Chest physiotherapy may be associated with brain damage in extremely premature infants

Thoracoabdominal rebalancing is not superior to manual hyperinflation to increase the amount of pulmonary secretion removed in preterm newborns: A randomized crossover trial

Background and Aims

Respiratory physical therapy is recommended to prevent complications of accumulated secretion in mechanical ventilated infants, but no consensus about the best technique is available.

Aims

To evaluate the effects of manual hyperinflation maneuver (MHM) and thoracoabdominal rebalancing method (TRM) in preterm newborns (PTNB) for bronchial hygiene.

Methods

Single-blind randomized crossover trial with intention-to-treat analysis was carried out with 24 PTNB (<37 weeks of gestation) under invasive ventilatory support via orotracheal cannula received both interventions (MHM and TRM) with an interval of 4 h, followed by tracheal suctioning. The primary outcome was the amount of pulmonary secretion, while secondary outcomes were the response of the autonomous (heart rate, respiratory rate [RR], tidal volume [TV], and oxygen saturation [SpO2]), motor (classification of general movements), and regulatory (pain and respiratory discomfort) systems pre and postintervention.

Results

Although the amount of secretion was not different after the MHM and TRM interventions (0.10 and 0.09 g, respectively, p = 0.47), a difference was observed in the increase of SpO2 (p ≤ 0.001), and in the decrease of RR (p ≤ 0.001) for TRM. The poor repertoire pattern was predominant (23 PTNB), and it did not alter after interventions. Pain was not observed during interventions, the respiratory discomfort decreased after both interventions (p = 0.50).

Conclusion

The amount of secretion removed was similar after MHM and TRM and both maneuvers did not negatively alter the response of the autonomous, motor, and regulatory systems.

Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old

BACKGROUND

Acute bronchiolitis is the leading cause of medical emergencies during winter months in infants younger than 24 months old. Chest physiotherapy is sometimes used to assist infants in the clearance of secretions in order to decrease ventilatory effort. This is an update of a Cochrane Review first published in 2005 and updated in 2006, 2012, and 2016.

OBJECTIVES

To determine the efficacy of chest physiotherapy in infants younger than 24 months old with acute bronchiolitis. A secondary objective was to determine the efficacy of different techniques of chest physiotherapy (vibration and percussion, passive exhalation, or instrumental).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, Web of Science, PEDro (October 2011 to 20 April 2022), and two trials registers (5 April 2022).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which chest physiotherapy was compared to control (conventional medical care with no physiotherapy intervention) or other respiratory physiotherapy techniques in infants younger than 24 months old with bronchiolitis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Our update of the searches dated 20 April 2022 identified five new RCTs with 430 participants. We included a total of 17 RCTs (1679 participants) comparing chest physiotherapy with no intervention or comparing different types of physiotherapy. Five trials (246 participants) assessed percussion and vibration techniques plus postural drainage (conventional chest physiotherapy), and 12 trials (1433 participants) assessed different passive flow-oriented expiratory techniques, of which three trials (628 participants) assessed forced expiratory techniques, and nine trials (805 participants) assessed slow expiratory techniques. In the slow expiratory subgroup, two trials (78 participants) compared the technique with instrumental physiotherapy techniques, and two recent trials (116 participants) combined slow expiratory techniques with rhinopharyngeal retrograde technique (RRT). One trial used RRT alone as the main component of the physiotherapy intervention. Clinical severity was mild in one trial, severe in four trials, moderate in six trials, and mild to moderate in five trials. One study did not report clinical severity. Two trials were performed on non-hospitalised participants. Overall risk of bias was high in six trials, unclear in five, and low in six trials. The analyses showed no effects of conventional techniques on change in bronchiolitis severity status, respiratory parameters, hours with oxygen supplementation, or length of hospital stay (5 trials, 246 participants).  Regarding instrumental techniques (2 trials, 80 participants), one trial observed similar results in bronchiolitis severity status when comparing slow expiration to instrumental techniques (mean difference 0.10, 95% confidence interval (C) -0.17 to 0.37).  Forced passive expiratory techniques failed to show an effect on bronchiolitis severity in time to recovery (2 trials, 509 participants; high-certainty evidence) and time to clinical stability (1 trial, 99 participants; high-certainty evidence) in infants with severe bronchiolitis. Important adverse effects were reported with the use of forced expiratory techniques.  Regarding slow expiratory techniques, a mild to moderate improvement was observed in bronchiolitis severity score (standardised mean difference -0.43, 95% CI -0.73 to -0.13; I2 = 55%; 7 trials, 434 participants; low-certainty evidence). Also, in one trial an improvement in time to recovery was observed with the use of slow expiratory techniques. No benefit was observed in length of hospital stay, except for one trial which showed a one-day reduction. No effects were shown or reported for other clinical outcomes such as duration on oxygen supplementation, use of bronchodilators, or parents' impression of physiotherapy benefit.

AUTHORS' CONCLUSIONS

We found low-certainty evidence that passive slow expiratory technique may result in a mild to moderate improvement in bronchiolitis severity when compared to control. This evidence comes mostly from infants with moderately acute bronchiolitis treated in hospital. The evidence was limited with regard to infants with severe bronchiolitis and those with moderately severe bronchiolitis treated in ambulatory settings. We found high-certainty evidence that conventional techniques and forced expiratory techniques result in no difference in bronchiolitis severity or any other outcome. We found high-certainty evidence that forced expiratory techniques in infants with severe bronchiolitis do not improve their health status and can lead to severe adverse effects. Currently, the evidence regarding new physiotherapy techniques such as RRT or instrumental physiotherapy is scarce, and further trials are needed to determine their effects and potential for use in infants with moderate bronchiolitis, as well as the potential additional effect of RRT when combined with slow passive expiratory techniques. Finally, the effectiveness of combining chest physiotherapy with hypertonic saline should also be investigated.

[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.

Fisioterapia respiratória não altera agudamente os parâmetros fisiológicos ou os níveis de dor em prematuros com síndrome do desconforto respiratório internados em unidade de terapia intensiva

RESUMO Objetivo: avaliar a ocorrência de alterações fisiológicas adversas agudas e a presença de dor em recém-nascidos prematuros com síndrome do desconforto respiratório internados em uma unidade de terapia intensiva neonatal após a fisioterapia respiratória. Métodos: estudo transversal que avaliou 30 neonatos prematuros em três momentos, sendo eles Momento um (M1), antes da fisioterapia, Momento dois (M2), imediatamente após a fisioterapia, e Momento três (M3), 15 minutos após. Consideraram-se alterações fisiológicas as variações da frequência cardíaca (FC), da frequência respiratória (FR), da saturação periférica de oxigênio (SpO2) e da temperatura corporal. A presença de dor foi avaliada pelas escalas neonatal infant pain scale e neonatal facial coding system. Resultados: houve aumento estatisticamente significativo na FC no M2 quando comparados os três momentos, porém com retorno aos valores basais 15 minutos após a fisioterapia. Outras variáveis fisiológicas (FR, SpO2 e temperatura) e a avaliação da dor não apresentaram alterações significativas. Conclusão: parâmetros fisiológicos e comportamentais permaneceram estáveis após a realização da fisioterapia respiratória, com discretas alterações imediatamente após o procedimento, mas com retorno aos valores basais, indicando que a fisioterapia respiratória não alterou agudamente os sinais vitais e os níveis de dor dos neonatos.

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.

Physiological effects of a single chest physiotherapy session in mechanically ventilated and extubated preterm neonates

OBJECTIVE

To assess the changes on various physiological cardio-respiratory parameters with a single chest physiotherapy session in mechanically ventilated and extubated preterm neonates with respiratory distress syndrome.

STUDY DESIGN

This is a prospective observational study in a neonatal intensive care unit setting. Sixty preterm neonates with respiratory distress syndrome, thirty mechanically ventilated and thirty extubated preterm neonates requiring chest physiotherapy were enrolled in the study. Parameters like heart rate (HR), respiratory rate (RR), Silverman Anderson score (SA score in extubated), oxygen saturation (SpO2) and auscultation findings were noted just before, immediately after chest physiotherapy but before suctioning, immediately after suctioning and after 5 minutes of the session.

RESULTS

The mean age of neonates was 9.55±5.86 days and mean birth weight was 1550±511.5 g. As there was no significant difference in the change in parameters on intergroup comparison, further analysis was done considering two groups together (n = 60) except for SA score. As SA score was measured only in extubated neonates. HR did not change significantly during chest physiotherapy compared to the baseline but significantly decreased after 15 minutes (p = 0.01). RR and SA score significantly increased after suctioning (p = 0.014) but reduced after 15 minutes (p = <0.0001). SpO2 significantly reduced post-suctioning compared to the baseline and increased after positioning and 15 minutes of chest physiotherapy (p = <0.0001). Clinically, there was a reduction in HR, RR and SA score with an improvement in SpO2. This signifies that chest physiotherapy may help facilitate the overall well-being of a fragile preterm neonate. Lung auscultation finding suggests that after suctioning, there was a significant reduction in crepitation (p = 0.0000) but significant increase in crepitation after 15 minutes (p = <0.01), suggesting the importance of around-the-clock chest physiotherapy.

CONCLUSION

Chest physiotherapy is safe in preterm neonates. Suctioning causes significant cardio-respiratory parameter changes, but within normal physiological range. Thus, chest physiotherapy should be performed with continuous monitoring only when indicated and not as a routine procedure. More research is needed to study the long term effects of chest physical therapy.

Cerebral blood flow assessment of preterm infants during respiratory therapy with the expiratory flow increase technique

Objective:

To assess the impact of respiratory therapy with the expiratory flow increase technique on cerebral hemodynamics of premature newborns.

Methods:

This is an intervention study, which included 40 preterm infants (≤34 weeks) aged 8-15 days of life, clinically stable in ambient air or oxygen catheter use. Children with heart defects, diagnosis of brain lesion and/or those using vasoactive drugs were excluded. Ultrasonographic assessments with transcranial Doppler flowmetry were performed before, during and after the increase in expiratory flow session, which lasted 5min. Cerebral blood flow velocity and resistance and pulsatility indices in the pericallosal artery were assessed.

Results:

Respiratory physical therapy did not significantly alter flow velocity at the systolic peak (p=0.50), the end diastolic flow velocity (p=0.17), the mean flow velocity (p=0.07), the resistance index (p=0.41) and the pulsatility index (p=0.67) over time.

Conclusions:

The expiratory flow increase technique did not affect cerebral blood flow in clinically-stable preterm infants.

[Cerebral blood flow assessment of preterm infants during respiratory therapy with the expiratory flow increase technique]

OBJECTIVE

To assess the impact of respiratory therapy with the expiratory flow increase technique on cerebral hemodynamics of premature newborns.

