An Evaluation of Chest Physiotherapy in the Management of Acute Bronchiolitis

Changing clinical practice

Summary Aims A clinical trial was undertaken to test the hypothesis that CPT may be of benefit to those infants with acute viral bronchiolitis whose disease on admission was severe enough to require nasogastric or intravenous feeding. The clinical impression that CPT does not increase respiratory distress was also investigated. Method The treatment group (n = 26) receiving physiotherapy was compared with a control group (n = 24). Subjects in the control group were nursed in modified postural drainage positions with suction as required. Outcome was assessed by comparison of clinical score, duration of hospital stay, requirement for oxygen, and nasogastric feeding. Results There was no significant difference in overall outcomes between the two groups. Analysis of clinical scores suggested that less severely ill infants (score < 9.5 on admission) in the treatment group recovered at a slower rate than the equivalent infants in the control group. Conclusions There was no increase in the respiratory distress of infants who received CPT according to the protocol, but chest physiotherapy is of no benefit in the management of acute viral bronchiolitis in the absence of other pathologies.
Introduction Bronchiolitis is the most common acute respiratory tract infection in infants. Epidemics tend to occur during winter months (Phelan, 1982). This infection, predominantly due to respiratory syncytial virus, results in admission to hospital of between 1% and 2% of all infants born in the United Kingdom (Milner, 1982, 1988). It is a self-limiting disease causing production of secretions which may, in the age group affected, require nasopharyngeal suction (Young, 1988). The use of chest physiotherapy (CPT), including the use of manual techniques, had in 1986 become common practice at the Royal Hospital for Sick Children, Edinburgh (RHSCE), most infants suffering from acute bronchiolitis being automatically referred for physiotherapy. The dilemma for the referring physicians and physiotherapists was

Key Words Chest physiotherapy, bronchiolitis. by K J Nicholas M O Dhouieb T G Marshall A T Edmunds M B Grant

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whether CPT was a necessary component in the management of these patients. The clinical impression of the paediatricians and physiotherapists at RHSCE was that CPT reduced the intensity of the acute illness in those children whose disease was at the severe end of the spectrum and did not increase their respiratory distress. This impression was contrary to a previous trial (Webb et al, 1985), which found that CPT had no effect on the natural course of the illness and suggested that the handling inherent in CPT increased the respiratory distress of the infants treated. A subsequent article reviewing adult chest physiotherapy (Sutton, 1988), recommended that the use of CPT should be limited to those patients with actual or potential sputum production. The question asked in this trial was whether CPT was required for infants producing secretions, or whether good nursing care, including positioning and suctioning before feeds, would relieve the airway obstruction with minimal handling. The aim of the RHSCE study was to investigate the clinical impression that CPT was of benefit to infants whose disease was at the severe end of the spectrum and, as performed by the RHSCE physiotherapists, did not cause an increase in their respiratory distress. Method Sample During the three years 1986 to 1989, October to April inclusive, infants were identified for inclusion in the present study if they had been admitted to RHSCE with a clinical diagnosis of acute bronchiolitis and their respiratory distress was so severe that clinical staff judged that they required nasogastric tube feeding or intravenous fluids. The requirement for nasogastric
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Nicholas, K J, Dhouieb, E M O, Marshall, T G, Edmunds, A T and Grant, M B (1999). An evaluation of chest physiotherapy in the management of acute bronchiolitis: Changing clinical practice, Physiotherapy, 85, 12, 669-674.

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feeding or intravenous fluids defines a band of relative severity, as they are required when infants are too ill to tolerate breast or bottle feeding because of breathlessness, exhaustion, hypoxia, coughing or inability to absorb nasogastric feeds. Following informed parental consent, 50 infants (23 boys, 27 girls) with a mean age of 2.8 months (range 0.4 to 7.6 months) were studied.

Physiotherapy Protocol
Optimal treatment
Patient is treated on physiotherapist's knee; percussion and vibration in right side lying, left side lying and sitting; suction performed after each side if necessary until clear; no oxygen required during treatment. Two people to do physiotherapy and suction.

