Bradley 1996

Physical training for bronchiectasis (Review)
Bradley JM, Moran F, Greenstone M
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2002, Issue 2
http://www.thecochranelibrary.com

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Inspiratory Muscle Training versus Sham or no intervention (change from baseline), Outcome
1 Endurance (metres). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 Incremental shuttle walking test (metres). . . . . . . . . . . . . . . . . . . . . . . .
3 Health Status (CRDQ score). . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 Pi Max (cms of water). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.1. Comparison 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results), Outcome 1
Endurance (metres). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Incremental shuttle walking test (metres). . . . . . . . . . . . . . . . . . . . . . . . .
Health Status (CRDQ score). . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.4. Comparison 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results), Outcome 4 Pi
Max (cms of water). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS
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[Intervention Review]
Physical training for bronchiectasis

Judy M Bradley1 , Fidelma Moran2 , Michael Greenstone3
1 Rehabilitation Sciences Research Institute School, University of Ulster and Belfast City Hospital, Newtownabbey, UK. 2 Room 14J07,
School of Health Sciences, University of Ulster, Newtownabbey, UK. 3 Castle Hill Hospital, Cottingham, UK
Contact address: Judy M Bradley, Rehabilitation Sciences Research Institute School, University of Ulster and Belfast City Hospital,
University of Ulster, Shore Road, Newtownabbey, Northern Ireland, BT37 0QB, UK. jm.bradley@ulster.ac.uk.
Editorial group: Cochrane Airways Group.
Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.
Review content assessed as up-to-date: 9 February 2005.
Citation: Bradley JM, Moran F, Greenstone M. Physical training for bronchiectasis. Cochrane Database of Systematic Reviews 2002,
Issue 2. Art. No.: CD002166. DOI: 10.1002/14651858.CD002166.
ABSTRACT
Background
The pathophysiology of bronchiectasis may result in the development of dyspnoea and decreased exercise tolerance, both of which can
impact on a patients quality of life and ability to perform activities of daily living. There is little information regarding the benefits of
physical training in bronchiectasis: however it is probable that the benefits of physical training in bronchiectasis are at least comparable to
benefits demonstrated in other respiratory conditions. There is also no information regarding the effects of non-adherence to prescribed
physical training in bronchiectasis. However as in patients with COPD non-adherence may contribute to a deterioration in the patients
condition and conceivably the long term prognosis.
Objectives
The objective of this review is to determine whether a prescribed regime of physical training produces improvements or prevents
deterioration in physiological and clinical outcomes in bronchiectasis compared to no physical training.
Search methods
We searched the Cochrane Airways Group trials register and the Cochrane Central Register of Controlled Trials.
Selection criteria
Randomised or quasi randomised controlled trials in which a prescribed regimen of physical training is compared to no physical training
in patients with bronchiectasis.
Data collection and analysis
We identified three studies. One was did not meet the inclusion criteria and two appeared in abstract form only. More comprehensive
data will be incorporated into this review once data from those two trials are published, and when further data is made available to the
authors of this review. An update search in February 2005 identified one excluded study.
Main results
Results from the two studies published in abstract showed that inspiratory muscle training compared to sham or no inspiratory
muscle training improved endurance exercise capacity: Weighted Mean Difference (WMD) 264 metres (95% CI 16.4 to 512 metres).
Maximum inspiratory pressure (PiMax) improved: WMD 25 cms H20 (95% CI 11.6 to 38.4 cms H2O ) as did quality of life measured
with the CRQ: WMD 12.4 units (95% CI 2.4 to 22.5 units).
Authors conclusions
This review only provides evidence of the benefits of inspiratory muscle training and provides no evidence of the effect of other types
of physical training (including pulmonary rehabilitation) in bronchiectasis.
PLAIN LANGUAGE SUMMARY