METHODS

This is an intervention study, which included 40 preterm infants (≤34 weeks) aged 8-15 days of life, clinically stable in ambient air or oxygen catheter use. Children with heart defects, diagnosis of brain lesion and/or those using vasoactive drugs were excluded. Ultrasonographic assessments with transcranial Doppler flowmetry were performed before, during and after the increase in expiratory flow session, which lasted 5minutes. Cerebral blood flow velocity and resistance and pulsatility indices in the pericallosal artery were assessed.

RESULTS

Respiratory physical therapy did not significantly alter flow velocity at the systolic peak (p=0.50), the end diastolic flow velocity (p=0.17), the mean flow velocity (p=0.07), the resistance index (p=0.41) and the pulsatility index (p=0.67) over time.

CONCLUSIONS

The expiratory flow increase technique did not affect cerebral blood flow in clinically-stable preterm infants.

Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old

BACKGROUND

This Cochrane review was first published in 2005 and updated in 2007, 2012 and now 2015. Acute bronchiolitis is the leading cause of medical emergencies during winter in children younger than two years of age. Chest physiotherapy is sometimes used to assist infants in the clearance of secretions in order to decrease ventilatory effort.

OBJECTIVES

To determine the efficacy of chest physiotherapy in infants aged less than 24 months old with acute bronchiolitis. A secondary objective was to determine the efficacy of different techniques of chest physiotherapy (for example, vibration and percussion and passive forced exhalation).

SEARCH METHODS

We searched CENTRAL (2015, Issue 9) (accessed 8 July 2015), MEDLINE (1966 to July 2015), MEDLINE in-process and other non-indexed citations (July 2015), EMBASE (1990 to July 2015), CINAHL (1982 to July 2015), LILACS (1985 to July 2015), Web of Science (1985 to July 2015) and Pedro (1929 to July 2015).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which chest physiotherapy was compared against no intervention or against another type of physiotherapy in bronchiolitis patients younger than 24 months of age.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. Primary outcomes were change in the severity status of bronchiolitis and time to recovery. Secondary outcomes were respiratory parameters, duration of oxygen supplementation, length of hospital stay, use of bronchodilators and steroids, adverse events and parents' impression of physiotherapy benefit. No pooling of data was possible.

MAIN RESULTS

We included 12 RCTs (1249 participants), three more than the previous Cochrane review, comparing physiotherapy with no intervention. Five trials (246 participants) evaluated conventional techniques (vibration and percussion plus postural drainage), and seven trials (1003 participants) evaluated passive flow-oriented expiratory techniques: slow passive expiratory techniques in four trials, and forced passive expiratory techniques in three trials.Conventional techniques failed to show a benefit in the primary outcome of change in severity status of bronchiolitis measured by means of clinical scores (five trials, 241 participants analysed). Safety of conventional techniques has been studied only anecdotally, with one case of atelectasis, the collapse or closure of the lung resulting in reduced or absent gas exchange, reported in the control arm of one trial.Slow passive expiratory techniques failed to show a benefit in the primary outcomes of severity status of bronchiolitis and in time to recovery (low quality of evidence). Three trials analysing 286 participants measured severity of bronchiolitis through clinical scores, with no significant differences between groups in any of these trials, conducted in patients with moderate and severe disease. Only one trial observed a transient significant small improvement in the Wang clinical score immediately after the intervention in patients with moderate severity of disease. There is very low quality evidence that slow passive expiratory techniques seem to be safe, as two studies (256 participants) reported that no adverse effects were observed.Forced passive expiratory techniques failed to show an effect on severity of bronchiolitis in terms of time to recovery (two trials, 509 participants) and time to clinical stability (one trial, 99 participants analysed). This evidence is of high quality and corresponds to patients with severe bronchiolitis. Furthermore, there is also high quality evidence that these techniques are related to an increased risk of transient respiratory destabilisation (risk ratio (RR) 10.2, 95% confidence interval (CI) 1.3 to 78.8, one trial) and vomiting during the procedure (RR 5.4, 95% CI 1.6 to 18.4, one trial). Results are inconclusive for bradycardia with desaturation (RR 1.0, 95% CI 0.2 to 5.0, one trial) and bradycardia without desaturation (RR 3.6, 95% CI 0.7 to 16.9, one trial), due to the limited precision of estimators. However, in mild to moderate bronchiolitis patients, forced expiration combined with conventional techniques produced an immediate relief of disease severity (one trial, 13 participants).

AUTHORS' CONCLUSIONS

None of the chest physiotherapy techniques analysed in this review (conventional, slow passive expiratory techniques or forced expiratory techniques) have demonstrated a reduction in the severity of disease. For these reasons, these techniques cannot be used as standard clinical practice for hospitalised patients with severe bronchiolitis. There is high quality evidence that forced expiratory techniques in severe patients do not improve their health status and can lead to severe adverse events. Slow passive expiratory techniques provide an immediate and transient relief in moderate patients without impact on duration. Future studies should test the potential effect of slow passive expiratory techniques in mild to moderate non-hospitalised patients and patients who are respiratory syncytial virus (RSV) positive. Also, they could explore the combination of chest physiotherapy with salbutamol or hypertonic saline.

