Submitted on October 19, 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05639-1.

Cough-Inducing Method Using a Tartaric Acid Nebulizer for Patients with Silent Aspiration

The tartaric acid nebulizer is a well-known cough test to evaluate cough function. This study aimed to evaluate the effectiveness of a cough-inducing method using tartaric acid (CiTA). Patients with dysphagia examined by videofluoroscopic examination of swallowing (VF) at a single institution from May 2017 to August 2017 were included in this retrospective observational study. Although undergoing VF, patients who had aspirated without reflexively coughing or who had coughed insufficiently, were instructed to cough voluntarily. Patients who could not cough voluntarily or had expectorated insufficiently underwent the CiTA method. The rate of cough induction and the effectiveness of expectoration using the CiTA method were evaluated. One hundred fifty-four patients (mean age 69.2 ± 16.8 years) were evaluated. Eighty-seven patients aspirated during VF. Of those patients, 15 were able to expectorate via the cough reflex, 18 were able to expectorate with a voluntary cough, and 12 required suctioning for removal of aspirated material. The remaining 42 patients underwent the CiTA method. Thirty-eight patients (90.4%) could reflexively cough, and 30 (71.4%) could expectorate the aspirated material. This novel method, CiTA, was effective for cough induction in patients with dysphagia, especially for those with silent aspiration.

Exercise Training and Cardiac Rehabilitation in COVID-19 Patients with Cardiovascular Complications: State of Art

Recent scientific literature has investigated the cardiovascular implications of COVID-19. The mechanisms of cardiovascular damage seem to involve the protein angiotensin-converting enzyme 2 (ACE2), to which severe acute respiratory syndrome (SARS) coronavirus-2 (CoV-2) binds to penetrate cells and other mechanisms, most of which are still under study. Cardiovascular sequelae of COVID-19 include heart failure, cardiomyopathy, acute coronary syndrome, arrhythmias, and venous thromboembolism. This article aims to collect scientific evidence by exploiting PubMed, Scopus, and Pedro databases to highlight the cardiovascular complications of COVID-19 and to define the physiotherapy treatment recommended for these patients. Exercise training (ET), an important part of cardiac rehabilitation, is a powerful tool in physiotherapy, capable of inducing significant changes in the cardiovascular system and functional in the recovery of endothelial dysfunction and for the containment of thromboembolic complications. In conclusion, due to the wide variety of possible exercise programs that can be obtained by combining intensity, duration, and speed in various ways, and by adjusting the program based on continuous patient monitoring, exercise training is well suited to the treatment of post-COVID patients with an impaired cardiovascular system of various degrees.

Physiotherapists' use of airway clearance techniques during an acute exacerbation of bronchiectasis: a survey study

BACKGROUND

Airway clearance techniques are recommended for individuals with bronchiectasis both in stable state and during an acute exacerbation, however the current use of airway clearance techniques in the management of individuals during an acute exacerbation is unclear. The aims of this study were to establish what current physiotherapy clinical practice comprises for adults and paediatrics during an acute exacerbation of bronchiectasis; identify physiotherapist's perceptions of the effectiveness of airway clearance techniques and identify what factors influence their treatment decisions in this population.

METHODS

An anonymous online survey was distributed to the members of the Australian Physiotherapy Association and Physiotherapy New Zealand between August 2016 and April 2017.

RESULTS

The survey was accessed by 130 physiotherapists and 121 of those deemed themselves eligible and consented to participate. Most participants (89%) reported prescribing airway clearance techniques for 81-100% of individuals during an acute exacerbation of bronchiectasis. The most commonly used airway clearance techniques with adults were huffing (92%), exercise (89%) and the active cycle of breathing technique (89%). The techniques perceived most effective for adults were physical exercise (100%), oscillating positive expiratory pressure devices (97%), directed huffing (95%) the active cycle of breathing technique (90%) and positive expiratory pressure (90%). The most commonly used airway clearance techniques for paediatric patients were: newborn-3 years - percussion (85%) and modified postural drainage (85%); 4-10 years - huffing (100%) and exercise (85%); 11-18 years - huffing (92%) and exercise (77%), active cycle of breathing technique (77%) and positive expiratory pressure therapy (77%). The techniques perceived most effective for paediatric patients were directed huffing (100%), percussion (100%) and positive expiratory pressure via a mask or mouthpiece (93%). The most commonly reported factors influencing choice of technique were patient clinical presentation (72%) and the presence/absence of contra-indications (72%).

