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Chest physiotherapy for pneumonia in adults

  1. Ming Yang1,
  2. Yuping Yan2,
  3. Xiangli Yin3,
  4. Bin Y Wang4,
  5. Taixiang Wu5,
  6. Guan J Liu6,
  7. Bi Rong Dong1,*

Editorial Group: Cochrane Acute Respiratory Infections Group

Published Online: 28 FEB 2013

DOI: 10.1002/14651858.CD006338.pub3


How to Cite

Yang M, Yan Y, Yin X, Wang BY, Wu T, Liu GJ, Dong BR. Chest physiotherapy for pneumonia in adults. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD006338. DOI: 10.1002/14651858.CD006338.pub3.

Author Information

  1. 1

    West China Hospital, Sichuan University, Department of Geriatrics, Chengdu, Sichuan, China

  2. 2

    Affiliated Hospital, Medical College of Yanan University, Department of Cardiovascular Medicine, Yanan, Shaanxi, China

  3. 3

    Affiliated Hospital, Medical College of Yanan University, Department of Pathology, Yanan, Shaanxi, China

  4. 4

    West China Hospital, Sichuan University, Department of Gerontology, Chengdu, Sichuan, China

  5. 5

    West China Hospital, Sichuan University, Chinese Clinical Trial Registry, Chinese Ethics Committee of Registering Clinical Trials, Chengdu, Sichuan, China

  6. 6

    West China Hospital, Sichuan University, Chinese Cochrane Centre, Chinese Evidence-Based Medicine Centre, Chengdu, Sichuan, China

*Bi Rong Dong, Department of Geriatrics, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, Sichuan, 610041, China. birongdong@163.com.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 28 FEB 2013

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Characteristics of included studies [ordered by study ID]

MethodsRandomised, parallel-group trial


ParticipantsIn-patient setting; relevant details of health status of participants; age; sex; country

50 treatment, 48 control

16 to 95 years old (mean 65)

Male/female: 84 /61

Conducted in Sweden


InterventionsThe physiotherapy was positive expiratory pressure (PEP). In this study a bottle containing 10 cm of tap water was used. Patients were asked to sit up with their feet on the floor and blow bubbles at a calm speed into the bottle through a plastic tube (10 mm in diameter) with an air pressure just sufficient to overcome the resistance of the water. This method was used 20 times per hour from 9 am to 8 pm and continued after discharge. This study consisted of three group (A, B, C). Group A was control which underwent early mobilisation and "huffing". Group B members were given the same as A and deep breaths. Group C members were given the same as A and the method of bottle-blowing


OutcomesPrimary outcomes: death

Secondary outcomes: duration of hospital stay (days); fever clearance time; CRP; VC; FEV1; PEF


NotesThe study was supported financially by the Orebro County Council Research Committee and the Orebro Medical Center Research Foundation


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskThe randomised method was not clearly reported

Allocation concealment (selection bias)Low risk"Sealed envelopes" were used

Blinding (performance bias and detection bias)
All outcomes
High riskNo blinding

Incomplete outcome data (attrition bias)
All outcomes
Low risk19 (13%) patients were drop-outs. However, ITT analysis was performed

Selective reporting (reporting bias)Unclear riskInsufficient information

Other biasUnclear riskInsufficient information


MethodsRandomised, parallel-group, single-blind trial


ParticipantsIn-patient setting; relevant details of health status of participants; age; sex; country

83 treatment, 88 control

15 to 75 years old (control: 47.2, treatment: 47.4)

Male/female: 74/97

Conducted in Sweden


InterventionsThe chest physiotherapy consisted of postural drainage, external help with breathing, percussion and vibration. The placebo was to receive advice on expectoration, deep breathing and how to exercise to avoid thrombosis


OutcomesPrimary outcomes: death; cure rate

Secondary outcomes: duration of hospital stay (days); healing time (days); fever clearance time; FEV1


NotesThe study was approved by the ethical committee of the Karolinska Hospital, Stockholm

Sources of funding were not stated


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskThe randomised method was not clearly reported

Allocation concealment (selection bias)Low risk"Sealed envelopes" were used

Blinding (performance bias and detection bias)
All outcomes
Low riskOutcome assessor was blinded