Procedure Infants were randomly allocated to control (n = 24) and treatment (n = 26) groups using a random sequence number generated by the Medical Statistics Unit of the University of Edinburgh. Both groups received similar nursing and medical management. Standard RHSCE management included maintenance of normal blood gases, nasopharangeal suction to clear secretions, maintenance of fluid balance, temperature control, positioning, monitoring of vital signs, and antibiotics if indicated. Exit from the trial was automatic after five days. Exit from the trial also occurred if there was clinical deterioration to the point where the patient required admission to the intensive care unit. One infant came into this category. Treatment Protocol A physiotherapy protocol was established which identified both an optimal treatment, CPT manual techniques of percussion and vibrations performed in postural drainage positions and the possible modifications required (see panel). Physiotherapy input and suction were responsive, ie balancing the need for secretion clearance with the infant's ability to tolerate intervention. The selection and sequence of techniques to be used were based on the clinical judgement of the physiotherapists working on the medical wards including on-call and weekend staff. Suction was performed by nurses during physiotherapy and before feeds as necessary. Oxygen saturation was measured using pulse oximetry before, during and after physiotherapy sessions. Infants in the control group were nursed in modified postural drainage positions with suction performed by nurses as required. Data Collection Clinical Outcome Measures The effectiveness of CPT was evaluated using a set of specific parameters, ie a clinical scoring system (Webb et al, 1985) to assess change in clinical status, differences in length of hospital stay, provision of inspired oxygen and requirement for nasogastric feeding. A concurrent pilot study of changes in oxygen saturation (SaO 2 ) during physiotherapy was initiated to evaluate the possibility of respiratory distress resulting from physiotherapy handling.

Modifications
General position: If unable to tolerate treatment on knee then on flat cot, if unable to tolerate this then on head-up tipped cot (as nursed). Postural drainage: If patient is treated in cot then sitting modified to supine lying with head-up tip. If not tolerating change of position, then as many as able in one session. If not handling well, then treated in position found. Treatment timed with turning to concentrate on any area of collapse/consolidation. Treatment timed with nursing procedures to create minimum disturbance. Techniques: If patient is unstable and unable to tolerate percussion then vibrations only. Suction: If not tolerated until clear then as often as able. Oxygen: An oxygen supply via mask or bag will be on hand during all treatment. If not tolerating treatment with no oxygen then it will be given during treatment. If not tolerating this then infant will remain in headbox with extra oxygen during treatment.
Not tolerating is defined by respiratory distress, ie raised cyanosis, raised recession and respiratory rate, raised heart rate to unacceptable levels for that patient.

Table 1: Clinical scoring system

0 - 0.5 Respiratory rate Heart rate Blood gases PCO2 kPa Rhinitis Hyperinflation Use of accessory muscles Recession Cough Wheeze Crackles < 40 < 120 <6 Mild Mild Mild Mild Mild Nil Nil 1 - 1.5 40 - 60 120 - 160 6-8 Moderate Moderate Moderate Moderate Moderate Auscultate Local 2 > 60 >160 >8 Severe Severe Severe Severe Severe Audible Widespread Total

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Clinical Status A validated scoring system (Dick, 1991) was used to assess any change in clinical status over five days (table 1). The higher the score, the more severe the clinical signs and symptoms. All components were scored individually, twice in 24 hours, so far as possible by a single observer -- ie two medical staff in the first year (TM 84%, RH 16%) and by one (TM) during the subsequent two years. Oxygen Saturation A pilot study using pulse oximetry to measure oxygen saturation (SaO 2 ) ran concurrently with the main trial. SaO2 was measured at three points during a physiotherapy session; five minutes before treatment (baseline), during treatment (intervention) and ten minutes after the end of treatment (recovery). A sensor was fixed to the infant's toe or thumb, the basic requirement being the achievement of a reliable signal. Patients who did not require supplementary oxygen were treated and measured in air. Those patients who did not desaturate on the removal of oxygen were treated and measured in air with oxygen to hand. The patients who did desaturate received supplemental oxygen throughout treatment and measurement. Responsive Physiotherapy The selection of chest physiotherapy techniques, length of treatment and number of treatments was based on the clinical judgement of the physiotherapists according to the optimal protocol (see panel). All selected components were recorded on a data collection sheet to allow for retrospective analysis. The components of CPT to be selected were listed on the data collection sheet and include general and specific postural drainage positions and manual techniques; large and small amplitude vibrations and percussion. The data collection sheet was completed during each treatment session and the data analysed retrospectively (Dick, 1991). Ethical Approval Ethical approval was obtained before the trial from the Paediatric/ Reproductive Medicine Ethics Group, RHSCE. Patients were excluded from the trial if parental permission was refused or if they had another underlying pathological condition compromising respiratory status, for

