Review question
Is chest physiotherapy effective and safe as a supportive treatment for adults with pneumonia?
Background
Pneumonia is one of the most common health problems affecting all age groups around the world. Antibiotics represent the mainstay of pneumonia treatment, whilst some other supportive therapies, such as supplementary oxygen, might also be beneficial in improving patient outcomes. Chest physiotherapy, an airway clearance technique, has been widely used as a supportive therapy for pneumonia in adults without reliable evidence.
Search date
The evidence is current to May 2022.
Study characteristics
We included eight studies involving a total of 974 participants. We included two new studies (540 participants) in this update. All studies included hospitalised patients. The studies looked at five types of chest physiotherapy, namely conventional chest physiotherapy (manual handling techniques to help clear sputum), active cycle of breathing techniques (a set of breathing exercises to help clear sputum), osteopathic manipulative treatment (OMT) (a therapeutic application of manually guided forces by a physiotherapist to improve respiratory function and sputum clearance), positive expiratory pressure (use of a device that increases airflow resistance to improve sputum clearance), and high-frequency chest wall oscillation (chest wall vibration with a specialised device to promote sputum clearance).
Key results
1. Death
Conventional chest physiotherapy, OMT, and high-frequency chest wall oscillation (versus no physiotherapy or placebo therapy) may have little to no effect on reducing death, but the certainty of evidence is very low.
2. Cure rate
OMT (versus placebo therapy) may improve cure rate as defined by the study authors, but the certainty of evidence is very low. Conventional chest physiotherapy (versus no physiotherapy) and active cycle of breathing techniques may have little to no effect on improving cure rate, but the certainty of evidence is very low.
3. Duration of hospital stay
Positive expiratory pressure (versus no physiotherapy) may reduce the duration of hospital stay by 1.4 days, but the certainty of evidence is very low. OMT, conventional chest physiotherapy, and active cycle of breathing techniques (versus placebo therapy or no physiotherapy) may have little to no effect on duration of hospital stay, but the certainty of evidence is very low.
4. Duration of fever
Positive expiratory pressure (versus no physiotherapy) may reduce the duration of fever by 0.7 days, but the certainty of evidence is very low. Conventional chest physiotherapy (versus no physiotherapy) or OMT (versus placebo therapy) may have little to no effect on duration of fever, but the certainty of evidence is very low.
5. Duration of antibiotic use
OMT (versus placebo therapy) and active cycle of breathing techniques (versus no physiotherapy) may have little to no effect on the duration of antibiotic use, but the certainty of evidence is very low.
6. Duration of intensive care unit (ICU) stay
High-frequency chest wall oscillation (versus no physiotherapy) may reduce the duration of ICU stay by 3.8 days in people with severe pneumonia who received mechanical ventilation (use of a machine to help people breathe), but the certainty of evidence is very low.
7. Duration of mechanical ventilation
High-frequency chest wall oscillation (versus no physiotherapy) may reduce the duration of mechanism ventilation by three days in people with severe pneumonia who received mechanical ventilation, but the certainty of evidence is very low.
8. Adverse events (unwanted events that cause harm to the patient)
One study reported three serious adverse events (not specified) that caused early withdrawal of participants after OMT. One study reported adverse events as short-term muscle tenderness after treatment in two participants. Another study reported no adverse events.
Certainty of the evidence
In summary, the certainty of evidence is very low due to research limitations, the small number of participants, and/or imprecision of the results (estimated effects of the treatment were very imprecise). Very low certainty evidence suggests that some physiotherapies may slightly shorten hospital stays, fever duration, antibiotic treatment duration, and ICU stay, as well as mechanical ventilation, but this needs to be further explored.
The inclusion of two new trials in this update did not change the main conclusions of the original review. The current evidence is very uncertain about the effect of chest physiotherapy on improving mortality and cure rate in adults with pneumonia. Some physiotherapies may slightly shorten hospital stays, fever duration, and ICU stays, as well as mechanical ventilation. However, all of these findings are based on very low certainty evidence and need to be further validated.
Despite conflicting evidence, chest physiotherapy has been widely used as an adjunctive treatment for adults with pneumonia. This is an update of a review first published in 2010 and updated in 2013.
To assess the effectiveness and safety of chest physiotherapy for pneumonia in adults.
We updated our searches in the following databases to May 2022: the Cochrane Central Register of Controlled Trials (CENTRAL) via OvidSP, MEDLINE via OvidSP (from 1966), Embase via embase.com (from 1974), Physiotherapy Evidence Database (PEDro) (from 1929), CINAHL via EBSCO (from 2009), and the Chinese Biomedical Literature Database (CBM) (from 1978).
