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

  • Review
  • Intervention

Authors


Abstract

Background

Chest physiotherapy has been used to clear secretions and help lung ventilation in newborns who have needed mechanical ventilation for respiratory problems. However, there are concerns about the safety of some forms of chest physiotherapy.

Objectives

To determine the effects of active chest physiotherapy on infants being extubated from mechanical ventilation for respiratory failure.

Search methods

The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of electronic databases: Oxford Database of Perinatal Trials; Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2005); MEDLINE (1966 to February 2009); CINAHL (1982 to February 2009); and EMBASE (2006 to February 2009), previous reviews including cross references, abstracts, conferences, symposia proceedings, expert informants and journal hand searching.

Selection criteria

All trials utilising random or quasi-random patient allocation, in which active chest physiotherapy was compared with non-active techniques (e.g. positioning and suction alone) or no intervention in the peri-extubation period.

Data collection and analysis

Assessment of methodological quality and extraction of data for each included trial was undertaken independently by the authors. Subgroup analysis was performed on different treatment frequencies and gestational age less than 32 weeks. Meta-analysis was conducted using a fixed effects model. Results are presented as relative risk (RR), risk difference (RD) and number needed to treat (NNT) for categorical data and mean difference (MD) for data measured on a continuous scale. All outcomes are reported with the use of 95% confidence intervals.

Main results

In this review of four trials, two of which were carried out 15 and 23 years ago, no clear benefit of peri-extubation active chest physiotherapy can be seen. Active chest physiotherapy did not significantly reduce the rate of postextubation lobar collapse [typical RR 0.80 (95% CI 0.49,1.29)], though a reduction in the use of reintubation was shown in the overall analysis [typical RR 0.32 (95% CI 0.13,0.82); typical RD -7% (95% CI-13, -2); NNT 14 (95% CI 8, 50)]. There is insufficient information to adequately assess important short and longer term outcomes, including adverse effects.

Authors' conclusions

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.

摘要

背景

胸部物理療法預防嬰兒呼吸器治療拔管後的罹病率

胸部物理療法被用於清除分泌物並幫助因呼吸問題需呼吸器治療的新生兒的肺部通氣。然而對有些類型肺部物理療法的安全性仍有疑慮。

目標

評估積極肺部物理療法對因呼吸衰竭呼吸器治療新生兒拔管後的影響

搜尋策略

使用Cochrane Neonatal Review Group 的標準策略進行檢索,檢索了以下電子數據庫:Oxford Database of Perinatal Trials; Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2005年第1期);MEDLINE(1966年至2009年2月);以及CINAHL (1982年至2009年2月),先前回顧包括參考文獻,摘要,研討會論文集,專家訊息和對主要是英文雜誌進行手工檢索。

選擇標準

所有使用隨機或半隨機分配患者,對拔管前後使用積極肺部物理療法與非積極技術(例如僅以體位引流和吸出)或無處理進行比較的試驗。

資料收集與分析

由每位作者獨立對納入的每項試驗進行方法學質量評估和提取數據。提取拔管後肺葉塌陷、重新插管、氧療時間、顱內出血、腦內囊性病灶、長期感覺神經損害和死亡等主要結果的數據。按不同治療頻率和孕齡小於32週進行分層分析。使用固定效應模型進行綜合分析。對分類數據用相對風險(RR),風險差(RD)和需治療例數(NNT),對用連續尺度測量的數據用平均差(MD)表示結果。所有結果以95%信賴區間報告。

主要結論

在本回顧的4個試驗中,有2個是在15年和23年前進行的,積極胸部物理療法在拔管前後沒有明確好處。積極胸部物理療法無統計學顯著性減少拔管後肺葉塌陷的發生率[RR 0.80 (95% CI 0.49,1.29)],但在整體分析中發現再插管率減少:RR 0.32 (95% CI 0.13,0.820);RD −7%(95% CI −13,−2);NNT 14(95% CI 8,50)。沒有資料足以適當評估短期和長期結果,包括不良反應。

作者結論

本回顧的結果無法提供明確的臨床治療指引。當解釋胸部物理療法對減少再插管率的可能積極效果和拔管後肺弛張不全減少趨勢時,需要謹慎,由於所研究嬰兒數少,各試驗間結果不一致,且有關安全性的數據不夠,因而在目前臨床適用性有限。對新生兒後拔管後預防性積極胸部物理療法的作用進行進一步的隨機對照試驗可能沒有必要。

翻譯人

本摘要由臺中榮民總醫院葉惠英翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

積極胸部物理療法對所有脫離呼吸器的嬰兒可能沒有幫忙。機械通氣治療(機械輔助呼吸)增加嬰兒分泌物。胸部物理療法(輕拍或震動胸部)被認為能清潔嬰兒肺部並常在嬰兒(拔管)脫離呼吸器後使用。雖然本回顧發現物理療法有助於減少嬰兒再接受呼吸器治療但沒有其他好處。同時這些結果主要來自很久以前沒有較好的加濕系統潤濕嬰兒的呼吸藥物表面活性劑時代所做的研究。這些進展曾減少拔管時產生併發症的風險。所以這些結果可能不適於現代新生兒護理。本回顧也未發現嬰兒拔管後短期接受胸部物理療法有任何害處。

Plain language summary

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

Active chest physiotherapy may not be helpful for all babies being taken off mechanical breathing support. Mechanical ventilation (machine-assisted breathing) increases a baby's lung secretions. Chest physiotherapy (tapping or vibrating on the chest) is thought to clear the baby's lungs, and is often done when taking the baby off the ventilator (extubation). Although this review found a benefit for physiotherapy in terms of less babies needing to go back on the ventilator, no other benefits were shown. Also, this benefit was mainly due to the results of studies conducted a long time ago before advances such as better humidification systems to moisten the air the baby breaths and the drug surfactant. These advances may have reduced the risk of complications around the time of extubation so these results may not apply to babies in today's neonatal nurseries. This review did not show any evidence of harm for babies receiving a short course of chest physiotherapy following extubation.

Laienverständliche Zusammenfassung

Vorbeugende Atemphysiotherapie, bei Säuglingen, die künstlich beatmet werden mussten

Aktive Atemphysiotherapie ist möglicherweise nicht für alle Babys hilfreich, die von der künstlichen Beatmung entwöhnt werden. Wird ein Säugling künstlich beatmet (maschinelle Beatmung) so bildet sich Schleim in seiner Lunge. Man geht davon aus, dass Atemphysiotherapie (d.h. Beklopfen und Vibrationsmassage des Brustkorbs) die Lunge von Schleim befreit. Daher wird sie häufig eingesetzt, wenn ein Säugling von der künstlichen Beatmung entwöhnt wird (sog. Extubation). Dieser Review zeigt einen Nutzen der Physiotherapie, dadurch dass weniger Säuglinge erneut künstliche Beatmung benötigten. Es wurden aber keine anderen Vorteile gefunden. Zudem zeigte sich dieser Nutzen vor allem in Studien, die vor langer Zeit durchgeführt wurden, d.h. vor wesentlichen Verbesserungen bei der künstlichen Beatmung, wie z.B. verbesserter Befeuchtung der Atemluft und Einsatz von Surfactant. Diese Fortschritte haben das Risiko für Komplikation zum Zeitpunkt der Extubation möglicherweise verringert. Daher könnte diese Ergebnisse für Säuglinge auf heutigen Neugeborenenstationen eventuell nicht mehr zutreffen. Dieser Review zeigt keine Evidenz dafür, dass eine kurzfristige Physiotherapie nach der Extubation für den Säugling schädlich ist.

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