A search for controlled trials of physical training in bronchiectasis only identified two early reports (abstracts) including 43 patients in
total. These suggest some benefits of inspiratory muscle training on exercise capacity, quality of life and respiratory muscle function at
eight weeks, but further research is needed to confirm these findings in larger numbers of people with bronchiectasis. Further research
is also needed to assess the benefit of other types of physical training and pulmonary rehabilitation in bronchiectasis.
BACKGROUND
Bronchiectasis can be defined as a disease that results in an abnormal dilatation of one or more bronchi. The primary cause of
bronchiectasis is an insult to the respiratory tract e.g. severe pneumonia, viral infection or aspiration of a foreign body. Genetic diseases such as cystic fibrosis (CF), primary ciliary dyskinesia (including Kartageners syndrome) and immunodeficiency can also
result in bronchiectasis. Any one of these conditions predisposes
the airways to lower respiratory colonisation by bacteria such as
Haemophilus influenzae or Pseudomonas aeruginosa.
Although infection and obstruction are implicated in the development of bronchiectasis , the inflammatory response may also
be important in disease progression: the hosts response to infection may fail to completely eradicate the infecting organism and
chronic colonisation is established . A vicious cycle of microbial
colonisation/ infection has been proposed whereby bacteria elaborate substances toxic to the mucociliary escalator and perpetuates
the failure to eliminate the organisms. The inflammatory response
leads to further damage of the bronchial tree and lung parenchyma
and is usually associated with excessive secretions and the development of airflow obstruction.
The consequences of this may include the development of chronic
respiratory symptoms including cough, excessive purulent sputum, haemoptysis, breathlessness and decreased exercise tolerance.
The causes of breathlessness and decreased exercise tolerance are
multifactorial and may include altered pulmonary mechanics, inefficient gas exchange, decreased muscle bulk and confounding
psychological morbidity. All of these factors initiate a cyclical phenomenon whereby decreased exercise tolerance leads to progressive
detraining which in turn results in further reductions in exercise
tolerance.
Physical training is defined as participation in a programme of regular vigorous physical activity designed to improve physical performance, and/or cardiovascular function and/or muscle strength
(Shepherd 1994). Physical training has been shown to improve
exercise tolerance and reduce symptoms of breathlessness in many
patient populations including CF and chronic obstructive pulmonary disease (COPD). A meta-analysis of randomised trials
examining the role of physical training in COPD conducted by
Smith 1992, indicated a small non-significant trend in favour of
respiratory muscle training for most outcomes. There is little information regarding the benefits of physical training in bronchiectasis: however it is probable that the benefits of physical training
in bronchiectasis are at least comparable to benefits demonstrated
in other respiratory conditions (Morgan 1997). There is also no
information regarding the effects of non-adherence to prescribed
physical training in bronchiectasis. However as in patients with
COPD non-adherence may contribute to a deterioration in the
patients condition and conceivably the long term prognosis.
This review will aim to determine the evidence base benefit for
the use of physical training programmes in the management of
patients with bronchiectasis.
OBJECTIVES
The objective of this review is to determine whether a prescribed
regime of physical training in bronchiectasis produces improvements or prevents deterioration in physiological and clinical outcomes in bronchiectasis compared to no physical training.
METHODS

Criteria for considering studies for this review
Types of studies
Only randomised or quasi -randomised controlled trials in which
a prescribed regimen of physical training is compared to no physical training in patients with bronchiectasis will be considered for
this review. Single blind and open studies will be considered for
inclusion.
Types of participants
We will include patients (adults and children) with stable
bronchiectasis. Patients with cystic fibrosis will be excluded. Diagnosis will be based on symptoms and appropriate imaging (bronchography or high resolution CT scanning).
Types of interventions
We will consider any type of prescribed physical training including
pulmonary rehabilitation. We will record, wherever possible, the
precise nature of the training (intensity, frequency and duration)
will be recorded. We will exclued any studies which do not include
a prescribed physical training component. Important alterations
in patient management such as airway clearance techniques or
medication must be controlled for.
Types of outcome measures

The most appropriate outcome measure in bronchiectasis has not
been defined. The assessment of impairment, disability and handicap is necessary to provide a comprehensive evaluation of treatment outcome.
Primary outcomes
Exercise tolerance: Objective change in exercise tolerance (maximal oxygen uptake (VO2 max), peak oxygen uptake (VO2 peak),
maximal ventilation (Ve max), heart rate, subjective assessment of
dyspnoea) as measured during formal exercise tests or field exercise
tests.
Secondary outcomes
1. Measures of specific indices of respiratory muscle strength:

peak inspiratory pressure (PImax), peak expiratory strength
(PEMax). Other measures of muscle strength, mass, effort and
general fatigue will be included.
2. Pulmonary function tests: forced expiratory volume in one
second (FEV1), forced vital capacity (FVC), forced expiratory
flow at 25 to 75% of FVC (FEF25-75), peak expiratory flow
(PEF), total lung capacity (TLC) and fixed respiratory capacity
(FRC): change in % predicted or and absolute change from

baseline compared to control will be assessed. Peak inspiratory If
other parameters are used, they will be considered.
3. Dyspnoea: All measures of dyspnoea used will be
considered.
4. Quality of life: Change in quality of life as measured by
generic or disease - specific quality of life instruments, or by
subjective perception of well-being. All quality of life
instruments used will be considered.
5. Weight: Absolute weight change, change in % ideal body
weight, or weight standard deviation score or change in body
composition will be assessed.
6. Expectorated secretions: Dry or wet weight or volume.
7. Changes in physical symptoms such as cough and wheeze
8. Number of acute exacerbations, duration, hospitalisation,
IV antibiotic courses and time off work will be considered.
9. Oxygen saturation measured by pulsed or transcutaneous
oximetry.
10. Compliance with physical training will be recorded in
detail.
11. Compliance with other treatment, such as airway clearance
techniques, nutritional regimes if measured. Methods of
assessing compliance will be recorded in detail.
12. Adverse effects including fractures, skeletal muscle injuries
and death will be recorded.
13. Cost evaluation.
If outcomes have been measured more than once in a study, we
will record the outcome measured most distant from the commencement of physical training.
Search methods for identification of studies

