[Influence of chest physiotherapy on gastro-œsophageal reflux in children]

The effects of assisted autogenic drainage, combined or not with bouncing on gastroesophageal reflux in infants

AIM

This study aimed to determine the effect of assisted autogenic drainage (AAD) with or without bouncing (BAAD) on both acid and non-acid gastroesophageal reflux (GER) in infants <1 year.

METHODS

During a 24-h multichannel intraluminal impedance-pH monitoring (MII-pH), infants were treated with a 20-min intervention of AAD (in supine position) or BAAD (in upright position), 2 h postprandial. In this controlled trial with intra-subject design, the number of reflux episodes (REs) was the primary outcome measure. The results during AAD and BAAD were compared to a baseline period before intervention and 20 min after intervention.

RESULTS

Overall, 50 infants were included in both groups. During AAD a significant decrease of RE's was found compared to baseline (p = 0.001). No significant differences were found in the BAAD group compared to baseline (p = 0.125).

CONCLUSION

AAD and BAAD do not cause or increase GER in infants under the age of 1 year.

Prolonged Slow Expiration Technique and Gastroesophageal Reflux in Infants Under the Age of 1 Year

Background: The Prolonged Slow Expiration Technique (PSE) is an airway clearance technique (ACT) carried out in newborn children with bronchial obstruction and hypersecretion to clear away the mucus from the respiratory tract. Evidence about the effect of PSE on gastroesophageal reflux (GER) is currently lacking in the literature. This study aimed to evaluate the influence of PSE on GER in infants under the age of 1 year. Methods: Infants were observed using multichannel intraluminal impedance-pH monitoring (MII-pH) over 24 h. During monitoring, the participants were treated with one 20 min intervention of PSE in supine position, 2 h after feeding. In this controlled trial with intra-subject design, the number of reflux episodes (REs) during PSE were compared to 20 min before and after PSE. Results: Fifty infants younger than 1 year were screened of whom 22 had a pathological GER. For the entire group, no significant difference was seen in the total number of REs between before, during, or after the PSE treatment (P = 0.76). No significant difference in total REs was found between the three measuring points (P = 0.59) in the group of infants with an abnormal MII-pH (n = 22). Conclusion: PSE does not cause a significant difference in REs in infants younger than 1 year. Registration number: NCT03341585.

Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis

BACKGROUND

Chest physiotherapy is widely prescribed to assist the clearance of airway secretions in people with cystic fibrosis (CF). Positive expiratory pressure (PEP) devices provide back pressure to the airways during expiration. This may improve clearance by building up gas behind mucus via collateral ventilation and by temporarily increasing functional residual capacity. The developers of the PEP technique recommend using PEP with a mask in order to avoid air leaks via the upper airways and mouth. In addition, increasing forced residual capacity (FRC) has not been demonstrated using mouthpiece PEP. Given the widespread use of PEP devices, there is a need to determine the evidence for their effect. This is an update of a previously published review.

OBJECTIVES

To determine the effectiveness and acceptability of PEP devices compared to other forms of physiotherapy as a means of improving mucus clearance and other outcomes in people with CF.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. The electronic database CINAHL was also searched from 1982 to 2017. Most recent search of the Group's CF Trials Register: 20 February 2019.

SELECTION CRITERIA

Randomised controlled studies in which PEP was compared with any other form of physiotherapy in people with CF. This included, postural drainage and percussion (PDPV), active cycle of breathing techniques (ACBT), oscillating PEP devices, thoracic oscillating devices, bilevel positive airway pressure (BiPaP) and exercise.

DATA COLLECTION AND ANALYSIS

Three authors independently applied the inclusion and exclusion criteria to publications, assessed the risk of bias of the included studies and assessed the quality of the evidence using the GRADE recommendations.

