Physiotherapy 96 (2010) 113

Systematic review

Chest physiotherapy for patients admittedex ulm

view, FelBox 13doora,

Abstract

Objectives To examine the effectiveness of chest physiotherapy for patients admitted to hospital with an acute exacerbation of chronicobstructive pulmonary disease (COPD).Data source CINAHL, MEDLINE, Embase, Cochrane, Expanded Academic Index, Clinical Evidence, PEDro, Pubmed, Web of Knowledgeand Proquest were searched from the earliest available time to September 2007, using the key elements of COPD, acute exacerbation andchest physiotherapy interventions.Review metevaluate at lthe PEDro sResults Thpressure werin arterial bltechniques tConclusionpatients withwith an exac 2009 Cha

Keywords: A

Introducti

Chronicnificant chin the UKadmitted to[2].

It has beroutinely aadmitted to[3]. Chest p

CorresponE-mail ad

0031-9406/$doi:10.1016/jhods To be included, trials had to investigate patients during admission to hospital with an acute exacerbation of COPD, and toeast one physiotherapy intervention. Two reviewers independently applied the inclusion criteria, and assessed trial quality usingcale. Results were expressed as standardised mean differences and analysed qualitatively with a best-evidence synthesis.irteen trials were identified. There was moderate evidence that intermittent positive pressure ventilation and positive expiratorye effective in improving sputum expectoration. In addition, there was moderate evidence that walking programmes led to benefitsood gases, lung function, dyspnoea and quality of life. No evidence was found supporting the use of any other chest physiotherapyo change lung function, arterial blood gases, perceived level of dyspnoea or quality of life.s Chest physiotherapy techniques such as intermittent positive pressure ventilation and positive expiratory pressure may benefit

COPD requiring assistance with sputum clearance, while walking programmes may have wider benefits for patients admittederbation of COPD. Chest physiotherapy techniques other than percussion are safe for administration to this patient population.rtered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

cute; COPD; Chest physiotherapy; Exacerbation

on

obstructive pulmonary disease (COPD) is a sig-ronic disease affecting about 1.5 million people[1]. On average, 25% of people with COPD arean acute hospital with an exacerbation each year

en reported that 77% of physiotherapists in the UKpply chest physiotherapy techniques to patients

hospital with an acute exacerbation of COPDhysiotherapy is a broad term used for techniques

ding author. Tel.: +61 3 98713502; fax: +61 3 98713501.dress: clarice.tang@easternhealth.org.au (C.Y. Tang).

or strategies aimed at improving lung volumes or facilitatingthe removal of airway secretions [4]. Common chest phys-iotherapy techniques include percussion, vibration, posturaldrainage, active cycle of breathing, continuous or oscillat-ing positive expiratory pressure (PEP), intermittent positivepressure ventilation (IPPV), thoracic expansion exercises andwalking programmes [5]. Despite the routine application ofchest physiotherapy [3], recommendations for managementof an acute exacerbation of COPD have not included the useof chest physiotherapy techniques [1].

The safety of chest physiotherapy has also been ques-tioned. Vincenza et al. [6] claimed that chest physiotherapytechniques, particularly percussion, might harm the lungfunction of patients with an exacerbation of COPD.

see front matter 2009 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved..physio.2009.06.008acerbation of chronic obstructive pa systematic re

Clarice Y. Tang a,, Nicholas F. Taylor ba Physiotherapy Department, Maroondah Hospital, Eastern Health, PO

b School of Physiotherapy, La Trobe University, Bunto hospital with an acuteonary disease (COPD):

icity C. Blackstock b5, Ringwood, East Victoria 3135, AustraliaVictoria 3086, Australia

2 C.Y. Tang et al. / Physiotherapy 96 (2010) 113

There is a need to clarify the effects of chest physio-therapy techniques for this group of patients. Therefore, themain aim of this review was to investigate the benefits ofchest physan acute exreview wasfor patientsCOPD.

Methods

Search stra

The follfrom the eaMEDLINEClinical EvProquest.

The seaacute exacand chestwas linkedpital admisoperator. Cusing synoand COPDclearance tical therapywith the grouped toals includeterms.

Inclusion a

Inclusioand abstractrials had toinpatient wat least onstay.

Potentiaand mechaoutcomes aventilated p[7]. Trialswere unabltions, suchinclusion a

Trial select

Two revapplied theabstracts o

Table 1Search strategy for CINAHL.