Importance of physiotherapy/nursing multidisciplinary integration about update newborn position in the neonatal intensive care unit

AbstractIntroduction The high-risk newborns may require long periods of hospitalization until they reach clinical stability for hospital discharge. Avoiding babies to be in only one body position may be an effective way to cause respiratory and neuro-psycho-motor benefits, comfort and preventing pressure ulcers.Objectives This study investigated the impact of physiotherapy/nursing integration in update on body positioning of the newborn in the Neonatal Intensive Care Unit.Methods A questionnaire was administered to nurses and nursing technicians of the neonatal unit of Maternity School of UFRJ and nurses of the Advanced Course in Neonatal Nursing from the same institution. Two classes were taught by the physical therapist of the sector and the questions answered before and after these lessons. It was also a brief characterization of professional participants of the study. We used the Student's t test to compare the correct answers before (PRE) and after (POST) the classes, considering p < 0.05.Results There was a significant increase in the degree of knowledge of nurses and nursing technicians when compared the responses before (nurses: 68.8%; technicians: 70.1%) and after classes (nurses: 78.4 %; technicians: 88.9%). The nurses were less than five years of graduated (45%) and little time of professional experience in neonatology (60%). Forty-seven percent of technicians had less than five years of training and 82% had less than 10 years of experience.Conclusion The use of training by the nursing staff was significant, showing the importance of multidisciplinary approach and the integration of knowledge in the search for a humanized and effective care.

Chest Physiotherapy in the Pediatric Intensive Care Unit

Despite widespread practice, there is very little, high-level evidence supporting the indications for and effectiveness of cardiopulmonary/chest physiotherapy (CPT) in critically ill infants and children. Conversely, most studies highlight the detrimental effects or lack of effect of different manual modalities. Conventional CPT should not be a routine intervention in the pediatric intensive care unit, but can be considered when obstructive secretions are present which impact on lung mechanics and/or gaseous exchange and/or where there is the potential for long-term complications. Techniques such as positioning, early mobilization, and rehabilitation have been shown to be beneficial in adult intensive care patients; however, little attention has been paid to this important area of practice in pediatric intensive care units. This article presents a narrative review of chest physiotherapy in pediatric critical illness, including effects, indications, precautions, and specific treatment modalities and techniques.

Tecnicas de fisioterapia respiratoria: efeito nos parametros cardiorrespiratorios e na dor do neonato estavel em UTIN

OBJETIVOS: verificar os efeitos de técnicas de fisioterapia respiratória (TFR) na dor e na função cardiorrespiratória de recém-nascidos (RN) clinicamente estáveis com prescrição de TFR, internados em unidade de terapia intensiva neonatal. MÉTODOS: ensaio clínico randomizado cego. Os RN foram alocados em três grupos: G1-controle; G2- fisioterapia convencional; G3-reequilíbrio tóracoabdominal. Neonatos do G2 e G3 receberam intervenção em atendimento único. Todos foram avaliados antes, imediatamente após e 15 minutos após o término da intervenção/repouso quanto aos parâmetros cardiorrespiratórios (saturação periférica de oxigênio/SpO2, frequências cardíaca/fc e respiratória/fr) e dor (escalas específicas: NIPS, NFCS e PIPP). Para análise dos dados foram aplicados: testes qui-quadrado, Friedman, Kruskal- Wallis e, posteriormente, análise de comparações múltiplas, com p<0,05 significativo. RESULTADOS: participaram do estudo 60 RN, dos quais 56,7% eram do sexo feminino, 68,3% prétermo/ muito baixo peso, com média de idade gestacional corrigida de 38,88 ± 2,03 semanas, idade de 13,22 ± 7,37 dias e peso de 1603,42 ± 439,16 gramas. Antes da intervenção, os grupos eram equivalentes quanto à presença de dor e parâmetros cardiorrespiratórios basais. Comparando os efeitos de cada um dos procedimentos, entre os grupos e no decorrer das três avaliações, não houve alterações significativas em nenhum dos parâmetros cardiorrespiratórios avaliados (p>0,05) e em relação à dor houve mudanças significativas nas escalas NIPS (G1 e G2, p=0,037 e p=0,011, respectivamente) e PIPP (G2, p=0,005). CONCLUSÕES: técnicas de fisioterapia respiratória não desencadearam dor, nem instabilidade cardiorrespiratória nos RN estudados.

Laser photocoagulation in patients with retinopathy of prematurity undergoing chest physiotherapy

The authors report the correlation between chest physiotherapy and increased risk of vitreous hemorrhage after laser photocoagulation therapy in patients with retinopathy of prematurity (ROP). Two premature neonates, the first born at 26 weeks and the second at 31 weeks gestational age, both underwent chest physiotherapy, the first for congenital cystic fibrosis and bronchopulmonary dysplasia and the second for premature alveolar atelectasis. Both were diagnosed as having ROP that necessitated laser photocoagulation treatment at 34 and 37 weeks, respectively. The first patient developed bilateral vitreous hemorrhage and bilateral cataracts. The second patient developed vitreous hemorrhage in one eye. Chest physiotherapy in neonates with ROP significantly increases the risk of hemorrhage after laser photocoagulation in an otherwise fragile retinal vasculature.

Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old

BACKGROUND

This is an update of the original Cochrane review published in 2005 and updated in 2007. Acute bronchiolitis is the leading cause of medical emergencies during winter in children younger than two years of age. Chest physiotherapy is thought to assist infants in the clearance of secretions and to decrease ventilatory effort.

OBJECTIVES

The main objective was to determine the efficacy of chest physiotherapy in infants aged less than 24 months old with acute bronchiolitis. A secondary objective was to determine the efficacy of different techniques of chest physiotherapy (for example, vibration and percussion and passive forced exhalation).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to November week 3, 2011), MEDLINE in-process and other non-indexed citations (8 December 2011), EMBASE.com (1990 to December 2011), CINAHL (1982 to December 2011), LILACS (1985 to December 2011) and Web of Science (1985 to December 2011).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which chest physiotherapy was compared against no intervention or against another type of physiotherapy in bronchiolitis patients younger than 24 months of age.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. Primary outcomes were respiratory parameters and improvement in severity of disease. Secondary outcomes were length of hospital stay, duration of oxygen supplementation and the use of bronchodilators and steroids. No pooling of data was possible.