CONCLUSION

This survey demonstrates that airway clearance techniques are routinely used as part of physiotherapy management of individuals experiencing an acute exacerbation of bronchiectasis, and that choice of technique and perceived effectiveness varies depending on the age of the patient.

Role of active cycle of breathing technique for patients with chronic obstructive pulmonary disease: A pragmatic, randomized clinical trial

BACKGROUND

While active cycle of breathing technique for chronic obstructive pulmonary disease patients with more sputum can improve clinic outcomes, less is known about sputum viscosity and sputum production of the intervention.

OBJECTIVE

The purpose of our study was to explore the effect of active cycle of breathing technique on sputum viscosity and production among patients with chronic obstructive pulmonary disease.

DESIGN

This was a two-arms, parallel, randomized clinical trial.

SETTING

Study enrollment, randomization and implementation were conducted in the department of respiratory medicine inpatient at the Medical Center in Changchun, China.

PARTICIPANTS

Hospitalized patients due to chronic obstructive pulmonary disease who met additional eligibility criteria were randomized to active cycle of breathing technique (n = 50) or usual care group (n = 50).

METHODS

Patients in the intervention group received a week-long intervention from an experienced physical therapist. Patients in the usual care group received usual care as well as information and advice in the light of their health plan from respiratory medicine. The primary outcome was the changes on sputum viscosity and production.

RESULTS

Among one hundred patients who were randomized (mean [SD] age, 54.89 [12.06] years; females, 58%), ninety-six participants completed the study. No significant differences were found between two groups on the changes of sputum viscosity (t = 0.277, P = 0.782). And there were insignificant differences between groups in the average amount of sputum among 1 h (Z=-1.848, P = 0.065) and significant differences in the average amount of sputum among 24 h (Z=-2.236, P = 0.025). From admission to one week recovery, the changes in ratio of forced expiratory volume in 1 s to forced vital capacity (Z=-4.511, P<0.0001) and arterial oxygen saturation (Z=-2.997, P = 0.003) were better in active cycle breathing technique group. Total Chronic Obstructive Pulmonary Disease Assessment Test scale were similar among two groups (Z=-1.818, P = 0.069). No adverse events occurred during the study.

CONCLUSION

For patients with chronic obstructive pulmonary disease, active cycle of breathing technique can significantly result in sputum production and respiratory function, especially those of Global Initiative for Chronic Obstructive Lung Disease classification level 3, but did not result in the short-term improvement of sputum viscosity, quality of life and cost effectiveness. Registration number: ChiCTR2000033068.

Adding autogenic drainage to chest physiotherapy after upper abdominal surgery: effect on blood gases and pulmonary complications prevention. Randomized controlled trial

BACKGROUND

Hypoxemia and pulmonary complications are common after upper abdominal surgery (UAS).

OBJECTIVE

To examine whether inclusion of autogenic drainage (AD) in chest physiotherapy after UAS confers additional benefits in improving blood gases and reducing postoperative pulmonary complications (PPCs).

DESIGN AND SETTING

Randomized controlled study conducted at Kasr Al-Ainy teaching hospital, Egypt.

METHODS

A randomized controlled trial was conducted on 48 subjects undergoing elective UAS with high risk of developing PPCs. The study group received AD plus routine chest physiotherapy (deep diaphragmatic breathing, localized breathing and splinted coughing) and the control group received routine chest physiotherapy only. The outcomes included arterial blood gases measured at the first and seventh postoperative days, incidence of PPCs within the first seven days and length of hospital stay.

RESULTS

Baseline characteristics were similar between groups. In the AD group, SaO2, PaO2, PaCO2 and HCO3 significantly improved (P < 0.05) while in the physiotherapy group, only SaO2 and PaO2 significantly improved (P < 0.05). Nonetheless, significant differences in post-treatment SaO2 and PaO2 between the groups were observed. The overall incidence of PPCs was 16.66% (12.5% in the AD group and 20.8% in the physiotherapy group) (absolute risk reduction -8.3%; 95% confidence interval, CI, -13.5 to 29.6%), with no significant difference between the groups. The AD group had a significantly shorter hospital stay (P = 0.0001).