We carried out a search using the Cochrane Airways Group trials
register and the Cochrane Central Register of Controlled Trials.
This database is comprised of systematic MEDLINE, CINAHL
and EMBASE searches.
We searched these registers using the search terms;
Bronchiectasis AND training OR physical training OR physical
fitness OR physical activity OR physical rehabilitation OR physical therapy OR exercise training OR exercise rehabilitation OR
exercise therapy OR exercise OR pulmonary rehabilitation OR
physiotherapy
We searched the reference lists of each RCT for additional studies. We also contacted authors of RCTs for information on other
published and unpublished studies.
Data collection and analysis

Two reviewers (JB, FM) independently selected the trials to be
included in the review using a proforma capturing the main in-

clusion criteria listed above. Each reviewer assessed the methodological quality of each included trial.
The methodological quality of the RCTs was assessed using the
modified version of the five point instrument proposed by Jadad
1996 and the system for assessing treatment allocation concealment used by the Cochrane Collaboration.
JADAD FIVE POINT SYSTEM:
(1) Was the study described as randomised (1 = yes; 0 = no)?
(2) Was the study described as being double blind (1 = yes; 0 =
no)?
(3) Was there a description of withdrawals and dropouts (1 = yes;
0 = no)?
(4) Was the method of randomisation well described and appropriate (1 = yes; 0 = no)?
(5) Was the method of double blinding well described and appropriate (1 = yes; 0 = no)?
(6) Deduct 1 point if methods for randomisation or blinding were
inappropriate.
Concealment system:
A - adequate concealment
B - uncertain
C - clearly inadequate
We resolved disagreements by consensus.
For binary outcome measures, we sought data on the number of
participants with each outcome event, by allocated treated group,
(irrespective of compliance or subsequent eligibility) to allow an
intention-to-treat analysis. For continuous outcomes, we aimed to
record either mean change from baseline for each group or mean
post treatment / intervention values and the standard deviation
(SD) or standard error (standard error will be converted to SD).
For binary outcomes, we aimed to calculate a pooled estimate of
the treatment effect for each outcome across studies, (the odds of
an outcome among treatment allocated patients to the corresponding odds among controls). For continuous outcomes we aimed to
calculate a pooled estimate of treatment effect by calculating the
weighted mean difference.
RESULTS
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies.
Electronic searches yielded a total of 38 references. Three of these
were identified as potentially relevant. One was excluded (Choe
1996), for details see Excluded studies table. The other two fulfilled the inclusion criteria for the review but have been published
in abstract form only. In spite of efforts to obtain complete data
from these trials none has been made available to the authors of
this review. It is anticipated that more complete data will be available at a later date and will be incorporated into updated versions
of this review. An update search conducted in February 2005 identified one excluded study (Kellett 2005).
Both studies are described below, but will be subject to amendment
upon their full journal publication.
Newall 2000a was a randomised controlled eight week study.
NIneteen participants were involved (10 in the inspiratory muscle training group, nine in the control group). Inspiratory muscle
training was carried out using a pressure threshold device. The
control group had no intervention. Concealment of allocation was
unclear and no drop outs were reported.
Newall 2000b was a randomised controlled study, conducted over
an eight week period. 33 patients were randomised to receive either
inspiratory muscle training (using a pressure threshold device) plus
pulmonary rehabilitation (education, exercise training) or sham
inspiratory muscle training plus pulmonary rehabilitation or no
intervention. Twelve participants were in the active inspiratory
muscle training group, 12 in the sham inspiratory muscle training
group and nine in the control group. No data was available for the
control group in this study.
Risk of bias in included studies

In the two trials in this review, we ranked the method of concealment unclear (Grade B). Both studies achieved a score of 1/
5 on the Jadad scale however both studies are only available in
abstract form and this score may change when the full text studies
are published. We will, therefore, provide a clearer indication of
study quality when more data becomes available.
Effects of interventions
A limited amount of data was reported in abstract form on 43
participants with bronchiectasis from the two included studies
(Newall 2000a; Newall 2000b). No data was available for the control group in Newall 2000b, therefore no comparison has been
made between pulmonary rehabilitation and no pulmonary rehabilitation. There were considerable baseline difference between
groups in the studies. Therefore the results have been presented
using changes from baseline, but the absolute post treatment results are also shown as a second comparison.
EXERCISE TOLERANCE
The pooled results of the two studies show significant increase
from baseline in the inspiratory muscle training group versus sham
or no inspiratory muscle training in endurance (method of assessment not detailed), Weighted Mean Difference (WMD) 264
metres (95% CI 16.4 to 512 metres). Maximal exercise capacity

