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Paediatrics

Chest physical therapy for children hospitalised with

acute pneumonia: a randomised controlled trial

C Paludo, L Zhang, C S Lincho, D V Lemos, G G Real, J A Bergamin

Department of Maternal and ABSTRACT tory exudates and tracheobronchial secretions,

Child Health, Federal University Background: The indication for chest physical therapy as removing airway obstruction, reducing airway
of Rio Grande, Rio Grande, Brazil an adjunct to the treatment of children hospitalised with resistance, enhancing gas exchange and reducing
1–3
Correspondence to: acute pneumonia remains controversial and there is a lack the work of breathing. On the other hand, there
Dr L Zhang, Department of of robust scientific evidence for the effectiveness of this is a lack of robust scientific evidence for the
Maternal and child Health, modality in these patients. effectiveness of chest physical therapy in children
Federal University of Rio Grande, Methods: A randomised controlled trial was conducted in hospitalised with pneumonia. The British Thoracic
Rio Grande, Brazil 96010-140; two tertiary hospitals in southern Brazil. Children aged Society guidelines for managing pneumonia in
zhanglinjie63@yahoo.com.br 29 days to 12 years hospitalised with pneumonia childhood recommend that chest physical therapy
between February and October 2006 were recruited; 51 is not beneficial and should not be performed in
4
Received 31 July 2007 were randomly allocated to the intervention group (chest children with pneumonia; however, these recom-
Accepted 31 January 2008 physical therapy plus standard treatment for pneumonia) mendations are based mainly on the results of two
Published Online First and 47 to the control group (standard treatment for randomised controlled trials, one in adults and one
5 6
14 February 2008 pneumonia alone). The primary outcome was time to in children. Moreover, the validity of this old
clinical resolution. The secondary outcomes were length clinical trial in children is questionable due to the
of stay in hospital and duration of respiratory symptoms small sample size, exclusion of patients with
and signs. pneumonia of presumed bacterial origin and
6
Results: There were no significant differences in terms of inadequate randomisation and blinding. More
median time to clinical resolution (4.0 vs 4.0 days,
p = 0.84) and median length of hospital stay (6.0 vs
6.0 days, p = 0.76) between the intervention and control
groups. The intervention group had a longer median
duration of coughing (5.0 vs 4.0 days, p = 0.04) and of
rhonchi on lung auscultation (2.0 vs 0.5 days, p = 0.03)
than the control group.
Conclusions: Chest physical therapy as an adjunct to
standard treatment does not hasten clinical resolution of
children hospitalised with acute pneumonia and may
prolong duration of coughing and rhonchi.

The indication for chest physical therapy as an

adjunct to the treatment of children hospitalised
with acute pneumonia remains controversial. On
the one hand, chest physical therapy has been, and
continues to be, widely applied to these patients in
paediatric practice based on beliefs of the potential
benefits of this modality in evacuating inflamma-
data are therefore needed fro Study setting min (bpm); 2–12 months: 50 bpm; .1–5 years: 40
m high quality The study was conducted in the paediatric wards bpm; .5 years: 30 bpm; (3) consolidations and/or
randomised trials to make a more of two tertiary hospitals: the 30-bed teaching infiltrates associated or not with other findings
precise decision hospital of the Federal University of Rio Grande compatible with pneumonia on the chest radio-
on the use of chest physical th and the 30-bed Hospital da Santa Casa de Rio graph. All chest radiographs were interpreted
erapy for acute Grande. These are two unique hospitals in the city routinely in the Department of Radiology and
pneumonia in childhood. of Rio Grande in southern Brazil, covering a reviewed by a senior paediatric pulmologist (ZL).
This randomised controlled trial population of approximately 200 000. The ethics Any disagreement was resolved by discussion with
was conducted committee of the Federal University of Rio Grande a reference radiologist. Patients who needed a chest
to assess the effectiveness of chest (Rio Grande, RS, Brazil) and the ethics committee drain, had haemodynamic instability, bone fragi-
physical therapy of the Hospital da Santa Casa de Rio Grande (Rio lity or rib fractures and any other contraindication
1
in children hospitalised with acute Grande, RS, Brazil) approved the study. to chest physical therapy were excluded. The
pneumonia. We recruitment of participants occurred between
hypothesised that chest physical Participants February and October 2006. The parents or legal
therapy as an Children aged 29 days to 12 years hospitalised guardians of each child gave written informed
adjunct to standard treatment c with a diagnosis of acute pneumonia were assessed consent before enrolment in the study.
ould hasten the for eligibility for the study. Patients were included
clinical resolution of acute pneumo in the study if they met all of the following clinical Study design and protocol
4 7
nia in paediatric and radiological diagnosis criteria for pneumonia: This study was a randomised controlled clinical
inpatients. (1) presence of coughing and/or fever; (2) tachy- trial. Simple randomisation was performed from
pnoea, defined as respiratory rate above age- a table of random numbers. The recruited
METHODS dependent upper limits: ,2 months: 60 breaths/

