- Email: [email protected]
Effects of the use of respiratory physiotherapy in children admitted with acute viral bronchiolitis
Archives de Pe´diatrie 25 (2018) 394–398
Available online at
ScienceDirect www.sciencedirect.com
Review article
Effects of the use of respiratory physiotherapy in children admitted with acute viral bronchiolitis G.R. Gomes a, M.V.F. Donadio b,* a b
Pontifı´cia Universidade Cato´lica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil Centro Infant, Institute of Biomedical Research, Pontifı´cia Universidade Cato´lica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 October 2017 Accepted 24 June 2018 Available online 29 July 2018
Objective: To evaluate the effects of the use of respiratory physiotherapy in children admitted with acute viral bronchiolitis (AVB). Methods: A literature review was done searching the Pubmed, LILACS, PEDro, and Scielo databases. The following key words were used: bronchiolitis, physiotherapy, techniques, physical therapy, and chest physiotherapy. Both controlled and uncontrolled clinical trials, without limits as to date, were selected. Results: Fifteen articles were included and the use of different techniques of respiratory physiotherapy showed positive results in eight studies. Most (11) were controlled clinical trials, and only two had a double-blind design. Of the 14 studies with a control group, in six this group was submitted to nasopharyngeal aspiration. The most widely used techniques were manual vibration and postural drainage (eight studies), and then tapping/percussion (seven studied). The maneuvers considered as current, e.g., prolonged slow expiration, expiratory flow acceleration, and rhinopharyngeal retrograde clearance, were used in four, four, and two studies, respectively. Conclusions: The use of respiratory physiotherapy in children with AVB remains controversial. The heterogeneity of techniques evaluated in the studies limits the interpretation of efficacy, although its use was considered safe. Recent findings indicating a reduction in the length of the hospital stay remain to be confirmed. C 2018 Elsevier Masson SAS. All rights reserved.
Keywords: Acute viral bronchiolitis Chest physiotherapy Physiotherapy techniques
1. Introduction Acute viral bronchiolitis (AVB) is an acute injury to the respiratory bronchioles associated with a viral infection, with a peak incidence at the age of 2–6 months [1,2]. It results in obstruction of the small-caliber airways, due to infection by seasonal viruses [3]. Although it is usually a self-limiting disease, it produces significant morbidity in infants less than 6 months of age and patients with chronic diseases, as a result of the ventilation-perfusion mismatch, characterized by increased respiratory work [4,5]. The basic principles for the care of children during the hospital stay are oxygen support therapy, fluid administration to prevent dehydration, and guidance to parents [5,6]. In some cases it may be necessary to clear the airway by removing secretions [7]. Among * Corresponding author. Centro Infant, Instituto de Pesquisas Biome´dicas (IPB), avenue Ipiranga, 6690, 28 andar, CEP 90610-000, Porto Alegre, Rio Grande do Sul, Brasil. E-mail address: [email protected] (M.V.F. Donadio). https://doi.org/10.1016/j.arcped.2018.06.004 C 2018 Elsevier Masson SAS. All rights reserved. 0929-693X/
the most commonly used respiratory physiotherapy techniques are those described as conventional physiotherapy, which consists of a combination of tapping, percussion, postural drainage, and assisted cough [8], as well as newer techniques such as prolonged slow expiration (PSE) and rhinopharyngeal retrograde clearance (RRC) [9,10]. Although more recent recommendations suggest that the use of respiratory physiotherapy techniques in the management of AVB should be indicated according to the severity of the disease [7], evaluated through clinical scores [11], the role of these techniques is still controversial and its recommendation challenging. The last systematic review [12] maintained the conclusion that the use of respiratory physiotherapy does not reduce the severity of the disease and should therefore not be used as standard clinical practice for hospitalized patients with severe bronchiolitis. Several aspects should then be carefully examined and revised, including the relation of severity with indication, the main outcomes to be measured, and the type of respiratory technique to be applied. Older studies using conventional techniques did not demonstrate benefits with their use, based on the lack of statistical significance
G.R. Gomes, M.V.F. Donadio / Archives de Pe´diatrie 25 (2018) 394–398
in criteria such as clinical scores, length of hospital stay, or days of oxygen therapy use [13–15]. On the other hand, more recent studies including the use of new techniques of respiratory physiotherapy have demonstrated positive effects in the removal of secretion, reduction of clinical scores, and respiratory discomfort with short-term improvement of respiratory signs and symptoms [10,16,17], as well as length of hospital stay [18]. Therefore, considering the controversies regarding the use of respiratory physiotherapy in children with AVB, the new evidence on more modern techniques and the recent recommendation of basing physiotherapeutic management on disease severity, a comprehensive review on the subject is warranted. Therefore, the objective of this study was to evaluate, through a review of the literature, the effects of the use of respiratory physiotherapy in hospitalized children with AVB. 2. Methods This is an integrative literature review study. Clinical trials evaluating the effects of respiratory physiotherapy in children admitted with a diagnosis of AVB were included. Articles including patients with chronic conditions, review studies, case studies, experimental models, abstracts, response letters, editorials, and duplicate publications, as well as those that did not meet inclusion criteria or that did not address the subject matter were excluded after the analysis of the abstract or full text. The Medline/PubMed, Scielo, LILACS, and PEDro databases were searched, using the following combination of Keywords: ‘‘bronchiolitis AND physiotherapy’’, ‘‘bronchiolitis AND physiotherapy AND techniques’’, ‘‘bronchiolitis AND physical therapy’’, ‘‘bronchiolitis AND physical therapy AND techniques’’, ‘‘bronchiolitis AND chest physiotherapy’’ and ‘‘bronchiolitis AND chest physiotherapy AND techniques’’. Also; a manual search was conducted in the bibliographic references of selected articles; as well as in systematic reviews; in order to search for additional publications that were pertinent to the study. No relevant articles were found through this search. No filters were used for language selection. The searches were conducted from October to December 2016 by two independent authors. After reading the title, followed by the abstract, only studies reported as clinical trials, whether or not they were controlled, were included. No limit was used as to the date of publication or for article selection. Articles that met the inclusion criteria were read in full and the following data were extracted: title, author, year of publication, study design, sample size, respiratory physiotherapy technique, outcomes, and main results. Data collected were tabulated in a Microsoft Excel spreadsheet for analysis. 3. Summary of findings A total of 504 articles were searched. After careful reading of the title and the abstract, 489 were excluded and a total of 15 articles that met the inclusion criteria were selected. Fig. 1 shows the complete search flow of the study. 3.1. Study designs and sample size As shown in Table 1, of the total of 15 articles, the majority (13 articles) were randomized clinical trials [9,10,13–16,18–24], of which only three used a double-blind design [18,20,21]. In 14 studies, a control group was included, but in only six studies was the control group submitted to nasopharyngeal aspiration/ nasal suction [9,10,14,15,19,21]. Also, in six studies, the control group was not submitted to any airway clearance intervention [13,16,18,20,22,24] and in one study healthy children were