# Searches

(Acutehospitoriginword](Chroemphyobstru[mp =headin(ChesclearaOR fosputumof sub(ActivdrainaoscillahumidtheraptechniambulexerciETGOword, subject heading word](Respiratory therapy OR sputum clearance technique OR sputummobilisation OR airway clearance technique OR intermittentpositive pressure ventilation OR thoracic expansion exercise ORpercussion OR cough OR incentive spirometry).mp. [mp = title,original title, abstract, name of substance word, subject headingword](Physical therapy OR chest physiotherapy OR physiotherapyOR respiratory therapy OR sputum clearance technique).mp.[mp = title, original title, abstract, name of substance word, subjectheading word]3 AND 4 AND 5 AND 61 AND 2 AND 7

considered for possible inclusion after this initial stepthen obtained, and each reviewer (CT and either NT oretermined in further depth whether the inclusion criteriamet. A third reviewer was consulted if consensus coulde achieved between the two reviewers. References ofded trials were checked to ensure that all possible trialsconsidered for the review.

ity assessment

assess the methodological quality of all included tri-he Physiotherapy Evidence Database (PEDro) scale wased [8]. PEDro yields a score of 10 points if all criteria areed. Two assessors (CT and NT or FB) independently

ed the PEDro scale criteria. No trials were omitted onasis of the quality assessment, but quality scores wereinto account when interpreting results. Trials with a

ro score of less than 4 out of 10 were considered to beower quality [9].iotherapy for patients admitted to hospital withacerbation of COPD. The secondary aim of thisto investigate the safety of chest physiotherapyadmitted to hospital with an acute exacerbation of

tegy

owing relevant electronic databases were searchedrliest available time to September 2007: CINAHL,, Embase, Cochrane, Expanded Academic Index,idence, PEDro, Pubmed, Web of Knowledge and

rch strategy consisted of three main elements:erbation, chronic obstructive pulmonary diseasephysiotherapy interventions. Acute exacerbationwith synonymous terms such as inpatient, hos-sion and infective exacerbation with the ORhronic obstructive pulmonary disease was linkednyms such as chronic obstructive airway disease. For chest physiotherapy interventions, sputumechniques, airway clearance techniques and phys-

were some of the synonyms that were combinedOR operator. Finally, all three elements weregether using the AND operator so that tri-d all three elements. Table 1 shows the search

nd exclusion criteria

n and exclusion criteria were applied to all titlests identified by the search. Patients involved in thehave been admitted to an acute care hospital as an

ith an acute exacerbation of COPD, and receivede physiotherapy technique during their inpatient

l trials were excluded if patients were intubatednically ventilated, as the respiratory mechanics,nd demands for physiotherapy on mechanicallyatients are different from self-ventilated patients

were also excluded if they included patients whoe to actively participate in physiotherapy interven-as patients who were sedated. Table 2 details allnd exclusion criteria.

ion

iewers (CT and either NT or FB) independentlyinclusion and exclusion criteria to the titles and

f all sourced trials. The full papers of the trials

1

2

3

4

5

6

78

stillwere

FB) dwere

not bincluwere

Qual

Toals, tapplisatisfiapplithe btakenPEDof a lexacerbation OR acute management OR inpatient ORal admission OR infective exacerbation).mp. [mp = title,al title, abstract, name of substance word, subject heading

nic obstructive pulmonary disease OR chronic bronchitis ORsema OR chronic obstructive airway disease OR chronicctive lung disease OR bronchiectasis OR copd).mp.title, original title, abstract, name of substance word, subjectg word]

t physiotherapy OR sputum clearance technique OR airwaynce technique OR sputum mobilisation OR physical therapyrce expiratory technique OR respiratory physiotherapy OR

mobilisation).mp. [mp = title, original title, abstract, namestance word, subject heading word]e cycle of breathing OR autogenic drainage OR posturalge OR bubble pep OR positive expiratory pressure ORting PEP OR flutter OR acapella OR vibration ORification OR saline nebuliser OR mobilisation OR physicaly OR force expiratory techniques OR secretion clearanceque OR intrapulmonary percussive ventilation ORation OR physical therapy OR walking programme ORse OR expiration with glottis open in lateral position ORL).mp. [mp = title, original title, abstract, name of substance

C.Y. Tang et al. / Physiotherapy 96 (2010) 113 3

Table 2Inclusion and exclusion criteria.