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskInsufficient information

Selective reporting (reporting bias)Unclear riskInsufficient information

Other biasHigh riskThe standard deviations of duration of hospital stay and fever were not reported


MethodsRandomised, parallel-group trial


ParticipantsIn-patient setting; relevant details of health status of participants; age; sex; country

27 treatment, 27 control

Age (mean ± SD): control: 63 ± 3 years old, treatment: 61 ± 4 years old

Male/female: control 13/14, treatment 14/13

Conducted in Sweden


InterventionsThe chest physiotherapy consisted of postural drainage, chest percussion and vibration, with encouragement of deep breathing and coughing. This therapy was used concomitantly with intermittent positive pressure breathing every 4 hours during the first 24 hours. Therapy was given for at least 3 days to all the treated participants, with an average duration of 5 days


OutcomesPrimary outcomes: death; cure rate

Secondary outcomes: duration of hospital stay (days); rate of clearing of X-ray film; fever clearance time


NotesThe study was supported by a grant (PHS 17292) to the Vermont Lung Center from the National Heart, Lung, and Blood Institute, National Institutes of Health

Sources of funding not stated


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskThe method of randomisation was not described

Allocation concealment (selection bias)Low risk"Sealed envelopes" were used

Blinding (performance bias and detection bias)
All outcomes
Unclear riskInsufficient information

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskInsufficient information

Selective reporting (reporting bias)Unclear riskInsufficient information

Other biasUnclear riskInsufficient information


MethodsRandomised, parallel-group, double-blind trial


ParticipantsIn-patient setting; relevant details of health status of participants; age; sex; country

11 in treatment group, 10 in control group

The mean age was 78.7 in the control group, 82.5 in the treatment group

Male/female: control 3/7, treatment 3/8

The trial was conducted in the United States


InterventionsPatients in the treatment group received a standardised osteopathic manipulative treatment protocol treatment consisting of 7 osteopathic manipulative techniques and non-standardised osteopathic manipulative treatments from an osteopathic manipulative treatment specialist, while participants in the control group received a standardised light touch protocol treatment (sham treatment), with care taken not to move myofascial structures or to articulate joints. The session was 10 to 15 minutes, and the frequency of treatment was 2 sessions per day


OutcomesPrimary outcomes: death; cure rate

Secondary outcomes: duration of hospital stay (days); rate of clearing of X-ray film; duration of antibiotic therapy; duration of leukocytosis


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskThe method of randomisation was not described

Allocation concealment (selection bias)Unclear riskInsufficient information

Blinding (performance bias and detection bias)
All outcomes
Low riskPatients and outcome assessors were blinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs

Selective reporting (reporting bias)Unclear riskInsufficient information

Other biasUnclear riskInsufficient information


MethodsRandomised, double-blind, parallel trial


ParticipantsIn-patient setting; relevant details of health status of participants; age; sex; country

28 in treatment group; 30 in control group

Age (mean ± SD): control group: 77.0 ± 17.2 years old; treatment group: 77.7 ± 17.1 years old

Male/female: control group: 16/14; treatment group: 14/14

The trial was conducted in the United States


InterventionsPatients in the treatment group received a standardised osteopathic manipulative treatment protocol treatment consisting of 7 osteopathic manipulative techniques and non-standardised osteopathic manipulative treatments from an osteopathic manipulative treatment specialist, while participants in the control group received a standardised light touch protocol treatment (sham treatment), with care taken not to move myofascial structures or to articulate joints. The session was 10 to 15 minutes, and the frequency of treatment was 2 sessions per day


OutcomesPrimary outcomes: death; cure rate

Secondary outcomes: duration of hospital stay (days); rate of clearing of X-ray film; duration of antibiotic therapy; change in leukocyte count; mean leukocyte count


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskThe method of randomisation was not described

Allocation concealment (selection bias)Unclear riskInsufficient information

Blinding (performance bias and detection bias)
All outcomes
Low riskPatients and outcome assessors were blinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs

Selective reporting (reporting bias)Unclear riskInsufficient information

Other biasUnclear riskInsufficient information


MethodsRandomised, parallel-group trial


ParticipantsIn-patient setting; relevant details of health status of participants; age; sex; country

12 treatment, 20 control

Age (mean ± SD): control: 36.80 ± 16.91 years old, treatment: 42.08 ± 15.59 years old