CONCLUSION

Adding AD to routine chest physiotherapy after UAS provided a favorable blood gas outcome and reduced the length of hospital stay. It tended to reduce the incidence of PPCs.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04446520.

Geriatric Rehabilitation and COVID-19: a Case Report

The COVID-19 infection has particularly affected older adults. Clinical observations in this population highlight major respiratory impairment associated with the development or aggravation of the patient’s frailty state. Mr. P is a 93-year-old frail patient, hospitalized after a COVID-19 infection. The assessment process of this patient has been supported by an innovative multi-systemic tool developed in view of the COVID-19 clinical consequences and a systemic evaluation of motor functions by the Frail’BESTest. This process allowed a mixed clinical picture associated with significant respiratory distress (linked with acute respiratory distress syndrome) and an evident motor frailty. The care plan was developed accordingly, and four assessments were done in the same manner until Mr. P returned home. This case report allows us to see a holistic COVID-19 clinical picture, showing the different axes of clinical reasoning to enhance the rehabilitation process. Furthermore, this case report illustrates the importance of rehabilitation in the COVID-19 context.

Chest physiotherapy: An important adjuvant in critically ill mechanically ventilated patients with COVID-19

In late 2019, an outbreak of a novel human coronavirus causing respiratory disease was identified in Wuhan, China. The virus spread rapidly worldwide, reaching pandemic status. Chest computed tomography scans of patients with coronavirus disease-2019 (COVID-19) have revealed different stages of respiratory involvement, with extremely variable lung presentations, which require individualized ventilatory strategies in those who become critically ill. Chest physiotherapy has proven to be effective for improving long-term respiratory physical function among ICU survivors. The ARIR recently reported the role of chest physiotherapy in the acute phase of COVID-19, pointing out limitation of some procedures due to the limited experience with this disease in the ICU setting. Evidence on the efficacy of chest physiotherapy in COVID-19 is still lacking. In this line, the current review discusses the important role of chest physiotherapy in critically ill mechanically ventilated patients with COVID-19, around the weaning process, and how it can be safely applied with careful organization, including the training of healthcare staff and the appropriate use of personal protective equipment to minimize the risk of viral exposure.

Development of a tool to assess core cardiorespiratory physiotherapy skills: a Delphi study

PURPOSE

This study reports on the development of an outcome measure designed to evaluate pre-registration physiotherapy students' ability in performing core cardiorespiratory skills.

METHOD

A four round, e- Delphi study using an international panel of expert cardiorespiratory physiotherapists involved in pre-registration student education was undertaken. In round one participants identified what they look for in students competently performing core cardio-respiratory physiotherapy assessment and treatment skills. These items were refined in rounds two and three. Item content validity score (iCVI) of ≥ 0.8 at round four identified consensus. Scale content validity index (SCVI) was calculated.

RESULTS

Response rate for round one was 46% (6/13). Additional experts were invited to participate and response rates increased to 71% (round 2), 88% (round 3) and 100% (round 4). Of the 207 items across the seven skills identified in round one, 140 were presented in round four. Of these, consensus was achieved for 128 items, with 12 being excluded. The SCVI was 0.907.

CONCLUSION

This e-Delphi study enabled the development of a draft outcome measure, which aims to assess performance of seven cardiorespiratory physiotherapy skills. This tool will enable rigorous evaluation of different education methods to establish their effectiveness. However, it is first necessary to establish construct validity and assess inter and intra-rater reliability.

Recommendations for Hospital-Based Physical Therapists Managing Patients With COVID-19

OBJECTIVE

The COVID-19 pandemic is rapidly evolving and has led to increased numbers of hospitalizations worldwide. Hospitalized patients with COVID-19 experience a variety of symptoms, including fever, muscle pain, tiredness, cough, and difficulty breathing. Elderly people and those with underlying health conditions are considered to be more at risk of developing severe symptoms and have a higher risk of physical deconditioning during their hospital stay. Physical therapists have an important role in supporting hospitalized patients with COVID-19 but also need to be aware of challenges when treating these patients. In line with international initiatives, this article aims to provide guidance and detailed recommendations for hospital-based physical therapists managing patients hospitalized with COVID-19 through a national approach in the Netherlands.