example prematurity, cardiac problems or a neurological condition. Statistical Analysis In order to fulfil the aim of the present study, the infants clinical scores were subjected to the Students t-test for matched subjects in order to compare differences between the two groups. In addition the pulse oximetry data from the two groups were compared using the paired Students t-test, and the Mann-Whitney U-test was used to compare differences in length of hospital stay, provision of inspired oxygen and requirement for nasogastric feeding. There was retrospective descriptive analysis of chest physiotherapy. The alpha value was set at 0.05. Results A total of 50 infants (23 boys, 27 girls) with a mean age 2.8 months (range 0.4 to 7.6) were studied over three years. The two groups were similar in regard to age, sex, admission score, and the proportion who were respiratory syncytial virus positive (table 2).
Table 2: Group characteristics of trial subjects

Characteristics Age Mean (months) Range (months) Sex M : F Admission clinical score Mean Minimum Maximum Virology RSV positive RSV negative No result Supplemental oxygen Mean (hours) Range (hours) Patient numbers Nasogastric feeds Mean (hours) Range (hours) Hospital stay Mean (days) Range (days)

Control (n = 24)

Physiotherapy (n = 26)

3.2 0.4 - 8.3 10 : 14

2.4 0.4 - 6.9 13 : 13

9.1 5 17

10.86 4 14.5

19 ( 79% ) 3 ( 13% ) 2 ( 8% )

22 ( 85% ) 3 ( 12% ) 1 (4% )

63 2.3 - 128 17 ( 70.8% )

86 36 - 148 17 ( 65.3%)

92 8 - 225

86 18 - 161

6.6 2.3 - 11.5

6.7 3 - 9.5

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12

10

0 1 2 3 4 5 6 7 8 9 10

Data collection points (5 days) Treatment group (n = 9) Control group (n = 15) + 2SD 2SD

in five daily scores for those infants with admission scores greater than 9.5 (control 9, physiotherapy 16). Analysis of daily scores in those with admission scores less than 9.5 (control 15, physiotherapy 9), suggested that the infants in the treatment group recovered at a slower rate than their equivalents in the control group. There was a statistically significant difference in scores 7, 8, and 9 corresponding to days 4 and 5 (see figure). The results were not significant when using the Mann-Whitney U test to compare the observed differences between the two groups in provision of oxygen and the requirement for nasogastric or intravenous feeding. Hospital stays in both groups were very similar. Exit from the trial was required for one infant owing to admission to intensive care. Oxygen Saturation The paired Students t-test was used to compare the progressive result of CPT on SaO2 in air or oxygen in the same subjects. This group (n = 28) included two infants excluded from the trial as they had not been clinically scored. The baseline (before physiotherapy) readings were compared against intervention (physiotherapy) and recovery (after physiotherapy) readings (fig 2). Intervention readings were similarly compared with recovery readings. There was a decrease in SaO 2 between baseline and intervention which was not statistically significant. A subsequent rise in SaO 2 between inter vention and recovery was significant at the 0.05 level. Responsive Physiotherapy Descriptive analysis of these data indicated that, in keeping with the protocol, the treatments generally progressed from the least stressful postural drainage position, eg one position on a tipped bed, to the most stressful, eg all postural drainage positions on a physiotherapist's knee. Subjective obser vation of the physiotherapists treatment during the trial indicated that if a patient was unable to tolerate a full treatment, the response was to decrease the treatment time and increase the number of treatments, ie the physiotherapists appeared to modify their treatment in response to the patients ability to withstand the handling inherent in CPT. Discussion The trial did not confirm the clinical impression that CPT reduced the intensity of

Fig 1: Sequential clinical scores for infants with admission score < 9.5

Mean scores (SaO2)

100

98

96

94

92

90

88

86

84

82

80

Before physiotherapy

Physiotherapy

After physiotherapy

Fig 2: Mean oxygen saturation (SaO2) 1 SD in air and supplementary oxygen (N = 28)

On analysis of the sequential clinical scores over five days in all 50 cases (control group n = 24, physiotherapy group n = 26), the mean scores were higher in the physiotherapy group than in the controls. The differences were not, however, statistically significant. Subsequently, on the basis of the mean clinical score on admission, the infants were divided into two groups: those scoring 9.5 or below on admission (n = 24) and those scoring 10 or above (n = 26); the higher scoring of the second group reflecting a greater illness severity on admission. Using the Students t-test for matched subjects there were no significant differences
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the acute illness in these patients. It is possible that that the inclusion of CPT slows the normal recovery in patients who on admission are moderately ill, but does not significantly affect the course of the illness of severely ill patients. The inclusion of CPT had no statistically significant effect on the length of hospital stay, the requirement for supplemental oxygen or nasogastric feeding. However, the degree of handling which these patients received during CPT did not appear to increase their respiratory distress and it is possible that the suggestion by Webb et al (1985) that CPT increases the respiratory distress of infants may be explained by the difference in CPT interventions, and that respiratory distress was avoided in the RHSCE trial by the use of responsive CPT. Analysis of oxygen saturation readings indicated that responsive CPT as per formed did not cause desaturation. The Webb trial had described a standard CPT treatment for all infants admitted with bronchiolitis which had resulted in a total of 30 minutes daily treatment. Discussion during the design stage of this trial had revealed conflicts present between a clinical and a research approach to the evaluation of CPT. The RHSCE physiotherapists felt that a standard treatment removed elements which were an essential part of their practice. They wished to be able to respond to any changing clinical situation and felt that a standard treatment dose increased the possibility of over-treatment and with it the chance of increasing respiratory distress. The functional requirement for nasogastric feeding as a criterion for entry to the RHSCE trial had allowed the selection of those infants whose disease was at the severe end of the spectrum. In the previous study (Webb et al, 1985) there was no apparent selection, all infants admitted with bronchiolitis during the study period being eligible for inclusion. In spite of these trial design differences, the combined results of this and the previous bronchiolitis trial (Webb et al, 1985), indicate that CPT does not affect the progress of any infant with uncomplicated acute bronchiolitis. The explanation for the conclusions of both of these trials may be that the inclusion of percussion and vibration -- manual techniques to mobilise adherent secretions (Gallon, 1992 ) -- are unnecessary in the presence of generally free-moving mucus in

the airways of infants whose bronchiolitis is uncomplicated by any other pathology. In these circumstances excess mucus may be cleared by nursing positioning and suction. The major limitations of this study arise partly from the effects of study design and partly from the lack of reliable and valid tools to evaluate CPT. The low number (50) of infants recruited to a three-year trial may be explained by entry to the trial being limited to those patients with moderate to severe bronchiolitis as evidenced by the need for nasogastric or intravenous feeding. The selection of a responsive approach to treatment poses obvious problems for others wishing to replicate this study, though an attempt was made in this case to define an optimal protocol with modifications. A further limitation was common to a number of bronchiolitis trials (Henry et al, 1983; Webb et al, 1985; Barry et al, 1986), ie the use of a non-validated clinical score system. This limitation was addressed in this trial by using a questionnaire circulated to consultant paediatricians and senior registrars with responsibility for infants with bronchiolitis, to validate the most common clinical markers used in bronchiolitis. As the trial did not confirm the clinical impression that CPT reduced the intensity of acute viral bronchiolitis, the report was not offered for publication in 1989 or 1990. In the meantime, the concomitant finding that chest physiotherapy is of no benefit in the absence of other pathologies has added value to the study. The results of the trial have changed clinical practice for both medical and physiotherapy staff at the RHSCE. Patients with acute viral bronchiolitis and no other pathology are no longer being referred for physiotherapy, and the resulting change in medical clinical practice has decreased the overall physiotherapy departmental workload in the epidemic winter months, and enabled a more effective use of paediatric physiotherapy resources in the paediatric setting. Previously staff had had to be relocated from other duties during the week, taking resources from other physiotherapy areas, and a second on-call physiotherapist was required. The results of ongoing clinical monitoring give no reason to reverse the decision to change practice. There has been no increase in the numbers of infants with uncomplicated acute viral bronchiolitis developing lobar consolidation or collapse, or requiring admission to intensive care.

Authors Kate Nicholas (ne Dick) MCSP DipTP BA MPhil was a senior lecturer in physiotherapy at Queen Margaret College. This trial was part of her thesis submitted for the degree of Master of Philosophy. Elaine Dhouieb MCSP is a senior physiotherapist at Edinburgh Sick Children's NHS Trust and was principal clinical physiotherapist on the trial. Tom Marshall is a consultant paediatrican at Edinburgh Sick Children's NHS Trust. At the time of the study he was senior registrar and clinically scored the patients. Trevor Edmunds is a consultant paediatrican and Mo Grant MCSP is head of physiotherapy at Edinburgh Sick Children's NHS Trust. The trial was designed and run as a collaborative effort between the staff of the Royal Hospital for Sick Children and the Department of Physiotherapy, Queen Margaret College. This article was received on July 21, 1997, and accepted on July 29, 1998.

Address for Correspondence Mrs K J Nicholas, Department of Physiotherapy, Queen Margaret University College, Leith Campus, Duke Street, Edinburgh EH6 8HF.

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Acknowledgements We thank the parents who consented to their child's entry to the trial. Thanks are also due to Dr Robin Prescott, Director of the Medical Statistics Unit, Edinburgh University, for his help with statistical analysis; to the Avenol Trust for its financial support, and to all the on-call physiotherapists who added pulse oximetry to their workload.

Conclusion While numbers in the study were limited, it appears that chest physiotherapy has no effect on the course of recovery in severely ill infants and appeared to slow down the recovery of moderately ill infants who had acute viral bronchiolitis with no other underlying pathology. Chest physiotherapy per formed using the protocol did not appear to increase respiratory distress in the patients treated, perhaps because CPT was responsive to the patients clinical state. It is now standard clinical practice at the Royal
References Barry, W, Cockburn, F, Cornall, R, Price, J F, Sutherland, G and Vardag, A (1986). Ribavirin aerosol for acute bronchiolitis, Archives of Disease in Childhood, 61, 593-597. Dick, K J (1991). Investigation and evaluation of physiotherapy intervention in acute bronchiolitis of infancy, Masters Thesis, Department of Physiotherapy, Queen Margaret College, Edinburgh. Etches, P C and Scott, B (1978). Chest physiotherapy in the newborn: Effect on secretions removed, Paediatrics, 61, 713-715. Finer, N N, Boyd, J and Grace, M G (1978). Chest physiotherapy in the neonate: A controlled study, Pediatrics, 61, 282-285. Finer, N N, Moriarty, R R, Boyd, J, Phillips, H J, Stewart, A R and Ulan, O (1979). Postextubation atelectasis: A retrospective review and prospective study, Journal of Paediatrics, 94, 110-113. Gallon, A (1992). The use of percussion, Physiotherapy, 78, 2, 85-89.

Hospital for Sick Children in Edinburgh that patients with acute viral bronchiolitis and no other pathology are no longer being referred for physiotherapy. This change has not resulted in an increase in the complications of this disease. Patients with additional pathology compromising respiratory function, eg neurological conditions, heart defects, lung pathology, are still assessed by the physiotherapists for chest physiotherapy, as are those requiring admission to intensive care and ventilation.

Henry, R L, Milner, A D and Stokes, G M (1983). Ineffectiveness of ipratropium bromide in acute bronchiolitis, Archives of Diseases of Childhood, 58, 925-926. Hough, A (1996). Physiotherapy in Respiratory Care, Chapman and Hall, London. Milner, A D (1982 ). Acute airway obstruction in children under five, Thorax, 37, 641-645. Milner, A D (1988). Acute bronchiolitis in infants, Booth Hall Childrens Postgraduate Centre, July 15, Update. Phelan, P D (1982). Respiratory Illness in Children, Blackwell, Oxford, 2nd edn. Sutton, P P (1988). Chest physiotherapy: A time for reappraisal, British Journal of Diseases of the Chest, 82, 127-137. Webb, M, Martin, J, Cartiledge, P, Ng, Y and Wright, N (1985). Chest physiotherapy in acute bronchiolitis, Archives of Diseases of Childhood, 60, 1078-79. Young, C S (1988).Airway suctioning: A study of physiotherapy practice, Physiotherapy, 74, 1, 13-15.

Key Messages I The presence of secretions does not inevitably mean that chest physiotherapy is indicated. I In infants, the requirement for nasogastric feeding or intravenous fluids is a useful functional measure to define a band of relative severity. I A responsive approach to physiotherapy, ie balancing the need for suction clearance with the infants ability to

tolerate intervention, is effective in minimising any respiratory distress which may be caused by the handling inherent in chest physiotherapy I Clinical team research is an effective way to change clinical practice. Leads to a general acceptance of results, and consequent changing of practice.

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