MAIN RESULTS

Nine clinical trials including 891 participants were included comparing physiotherapy with no intervention. Five trials (246 participants) evaluated vibration and percussion techniques and four trials (645 participants) evaluated passive expiratory techniques. We observed no significant differences in the severity of disease (eight trials, 867 participants). Results were negative for both types of physiotherapy. We observed no differences between groups in respiratory parameters (two trials, 118 participants), oxygen requirements (one trial, 50 participants), length of stay (five trials, 222 participants) or severe side effects (two trials, 595 participants). Differences in mild transient adverse effects (vomiting and respiratory instability) have been observed (one trial, 496 participants).

AUTHORS' CONCLUSIONS

Since the last publication of this review new good-quality evidence has appeared, strengthening the conclusions of the review. Chest physiotherapy does not improve the severity of the disease, respiratory parameters, or reduce length of hospital stay or oxygen requirements in hospitalised infants with acute bronchiolitis not on mechanical ventilation. Chest physiotherapy modalities (vibration and percussion or forced expiratory techniques) have shown equally negative results.

Resolution of lung collapse in a preterm neonate following chest physiotherapy

Preterm neonates are prone to lung collapse because of many reasons. Chest physiotherapy can be used successfully in such cases with lung collapse in order to facilitate removal of secretions and re-expansion of the lung. With the help of a chest radiograph, improvement can be noted as in this case.

Perioperative care following complex laryngotracheal reconstruction in infants and children

Laryngotracheal reconstruction (LTR) involves surgical correction of a stenotic airway with cartilage interpositional grafting, followed by either placement of a tracheostomy and an intraluminal stent (two-stage LTR) or placement of an endotracheal tube with postoperative sedation and mechanical ventilation for an extended period of time (singlestage LTR). With single-stage repair, there may be several perioperative challenges including the provision of adequate sedation, avoidance of the development of tolerance to sedative and analgesia agents, the need to use neuromuscular blocking agents, the maintenance of adequate pulmonary toilet to avoid perioperative nosocomial infections, and optimization of postoperative respiratory function to facilitate successful tracheal extubation. We review the perioperative management of these patients, discuss the challenges during the postoperative period, and propose recommendations for the prevention of reversible causes of extubation failure in this article. Optimization to ensure a timely tracheal extubation and successful weaning of mechanical ventilator, remains the primary key to success in these surgeries as extubation failure or the need for prolonged postoperative mechanical ventilation can lead to failure of the graft site, the need for prolonged Pediatric Intensive Care Unit care, and in some cases, the need for a tracheostomy to maintain an adequate airway.

Chest physiotherapy in preterm infants with lung diseases

BACKGROUND

In neonatology the role of chest physiotherapy is still uncertain because of the controversial outcomes.

METHODS

The aim of this study was to test the applicability in preterm infants of 'reflex rolling', from the Vojta method, in preterm neonates with lung pathology, with particular attention to the effects on blood gases and oxygen saturation, on the spontaneous breathing, on the onset of stress or pain. The study included 34 preterm newborns with mean gestational age of 30.5 (1.6) weeks - mean (DS) - and birth weight of 1430 (423) g - mean (DS) -, who suffered from hyaline membrane disease, under treatment with nasal CPAP (continuous positive airways pressure), or from pneumonia, under treatment with oxygen-therapy. The neonates underwent phase 1 of 'reflex rolling' according to Vojta method three times daily. Respiratory rate, SatO2, transcutaneous PtcCO2 e PtcO2 were monitored; in order to evaluate the onset of stress or pain following the stimulations, the NIPS score and the PIPP score were recorded; cerebral ultrasound scans were performed on postnatal days 1-3-5-7, and then weekly.

RESULTS

In this population the first phase of Vojta's 'reflex rolling' caused an increase of PtcO2 and SatO2 values. No negative effects on PtcCO2 and respiratory rate were observed, NIPS and PIPP stress scores remained unmodified during the treatment; in no patient the intraventricular haemorrhage worsened in time and none of the infants developed periventricular leucomalacia.

CONCLUSIONS

Our experience, using the Vojta method, allows to affirm that this method is safe for preterm neonates, but further investigations are necessary to confirm its positive effects and to evaluate long-term respiratory outcomes.

Influência da fisioterapia respiratória sobre a função cardiopulmonar em recém-nascidos de muito baixo peso

OBJETIVO: Avaliar as repercussões da fisioterapia respiratória sobre a função cardiopulmonar em recém-nascidos pré-termo (RNPT) submetidos à ventilação mecânica. MÉTODOS: Estudo prospectivo de RNPT com peso de nascimento menor que 1500g, sendo verificados os valores de frequência cardíaca (FC), saturação de oxigênio (SatO2), frequência respiratória (FR) e pressão arterial sistêmica (PA) antes e após a fisioterapia respiratória e a aspiração endotraqueal. Os RNPT incluídos foram avaliados em sessões sequenciais entre o 3º-7º dias de vida por dois fisioterapeutas da unidade neonatal. Os valores de FC, SatO2 e PA foram coletados por monitorização eletrônica e a FR, por cronômetro. Na análise estatística, foi utilizado o teste de ANOVA para medidas repetidas, sendo significante p<0,05. RESULTADOS: Foram estudados 42 recém-nascidos, 57% do sexo feminino, com peso de nascimento médio de 1024g e idade gestacional média de 29,5 semanas. Somente 3 RNPT apresentaram Apgar de 5º minuto menor que 5 e a Doença das Membranas Hialinas foi o principal diagnóstico respiratório (88%). Foram realizadas 252 sessões de fisioterapia. A FC, FR, SatO2 e PA atingiram valores considerados fisiológicos após os procedimentos fisioterapêuticos e a aspiração endotraqueal. CONCLUSÕES: Os procedimentos de fisioterapia respiratória e de aspiração endotraqueal não apresentaram influências significativas na função cardiopulmonar, sugerindo que, quando bem indicados e realizados, não comprometem a estabilidade clínica de RNPT.

Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support

BACKGROUND

Chest physiotherapy (CPT) has been used in many neonatal nurseries around the world to improve airway clearance and treat lung collapse; however, the evidence to support its use has been conflicting. Despite the large number of studies there is very little evidence of sufficiently good quality on which to base current practice.

OBJECTIVES

To assess the effects of active CPT techniques, such as percussion and vibration followed by suction compared with suction alone, on the respiratory system in infants receiving mechanical ventilation. Additionally, differences between types of active CPT techniques were assessed.

SEARCH STRATEGY

Our search included The Cochrane Library (Issue 2, 2007), MEDLINE (1966 to 2007), EMBASE (1988 to 2007), CINAHL, Science Citation Index, previous reviews including cross-references, abstracts, conference proceedings and grey literature.

SELECTION CRITERIA

Trials in which ventilated newborn infants up to four weeks of age were randomly or quasi-randomly assigned to receive active CPT or suction alone. Infants receiving CPT for the extubation period were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted quality assessments and data extraction for included trials. We analysed data for individual trial results using relative risk (RR) and mean difference (MD). Results are presented with 95% confidence intervals (CI). Due to insufficient data, we could not undertake meta-analysis.

MAIN RESULTS

Three trials involving 106 infants were included in this review. In one trial (n = 20) CPT was no better than standard care in clearing secretions. No increase in the risk of intraventricular haemorrhage was noted. Two trials compared different types of active CPT. One trial (n = 56) showed that non-resolved atelectasis was reduced in more neonates receiving the lung squeezing technique (LST) when compared to postural drainage, percussion and vibration (PDPV) (RR 0.25; 95% CI 0.11 to 0.57). No difference in secretion clearance or in the rate of intraventricular haemorrhage or periventricular leucomalacia was demonstrated. The other trial (n = 30) showed that the use of percussion or 'cupping' resulted in an increased incidence of hypoxaemia (RR 0.53; 95% CI 0.28 to 0.99) and increased oxygen requirements (MD -9.68; 95% CI -14.16 to -5.20) when compared with contact heel percussion. There was insufficient information to adequately assess important short and longer-term outcomes, including adverse effects.

AUTHORS' CONCLUSIONS

The results of this review do not provide sufficient evidence on which to base clinical practice. There is a need for larger randomised controlled trials to address these issues.

Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old

BACKGROUND

Acute bronchiolitis is the leading cause of medical emergencies during winter in children younger than two years of age. Chest physiotherapy is thought to assist infants in the clearance of secretions and to decrease ventilatory effort.

OBJECTIVES

To determine the efficacy and safety of chest physiotherapy in infants aged less than 24 months old with acute bronchiolitis.

SEARCH STRATEGY

In June 2006 we updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006); MEDLINE (2004 to May Week 4 2006); EMBASE (July 2004 to December 2005) and CINAHL (1982 to May Week 4 2006).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which chest physiotherapy was compared against no intervention or against another type of physiotherapy in paediatric patients younger than 24 months old.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data. The primary outcome was a severity clinical score. Secondary outcomes were length of hospital stay, duration of oxygen supplementation, and the use of bronchodilators and steroids.

MAIN RESULTS

Three clinical trials met the inclusion criteria. All evaluated vibration and percussion techniques with children in postural drainage positions compared to no intervention. The study populations were hospitalised infants with a clinical diagnosis of acute bronchiolitis, although one study included only infants who required nasogastric tube feeding or intravenous fluids. None of the other included trails observed any differences in the severity of the clinical score at day five, during each of the five days of the trial, or until discharge; length of hospital stay; or oxygen requirements between paediatric patients receiving chest physiotherapy and control.

AUTHORS' CONCLUSIONS

Based on the results of three RCTs, chest physiotherapy using vibration and percussion techniques does not reduce length of hospital stay, oxygen requirements, or improve the severity clinical score in infants with acute bronchiolitis. These were infants who were not on mechanical ventilation and who did not have any other co-morbidity. Chest physiotherapy using forced expiratory techniques needs to be further evaluated by clinical research.

Routine neonatal postextubation chest physiotherapy: a randomized controlled trial

OBJECTIVE

To test the effects of a neonatal postextubation programme on the incidence of postextubation collapse and adverse outcomes.

METHODS

A randomized controlled trial was carried out at the Mater Mothers' Hospital, Brisbane. Mechanically ventilated infants were randomized into one of two groups, physiotherapy group--which involved a regimen of chest wall percussion and oropharyngeal suctioning and control group - which involved suctioning without the percussion unless indicated. Chest X-rays were taken at 6 h and at 24 h postextubation. The primary outcome measure was postextubation collapse as determined by a paediatric radiologist blinded to the group allocation.

RESULTS

One hundred and seventy-seven neonates were enrolled in the trial between 1997 and 1999. After an interim analysis, the trial was stopped early. No statistically significant difference was shown in the rate of postextubation collapse (15 of 87 (17.2%) physiotherapy group and 17 of 86 (19.8%) control group (P = 0.85)). No differences were shown between the groups in the number of apnoeic or bradycardic events, duration of requirement for supplemental oxygen or the need for re-intubation within 24 h postextubation.

CONCLUSION

The results of this trial suggest that a routine neonatal postextubation chest physiotherapy programme for all infants is not indicated. There was no evidence that chest physiotherapy is associated with any adverse outcomes.

Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old

BACKGROUND

Acute bronchiolitis is the leading causes of medical emergencies during winter in children younger than two years of age. Chest physiotherapy is thought to assist infants in the clearance of secretions and decrease ventilatory effort.

OBJECTIVES

To determine the efficacy and safety of chest physiotherapy in infants aged less than 24 months old with acute bronchiolitis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2004) which contains the Acute Respiratory Infection Group's specialised register; MEDLINE (January 1966 to June 2004); EMBASE (1990 to June 2004); PASCAL; SCISEARCH; LILACS; and Cumulative Index to the Nursing & Allied Health Literature (CINAHL) (1982 to May 2004).

SELECTION CRITERIA

Randomised controlled trails (RCTs) in paediatric patients younger than twenty four months old in which chest physiotherapy was compared against no intervention or against another type of physiotherapy.

DATA COLLECTION AND ANALYSIS

Two independent reviewers extracted the data. Primary outcome was a severity clinical score. Secondary outcomes were length of hospital stay, duration of oxygen supplementation, and the use of bronchodilators and steroids.

MAIN RESULTS

Three clinical trials met the inclusion criteria. All evaluated vibration and percussion techniques in postural drainage positions compared to no intervention. The study population were hospitalised infants with a clinical diagnosis of acute bronchiolitis, although one study included only infants who required nasogastric tube feeding or intravenous fluids. None of the other included trails observed any differences in the severity of the clinical score at day five or during each of the five days of the trial or until discharge, length of hospital stay, or oxygen requirements between chest physiotherapy group and control.

AUTHORS' CONCLUSIONS

Based on the results of three RCTs, chest physiotherapy using vibration and percussion techniques does not reduce length of hospital stay, oxygen requirements, or improve the severity clinical score in infants with acute bronchiolitis that are not under mechanical ventilation, and who do not have any other co-morbidity. Chest physiotherapy using forced expiratory technique needs to be evaluated by clinical research.

Peri-intraventricular hemorrhage in newborns weighing less than 1500 grams: comparative analysis between 2 institutions

PURPOSE

This study aims to characterize the peri-intraventricular hemorrhages in the neonatal period in very low birth weight newborns in 2 institutions that provide neonatal tertiary assistance.

METHOD

This was a comparative and observational study in 2 neonatal intensive care units, the Maternity Hospital of Campinas and the "Centro de Aten o Integrada Sa de da Mulher" of the State University of Campinas, from December 01, 1998 to November 30, 1999. We examined 187 newborns for peri-intraventricular hemorrhages, using transfontanel ultrasound (76 and 11 respectively at the first and second unit), and classified them into 4 grades. We observed their gender, intrauterine growth, weight, and gestational age at birth.

RESULTS

We diagnosed 34 cases of peri-intraventricular hemorrhages (13 and 21, respectively), and both groups differed as to the birth weight and the adequacy of weight to the gestational age at birth. There was no difference in the prevalence or extent of peri-intraventricular hemorrhages among cases. There was a statistically significant occurrence of lower birth weight at gestational ages of less than 30 weeks.

CONCLUSIONS

The prevalence of peri-intraventricular hemorrhages in our study was compared to that reported in the world literature. Although the cases of the second institution had a smaller mean birth weight, the prevalence of peri-intraventricular hemorrhages was similar to that at the first institution, probably because in the first one, 69% of the gestational ages of the neonates with hemorrhage were less than 30 weeks as compared to 48% in the second one. We stress the importance of the ultrasonographic method for diagnosing peri-intraventricular hemorrhages in very low birth weight newborns.

Neonatal respiratory therapy in the new millennium: Does clinical practice reflect scientific evidence?

Respiratory therapy has historically been considered the primary role of the physiotherapist in neonatal intensive care in Australia. In 2001 a survey was undertaken of all level three neonatal intensive care units in Australia to determine the role of the physiotherapist and of respiratory therapy in clinical practice. It appears that respiratory therapy is provided infrequently, with the number of infants treated per month ranging from 0 to 10 in 15 of the 20 units who provide respiratory therapy, regardless of therapist availability. The median number of respiratory treatments per month during the week was three, and on weekends it was one. Respiratory therapy was carried out by physiotherapists and nurses in 54.6% of units, by physiotherapists only in 36.4% of units, and by nurses only in the remaining 9% of units surveyed. There was also a diminution of the role of respiratory therapy in the extubation of premature infants. A review of the literature shows that overall the use of respiratory therapy reflects current evidence. The question remains whether it is possible to maintain the competency of staff and justify the cost of training in the current healthcare economic climate. It seems probable that the future role of physiotherapists in neonatal intensive care unit may be in the facilitation of optimal neurological development of surviving very low birth weight infants.

Skin conductance and behaviour during sensory stimulation of preterm and term infants

AIM

To investigate the responses to painful and tactile stimulation in preterm and term infants in terms of changes in the plantar skin conductance activity (SCA) and behavioural state. Plantar SCA reflects activity in the sympathetic nervous system.

DESIGN

The plantar SCA and behavioural state in response to nociceptive (the heel prick for blood samples, or immunization) and tactile (routine nursery handling) simulation was recorded in four different groups of infants (n=71): Preterm and term neonatal infants (defined here as up to 1 week old), and preterm and term infants in the postneonatal period.

RESULTS

The preterm infants had significant increases in all skin conductance variables during both tactile and nociceptive stimulation (p<0.02), except for wave amplitude when newborns were heel pricked. The term infants displayed a more varied picture, but both the number and amplitude of the waves increased significantly during both procedures in the newborn groups, while the postneonatal groups only showed significant increases in wave amplitude during nociceptive stimulation (p<0.05). Tactile stimulation of the preterm newborn infants produced significantly higher increases in SCA than nociceptive stimulation (p<0.01), while the behavioural state was highest during nociceptive stimulation (p<0.05). A gradual change in this relation was seen with advancing total age.

CONCLUSION

Non-painful sensory stimulation of infants, especially the newborn and preterm ones, can produce equal or higher levels of physiological stress activation than painful stimulation. Repeated nociceptive stimulation probably sensitises the infants to pain.

Risks and benefits of therapies for apnoea in premature infants

Apnoea in infants can result from a wide range of causes, and requires thorough evaluation before deciding on appropriate treatment. Continuous monitoring of premature infants with apnoea is mandatory in order to define the pathophysiology and type of apnoea; selection of treatment involves careful assessment of aetiology, as well as efficacy and tolerability in each individual case. The objective of treatment is to prevent the deleterious consequences of apnoeas that last >20 seconds and/or are associated with bradycardia, cyanosis or pallor, and occur more often than once an hour over a 12-hour period. Apnoea management involves both pharmacological and nonpharmacological treatment. We suggest methylxanthines as first-line therapy for idiopathic apnoeas; evidence suggests that caffeine is better tolerated and as efficacious as theophylline (since it is particularly efficacious against the 'central' component of idiopathic apnoea of prematurity). If treatment fails, additional measures such as doxapram may be appropriate when hypoventilation is present, or nasal continuous positive airway pressure when upper airway instability or obstructive apnoeas are predominant. Apnoea prophylaxis is an additional reason to advocate prenatal maturation with betamethasone. Weaning from treatment is attempted 4 to 5 days after complete resolution of apnoea, beginning with the last treatment introduced. Monitoring should be maintained for 4 to 5 days to detect any relapse of recurrent and severe apnoeas, which would lead to the resumption of the most recently withdrawn treatment.

Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation

BACKGROUND

This section is under preparation and will be included in the next issue.

OBJECTIVES

To assess the effects of active chest physiotherapy on babies being extubated from mechanical ventilation for neonatal respiratory failure.

SEARCH STRATEGY

The standard search strategy for the Neonatal Review Group was used as outlined in the Cochrane Handbook in the Cochrane Library.

SELECTION CRITERIA

All trials utilising random or quasi-random patient allocation, in which active chest physiotherapy was compared with non-active techniques (eg positioning and suction alone) or no intervention in the periextubation period. The methodological quality of each trial was assessed by two independent authors.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two authors. The data were analysed from 3 trials. Subgroup analysis was performed on different treatment frequencies.

MAIN RESULTS

In this review of 3 small trials, 2 of which were carried out 10 & 20 years ago, no clear benefit of periextubation active chest physiotherapy can be seen. Active chest physiotherapy did not significantly reduce the rate of postextubation lobar collapse (RR 0.69;0.33,1.45), though a reduction in the use of reintubation was shown in the overall analysis (RR 0.24;0.08,0.75). Subgroup analysis of different treatment frequencies showed the same effect with more frequent treatment (1 & 2 hourly) but showed a trend to increased lobar collapse, and no reduction in the use of reintubation, with less frequent treatment (4 hourly). There is insufficient information to assess other important short and long term outcomes, including adverse effects.

REVIEWER'S CONCLUSIONS

The results of this review do not allow development of clear guidelines for clinical practice. Caution is required when interpreting the possible positive effects of chest physiotherapy of a reduction in the use of reintubation and the trend for decreased post-extubation atelectasis as the numbers of babies studied are small, the results are not consistent across trials, data on safety are insufficient, and applicability to current practice may be limited.

Suctioning smarter: answers to eight common questions about endotracheal suctioning in neonates

ENDOTRACHEAL SUCTIONING IS important to clear secretions, maintain airway patency, and facilitate oxygenation and ventilation in intubated infants. But suctioning is not a benign procedure. It can cause hypoxia, atelectasis, pneumothorax, infection, tissue damage, and changes in heart rate, blood pressure, and intracranial pressure.1–17Studies have been conducted in both adults and infants to identify the best approach to suctioning.3,6,7,18,19This article uses research findings to address eight common questions about endotracheal suctioning. When suctioning practices are based on research, rather than on tradition, outcomes should improve.

The role of neonatal chest physiotherapy in preventing postextubation atelectasis

We retrospectively assessed atelectasis in 297 postextubation radiographs from 220 babies who underwent ventilation over a 2-year period. All 95 babies in the first year received peri-extubation chest physiotherapy; none of the 125 babies in the second year received chest physiotherapy. There was no difference in the incidence of postextubation atelectasis between the two groups.