(incremental shuttle walking test) did not show a significant increase from baseline, WMD 54 metres (95% CI -34 to 142 metres). The post treatment results showed bigger treatment effects,
but also introduced heterogeneity. The baseline endurance in the
treatment group was 160 m less (500 m versus 661 m) in the
treatment group in Newall 2000a and 328 m more (732 m versus
404 m) in Newall 2000b.
QUALITY OF LIFE
The pooled results of the two studies indicate an increase in the
quality of life following treatment compared to baseline in the
inspiratory muscle training group versus sham or no inspiratory
muscle training WMD 12.4 units on the CRQ scale (95% CI 2.38
to 22.48). Again the larger treatment effects shown in the post
treatment scores relate to the higher baseline quality of life in the
treatment groups.
PULMONARY FUNCTION
Pooled results from the two trials showed significant increases
in maximal inspiratory pressure (PiMax) from baseline following
treatment compared to baseline in the inspiratory muscle training
group versus sham or no inspiratory muscle training WMD 25
cms of water (95% CI 11.6 to 38.4 cms). Post treatment analysis
showed similar results.
At present there is no evidence from randomised control trials
to indicate whether physical training in bronchiectasis has an effect on peripheral muscle strength, mass, effort and general fatigue; dyspnoea; weight; expectorated secretions; physical symptoms; number of and treatment of acute exacerbations; duration,
hospitalisation, IV antibiotic courses and time off work ; oxygen
saturation of the haemoglobin of arterial blood (SaO2); bone mineral density and diabetes; compliance; nutritional regimes; adverse
effects and cost.
Neither study was reported to be double blinded however this

quality issue must be considered in the context of the difficulty
of blinding any type of physical training study. Both studies used
random allocation, however neither provided details on the specific
procedures used. This may be due to the fact that both studies were
reported in abstract form only. In both studies the randomisation
used was not successful in ensuring the groups were balanced at
baseline in all measures. These quality issues effect the internal
validity of the studies and justify the low Jadad scores reported.
The primary outcome measure in this review was exercise tolerance. Secondary outcome measures included pulmonary function
tests and quality of life. Analyses of the two studies suggest that
there is some evidence of the effect of inspiratory muscle training
on endurance exercise capacity, lung function and quality of life
but did not show any benefit in terms of maximal exercise capacity.
Baseline differences make it difficult to be sure of the size of the
treatment effect, and the standard deviation of the changes from
baseline is not reported so has been assumed to be similar to the
standard deviation of the post treatment results (this is likely to be
a conservative estimate).
AUTHORS CONCLUSIONS
Implications for practice
It has been suggested that the magnitude of improvement from
physical training programmes in patients with bronchiectasis
should at least be comparable to the improvements demonstrated
in other respiratory disease populations. These claims are based primarily on expert opinion of the benefits of training in bronchiectasis, albeit supported by a sound physiological rationale. This review
only provides evidence of the benefits of inspiratory muscle training and provides no evidence of the effect of other types of physical
training (including pulmonary rehabilitation) in bronchiectasis.
Implications for research
DISCUSSION
This systematic review examined the effectiveness of physical training in the management of bronchiectasis. This was in order to
determine whether a prescribed regimen of physical training in
bronchiectasis produces improvements or prevents deterioration,
in physiological and clinical outcomes in bronchiectasis compared
to no physical training.
Despite an exhaustive review of available literature, we only identified two relevant primary trials. Both of these trials investigated
the efficacy of inspiratory muscle training in bronchiectasis. As
there are only two studies the results should be viewed in the context of possible publication bias.
This review has identified that there are no trials assessing the effect of physical training in bronchiectasis. There is a need for well
designed, adequately powered, randomised controlled clinical trials to assess the net benefit (positive effects and side effects) of
adherence to different forms of prescribed physical training programmes, in patients with bronchiectasis. As it is likely that the
benefits and side effects of adherence to different types of physical
training differs in patients with mild, moderate and severe disease,
the influence of disease severity should be considered in the design of any future trial. The full benefit of any prescribed physical
training is unlikely to be demonstrated in programmes that are of
insufficient length or intensity. Therefore any future trial should
be of sufficient duration, intensity and frequency to assess the net
benefit of training on measures of disease impairment, disability
and handicap. Further research should also consider whether phys-

ical training programmes delivered within the context of a pulmonary rehabilitation program offers any additional advantages
to physical training alone.
ACKNOWLEDGEMENTS
We gratefully thank Claire Allen for assistance with the preparation
of the synopsis and Kirsty Olsen who copy edited this review.
REFERENCES
References to studies included in this review
Additional references
Newall 2000a {published data only}

