CRITICAL CARE
Chest Physiotherapy for Pneumonia
Source: Lukrafka JL, Fuchs SC, Fischer GB, et al. Chest phys-
iotherapy in paediatric patients hospitalized with community-
acquired pneumonia: a randomized clinical trial. Arch Dis Child.
2012;97(11):967-971; doi:10.1136/archdischild-2012-302279
R
esearchers from Brazil
and Chile sought to as- PICO
Question: Among children hospitalized with
sess the efficacy of chest
community-acquired pneumonia, does chest
physiotherapy (CPT) among physiotherapy improve respiratory rate,
children hospitalized with com- illness severity, and length of hospital stay?
munity-acquired pneumonia. Question type: Intervention
Hospitalized children 1 to 12 Study design: Prospective randomized
years of age who met clinical
and radiologic criteria for community-acquired pneumonia were
enrolled. Children were randomized to either the intervention (CPT)
or control group. Children in the control group received routine care
that included nonmandatory requests to encourage cough and deep
breathing. Children <5 years old assigned to the intervention group
received a standardized CPT protocol (manual thoracic vibration
with cupped hands, thoracic compression, positive expiratory pres-
sure, and artificially stimulated cough and suctioning if needed).
Those >5 years old received the same CPT protocol and in addition
were required to do breathing exercises consisting of forced exhala-
tion with the glottis open. These treatments were done 3 times per
day for a period of 10 to 15 minutes each. Children in both groups
received antibiotics and, if indicated, oxygen. The primary endpoints
were reduction of respiratory rate and improvement in an illness
severity score based on the presence or absence of tachypnea, retrac-
tions, desaturation, fever, and radiograph evidence of pleural effu-
sion. A secondary outcome was duration of hospitalization.
Of the 362 potentially eligible patients, 41 were enrolled in the
control group and 38 in the CPT group. At baseline, neither demo-
graphic features, severity of illness, nor initial radiologic lung find-
ings differed significantly between study groups. Notably, however,
10 children (29%) in the CPT group had a pleural effusion compared
to 4 (11%) in the standard therapy group (P = .06). During hospi-
talization, 4 children (3 in the CPT group) were treated with chest
tubes and were excluded from further study analysis. Neither length
of hospital stay (median 8 days in the CPT vs 6 in the control group),
changes in respiratory rate, nor changes in severity scores differed
significantly by study group.
The authors conclude that CPT provided no additional benefit for
hospitalized children with community-acquired pneumonia. Their
conclusions support the recent British Thoracic Society Guidelines
that recommend against CPT for treatment of pneumonia in chil-
dren.1
Commentary by
Linda Keele, MD, Pediatric Critical Care Medicine, University of Utah, Salt
Lake City, UT
Dr Keele has disclosed no financial relationship relevant to this commentary. This commentary does not contain a
discussion of an unapproved/investigative use of a commercial product/device.
CPT consists of various techniques, including gravity-assisted
drainage/postural drainage, chest wall percussion, chest wall vibra-
tions, deep breathing or bagging methods to increase chest inflation,
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and directed cough.1-3 More recent additions include mechanical
devices such as flutter, intrapulmonary percussive ventilation (IPV),
and positive expiratory pressure (PEP) masks. All of these techniques
are used to promote either secretion clearance or re-expansion of
atelectatic areas.2-3 CPT is performed by trained physiotherapists or
respiratory therapists with patient-specific directed goals. Despite
lack of evidence demonstrating its utility, it is used commonly in
ICUs and on the wards in hospitals throughout the world.
Multiple randomized controlled studies in adults and children
have investigated the utility of CPT for various disease processes
including ventilator-associated pneumonia, bronchiolitis, atelectasis,
spinal muscular atrophy, and cystic fibrosis. Most have not shown
benefit. A 2012 Cochrane review of 9 clinical trials including 891
participants with bronchiolitis reported that CPT did not improve
respiratory parameters, length of hospital stay, severity of illness,
or oxygen requirements.4 CPT used in these studies consisted of
vibration and percussion techniques as well as passive expiratory
techniques. This review updated prior bronchiolitis and CPT reviews
in 2002 and 2007 reporting similar conclusions.
The current investigators evaluated the addition of CPT to stan-
dard treatment of community-acquired pneumonia in children.
Consistent with the results of previous studies, they found no benefit
from CPT in terms of improved clinical status or decreased duration
of hospitalization. Despite this lack of evidence, CPT is still com-
monly used in children without chronic pulmonary disease.
The evidence for the use of CPT in some chronic diseases is less
clear. The cystic fibrosis guidelines developed in 2009 recommend
use of all of these techniques to enhance mucous transport and lung
function, but only short-term effects were documented. They state
that a lack of evidence does not equate to a lack of benefit and thus
recommend prolonged therapy with CPT.5 Similarly, a consensus
statement on the care for infants and children with spinal muscular
atrophy recommends use of CPT, but drew no conclusions regarding
the optimal technique for secretion mobilization because evidence
was lacking.6
Overall, CPT is a relatively benign therapy with very few side ef-
fects and typically is well tolerated by children. For those with chronic
illnesses marked by poor airway clearance CPT may be helpful.
Editors’ Note
Given multiple trials in a variety of settings showing no or limited
efficacy, one wonders why CPT is used for any condition in pediatrics.
Perhaps tradition trumps evidence. Although it may be benign, CPT
provided by highly skilled professionals is far from inexpensive.
References
1. Harris M, et al. Thorax. 2011;66(suppl 2):ii1-ii23; doi:10.1136/thoraxjnl-2011-200598
2. Nitoumenopoulos G, et al. Intensive Care Med. 2002;28(7):850-856; doi:10.1007/s00134-
002-1342-2
3. Nowobilski R, et al. Polskie Arch. 2010;120(11):468-478
4. Roque I, et al. Cochrane Database Syst Rev. 2012;2:CD004873
5. Flume PA, et al. Respir Care. 2009;54(4):522-537
6. Wang CH, et al. J Child Neurol. 2007;22(8):1027-1049; doi:10.1177/0883073807305788
Key words: pneumonia, chest physiotherapy, pleural effusion
 Chest Physiotherapy for Pneumonia
AAP Grand Rounds 2013;29;18
DOI: 10.1542/gr.29-2-18

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 Chest Physiotherapy for Pneumonia
AAP Grand Rounds 2013;29;18
DOI: 10.1542/gr.29-2-18

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