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Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol)

Hough JL, Flenady VJ, Woodgate PG

This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2007, Issue 4 http://www.thecochranelibrary.com

Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

TABLE OF CONTENTS ABSTRACT . . . . . . . . . . . . . . . . . . . . BACKGROUND . . . . . . . . . . . . . . . . . . OBJECTIVES . . . . . . . . . . . . . . . . . . . CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW SEARCH METHODS FOR IDENTIFICATION OF STUDIES . METHODS OF THE REVIEW . . . . . . . . . . . . . POTENTIAL CONFLICT OF INTEREST . . . . . . . . . SOURCES OF SUPPORT . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 2 2 3 3 3 4 4 5

Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol)
Hough JL, Flenady VJ, Woodgate PG

This record should be cited as: Hough JL, Flenady VJ, Woodgate PG. Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support. (Protocol) Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD006445. DOI: 10.1002/14651858.CD006445. This version rst published online: 18 April 2007 in Issue 2, 2007. Date of most recent substantive amendment: 01 December 2006

ABSTRACT This is the protocol for a review and there is no abstract. The objectives are as follows: 1. To determine the effects of active chest physiotherapy, including percussion and vibrations, compared to nonactive techniques, such as suction with or without the addition of positioning, in newborn infants receiving mechanical ventilation: electively for the prevention of atelectasis, consolidation, or other respiratory morbidity therapeutically for the treatment of atelectasis or consolidation 2. To determine the effects of the different types of active CPT. The following subgroup analyses are planned: 1. Population Gestational age: < 30 weeks ; < 37 weeks; 37 weeks and over Birth weight : < 1500 grams, < 2500 grams, 2500 grams and over Underlying pulmonary disorder: respiratory distress syndrome (RDS), aspiration, infection or chronic lung disease (CLD) 2. Intervention - techniques Type of technique: percussion (including cupping with a face mask, contact heel percussion and nger percussion); vibration (with ngers or mechanical vibrator) Frequency: 4 hours or less; > 4 hours

BACKGROUND Approximately two to three per cent of all babies born in Australia and New Zealand require admission to a level three neonatal intensive care unit (NICU) (ANZNN 2005). In this group of high risk infants, 89% require assisted ventilation. Chest physiotherapy (CPT) techniques are used in many NICUs throughout the world to improve airway clearance in these infants on ventilatory support. The application of CPT in airway management of mechanically ventilated adults has been shown to improve total lung/thoracic compliance and cardiorespiratory function (Mackenzie 1985); however, little is known about its effect on neonates. Acute lobar atelectasis is a common problem in infants receiving mechanical ventilation. Atelectasis contributes to morbidity in the neona-

tal nursery, necessitating prolongation of oxygen administration (Ehrlich 1972). Although CPT has been shown to be effective in the treatment of both nonventilated children (Zach 1987) and intubated adults (Stiller 1990) with acute lobar collapse, studies of the effectiveness in the neonatal population are conicting. In the neonatal population, CPT is used both as a prophylactic measure (by removing secretions) and also as a treatment technique for lung collapse and consolidation. Some studies in the neonatal population have shown positive effects of CPT, including improved oxygenation (Finer 1978; Curran 1979) and increased removal of secretions (Etches 1978). However, the use of CPT has also received much criticism, largely as a result of reports of adverse outcomes. Documented adverse outcomes include hypoxaemia (Holloway 1966; Fox 1978), bruising, rib fractures (Purohit 1975; Dabezies 1997), and intracranial pathology such as in1

Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

traventricular haemorrhage (Raval 1987) and porencephalic cysts (Harding 1998; Cross 1992). Chest physiotherapy in the preterm infant consists of a variety of techniques that include positioning, active techniques such as percussion and vibrations, and suction. Percussion involves a rhythmical cupping action applied to the chest wall performed with a full cupped hand, tented ngers, or by using an infant resuscitation face mask (cupping). The technique of vibration can be performed manually by using the ngers to cause a ne shaking motion of the chest wall. Alternatively, an electric toothbrush or other vibrating device can be used. The use of these techniques, in varying combinations and frequencies, has become standard treatment for a variety of pulmonary conditions. As there are many combinations of treatments that constitute CPT, it is difcult to determine the exact effect of any particular treatment technique. There has been some attempt in the past to ascertain which techniques produced the most clinically relevant results, but the results are equivocal. Some studies have found percussion to be better than vibrations (Crane 1978; Tudehope 1980), while another has found the opposite to be the case (Curran 1979) and yet another has found that there was no difference between the techniques (Hartrick 1982). In clinical practice, percussion and vibrations are rarely used in isolation; most often, percussion and vibration are given in combination with positioning, postural drainage and airway suction. Therefore, it is difcult to assess the efcacy of each treatment component separately. Previous Cochrane reviews have investigated the positioning (Balaguer 2006) and suctioning (Pritchard 2004; Spence 2004; Woodgate 2004) components of CPT. Only one review has assessed the effect of active chest physiotherapy techniques on preterm infants, and this has been in the population of infants being extubated (Flenady 2004). This review could not recommend guidelines for clinical practice, due to small numbers of infants studied and insufcient information on outcomes other than the reduction in post extubation atelectasis (Flenady 2004). In light of the results of this review and the amount of conicting information from other studies, it is important to investigate the wider use of the techniques of percussion and vibration in the preterm population. As the issue of the effectiveness of physiotherapy is still a controversial topic, it is anticipated that this review will provide guidelines on the provision of the respiratory physiotherapy techniques of percussion and vibrations in the infant on ventilatory support.

electively for the prevention of atelectasis, consolidation, or other respiratory morbidity therapeutically for the treatment of atelectasis or consolidation 2. To determine the effects of the different types of active CPT. The following subgroup analyses are planned: 1. Population Gestational age: < 30 weeks ; < 37 weeks; 37 weeks and over Birth weight : < 1500 grams, < 2500 grams, 2500 grams and over Underlying pulmonary disorder: respiratory distress syndrome (RDS), aspiration, infection or chronic lung disease (CLD) 2. Intervention - techniques Type of technique: percussion (including cupping with a face mask, contact heel percussion and nger percussion); vibration (with ngers or mechanical vibrator) Frequency: 4 hours or less; > 4 hours

CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW Types of studies All trials utilising random or quasi-random patient allocation. Types of participants All newborn infants receiving mechanical ventilation for neonatal respiratory disease with the intervention initiated in the rst four weeks of life. Infants receiving prophylactic chest physiotherapy for the extubation period will be excluded (Flenady 2004). Types of intervention Active chest physiotherapy techniques (vibrations or percussion with or without the use of devices such as face masks and electric vibrators) compared with standard care (suction with or without positioning). Studies comparing two or more methods of chest physiotherapy intervention will be eligible. Types of outcome measures Primary outcomes:

OBJECTIVES 1. To determine the effects of active chest physiotherapy, including percussion and vibrations, compared to nonactive techniques, such as suction with or without the addition of positioning, in newborn infants receiving mechanical ventilation:

Duration of mechanical ventilation (MV) (days) Duration of supplemental oxygen after intervention (days) Duration of hospital stay (days) Secondary outcomes: Atelectasis or consolidation based on pre/post radiographs
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Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

incidence of atelectasis or consolidation (for prophylactic group) resolution or extension of atelectasis or consolidation (for treatment group) Oxygenation incidence of hypoxaemia (SaO2 < 90% or TcPO2 < 50 mmHg) during intervention per cent change PaCO2 and PaO2 pre and post intervention per cent change inspired oxygen received (FiO2) pre and post intervention Secretion clearance sputum weight (g) post intervention sputum volume (ml) post intervention Rates and type of intracranial lesions diagnosed by ultrasound scan intraventricular haemorrhage (IVH) (any IVH, grade 3 - 4) (Papile 1978) periventricular leucomalacia (PVL) [any grade, and severe (grades 3-4)] (Papile 1978) Bradycardia (change in heart rate < 30% of baseline or < 100 beats per minute) during intervention