Newall C, Henson M, McConnell AK, Stockley RA, Hill
SL. The effect of inspiratory muscle training (IMT) on
pulmonary function, exercise tolerance, and quality of life
in patients with bronchiectasis (BE). European Respiratory
Society. 2000; Vol. August September:1.
Jadad 1996
Jadad A, Moore RA, Carroll D, Jenkinson C, Reynolds
JM, Gavaghan DJ, et al.Assessing the quality of reports
of randomised controlled trials: is blinding necessary?.
Controlled Clinical Trials 1996;17(1):112.
Newall 2000b {published data only}

Newall C, Henson M, McConnell AK, Stockley RA, Hill
SL. The effects of pulmonary rehabilitation (PR ) in patients
with bronchiectasis (BE). European Respiratory Society.
2000; Vol. AugustSept:3.
References to studies excluded from this review

Choe 1996 {published data only}
Choe KH Park YJ, et al.The effect of pulmonary
rehabilitation in patients with chronic lung disease.
Tuberculosis and respiratory diseases 1996;43(5):73645.
Kellett 2005 {published data only}
Kellett F, Redfern J, Niven RMcL. Evaluation of nebulised

hypertonic saline (7%) as an adjunct to physiotherapy in
patients with stable bronchiectasis. Respiratory Medicine
2005;99(1):2731.
Morgan 1997
Morgan M, Singh S. Practical Pulmonary Rehabilitation. 1st
Edition. London: Chapman and Hall Medical, 1997.
Revill 1999
Revill SM, Morgan MDL, Singh SJ, Williams J, Hardman
AE. The endurance shuttle walk: A new field test for the
assessment of endurance capacity in chronic obstructive
pulmonary disease. Thorax 1999;54(3):21322.
Shepherd 1994
Shephard RJ. Aerobic Fitness and Health. Leeds, England:
Human Kinetic Publishers, 1994.
Smith 1992
Smith K, Cook D, Guyatt G, Madhavan J, Oxman A.
Respiratory Muscle Training in Chronic Airflow Limitation:
A Meta-Analysis. American Review of Respiratory Disease
1992;145(3):5339.
Indicates the major publication for the study

CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Newall 2000a
Methods
8 week study; concealment unclear; no dropouts specified; groups not similar at baseline
Participants
19 patients with bronchiectasis (IMT group, n = 10. Mean age 62.4 +/- 16.53); (control group, n = 9.
Mean age 62.8 +/- 11.6)
Interventions
8 weeks IMT using a pressure threshold device

control no intervention
Outcomes
Included in this study were PImax; VC; RV; TLC; endurance; ISWT; CRDQ
Notes
Jadad = 1
Risk of bias
Item
Authors judgement
Description
Allocation concealment?
Unclear
Information not available (Cochrane Grade B)
Newall 2000b
Methods
8 week study concealment unclear; no dropouts specified; groups not similar at baseline
Participants
33 patients with bronchiectasis

(IMT plus PR: n = 12; mean age 56.8 +/- 7.8 years)
(sham IMT plus PR: n = 12 mean age 63 +/- 8.9)
(control: n = 9 mean age 62 +/- 11.6)
Interventions
IMT using a pressure threshold device plus PR (education and exercise training)
sham IMT plus PR
control- no intervention
Outcomes
Included in this study were PImax; endurance; ISWT; CRDQ
Notes
Jadad = 1
Risk of bias
Item
Authors judgement
Description
Allocation concealment?
Unclear
Information not available (Cochrane Grade B)
CRDQ: Chronic respiratory disease questionnaire

IMT: Inspiratory muscle training

ISWT: Incremental shuttle walking test
PImax: Peak inspiratory pressure (cmH2O)
PR: pulmonary rehabilitation (education, exercise training)
RV: Residual Volume (L)
TLC: Total Lung Capacity (L)
VC: Vital Capacity (L)
Characteristics of excluded studies [ordered by study ID]
Study
Reason for exclusion
Choe 1996
Inappropriate patient population (only 1 patient had bronchiectasis) and no randomisation
Kellett 2005
Assessment of the addition of hypertonic saline to breathing technique. In the absence of an inactive control we
excluded the study

DATA AND ANALYSES
Comparison 1. Inspiratory Muscle Training versus Sham or no intervention (change from baseline)
No. of
studies
No. of
participants
1 Endurance (metres)
43
Mean Difference (IV, Fixed, 95% CI)
1.1 Compared to no
intervention
1.2 Compared to sham
(both groups had Pulmonary
Rehabilitation)
2 Incremental shuttle walking test
(metres)
2.1 Compared to no
intervention
Rehabilitation)
3 Health Status (CRDQ score)
3.1 Compared to no
intervention
Rehabilitation)
4 Pi Max (cms of water)
4.1 Compared to no
intervention
Rehabilitation)
19
24
43
19
24
2
1
43
19