Categories Inclusion Exclusion

Population Participants admitted into an acute hospital OtprHodisPainPaiss

Intervention IndrtheInvintM

SuVe

Outcome NA

Type of studie SiQuNoPaReInTh

COPD, chron ; BiPApressure venti

Data analy

Data wedard form.sizes, studyeffects andclassified amoderate o

Whereknown as ecalculatedoutcomes,

The resutively using

Strong:domised

ModeratRCTs a(CCTs)

Limited:ings from

Insufficieffectiveor a sing

ConflictiPrimary admitting diagnosis was an acute exacerbation ofCOPD

Interventions must be considered physiotherapy interventions

Interventions could be carried out by any professionals

Pulmonary rehabilitation that is provided as a part of recoveryfrom the acute episode during admissionCPAP, BiPAP and IPPV if they are part of the physiotherapytreatment

Studies must have at least one outcome measure relevant topotential impairments or activity limitations in COPD

s Published clinical trials in peer-reviewed journalsEmpirical trialsFull textAll papers must be in English

ic obstructive pulmonary disease; CPAP, continuous positive airway pressurelation; NA, not applicable.sis

re extracted from included trials using a stan-Data extracted included details of the sampledesign, severity of COPD, interventions, adverseoutcome measures. The severity of COPD was

ccording to the Global Initiative for COPD as mild,r severe [10].possible, standardised mean differences (alsoffect sizes) with 95% confidence intervals were

using web-based software [11]. For dichotomousodds ratios were calculated.lts of the included trials were combined qualita-a best-evidence synthesis [12]:

consistent findings among high-quality ran-controlled trials (RCTs).

e: consistent findings among multiple low-qualitynd/or non-randomised clinical controlled trialsand/or one high-quality RCT.one low-quality RCT or CCT or consistent find-pre- to post-trials.

ent: insufficient evidence to support or refute theness of the intervention with no RCT and/or CCT,le prepost-trial.ng: inconsistent findings among multiple trials.

Results

Yield

Four hufrom searcing the inclwere obtaiassessmentsion of 3722 articlescle was bamajority oiotherapythree articlwere identlists of incin this revition.

Study quali

Five RC[18], twogroup pre(Table 3).her respiratory conditions that can cause increasedoduction of sputum, e.g. cystic fibrosisme therapy, community care or pulmonary rehabilitation oncharge from the acute hospitalrticipants who were intubated and unable to actively take partthe studyrticipants who were admitted with other complex medicalue(s), e.g. cardiac failureterventions not considered to be physiotherapy treatment, e.g.ug therapy, invasive or non-invasive ventilation, oxygenrapyasive physiotherapy interventions typically requiringubationsanual hyperinflation

ctionntilator hyperinflation

ngle case studiesalitative studiesn-English paperspers with abstracts onlyviews (narrative and systematic)

dividual opinions and editorialsesis

P, bi-level positive airway pressure; IPPV, intermittent positivendred and seventy-eight articles were identifiedhing, of which 430 were excluded after apply-usion criteria to the title and abstract. Full papersned for the remaining 48 articles and a detailed

was performed, resulting in the further exclu-articles. Of the 37 full-text articles excluded,were based in an outpatient setting, one arti-

sed in the intensive care environment with thef patients intubated, two articles had no phys-interventions, nine articles were editorials andes were systematic reviews. Two more articlesified and included from searching the referenceluded articles. In total, 13 trials were includedew. Fig. 1 illustrates the process of study selec-

ty and design

Ts [1317], one randomised parallel groups trialnon-randomised CCTs [19,20] and five singlepost-trials [2125] were included in this reviewA median score of 3 (range 16) on the PEDro

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Table 3Detailed information regarding participants.

Reference Study design Intervention Sample size Mean age Gender Dosage Outcome measures

Int Con Int Con M F

Anthonisen 1964 [19] Non-randomisedcontrolled trial

Posturaldrainage + vibrationcompared with standardcare

35 33 59.5 59 44 24 Not reported Daily temperatureDaily amount of sputumexpectorate (grams)ElectrocardiogramChest X-rayArterial blood gases

Basoglu 2005 [13] Randomisedcontrolled trial

Incentive spirometrycompared with standardcare

15 12 65.5 72.0 26 1 5 to 10 breaths withincentive spirometry,every hour

Arterial blood gasesPerceived level ofdyspnoea via visualanalogue scaleFEV1St Georges RespiratoryQuestionnaire