METHODS

A pragmatic approach was used. A working group conducted a purposive scan of the literature and drafted initial recommendations based on the knowledge of symptoms in patients with COVID-19 and current practice for physical therapist management for patients hospitalized with lung disease and patients admitted to the intensive care unit. An expert group of hospital-based physical therapists in the Netherlands provided feedback on the recommendations, which were finalized when consensus was reached among the members of the working group.

RESULTS

The recommendations include safety recommendations, treatment recommendations, discharge recommendations, and staffing recommendations. Treatment recommendations address 2 phases of hospitalization: when patients are critically ill and admitted to the intensive care unit, and when patients are severely ill and admitted to the COVID ward. Physical therapist management for patients hospitalized with COVID-19 comprises elements of respiratory support and active mobilization. Respiratory support includes breathing control, thoracic expansion exercises, airway clearance techniques, and respiratory muscle strength training. Recommendations toward active mobilization include bed mobility activities, active range-of-motion exercises, active (assisted) limb exercises, activities-of-daily-living training, transfer training, cycle ergometer, pre-gait exercises, and ambulation.

Chest physical therapy reduces pneumonia following inhalation injury

PURPOSE

The purpose of this study was to clarify the efficacy of chest physiotherapy (CPT) in patients with inhalation injury in the acute phase.

PATIENTS AND METHODS

This was a single-institution retrospective study of patients with inhalation injury admitted to the Chukyo Hospital Burn Center from April 2004 to March 2014 who required endotracheal intubation for respiratory care. The patients were divided into two groups: the CPT group and the conventional physical therapy group. We compared the two groups according to the incidence of pneumonia, length of ICU/hospital stay, and level of activities of daily living at discharge. To match subject backgrounds, we conducted a propensity score matching analysis, and using a Cox regression analysis, we evaluated the effect of CPT on the first pneumonia event.

RESULTS

Of 271 patients admitted to the burn center, 139 patients were included. The incidence of pneumonia in the CPT group was significantly lower and these patients required fewer days until they could sit on the edge of the bed compared with the conventional physical therapy group. In a Cox regression model, the hazard ratio for the first incidence of pneumonia in the CPT group vs. the conventional therapy group was 0.27 (95% confidence interval: 0.13-0.54, P = 0.0002) after propensity score matching.

CONCLUSIONS

CPT reduces the incidence of pneumonia and facilitates patient mobilization following inhalation injury.

A randomized controlled trial of respiratory physiotherapy in lower respiratory tract infections

INTRODUCTION

Physiotherapy may play a role in the recovery of signs, symptoms and function of patients with lower respiratory tract infections (LRTI) but its effectiveness is still controversial.

OBJECTIVES

To assess the effects of respiratory physiotherapy compared with standard pharmacological care on symptoms and function in outpatients with LRTI.

DESIGN

Single-blind, randomised controlled trial.

SETTING

Outpatients were recruited from the casualties of a central hospital.

PARTICIPANTS

Outpatients with LRTI were recruited and randomly allocated to the control (pharmacological) or experimental (pharmacological and respiratory physiotherapy) group.

INTERVENTION

The intervention consisted of conventional pharmacological treatment and conventional pharmacological treatment plus respiratory physiotherapy. Respiratory physiotherapy included breathing and airway clearance techniques, exercise training and education during 3-weeks, 3 times per week.

MAIN OUTCOME MEASURE

Primary outcome measures - occupation rate of wheezes Wh%; Secondary outcome measures - number of crackles, peripheral oxygen saturation (SpO2) modified Borg scale (mBorg), modified Medical Research Council scale (mMRC), 6-min walk test (6MWT), forced expiratory volume in 1 s and forced vital capacity, and volume and density of the lung and bronchial tree volume.

