Evidence
Alert

Chest physiotherapy for acute bronchiolitis is ineffective and may be harmful

Chest physiotherapy for acute bronchiolitis in children under two has no benefits and may be harmful, according to a systematic review published by the Cochrane Collaboration.

The research looked at three different types of chest physiotherapy. It found that none of the techniques helped children with bronchiolitis recover more quickly or led to any improvement in their condition. Some types of chest physiotherapy may make breathing and blood-oxygen levels worse.

This review’s findings suggest that chest physiotherapy should not normally be used for children hospitalised with severe bronchiolitis. The findings support current NICE guidance which says that children (who don’t have another condition) should not be given chest physiotherapy on the basis of having bronchiolitis.

 

Why was this study needed?

Acute bronchiolitis is a common viral infection in children under two, in which the airways become inflamed and narrowed. About 30% of infants will develop the disease in the first year of life, of which 2 to 3% will need admission to hospital. In severe cases children may have difficulty breathing and suffer lack of oxygen.

Chest physiotherapy is used in many other lung conditions and it has been proposed that it may help clear the airways and make breathing easier in cases of acute bronchiolitis.

The first Cochrane review of the subject was published in 2004 and updated in 2005, 2007 and 2012. All the reviews concluded that chest physiotherapy was ineffective for acute bronchiolitis. However, chest physiotherapy, including new and gentler techniques, is still being used for acute bronchiolitis in some countries.

The latest review assessed the safety and effectiveness of chest physiotherapy, including more recent techniques, in infants aged less than two years with acute bronchiolitis.

 

What did this study do?

The review compared chest physiotherapy with no intervention or with another type of treatment such as suctioning secretions or applying nasal drops. The 12 included trials (three new to this update) covered 1,249 children with bronchiolitis younger than 24 months who had been admitted to hospital. Two studies were carried out in the UK, the rest were mainly from Europe or Latin America.

The researchers looked at whether vibration and percussion plus postural drainage, or the newer, gentler techniques of slow passive expiration, or forced expiration reduced the severity of the illness and the time it took patients to recover. These were measured using different outcome scores, which could not be combined numerically. Other outcomes included harms associated with physiotherapy.

This Cochrane review was carried out using reliable methods. There was high grade evidence in trials measuring time to recovery for forced expiration techniques, which means we can be confident in findings. However, we can be less certain about other techniques and findings, where the trials were at risk of bias and presented imprecise estimates of any effect.

 

What did it find?

  • In three trials, forced passive expiratory techniques had no effect on disease severity, measured by the time it took children to recover or to reach a stable condition. These trials were graded as high quality evidence with low risk of bias, so we can be confident in the findings.
  • One high quality trial showed this technique was associated with harm, including increased risk of vomiting (relative risk [RR] 10.2, 95% confidence interval [CI] 1.3 to 78.8) and of a child’s breathing becoming worse (RR 5.4, 95% CI 1.6 to 18.4).
  • In five trials, vibration and percussion plus postural drainage did not reduce the severity of the disease, as measured by patients’ clinical scores. The trials included did not have information on possible harms of percussion and vibration, and had unclear risk of bias due to selective reporting. This means we cannot be sure of the findings for these outcomes in this group.
  • Slow passive expiratory techniques were studied in four trials. Three showed no effect or small, transient improvement in severity of the illness, as measured by patients’ clinical scores. This technique appears to be safe, with no adverse effects reported in two trials. However, all the research on slow passive expiration was unclear in its description of bias reducing our confidence in these findings too.

 

What does current guidance say on this issue?

Guidance from NICE on managing bronchiolitis in children in hospital was published in 2015. It says that chest physiotherapy should not be performed on children with bronchiolitis who do not have other illnesses affecting the airways, for example, where children cannot clear secretions due to muscle weakness.

NICE advises clinicians to consider requesting a chest physiotherapy assessment in children who have other relevant illness, when there may be additional difficulty clearing lung secretions.

 

What are the implications?

Updated evidence from this high quality review continues to support 2015 NICE guideline recommendations not to use chest physiotherapy for children with acute bronchiolitis who do not have other reasons for physiotherapy. This guideline warns that chest physiotherapy can be uncomfortable for the child and distressing for the carers. There is also the potential that it can worsen the condition.

Given the strong evidence of lack of health benefits of physiotherapy for this condition, and the more uncertain risk of harmful effects for some types of physiotherapy, this reviews’ findings could help align practice with evidence. The imprecision in estimating the extent of any harm should not deter clinicians from assuming that at least some harm does exist, taking a precautionary approach. Based on this evidence there is the potential to save resources in terms of the cost of treating harms and releasing a physiotherapist’s time for other treatments.

 

Citation and Funding

Roqué I Figuls M, Giné-Garriga M, Granados Rugeles C, et al. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev. 2016;2:CD004873.

No funding information was provided for this study.

 

Bibliography

Gajdos V, Katsahian S, Beydon N, et al. Effectiveness of chest physiotherapy in infants hospitalized with acute bronchiolitis: a multicenter, randomized, controlled trial. PLoS Med. 2010;7(9):e1000345.

NHS Choices. Bronchiolitis.  Leeds: NHS Choices; 2015.

NICE. Bronchiolitis in children: diagnosis and management. NG9. London: National Institute for Health and Care Excellence; 2015.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

 

Definitions

The types of chest physiotherapy studied in this review are vibration and percussion, forced expiratory techniques and slow passive expiratory techniques.

Vibration and percussion with postural drainage is a common physiotherapy approach for mucus removal. Percussion involves the physiotherapist clapping on the chest or back to help break up secretions. In vibration, the physiotherapist applies light manual pressure, creating a shaking movement on specific areas of the chest wall. The child is held in a position to help drain fluid from the lungs.

In forced expiratory technique, the physiotherapist presses suddenly on the chest or abdomen to increase the breath out and help clear secretions. In slow passive expiratory technique the rib cage and abdominal cavity is gradually and gently compressed from mid breath to the end of the breath out, to help clear secretions.

Commentaries

Expert commentary

Acute bronchiolitis is a common emergency in the first two years of life, and there is no effective treatment. The authors have identified that there is no evidence that chest physiotherapy is useful, nor is this surprising given the pathophysiology of the disease. Also, handling these sick babies may cause acute decompensation, so chest physiotherapy may actually be harmful. The authors call for further studies on physiotherapy combined with hypertonic saline or salbutamol, two other useless therapies for bronchiolitis; I cannot agree with this conclusion.

Andrew Bush, Professor of Paediatrics and Head of Section (Paediatrics), Imperial College; Professor of Paediatric Respirology, National Heart and Lung Institute; Consultant Paediatric Chest Physician, Royal Brompton and Harefield NHS Foundation Trust

Expert commentary

The theoretical rationale for physiotherapy interventions to relieve lung hyperinflation or mucus plugging in acute bronchiolitis is plausible. However, inflammation, tachypnea, paroxysmal cough and critical airway narrowing in small airways, mean that treatments in infants with severe illness are fraught with balancing clinical benefit against the risk of triggering respiratory failure.

This review includes data from 12 studies in 9 countries across the UK, Europe, South America and the Middle East, which represent many heterogeneous therapeutic interventions. There is no persuasive evidence of overall clinical benefit which would justify routine physiotherapy in this vulnerable population. Credible evidence from one European study suggests that the risks of respiratory decline after forced expiratory techniques can be significant for severely affected infants.

Professor Eleanor Main, Programme Director: UCL MSc, Diploma and Certificate in Physiotherapy