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Three Part Question

In [a child with community acquired pneumonia], does [chest physiotherapy] reduce [the length of hospital admission]?

Clinical Scenario

A 7-year-old boy is admitted to the general paediatric ward with bacterial community acquired pneumonia affecting the right lower lobe. It is suggested on the ward round that we arrange chest physiotherapy to try to reduce the length of his hospital stay. We wonder if there is evidence to support the use of physiotherapy in this case.

Search Strategy

Search date: March 2007.
Cochrane Library using "pneumonia and child* and physiotherapy" revealed 19 results but none of these were relevant.
Pubmed using the same search terms revealed 110 articles. Eleven of these were relevant, but only two were available in English (six in Russian, one in French, one in German and one in Italian). One was a randomised control trial and one was a case series.
PEDro (physiotherapy evidence database). Selecting options of "respiratory therapy" for therapy, "difficulty with sputum clearance" for problem, "chest" for body part and "paediatrics" for subdiscipline revealed 62 articles, none of which was relevant. A second search for articles with "pneumonia" in the title revealed 14 articles; one randomised control trial was relevant.

Search Outcome

3 articles were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Levine 1978	55 children aged 2–12 years with presumed viral pneumonia. 32 received chest physiotherapy and 23 did not	RCT (level 2b)	Time until improvement in pneumonic infiltrate seen on serial CXRs	No statistical difference in time until CXR improvement seen between treatment group and controls (means 5.91 and 6.13 days)	Poor method of randomisation Different numbers of patients in treatment and control groups not explained Diagnosis of viral pneumonia not confirmed by isolation studies or serology Antibiotic therapy before or after admission not deemed significant
			Duration of fever	Fever persisted for longer in treated group than in controls (means 2.1 and 1.4 days, p<0.05)
Stapleton 1985	55 children with acute uncomplicated respiratory tract infections. 34 received chest physiotherapy, 21 did not	Case series (level 4)	Length of hospital stay, duration of cough or coryza and persistence of wheeze, rhonci and rales	No statistically significant difference between the two groups in any of the outcomes	Patients included in trial with mix of diagnoses (9 bronchitis, 20 bronchiolitis and 26 pneumonia) No information as to the numbers with each diagnosis in the treatment groups No details on the age of the children in the trial Textual summary of findings given but limited data
Britton et al 1985	171 patients aged 15–75 years with primary pneumonia. 94 randomised to receive chest physiotherapy and 106 randomised to control group	RCT (level 1b)	Duration of fever, length of hospital stay, sequential determination of dynamic airflow and subjective assessment of time to complete healing	No statistically significant difference between treatment and control group in duration of hospital stay (means 9.0 and 7.8 days), improvement in FEV1 after 5 days (means 0.4 and 0.4 l) or subjective healing time (means 30.6 and 31.3 days). Duration of fever significantly longer in treatment group compared to controls (means 6.8 and 4.9 days, p<0.01)	Trial of adults (15–75 years) not children

Comment(s)

The three studies failed to show any benefit from chest physiotherapy in the treatment of community acquired pneumonia in terms of: rate of initial improvement of pneumonic infiltrates on chest x ray (Levine), length of hospital stay,(Stapleton, Britton), duration of cough or coryza (Stapleton), persistence of wheeze, rhonchi and rales (Stapleton), development of dynamic airflow (Britten) or subjective assessment of healing time (Britten). Two of the studies (Levine, Britton) also showed that chest physiotherapy was associated with a significant increase in the duration of fever. The types of chest physiotherapy used in the three studies included: intermittent positive pressure breathing (Levine), postural drainage, (Levine, Britton) vibration, (Levine, Britton) percussion (Levine, Stapleton, Britton) and external help with breathing (Britton). The study by Britton et al is a good quality single blind randomised control trial, but there are methodological flaws in the other two trials. The method of randomisation was poor in the study of Levine. Randomisation consisted of numbering the patients consecutively at entry, even-numbered patients then received chest physiotherapy and odd-numbered patients did not. Given this method of randomisation, they failed to explain the difference in the size of the two groups (32 treated, 23 controls). The study by Stapleton was an observational study in which 34 patients received chest physiotherapy and 21 did not; this was decided according to the practice of the admitting doctor. Both of these methods allow bias to be introduced into the studies. The Levine study included children with presumed viral pneumonia and therefore the use of antibiotics prior to or during admission was not deemed significant. As they did not confirm the diagnosis of viral pneumonia by viral isolation or serological studies, children with bacterial pneumonia may have been included in the study. If such patients were included, antibiotics are likely to have influenced the pneumonic infiltrates and the duration of fever and so any difference between the treatment and control groups in terms of the use of antibiotics should have been further assessed. Stapleton provided a textual summary of the findings of his study but the only numerical data he gave referred to the mean hospital stay of the two groups. He also supplied no information as to how many children there were with each of the three diagnoses in the two treatment groups and did not mention the age of the children in the study, other than saying that the mean age did not differ between the two groups.

Clinical Bottom Line

There are currently no data to direct clinical practice regarding the use of chest physiotherapy in children with community acquired pneumonia but there are low-quality data from similar patient populations suggesting that it is not of any benefit. (Level C)

References

1. Levine A. Chest physical therapy for children with pneumonia. J Am Osteopath Assoc 1978; 78: 122–5.
2. Stapleton T. Chest physiotherapy in primary pneumonia. BMJ 1985; 291:143.
3. Britton S, Bejstedt M, Vedin L. Chest physiotherapy in primary pneumonia. BMJ (Clin Res Ed) 1985 290:1703–4.