Pediatric Pulmonology 52:225–231 (2017)

Effectiveness of Airway Clearance Techniques in Children

Hospitalized With Acute Bronchiolitis
F. Van Ginderdeuren, PT, MSc,1,2* Y. Vandenplas, MD, PhD,3 M. Deneyer, MD, PhD,3
S. Vanlaethem, PT, MSc,2 R. Buyl, PT, PhD,4 and E. Kerckhofs, PT, PhD1
Summary. Objective: To evaluate the effectiveness of two airway clearance techniques (ACT’s)
in children <24 months hospitalized with mild to moderate bronchiolitis. Design: One hundred and
three children were randomly allocated to receive one 20-min session daily, either assisted
autogenic drainage (AAD), intrapulmonary percussive ventilation (IPV), or bouncing (B) (control
group), ninety-three finished the study. Outcome measures: Mean time to recovery in days was our
primary outcome measure. The impact of the treatment and the daily improvement was also
assessed by a validated clinical and respiratory severity score (WANG score), heart rate (HR), and
oxygen saturation (SaO2). Results: Mean time to recovery was 4.5
1.9 days for the control
group, 3.6
1.4 days, P < 0.05 for the AAD group and 3.5
1.3 days, P ¼ 0.03 for the IPV group.
Wang scores improved significantly for both physiotherapy techniques compared to the control
group. Conclusion: Both ACT’s reduced significantly the length of hospital stay compared to no
physiotherapy. Pediatr Pulmonol. 2017;52:225–231. ß 2016 Wiley Periodicals, Inc.

Key words: airway clearance techniques; respiratory physiotherapy; intrapulmonary

percussive ventilation; autogenic drainage; bronchiolitis.

Funding source: none reported.

INTRODUCTION in the treatment of children with chronic respiratory

disease, but has been debated for a long time as a
Acute bronchiolitis is the most common lower
treatment in bronchiolitis. No evidence was found that
respiratory tract infection in infants and children younger
chest physiotherapy has a clinical benefit in children with
than 2 years of age and occurs in a seasonal pattern. It is
acute bronchiolitis.2,8 The latest Cochrane review
mostly a self-limiting condition associated with the
concluded that chest physiotherapy (chest percussion,
respiratory syncytial virus (70–85%).1 Usually it is a mild
vibrations in postural drainage positions, and forced
to moderate disease, characterized by acute inflammation,
edema, increased mucus production and bronchospasm,
which affect the flow and permeability of the small 1
Faculty of Physical Education and Physiotherapy, Vrije Universiteit
airways, causing hyperinflation, wheezing, and even Brussel, Laarbeeklaan 103, Brussels 1090, Belgium.
atelectasis. However in 1–3% of the cases, severe disease
is developed and hospitalization is necessary.2 2
Department of Physiotherapy, UZ Brussel, Brussels, Belgium.
The treatment of bronchiolitis in children is largely
3
symptomatic and supportive. Supplemental oxygen, fluid Department of Pediatrics, UZ Brussel, Vrije Universiteit Brussel, Brussels,
Belgium.
therapy, and respiratory support remain the mainstay of
treatment.3 In 2013, a Cochrane meta-analysis concluded 4
Information Research Group, Department of Public Health, Biostatistics
that hypertonic saline (HS) significantly reduced the and Medical Informatics, Vrije Universiteit Brussel, Brussels, Belgium.
hospital length of stay among children hospitalized with
mild-to-moderate bronchiolitis and also improved clinical Conflicts of interest: None.
severity scores. HS increases the surface liquid by its 
Correspondence to: F. Van Ginderdeuren, PT, MSc, Faculty of Physical
osmotic action on the submucosal edema, improves Education and Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103,
mucociliary function and facilitates airway clearance.4 Brussels 1090, Belgium. E-mail: [email protected]
However, recent studies suggest that HS has no effect on
length of hospital stay.5–7 Received 9 November 2015; Revised 5 May 2016; Accepted 13 May 2016.
Chest physiotherapy aims to clear airway obstruction, DOI 10.1002/ppul.23495
thereby decreasing airway resistance, improving gas Published online 2 June 2016 in Wiley Online Library
exchange, and reducing respiratory load. It is widely used (wileyonlinelibrary.com).