MAIN RESULTS

A total of 28 studies (involving 788 children and adults) were included in the review; 18 studies involving 296 participants were cross-over in design. Data were not published in sufficient detail in most of these studies to perform any meta-analysis. In 22 of the 28 studies the PEP technique was performed using a mask, in three of the studies a mouthpiece was used with nose clips and in three studies it was unclear whether a mask or mouthpiece was used. These studies compared PEP to ACBT, autogenic drainage (AD), oral oscillating PEP devices, high-frequency chest wall oscillation (HFCWO) and BiPaP and exercise. Forced expiratory volume in one second was the review's primary outcome and the most frequently reported outcome in the studies (24 studies, 716 participants). Single interventions or series of treatments that continued for up to three months demonstrated little or no difference in effect between PEP and other methods of airway clearance on this outcome (low- to moderate-quality evidence). However, long-term studies had equivocal or conflicting results regarding the effect on this outcome (low- to moderate-quality evidence). A second primary outcome was the number of respiratory exacerbations. There was a lower exacerbation rate in participants using PEP compared to other techniques when used with a mask for at least one year (five studies, 232 participants; moderate- to high-quality evidence). In one of the included studies which used PEP with a mouthpiece, it was reported (personal communication) that there was no difference in the number of respiratory exacerbations (66 participants, low-quality evidence). Participant preference was reported in 10 studies; and in all studies with an intervention period of at least one month, this was in favour of PEP. The results for the remaining outcome measures (including our third primary outcome of mucus clearance) were not examined or reported in sufficient detail to provide any high-quality evidence; only very low- to moderate-quality evidence was available for other outcomes. There was limited evidence reported on adverse events; these were measured in five studies, two of which found no events. In a study where infants performing either PEP or PDPV experienced some gastro-oesophageal reflux , this was more severe in the PDPV group (26 infants, low-quality evidence). In PEP versus oscillating PEP, adverse events were only reported in the flutter group (five participants complained of dizziness, which improved after further instructions on device use was provided) (22 participants, low-quality evidence). In PEP versus HFCWO, from one long-term high-quality study (107 participants) there was little or no difference in terms of number of adverse events; however, those in the PEP group had fewer adverse events related to the lower airways when compared to HFCWO (high-certainty evidence). Many studies had a risk of bias as they did not report how the randomisation sequence was either generated or concealed. Most studies reported the number of dropouts and also reported on all planned outcome measures.

AUTHORS' CONCLUSIONS

The evidence provided by this review is of variable quality, but suggests that all techniques and devices described may have a place in the clinical treatment of people with CF. Following meta-analyses of the effects of PEP versus other airway clearance techniques on lung function and patient preference, this Cochrane Review demonstrated that there was high-quality evidence that showed a significant reduction in pulmonary exacerbations when PEP using a mask was compared with HFCWO. It is important to note that airway clearance techniques should be individualised throughout life according to developmental stages, patient preferences, pulmonary symptoms and lung function. This also applies as conditions vary between baseline function and pulmonary exacerbations.

[Respiratory physiotherapy in acute viral bronchiolitis in the newborn. Pro/con arguments]

This article reports an exchange of unbiased arguments between Mr Guy Postiaux speaking in favour of respiratory physiotherapy in acute viral bronchiolitis in the newborn and Prof. Jean-Christoph Dubus arguing against. A review of the literature suggests that traditional methods of physiotherapy should be abandoned because they are not validated and because they have harmful side effects. The latest Cochrane revue (2016) suggests the use of slow expiration techniques that have some validated elements and cause no harmful side effects. Large multicentre studies should be undertaken to confirm or refute the results of the five studies in the Cochrane review. Their analysis would allow extraction of objective evidence for the efficacy of slow expiration techniques on the relief of bronchopulmonary obstruction and the reduction of the degree of severity in the short and medium term. Studies of the effect of ambulatory respiratory physiotherapy for bronchiolitis of a moderate degree not requiring hospitalisation are not available. An evaluation is needed which is based on the pathophysiology of multifactorial bronchial obstruction and on the physical signs, of which auscultation is the cornerstone.