12.40 [2.38, 22.43]

1.90 [-13.52, 17.32]
24
20.1 [6.90, 33.30]
2
1
43
19

25.03 [11.63, 38.44]

32.4 [6.09, 58.71]
24
22.45 [6.87, 38.03]
Outcome or subgroup title
Statistical method
Effect size
264.21 [16.40, 512.
02]
204.60 [-374.01,
783.21]
277.60 [3.36, 551.
84]
54.01 [-33.98, 142.
01]
46.8 [-129.87, 223.
47]
56.39 [-45.09, 157.
87]
Comparison 2. Inspiratory Muscle Training v Sham or no intervention (post treatment results)
Outcome or subgroup title

1 Endurance (metres)
1.1 Compared to no
intervention
Rehabilitation)
No. of
studies
No. of
participants
43
19
24
Statistical method

Effect size
502.48 [254.67,
750.30]
43.90 [-534.71, 622.
51]
605.5 [331.26, 879.
74]
9
2 Incremental shuttle walking test

(metres)
2.1 Compared to no
intervention
Rehabilitation)
3 Health Status (CRDQ score)
3.1 Compared to no
intervention
Rehabilitation)
4 Pi Max (cms of water)
4.1 Compared to no
intervention
Rehabilitation)
43
148.96 [60.96, 236.

95]
-14.20 [-190.87,
162.47]
202.79 [101.31,
304.27]
19
24
2
1
43
19

22.89 [12.87, 32.92]

17.70 [2.28, 33.12]
24
26.70 [13.50, 39.90]
2
1
43
19

25.77 [12.36, 39.18]

24.40 [-1.91, 50.71]
24
26.25 [10.67, 41.83]
Analysis 1.1. Comparison 1 Inspiratory Muscle Training versus Sham or no intervention (change from
baseline), Outcome 1 Endurance (metres).
Review:
Comparison: 1 Inspiratory Muscle Training versus Sham or no intervention (change from baseline)
Outcome: 1 Endurance (metres)
Study or subgroup
IMT
N
Mean
Difference
Control
Mean(SD)
Mean(SD)
271.4 (651.2)
66.8 (634.6)
Weight
IV,Fixed,95% CI
Mean
Difference
IV,Fixed,95% CI
1 Compared to no intervention
Newall 2000a
Subtotal (95% CI)
10
10
18.3 %
204.60 [ -374.01, 783.21 ]
18.3 %
204.60 [ -374.01, 783.21 ]
81.7 %
277.60 [ 3.36, 551.84 ]
12
81.7 %
277.60 [ 3.36, 551.84 ]
21
100.0 %
264.21 [ 16.40, 512.02 ]
Heterogeneity: not applicable

Test for overall effect: Z = 0.69 (P = 0.49)
2 Compared to sham (both groups had Pulmonary Rehabilitation)
Newall 2000b
Subtotal (95% CI)
12
678.3 (400.3)
12
12
400.7 (273.3)

Total (95% CI)
22
Heterogeneity: Chi2 = 0.05, df = 1 (P = 0.82); I2 =0.0%

Test for subgroup differences: Chi2 = 0.05, df = 1 (P = 0.82), I2 =0.0%
-1000
-500
Favours control

500
1000
Favours IMT
10
baseline), Outcome 2 Incremental shuttle walking test (metres).
Review:
Outcome: 2 Incremental shuttle walking test (metres)
Study or subgroup
IMT
N
Mean
Difference
Control
Mean(SD)
Mean(SD)
57.8 (162.9)
11 (221.9)
Weight
IV,Fixed,95% CI
Mean
Difference
IV,Fixed,95% CI
Newall 2000a
Subtotal (95% CI)
10
10
24.8 %
46.80 [ -129.87, 223.47 ]
24.8 %
46.80 [ -129.87, 223.47 ]
75.2 %
56.39 [ -45.09, 157.87 ]
12
75.2 %
56.39 [ -45.09, 157.87 ]
21
100.0 %
54.01 [ -33.98, 142.01 ]

Newall 2000b
Subtotal (95% CI)
12
110.89 (134.9)
12
12
54.5 (118.2)

Total (95% CI)
22

-1000
-500
Favours control

500
1000
Favours IMT
11
baseline), Outcome 3 Health Status (CRDQ score).
Review:
Outcome: 3 Health Status (CRDQ score)
Study or subgroup
IMT
Mean
Difference
Control
Mean(SD)
Mean(SD)
10
7.3 (10.7)
5.4 (21.3)
Weight
IV,Fixed,95% CI
Mean
Difference
IV,Fixed,95% CI
Newall 2000a
Subtotal (95% CI)
10
42.3 %
1.90 [ -13.52, 17.32 ]
42.3 %
1.90 [ -13.52, 17.32 ]
57.7 %
20.10 [ 6.90, 33.30 ]
12
57.7 %
20.10 [ 6.90, 33.30 ]
21
100.0 %
12.40 [ 2.38, 22.43 ]