Bellone 2000 [21] Single groupprepost

Postural drainagecompared with oscillatingPEP compared withETGOL

10 NA 55.5 NA 10 0 30 minutes, once a day Sputum wet weight(grams)Arterial oxygen saturationFEV1

Bellone 2002 [14] Randomisedcontrolled trial

PEP compared withstandard care

13 14 65.0 64.0 17 10 2 minutes of breathingwith mask, assistedcoughing followed by2 minutes of breathingwithout mask, five toseven times a day

Total sputumexpectoration (grams)Dropout rate within maskgroupWeaning time offnon-invasive ventilation

Buscaglia 1983 [22] Single groupprepost

Percussion + posturaldrainage

10 NA 70.0 NA 7 3 12 supineTrendelenburgposition for20 minutes including10 minutes ofclapping + 1 to2 minutes of vibration

Arterial oxygen saturation

Campbell 1975 [20] Non-randomisedcontrolled trial

Percussion + posturaldrainage compared withpostural drainage

7 10 65.5 65.5 NA NA 12 Trendelenburgposition for20 minutes with20 minutes ofpercussion on lateraland posterior chest

FEV1

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Kristen 1998 [15] Randomisedcontrolled trial

Walking compared withstandard care

15 14 62.3 65.6 26 3 Five walking sessions perday at 75% of maximalwalking distance achievedin walking test

Lung function testincluding FEV1Arterial blood gases6-minute walk testTransition dyspnoea indexBorg scoreMinute ventilation,oxygen uptake and carbondioxide output

Newton 1978 [16] Randomisedcontrolled trial

Intermittent positivepressure ventilationcompared with standardcare

40 39 69 69.5 63 16 Three times daily for 10to 15 minutes

Daily temperatureDaily weightmeasurementDaily eating and sleepscore

Daily walking distance in1 minuteLength of stayArterial blood gasesLung function testincluding FEV1Mean sputum volume(ml)

Newton 1978 [23] Single groupprepost

Combination therapy atdifferent intervals

23 NA NA NA NA NA 15 minutes consisting ofbreathing exercise, chestvibration, percussion andpostural drainage

Thoracic gas volumeusing a bodyplethysmographAirway resistancecalculated using thoracicgas volume multiplied byderivative specificconductanceFEV1Vital capacity

Petersen 1967 [17] Randomisedcontrolled trial

Combination therapycompared with standardcare

10 28 64.0 63.7 23 15 Not reported Vital capacityExpiratory reservevolumeFunctional residualcapacityPeak expiratory flowTidal volumeMinute ventilationRespiratory rateNitrogen distributionVentilationperfusionratioSputum expectoration(ml)

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Table 3 (Continued )Reference Study design Intervention Sample size Mean age Gender Dosage Outcome measures

Int Con Int Con M F

Wollmer 1985 [24] Single groupprepost

Percussion + posturaldrainage compared withpostural drainage

10 NA 71.6 NA 6 4 5 minutes in each of threepositions (supine, rightand left side) with15 minutes of percussion

FEV1Vital capacityArterial oxygen saturationPenetration index tomeasure deposition andclearance of inhaledradioparticles

Vitacca 1998 [25] Single groupprepost

Deep breathing 25 NA 64.0 NA 23 2 Twice daily for30 minutes

Arterial oxygen saturationTranscutaneous partialpressure of carbondioxideTranscutaneous partialpressure of oxygenHeart rateRespiratory rateTidal volumePerceived level ofdyspnoea via visualanalogue scale

Yohannes 2003 [18] Randomisedparallel groupstrial

Walking programmeusing gutter frame withoxygen or air and rollatorwith oxygen or air

Four groups Four groups 59 51 Three times daily,15 minutes per session

Borg score1st: 26 1st: 76 Barthel index2nd: 28 2nd: 75 Compliance of patients

using nurses assessment3rd: 28 3rd: 74 Re-admission within 1

month4th: 28 4th: 74 Length of stay

PEP, positive expiratory pressure; ETGOL, expiration with glottis open in lateral position; FEV1, forced expiratory volume in 1 second; NA, not applicable; Int, intervention; Con, control.

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Table 4Quality assessment of studies using a PEDro scale.Study Eligibility

criteriaRandomallocation

Allocationconcealment

Groupssimilar atbaseline

Blindingof subjects

Blinding oftherapists

Blindingof assesors

More than onemeasure on 85%of subjects

All subjectsincluded orintention to treat

Statisticalcomparison ofgroups

Point andvariabilitymeasures

Finalscore

(10)Anthonisen 1964 [19] Y N N N N N N Y N N N 1Basoglu 2005 [13] Y Y N N N N N N N N Y 2Bellone 2000 [21] N N N N N N N Y Y N Y 3Bellone 2002 [14] Y Y N Y N N N Y Y Y Y 6Buscaglia 1983 [22] Y N N N N N N Y Y N N 2Campbell 1975 [20] Y N N N N N N Y Y N Y 3Kirsten 1998 [15] Y Y N Y N N N Y N Y Y 5Newton 1978 [16] Y Y Y Y N N N Y N Y Y 6Newton 1978 [23] Y N N N N N Y N N N Y 2Petersen 1967 [17] Y Y N N N N N Y N N N 2Wollmer 1985 [24] N N N N N N N Y Y N Y 3Vitacca 1998 [25] Y N N N N N N Y Y N Y 3Yohannes 2003 [18] Y Y N Y N N N Y N Y Y 5

8 C.Y. Tang et al. / Physiotherapy 96 (2010) 113

Fig. 1. Flow c

scale (1999to be of lreported cofulfilled theone outcom

Trial chara

In total,trials. The mdard deviaCOPD wasvided sufficCOPD withage predic(SD 13) (T

Chest phys

Chest pincluded vipercussiontions [192via fluttertion (ETG

[14] and walking programmes [15,18]. Two trials [17,23]looked at combination therapy of various chest physiotherapytechniques such as breathing exercises, postural education,

ral drle trant wasull detach tri

iologi

m expf theded inase spsignifistand

ion wipatie(PaO

OL prion botionsignifistanda

ial blopostumusc

patiethe ffor e

Phys

SputuO

incluincrein awithtoratmalebloodETGtoratVibraany swith

Arter

hart of the trial selection.

) was obtained, with nine of 13 trials consideredower quality [13,17,19,2025]. Only one trialncealment of allocation [16], and one other trialcriterion of blinding of the assessors for at leaste measure [23] (Table 4).

cteristics

473 participants were involved in the includedean sample size of included trials was 36.2 [stan-

tion (SD) 30.4]. The mean age of patients with65.5 years (SD 4.72). The six trials that pro-

ient information investigated patients with severea forced expiratory volume in 1 second percent-

ted (FEV1%) varying from 34% (SD 8) to 44%able 3).

iotherapy techniques

hysiotherapy techniques examined by the trialsbrations [19], deep diaphragmatic breathing [25],s [20,22,24], postural drainage in different posi-2,24], incentive spirometry [13], oscillating PEP

[21], expiration with glottis open in lateral posi-OL) [21], IPPV [16], PEP using a PEP mask

Implemchest physeffect oncare (Figs.nificant insignificantsure of cafavouringof the othsignificantwith standdiaphragmresulted intion.

Lung functA walk

demonstratWalking reventilationdemonstratstandard cadifferent te[13,15,16,2in combinastatisticallywith postur[24].ainage, percussion, respiratory and abdominalining; however, the exact intervention for eachnot reported in one of the trials [17]. Table 3 showsails on dosing techniques and outcome measuresal.

cal outcome measures

ectoration11 different chest physiotherapy techniquesthis review, only four techniques were found to

utum expectoration [14,16,21]. PEP [14] resultedcant increase in sputum expectoration comparedard care, while the increment in sputum expec-th the use of IPPV [16] seemed to be limited tonts with a partial pressure of oxygen in arterial2) >60 mmHg (Fig. 2). Both oscillating PEP andoduced a significant increase in sputum expec-th immediately and 1 hour after treatment [21].[19] and combination therapy [17] did not producecant increase in sputum expectoration comparedrd care.