395
included [25]. Regarding the sample size, eight articles included a sample with between 19 and 50 patients [9,14–17,19,23,25], four between 81 and 100 [10,13,18,24] and three studied a sample between 103 and 496 patients [20–22]. Although an adequate study design to test an intervention (randomized controlled clinical trial) was used in 14 out of 15 studies, the sample size could be considered small, which was a limitation in most of the studies included. 3.2. Respiratory physiotherapy techniques The most widely used techniques in the articles selected for this review were manual vibration, which appeared in eight articles [9,14,15,17,19,20,24,25] and postural drainage in another eight studies [9,13–15,19,23–25], followed by tapping/percussion in seven studies [13–15,17,19,23,25]. The combination of respiratory physiotherapy techniques and provoked cough appeared in four studies [16,20,22,24] and combined with nasopharyngeal aspiration/nasal suction in eight studies [13–15,17,19,21,23,25]. On the other hand, the maneuvers considered as more recent in pediatric respiratory physiotherapy, such as PSE, acceleration of expiratory flow (AEF) and RRC, were used in four [9,16,20,22], four [17,22–24], and two studies [9,10], respectively. The summary of these findings is presented in Table 1. The use of techniques considered as modern, such as PSE, AEF, and RRC, presented favorable results in the outcomes evaluated in four studies. The PSE is derived from a variation of the total slow expiration in infralateral decubitus with the open glottis, and may be associated with provoked cough and/or preceded by treatment with bronchodilators [8]. It is considered to be well tolerated by infants with muscle fatigue and bronchial reactivity without adverse effects such as alveolar collapse and increased transmural pressure. However, the results of this review point to divergent findings regarding this technique, since the studies by Postiaux et al. [16] and Gomes et al. [9] showed improvements in signs, symptoms, and clinical scores, and the study by Rochat et al. [22] showed no benefits. It is known that pediatric respiratory physiotherapy developed as an adaptation of the techniques used in adult patients. With the emergence of new studies and discoveries, new maneuvers have emerged to fit the anatomical and physiological differences of pediatric patients, especially young infants [5]. On the other hand, some techniques have already been reported as potentially harmful or unsafe for infants, such as tapping and manual vibration [26]. The mechanical action of these techniques may lead to hypoxemia, an increase in intrathoracic pressure, and inefficiency in the clearance of bronchial secretions [26–28], which could explain the lack of efficacy of respiratory physiotherapy using such techniques in infants with AVB. There are also reports of the use of postural drainage, which has been shown to be unfavorable for increasing intracranial pressure, esophageal reflux, and risk of bronchoaspiration [29,30]. Of the articles included reporting the use of postural drainage, only two described the technique, making it difficult to interpret and differentiate the use of positioning during respiratory physiotherapy and the actual use of postural drainage. In the literature, postural drainage is commonly seen and used in adults with excessive production of secretion and with difficulty in sputum clearance, mainly and historically in patients with cystic fibrosis, demanding time in positions of angulated decubitus and knowledge of the anatomy of the airways so that previously mobilized secretion present in the distal bronchi may travel to the central region and/or near the trachea by the effect of gravity on secretions [31]. On the other hand, positioning during respiratory physiotherapy consists in changing the position of the patient to favor ventilation and perfusion and is not necessarily based on the action of gravity [31].
396
G.R. Gomes, M.V.F. Donadio / Archives de Pe´diatrie 25 (2018) 394–398
Fig. 1. Diagram of the search and selection of articles.
3.3. Effects on clinical outcomes Considering the outcomes evaluated, the majority (11 articles) used clinical scores [9,10,13–16,18,19,21–23], seven articles analyzed length of hospital stay [13–16,18,20,23], six analyzed changes in cardiorespiratory parameters [10,16–19,24], four analyzed the duration of oxygen therapy [17,20,21,23], four articles used the parents’ report and the occurrence of complications or adverse effects [10,17,21,23], and one study assessed heart rate variability [25]. Regardless of the techniques used or the type of control group adopted, eight studies (53.3%) [9,10,16–19,23,25] presented results considered by the authors as favorable to respiratory physiotherapy. The remaining articles (47.7%) did not show statistically significant benefits when evaluating the techniques tested [13–15,20–22,24]. These findings are partially in accordance with the 2014 guidelines of the American Academy of Pediatrics [6], which, based on the analysis of clinical and cohort studies, recommends basically supportive therapy, i.e., oxygen therapy, intravenous hydration, and minimal manipulation. According to these guidelines, the intervention of physiotherapy would have no impact on clinical improvement, hospitalization time, and disease course. Although outcomes such as length of hospital stay and oxygen therapy
duration did not show significant change in several studies [13– 16,20,23], a recent study [18] showed that respiratory physiotherapy significantly reduced the length of hospital stay compared to no physiotherapy. It is important to highlight that only mild to moderate severity children were included. On the other hand, it should be considered that one of the main objectives of respiratory physiotherapy is to promote the mobilization and removal of secretions in the airways, improving pulmonary ventilation and contributing to a decrease in breathing effort. In this sense, seven studies demonstrated improvement in parameters of clinical signs and symptoms (HR, RR, and SpO2) and respiratory effort scores (wheezing and chest retractions), indicating a possible benefit for these patients [9,10,16–19,25]. 3.4. Adverse effects Regarding possible adverse effects, only in the study reported by Gadjos et al. [21], with the analysis of 496 infants (mean age, 2 months), were there reports of negative outcomes such as adverse effects (vomiting and respiratory destabilization) and lower perception of comfort from parents during the use of increased expiration technique associated with cough provoked by nasal suction. On the other hand, the study by Castro et al. [17] also
G.R. Gomes, M.V.F. Donadio / Archives de Pe´diatrie 25 (2018) 394–398
397
Table 1 Characteristics, outcomes, and main results of the studies included. Author
Year
Design
n
Webb et al. [13]
1985
Randomized controlled clinical trial
90
Nicholas et al. [15]
1999
Randomized controlled clinical trial
50
Bohe et al. [14]
2004
Open randomized controlled clinical trial
32
Lanza et al. [19]
2008
Randomized controlled clinical trial
19
Pupin et al. [24]
2009
Randomized controlled clinical trial
81
Gajdos et al. [21]
2010
Double-blind randomized controlled clinical trial
496
Postiaux et al. [16]
2011
Randomized controlled clinical trial
20
PSE Provoked cough
Castro et al. [17]
2011
Quasi-experimental, uncontrolled beforeand-after trial
29
Rochat et al. [22]
2012
Open randomized controlled clinical trial
103
Positioning Manual percussion Manual vibration AEF Nasopharyngeal aspiration PSE Slow accelerated expiratory flow Provoked cough
Gomes et al. [9]
2012
Randomized controlled clinical trial
30
Sa´nchez et al. [20]
2012
236
Jacinto et al. [25]
2013
Double-blind randomized controlled clinical trial Nonrandomized controlled clinical trial
Remondini et al. [23]
2014
Randomized clinical trial
29
Van Ginderdeuren et al. [18]
2016
Double-blind randomized controlled clinical trial
93
Assisted autogenic drainage Intrapulmonary percussive ventilation
Length of hospital stay Clinical score SpO2 and HR
Gomes et al. [10]
2016
Randomized controlled clinical trial
100
RCC Nasopharyngeal aspiration
HR, RR, and SpO2 Clinical score
24
Techniques evaluated
Outcomes
Main results
Postural drainage Manual percussion Provoked cough Nasopharyngeal aspiration Postural drainage Manual percussion Manual vibration
Length of hospital stay Clinical score
No significant differences in clinical score and length of hospital stay
Clinical score Length of hospital stay Requirement for oxygen Nasogastric feeding Respiratory disability clinical score Length of hospital stay
" SpO2 after the intervention No significant differences in the other outcomes
HR, RR, and SpO2 Clinical score
HR, RR, and SpO2
# HR after 15 min of intervention in the three groups # Clinical score # RR in the AEF group
Time to clinical stability Adverse effects Parent’s perception of comfort PICU admission Artificial ventilation Antibiotic treatment Wang clinical score SpO2 and HR Length of hospital stay Changes in oxygen support Changes in clinical signs and symptoms Parent’s perception of comfort
Episodes of vomiting and respiratory destabilization and # comfort reported by parents in the group increased exhalation + cough No other differences # Wang score No difference in length of hospital stay No difference in oxygen support # Clinical signs and symptoms " Parent’s perception of comfort
Time to clinical stability Well-being score Respiratory score Occurrence of complications Wang clinical score Length of hospital stay
No significant differences in the outcomes evaluated
Postural drainage Manual percussion Manual vibration Nasopharyngeal aspiration Postural drainage Chest compression/vibration Manual percussion Postural drainage Manual vibration AEF Increased exhalation Provoked cough Nasal suction
Postural drainage Manual vibration PSE RRC Chest compression PSE Manual vibration Provoked cough Postural drainage Manual percussion Manual vibration Nasopharyngeal aspiration Postural drainage Manual percussion AEF Nasopharyngeal aspiration
Length of hospital stay Hours of oxygen use Heart rate variability
Length of hospital stay Clinical score SpO2 Parent’s perception of comfort
No significant differences in the outcomes evaluated
# Clinical score in both intervention groups No difference in length of hospital stay No difference in length of hospital stay # Hours of oxygen use Variation of the HR in the intervention group was similar to that of the control group at rest No difference in SpO2 and length of hospital stay # Clinical score after 10 min in both groups Positive perception of parents Reduction in the length of hospital stay and clinical score in both intervention groups No differences in SpO2 and HR # HR after 10 and 30 min Less occurrence of complications and respiratory discomfort
SpO2: peripheral oxygen saturation; HR: heart rate; PICU: pediatric intensive care unit; RR: respiratory rate; AEF: acceleration of expiratory flow; PSE: prolonged slow expiration; RRC: rhinopharyngeal retrograde clearance.
evaluated the perception of comfort from parents of 29 infants less than 1 year old, before and after respiratory physiotherapy, and a positive change in the perception was demonstrated with no adverse effects reported. It should be emphasized that the evaluation of parents’ perception of comfort differed between the studies. We believe it is also important to highlight that although only three studies selected side effects as a main
outcome, there were no reports of possible adverse effects in all the other studies included in the revision. 3.5. Safety As described above, seven studies demonstrated improvement in clinical signs, symptoms, and respiratory effort scores [9,10,16–
G.R. Gomes, M.V.F. Donadio / Archives de Pe´diatrie 25 (2018) 394–398
398
19,25]. In the remaining studies in which this improvement was not demonstrated, there was also no report of worsening of these outcomes, that is, studies that demonstrated nonfavorable results for respiratory physiotherapy in the management of AVB due to the absence of statistical significance did not conclude that its application caused any clinical worsening or destabilization of the infants, indicating that its use may be safe. The use of respiratory physiotherapy techniques associated with nasopharyngeal aspiration/nasal suction in the same study group was reported in seven studies [13–15,17,19,21,25], and only three of them reported positive results. Considering the wellknown side effects associated with nasopharyngeal aspiration [32], it is almost impossible to distinguish the effects of respiratory physiotherapy techniques from those associated with nasopharyngeal aspiration/nasal suction in these studies. Indeed, a recent study [10] that evaluated the use of RRC in comparison to nasopharyngeal aspiration in infants with AVB showed that RRC induced fewer complications and less respiratory effort as compared to nasopharyngeal aspiration. 3.6. Perspectives The last systematic review on the topic [12] maintained the conclusion that the use of respiratory physiotherapy techniques does not reduce the severity of the disease. However, it should be noted that more recent studies [10,18] with positive results were not yet included. Nevertheless, clinically, it is common to observe that children with severe or mild conditions do not benefit from the application of respiratory physiotherapy techniques [7]. On the other hand, children with moderate clinical condition seem to benefit [10,16,18]. Consequently, there is still a need for more randomized controlled studies examining modern techniques with slow flow application in a sample of children classified by the degree of severity in order to confirm recent findings. Indication of respiratory physiotherapy based on objective clinical severity evaluation also seems to be a candidate for future studies. 4. Conclusions This review indicates that the use of respiratory physiotherapy techniques in patients with AVB is still controversial. The heterogeneity of techniques evaluated in the studies limits the interpretation of efficacy, although its use was considered safe. The recent results indicating that children with moderate severity had reduced length of hospital stay when under physiotherapy treatment points to the need for multicenter controlled trials in order to confirm these findings. Funding There was no financial support for the study. Disclosure of interest The authors declare that they have no competing interest. References [1] Conway E, Schoettker PJ, Moore A, et al. Empowering respiratory therapists to take a more active role in delivering quality care for infants with bronchiolitis. Respir Care 2004;49:589–99. [2] Giugno KM, Machado DC, Amantea SL, et al. [Concentrations of interleukin-2 in the nasopharyngeal secretion of children with acute respiratory syncytial virus bronchiolitis]. J Pediatr (Rio J) 2004;80:315–20.