ß 2016 Wiley Periodicals, Inc.

226 Van Ginderdeuren et al.

expiratory techniques) and passive expiratory techniques and 8. The Wang clinical severity scoring system
showed no effect on hospital stay, oximetry, and severity assigns a value between 0 and 3 to each of four variables:
scores.9 Preliminary results on the prolonged slow respiratory rate, wheezing, retractions, and general
expiration technique, a slow passive and progressive condition (Table 1). A higher Wang score indicated a
expiration from functional residual capacity to expiratory worse condition.24 Exclusion criteria were: Wang score
reserve volume, showed significant effects on clinical <3 and >8, comorbidities such as cystic fibrosis,
symptoms in moderate bronchiolitis and a cumulative neuromuscular, or congenital heart disease; respiratory
day-to-day improvement. Larger randomized controlled distress, necessitating immediately admission to the
trials are necessary to confirm these findings.10 intensive care unit, gestational age <34 weeks, immediate
Autogenic drainage (AD) is a breathing routine treatment with corticosteroids, antibiotics, or more than
utilizing good body knowledge and expiratory airflow three inhalations with bronchodilators at hospital intake.
throughout the whole range of breathing from residual Patients were recruited by the participating physiothera-
volume to total lung capacity. The aim of AD is to move pists or by the study physician. Informed consent was
secretions progressively from peripheral to more central obtained by one of the parents. Children were randomized
airways by achieving an optimal expiratory flow to the different treatment modalities by the attribution of a
progressively through all generations of bronchi without computer generated number (Randomization.com, 2011),
causing dynamic airway collapse.11,12 The effectiveness using the method of randomly permuted blocks.25 Each
of AD has been demonstrated in cystic fibrosis (CF) number was contained in a sealed opaque envelope
patients13–15 and patients with chronic obstructive opened by the physiotherapist after inclusion. Envelopes
pulmonary disease (COPD).16 were prepared by a physiotherapist, not involved in the
Assisted autogenic drainage (AAD) is the adaptation of clinical phase of the study. All pediatric department staff
AD in infants and young children not yet capable of and parents were blind to treatment assignment.
carrying out this technique actively themselves. No data
on AAD in children with bronchiolitis are available. Study Intervention
Intrapulmonary percussive ventilation (IPV) improves
airway secretion clearance in Duchenne muscular Treatment, either intervention or control, began at least
dystrophy,17 children with atelectasis,18 COPD exacerba- 2 hr. after the latest inhalation and feeds in order to
tion,19,20 tracheostomized patients,21 and patients with exclude their influence on the outcome measures.
acute respiratory failure.20 Encouraging results with IPV Children had one 20-min treatment session daily,
have been obtained in patients with CF.22,23 To our performed by two well-trained physiotherapists in the
knowledge there have been no trials of IPV in children different modalities. If no spontaneous coughing
with bronchiolitis. occurred, coughing was triggered every 5 min by a gentle
The primary objective of this open randomized clinical pressure on the suprasternal notch.
trial (RCT) was to evaluate the effectiveness of AAD and Children were randomly assigned to one of the
IPV in reducing the time to clinical stability and discharge following treatment modalities during their hospital stay:
from hospital in children aged less than 24 months old Assisted autogenic drainage: AAD is based upon the
admitted for mild to moderate acute bronchiolitis, principles of autogenic drainage and used in children and
compared to children not receiving physiotherapy. patients unable to assist in the treatment. By modulating
The impact of the treatment and the daily improvement manually the functional breathing level within the vital
was also assessed by a validated clinical and respiratory capacity, optimal airflow will be obtained at the targeted
severity score (WANG score), heart rate (HR), and airway generations, where secretions have been identi-
oxygen saturation (SaO2). fied. AAD is carried out in a gentle and progressive way,
using the patient’s breathing pattern and stabilizing the
MATERIALS AND METHODS child’s abdominal wall to avoid paradoxical movements.
A gentle increase of manual pressure on the chest during
Study Population
each inspiration is performed to guide the breathing of the
During three consecutive bronchiolitis outbreaks from patient towards the desired lung volume level. By
December 2012 through January 2015, patients were restricting manually the inspiratory level the patient is
recruited among children under the age of 2 years, stimulated to exhale slightly more than the previous
hospitalized with a first episode of bronchiolitis. breathing cycle. During expiration, the breathing move-
Bronchiolitis was diagnosed on the basis of clinical ment of the patient is followed gently. No thoracic
findings, including wheezing or wheezing with crackles compression or excessive force is performed, which could
and respiratory distress. Children were eligible within lead to a resisting response by the patient. Feedback plays
24 hr of admission if they presented as a mild to moderate a key-roll, feeling or hearing the secretions move while
bronchiolitis with a Wang clinical severity score 3 avoiding any early or abnormal airway compression or
Pediatric Pulmonology
 Airway Clearance Techniques in Bronchiolitis 227
TABLE 1— Wang Clinical Severity Scoring System