od gasesenting a walking programme was the onlyiotherapy intervention that had a favourablearterial blood gases compared with standard3 and 4). Kristen et al. [15] reported a sig-

crease in mean differences of PaO2 and adecrease in mean differences of partial pres-

rbon dioxide in arterial blood during exercise,the walking group over standard care. Noneer chest physiotherapy techniques produced aimprovement in arterial blood gases comparedard care and other techniques. However, deepatic breathing [25] and incentive spirometry [13]a significant increase in PaO2 prepost interven-

ioning programme was the only intervention thated a beneficial effect on lung function [15].sulted in a significant improvement in minutecompared with standard care [15]. No techniqueed a positive effect on FEV1 when compared withre or another technique (Fig. 5), despite sevenchniques including it as an outcome measure0,21,23,24]. Ten to fifteen minutes of percussiontion with postural drainage produced a small butsignificant negative short-term effect compared

al drainage alone [20] and prepost in another trial

C.Y. Tang et al. / Physiotherapy 96 (2010) 113 9

Fig. 2. Forest plot for sputum production. d = standardised mean difference (95% confidence interval). PEP, positive expiratory pressure; ETGOL, expirationwith glottis open in lateral position; IPPV, intermittent positive pressure ventilation.

Fig. 3. Forest plot for arterial blood gases (partial pressure of oxygen in arterial blood). d = standardised mean difference (95% confidence interval). IPPV,intermittent positive pressure ventilation.

Fig. 4. Forest plot for arterial blood gases (partial pressure of carbon dioxide in arterial blood). d = standardised mean difference (95% confidence interval).IPPV, intermittent positive pressure ventilation.

10 C.Y. Tang et al. / Physiotherapy 96 (2010) 113

Fig. 5. Forest dised mpositive press

Non-physio

Perceived lWalking

distance [1compared wThere wasthe use oflogue scaledyspnoea ibetween insignificantof deep dia

Exercise caParticip

maximal win walkinguptake per

Quality ofQuality

the thirteenin a signifiQuestionnamean increframe overnificant imexercise scowith standa

Length of sThe two

measure dilength of s

f IPPVids while nne etase o

rse efff the ths wer

rse effin bothV1 [2

inutesrticipwas n

of theplot for lung function (forced expiratory volume in 1 second). d = Standarure ventilation.

logical outcome measures

evel of dyspnoeafive times a day at 75% of maximal walking

5] significantly reduced dyspnoea post exerciseith standard care, as assessed with the Borg score.

no significant difference in Borg score betweenrollator and gutter frame [18]. The visual ana-was also used to measure the perceived level of

n two trials that found no significant differencecentive spirometry and standard care [13], and aworsening in dyspnoea during the administrationphragmatic breathing [25].

pacityants who walked five times a day at 75% ofalking distance achieved significant improvement

use o

gait aW

BellodecrePEP.

AdveO

niqueadvesionin FE20 mof pabut itNonedistance, lactic acid concentration and oxygenbody weight compared with standard care [15].

life/functionof life or function were only evaluated in three oftrials. In one trial, incentive spirometry resulted

cant improvement on the St George Respiratoryire compared with standard care [13], while aase in Barthel score favouring the use of gutterrollator was found in another trial [18]. No sig-

provement in daily weight, eating, sleeping andre was found when the IPPV group was comparedrd care [16].

taytrials that included length of stay as an outcome

d not show any significant decrease in hospitaltay when comparisons were made either between

an adverse

Best-eviden

There ishave bencapacity

There istum expcan incr>60 mm

There isdecrease[14].

There isthe comsputumgases [1ean differences (95% confidence interval). IPPV, intermittent

and standard care [16], or between two differentith a walking programme [18].ot specifically reviewing hospital length of stay,al. [14] reported that the use of PEP resulted in af 2.7 days spent on non-IPPV compared with no

ectsree trials [14,20,24] that reported how well tech-

e tolerated, two trials reported adverse events. Theects occurred immediately after the use of percus-trials, resulting in a small but significant decrease0,24]. However, FEV1 returned to baseline afterin one trial [20]. The third trial reported that 15%

ants experienced discomfort during use of PEP,ot severe enough for them to stop treatment [14].trials reported any participant withdrawal due toeffect from the techniques.

ce synthesis

moderate evidence that walking programmes caneficial effects on PaO2 during exercise, exerciseand perceived dyspnoea [15,18].

moderate evidence that PEP [14] can increase spu-ectoration, and moderate evidence that IPPV [16]ease sputum expectoration for males with PaO2Hg.

moderate evidence that the use of PEP canweaning time from non-invasive ventilation

moderate evidence showing a lack of effect withbination of postural drainage and percussion onexpectoration, lung function and arterial blood922,24].

C.Y. Tang et al. / Physiotherapy 96 (2010) 113 11

There is limited evidence that percussion can result in adrop in FEV1 during treatment [20,24].