[3] Alvarez AE, Marson FA, Bertuzzo CS, et al. [Epidemiological and genetic characteristics associated with the severity of acute viral bronchiolitis by respiratory syncytial virus]. J Pediatr (Rio J) 2013;89:531–43. [4] Teshome G, Gattu R, Brown R. Acute bronchiolitis. Pediatr Clin North Am 2013;60:1019–34. [5] Nicolai A, Ferrara M, Schiavariello C, et al. Viral bronchiolitis in children: a common condition with few therapeutic options. Early Hum Dev 2013;89(Suppl. 3):7–11. [6] Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 2014;134:e1474–502. [7] Postiaux G, Zwaenepoel B, Louis J. Chest physical therapy in acute viral bronchiolitis: an updated review. Respir Care 2013;58:1541–5. [8] Vilaro´ J, Gimeno E, Balana A, et al. Noves propostes terape`utiques en fisiotera`pia de les malaties respirato`ries infantils. Pediatria Catalana 2007;67:278– 84. [9] Gomes ELFD, Postiaux G, Medeiros DRL, et al. Chest physical therapy is effective in reducing the clinical score in bronchiolitis: randomized controlled trial. Braz J Phys Ther 2012;16:241–7. [10] Gomes GR, Calvete FP, Rosito GF, et al. Rhinopharyngeal retrograde clearance induces less respiratory effort and fewer adverse effects in comparison with nasopharyngeal aspiration in infants with acute viral bronchiolitis. Respir Care 2016;61:1613–9. [11] Wang EE, Milner RA, Navas L, et al. Observer agreement for respiratory signs and oximetry in infants hospitalized with lower respiratory infections. Am Rev Respir Dis 1992;145:106–9. [12] Roque i Figuls M, Gine-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. [13] Webb MS, Martin JA, Cartlidge PH, et al. Chest physiotherapy in acute bronchiolitis. Arch Dis Child 1985;60:1078–9. [14] Bohe L, Ferrero ME, Cuestas E, et al. [Indications of conventional chest physiotherapy in acute bronchiolitis]. Medicina [B Aires] 2004;64:198–200. [15] Nicholas KJ, Dhouieb MO, Marshall TG, et al. An evaluation of chest physiotherapy in the management of acute bronchiolitis: changing clinical practice. Physiotherapy 1999;85:669–74. [16] Postiaux G, Louis J, Labasse HC, et al. Evaluation of an alternative chest physiotherapy method in infants with respiratory syncytial virus bronchiolitis. Respir Care 2011;56:989–94. [17] Castro G, Remondini R, Santos A, et al. Ana´lise dos sintomas, sinais clı´nicos e suporte de oxigeˆnio em pacientes com bronquiolite antes e apo´s fisioterapia respirato´ria durante a internac¸a˜o hospitalar. Revista Paulista de Pediatria 2011;29:599–605. [18] Van Ginderdeuren F, Vandenplas Y, Deneyer M, et al. Effectiveness of airway clearance techniques in children hospitalized with acute bronchiolitis. Pediatr Pulmonol 2017;52:225–31. [19] Lanza FDC, Gazzotti MR, Luque A, et al. Fisioterapia respirato´ria em lactentes com bronquiolite: realizar ou na˜o? Mundo da Sau´de Sa˜o Paulo 2008;32:183–8. [20] Sanchez Bayle M, Martin Martin R, Cano Fernandez J, et al. [Chest physiotherapy and bronchiolitis in the hospitalised infant. Double-blind clinical trial]. An Pediatr [Barcelona] 2012;77:5–11 [Article in Spanish]. [21] 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:e1000345. [22] Rochat I, Leis P, Bouchardy M, et al. Chest physiotherapy using passive expiratory techniques does not reduce bronchiolitis severity: a randomised controlled trial. Europ J Pediatr 2012;171:457–62. [23] Remondini R, Santos AZ, Castro G, et al. [Comparative analysis of the effects of two chest physical therapy interventions in patients with bronchiolitis during hospitalization period]. Einstein [Sao Paulo] 2014;12:452–8. [24] Pupin MK, Riccetto AGL, Ribeiro JD, et al. Comparison of the effects that two different respiratory physical therapy techniques have on cardiorespiratory parameters in infants with acute viral bronchiolitis. J Bras Pneumol 2009;35:860–7. [25] Jacinto CP, Gastaldi AC, Aguiar DY, et al. Physical therapy for airway clearance improves cardiac autonomic modulation in children with acute bronchiolitis. Braz J Phys Ther 2013;17:533–40. [26] Halna M, Leblond P, Aissi E, et al. Impact of the consensus conference on the ambulatory treatment of bronchiolitis in infants. Presse Med 2005;34:277–81. [27] Holloway R, Adams EB, Desai SD, et al. Effect of chest physiotherapy on blood gases of neonates treated by intermittent positive pressure respiration. Thorax 1969;24:421–6. [28] McDonnell T, McNicholas WT, et al. Hypoxaemia during chest physiotherapy in patients with cystic fibrosis. Ir J Med Sci 1986;155:345–8. [29] Argent AC, Morrow BM. What does chest physiotherapy do to sick infants and children? Intensive Care Med 2004;30:1014–6. [30] Krause MF, Hoehn T. Chest physiotherapy in mechanically ventilated children: a review. Critical Care Med 2000;28:1648–51. [31] Fink JB. Positioning versus postural drainage. Respiratory Care 2002;47(7): 769–77. [32] American Association for Respiratory Care. Nasotracheal Suctioning-2004 Revision & Update. Respir Care 2004;49:1080–4.
Available online at
ScienceDirect www.sciencedirect.com
Review article
Effects of the use of respiratory physiotherapy in children admitted with acute viral bronchiolitis G.R. Gomes a, M.V.F. Donadio b,* a b
Pontifı´cia Universidade Cato´lica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil Centro Infant, Institute of Biomedical Research, Pontifı´cia Universidade Cato´lica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 October 2017 Accepted 24 June 2018 Available online 29 July 2018
Objective: To evaluate the effects of the use of respiratory physiotherapy in children admitted with acute viral bronchiolitis (AVB). Methods: A literature review was done searching the Pubmed, LILACS, PEDro, and Scielo databases. The following key words were used: bronchiolitis, physiotherapy, techniques, physical therapy, and chest physiotherapy. Both controlled and uncontrolled clinical trials, without limits as to date, were selected. Results: Fifteen articles were included and the use of different techniques of respiratory physiotherapy showed positive results in eight studies. Most (11) were controlled clinical trials, and only two had a double-blind design. Of the 14 studies with a control group, in six this group was submitted to nasopharyngeal aspiration. The most widely used techniques were manual vibration and postural drainage (eight studies), and then tapping/percussion (seven studied). The maneuvers considered as current, e.g., prolonged slow expiration, expiratory flow acceleration, and rhinopharyngeal retrograde clearance, were used in four, four, and two studies, respectively. Conclusions: The use of respiratory physiotherapy in children with AVB remains controversial. The heterogeneity of techniques evaluated in the studies limits the interpretation of efficacy, although its use was considered safe. Recent findings indicating a reduction in the length of the hospital stay remain to be confirmed. C 2018 Elsevier Masson SAS. All rights reserved.
Keywords: Acute viral bronchiolitis Chest physiotherapy Physiotherapy techniques
1. Introduction Acute viral bronchiolitis (AVB) is an acute injury to the respiratory bronchioles associated with a viral infection, with a peak incidence at the age of 2–6 months [1,2]. It results in obstruction of the small-caliber airways, due to infection by seasonal viruses [3]. Although it is usually a self-limiting disease, it produces significant morbidity in infants less than 6 months of age and patients with chronic diseases, as a result of the ventilation-perfusion mismatch, characterized by increased respiratory work [4,5]. The basic principles for the care of children during the hospital stay are oxygen support therapy, fluid administration to prevent dehydration, and guidance to parents [5,6]. In some cases it may be necessary to clear the airway by removing secretions [7]. Among * Corresponding author. Centro Infant, Instituto de Pesquisas Biome´dicas (IPB), avenue Ipiranga, 6690, 28 andar, CEP 90610-000, Porto Alegre, Rio Grande do Sul, Brasil. E-mail address: [email protected] (M.V.F. Donadio). https://doi.org/10.1016/j.arcped.2018.06.004 C 2018 Elsevier Masson SAS. All rights reserved. 0929-693X/
the most commonly used respiratory physiotherapy techniques are those described as conventional physiotherapy, which consists of a combination of tapping, percussion, postural drainage, and assisted cough [8], as well as newer techniques such as prolonged slow expiration (PSE) and rhinopharyngeal retrograde clearance (RRC) [9,10]. Although more recent recommendations suggest that the use of respiratory physiotherapy techniques in the management of AVB should be indicated according to the severity of the disease [7], evaluated through clinical scores [11], the role of these techniques is still controversial and its recommendation challenging. The last systematic review [12] maintained the conclusion that the use of respiratory physiotherapy does not reduce the severity of the disease and should therefore not be used as standard clinical practice for hospitalized patients with severe bronchiolitis. Several aspects should then be carefully examined and revised, including the relation of severity with indication, the main outcomes to be measured, and the type of respiratory technique to be applied. Older studies using conventional techniques did not demonstrate benefits with their use, based on the lack of statistical significance
G.R. Gomes, M.V.F. Donadio / Archives de Pe´diatrie 25 (2018) 394–398
in criteria such as clinical scores, length of hospital stay, or days of oxygen therapy use [13–15]. On the other hand, more recent studies including the use of new techniques of respiratory physiotherapy have demonstrated positive effects in the removal of secretion, reduction of clinical scores, and respiratory discomfort with short-term improvement of respiratory signs and symptoms [10,16,17], as well as length of hospital stay [18]. Therefore, considering the controversies regarding the use of respiratory physiotherapy in children with AVB, the new evidence on more modern techniques and the recent recommendation of basing physiotherapeutic management on disease severity, a comprehensive review on the subject is warranted. Therefore, the objective of this study was to evaluate, through a review of the literature, the effects of the use of respiratory physiotherapy in hospitalized children with AVB. 2. Methods This is an integrative literature review study. Clinical trials evaluating the effects of respiratory physiotherapy in children admitted with a diagnosis of AVB were included. Articles including patients with chronic conditions, review studies, case studies, experimental models, abstracts, response letters, editorials, and duplicate publications, as well as those that did not meet inclusion criteria or that did not address the subject matter were excluded after the analysis of the abstract or full text. The Medline/PubMed, Scielo, LILACS, and PEDro databases were searched, using the following combination of Keywords: ‘‘bronchiolitis AND physiotherapy’’, ‘‘bronchiolitis AND physiotherapy AND techniques’’, ‘‘bronchiolitis AND physical therapy’’, ‘‘bronchiolitis AND physical therapy AND techniques’’, ‘‘bronchiolitis AND chest physiotherapy’’ and ‘‘bronchiolitis AND chest physiotherapy AND techniques’’. Also; a manual search was conducted in the bibliographic references of selected articles; as well as in systematic reviews; in order to search for additional publications that were pertinent to the study. No relevant articles were found through this search. No filters were used for language selection. The searches were conducted from October to December 2016 by two independent authors. After reading the title, followed by the abstract, only studies reported as clinical trials, whether or not they were controlled, were included. No limit was used as to the date of publication or for article selection. Articles that met the inclusion criteria were read in full and the following data were extracted: title, author, year of publication, study design, sample size, respiratory physiotherapy technique, outcomes, and main results. Data collected were tabulated in a Microsoft Excel spreadsheet for analysis. 3. Summary of findings A total of 504 articles were searched. After careful reading of the title and the abstract, 489 were excluded and a total of 15 articles that met the inclusion criteria were selected. Fig. 1 shows the complete search flow of the study. 3.1. Study designs and sample size As shown in Table 1, of the total of 15 articles, the majority (13 articles) were randomized clinical trials [9,10,13–16,18–24], of which only three used a double-blind design [18,20,21]. In 14 studies, a control group was included, but in only six studies was the control group submitted to nasopharyngeal aspiration/ nasal suction [9,10,14,15,19,21]. Also, in six studies, the control group was not submitted to any airway clearance intervention [13,16,18,20,22,24] and in one study healthy children were