Newall 2000b
Subtotal (95% CI)
12
10.5 (19.5)
12
12
-9.6 (12.8)

Total (95% CI)
22
Heterogeneity: Chi2 = 3.09, df = 1 (P = 0.08); I2 =68%

Test for subgroup differences: Chi2 = 3.09, df = 1 (P = 0.08), I2 =68%
-100
-50
Favours control

50
100
Favours IMT
12
baseline), Outcome 4 Pi Max (cms of water).
Review:
Outcome: 4 Pi Max (cms of water)
Study or subgroup
IMT
N
Mean
Difference
Control
Mean(SD)
Mean(SD)
30.8 (31.6)
-1.6 (26.9)
Weight
IV,Fixed,95% CI
Mean
Difference
IV,Fixed,95% CI
Newall 2000a
Subtotal (95% CI)
10
10
26.0 %
32.40 [ 6.09, 58.71 ]
26.0 %
32.40 [ 6.09, 58.71 ]
74.0 %
22.45 [ 6.87, 38.03 ]
12
74.0 %
22.45 [ 6.87, 38.03 ]
21
100.0 %
25.03 [ 11.63, 38.44 ]

Newall 2000b
Subtotal (95% CI)
12
28.25 (25.7)
12
12
5.8 (9.9)

Total (95% CI)
22

-100
-50
Favours control

50
100
Favours IMT
13
Analysis 2.1. Comparison 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results),
Outcome 1 Endurance (metres).
Review:
Comparison: 2 Inspiratory Muscle Training v Sham or no intervention (post treatment results)

Outcome: 1 Endurance (metres)
Study or subgroup
IMT
N
Mean
Difference
Control
Mean(SD)
Mean(SD)
772.1 (651.2)
728.2 (634.6)
Weight
IV,Fixed,95% CI
Mean
Difference
IV,Fixed,95% CI
Newall 2000a
Subtotal (95% CI)
10
10
18.3 %
43.90 [ -534.71, 622.51 ]
18.3 %
43.90 [ -534.71, 622.51 ]
81.7 %
605.50 [ 331.26, 879.74 ]
12
81.7 %
605.50 [ 331.26, 879.74 ]
21
100.0 %
502.48 [ 254.67, 750.30 ]

Newall 2000b
Subtotal (95% CI)
12
1410 (400.3)
12
12
804.5 (273.3)

Total (95% CI)
22

-1000
-500
Favours control

500
1000
Favours IMT
14
Outcome 2 Incremental shuttle walking test (metres).
Review:

Outcome: 2 Incremental shuttle walking test (metres)
Study or subgroup
IMT
N
Mean
Difference
Control
Mean(SD)
Mean(SD)
448.8 (162.9)
463 (221.9)
Weight
IV,Fixed,95% CI
Mean
Difference
IV,Fixed,95% CI
Newall 2000a
Subtotal (95% CI)
10
10
24.8 %
-14.20 [ -190.87, 162.47 ]
24.8 % -14.20 [ -190.87, 162.47 ]

Newall 2000b
Subtotal (95% CI)
12
579.09 (134.9)
12
12
376.3 (118.2)
75.2 %
202.79 [ 101.31, 304.27 ]
12
75.2 %
202.79 [ 101.31, 304.27 ]
21
100.0 %
148.96 [ 60.96, 236.95 ]

Total (95% CI)
22

-1000
-500
Favours control

500
1000
Favours IMT
15
Outcome 3 Health Status (CRDQ score).
Review:

Outcome: 3 Health Status (CRDQ score)
Study or subgroup
IMT
N
Mean
Difference
Control
Mean(SD)
Mean(SD)
97.2 (10.7)
79.5 (21.3)
Weight
IV,Fixed,95% CI
Mean
Difference
IV,Fixed,95% CI
Newall 2000a
Subtotal (95% CI)
10
10
42.3 %
17.70 [ 2.28, 33.12 ]
42.3 %
17.70 [ 2.28, 33.12 ]
57.7 %
26.70 [ 13.50, 39.90 ]
12
57.7 %
26.70 [ 13.50, 39.90 ]
21
100.0 %
22.89 [ 12.87, 32.92 ]

Newall 2000b
Subtotal (95% CI)
12
101.5 (19.5)
12
12
74.8 (12.8)

Total (95% CI)
22

Test for overall effect: Z = 4.48 (P < 0.00001)
-100
-50
Favours control

50
100
Favours IMT
16
Outcome 4 Pi Max (cms of water).
Review:

