chest physiotherapy for preventing morbidity in babies being extubated from mechanical...

Chest physiotherapy for preventing morbidity in babies being

extubated from mechanical ventilation (Review)

Flenady V, Gray PH

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library

2010, Issue 10

http://www.thecochranelibrary.com

Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 1 Postextubation lobar

collapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Analysis 1.2. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 2 Reintubation within

24hrs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Analysis 1.3. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 3 Pneumonia. . . 19

Analysis 1.4. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 4 Bradycardia. . 19

Analysis 1.5. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 5 Intraventricular

haemorrhage-all grades. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Analysis 1.6. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 6 Intraventricular

haemorrhage - Grades 3 and 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Analysis 1.7. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 7 Death prior to

discharge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Analysis 1.8. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 8 Duration of mechanical

ventilation (days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Analysis 1.9. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 9 Duration of

nasopharyngeal CPAP( days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22


supplemental oxygen (days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22


neonatal intensive care stay (days). . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Analysis 2.1. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation, Outcome 1

Postextubation lobar collapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23


Reintubation within 24hrs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24


Bradycardia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24


Intraventricular haemorrhage - all grades. . . . . . . . . . . . . . . . . . . . . . . . . 25


Intraventricular haemorrhage - Grades 3 and 4. . . . . . . . . . . . . . . . . . . . . . . 25

Analysis 2.6. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation, Outcome 6 Death

prior to discharge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26


Duration of mechanical ventilation (days). . . . . . . . . . . . . . . . . . . . . . . . . 26


Duration of nasopharyngeal CPAP( days). . . . . . . . . . . . . . . . . . . . . . . . . 27


Duration of supplemental oxygen (days). . . . . . . . . . . . . . . . . . . . . . . . . 27

iChest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)



Duration of neonatal intensive care stay (days). . . . . . . . . . . . . . . . . . . . . . . 28

Analysis 3.1. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency),

Outcome 1 Post extubation lobar collapse. . . . . . . . . . . . . . . . . . . . . . . . . 28


Outcome 2 Reintubation within 24 hours. . . . . . . . . . . . . . . . . . . . . . . . . 29


Outcome 3 Pneumonia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30


Outcome 4 Bradycardia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31


Outcome 5 Intraventricular haemorrhage- all grades. . . . . . . . . . . . . . . . . . . . . 32


Outcome 6 Intraventricular haemorrhage - Grades 3 and 4. . . . . . . . . . . . . . . . . . . 33


Outcome 7 Death prior to discharge. . . . . . . . . . . . . . . . . . . . . . . . . . . 34


Outcome 8 Duration of mechanical ventilation (days). . . . . . . . . . . . . . . . . . . . . 35


Outcome 9 Duration of nasopharyngeal CPAP( days). . . . . . . . . . . . . . . . . . . . . 35


Outcome 10 Duration of supplemental oxygen (days). . . . . . . . . . . . . . . . . . . . . 36


Outcome 11 Duration of neonatal intensive care stay (days). . . . . . . . . . . . . . . . . . . 37

37WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

37HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iiChest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)


[Intervention Review]

Chest physiotherapy for preventing morbidity in babies beingextubated from mechanical ventilation

Vicki Flenady1, Peter H Gray2

1Mater Medical Research Institute, Mater Health Services, Wooloongabba, Australia. 2Newborn Services, University of Queensland,

South Brisbane, Australia

Contact address: Vicki Flenady, Mater Medical Research Institute, Mater Health Services, Level 2 Quarters Building, Annerley Road,

Wooloongabba, Queensland, 4102, Australia. [email protected].

Editorial group: Cochrane Neonatal Group.

Publication status and date: Edited (no change to conclusions), published in Issue 10, 2010.

Review content assessed as up-to-date: 9 November 2009.

Citation: Flenady V, Gray PH. Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation.

Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000283. DOI: 10.1002/14651858.CD000283.


A B S T R A C T

Background

Chest physiotherapy has been used to clear secretions and help lung ventilation in newborns who have needed mechanical ventilation

for respiratory problems. However, there are concerns about the safety of some forms of chest physiotherapy.

Objectives

To determine the effects of active chest physiotherapy on infants being extubated from mechanical ventilation for respiratory failure.

Search strategy

The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of electronic databases: Oxford

Database of Perinatal Trials; Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2005);

MEDLINE (1966 to February 2009); CINAHL (1982 to February 2009); and EMBASE (2006 to February 2009), previous reviews

including cross references, abstracts, conferences, symposia proceedings, expert informants and journal hand searching.

Selection criteria

All trials utilising random or quasi-random patient allocation, in which active chest physiotherapy was compared with non-active

techniques (e.g. positioning and suction alone) or no intervention in the peri-extubation period.

Data collection and analysis

Assessment of methodological quality and extraction of data for each included trial was undertaken independently by the authors.

Subgroup analysis was performed on different treatment frequencies and gestational age less than 32 weeks. Meta-analysis was conducted

using a fixed effects model. Results are presented as relative risk (RR), risk difference (RD) and number needed to treat (NNT) for

categorical data and mean difference (MD) for data measured on a continuous scale. All outcomes are reported with the use of 95%

confidence intervals.

1Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)


mailto:[email protected]

Main results

In this review of four trials, two of which were carried out 15 and 23 years ago, no clear benefit of peri-extubation active chest

physiotherapy can be seen. Active chest physiotherapy did not significantly reduce the rate of postextubation lobar collapse [typical

RR 0.80 (95% CI 0.49,1.29)], though a reduction in the use of reintubation was shown in the overall analysis [typical RR 0.32 (95%

CI 0.13,0.82); typical RD -7% (95% CI-13, -2); NNT 14 (95% CI 8, 50)]. There is insufficient information to adequately assess

important short and longer term outcomes, including adverse effects.

Authors’ conclusions

Caution is required when interpreting the possible positive effects of chest physiotherapy of a reduction in the use of reintubation and

the trend for decreased post-extubation atelectasis as the numbers of babies studied are small, the results are not consistent across trials,

data on safety are insufficient, and applicability to current practice may be limited.

P L A I N L A N G U A G E S U M M A R Y

Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation

Active chest physiotherapy may not be helpful for all babies being taken off mechanical breathing support. Mechanical ventilation

(machine-assisted breathing) increases a baby’s lung secretions. Chest physiotherapy (tapping or vibrating on the chest) is thought to

clear the baby’s lungs, and is often done when taking the baby off the ventilator (extubation). Although this review found a benefit for

physiotherapy in terms of less babies needing to go back on the ventilator, no other benefits were shown. Also, this benefit was mainly

due to the results of studies conducted a long time ago before advances such as better humidification systems to moisten the air the

baby breaths and the drug surfactant. These advances may have reduced the risk of complications around the time of extubation so

these results may not apply to babies in today’s neonatal nurseries. This review did not show any evidence of harm for babies receiving

a short course of chest physiotherapy following extubation.

B A C K G R O U N D

Description of the condition

Endotracheal intubation and mechanical ventilation cause trauma

and inflammation to the airways and increase secretions in the

lungs. These effects may contribute to respiratory complications

following cessation of mechanical ventilation and extubation. Pos-

textubation complications range from problematic secretion build

up causing discomfort, agitation and distress (necessitating fre-

quent suctioning) to obstruction of major airways with resultant

lung collapse. The presence of lung collapse may require increased

support such as additional oxygen and occasionally reintubation

for further mechanical ventilation. These complications poten-

tially prolong the recovery phase and may impact on long term

outcomes.

The neonate is particularly at risk of respiratory complications due

to immaturity of the respiratory system. Decreasing birth weight

(Odita 1993), increasing duration of mechanical ventilation, high

oxygen concentrations, multiple intubations (Wyman 1977), pres-

ence of disease states such as sepsis and patent ductus arteriosus

(Odita 1993) and nasal intubation (Roper 1976; Spitzer 1982)

have been identified as risk factors for postextubation lobar col-

lapse (PEC). The incidence of neonatal PEC has been reported at

between 11 and 50% over the past decade (Halliday 1992; Odita

1993), with reintubation required in 10-30% of cases (Halliday

1992).

Description of the intervention

Respiratory physiotherapy techniques include chest percussion

and vibrations (often referred to as active chest physiotherapy).