There is limited evidence that incentive spirometry leadsto an im

There isnot imprlung fun

There islating PE[21].

There ideep di[25].

There ismental smoderatniques a

Discussion

Accordiiotherapistsmanagemeerbation ofreview indpatients adited. Theretechniquesexpectoratiexercise canoea. Thereactive cyclthis, 88% ocycle of br

Accordimore than 2ing in lobar[7]. An incmay not rshould onlof PEP anda problem,

Walkingchest physacute exacable indicaarterial bloBased on thconsider pwhen treatexacerbatio

Exerciseduced succform of puis strong e

trolled trials and 979 participants that people with stableCOPD who performed upper and lower extremity exercisesof 652 weeks duration improved their exercise capacity and

rienceevidents wiise coking pn acu

n somstagethis rspitalents

rch neualitypicturest phynts ad

y of ph

nly thtolera

tive efided wperc

ever, s

ts in pevide

t of pe

pariso

e streffectiving prand vpartlyPD. H

eviewnly ooweentio

an acu

maticporatene ofare al

mationted. Inw, thes trialPPV, Pmationtervenprovement in quality of life [13].limited evidence that combination therapy doesove sputum expectoration, arterial blood gases orction [17,23].insufficient evidence to determine whether oscil-P and ETGOL can increase sputum expectoration

s insufficient evidence to determine whetheraphragmatic breathing can improve outcomes

moderate evidence that percussion can have detri-hort-term effects on lung function [14,20,24], bute evidence that other chest physiotherapy tech-re safe.

ng to a recent UK survey [3], 77% of phys-used chest physiotherapy techniques in their

nt of patients admitted to hospital with an exac-COPD. However, the results of this systematic

icate that the benefits of chest physiotherapy formitted with an exacerbation of COPD are lim-is moderate evidence that chest physiotherapy

, specifically PEP and IPPV, can increase sputumon, and that a walking programme can improvepacity, PaO2 during exercise and perceived dysp-

was no evidence available on techniques such ase of breathing specific to this population. Despitef physiotherapists in UK always or often use activeeathing with this population [3].ng to one guideline, only patients who produce5 ml of sputum per day or mucus plugging result-atelectasis may benefit from chest physiotherapy

rease in sputum expectoration of less than 25 mlequire focused treatment. Therefore, cliniciansy consider using chest physiotherapy techniques

IPPV on patients when sputum expectoration isand not as a routine management strategy.programmes may be more effective than other

iotherapy techniques for many patients with anerbation of COPD. Moderate evidence is avail-ting that walking programmes lead to benefits inod gases, dyspnoea and exercise capacity [15,18].is preliminary evidence, physiotherapists should

lacing more emphasis on a walking programmeing patients admitted to hospital with an acuten of COPD.s including walking programmes have been intro-essfully to patients with stable COPD in thelmonary rehabilitation programmes [1,3]. Therevidence from a review of 20 randomised con-

expeeratepatieexerc

a waling aobtaiearly

Inof hosurem

resea

and qpleteof chpatie

Safet

Owere

negacoincularlyHoweffecis noeffec

Com

Ththe ewalksionhaveof COrent rand oand Rintervwithsysteincor

Ocompinforreporrevieacros

ing Iinforthe ind less shortness of breath [26]. Since there is mod-nce supporting the use of a walking programme onth an acute exacerbation of COPD, introducing themponent of pulmonary rehabilitation that includesrogramme and some strengthening exercises dur-te exacerbation of COPD may allow patients toe of the benefits of pulmonary rehabilitation at anand merits further investigation.eview, few trials reported on changes in lengthstay or discharge destination, or included mea-

of dyspnoea, function or quality of life. Futureeds to include length of stay, functional outcomes-of-life measurements in order to provide a com-e of the benefits of each technique, and the effectssiotherapy in changing healthcare utilisation with

mitted to hospital with an exacerbation of COPD.

ysiotherapy techniques

ree trials [14,20,24] reported on how techniquested by patients. Two trials [20,24] reported a

fect on FEV1 during the use of percussion. Thisith some suggestions that physiotherapy, partic-

ussion, may be harmful to this population [6,27].ince percussion did not produce any beneficial

atients with an acute exacerbation of COPD, therence to support its use regardless of the negativercussion on FEV1.

