18 www.aapgrandrounds.

org
CRITICAL CARE
Chest Physiotherapy for Pneumonia
Source: Lukrafa JL, Fuchs SC, Fischer GB, et al. Chest phys-
iotherapy in paediatric patients hospitalized with community-
acquired pneumonia: a randomized clinical trial. Arch Dis Child.
2012;97(11):967-971; doi:10.1136/archdischild-2012-302279
R
esearchers from Brazil
and Chile sought to as-
sess the efcacy of chest
physiotherapy (CPT) among
children hospitalized with com-
munity-acquired pneumonia.
Hospitalized children 1 to 12
years of age who met clinical
and radiologic criteria for community-acquired pneumonia were
enrolled. Children were randomized to either the intervention (CPT)
or control group. Children in the control group received routine care
that included nonmandatory requests to encourage cough and deep
breathing. Children <5 years old assigned to the intervention group
received a standardized CPT protocol (manual thoracic vibration
with cupped hands, thoracic compression, positive expiratory pres-
sure, and artifcially stimulated cough and suctioning if needed).
Tose >5 years old received the same CPT protocol and in addition
were required to do breathing exercises consisting of forced exhala-
tion with the glottis open. Tese treatments were done 3 times per
day for a period of 10 to 15 minutes each. Children in both groups
received antibiotics and, if indicated, oxygen. Te primary endpoints
were reduction of respiratory rate and improvement in an illness
severity score based on the presence or absence of tachypnea, retrac-
tions, desaturation, fever, and radiograph evidence of pleural efu-
sion. A secondary outcome was duration of hospitalization.
Of the 362 potentially eligible patients, 41 were enrolled in the
control group and 38 in the CPT group. At baseline, neither demo-
graphic features, severity of illness, nor initial radiologic lung fnd-
ings difered signifcantly between study groups. Notably, however,
10 children (29%) in the CPT group had a pleural efusion compared
to 4 (11%) in the standard therapy group (P = .06). During hospi-
talization, 4 children (3 in the CPT group) were treated with chest
tubes and were excluded from further study analysis. Neither length
of hospital stay (median 8 days in the CPT vs 6 in the control group),
changes in respiratory rate, nor changes in severity scores difered
signifcantly by study group.
Te authors conclude that CPT provided no additional beneft for
hospitalized children with community-acquired pneumonia. Teir
conclusions support the recent British Toracic Society Guidelines
that recommend against CPT for treatment of pneumonia in chil-
dren.
1

Commentary by
Linda Keele, MD, Pediatric Critical Care Medicine, University of Utah, Salt
Lake City, UT
Dr Keele has disclosed no nancial relationship relevant to this commentary. This commentary does not contain a
discussion of an unapproved/investigative use of a commercial product/device.
CPT consists of various techniques, including gravity-assisted
drainage/postural drainage, chest wall percussion, chest wall vibra-
tions, deep breathing or bagging methods to increase chest infation,
and directed cough.
1-3
More recent additions include mechanical
devices such as futter, intrapulmonary percussive ventilation (IPV),
and positive expiratory pressure (PEP) masks. All of these techniques
are used to promote either secretion clearance or re-expansion of
atelectatic areas.
2-3
CPT is performed by trained physiotherapists or
respiratory therapists with patient-specifc directed goals. Despite
lack of evidence demonstrating its utility, it is used commonly in
ICUs and on the wards in hospitals throughout the world.
Multiple randomized controlled studies in adults and children
have investigated the utility of CPT for various disease processes
including ventilator-associated pneumonia, bronchiolitis, atelectasis,
spinal muscular atrophy, and cystic fbrosis. Most have not shown
beneft. A 2012 Cochrane review of 9 clinical trials including 891
participants with bronchiolitis reported that CPT did not improve
respiratory parameters, length of hospital stay, severity of illness,
or oxygen requirements.
4
CPT used in these studies consisted of
vibration and percussion techniques as well as passive expiratory
techniques. Tis review updated prior bronchiolitis and CPT reviews
in 2002 and 2007 reporting similar conclusions.
Te current investigators evaluated the addition of CPT to stan-
dard treatment of community-acquired pneumonia in children.
Consistent with the results of previous studies, they found no beneft
from CPT in terms of improved clinical status or decreased duration
of hospitalization. Despite this lack of evidence, CPT is still com-
monly used in children without chronic pulmonary disease.
Te evidence for the use of CPT in some chronic diseases is less
clear. Te cystic fbrosis guidelines developed in 2009 recommend
use of all of these techniques to enhance mucous transport and lung
function, but only short-term efects were documented. Tey state
that a lack of evidence does not equate to a lack of beneft and thus
recommend prolonged therapy with CPT.
5
Similarly, a consensus
statement on the care for infants and children with spinal muscular
atrophy recommends use of CPT, but drew no conclusions regarding
the optimal technique for secretion mobilization because evidence
was lacking.
6

Overall, CPT is a relatively benign therapy with very few side ef-
fects and typically is well tolerated by children. For those with chronic
illnesses marked by poor airway clearance CPT may be helpful.
Editors Note
Given multiple trials in a variety of settings showing no or limited
efcacy, one wonders why CPT is used for any condition in pediatrics.
Perhaps tradition trumps evidence. Although it may be benign, CPT
provided by highly skilled professionals is far from inexpensive.
References
1. Harris M, et al. Torax. 2011;66(suppl 2):ii1-ii23; doi:10.1136/thoraxjnl-2011-200598
2. Nitoumenopoulos G, et al. Intensive Care Med. 2002;28(7):850-856; doi:10.1007/s00134-
002-1342-2
3. Nowobilski R, et al. Polskie Arch. 2010;120(11):468-478
4. Roque I, et al. Cochrane Database Syst Rev. 2012;2:CD004873
5. Flume PA, et al. Respir Care. 2009;54(4):522-537
6. Wang CH, et al. J Child Neurol. 2007;22(8):1027-1049; doi:10.1177/0883073807305788
Key words: pneumonia, chest physiotherapy, pleural efusion
PICO
Question: Among children hospitalized with
community-acquired pneumonia, does chest
physiotherapy improve respiratory rate,
illness severity, and length of hospital stay?
Question type: Intervention
Study design: Prospective randomized