How the intervention might work

Respiratory physiotherapy techniques such as chest percussion

and vibrations (often referred to as active chest physiotherapy) are

thought to reduce respiratory complications by promoting clear-

ance of secretions (Etches 1978), thus improving ventilation of the



lungs. Improvement in oxygenation following active physiother-

apy has been reported (Tudehope 1980). However, reports on the

effects of the different methods of active physiotherapy show con-

flicting results (Crane 1978; Curran 1979; Tudehope 1980). Sa-

fety in terms of stability of intracranial blood flow during suction

(Paratz 1994), no increase in the rate of cerebral lesions (Beeby

1998), and benefit in terms of reducing hypoxaemia during suc-

tion (Bradbury-Hough 1995) has been reported. However, con-

cerns have also been expressed regarding the safety of this inter-

vention. Reports of adverse effects include hypoxaemia (Holloway

1969; Fox 1978), rib fractures (Purohit 1975) and associated brain

lesions (Raval 1987; Cross 1992; Ramsay 1995; Coney 1995;

Harding 1998).

Following the publication of a small trial in 1979 (Finer 1979),

the use of active chest physiotherapy techniques for the prevention

of postextubation lung collapse became a part of routine care in

many neonatal nurseries. However, a growing body of conflicting

literature on the effects of active chest physiotherapy has resulted in

differences of opinion about the risk/benefit ratio of many neonatal

physiotherapy techniques, and also differences in practice (Lewis

1992; Flenady 1997).

Why it is important to do this review

This review updates the existing review “Chest physiotherapy for

preventing morbidity in babies being extubated from mechanical

ventilation” published in the Cochrane Database of Systematic

Reviews Flenady 2002.

O B J E C T I V E S

To determine the effects of active chest physiotherapy on infants

being extubated from mechanical ventilation for neonatal respi-

ratory failure on outcomes of post-extubation lobar collapse, the

use of reintubation and adverse effects such as bradycardia, hypox-

aemia and the incidence of intracranial lesions.

A priori sub-group analyses:

Different treatment intervals - frequent (one and two hourly) ver-

sus four hourly.

Different treatment methods - vibrations versus percussion.

Preterm < 28 weeks gestation or < 1000 g birthweight.

Preterm < 32 weeks gestation or <1500 g birthweight.

M E T H O D S

Criteria for considering studies for this review

Types of studies

All trials utilising random or quasi-random patient allocation, in

which active chest physiotherapy was compared with non-active

techniques (e.g. positioning and suction alone) or no intervention

in the peri-extubation period.

Types of participants

All infants being extubated following a period of mechanical ven-

tilation for neonatal respiratory failure.

Types of interventions

Active chest physiotherapy techniques including the use of vibra-

tions or percussion with or without the use of devices such as face

masks and electric vibrators.

Types of outcome measures

Primary outcomes

Lobar collapse of the lung shortly after extubation.

Use of reintubation.

Hypoxaemic episodes.

Bradycardia.

Duration of oxygen therapy.

Intracranial haemorrhage.

Cerebral cystic lesions (Periventricular leukomalacia, poren-

cephalic cysts).

Long term neurosensory impairment.

Death prior to hospital discharge.

Secondary outcomes

Pulmonary air leak.

Duration of mechanical ventilation (days).

Duration of nasopharyngeal CPAP (days).

Chronic lung disease: oxygen use at 28 days of age; oxygen use at

36 weeks postmenstrual age.

Frequency of suctioning and handling.

Duration of neonatal intensive care unit stay (days).

Duration of hospital stay (days).

Search methods for identification of studies

The standard search strategy for the Cochrane Neonatal Review

Group was used.



Electronic searches

We searched the following electronic databases for published

manuscripts: Oxford Database of Perinatal Trials; Cochrane Cen-

tral Register of Controlled Trials (CENTRAL, The Cochrane Li-

brary, Issue 1, 2005); MEDLINE (1966 to January 2005); and

CINAHL (1982 to January 2005) using MeSH term infant-new-

born and text terms extubat*; atelectasis; lung collapse; lobar col-

lapse; chest physiotherapy; respiratory therapy, chest physical ther-

apy.

In 2009, the search was updated as follows: MEDLINE (search via

PubMed), CINAHL, EMBASE and The Cochrane Library were

search from 2006 to 2009.

Search terms: extubat* OR atelectasis OR lung collapse OR lobar

collapse OR chest physiotherapy OR respiratory therapy OR chest

physical therap. Limits: human, newborn infant and clinical trial.

No language restrictions were applied. The bibliography cited in

each publication obtained was searched in order to identify addi-

tional relevant articles.

Searching other resources

In addition we searched previous reviews including cross refer-

ences, abstracts, conference and symposia proceedings, expert in-

formants, journal hand searching in the English language.

Clinical trials registries were also searched for ongoing or re-

cently completed trials (clinicaltrials.gov; controlled-trials.com;

and who.int/ictrp)

Data collection and analysis

The standard methods of the Cochrane Collaboration and its

Neonatal Review Group were used.

Selection of studies

All randomised and quasi-randomized controlled trials fulfilling

the selection criteria described in the previous section were in-

cluded. The authors reviewed the results of the search and sep-

arately selected the studies for inclusion. The review authors re-

solved any disagreement by discussion.

Data extraction and management

Each author independently extracted data then compared and re-

solved differences. For the 2002 update, extraction of data from

the previously included trials was conducted for the additional

outcomes specified.

Additional data on neonatal morbidity were sought from the in-

vestigators of three trials (V- Beresford 1987; Al-Alaiyan 1996;

Bagley 2005). One trial (Bagley 2005) provided additional data.

Data were received on outcomes for one infant excluded following

randomisation in Al-Alaiyan 1996. In Bagley 2005, there were four

post randomisation exclusions for the outcome of postextubation

collapse (PEC), two for intraventricular haemorrhage (IVH) and

one for the outcome of duration of oxygen therapy. In this review,

all infants randomised into this trial were included in the denom-

inator for the outcomes of PEC and IVH. Bagley 2005 also pro-

vided additional data on the outcome of cerebral cystic lesions at

six weeks of age; however, due to large number of losses to follow-

up (20 and 30% in the two groups), this outcome has not been

included in the review. Data for the outcomes of the duration of

mechanical ventilation, oxygen therapy, CPAP and neonatal in-

tensive care stay came from one trial (Bagley 2005). In this trial,

these outcomes were calculated for the period from admission to

the nursery (not from the time of random allocation) to discharge

from hospital.

Two trials included study groups of differing treatment frequencies

(Al-Alaiyan 1996; V- Beresford 1987). In the analysis, the hourly,

two hourly and four hourly physiotherapy groups in V- Beresford

1987 and the two hourly and four hourly groups in Al-Alaiyan

1996 were combined for the overall comparison.

Assessment of risk of bias in included studies

All included studies were assessed for blinding of randomisation,

blinding of intervention, completeness of follow-up, and blinding

of outcome assessment. The authors independently undertook

this assessment and assigned a rating of either Yes (Adequate),

Can’t Tell (Unclear), or No (Inadequate) for each. Differences were

resolved by discussion. Information was also sought and received

on methods of random allocation for two trials (V- Beresford

1987; Al-Alaiyan 1996). This information was added to the table

’Characteristics of Included Studies’.

In addition, following issues were evaluated and entered into the

Risk of Bias Table:

1. Sequence generation: Was the allocation sequence adequately

generated?

2. Allocation concealment: Was allocation adequately concealed?

3. Blinding of participants, personnel and outcome assessors: Was

knowledge of the allocated intervention adequately prevented dur-

ing the study? At study entry? At the time of outcome assessment?

4. Incomplete outcome data: Were incomplete outcome data ad-

equately addressed?

5. Selective outcome reporting: Are reports of the study free of

suggestion of selective outcome reporting?

6. Other sources of bias: Was the study apparently free of other

problems that could put it at a high risk of bias?.

Measures of treatment effect

Statistical analyses were performed using Review Manager soft-

ware. Categorical data were analyzed using relative risk (RR), risk

difference (RD) and the number needed to treat (NNT). Contin-

uous data were analyzed using weighted mean difference (WMD).