n with other reviews

ngth of this systematic review is that it evaluatedeness of all areas of chest physiotherapy includingogrammes, postural drainage, PEP, IPPV, percus-ibrations. Two other systematic reviews [27,28]examined physiotherapy in acute exacerbationsowever, only three trials [19,22,23] from the cur-were included in the review by Bach et al. [27],

ne trial [23] was included in the review by Jones[28]. Both reviews concluded that physiotherapyns were either not effective or harmful for patientste exacerbation of COPD. The conclusion of thisreview is based on evidence from more trials ands a broader definition of chest physiotherapy.the limitations of this review is the inability tol interventions against best-practice guidelines as

regarding dosages of certain techniques was notorder to provide an accurate concise systematic

quality of interventions used has to be consistents [29]. Of the 13 trials, only the trials examin-EP and incentive spirometry included sufficientabout dosage to confidently comment on whethertion was based on best-practice guidelines. Only

12 C.Y. Tang et al. / Physiotherapy 96 (2010) 113

IPPV andpractice recpercussionthese two tedifferencespractice gudrainage acwhile the12 acrossmended 15the techniquous percu[20,22,24].mended timthus may hvention. Thinterventiocussion maFuture trialinterventio

The othevariety of omeasures w

heterogeneresults qua

Conclusion

PEP anpatients adCOPD, sugchest physincrease inexpectoratiall patientstion of a wphysiotheraadministratate evidencpopulationFuture resemeasures o

the qualitybest-practicfurther evidgrammes inwith an exa

Acknowled

The autPhysiotherConict of

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rimaryepartmublic hvailablublicatiohanne

ion, shaith acuhysiothndersoallied

ryor JAherapy tincenzagementart 1. CcKenzcDona

uidelinease. Meentreentrettp://wwaher C

ow backuist AS, et al.uide totive Courriculurham:

emcent1/02/20an Tulduidelineeview Gasoglu

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ollowinbstructinthonis

herapycta Meampbe

otherapy35.elloneal theraincentive spirometry were consistent with best-ommendations [5]. As for postural drainage and

, although three of the trials [20,22,24] includedchniques and described dosages in full, there werebetween the trials and inconsistencies with best-idelines. The duration of treatment for posturalross the three trials varied from 15 to 20 minutes,

degree of tilt, when reported, was consistent attwo trials [20,22]. This differs from the recom-to 20 [5], and thus may have contributed to

ue being ineffective. On the other hand, contin-ssion was performed between 5 and 15 minutesThis length of time is longer than the recom-e of 12 minutes per burst in one position [5], and

ave resulted in the decrease in FEV1 during inter-erefore, it is possible that a lack of the quality of

n in the trials evaluating postural drainage and per-y have influenced the findings of a lack of effect.s should ensure that the dosages and positions ofns are based on best-practice guidelines.r limitation to this review is the presence of a largeutcome measures. Thirty-nine different outcomeere used across the 13 trials, resulting in clinical

ity; therefore, it was not possible to synthesise thentitatively and complete a meta-analysis.

d IPPV can increase sputum expectoration formitted to hospital with an acute exacerbation ofgesting that clinicians should consider using theseiotherapy techniques with patients exhibiting ansputum expectoration or difficulty with sputum

on, rather than using it as a routine treatment for. There is moderate evidence that the introduc-alking programme is beneficial and that chestpy techniques other than percussion are safe forion to this patient population. As there is moder-e that percussion is not beneficial for this patient, it should not be included as part of the treatment.arch should consider including more outcome

n quality of life and healthcare utilisation, improveof interventions by standardising dosages as pere guidelines when possible, and aim to provideence to support the role of walking or exercise pro-the management of patients admitted to hospital

cerbation of COPD.

gements

hors wish to thank Anne Pagram, Maroondahapy Department for supporting this project.interest: None declared.

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Available online at www.sciencedirect.com

Chest physiotherapy for patients admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD): a systematic reviewIntroductionMethodsSearch strategyInclusion and exclusion criteriaTrial selectionQuality assessmentData analysis

ResultsYieldStudy quality and designTrial characteristicsChest physiotherapy techniquesPhysiological outcome measuresSputum expectorationArterial blood gasesLung function

Non-physiological outcome measuresPerceived level of dyspnoeaExercise capacityQuality of life/functionLength of stayAdverse effects

Best-evidence synthesis

DiscussionSafety of physiotherapy techniquesComparison with other reviews

ConclusionAcknowledgementsReferences