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Paediatrics

participants were randomly allocated to the intervention group (tachy-pnoea, chest indrawing, rhonchus, wheezes, fine crackles
or the control group. The intervention group received chest and coarse crackles) was evaluated and kappa indexes of 0.53,
physical therapy twice daily plus standard treatment for 0.63, 0.48, 0.70, 0.60 and 0.47, respectively, were achieved. The
pneumonia until discharge and the control group received daily maximum body temperature was noted by the investiga-
standard treatment for pneumonia alone. Each session of chest tors based on the patient’s nursing record. The patient’s axillary
physical therapy took about 30 min and consisted of postural temperature was measured by the attending nurses every 3 h
drainage, thoracic squeezing, chest percussion, vibration, cough throughout the hospital stay. All investigators and nurses were
1 5 6
stimulation and aspiration of secretions (if necessary). The blinded to group assignment and study protocol. Different
positions for postural drainage were guided by the chest schedules were arranged for the investigators and physiothera-
radiograph to allow more effective drainage of tracheobronchial pist to avoid their chance encounter at a patient’s bedside.
secretions and inflammatory exudates in the most affected
1 6
areas. The same certified physiotherapist (CP) administered Outcome measures
chest physical therapy to all patients. The primary outcome was time to clinical resolution which was
The standard treatment for pneumonia in each patient was defined as the number of days needed for a patient to achieve
administered by the attending paediatrician based on the the following clinical parameters: afebrile (daily maximum body
recommendations of the Brazilian guidelines for the diagnosis temperature ,37.5uC), absence of severe signs (chest indrawing,
7
and treatment of pneumonia. It included antibiotic therapy, nasal flaring, cyanosis), normal respiratory rate and arterial
fluid therapy and oxygen therapy if needed. The decision to oxygen saturation >95%. Secondary outcomes were length of
discharge from hospital was also made by the attending hospital stay (in days) and persistence of respiratory symptoms
pediatrician. All attending pediatricians were blinded to group and signs (fever, cough, wheezing, tachypnoea, chest indrawing,
assignment and study protocol. adventitious sounds on lung auscultation and arterial oxygen
The patients were assessed at enrolment and every day saturation ,95%) (in days).
between 17.00 and 18.00 h by one of four investigators using a
pre-codified questionnaire. The same investigator was respon- Sample size
sible for assessment of each patient from enrolment to The sample size was determined on the assumption that the
discharge. Patient assessment included respiratory symptoms, mean (SD) time to clinical resolution in the control group was 6
6
respiratory signs (respiratory rate, chest indrawing, nasal (1.5) days. To detect a clinically relevant reduction of 1 day in
flaring, cyanosis and lung auscultation) and arterial oxygen the time to clinical resolution, 47 participants were needed in
saturation measured by pulse oximetry. All four investigators each group (two-sided a of 5% and power of 90%).
received adequate training in assessment of the patient,
especially in measuring respiratory rate and arterial oxygen Statistical analysis
saturation, in observing chest indrawing and in lung ausculta- Statistical analysis was performed using the Stata Version 8.0
2
tion. The standard technique for measurement of respiratory program (Stata Corporation, Texas, USA). The x test was used
rate and arterial oxygen saturation was the same as previously for analysis of dichotomous data and the unpaired Student t test
8
reported. The definition of adventitious sounds on lung or Mann-Whitney rank sum test were used for analysis of
auscultation was based on the recommendations of the 1985 continuous data as appropriate. Analyses were based on the
9
International Symposium on Lung Sounds. The inter- intention-to-treat principle. In the additional analysis we
observer agreement between the four investigators and a excluded the possible cases of acute bronchiolitis (ie, patients
senior paediatric pulmologist (ZL) regarding respiratory signs aged ,2 years who presented with wheeze on lung auscultation

Figure 1 Flow diagram of the trial.