The 95% Confidence interval (CI) was reported on all estimates.



Assessment of heterogeneity

We estimated the treatment effects of individual trials and exam-

ined heterogeneity between trials by inspecting the forest plots and

quantifying the impact of heterogeneity using the I2 statistic. If we

detected statistical heterogeneity, we explored the possible causes

using the subgroups noted below.

Assessment of reporting biases

Reporting bias was investigated by examining the degree of asym-

metry of the funnel plot. Information was also sought and received

on methods of random allocation for two trials (V- Beresford 1987;

Al-Alaiyan 1996).

Data synthesis

Meta-analysis was performed using Review Manager software

(RevMan 5) supplied by the Cochrane Collaboration. Meta-anal-

ysis was conducted using the fixed effect model. Mean Differences

(MD) were used for outcome data measured on a continuous scale

and relative risk, risk difference and number needed to treat as

appropriate for categorical data. 95% Confidence Intervals (CI)

are presented for all reported outcomes.

Subgroup analysis and investigation of heterogeneity

Different treatment intervals: frequent (one and two hourly) versus

four hourly.

Different treatment methods: vibrations versus percussion.

Preterm < 28 weeks gestation or < 1000 g birthweight.

Preterm < 32 weeks gestation or <1500 g birthweight.

R E S U L T S

Description of studies

See: Characteristics of included studies.

Results of the search

Four randomised trials addressing the issue of active chest physio-

therapy in the peri-extubation period were identified and included

in this review ( Finer 1979; V- Beresford 1987; Al-Alaiyan 1996;

Bagley 2005). A full description of each is included in the table,

Characteristics of Included Studies.

Included studies

Participants

The participants of the four trials differed somewhat with respect

to primary diagnosis and gestational ages. The groups in Finer

1979 and Al-Alaiyan 1996 were more mature than in V- Beresford

1987 and Bagley 2005. Mean gestational age in was 35 weeks in

Finer 1979, 33-35 weeks across the groups in Al-Alaiyan 1996,

29-32 weeks in V- Beresford 1987 and 30 weeks in Bagley 2005.

Nine babies had multiple intubations (maximum of three) prior

to enrolment in Finer 1979. Two trials randomised infants under-

going extubation from a primary course of ventilation only (V-

Beresford 1987; Bagley 2005). The number of courses of mechan-

ical ventilation prior to randomisation is unknown for infants in

Al-Alaiyan 1996. The main diagnosis of babies enrolled in the

four trials was respiratory distress syndrome, however Al-Alaiyan

1996 enrolled a higher proportion of babies with thoracoabdom-

inal surgery (30%) and only Finer 1979 included infants with

meconium aspiration and bacterial pneumonia.

Intervention

The intervention differed in that Finer 1979 and Al-Alaiyan 1996

used vibrations whereas V- Beresford 1987 and Bagley 2005 used

percussion. Al-Alaiyan 1996 used an electric vibrator to deliver

the chest wall vibrations. The frequency of treatments differed

among the three trials. Al-Alaiyan 1996 and V- Beresford 1987

enrolled babies into groups of differing treatment frequencies. V-

Beresford 1987 and Finer 1979 commenced active physiotherapy

1 hour prior to extubation whereas Al-Alaiyan 1996 and Bagley

2005 commenced the treatments following extubation.

Outcomes

The outcomes of postextubation lobar collapse and the use of en-

dotracheal reintubation within 24 hours of extubation were as-

sessed in all trials. Adverse effects were assessed in Bagley 2005

(short term neonatal morbidity and mortality) and V- Beresford

1987 (bradycardia only). Bagley 2005 reported on duration of

respiratory support (mechanical ventilation, oxygen therapy and

CPAP) and also for neonatal intensive care and hospital stay for

the period from admission to the nursery to the initial discharge

from hospital.

Excluded studies

None noted.

Risk of bias in included studies

Details of each study appear in the table, Characteristics of In-

cluded Studies.

Allocation

Concealment of allocation:



All of the included trials assigned babies to study groups by ran-

dom allocation. Adequate concealment of treatment allocation by

the use of sealed envelopes was undertaken in three trials (Finer

1979; Al-Alaiyan 1996; Bagley 2005). Concealment of treatment

allocation was not achieved in V- Beresford 1987. In this trial,

four treatment allocations (one for each of the four groups) were

included in one sealed envelope.

Blinding

Blinding of the intervention: Blinding of the intervention was not

possible.

Blinding of outcome: Diagnosis of post-extubation collapse was

performed by an assessor blinded to the treatment allocation in all

included trials.

Incomplete outcome data

Completeness of follow-up:

Finer 1979 and V- Beresford 1987 reported on outcomes for all

randomised babies. In the Al-Alaiyan 1996 trial one baby who

failed extubation was excluded; this baby has been included in this

review following personal communication with the investigator.

Bagley 2005 excluded four infants for the outcome of post extu-

bation collapse as chest radiography was not performed, and two

infants for the outcome of intraventricular haemorrhage as head

ultrasonography was not performed; greater than 20% loss to fol-

low-up was reported for the outcome of cerebral cystic lesions at

six weeks.

Effects of interventions

Active chest physiotherapy vs. no active chest physiotherapy

(Comparison 1):

Primary outcomes:

Post extubation collapse (PEC) and reintubation were the only

outcomes reported in all of the included trials. The overall analysis

shows a trend towards a reduction in the rate of PEC with active

chest physiotherapy which is not statistically significant [(typical

RR 0.80 (95% CI 0.49, 1.29)]. A significant reduction in the use

of reintubation within 24 hours of extubation was shown for ba-

bies receiving active chest physiotherapy [(typical RR 0.32 (95%

CI 0.13, 0.82); typical RD -7% (95% CI -13, -2)]. Thus, number

needed to treat (NNT) to expect to prevent one baby receiving

reintubation is 14 (95% CI 8, 50). There was insufficient infor-

mation to adequately assess the outcomes of bradycardia, duration

of oxygen therapy, cerebral haemorrhage, cerebral cystic lesions,

long term neurosensory impairment or death.

Secondary outcomes:

No statistically significant differences were shown in any other

short term outcomes (duration of CPAP and mechanical venti-

lation, duration of neonatal intensive care) reported by one trial

(Bagley 2005).

Subgroup analysis by gestation age (Comparison 2):

No significant effect of chest physiotherapy on the following out-

comes was shown in sub-group analyses of infants born less than

32 weeks gestation reported by one trial (Bagley 2005): postextu-

bation collapse, use of reintubation, duration of oxygen therapy,

cerebral haemorrhage, bradycardia, duration of CPAP and me-

chanical ventilation, duration of neonatal intensive care stay and

death. Although no trend to a reduction in PEC was shown as

for the overall analysis [RR 1.09 (95% CI 0.45, 2.63)], the trend

to a reduction in reintubation remained [RR 0.64 (95% CI 0.11,

3.72)].

Sub-group analyses of differing treatment frequencies (Com-

parison 3):

Four trials contributed to the comparison of more frequent treat-

ment (one and two hourly groups combined) with no treatment.

In keeping with the overall analysis, there was a non significant re-

duction in the rate of PEC [typical RR 0.76 (95% CI 0.47, 1.24)]

and a significant reduction in the use of reintubation [typical RR

0.24 (95% CI 0.08, 0.72); typical RD -8% (95% CI -14, -3);

NNT 13 (95% CI 7, 33)]. Less frequent treatment (4 hourly) was

compared to no treatment. Two trials were included in this analysis

(V- Beresford 1987; Al-Alaiyan 1996), which showed an increase

in PEC with active physiotherapy which is not statistically signif-

icant [(typical RR 1.45; (95% CI 0.51, 4.09)]. The reduction in

the use of reintubation is also not statistically significant [(typical

RR 0.80; 95% CI 0.21, 2.99)].

D I S C U S S I O N

Summary of main results

This review identified several important limitations of the

presently available evidence from randomised trials:

Small sample sizes

Due to small numbers of infants in the four included trials, all

estimates of effect are imprecise resulting in the inability to ade-

quately assess the effects of this intervention.