RESULTS

Ninety-seven patients (53 controls and 44 experimental) completed the intervention. After the intervention, both groups improved significantly in all variables (0.0001 < p < 0.04; 0.001<ƞ²<0.092), with the exception of the mBorg. The magnitude of improvement of the experimental group exceeded the control group in the number of crackles, SpO2 levels, mMRC and 6MWT (0.002 < p < 0.032; 0.002<ƞ²<0.092).

CONCLUSION

Adding respiratory physiotherapy to the pharmacological treatment of outpatients with LRTI results in greater recovery of symptoms and function parameters.

TRIAL REGISTRATION

NCT02053870.

Airway clearance therapy in acute paediatric respiratory illness: A state-of-the-art review

Background

Despite unclear evidence of effectiveness or safety, airway clearance therapy (ACT) is frequently performed in infants and children with acute pulmonary disease.

Objectives

The aim of this review was to critically synthesise published evidence, expert opinion and pathophysiological principles to describe the indications, effects, precautions and application of commonly used ACT modalities for managing infants and children with acute pulmonary disease.

Method

A comprehensive narrative review of published literature was conducted. Articles describing paediatric populations were prioritised, but adult and animal studies were also considered where appropriate.

Results

There is a dearth of high-level evidence supporting the use of ACT in acutely ill infants and children. Conversely, studies have highlighted the lack of effect of different modalities for a variety of conditions, and in some cases serious associated complications have been reported.Airway clearance therapy may be considered when there is retention of pulmonary secretions, and the consequential airway obstruction impacts either acutely on respiratory mechanics and gaseous exchange and/or has the potential for long-term adverse sequelae [a condition that is the consequence of a previous disease or injury]. However, it should not be considered a routine intervention.

Conclusion

Airway clearance therapy should not be performed routinely in children admitted to hospital with acute respiratory conditions. Patients should be clinically assessed and treatment planned according to individual presentation, in those with signs and symptoms that are potentially amenable to ACT.

Clinical implications

This review can serve as a guide for physiotherapists in the respiratory management of children with acute respiratory illness, as well as identifying areas for clinical research.

Does 6-Month Home Caregiver-Supervised Physiotherapy Improve Post-Critical Care Outcomes?: A Randomized Controlled Trial

OBJECTIVE

This study aims to determine whether a 6-month home physiotherapy program can improve outcomes in critical care survivors.

DESIGN

Forty-eight consecutive patients were randomized. The treatment group underwent 2 sessions/day of breathing retraining and bronchial hygiene, physical activity (mobilization, sit-to-stand gait, limb strengthening), and exercise re-conditioning whereas controls underwent standard care. Maximum inspiratory/expiratory pressures (MIP/MEP), forced volumes, blood gases, dyspnea, respiratory rate, disability, peripheral force measurements, perceived health status (Euroquol-5D), patient adherence/satisfaction, safety, and costs were assessed.

RESULTS

Outcomes of treatment versus controls: MIP 14 ± 17 vs. -0.2 ± 14 cm H2O, MEP 27 ± 27 vs. 6 ± 21 cm H2O both P < 0.03; in addition, quality of life (Euroquol-5D) (P = 0.04), FEV1 (P = 0.03), dyspnea (P = 0.002), and respiratory rate (P = 0.009) were significantly improved for treated cardiorespiratory patients only. Eighty-three percent of the treated patients were decannulated versus 14% of controls (P = 0.01). Compliance was high (74 ± 25%) and there were no side effects. The majority (87.4%) expressed satisfaction with the program. Treatment cost was 459&OV0556;/patient/month.

CONCLUSIONS

Carrying over regular bronchial hygiene techniques, physical activity, and exercise into the home after long critical care stays is safe and has a beneficial effect on respiratory muscles, decannulation, pulmonary function, and quality of life.