Score

0 1 2 3
Respiratory rate <30 31–45 46–60 >60
(breaths/min)
Wheezing None Terminal expiratory or only Entire expiration or audible during Inspiration and expiration
with stethoscope expiration without stethoscope without stethoscope
Retractions None Intercostal only Tracheosternal Severe with nasal flaring
General condition Normal – – Irritable, lethargic, poor
feeding

closure.11 This manoeuvre is carried out during an Outcome Measure

individualized number of breathing cycles waiting for the
child to cough spontaneously. When a spontaneous cough Primary Outcome
occurs, the manoeuvre recommences. The primary outcome was time from inclusion to
Intrapulmonary percussive ventilation: Intrapulmo- discharge from hospital.
nary percussive ventilation (IPV) delivers small bursts Secondary Outcomes
of high-flow gas within a frequency range of 100–300 One pediatrician and two physiotherapists evaluated
cycles/min. IPV provides a convective front of gas to the the Wang score variables, SaO2 and heart rate (Mindray
distal airways and a more homogenous distribution of iMEC8, Innomediq, Belgium) before (T0), after (T20),
alveolar ventilation. IPV promotes alveolar recruitment, and 1 hr after treatment (T80). They were blinded to the
helps to “unstick” mucus in small and middle-sized applied treatment. The different variables used in the
airways, and propels secretions cephalad to the central Wang score showed a high level of inter-observer
airways by its asymmetrical flow pattern, whereby agreement between physicians, nurses and respiratory
expiratory flow exceeds inspiratory flow.26,27 IPV was therapists in a multi-center study.29 All adverse events
delivered using a well fitted mask with a frequency of during treatment were reported.
300 cycles/min and a pressure between 6 and 10 mbar.
Each child received four cycles of 5 min of IPV. Sample Size
Frequency nor pressure were altered between the
different cycles. The mean time to discharge from hospital in hospital-
AAD and IPV were combined with bouncing. Bouncing ized children <24 months with mild to moderate
at low amplitude (4–6 cm), a gentle up-and-down bronchiolitis, receiving three inhalations daily with
movement on a physio ball, was used to maximize the 0.5 ml salbutamol dissolved in 4.0 ml NaCl 3% was 6
relaxation of the child, avoiding resistance against or (SD 1.2) days.30 This study was designed to detect a
crying during treatment.11 difference of 1 day in time to clinical stability and
Bouncing (B): Control Group. discharge from hospital between the different treatment
The children were well supported in upright sitting, modalities with a power of 90% and type one error of 5%.
avoiding a slumped sitting position which may in turn The calculated sample size was 31 patients in each arm.
predispose to GOR during treatment.11,28
Statistics
Other Interventions
Demographic and clinical characteristics were com-
All children received three inhalations daily with 0.5 ml pared at baseline (Table 2). Time to discharge was
salbutamol dissolved in 4 ml hypertonic (3%) saline compared using ANCOVAwith age as covariate. One way
(NaCl3%), nebulized over 10 min with a Sidestream ANOVAwas used to compare the mean difference of heart
nebulizer (Respironics, Pennsylvania) at a flow of 6 L/min. rate, SaO2, and Wang score and its consisting variables,
The children followed the same clinical treatment pathway before and after (T0–T20) and before and 1 hr after
to ensure consistent care with minimal variability of the (T0–T80) treatment over the period of hospital stay and
results. Rhinopharyngeal rinsing with normal saline was on day 1 and days 1 and 2 between the three groups.
applied to all patients, if needed. Oxygen supplementation Tukey’s post hoc test was used for further analysis to find
was administered if SaO2 was 92%. Orogastric feeding out group differences. The level of significance for the
was offered to children spontaneously ingesting less than tests was set at 0.05. Analyses were performed using
50% of their daily needs. SPSS (Version 22, Chicago, IL).
Pediatric Pulmonology
228 Van Ginderdeuren et al.
TABLE 2— Infants Demographics and Clinical Severity Data Primary Outcome Measure
Bouncing AAD IPV Both ACT’s had a significant effect on time to
Characteristic (n ¼ 31) (n ¼ 31) (n ¼ 31) discharge compared to the control group. The proportion
Age
SD (days) 160
143 121
118 135
132 of hospitalized patients in the three groups versus
Weight
SD (kg) 6.4
2.5 6.2
2.4 6.6
2.2 hospitalization time in days has been presented in
Sex M/F 13/18 16/15 15/16 Figure 2. The mean time to discharge was 4.5
1.9