Male/female: control 10/10, treatment 9/3

Conducted in UK


InterventionsThe physiotherapy was active cycle of breathing techniques, which consisted of breathing control using the diaphragm; localised expansion exercises; postural drainage; thoracic expansion exercises with vibrations on expiration; percussion. The first 2 methods were continued to discharge and the other methods were used when participants became productive of sputum. The dose of the therapy was dependent on the patient's tolerance and the sputum production


OutcomesPrimary outcomes: death; cure rate

Secondary outcomes: duration of hospital stay (days); rate of clearing of X-ray film; duration of all antibiotic therapy; duration of production of sputum; in-patient sputum weight


NotesThis study was under the funding of Norwich Health Authority and the East Anglian Regional Health Authority Research Committee


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskThe method of randomisation was not described

Allocation concealment (selection bias)Unclear riskInsufficient information

Blinding (performance bias and detection bias)
All outcomes
High riskBlinding was not performed

Incomplete outcome data (attrition bias)
All outcomes
Low riskOnly 4 (11%) patients did not complete the study. Among them, 1 patient died, 2 patients were re-diagnosed as having other disease and 1 patient could not attend sufficient assessments

Selective reporting (reporting bias)Unclear riskInsufficient information

Other biasUnclear riskInsufficient information

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Barkov 1987Physical agent; no control

Britton 1983aSecondary publications under Britton 1985

Britton 1983bSecondary publications under Britton 1985

Burioka 1998The participants had diffuse panbronchiolitis

Cheng 2004This study was not a RCT or quasi-RCT. It covered mechanical ventilation for patients with acute respiratory failure caused by pneumonia

Choi 2005Study was about mechanical ventilation for patients with pneumonia

Confalonieri 1998aStudy was about respiratory failure caused by pneumonia

Confalonieri 1998bStudy was about respiratory failure caused by pneumonia

Dangour 2011It was a prevention study

Fu 2005In addition to pneumonia, the participants also had asthma, chronic bronchitis or bronchiectasis. Not a RCT or quasi-RCT

Holody 1981In addition to pneumonia, the participants had atelectasis. Not a RCT or quasi-RCT

Jolliet 2001Not a RCT or quasi-RCT

Li 2005Some participants with pneumonia also had congestive heart failure or diabetes mellitus. Not a RCT or quasi-RCT

Mo 2004Some participants with pneumonia also had COPD or asthma. A before-and-after study in the same participants

Noll 2008It was a study protocol

Patman 2009Some participants in the study were less than 18 years old. There was no subgroup analysis for adults provided in the study

Schultz 2006The participants also had asthma, lung cancer, COPD or pulmonary embolism

Wan 2004Participants had lower respiratory tract infections, not only pneumonia. Not a RCT or quasi-RCT

Wang 1997The participants also had chronic bronchitis or acute bronchitis, not only pneumonia. Not a RCT or quasi-RCT

Wu 2005aParticipants had a pulmonary infection, not only pneumonia. Not a RCT or quasi-RCT

Wu 2005bParticipants had a pulmonary infection, not only pneumonia. Not a RCT or quasi-RCT

Wu 2005cParticipants had pneumonia caused by chronic bronchitis. Not a RCT or quasi-RCT

Xia 2005Participants had a pulmonary infection, not only pneumonia. Not a RCT or quasi-RCT

Xu 2004Participants had lower respiratory tract infections, not only pneumonia. Not a RCT or quasi-RCT

Zha 2004The participants had acute lung abscesses. Not a RCT or quasi-RCT

Zhang 2004Participants had pneumonia caused by COPD, not only pneumonia. Not a RCT or quasi-RCT

 
Characteristics of studies awaiting assessment [ordered by study ID]

MethodsUnclear

ParticipantsUnclear

InterventionsUnclear

OutcomesUnclear

Notes


MethodsUnclear

ParticipantsUnclear

InterventionsUnclear

OutcomesUnclear

Notes


MethodsUnclear

ParticipantsUnclear

InterventionsUnclear

OutcomesUnclear

Notes


MethodsUnclear

ParticipantsUnclear

InterventionsUnclear

OutcomesUnclear

Notes


MethodsUnclear

ParticipantsUnclear

InterventionsUnclear

OutcomesUnclear

Notes


MethodsUnclear

ParticipantsUnclear

InterventionsUnclear

OutcomesUnclear

Notes

 
Characteristics of ongoing studies [ordered by study ID]