Outcome: 4 Pi Max (cms of water)
Study or subgroup
IMT
Mean
Difference
Control
Mean(SD)
Mean(SD)
100 (31.6)
75.6 (26.9)
Weight
IV,Fixed,95% CI
Mean
Difference
IV,Fixed,95% CI
Newall 2000a
10
Subtotal (95% CI)
10
26.0 %
24.40 [ -1.91, 50.71 ]
26.0 %
24.40 [ -1.91, 50.71 ]
74.0 %
26.25 [ 10.67, 41.83 ]
12
74.0 %
26.25 [ 10.67, 41.83 ]
21
100.0 %
25.77 [ 12.36, 39.18 ]

Newall 2000b
12
Subtotal (95% CI)
100.55 (25.7)
12
12
74.3 (9.9)

Total (95% CI)
22

-100
-50
Favours control
50
100
Favours IMT
WHATS NEW
Last assessed as up-to-date: 9 February 2005.
Date
Event
Description
30 September 2008
Amended
Converted to new review format.

17
HISTORY
Protocol first published: Issue 1, 2001
Review first published: Issue 2, 2002
Date
Event
Description
1 February 2002
New citation required and conclusions have changed
Substantive amendment
CONTRIBUTIONS OF AUTHORS
The review was conceived by the Cochrane Airways Group and designed by Dr Judy Bradley and Ms Fidelma Moran. Searches for
relevant studies were conducted by Dr Judy Bradley and Ms Fidelma Moran and by the Cochrane Airways Group. Dr Judy Bradley
and Ms Fidelma Moran screened, appraised and abstracted data for review. Data entry was and analysis was performed by Dr Judy
Bradley and Ms Fidelma Moran with advice from the editor, Dr Mike Greenstone and the Cochrane Airways Group
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Internal sources
NHS Research and Development, UK.
External sources
Garfield Weston Foundation, UK.
INDEX TERMS
Medical Subject Headings (MeSH)
Respiratory
Muscles; Bronchiectasis [ therapy]; Exercise Therapy [ methods]; Physical Endurance

18
MeSH check words

Humans

19

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Physical training for bronchiectasis (Review)

Bradley JM, Moran F, Greenstone M

Physical training for bronchiectasis (Review)

Physical training for bronchiectasis (Review)

Physical training for bronchiectasis

PLAIN LANGUAGE SUMMARY

Physical training for bronchiectasis (Review)

Criteria for considering studies for this review

Types of outcome measures

1. Measures of specific indices of respiratory muscle strength:

(FRC): change in % predicted or and absolute change from

Search methods for identification of studies

Data collection and analysis

Physical training for bronchiectasis (Review)

Risk of bias in included studies

Physical training for bronchiectasis (Review)

Neither study was reported to be double blinded however this

Implications for research

Physical training for bronchiectasis (Review)

References to studies included in this review

Newall 2000a {published data only}

Newall 2000b {published data only}

References to studies excluded from this review

Kellett F, Redfern J, Niven RMcL. Evaluation of nebulised

Indicates the major publication for the study

Physical training for bronchiectasis (Review)

Characteristics of included studies [ordered by study ID]

8 weeks IMT using a pressure threshold device

Information not available (Cochrane Grade B)

33 patients with bronchiectasis

Included in this study were PImax; endurance; ISWT; CRDQ

Information not available (Cochrane Grade B)

CRDQ: Chronic respiratory disease questionnaire

IMT: Inspiratory muscle training

Characteristics of excluded studies [ordered by study ID]

Reason for exclusion

Inappropriate patient population (only 1 patient had bronchiectasis) and no randomisation

Physical training for bronchiectasis (Review)

DATA AND ANALYSES

Mean Difference (IV, Fixed, 95% CI)

Mean Difference (IV, Fixed, 95% CI)

Mean Difference (IV, Fixed, 95% CI)

Mean Difference (IV, Fixed, 95% CI)

Mean Difference (IV, Fixed, 95% CI)

Mean Difference (IV, Fixed, 95% CI)

Mean Difference (IV, Fixed, 95% CI)

12.40 [2.38, 22.43]

Mean Difference (IV, Fixed, 95% CI)

20.1 [6.90, 33.30]

Mean Difference (IV, Fixed, 95% CI)

25.03 [11.63, 38.44]

Mean Difference (IV, Fixed, 95% CI)

22.45 [6.87, 38.03]

Outcome or subgroup title

Comparison 2. Inspiratory Muscle Training v Sham or no intervention (post treatment results)

Outcome or subgroup title

Mean Difference (IV, Fixed, 95% CI)

Mean Difference (IV, Fixed, 95% CI)

Mean Difference (IV, Fixed, 95% CI)

Physical training for bronchiectasis (Review)

2 Incremental shuttle walking test

Mean Difference (IV, Fixed, 95% CI)

148.96 [60.96, 236.

Mean Difference (IV, Fixed, 95% CI)