792 Thorax 2008;63:791–794. doi:10.1136/thx.2007.088195
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Paediatrics

Table 1 Baseline characteristics of the 89 patients Table 2 Effects of chest physical therapy on clinical evolution of
Intervention group Control group children hospitalised with acute pneumonia
Characteristic (n = 47) (n = 42) p Value Intervention group Control group

Age (months) 44.0 (31.6 to 56.4) 32.2 (22.5 to 41.9) 0.14 Outcomes (n = 47) (n = 42) p Value

Male sex 29 (61.7%) 24 (57.1%) 0.66 Time to clinical resolution 4.0 (2.0–7.0) 4.0 (3.0–6.0) 0.84

Low birth weight (,2500 g) 5 (10.6%) 4 (9.5%) 0.86 Length of hospital stay 6.0 (4.0–9.0) 6.0 (4.0–8.0) 0.76

Prematurity (,37 weeks) 8 (17.0%) 6 (14.2%) 0.72 Time to normal respiratory rate 3.0 (0–7.0) 3.0 (1.0–6.0) 0.75

Maternal smoking 17 (36.1%) 17 (40.4%) 0.67 Time to normal arterial oxygen 1.0 (0–2.0) 0.5 (0–2.0) 0.98

Respiratory symptoms and saturation (>95%)

signs Time to normal lung auscultation 4.0 (3.0–6.0) 4.0 (2.0–6.0) 0.28

Coughing 46 (97.8%) 38 (92.6%) 0.24 Duration of fever 2.0 (0–2.0) 1.0 (0–3.0) 0.78

Fever 45 (95.7%) 37 (90.2%) 0.30 Duration of coughing 5.0 (4.0–8.0) 4.0 (3.0–6.0) 0.04

Parent’s reported wheezing 31 (65.9%) 24 (58.5%) 0.47 Duration of parent’s reported 1.5 (0–5.0) 1.0 (0–3.5) 0.29

Respiratory rate (bpm) 45.0 (40.9 to 49.1) 45.8 (41.6 to 50.1) 0.78 rhonchi on lung auscultation (2.0 vs 0.5 days, p = 0.03) than the
Chest indrawing 24 (51.0%) 22 (53.6%) 0.80 control group. There were no significant differences between
Fine crackles 16 (34.0%) 11 (26.8%) 0.46 the two groups in the other parameters of clinical evolution.
Coarse crackles 17 (36.1%) 19 (46.3%) 0.33 No significant changes were observed in the results when an
Rhonchi 9 (19.2%) 6 (14.6%) 0.57 additional analysis (excluding 12 patients who were aged
Wheezes 13 (27.6%) 5 (12.2%) 0.07 ,2 years who presented with wheeze at enrolment) and an
Chest radiographic findings explanatory analysis (excluding 7 patients in the control group
Consolidation 39/45 (86.7%) 35/39 (89.7%) 0.66 who received chest physical therapy indicated by attending
Hyperinflation 6/45 (13.3%) 5/39 (12.8%) 0.95 pediatricians) were performed.
Pleural effusion 5/45 (11.1%) 6/39 (15.4%) 0.56