395
included [25]. Regarding the sample size, eight articles included a sample with between 19 and 50 patients [9,14–17,19,23,25], four between 81 and 100 [10,13,18,24] and three studied a sample between 103 and 496 patients [20–22]. Although an adequate study design to test an intervention (randomized controlled clinical trial) was used in 14 out of 15 studies, the sample size could be considered small, which was a limitation in most of the studies included. 3.2. Respiratory physiotherapy techniques The most widely used techniques in the articles selected for this review were manual vibration, which appeared in eight articles [9,14,15,17,19,20,24,25] and postural drainage in another eight studies [9,13–15,19,23–25], followed by tapping/percussion in seven studies [13–15,17,19,23,25]. The combination of respiratory physiotherapy techniques and provoked cough appeared in four studies [16,20,22,24] and combined with nasopharyngeal aspiration/nasal suction in eight studies [13–15,17,19,21,23,25]. On the other hand, the maneuvers considered as more recent in pediatric respiratory physiotherapy, such as PSE, acceleration of expiratory flow (AEF) and RRC, were used in four [9,16,20,22], four [17,22–24], and two studies [9,10], respectively. The summary of these findings is presented in Table 1. The use of techniques considered as modern, such as PSE, AEF, and RRC, presented favorable results in the outcomes evaluated in four studies. The PSE is derived from a variation of the total slow expiration in infralateral decubitus with the open glottis, and may be associated with provoked cough and/or preceded by treatment with bronchodilators [8]. It is considered to be well tolerated by infants with muscle fatigue and bronchial reactivity without adverse effects such as alveolar collapse and increased transmural pressure. However, the results of this review point to divergent findings regarding this technique, since the studies by Postiaux et al. [16] and Gomes et al. [9] showed improvements in signs, symptoms, and clinical scores, and the study by Rochat et al. [22] showed no benefits. It is known that pediatric respiratory physiotherapy developed as an adaptation of the techniques used in adult patients. With the emergence of new studies and discoveries, new maneuvers have emerged to fit the anatomical and physiological differences of pediatric patients, especially young infants [5]. On the other hand, some techniques have already been reported as potentially harmful or unsafe for infants, such as tapping and manual vibration [26]. The mechanical action of these techniques may lead to hypoxemia, an increase in intrathoracic pressure, and inefficiency in the clearance of bronchial secretions [26–28], which could explain the lack of efficacy of respiratory physiotherapy using such techniques in infants with AVB. There are also reports of the use of postural drainage, which has been shown to be unfavorable for increasing intracranial pressure, esophageal reflux, and risk of bronchoaspiration [29,30]. Of the articles included reporting the use of postural drainage, only two described the technique, making it difficult to interpret and differentiate the use of positioning during respiratory physiotherapy and the actual use of postural drainage. In the literature, postural drainage is commonly seen and used in adults with excessive production of secretion and with difficulty in sputum clearance, mainly and historically in patients with cystic fibrosis, demanding time in positions of angulated decubitus and knowledge of the anatomy of the airways so that previously mobilized secretion present in the distal bronchi may travel to the central region and/or near the trachea by the effect of gravity on secretions [31]. On the other hand, positioning during respiratory physiotherapy consists in changing the position of the patient to favor ventilation and perfusion and is not necessarily based on the action of gravity [31].
396
G.R. Gomes, M.V.F. Donadio / Archives de Pe´diatrie 25 (2018) 394–398
Fig. 1. Diagram of the search and selection of articles.
3.3. Effects on clinical outcomes Considering the outcomes evaluated, the majority (11 articles) used clinical scores [9,10,13–16,18,19,21–23], seven articles analyzed length of hospital stay [13–16,18,20,23], six analyzed changes in cardiorespiratory parameters [10,16–19,24], four analyzed the duration of oxygen therapy [17,20,21,23], four articles used the parents’ report and the occurrence of complications or adverse effects [10,17,21,23], and one study assessed heart rate variability [25]. Regardless of the techniques used or the type of control group adopted, eight studies (53.3%) [9,10,16–19,23,25] presented results considered by the authors as favorable to respiratory physiotherapy. The remaining articles (47.7%) did not show statistically significant benefits when evaluating the techniques tested [13–15,20–22,24]. These findings are partially in accordance with the 2014 guidelines of the American Academy of Pediatrics [6], which, based on the analysis of clinical and cohort studies, recommends basically supportive therapy, i.e., oxygen therapy, intravenous hydration, and minimal manipulation. According to these guidelines, the intervention of physiotherapy would have no impact on clinical improvement, hospitalization time, and disease course. Although outcomes such as length of hospital stay and oxygen therapy
duration did not show significant change in several studies [13– 16,20,23], a recent study [18] showed that respiratory physiotherapy significantly reduced the length of hospital stay compared to no physiotherapy. It is important to highlight that only mild to moderate severity children were included. On the other hand, it should be considered that one of the main objectives of respiratory physiotherapy is to promote the mobilization and removal of secretions in the airways, improving pulmonary ventilation and contributing to a decrease in breathing effort. In this sense, seven studies demonstrated improvement in parameters of clinical signs and symptoms (HR, RR, and SpO2) and respiratory effort scores (wheezing and chest retractions), indicating a possible benefit for these patients [9,10,16–19,25]. 3.4. Adverse effects Regarding possible adverse effects, only in the study reported by Gadjos et al. [21], with the analysis of 496 infants (mean age, 2 months), were there reports of negative outcomes such as adverse effects (vomiting and respiratory destabilization) and lower perception of comfort from parents during the use of increased expiration technique associated with cough provoked by nasal suction. On the other hand, the study by Castro et al. [17] also
G.R. Gomes, M.V.F. Donadio / Archives de Pe´diatrie 25 (2018) 394–398
397
Table 1 Characteristics, outcomes, and main results of the studies included. Author
Year
Design
n
Webb et al. [13]
1985
Randomized controlled clinical trial
90
Nicholas et al. [15]
1999
Randomized controlled clinical trial
50
Bohe et al. [14]
2004
Open randomized controlled clinical trial
32
Lanza et al. [19]
2008
Randomized controlled clinical trial
19
Pupin et al. [24]
2009
Randomized controlled clinical trial
81
Gajdos et al. [21]
2010
Double-blind randomized controlled clinical trial
496
Postiaux et al. [16]
2011