Raising awareness of bronchiectasis in primary care: overview of diagnosis and management strategies in adults

Bronchiectasis is a chronic lung disease characterised by recurrent infection, inflammation, persistent cough and sputum production. The disease is increasing in prevalence, requiring a greater awareness of the disease across primary and secondary care. Mild and moderate cases of bronchiectasis in adults can often be managed by primary care clinicians. Initial assessments and long-term treatment plans that include both pharmacological and non-pharmacological treatments, however, should be undertaken in collaboration with a secondary care team that includes physiotherapists and specialists in respiratory medicine. Bronchiectasis is often identified in patients with other lung diseases, such as chronic obstructive pulmonary disease, asthma, and in a lesser but not insignificant number of patients with other inflammatory diseases, such as rheumatoid arthritis and inflammatory bowel disease. Overall goals of therapy are to prevent exacerbations, improve symptoms, improve quality of life and preserve lung function. Prompt treatment of exacerbations with antibiotic therapy is important to limit the impact of exacerbations on quality of life and lung function decline. Patient education and cooperation with health-care providers to implement treatment plans are key to successful disease management. It is important for the primary care provider to work with secondary care providers to develop an individualised treatment plan to optimise care with the goal to delay disease progression. Here, we review the diagnosis and treatment of bronchiectasis with a focus on practical considerations that will be useful to primary care.

[Manual airway clearance techniques in adults and adolescents: What level of evidence?]

BACKGROUND

The aim of this systematic literature review was to grade the levels of evidence of the most widely used manual airway clearance techniques.

METHODS

A literature search was conducted over the period 1995-2014 from the Medline, PEDro, ScienceDirect, Cochrane Library, REEDOC and kinedoc databases, with the following keywords: "postural drainage", "manual vibrations", "manual chest percussion", "directed cough", "increased expiratory flow", "ELTGOL", "autogenic drainage" and "active cycle of breathing technique".

RESULTS

Two-hundred and fifty-six articles were identified. After removing duplicates and reading the titles and abstracts, 63 articles were selected, including 9 systematic reviews. This work highlights the lack of useful scientific data and the difficulty of determining levels of evidence for manual airway clearance techniques. Techniques were assessed principally with patients with sputum production (cystic fibrosis, DDB, COPD, etc.). It also shows the limited pertinence of outcome measures to quantify congestion and hence the efficacy of airway clearance techniques.

CONCLUSION

The 1994 consensus conference summary table classifying airway clearance techniques according to physical mechanism provides an interesting tool for assessment, grouping together techniques having identical mechanisms of action. From the findings of the present systematic review, it appears that only ELTGOL, autogenic drainage and ACBT present levels of evidence "B". All other techniques have lower levels of evidence.

LEVEL OF EVIDENCE

II.

The effect of two passive head-down tilt positions on diaphragm excursion in healthy adults: A preliminary study

BACKGROUND AND PURPOSE

A head-down tilt position could influence diaphragm excursion due to abdominal content displacement. The purpose of the study was to determine if excursion could be influenced by a head-down tilt position and if this change in excursion alters the diaphragm function.

DESIGN

Prospective quasi-experimental study.

PARTICIPANTS

Seventy healthy adult students.

INTERVENTION

Four head-down tilt positions: 1) 15° (30 seconds); 2) 15° (120 seconds); 3) 30° (30 seconds); and 4) 30° (120 seconds).

OUTCOME MEASURES

Change in diaphragm excursion was assessed using M-Mode ultrasound and diaphragm function was recorded in terms of the peak expiratory flow rate (PEFR) and thoracic expansion. Data were analyzed using descriptive statistics, Analysis of Variance (ANOVA), Kruskal Wallis and student's t-test.

RESULTS

The cohort consisted of 56 women (80%) and 14 men (20%) with a mean age of 20.7 (±1.7) years and a mean body mass index (BMI) of 23.0 (±3.7) kg/m(2). The greatest mean change in the hemi-diaphragm, for both genders measured from rest, was 38.8 (±11.5) mm on the left and 39.4 (±11.9) mm on the right. The greatest stretch occurred after a 30° head-down tilt for 30 seconds for both the right and left hemi-diaphragms in males and right hemi-diaphragm in females. The left hemi-diaphragm in females achieved its maximum stretch after 30° head-down tilt for 120 seconds. No significant changes in thoracic expansion or PEFR were observed but baseline values were less than predicted.

CONCLUSION

Optimal change in hemi-diaphragm excursion was obtained utilizing 30° head-down tilt positions in healthy subjects.