RSVþ 23 (74%) 22 (71%) 23 (74%) days for the Bouncing (control) group, 3.6
1.4 days,
Oxygen/no oxygen (n) 20/11 23/8 18/13
Days of coryzal 2.0
0.8 2.1
0.8 2.1
0.9 PB-AAD < 0.05 for the AAD group, and 3.5
1.3 days,
symptoms PB-IPV ¼ 0.03 for the IPV group. There was no difference
Time
SD (A–I) 12
6 14
5 15
6 in time to discharge between the AAD and IPV group,
(hours) PAAD-IPV ¼ 1.00 (Table 3). The results were not substan-
Baseline Wang 5.3
0.9 5.3
1.2 5.5
0.9 tially altered when the children aged >12 months in the
score
SD
different groups (n ¼ 9) were removed.
One way ANOVA for age, number of days of coryzal symptoms before
admission, time between admission (A) and inclusion (I), and baseline Secondary Outcome Measures
Wang score showed no significant differences between the three groups.
Overall, Wang scores improved significantly at T20 and
T80 for both physiotherapy techniques compared to the
Ethics Statement control group. The improvement was significantly better at
T20 in the IPV group compared to the AAD group.
This study was approved by the UZ Brussel ethics
Looking at the subscores, wheezing improved significantly
committee (BUN143201215440) and registered at Clin-
icalTrials.gov (NCT02126748). All children’s parents at T20 and T80 in the IPV group compared to the AAD and
control group. Retractions were significant lower in both
provided written informed consent.
intervention groups at T20 compared to the control group.
RESULTS
Changes in HR and SaO2 at T20 and T80 were not
significantly different in the three groups (Table 3).
Four hundred and thirty-two children with bronchiolitis No changes in “general condition” were noticed at T20
were hospitalized during the study period. A total of 103 and T80 between the different groups on any day. No
children were eligible to participate and randomized in our direct complications (respiratory deterioration with
RCT; 33 in the IPV group, 34 in the AAD group, and 36 in oxygen desaturation, bradycardia, vomiting) due to the
the control group. Ten patients did not complete the study treatment occurred in any patient. Complications during
(two in the IPV group, three in the AAD group, and five in inclusion due to bronchiolitis severity, requiring high flow
the control group). Nine parents decided not to continue the oxygen therapy, antibiotics, and/or corticosteroids oc-
study trial after the first treatment, one demanded discharge curred in four children (4.3%): two patients in the control
from hospital. Three hundred and twenty-nine patients group, one in the AAD group, and one in the IPV group.
were not recruited, because 24% were too sick (Wang score
>8), 15% were not sick enough (Wang score <3), 56%
DISCUSSION
were prescribed more than three inhalations with
salbutamol before inclusion, and 5% were transferred to This randomized controlled trial assessed the effec-
ICU before inclusion. The data of 93 children were tiveness of two airway clearance techniques (ACT’s) in
analyzed (Fig. 1). Children’s demographics and clinical children hospitalized with mild to moderate bronchiolitis.
severity data were reported in Table 2. The three groups This trial showed significant clinical benefits of both
were comparable at baseline. There was no difference in ACT’s compared to sham physiotherapy. Previously no
clinical severity (Wang score) at admission (P ¼ 0.59). The benefit has been reported from chest physiotherapy
difference between the time of day of admission to hospital techniques using postural drainage combined with
and inclusion in the trial for each group (P ¼ 0.5) and what clapping or passive expiratory manoeuvres in children
day of coryzal symptoms they were admitted to hospital on hospitalized for bronchiolitis.2,9,31 The use of postural
(P ¼ 0.76) were not statistically different. Twenty children drainage with head-down tilt could exacerbate gastro-
received oxygen for at least 1 day in the control group, 23 oesophageal reflux (GOR) and is contra-indicated in
children in the AAD group, and 18 children in the IPV patients with GOR.32
group (Table 2). A child was discharged from hospital if no Both ACT’s used in this study rely heavily on basic
oxygen supplementation had been given for at least 12 hr, airway physiology to enhance clearance. There are only
the Wang score was normalized with minimal or no chest two physical principles to ACT’s: first, there must be
recession and food intake was more than two-thirds of airflow and second, for the patient to have airflow, the
daily needs. patient must be able to get air behind the secretions. High
Pediatric Pulmonology
 Airway Clearance Techniques in Bronchiolitis 229