Randomized controlled clinical trial
20
PSE Provoked cough
Castro et al. [17]
2011
Quasi-experimental, uncontrolled beforeand-after trial
29
Rochat et al. [22]
2012
Open randomized controlled clinical trial
103
Positioning Manual percussion Manual vibration AEF Nasopharyngeal aspiration PSE Slow accelerated expiratory flow Provoked cough
Gomes et al. [9]
2012
Randomized controlled clinical trial
30
Sa´nchez et al. [20]
2012
236
Jacinto et al. [25]
2013
Double-blind randomized controlled clinical trial Nonrandomized controlled clinical trial
Remondini et al. [23]
2014
Randomized clinical trial
29
Van Ginderdeuren et al. [18]
2016
Double-blind randomized controlled clinical trial
93
Assisted autogenic drainage Intrapulmonary percussive ventilation
Length of hospital stay Clinical score SpO2 and HR
Gomes et al. [10]
2016
Randomized controlled clinical trial
100
RCC Nasopharyngeal aspiration
HR, RR, and SpO2 Clinical score
24
Techniques evaluated
Outcomes
Main results
Postural drainage Manual percussion Provoked cough Nasopharyngeal aspiration Postural drainage Manual percussion Manual vibration
Length of hospital stay Clinical score
No significant differences in clinical score and length of hospital stay
Clinical score Length of hospital stay Requirement for oxygen Nasogastric feeding Respiratory disability clinical score Length of hospital stay
" SpO2 after the intervention No significant differences in the other outcomes
HR, RR, and SpO2 Clinical score
HR, RR, and SpO2
# HR after 15 min of intervention in the three groups # Clinical score # RR in the AEF group
Time to clinical stability Adverse effects Parent’s perception of comfort PICU admission Artificial ventilation Antibiotic treatment Wang clinical score SpO2 and HR Length of hospital stay Changes in oxygen support Changes in clinical signs and symptoms Parent’s perception of comfort
Episodes of vomiting and respiratory destabilization and # comfort reported by parents in the group increased exhalation + cough No other differences # Wang score No difference in length of hospital stay No difference in oxygen support # Clinical signs and symptoms " Parent’s perception of comfort
Time to clinical stability Well-being score Respiratory score Occurrence of complications Wang clinical score Length of hospital stay
No significant differences in the outcomes evaluated
Postural drainage Manual percussion Manual vibration Nasopharyngeal aspiration Postural drainage Chest compression/vibration Manual percussion Postural drainage Manual vibration AEF Increased exhalation Provoked cough Nasal suction
Postural drainage Manual vibration PSE RRC Chest compression PSE Manual vibration Provoked cough Postural drainage Manual percussion Manual vibration Nasopharyngeal aspiration Postural drainage Manual percussion AEF Nasopharyngeal aspiration
Length of hospital stay Hours of oxygen use Heart rate variability
Length of hospital stay Clinical score SpO2 Parent’s perception of comfort
No significant differences in the outcomes evaluated
# Clinical score in both intervention groups No difference in length of hospital stay No difference in length of hospital stay # Hours of oxygen use Variation of the HR in the intervention group was similar to that of the control group at rest No difference in SpO2 and length of hospital stay # Clinical score after 10 min in both groups Positive perception of parents Reduction in the length of hospital stay and clinical score in both intervention groups No differences in SpO2 and HR # HR after 10 and 30 min Less occurrence of complications and respiratory discomfort
SpO2: peripheral oxygen saturation; HR: heart rate; PICU: pediatric intensive care unit; RR: respiratory rate; AEF: acceleration of expiratory flow; PSE: prolonged slow expiration; RRC: rhinopharyngeal retrograde clearance.
evaluated the perception of comfort from parents of 29 infants less than 1 year old, before and after respiratory physiotherapy, and a positive change in the perception was demonstrated with no adverse effects reported. It should be emphasized that the evaluation of parents’ perception of comfort differed between the studies. We believe it is also important to highlight that although only three studies selected side effects as a main
outcome, there were no reports of possible adverse effects in all the other studies included in the revision. 3.5. Safety As described above, seven studies demonstrated improvement in clinical signs, symptoms, and respiratory effort scores [9,10,16–
G.R. Gomes, M.V.F. Donadio / Archives de Pe´diatrie 25 (2018) 394–398
398
19,25]. In the remaining studies in which this improvement was not demonstrated, there was also no report of worsening of these outcomes, that is, studies that demonstrated nonfavorable results for respiratory physiotherapy in the management of AVB due to the absence of statistical significance did not conclude that its application caused any clinical worsening or destabilization of the infants, indicating that its use may be safe. The use of respiratory physiotherapy techniques associated with nasopharyngeal aspiration/nasal suction in the same study group was reported in seven studies [13–15,17,19,21,25], and only three of them reported positive results. Considering the wellknown side effects associated with nasopharyngeal aspiration [32], it is almost impossible to distinguish the effects of respiratory physiotherapy techniques from those associated with nasopharyngeal aspiration/nasal suction in these studies. Indeed, a recent study [10] that evaluated the use of RRC in comparison to nasopharyngeal aspiration in infants with AVB showed that RRC induced fewer complications and less respiratory effort as compared to nasopharyngeal aspiration. 3.6. Perspectives The last systematic review on the topic [12] maintained the conclusion that the use of respiratory physiotherapy techniques does not reduce the severity of the disease. However, it should be noted that more recent studies [10,18] with positive results were not yet included. Nevertheless, clinically, it is common to observe that children with severe or mild conditions do not benefit from the application of respiratory physiotherapy techniques [7]. On the other hand, children with moderate clinical condition seem to benefit [10,16,18]. Consequently, there is still a need for more randomized controlled studies examining modern techniques with slow flow application in a sample of children classified by the degree of severity in order to confirm recent findings. Indication of respiratory physiotherapy based on objective clinical severity evaluation also seems to be a candidate for future studies. 4. Conclusions This review indicates that the use of respiratory physiotherapy techniques in patients with AVB is still controversial. The heterogeneity of techniques evaluated in the studies limits the interpretation of efficacy, although its use was considered safe. The recent results indicating that children with moderate severity had reduced length of hospital stay when under physiotherapy treatment points to the need for multicenter controlled trials in order to confirm these findings. Funding There was no financial support for the study. Disclosure of interest The authors declare that they have no competing interest. References [1] Conway E, Schoettker PJ, Moore A, et al. Empowering respiratory therapists to take a more active role in delivering quality care for infants with bronchiolitis. Respir Care 2004;49:589–99. [2] Giugno KM, Machado DC, Amantea SL, et al. [Concentrations of interleukin-2 in the nasopharyngeal secretion of children with acute respiratory syncytial virus bronchiolitis]. J Pediatr (Rio J) 2004;80:315–20.