Inconsistency of results

Some of the effects, particularly the effect on postextubation alve-

olar collapse, are inconsistent across trials. In the case of PEC,

there is some evidence of a secular trend in that the rates in the

control groups of the different trials fell from 38% (Finer 1979) to

25% (V- Beresford 1987) to 13% (Al-Alaiyan 1996) and 20% in

Bagley 2005. The size and the direction of treatment effect varies

with control event rate, so that the point estimates for risk dif-

ference are -38% (Finer 1979), -13% (V- Beresford 1987), +16%



(Al-Alaiyan 1996) and -2% (Bagley 2005). Thus, a source of the

heterogeneity of treatment effect on PEC may be the level of risk

for PEC in the absence of chest physiotherapy. A similar trend

across time, again correlated with size of treatment effect, is shown

for reintubation. The rate of reintubation and the risk difference

in the control groups are as follows: Finer 1979 33% (RD -33%),

V- Beresford 1987 25% (RD -21%), Al-Alaiyan 1996 8.7% (RD

-1.4%) and Bagley 2005 3.4% (RD -1.1%).

Overall completeness and applicability ofevidence

Lack of safety data

Over the past decade, concerns regarding the safety of chest phys-

iotherapy, particularly in the small preterm infant, have been re-

ported. Information on possible adverse effects was inadequate in

these trials to allow assessment of safety.

Although no difference was found in the number of infants with

bradycardia following extubation reported by two trials, the num-

bers of infants studied are too small to be confident about this

outcome or other more important adverse short term outcomes

such as hypoxaemia and cerebral haemorrhage or cysts. None of

the included trials reported measures of the important longer term

outcome of neurodevelopmental impairment.

Quality of the evidence

Applicability to present day practice

Two of the four trials were conducted 15 and 23 years ago. Ap-

plicability of the results of the review to current practice may be

compromised due to advancements in neonatal care which have

occurred over the interval since the earlier trials were performed.

Relevant improvements in neonatal care include better techniques

for humidification of inspired gases, introduction of exogenous

surfactant, strategies to reduce trauma during endotracheal suc-

tioning (less frequent suctioning and the use of measured smaller

bore catheters) and the use of prophylactic post-extubation nasal

continuous positive airway pressure (NCPAP). These innovations

may well have changed the nature of post-extubation complica-

tions considerably. For example, the use of prophylactic post-ex-

tubation NCPAP has been shown to reduce the rate of post-extu-

bation complications (Davis 2001). Only one trial (Bagley 2005)

used routine post-extubation NCPAP prophylactically for preterm

infants. Therefore, the results of this review may overestimate the

rates of PEC and reintubation in nurseries where prophylactic

post-extubation NCPAP is now being used.

Potential biases in the review process

Caution is required in interpreting the results of this review and

applying them to current practice. Although the number needed

to treat of 14 to avoid reintubation shown in the overall analysis

of this review suggests that active chest physiotherapy in this situ-

ation may be a worthwhile intervention, this finding was heavily

weighted by the two trials conducted some time ago (Finer 1979;

V- Beresford 1987) and was not supported by the results of the two

more recent trials in this review. No benefit for chest physiother-

apy was shown in one trial (Bagley 2005) in terms of the duration

of mechanical ventilation, NCPAP, oxygen therapy or neonatal

intensive care nursery stay. However, adequate assessment of the

effects of chest physiotherapy on these outcomes is difficult due

to insufficient data and also as the outcomes were measured from

admission to the nursery not from randomisation and institution

of the allocated treatment.

Agreements and disagreements with otherstudies or reviews

Although data in this review are insufficient to permit adequate

assessment of this intervention, the lack of clear benefit for postex-

tubation active chest physiotherapy shown is supported by other

recent reports. A similar rate of PEC and no evidence for benefit of

postextubation physiotherapy in terms of PEC was reported in a

recent before-and-after study assessing active postextubation phys-

iotherapy (Bloomfield 1998). Furthermore, the low risk of pos-

textubation complications (PEC and reintubation) evident in the

more recent trials in this review (Al-Alaiyan 1996; Bagley 2005)

is also supported by a recent retrospective study. Davies 1998 re-

ported a very low risk of PEC with no requirement for reintuba-

tion in these infants. Bagley 2005 reported no use of reintubation

for any infant with PEC (unpublished data).

Care providers need to consider the role of active postextuba-

tion chest physiotherapy in the light of the lack of clear evidence

for benefit, recent reports of severe adverse outcome associated

with active chest physiotherapy in some situations (Ramsay 1995;

Harding 1998) and the need to avoid unnecessary distress in the

care of sick newborn infants from interventions which may not be

beneficial. There are challenges in obtaining robust evidence for

physiotherapy interventions due to the difficulties with blinding

the intervention, and defining and measuring clinically meaning-

ful outcomes (Wallis 1999).

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

The results of this review do not give a clear direction for the

role of active chest physiotherapy for infants being extubated from

mechanical ventilation in today’s neonatal intensive care settings.

Evidence for benefit of this intervention is conflicting and it was



not possible to identify subgroups of babies who may benefit. No

benefit for more vs. less frequent treatment is evident.

Concerns regarding the safety of active chest physiotherapy for

preterm neonates have been reported. Information on adverse ef-

fects is inadequate in the trials included in this review to allow

assessment of safety. In view of this and the lack of clear evidence

for benefit, it would seem wise to use this intervention cautiously.

Implications for research

Further randomised controlled trials addressing the role of pro-

phylactic active chest physiotherapy for neonates in the postextu-

bation period may be unwarranted.

A C K N O W L E D G E M E N T S

The authors would like to acknowledge Catherine Bagley, Phys-

iotherapy Department, Mater Hospital, Brisbane, Australia; Dr

Saleh Al-Alaiyan, Department of Pediatrics, King Faisal Specialist

Hospital and Research Center, Riyadh, Saudi Arabia and Ann Vi-

vian-Beresford, Children’s Rehabilitation Centre, St John’s, New-

foundland, Canada for providing further information regarding

their trials.

We would also like to acknowledge Katie Welsh for assistance with

literature searching and formatting the review.

R E F E R E N C E S

References to studies included in this review

Al-Alaiyan 1996 {published data only}

Al-Alaiyan S, Dyer D, Khan B. Chest physiotherapy and post-

extubation atelectasis in infants. Pediatric Pulmonology 1996;21:

227–30.

Bagley 2005 {published data only}

Bagley C, Flenady V, Tudehope D, Gray P. The role of

postextubation chest physiotherapy: A randomised controlled trial.

Proceedings of the Perinatal Society of Australia and New Zealand

4th Annual Congress. Brisbane, 1999.

Bagley CE, Gray PH, Tudehope DI, Flenady V, Shearman AD,

Lamont A. Routine neonatal postextubation chest physiotherapy: a

randomized controlled trial. Journal of Paediatrics and Child Health

2005;41(11):592–7.

Finer 1979 {published data only}

Finer N, Moriartey R, Boyd J, Phillips H, Stewart A, Ulan O. Post-

extubation atelectasis: A retrospective review and a prospective

controlled study. Journal of Pediatrics 1979;94:110–3.

V- Beresford 1987 {published data only}

Vivian-Beresford A, King C, Macauley H. Neonatal post-

extubation complications: the preventive role of physiotherapy.

Physiotherapy Canada 1987;39:184–90.

Additional references

Beeby 1998

Beeby PJ, Henderson-Smart DJ, Lacey JL, Rieger I. Short- and

long-term neurological outcomes following neonatal chest

physiotherapy. Journal of Paediatrics and Child Health 1998;34:

60–2.

Bloomfield 1998

Bloomfield FH, Teele RL, Voss M, Knight DB, Harding J. The role

of neonatal chest physiotherapy in preventing postextubation

atelectasis. Journal of Pediatrics 1998;133:269–71.

Bradbury-Hough 1995

Bradbury-Hough JB. Cupping: The effect of this respiratory

physiotherapy technique on the cardiorespiratory function of the neonate

with idiopathic respiratory distress syndrome [Masters of Physiotherapy

thesis]. Australia: University of Queensland, 1995.

Coney 1995

Coney S. Physiotherapy technique banned in Auckland. Lancet

1995; Vol. 345:510.