Trial name or titleMulti-Center Osteopathic Pneumonia Study in the Elderly (MOPSE)

MethodsRandomised, double-blind, placebo-controlled trial

ParticipantsInclusion criteria:

  • 50 years old or older
  • Patient is hospitalised in an acute care facility
  • Patient must exhibit at least 2 of the classic symptoms of pneumonia, to include:
    • respiration rate greater than or equal to 25 respirations per minute
    • new or increased cough
    • fever greater than or equal to 100.4 degrees F (38 degrees C)
    • pleuritic chest pain
    • worsening of mental or functional status
    • leukocytosis (WBC greater than 12,000 cells per cubic millimetre)
    • new or increased physical findings (rales, wheezing, bronchial breath sounds)


Exclusion criteria:

  • Lung abscess
  • Advancing pulmonary fibrosis
  • Bronchiectasis
  • Pulmonary tuberculosis
  • Lung cancer
  • Metastatic malignancy
  • Uncontrolled metabolic bone disease that places subject at risk of pathologic bone fracture (i.e. Paget's disease or hypoparathyroidism)
  • Acute or unhealed rib or vertebral fracture
  • History of pathologic bone fracture
  • Previous participation in the study
  • Respiratory failure (intubation)

InterventionsThe first group: osteopathic manipulative treatment (OMT)

The second group: light touch control

The third group: conventional care only

OutcomesPrimary outcome measures: length of hospital stay, time to clinical stability, rate of symptomatic and functional recovery
Secondary outcome measures: duration of IV and oral antibiotic usage in the hospital, number of complications and deaths secondary to pneumonia, duration and severity of fever, duration and severity of leukocytosis, patient satisfaction

Starting dateMarch 2004

Contact informationNot available

NotesThe trial had been completed when we were drafting this review, however it has not yet been published

 
Comparison 1. Chest physiotherapy plus routine treatment versus routine treatment alone

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mortality2225Risk Ratio (M-H, Fixed, 95% CI)1.03 [0.15, 7.13]

 2 Cure rate2225Risk Ratio (M-H, Fixed, 95% CI)0.97 [0.91, 1.04]

 3 Duration of hospital stay1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 4 Duration of fever1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 5 Rate of improvement of chest X-ray1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 2. Active cycle of breathing techniques plus routine treatment versus routine treatment alone

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Cure rate1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Duration of hospital stay1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Rate of improvement of chest X-ray1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Duration of antibiotic therapy1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 5 Duration of sputum production1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 In-patient
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.2 Out-patient
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    5.3 Total
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 In-patient sputum weight1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 
Comparison 3. Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mortality279Risk Ratio (M-H, Fixed, 95% CI)0.27 [0.05, 1.57]

 2 Cure rate279Risk Ratio (M-H, Fixed, 95% CI)1.54 [0.97, 2.46]

 3 Duration of hospital stay279Mean Difference (IV, Fixed, 95% CI)-2.02 [-3.46, -0.58]

 4 Duration of fever1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 5 Rate of improvement of chest X-ray275Risk Ratio (M-H, Fixed, 95% CI)1.16 [0.77, 1.73]

 6 Duration of oral antibiotic therapy279Mean Difference (IV, Random, 95% CI)0.97 [-1.25, 3.20]

 7 Duration of intervenous therapy279Mean Difference (IV, Fixed, 95% CI)-2.11 [-3.36, -0.87]

 8 Duration of total antibiotic therapy279Mean Difference (IV, Fixed, 95% CI)-1.93 [-3.12, -0.74]

 9 Duration of leukocytosis1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 10 Change in leukocyte count1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    10.1 Change between Day 3 and 1 from admission
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    10.2 Change between Day 5 and 1 from admission
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 11 Mean leukocyte count1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    11.1 Day 3 from admission
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    11.2 Day 5 from admission
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 4. Positive expiratory pressure plus routine treatment versus routine treatment alone

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Duration of hospital stay1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 2 Duration of fever1Mean Difference (IV, Fixed, 95% CI)Totals not selected