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Chest physiotherapy for adults with pneumonia: effective or not?
This Cochrane systematic review evaluates the research evidence for the effectiveness of chest physiotherapy with adult patients diagnosed with hospital-acquired, community-acquired or ventilator-acquired pneumonia. The review will interest healthcare professionals delivering care to this patient population. Pneumonia is an important clinical problem, with an annual incidence of community-acquired pneumonia of up to 12 per 1000 adults in the USA,1 and is a leading cause of death among infectious diseases.2 Although antibiotic therapy is the mainstay of treatment for pneumonia, chest physiotherapy is used in addition as it is believed to improve patients' respiratory status and speed recovery by aiding airway clearance. However, the evidence on whether chest physiotherapy is clinically effective is controversial.
No improvement in mortality and cure rates but some improvement shown for hospital stay, fever duration and duration of antibiotic therapy
Four types of chest physiotherapy were evaluated in this review: conventional chest physiotherapy (postural drainage, manual techniques and deep breathing), osteopathic manipulative treatment (OMT), active cycle of breathing techniques and positive expiratory pressure (PEP). Although no improvement was found in mortality, cure rates or chest x-ray findings for these techniques, there was some improvement in other outcomes. For patients treated with OMT, hospital stay was reduced by 2 days and duration of antibiotic therapy by 1.9 days. For patients treated with PEP, hospital stay was reduced by 1.4 days and fever duration by 0.7 days. However, these findings are extrapolated from a small numbers of trials. The authors conclude that chest physiotherapy might not be suitable as a routine adjunctive treatment for adults with pneumonia but that the evidence is limited.
Rigorous appraisal but limited evidence
A comprehensive search of the Cochrane Central Register of Controlled Trials (CENTRAL) and hand searching were performed, with no language restrictions. The usual assessments of methodological biases for Cochrane reviews were rigorously made and explicitly presented.
The authors experienced difficulties with the available research, with only six randomised controlled trials being suitable for inclusion. Most of these were of low methodological quality, and the risk of bias was assessed as moderate (two studies) to high (four studies). Differences between the physiotherapy interventions studied meant that meta-analysis could not be performed on all the included studies. Analyses were performed on similar interventions only. Therefore results included smaller numbers of participants, with potential for bias.
Translation into clinical practice
The findings of this review agree with those of many studies that have shown there is little evidence that chest physiotherapy for airway clearance benefits patients with pneumonia.3 In most of the trials the characteristics of the patients' pneumonia were not stated, and so it was not apparent whether the patients studied had secretions to clear. Larger trials to assess the clinical effects of airway clearance are needed, ideally with a focus on presence of secretions, because clinically no causative link has been demonstrated for some of the results reported in the review. From the limited evidence available we would recommend that patients do not have routine chest physiotherapy but that treatments are individualised. If a patient has secretions to clear, physiotherapy assessment and airway clearance techniques should be considered.
The review limits its scope for ‘chest physiotherapy’ and fails to consider other techniques, such as mobilisation or enhanced ventilation (non-invasive ventilation or continuous positive airway pressure), that have shown effectiveness in pneumonia.4 5 In more severe cases, techniques such as ventilator hyperinflations and suctioning in patients with secretions may be beneficial, although these techniques require further research evaluation.
Until there is further, larger-scale research to consider, routine use of mobilisation and enhanced ventilation (if indicated) with the addition of airway clearance techniques for patients who have secretions in line with clinical guidelines6 is recommended for adults with pneumonia.
Competing interests None.
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