Arterial oxygen saturation 95.0 (94.3 to 95.7) 95.7 (95.0 to 96.4) 0.15 DISCUSSION
Antibiotic therapy 47 (100%) 42 (100%) 1.00 This randomised trial failed to confirm that chest physical
Values expressed as mean (95% CI) or n (%). therapy as an adjunct to standard treatment hastens the clinical
resolution of children hospitalised with acute pneumonia. The
at enrolment. An explanatory analysis was also performed to time to clinical resolution and the length of hospital stay were
verify the potential changes in the results. A two-tailed p value similar in the intervention and control groups. Moreover, this
of ,0.05 was considered statistically significant. study showed that patients who received chest physical therapy
had had prolonged duration of coughing and rhonchi on lung
RESULTS auscultation. However, the persistence of these respiratory
One hundred and ten children were assessed for eligibility symptoms and signs may not necessarily represent an unfa-
during the study period and 98 were included in the trial (fig 1). vourable clinical evolution. Coughing might be induced by a
Of the 98 patients recruited, 51 were randomly allocated to the physiotherapist since it is an essential component of chest
intervention group and 47 to the control group. Table 1
summarises the baseline characteristics of the 89 patients. There
were no significant differences between the intervention and
control groups in terms of the baseline characteristics.
Table 2 compares the clinical evolution in the intervention
and the control groups. The intervention group had a longer
median duration of coughing (5.0 vs 4.0 days, p = 0.04) and of
wheezing prolonged fever in patients receiving this treatment. In the
Duration of fine crackles 0 (0–2.0) 0 (0–2.0) 0.72 present trial the intervention group had a longer median
Duration of coarse crackles 2.0 (0–4.0) 1.0 (0–3.0) 0.83 duration of fever than the control group (2.0 vs 1.0 days) but
Duration of wheezes 0 (0–5.0) 0 (0–4.0) 0.62 this difference was not statistically significant (p = 0.78).
Duration of rhonchi 2.0 (0–4.0) 0.5 (0–2.0) 0.03 The data derived from this randomised trial support the
4
Duration of chest indrawing 2.0 (0–3.0) 2.0 (0–3.0) 0.75 recommendations of the British Thoracic Society guidelines
Number of days expressed as median (interquartile range). that chest physical therapy is not beneficial in children with
acute pneumonia and should not be performed in these
physical therapy. Rhonchus, a typical ‘‘secretion sound’’ on lung patients. However, these recommendations may not be suitable
auscultation, might be prolonged by chest physical therapy as it for special groups of children with acute pneumonia, such as
could dislodge tracheobronchial secretions and produce this those with impaired mucociliary clearance or those with
adventitious sound. In this sense, chest physical therapy might complications such as atelectasis and pleural effusion needing
effectively mobilise tracheobronchial secretions in this group of a chest drain. Future randomised trials should focus on these
children but failed to modify the clinical evolution of acute special groups of patients.
pneumonia assessed by time to clinical resolution, length of Some methodological aspects of this trial deserve special
hospital stay and persistence of other individual clinical comment. First, no placebo is available to blind those involved
parameters such as fever, respiratory rate, chest indrawing and in a trial of physical therapy and it may be the source of
10
arterial oxygen saturation. performance and observation bias. To minimise these potential
One clinical trial reported no beneficial effect of chest biases, all investigators who assessed the patients and all
physical therapy in children hospitalised with viral pneumonia attending paediatricians and nurses were blinded to the group
in spite of serious methodological limitations mentioned assignment and study protocol. Second, no standard protocol of
6
previously. Moreover, prolonged fever was observed in the physical therapy is well defined for special respiratory disease
intervention group. A similar finding was reported by another and the ‘‘art’’ of this modality may introduce a number of
5
randomised trial in adults with primary pneumonia. It was personal and uncontrollable factors. In this trial the protocol of
speculated that the spread of infiltrates and physical activity physical therapy was defined a priori based on the experiences
associated with chest physical therapy might explain the

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Paediatrics

of the previous studies and on the potential benefits of each Ethics approval: The ethics committee of the Federal University of Rio Grande (Rio
1 5 6 11
component on acute pneumonia. To avoid inter-individual Grande, RS, Brazil) and the ethics committee of the Hospital da Santa Casa de Rio

variation caused by the ‘‘art’’ of physical therapy, the same Grande (Rio Grande, RS, Brazil) approved the study. The parents or legal guardians of

physiotherapist administered the treatment to all patients. each child gave written informed consent before enrolment.

Third, the outcomes currently used to assess the effectiveness of

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794 Thorax 2008;63:791–794. doi:10.1136/thx.2007.088195
 Downloaded from thorax.bmj.com on March 10, 2014 - Published by group.bmj.com

Chest physical therapy for children

hospitalised with acute pneumonia: a

randomised controlled trial

C Paludo, L Zhang, C S Lincho, et al.
Thorax 2008 63: 791-794 originally published online February 14, 2008
doi: 10.1136/thx.2007.088195

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