METHODS OF THE REVIEW The standard methods of the Neonatal Review Group of the Cochrane Collaboration will be used. Two review authors will work independently to search for and assess trials for inclusion and methodological quality. Eligible studies will be assessed using the following key criteria: allocation concealment (blinding of randomisation), blinding of intervention, completeness of follow up and blinding of outcome measurement. Each of these will be graded as yes, no, cant tell. Two review authors will extract data independently. Differences will be resolved by discussion. An attempt will be made to contact study investigators for additional information or data as required. Data analysis At least two review authors will independently extract data using prepared data extraction forms. Any discrepancies will be resolved by discussion. The Review Manager Software (RevMan 4.2.7) will be used for statistical analyses. Categorical data will be analysed using relative risk (RR), risk difference (RD) and number needed to treat (NNT) where appropriate. A xed effects model will be used to pool results. Weighted mean differences (WMD) will be used for data measured on a continuous scale. 95% condence intervals (CI) will be reported for all estimates. Sensitivity analyses to evaluate the effect of the trial quality (excluding quasi-randomised trials and considering trials with minimal bias) will be performed. Heterogeneity will be assessed by visual inspection of the outcomes tables and by using an I-squared test of heterogeneity (Higgins 2002). Where statistical heterogeneity is found, the review authors will look for an explanation using prespecied subgroup analyses. The following subgroup analyses will be performed: 1. Population Gestational age: < 30 weeks ; < 37 weeks; 37 weeks and over Birth weight : <1500 grams, <2500 grams, 2500 grams and over Underlying pulmonary disorder: respiratory distress syndrome (RDS), aspiration, infection or chronic lung disease (CLD) 2. Intervention - techniques Type of technique: percussion (including cupping with a face mask, contact heel percussion and nger percussion); vibration (with ngers or mechanical vibrator) Frequency: 4 hours or less; > 4 hours

SEARCH METHODS FOR IDENTIFICATION OF STUDIES See: methods used in reviews. See Neonatal Collaborative Review Group search strategy. The standard search strategy for the Cochrane Neonatal Review Group as outlined in The Cochrane Library will be used. This will include searches of the following electronic databases: The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, current issue), PubMed/MEDLINE (1966 - current), EMBASE (1988 - current), CINAHL (1982 - current), PEDro (1929 - present), Web of Science using the MeSH headings Infant, Newborn, Neonate, Respiratory, Lung, Chest, physiotherapy, physical therapy. No language restrictions will be applied. The search will also include searches of the Oxford Database of Perinatal Trials, previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants, journal handsearching restricted to the English language. Conference Proceedings of the Society for Pediatric Research (SPR) (1967- present), the European Society for Pediatric Research (ESPR) (1970) will be hand searched for unpublished work.

POTENTIAL CONFLICT OF INTEREST JH will be chief investigator in a trial investigating the effect of chest physiotherapy techniques on lung function in the preterm infant for her PhD thesis (2005-2007).
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Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

SOURCES OF SUPPORT External sources of support Queensland Health AUSTRALIA Internal sources of support Mater Hospital, South Brisbane AUSTRALIA University of Queensland AUSTRALIA

REFERENCES

Additional references
ANZNN 2005 Samanthi Abeywardana. The report of the Australian and New Zealand Network, 2003. Sydney: ANZNN, 2005. Bagley 2005 Bagley CE, Gray PH, Tudehope DI, Flenady V, Shearman AD, Lamont A. Routine neonatal postextubation chest physiotherapy: a randomized controlled trial. Journal of Paediatric and Child Health 2005; 41:5927. Balaguer 2006 Balaguer A, Escribano J, Roque M. Infant position in neonates receiving mechanical ventilation. The Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003668. DOI: 10.1002/14651858.CD003668.pub2. Crane 1978 Crane LD, Zombek M, Krauss AN, Auld PAM. Comparison of chest physiotherapy techniques in infants with HMD. Pediatric Research 1978;12:5599. Cross 1992 Cross JH, Harrison CJ, Preston PR, Rushton DI, Newell SJ, Morgan ME, Durbin GM. Postnatal encephaloclastic porencephaly--a new lesion?. Archives of Disease in Childhood 1992;67:30711. Curran 1979 Curran CL, Kachoyeanos MK. The effects on neonates of two methods of chest physical therapy. MCN American Journal of Maternal Child Nursing 1979;4:30913. Dabezies 1997 Dabezies EJ, Warren PD. Fractures in very low birth weight infants with rickets. Clinical Orthopaedics Related Research 1997;Feb:2339. Ehrlich 1972 Ehrlich R, Arnon RG. The intermittent endotracheal intubation technique for the treatment of recurrent atelectasis. Pediatrics 1972; 50:1447. Etches 1978 Etches PC, Scott B. Chest physiotherapy in the newborn: effect on secretions removed. Pediatrics 1978;62:7135. Finer 1978 Finer NN, Boyd J. Chest physiotherapy in the neonate: a controlled study. Pediatrics 1978;61:2825. Flenady 2004 Flenady VJ, Gray PH. Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation. The Cochrane

Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000283. DOI:10.1002/14651858.CD000283. Fox 1978 Fox WW, Schwartz JG, Shaffer TH. Pulmonary physiotherapy in neonates: physiologic changes and respiratory management. Journal of Pediatrics 1978;92:97781. Harding 1998 Harding JE, Miles FK, Becroft DM, Allen BC, Knight DB. Chest physiotherapy may be associated with brain damage in extremely premature infants. Journal of Pediatrics 1998;132(3 Pt 1):4404. Hartrick 1982 Hartrick J, Fluit L, Parrott J, Yu VYH. A controlled-study of chest physiotherapy methods in the newborn-infant. Australian Paediatric Journal 1982;18:141. Higgins 2002 Higgins J, Thompson S. Quantifying heterogeneity in meta-analysis. Statistics in medicine 2002;21:153958. Holloway 1966 Holloway R, Desai SD, Kelly SD, Thambiran AK, Strydom SE, Adams EB. The effect of chest physiotherapy on the arterial oxygenation of neonates during treatment of tetanus by intermittent positivepressure respiration. Sour African Medical Journal 1966;40:4457. Mackenzie 1985 Mackenzie CF, Shin B. Cardiorespiratory function before and after chest physiotherapy in mechanically ventilated patients with posttraumatic respiratory failure. Critical Care Medicine 1985;13:4836. Papile 1978 Papile L, Burstein J, Burstein R, Kofer H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500gm. The Journal of Pediatrics 1978; 92(4):5294. Pritchard 2004 Pritchard M, Flenady V, Woodgate P. Preoxygenation for tracheal suctioning in intubated, ventilated newborn infants. The Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD000427. DOI:10.1002/14651858.CD000427. Purohit 1975 Purohit DM, Caldwell C, Levkoff AH. Letter: Multiple rib fractures due to physiotherapy in a neonate with hyaline membrane disease. American Journal of Diseases of Children 1975;129:11034. [MedLine: medline; neonatal; physiotherapy].
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Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

Raval 1987 Raval D, Yeh TF, Mora A, Cuevas D, Pyati S, Pildes RS. Chest physiotherapy in preterm infants with RDS in the rst 24 hours of life. J Perinatol 1987;7:3014. Spence 2004 Spence K, Gillies D, Waterworth L. Deep versus shallow suction of endotracheal tubes in ventilated neonates and young infants. The Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003309. DOI:10.1002/14651858.CD003309. Stiller 1990 Stiller K, Geake T, Taylor J, Grant R, Hall B. Acute lobar atelectasis: a comparison of two chest physiotherapy regimens. Chest 1990;98: 133640. Tudehope 1980 Tudehope DI, Bagley C. Techniques of physiotherapy in intubated babies with the respiratory distress syndrome. Australian Paediatric Journal 1980;16:2268. Woodgate 2004 Woodgate PG, Flenady V. Tracheal suctioning without disconnection in intubated ventilated neonates. The Cochrane Library 2001, Issue 2. Art. No.: CD003065. DOI:10.1002/14651858.CD003065. Zach 1987 Zach MS, Oberwaldner B. Chest physiotherapy--the mechanical approach to antiinfective therapy in cystic brosis. Infection 1987;15: 3814.

COVER SHEET Title Authors Contribution of author(s) Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support Hough JL, Flenady VJ, Woodgate PG Judy Hough - wrote protocol Vicki Flenady - edited protocol Paul Woodgate - edited protocol 2007/2 05 February 2007 01 December 2006 Information not supplied by author Ms Judith Hough Physiotherapist/PhD candidate Physiotherapy Department Mater Hospital Raymond Terrace South Brisbane Queensland 4101 AUSTRALIA E-mail: judyhough@optusnet.com.au 10.1002/14651858.CD006445
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Issue protocol rst published Date of most recent amendment Date of most recent SUBSTANTIVE amendment Whats New Contact address

DOI

Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

Cochrane Library number Editorial group Editorial group code

CD006445 Cochrane Neonatal Group HM-NEONATAL

Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support (Protocol) Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd