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. 2022 Sep 6;9(9):CD006338.
doi: 10.1002/14651858.CD006338.pub4.

Chest physiotherapy for pneumonia in adults

Xiaomei Chen  1 , Jiaojiao Jiang  2 , Renjie Wang  2 , Hongbo Fu  3 , Jing Lu  4 , Ming Yang  3
Affiliations

Chest physiotherapy for pneumonia in adults

Xiaomei Chen et al. Cochrane Database Syst Rev. .

Abstract

Background: Despite conflicting evidence, chest physiotherapy has been widely used as an adjunctive treatment for adults with pneumonia. This is an update of a review first published in 2010 and updated in 2013.

Objectives: To assess the effectiveness and safety of chest physiotherapy for pneumonia in adults.

Search methods: We updated our searches in the following databases to May 2022: the Cochrane Central Register of Controlled Trials (CENTRAL) via OvidSP, MEDLINE via OvidSP (from 1966), Embase via embase.com (from 1974), Physiotherapy Evidence Database (PEDro) (from 1929), CINAHL via EBSCO (from 2009), and the Chinese Biomedical Literature Database (CBM) (from 1978).

Selection criteria: Randomised controlled trials (RCTs) and quasi-RCTs assessing the efficacy of chest physiotherapy for treating pneumonia in adults.

Data collection and analysis: We used standard methodological procedures expected by Cochrane.

Main results: We included two new trials in this update (540 participants), for a total of eight RCTs (974 participants). Four RCTs were conducted in the United States, two in Sweden, one in China, and one in the United Kingdom. The studies looked at five types of chest physiotherapy: conventional chest physiotherapy; osteopathic manipulative treatment (OMT, which includes paraspinal inhibition, rib raising, and myofascial release); active cycle of breathing techniques (which includes active breathing control, thoracic expansion exercises, and forced expiration techniques); positive expiratory pressure; and high-frequency chest wall oscillation. We assessed four trials as at unclear risk of bias and four trials as at high risk of bias. Conventional chest physiotherapy (versus no physiotherapy) may have little to no effect on improving mortality, but the certainty of evidence is very low (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.15 to 7.13; 2 trials, 225 participants; I² = 0%). OMT (versus placebo) may have little to no effect on improving mortality, but the certainty of evidence is very low (RR 0.43, 95% CI 0.12 to 1.50; 3 trials, 327 participants; I² = 0%). Similarly, high-frequency chest wall oscillation (versus no physiotherapy) may also have little to no effect on improving mortality, but the certainty of evidence is very low (RR 0.75, 95% CI 0.17 to 3.29; 1 trial, 286 participants). Conventional chest physiotherapy (versus no physiotherapy) may have little to no effect on improving cure rate, but the certainty of evidence is very low (RR 0.93, 95% CI 0.56 to 1.55; 2 trials, 225 participants; I² = 85%). Active cycle of breathing techniques (versus no physiotherapy) may have little to no effect on improving cure rate, but the certainty of evidence is very low (RR 0.60, 95% CI 0.29 to 1.23; 1 trial, 32 participants). OMT (versus placebo) may improve cure rate, but the certainty of evidence is very low (RR 1.59, 95% CI 1.01 to 2.51; 2 trials, 79 participants; I² = 0%). OMT (versus placebo) may have little to no effect on mean duration of hospital stay, but the certainty of evidence is very low (mean difference (MD) -1.08 days, 95% CI -2.39 to 0.23; 3 trials, 333 participants; I² = 50%). Conventional chest physiotherapy (versus no physiotherapy, MD 0.7 days, 95% CI -1.39 to 2.79; 1 trial, 54 participants) and active cycle of breathing techniques (versus no physiotherapy, MD 1.4 days, 95% CI -0.69 to 3.49; 1 trial, 32 participants) may also have little to no effect on duration of hospital stay, but the certainty of evidence is very low. Positive expiratory pressure (versus no physiotherapy) may reduce the mean duration of hospital stay by 1.4 days, but the certainty of evidence is very low (MD -1.4 days, 95% CI -2.77 to -0.03; 1 trial, 98 participants). Positive expiratory pressure (versus no physiotherapy) may reduce the duration of fever by 0.7 days, but the certainty of evidence is very low (MD -0.7 days, 95% CI -1.36 to -0.04; 1 trial, 98 participants). Conventional chest physiotherapy (versus no physiotherapy, MD 0.4 days, 95% CI -1.01 to 1.81; 1 trial, 54 participants) and OMT (versus placebo, MD 0.6 days, 95% CI -1.60 to 2.80; 1 trial, 21 participants) may have little to no effect on duration of fever, but the certainty of evidence is very low. OMT (versus placebo) may have little to no effect on the mean duration of total antibiotic therapy, but the certainty of evidence is very low (MD -1.07 days, 95% CI -2.37 to 0.23; 3 trials, 333 participants; I² = 61%). Active cycle of breathing techniques (versus no physiotherapy) may have little to no effect on duration of total antibiotic therapy, but the certainty of evidence is very low (MD 0.2 days, 95% CI -4.39 to 4.69; 1 trial, 32 participants). High-frequency chest wall oscillation plus fibrobronchoscope alveolar lavage (versus fibrobronchoscope alveolar lavage alone) may reduce the MD of intensive care unit (ICU) stay by 3.8 days (MD -3.8 days, 95% CI -5.00 to -2.60; 1 trial, 286 participants) and the MD of mechanical ventilation by three days (MD -3 days, 95% CI -3.68 to -2.32; 1 trial, 286 participants), but the certainty of evidence is very low. One trial reported transient muscle tenderness emerging after OMT in two participants. In another trial, three serious adverse events led to early withdrawal after OMT. One trial reported no adverse events after positive expiratory pressure treatment. Limitations of this review were the small sample size and unclear or high risk of bias of the included trials.