Crane 1978

Crane LD, Zombek M, Krauss AN, Auld PAM. Comparison of

chest physiotherapy techniques in infants with HMD. Pediatric

Research 1978;12:559.

Cross 1992

Cross JH, Harrison CJ, Preston PR, Rushton DI, Newell SJ,

Morgan MEI, et al.Postnatal encephaloclastic porencephaly - a new

lesion?. Archives of Disease in Childhood 1992;67:307–11.

Curran 1979

Curran LC, Kachoyeanos MK. The effects on neonates of two

methods of chest physical therapy. Mothercraft Nursing 1979;4:

309–13.

Davies 1998

Davies MW, Cartwright DW. Postextubation chest X-rays in

neonates: A routine no longer necessary. Journal of Paediatrcs and

Child Health 1998;34:147–50.

Davis 2001

Davis PG, Henderson-Smart DJ. Prophylactic post-extubation

nasal CPAP in preterm infants. Cochrane Database of Systematic

Reviews 2002, Issue 1. [DOI: 10.1002/14651858.CD000143]

Duara 1983

Duara S, Bessard K, Keszier L, Artes D, Batzer K. Evaluation of

different percussion time intervals of chest physiotherapy on

neonatal pulmonary function parameters [abstract]. Pediatric

Research 1983;17:310A.

Etches 1978

Etches PC, Scott B. Chest physiotherapy in the newborn: Effects

on secretions removed. Pediatrics 1978;62:713–5.

Finer 1978

Finer NN, Boyd DPT. Chest physiotherapy in the neonate: A

controlled study. Pediatrics 1978;61:282–5.



Flenady 1997

Flenady VJ, Bagley C, Tudehope DT. Active chest physiotherapy

practices in neonatal intensive care: A survey of units in Australia

and New Zealand. Proceedings of the Perinatal Society of Australia

and New Zealand Congress. Fremantle, 1997.

Fox 1978

Fox WH, Schwartz JG, Shaffer TH. Pulmonary physiotherapy in

neonates: Physiologic changes and respiratory management.

Journal of Pediatrics 1978;92:977–81.

Halliday 1992

Halliday HL. Other acute lung disorders. In: Sinclair JC, Bracken

MB editor(s). Effective Care of the Newborn Infant. Oxford: Oxford

University Press, 1992:359–384.

Harding 1998

Harding JE, Miles FKI, Becroft DMO, Allen BC, Knight DB.

Chest physiotherapy may be associated with brain damage in

extremely premature babies. Journal of Pediatrics 1998;132:440–4.

Higgins 2008

Higgins JPT, Green S, editors. Cochrane Handbook for Systemic

Reviews of Interventions Version 5.0.0 [updated February 2008].

The Cochrane Collaboration, 2008. Available from

www.cochrane–handbook.org.

Holloway 1969

Holloway R, Adams EB, Desai SD, Thambian AK. Effect of chest

physiotherapy on blood gases of neonates treated by intermittent

positive pressure respiration. Thorax 1969;24:421–6.

Lewis 1992

Lewis JA, Lacey JL, Henderson-Smart DJ. A review of chest

physiotherapy in neonatal intensive care units in Australia. Journal

of Paediatrics and Child Health 1992;28:297–303.

Odita 1993

Odita JC, Kayyali M, Ammari A. Post-extubation atelectasis in

newborn infants. Pediatric Radiology 1993;23:183–5.

Paratz 1994

Paratz JD. The effect of respiratory physiotherapy on intracranial

dynamics in preterm and term infants [Doctor of Philosophy thesis].

Australia: University of Queensland, 1994.

Purohit 1975

Purohit DM, Caldwell C, Levkoff AH. Multiple rib fractures due

to physiotherapy in a neonate with hyaline membrane disease.

American Journal of Disease of Children 1975;129:1103–4.

Ramsay 1995

Ramsay S. The Birmingham experience. Lancet 1995;345:510.

Raval 1987

Raval D, Yeh TF, Mora A, Cuevas D, Pyati S, Pildes RS. Chest

physiotherapy in preterm infants with RDS in the first 24 hours of

life. Journal of Perinatology 1987;7:301–4.

Roper 1976

Roper PC, Vonwiller JB, Fisk GC, Gupta JM. Lobar atelectasis

after nasotracheal intubation in newborn infants. Australian

Paediatric Journal 1976;12:272–5.

Spitzer 1982

Spitzer AR, Fox WW. Post-extubation atelectasis - the role of oral

versus nasal endotracheal tubes. Journal of Pediatrics 1982;100:

806–10.

Tudehope 1980

Tudehope DI, Bagley C. Techniques of physiotherapy in intubated

babies with respiratory distress syndrome. Australian Paediatric

Journal 1980;16:226–8.

Wallis 1999

Wallis C, Prasad A. Who needs chest physiotherapy? Moving from

anecdote to evidence. Archives of Disease in Childhood 1999;80:

393–7.

Wyman 1977

Wyman L, Kuhns L. Lobar opacification of the lung after tracheal

extubation in neonates. Journal of Pediatrics 1977;91:109–12.

References to other published versions of this review

Flenady 1998

Flenady VJ, Gray PH. Chest physiotherapy for preventing

morbidity in babies being extubated from mechanical ventilation.

Cochrane Database of Systematic Reviews 1998, Issue 1. [DOI:

10.1002/14651858.CD000283]

Flenady 2002

Flenady VJ, Gray PH. Chest physiotherapy for preventing

morbidity in babies being extubated from mechanical ventilation.

Cochrane Database of Systematic Reviews 2002, Issue 2. [DOI:

10.1002/14651858.CD000283]∗ Indicates the major publication for the study



C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Al-Alaiyan 1996

Methods Blinding of randomisation: yes

Blinding of intervention: no

Complete follow-up: yes

Blinding of outcome measure: yes for primary outcome (PEC)

Participants Electively extubated infants who were intubated for more than 24 hours.

Exclusions were atelectasis prior to extubation, meconium aspiration or pneumonia.

Main diagnoses were respiratory distress syndrome (52%) and thoracoabdominal surgery

(30%).

Mean gestational age across the groups was 33 - 35 weeks.

Duration of MV at randomisation:

Physio groups: 11.2 (16.7), and 11.4 (13.8)

Control group: 8.3 (11.2)

Mean (SD) days

Interventions Active chest physio n=41: Postural drainage(lateral decubitus) and bilateral chest wall

vibration (using a neo-cussor) were commenced immediately following extubation and

continued for a 24 hour period. Two active chest physio groups: a 2 hourly and a 4

hourly treatment frequency group.

All treatments were performed by a physiotherapist.

Controls n=23: No active chest physiotherapy.

Outcomes Atelectasis on chest radiography performed at 24 hours post-extubation, the use of

reintubation and nasopharyngeal CPAP up to 24 hours postextubation.

Notes All infants enrolled received active chest physiotherapy for postextubation collapse de-

tected on the chest radiography at 24 hrs postextubation. Additional outcome data were

received from the author for one infant excluded following randomisation.

Risk of bias

Item Authors’ judgement Description

Adequate sequence generation? Unclear Uncertain method of randomisation

Allocation concealment? Yes Blinding of randomisation: yes

Blinding?

All outcomes

No Blinding of intervention: no

Blinding of outcome measure: yes for pri-

mary outcome (PEC)



Al-Alaiyan 1996 (Continued)

Incomplete outcome data addressed?

All outcomes

Yes Complete follow-up: yes

Free of selective reporting? Yes Additional information received from au-

thor

Free of other bias? Unclear Insufficient information

Bagley 2005



Complete follow-up: no


Participants 177 infants receiving a primary course of MV deemed ready for extubation. Exclusions:

MV <24 hrs, unstable infants, infants with GA <28 weeks in the first week of life. Main

diagnosis was RDS (94%).

97% of extubations were elective.

At randomisation:

Duration of MV (days): physio-7.3 (7.7) Control- 6.5 (8.5)

Postnatal age (days):

Physio: 8.7 (8.6)

Control: 7.2 (7.8)

GA (weeks):

Physio- 30.1 (3.4), Controls- 30.5 (3.69) [mean(SD)]

Interventions Active chest physio n= 88: Percussion with a Laerdal or Bennetts face mask 2nd hourly

for 6 hrs starting 2 hrs post extubation

Majority of physio performed by physiotherapists.