[3] Alvarez AE, Marson FA, Bertuzzo CS, et al. [Epidemiological and genetic characteristics associated with the severity of acute viral bronchiolitis by respiratory syncytial virus]. J Pediatr (Rio J) 2013;89:531–43. [4] Teshome G, Gattu R, Brown R. Acute bronchiolitis. Pediatr Clin North Am 2013;60:1019–34. [5] Nicolai A, Ferrara M, Schiavariello C, et al. Viral bronchiolitis in children: a common condition with few therapeutic options. Early Hum Dev 2013;89(Suppl. 3):7–11. [6] Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 2014;134:e1474–502. [7] Postiaux G, Zwaenepoel B, Louis J. Chest physical therapy in acute viral bronchiolitis: an updated review. Respir Care 2013;58:1541–5. [8] Vilaro´ J, Gimeno E, Balana A, et al. Noves propostes terape`utiques en fisiotera`pia de les malaties respirato`ries infantils. Pediatria Catalana 2007;67:278– 84. [9] Gomes ELFD, Postiaux G, Medeiros DRL, et al. Chest physical therapy is effective in reducing the clinical score in bronchiolitis: randomized controlled trial. Braz J Phys Ther 2012;16:241–7. [10] Gomes GR, Calvete FP, Rosito GF, et al. Rhinopharyngeal retrograde clearance induces less respiratory effort and fewer adverse effects in comparison with nasopharyngeal aspiration in infants with acute viral bronchiolitis. Respir Care 2016;61:1613–9. [11] Wang EE, Milner RA, Navas L, et al. Observer agreement for respiratory signs and oximetry in infants hospitalized with lower respiratory infections. Am Rev Respir Dis 1992;145:106–9. [12] Roque i Figuls M, Gine-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. [13] Webb MS, Martin JA, Cartlidge PH, et al. Chest physiotherapy in acute bronchiolitis. Arch Dis Child 1985;60:1078–9. [14] Bohe L, Ferrero ME, Cuestas E, et al. [Indications of conventional chest physiotherapy in acute bronchiolitis]. Medicina [B Aires] 2004;64:198–200. [15] Nicholas KJ, Dhouieb MO, Marshall TG, et al. An evaluation of chest physiotherapy in the management of acute bronchiolitis: changing clinical practice. Physiotherapy 1999;85:669–74. [16] Postiaux G, Louis J, Labasse HC, et al. Evaluation of an alternative chest physiotherapy method in infants with respiratory syncytial virus bronchiolitis. Respir Care 2011;56:989–94. [17] Castro G, Remondini R, Santos A, et al. Ana´lise dos sintomas, sinais clı´nicos e suporte de oxigeˆnio em pacientes com bronquiolite antes e apo´s fisioterapia respirato´ria durante a internac¸a˜o hospitalar. Revista Paulista de Pediatria 2011;29:599–605. [18] Van Ginderdeuren F, Vandenplas Y, Deneyer M, et al. Effectiveness of airway clearance techniques in children hospitalized with acute bronchiolitis. Pediatr Pulmonol 2017;52:225–31. [19] Lanza FDC, Gazzotti MR, Luque A, et al. Fisioterapia respirato´ria em lactentes com bronquiolite: realizar ou na˜o? Mundo da Sau´de Sa˜o Paulo 2008;32:183–8. [20] Sanchez Bayle M, Martin Martin R, Cano Fernandez J, et al. [Chest physiotherapy and bronchiolitis in the hospitalised infant. Double-blind clinical trial]. An Pediatr [Barcelona] 2012;77:5–11 [Article in Spanish]. [21] 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:e1000345. [22] Rochat I, Leis P, Bouchardy M, et al. Chest physiotherapy using passive expiratory techniques does not reduce bronchiolitis severity: a randomised controlled trial. Europ J Pediatr 2012;171:457–62. [23] Remondini R, Santos AZ, Castro G, et al. [Comparative analysis of the effects of two chest physical therapy interventions in patients with bronchiolitis during hospitalization period]. Einstein [Sao Paulo] 2014;12:452–8. [24] Pupin MK, Riccetto AGL, Ribeiro JD, et al. Comparison of the effects that two different respiratory physical therapy techniques have on cardiorespiratory parameters in infants with acute viral bronchiolitis. J Bras Pneumol 2009;35:860–7. [25] Jacinto CP, Gastaldi AC, Aguiar DY, et al. Physical therapy for airway clearance improves cardiac autonomic modulation in children with acute bronchiolitis. Braz J Phys Ther 2013;17:533–40. [26] Halna M, Leblond P, Aissi E, et al. Impact of the consensus conference on the ambulatory treatment of bronchiolitis in infants. Presse Med 2005;34:277–81. [27] Holloway R, Adams EB, Desai SD, et al. Effect of chest physiotherapy on blood gases of neonates treated by intermittent positive pressure respiration. Thorax 1969;24:421–6. [28] McDonnell T, McNicholas WT, et al. Hypoxaemia during chest physiotherapy in patients with cystic fibrosis. Ir J Med Sci 1986;155:345–8. [29] Argent AC, Morrow BM. What does chest physiotherapy do to sick infants and children? Intensive Care Med 2004;30:1014–6. [30] Krause MF, Hoehn T. Chest physiotherapy in mechanically ventilated children: a review. Critical Care Med 2000;28:1648–51. [31] Fink JB. Positioning versus postural drainage. Respiratory Care 2002;47(7): 769–77. [32] American Association for Respiratory Care. Nasotracheal Suctioning-2004 Revision & Update. Respir Care 2004;49:1080–4.