Randomised controlled trials (RCTs) and quasi-RCTs assessing the efficacy of chest physiotherapy for treating pneumonia in adults.
We used standard methodological procedures expected by Cochrane.
We included two new trials in this update (540 participants), for a total of eight RCTs (974 participants). Four RCTs were conducted in the United States, two in Sweden, one in China, and one in the United Kingdom. The studies looked at five types of chest physiotherapy: conventional chest physiotherapy; osteopathic manipulative treatment (OMT, which includes paraspinal inhibition, rib raising, and myofascial release); active cycle of breathing techniques (which includes active breathing control, thoracic expansion exercises, and forced expiration techniques); positive expiratory pressure; and high-frequency chest wall oscillation.
We assessed four trials as at unclear risk of bias and four trials as at high risk of bias.
Conventional chest physiotherapy (versus no physiotherapy) may have little to no effect on improving mortality, but the certainty of evidence is very low (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.15 to 7.13; 2 trials, 225 participants; I² = 0%). OMT (versus placebo) may have little to no effect on improving mortality, but the certainty of evidence is very low (RR 0.43, 95% CI 0.12 to 1.50; 3 trials, 327 participants; I² = 0%). Similarly, high-frequency chest wall oscillation (versus no physiotherapy) may also have little to no effect on improving mortality, but the certainty of evidence is very low (RR 0.75, 95% CI 0.17 to 3.29; 1 trial, 286 participants).
Conventional chest physiotherapy (versus no physiotherapy) may have little to no effect on improving cure rate, but the certainty of evidence is very low (RR 0.93, 95% CI 0.56 to 1.55; 2 trials, 225 participants; I² = 85%). Active cycle of breathing techniques (versus no physiotherapy) may have little to no effect on improving cure rate, but the certainty of evidence is very low (RR 0.60, 95% CI 0.29 to 1.23; 1 trial, 32 participants). OMT (versus placebo) may improve cure rate, but the certainty of evidence is very low (RR 1.59, 95% CI 1.01 to 2.51; 2 trials, 79 participants; I² = 0%).
OMT (versus placebo) may have little to no effect on mean duration of hospital stay, but the certainty of evidence is very low (mean difference (MD) −1.08 days, 95% CI −2.39 to 0.23; 3 trials, 333 participants; I² = 50%). Conventional chest physiotherapy (versus no physiotherapy, MD 0.7 days, 95% CI −1.39 to 2.79; 1 trial, 54 participants) and active cycle of breathing techniques (versus no physiotherapy, MD 1.4 days, 95% CI −0.69 to 3.49; 1 trial, 32 participants) may also have little to no effect on duration of hospital stay, but the certainty of evidence is very low. Positive expiratory pressure (versus no physiotherapy) may reduce the mean duration of hospital stay by 1.4 days, but the certainty of evidence is very low (MD −1.4 days, 95% CI −2.77 to −0.03; 1 trial, 98 participants).
Positive expiratory pressure (versus no physiotherapy) may reduce the duration of fever by 0.7 days, but the certainty of evidence is very low (MD −0.7 days, 95% CI −1.36 to −0.04; 1 trial, 98 participants). Conventional chest physiotherapy (versus no physiotherapy, MD 0.4 days, 95% CI −1.01 to 1.81; 1 trial, 54 participants) and OMT (versus placebo, MD 0.6 days, 95% CI −1.60 to 2.80; 1 trial, 21 participants) may have little to no effect on duration of fever, but the certainty of evidence is very low.
OMT (versus placebo) may have little to no effect on the mean duration of total antibiotic therapy, but the certainty of evidence is very low (MD −1.07 days, 95% CI −2.37 to 0.23; 3 trials, 333 participants; I² = 61%). Active cycle of breathing techniques (versus no physiotherapy) may have little to no effect on duration of total antibiotic therapy, but the certainty of evidence is very low (MD 0.2 days, 95% CI −4.39 to 4.69; 1 trial, 32 participants).
High-frequency chest wall oscillation plus fibrobronchoscope alveolar lavage (versus fibrobronchoscope alveolar lavage alone) may reduce the MD of intensive care unit (ICU) stay by 3.8 days (MD −3.8 days, 95% CI −5.00 to −2.60; 1 trial, 286 participants) and the MD of mechanical ventilation by three days (MD −3 days, 95% CI −3.68 to −2.32; 1 trial, 286 participants), but the certainty of evidence is very low.
One trial reported transient muscle tenderness emerging after OMT in two participants. In another trial, three serious adverse events led to early withdrawal after OMT. One trial reported no adverse events after positive expiratory pressure treatment.
Limitations of this review were the small sample size and unclear or high risk of bias of the included trials.