Controls n=89: No active chest physiotherapy Positioning and suctioning program as

for the physio group.

Outcomes Lobar collapse on chest radiography performed at 6 and 24 hrs postextubation, rein-

tubation and bradycardia within 24 hrs of extubation, total episodes of MV, duration of

MV, oxygen treatment and NICU stay, IVH, intracranial haemorrhage, other cerebral

lesions, hypoxia measured by continuous pulse oximetry (subgroup only).

Notes Routine nursery practice included: oropharyngeal intubation, 4 hourly & prn ETT

suction using 6 gauge catheter,

prophylactic post extubation NCPAP for GA <32 weeks.

Infants remained in the original study group for each subsequent extubation episode.

The outcomes of PEC and reintubation for the initial extubation episode only were

included in the analysis

Additional data to that in the published abstract were included for Bagley 2005 as follows:

durations of mechanical ventilation, oxygen therapy, CPAP, neonatal intensive care and

hospital stay.

Sample size calculation: 430 needed to detect a 50% reduction in PEC from 40% in



Bagley 2005 (Continued)

control group. Trial stopped at interim analysis due to no difference in the rates of PEC.

Risk of bias




Blinding?

All outcomes



mary outcome (PEC)


All outcomes

No Complete follow-up: no

Free of selective reporting? Yes

Free of other bias? Yes

Finer 1979





Participants Mechanically ventilated for greater than 24 hours. Exclusion criteria are not mentioned.

The mean gestational age was 35 weeks.

Respiratory Distress Syndrome was the most common diagnosis (60%); other diag-

noses included meconium aspiration, bacterial pneumonia, asphyxia, thoracoabdominal

surgery and apnoea.

Duration of MV at randomisation (mean days):

Physio: 6

Controls: 6

Interventions Active chest physio n=21: Postural drainage and chest wall vibrations commenced one

hour prior to extubation and continued for a period of 48 hours as follows:

Hourly for 8 hours, 2 hourly for a further 16 hrs and 3 hourly until 48 hrs postextubation.

A physiotherapist performed all the treatments for the first 8 hours and nurses for the

remainder.

Controls n=21: Hourly positioning program for upper lobe drainage.

Outcomes Atelectasis on chest radiographs performed at 8 or 24 hours post-extubation.

Notes All infants enrolled received active chest physiotherapy for postextubation collapse de-

tected on the chest radiography at 8 or 24 hrs postextubation.



Finer 1979 (Continued)

Risk of bias




Blinding?

All outcomes



mary outcome (PEC)


All outcomes


Free of selective reporting? Unclear Insufficient information


V- Beresford 1987

Methods Blinding of randomisation: no



Blinding of outcome measurement: yes for primary outcome (PEC)

Participants Preterm infants with Respiratory Distress Syndrome undergoing a planned extubation

from a primary course of extubation were eligible. Exclusions were babies with severe

pulmonary oedema, apnoea or bradycardia, tachycardia or other signs of distress. Addi-

tional diagnoses were transient tachypnoea and pneumonia.

Mean gestational age across the groups was 29 - 32 weeks.

Duration of MV at randomisation (days):

Physio groups: 7, 9 and 16.

Control group: 16

Mean (SD) days

Interventions Active chest physio n=24: Chest wall percussion was given in three study groups of differ-

ent frequency: 4 hourly, 2 hourly and 1 hourly. Commencing at one hour pre-extubation

until 24 hrs post-extubation. The treatments were carried out by either physiotherapists

or nurses.

Controls n=8: No active chest physiotherapy. Similar positioning program as for inter-

vention.

Outcomes Atelectasis (detected on chest radiographs at 24 hours post-extubation), pneumonia,

bradycardia, respiratory distress and intolerance of treatment up to 24 hours post-extu-

bation.



V- Beresford 1987 (Continued)

Notes Sample size calculation required 60 babies in total; 15 in each arm. Sample size not

achieved due to poor recruitment rate.

Risk of bias



Allocation concealment? No Blinding of randomisation: no

Blinding?

All outcomes


Blinding of outcome measurement: yes for

primary outcome (PEC)


All outcomes


Free of selective reporting? Unclear Insufficient information




D A T A A N D A N A L Y S E S

Comparison 1. Active chest physiotherapy vs no active chest physiotherapy

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Postextubation lobar collapse 4 315 Risk Ratio (M-H, Fixed, 95% CI) 0.80 [0.49, 1.29]

2 Reintubation within 24hrs 4 315 Risk Ratio (M-H, Fixed, 95% CI) 0.32 [0.13, 0.82]

3 Pneumonia 1 32 Risk Ratio (M-H, Fixed, 95% CI) 1.0 [0.12, 8.31]

4 Bradycardia 2 209 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.66, 1.53]

5 Intraventricular haemorrhage-all

grades

1 177 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.58, 1.78]

6 Intraventricular haemorrhage -

Grades 3 and 4

1 177 Risk Ratio (M-H, Fixed, 95% CI) Not estimable

7 Death prior to discharge 1 177 Risk Ratio (M-H, Fixed, 95% CI) 0.25 [0.03, 2.22]

8 Duration of mechanical

ventilation (days)

1 177 Mean Difference (IV, Fixed, 95% CI) 1.74 [-1.26, 4.74]

9 Duration of nasopharyngeal

CPAP( days)


10 Duration of supplemental

oxygen (days)


11 Duration of neonatal intensive

care stay (days)


Comparison 2. Active chest physiotherapy vs no active physiotherapy - <32 wks gestation


studies

No. of


1 Postextubation lobar collapse 1 120 Risk Ratio (M-H, Fixed, 95% CI) 1.09 [0.45, 2.63]

2 Reintubation within 24hrs 1 120 Risk Ratio (M-H, Fixed, 95% CI) 0.64 [0.11, 3.72]

3 Bradycardia 1 120 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.63, 1.64]


all grades



Grades 3 and 4


6 Death prior to discharge 1 120 Risk Ratio (M-H, Fixed, 95% CI) 0.24 [0.03, 2.10]


ventilation (days)



CPAP( days)



oxygen (days)



care stay (days)




Comparison 3. Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)


studies

No. of


1 Post extubation lobar collapse 4 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only

1.1 1 and 2 hourly active

physiotherapy vs no active

physiotherapy


1.2 4 hourly active


physiotherapy


2 Reintubation within 24 hours 4 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only



physiotherapy


2.2 4 hourly active


physiotherapy


3 Pneumonia 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only



physiotherapy


3.2 4 hourly active


physiotherapy


4 Bradycardia 2 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only



physiotherapy


4.2 4 hourly active


physiotherapy


5 Intraventricular haemorrhage-

all grades

1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only



physiotherapy


5.2 4 hourly active


physiotherapy



Grades 3 and 4

1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only



physiotherapy


6.2 4 hourly active


physiotherapy


7 Death prior to discharge 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only





physiotherapy


7.2 4 hourly active


physiotherapy



ventilation (days)

1 Mean Difference (IV, Fixed, 95% CI) Subtotals only



physiotherapy


8.2 4 hourly active


physiotherapy

0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable


CPAP( days)




physiotherapy


9.2 4 hourly active


physiotherapy



oxygen (days)




physiotherapy

1 176 Mean Difference (IV, Fixed, 95% CI) 9.54 [0.42, 18.66]

10.2 4 hourly active


physiotherapy



care stay (days)




physiotherapy


11.2 4 hourly active


physiotherapy




Analysis 1.1. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 1

Postextubation lobar collapse.

Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation

Comparison: 1 Active chest physiotherapy vs no active chest physiotherapy

Outcome: 1 Postextubation lobar collapse

Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Al-Alaiyan 1996 12/41 3/23 11.9 % 2.24 [ 0.71, 7.14 ]

Bagley 2005 15/88 17/89 52.4 % 0.89 [ 0.48, 1.67 ]

Finer 1979 0/21 8/21 26.4 % 0.06 [ 0.00, 0.96 ]

V- Beresford 1987 3/24 2/8 9.3 % 0.50 [ 0.10, 2.48 ]

Total (95% CI) 174 141 100.0 % 0.80 [ 0.49, 1.29 ]

Total events: 30 (Treatment), 30 (Control)

Heterogeneity: Chi2 = 6.87, df = 3 (P = 0.08); I2 =56%

Test for overall effect: Z = 0.93 (P = 0.35)

0.002 0.1 1 10 500

Favours treatment Favours controls


Reintubation within 24hrs.



Outcome: 2 Reintubation within 24hrs



Al-Alaiyan 1996 3/41 2/23 16.0 % 0.84 [ 0.15, 4.67 ]

Bagley 2005 2/88 3/89 18.6 % 0.67 [ 0.12, 3.94 ]

Finer 1979 0/21 7/21 46.7 % 0.07 [ 0.00, 1.10 ]

V- Beresford 1987 1/24 2/8 18.7 % 0.17 [ 0.02, 1.60 ]

Total (95% CI) 174 141 100.0 % 0.32 [ 0.13, 0.82 ]




0.005 0.1 1 10 200





Pneumonia.



Outcome: 3 Pneumonia



V- Beresford 1987 3/24 1/8 100.0 % 1.00 [ 0.12, 8.31 ]

Total (95% CI) 24 8 100.0 % 1.00 [ 0.12, 8.31 ]


Heterogeneity: not applicable


0.1 0.2 0.5 1 2 5 10



Bradycardia.



Outcome: 4 Bradycardia



Bagley 2005 26/88 22/89 74.5 % 1.20 [ 0.74, 1.94 ]

V- Beresford 1987 7/24 5/8 25.5 % 0.47 [ 0.20, 1.06 ]

Total (95% CI) 112 97 100.0 % 1.01 [ 0.66, 1.53 ]




0.1 0.2 0.5 1 2 5 10





Intraventricular haemorrhage-all grades.



Outcome: 5 Intraventricular haemorrhage-all grades



Bagley 2005 19/88 19/89 100.0 % 1.01 [ 0.58, 1.78 ]

Total (95% CI) 88 89 100.0 % 1.01 [ 0.58, 1.78 ]




0.1 0.2 0.5 1 2 5 10

Favours treatment Favours control


Intraventricular haemorrhage - Grades 3 and 4.



Outcome: 6 Intraventricular haemorrhage - Grades 3 and 4

Study or subgroup Treatment Control Risk Ratio Risk Ratio


Bagley 2005 0/88 0/89 0.0 [ 0.0, 0.0 ]

Total (95% CI) 88 89 0.0 [ 0.0, 0.0 ]



Test for overall effect: Z = 0.0 (P < 0.00001)

0.1 0.2 0.5 1 2 5 10




Analysis 1.7. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 7 Death

prior to discharge.



Outcome: 7 Death prior to discharge



Bagley 2005 1/88 4/89 100.0 % 0.25 [ 0.03, 2.22 ]

Total (95% CI) 88 89 100.0 % 0.25 [ 0.03, 2.22 ]




0.02 0.1 1 10 50



Duration of mechanical ventilation (days).



Outcome: 8 Duration of mechanical ventilation (days)

Study or subgroup Treatment Control Mean Difference Weight Mean Difference

N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Bagley 2005 88 9.72 (9.94) 89 7.98 (10.4) 100.0 % 1.74 [ -1.26, 4.74 ]

Total (95% CI) 88 89 100.0 % 1.74 [ -1.26, 4.74 ]



-10 -5 0 5 10





Duration of nasopharyngeal CPAP( days).



Outcome: 9 Duration of nasopharyngeal CPAP( days)



Bagley 2005 88 7.09 (8.32) 89 5.26 (7.77) 100.0 % 1.83 [ -0.54, 4.20 ]

Total (95% CI) 88 89 100.0 % 1.83 [ -0.54, 4.20 ]



-10 -5 0 5 10



Duration of supplemental oxygen (days).



Outcome: 10 Duration of supplemental oxygen (days)



Bagley 2005 87 35.3 (39.65) 89 25.57 (30.11) 100.0 % 9.73 [ -0.69, 20.15 ]

Total (95% CI) 87 89 100.0 % 9.73 [ -0.69, 20.15 ]



-20 -10 0 10 20





Duration of neonatal intensive care stay (days).



Outcome: 11 Duration of neonatal intensive care stay (days)



Bagley 2005 88 25.16 (24.15) 89 21.25 (21.62) 100.0 % 3.91 [ -2.85, 10.67 ]

Total (95% CI) 88 89 100.0 % 3.91 [ -2.85, 10.67 ]



-20 -10 0 10 20


Analysis 2.1. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation,

Outcome 1 Postextubation lobar collapse.


Comparison: 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation

Outcome: 1 Postextubation lobar collapse



Bagley 2005 9/61 8/59 100.0 % 1.09 [ 0.45, 2.63 ]

Total (95% CI) 61 59 100.0 % 1.09 [ 0.45, 2.63 ]




0.1 0.2 0.5 1 2 5 10





Outcome 2 Reintubation within 24hrs.



Outcome: 2 Reintubation within 24hrs



Bagley 2005 2/61 3/59 100.0 % 0.64 [ 0.11, 3.72 ]

Total (95% CI) 61 59 100.0 % 0.64 [ 0.11, 3.72 ]




0.1 0.2 0.5 1 2 5 10



Outcome 3 Bradycardia.






Bagley 2005 22/61 21/59 100.0 % 1.01 [ 0.63, 1.64 ]

Total (95% CI) 61 59 100.0 % 1.01 [ 0.63, 1.64 ]




0.1 0.2 0.5 1 2 5 10





Outcome 4 Intraventricular haemorrhage - all grades.



Outcome: 4 Intraventricular haemorrhage - all grades



Bagley 2005 17/61 18/59 100.0 % 0.91 [ 0.52, 1.60 ]

Total (95% CI) 61 59 100.0 % 0.91 [ 0.52, 1.60 ]




0.1 0.2 0.5 1 2 5 10



Outcome 5 Intraventricular haemorrhage - Grades 3 and 4.






Bagley 2005 0/61 0/59 0.0 [ 0.0, 0.0 ]

Total (95% CI) 61 59 0.0 [ 0.0, 0.0 ]




0.1 0.2 0.5 1 2 5 10





Outcome 6 Death prior to discharge.






Bagley 2005 1/61 4/59 100.0 % 0.24 [ 0.03, 2.10 ]

Total (95% CI) 61 59 100.0 % 0.24 [ 0.03, 2.10 ]




0.02 0.1 1 10 50



Outcome 7 Duration of mechanical ventilation (days).






Bagley 2005 61 11.77 (10.61) 59 10.27 (12.16) 100.0 % 1.50 [ -2.59, 5.59 ]

Total (95% CI) 61 59 100.0 % 1.50 [ -2.59, 5.59 ]



-10 -5 0 5 10





Outcome 8 Duration of nasopharyngeal CPAP( days).






Bagley 2005 61 9.72 (8.72) 59 7.52 (8.66) 100.0 % 2.20 [ -0.91, 5.31 ]

Total (95% CI) 61 59 100.0 % 2.20 [ -0.91, 5.31 ]



-10 -5 0 5 10



Outcome 9 Duration of supplemental oxygen (days).






Bagley 2005 60 44.32 (42.7) 59 34.48 (33.36) 100.0 % 9.84 [ -3.91, 23.59 ]

Total (95% CI) 60 59 100.0 % 9.84 [ -3.91, 23.59 ]



-20 -10 0 10 20





Outcome 10 Duration of neonatal intensive care stay (days).






Bagley 2005 61 32.77 (25.43) 59 27.98 (23.8) 100.0 % 4.79 [ -4.02, 13.60 ]

Total (95% CI) 61 59 100.0 % 4.79 [ -4.02, 13.60 ]



-10 -5 0 5 10


Analysis 3.1. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by

frequency), Outcome 1 Post extubation lobar collapse.


Comparison: 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)

Outcome: 1 Post extubation lobar collapse



1 1 and 2 hourly active physiotherapy vs no active physiotherapy

Al-Alaiyan 1996 6/19 3/23 8.8 % 2.42 [ 0.70, 8.41 ]

Bagley 2005 15/88 17/89 54.9 % 0.89 [ 0.48, 1.67 ]

Finer 1979 0/21 8/21 27.6 % 0.06 [ 0.00, 0.96 ]

V- Beresford 1987 2/16 2/8 8.7 % 0.50 [ 0.09, 2.93 ]

Subtotal (95% CI) 144 141 100.0 % 0.76 [ 0.47, 1.24 ]




2 4 hourly active physiotherapy vs no active physiotherapy

Al-Alaiyan 1996 6/22 3/23 59.5 % 2.09 [ 0.60, 7.35 ]

0.005 0.1 1 10 200


(Continued . . . )



(. . . Continued)Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio


V- Beresford 1987 1/8 2/8 40.5 % 0.50 [ 0.06, 4.47 ]

Subtotal (95% CI) 30 31 100.0 % 1.45 [ 0.51, 4.09 ]




0.005 0.1 1 10 200



frequency), Outcome 2 Reintubation within 24 hours.



Outcome: 2 Reintubation within 24 hours




Al-Alaiyan 1996 0/19 2/23 14.7 % 0.24 [ 0.01, 4.71 ]

Bagley 2005 2/88 3/89 19.3 % 0.67 [ 0.12, 3.94 ]

Finer 1979 0/21 7/21 48.6 % 0.07 [ 0.00, 1.10 ]

V- Beresford 1987 1/16 2/8 17.3 % 0.25 [ 0.03, 2.36 ]

Subtotal (95% CI) 144 141 100.0 % 0.24 [ 0.08, 0.72 ]


Heterogeneity: Chi2 = 2.11, df = 3 (P = 0.55); I2 =0.0%



Al-Alaiyan 1996 3/22 2/23 43.9 % 1.57 [ 0.29, 8.51 ]

V- Beresford 1987 0/8 2/8 56.1 % 0.20 [ 0.01, 3.61 ]

Subtotal (95% CI) 30 31 100.0 % 0.80 [ 0.21, 2.99 ]




0.002 0.1 1 10 500





frequency), Outcome 3 Pneumonia.



Outcome: 3 Pneumonia




V- Beresford 1987 1/8 1/16 100.0 % 2.00 [ 0.14, 27.99 ]

Subtotal (95% CI) 8 16 100.0 % 2.00 [ 0.14, 27.99 ]





V- Beresford 1987 2/8 1/8 100.0 % 2.00 [ 0.22, 17.89 ]

Subtotal (95% CI) 8 8 100.0 % 2.00 [ 0.22, 17.89 ]




0.02 0.1 1 10 50





frequency), Outcome 4 Bradycardia.







Bagley 2005 26/88 22/89 76.6 % 1.20 [ 0.74, 1.94 ]

V- Beresford 1987 5/16 5/8 23.4 % 0.50 [ 0.20, 1.23 ]

Subtotal (95% CI) 104 97 100.0 % 1.03 [ 0.67, 1.58 ]





V- Beresford 1987 2/8 5/8 100.0 % 0.40 [ 0.11, 1.49 ]

Subtotal (95% CI) 8 8 100.0 % 0.40 [ 0.11, 1.49 ]




0.1 0.2 0.5 1 2 5 10





frequency), Outcome 5 Intraventricular haemorrhage- all grades.



Outcome: 5 Intraventricular haemorrhage- all grades




Bagley 2005 19/88 19/89 100.0 % 1.01 [ 0.58, 1.78 ]

Subtotal (95% CI) 88 89 100.0 % 1.01 [ 0.58, 1.78 ]





Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]



Test for overall effect: not applicable

0.1 0.2 0.5 1 2 5 10





frequency), Outcome 6 Intraventricular haemorrhage - Grades 3 and 4.







Bagley 2005 0/88 0/89 0.0 [ 0.0, 0.0 ]

Subtotal (95% CI) 88 89 0.0 [ 0.0, 0.0 ]





Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]




0.1 0.2 0.5 1 2 5 10





frequency), Outcome 7 Death prior to discharge.







Bagley 2005 1/88 4/89 100.0 % 0.25 [ 0.03, 2.22 ]

Subtotal (95% CI) 88 89 100.0 % 0.25 [ 0.03, 2.22 ]





Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]




0.02 0.1 1 10 50





frequency), Outcome 8 Duration of mechanical ventilation (days).







Bagley 2005 88 9.72 (9.94) 89 7.98 (10.4) 100.0 % 1.74 [ -1.26, 4.74 ]

Subtotal (95% CI) 88 89 100.0 % 1.74 [ -1.26, 4.74 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]



-10 -5 0 5 10



frequency), Outcome 9 Duration of nasopharyngeal CPAP( days).







Bagley 2005 88 7.09 (8.32) 89 5.26 (7.77) 100.0 % 1.83 [ -0.54, 4.20 ]

Subtotal (95% CI) 88 89 100.0 % 1.83 [ -0.54, 4.20 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]



-10 -5 0 5 10





frequency), Outcome 10 Duration of supplemental oxygen (days).







Bagley 2005 87 39.65 (35.3) 89 30.11 (25.57) 100.0 % 9.54 [ 0.42, 18.66 ]

Subtotal (95% CI) 87 89 100.0 % 9.54 [ 0.42, 18.66 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]



-20 -10 0 10 20





frequency), Outcome 11 Duration of neonatal intensive care stay (days).







Bagley 2005 88 25.16 (24.15) 89 21.25 (21.62) 100.0 % 3.91 [ -2.85, 10.67 ]

Subtotal (95% CI) 88 89 100.0 % 3.91 [ -2.85, 10.67 ]




Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]



-20 -10 0 10 20


W H A T ’ S N E W

Last assessed as up-to-date: 9 November 2009.

Date Event Description

7 September 2010 Amended Reference to included study Bagley CE updated from Abstract to full publication.

H I S T O R Y

Protocol first published: Issue 1, 1997

Review first published: Issue 1, 1998

Date Event Description

10 November 2009 New search has been performed This review updates the existing review “Chest phys-

iotherapy for preventing morbidity in babies being ex-

tubated from mechanical ventilation” published in the

Cochrane Database of Systematic Reviews (Flenady



(Continued)

2002).

Updated search found no new trials.

No changes to conclusions.

13 February 2009 Amended Updated contact details

16 October 2008 Amended Converted to new review format.

28 January 2005 New search has been performed This is an update of the existing review “Chest physio-

therapy for preventing morbidity in babies being extu-

bated from mechanical ventilation” published in The

Cochrane Library, Issue 1, 1998 and updated in Issue

2, 2002 (Flenady 2002).

No new trials were identified in the search updated to

January 2005, and as a result no substantive changes

were made to the review.

31 January 2002 New citation required and conclusions have changed Substantive amendment

C O N T R I B U T I O N S O F A U T H O R S

Vicki Flenady prepared the protocol for the review, initial review and subsequent updates. Peter Gray provided comment.

Vicki Flenady (VF) wrote the original review and updated the review in 2002 and 2006.

The 2009 update was conducted centrally by the Cochrane Neonatal Review Group staff (Yolanda Montagne, Roger Soll, Diane

Haughton) and reviewed and approved by VF.

D E C L A R A T I O N S O F I N T E R E S T

The authors were investigators on the trial Bagley 2005.

S O U R C E S O F S U P P O R T

Internal sources

• JP Kelly Research Foundation, Mater Hospital, Sth Brisbane, Queensland, Australia.

• Mater Mother’s Research Centre - Mater Hospital, Sth Brisbane, Queensland, Australia.

• Department of Neonatology, Mater Mothers’ Hospital, South Brisbane, Queensland, Australia.



External sources

• Department of Health and Ageing, Commonwealth Government, Canberra, ACT, Australia.

I N D E X T E R M S

Medical Subject Headings (MeSH)

∗Respiration, Artificial; Drainage, Postural; Infant, Newborn; Intubation, Intratracheal; Physical Therapy Modalities [adverse effects];

Respiratory Insufficiency [∗therapy]; Suction; Thorax

MeSH check words

Humans



chest physiotherapy for preventing morbidity in babies being extubated from mechanical...

Documents

active physiotherapy

active chest physiotherapy

bradycardia analysis

cochrane review

cochrane collaboration

cochrane library

gray ph

postextubation lobar