Authors' conclusions: The inclusion of two new trials in this update did not change the main conclusions of the original review. The current evidence is very uncertain about the effect of chest physiotherapy on improving mortality and cure rate in adults with pneumonia. Some physiotherapies may slightly shorten hospital stays, fever duration, and ICU stays, as well as mechanical ventilation. However, all of these findings are based on very low certainty evidence and need to be further validated.

Trial registration: ClinicalTrials.gov NCT05007457.

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Conflict of interest statement

Xiaomei Chen: declares that they have no conflict of interest. Jiaojiao Jiang: declares that they have no conflict of interest. Renjie Wang: declares that they have no conflict of interest. Hongbo Fu: declares that they have no conflict of interest. Jing Lu: declares that they have no conflict of interest. Ming Yang: declares that they have no conflict of interest.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Conventional chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 1: Mortality
1.2
1.2. Analysis
Comparison 1: Conventional chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 2: Cure rate
1.3
1.3. Analysis
Comparison 1: Conventional chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 3: Duration of hospital stay
1.4
1.4. Analysis
Comparison 1: Conventional chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 4: Duration of fever
1.5
1.5. Analysis
Comparison 1: Conventional chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 5: Rate of improvement of chest X‐ray
2.1
2.1. Analysis
Comparison 2: Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 1: Cure rate
2.2
2.2. Analysis
Comparison 2: Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 2: Duration of hospital stay
2.3
2.3. Analysis
Comparison 2: Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 3: Rate of improvement of chest X‐ray
2.4
2.4. Analysis
Comparison 2: Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 4: Duration of antibiotic therapy
2.5
2.5. Analysis
Comparison 2: Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 5: Duration of sputum production
2.6
2.6. Analysis
Comparison 2: Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 6: Inpatient sputum weight
3.1
3.1. Analysis
Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 1: Mortality
3.2
3.2. Analysis
Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 2: Cure rate
3.3
3.3. Analysis
Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 3: Duration of hospital stay
3.4
3.4. Analysis
Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 4: Duration of fever
3.5
3.5. Analysis
Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 5: Rate of improvement of chest X‐ray
3.6
3.6. Analysis
Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 6: Duration of total antibiotic therapy
3.7
3.7. Analysis
Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 7: Duration of intervenous antibiotic therapy
3.8
3.8. Analysis
Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 8: Duration of oral antibiotic therapy
3.9
3.9. Analysis
Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 9: Time to clinical stability
3.10
3.10. Analysis
Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 10: Rate of in‐hospital respiratory failure
3.11
3.11. Analysis
Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 11: Rate of 60‐day hospital readmission
3.12
3.12. Analysis
Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 12: Duration of leukocytosis
3.13
3.13. Analysis
Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 13: Change in leukocyte count
3.14
3.14. Analysis
Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 14: Mean leukocyte count
4.1
4.1. Analysis
Comparison 4: Positive expiratory pressure plus routine treatment versus routine treatment alone, Outcome 1: Duration of hospital stay
4.2
4.2. Analysis
Comparison 4: Positive expiratory pressure plus routine treatment versus routine treatment alone, Outcome 2: Duration of fever
5.1
5.1. Analysis
Comparison 5: High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage versus fibrobronchoscope alveolar lavage alone, Outcome 1: Mortality
5.2
5.2. Analysis
Comparison 5: High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage versus fibrobronchoscope alveolar lavage alone, Outcome 2: Duration of mechanical ventilation
5.3
5.3. Analysis
Comparison 5: High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage versus fibrobronchoscope alveolar lavage alone, Outcome 3: Duration of ICU stay
See this image and copyright information in PMC

Update of

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NCT05007457 {published data only}
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Additional references

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References to other published versions of this review

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