Fig. 1. Flow chart.

linear airflow velocity provides the turbulent flow, high airways and increased mucus production, ACT’s could be
shearing forces at the airway walls, and high kinetic efficacious in helping the clearance of airway secre-
energy that moves secretions cephalad.33 tions.31 Higher sputum volumes are correlated with a
In this study, analyzing the subscores of the Wang score higher degree of lung obstruction. In children the
separately to better distinguish the impact of AAD and intercostal muscles are underdeveloped and mechanically
IPV on different respiratory and general items, wheezing less efficient due to the horizontal alignment of the ribs.
improved significantly after IPV compared to AAD and Therefore, children depend on their diaphragm for
control and the effect maintained after 1 hr, probably due respiration. The flatter diaphragm is mechanically less
to the positive pressure delivered by the IPV device. efficient and has proportionally more fast twitch fibers and
Cambonie et al. reported previously a sharp reduction of fewer slow twitch (endurance) fibers and is, therefore,
expiratory wheezing after 1 hr of nasal continuous more vulnerable to respiratory fatigue than in the mature
positive airway pressure in children with bronchiolitis.34 individual. A higher degree of obstruction leads to more
In viral bronchiolitis, characterized by inflammation, respiratory distress, resulting in subcostal and intercostal
oedema, and necrosis of epithelial cells lining small retractions.11 AAD and IPVare both effective in removing

Fig. 2. Proportion of hospitalized patients versus hospitalization time.

Pediatric Pulmonology
230 Van Ginderdeuren et al.
TABLE 3— Length of Hospital Stay and Mean Differences of Wang Score, SaO2, and HR Between the Groups Over All
Hospitalization Days

Bouncing AAD IPV PB-AAD PB-IPV PAAD-IPV

Hospital stay (days)
SD 4.5
1.9 3.6
1.4 3.5
1.3 0.05 0.03 1.00 NS
Wang (T0–T20)
SD 0.2
0.3 0.5
0.5 0.7
0.5 0.04 <0.01 0.03
Wang (T0–T80)
SD 0.5
0.4 0.8
0.6 0.9
0.5 0.03 <0.01 0.77 NS
HR (T0–T20)
SD 5
10 3
10 4
13 0.68 NS 0.86 NS 0.94 NS
HR (T0–T80)
SD 6
10 8
8 7
10 0.65 NS 0.93 NS 0.86 NS
SaO2 (T0–T20)
SD 0
1 1
1 1
1 0.07 NS 0.10 NS 0.98 NS
SaO2 (T0–T80)
SD 1
3 0
1 0
1 0.91 NS 0.87 NS 0.99 NS

NS, not significant.

Hospital stay: ANCOVA for bouncing versus AAD or IPV and AAD versus IPV.
Wang score, HR, and SaO2: Tukey’s post hoc test for bouncing versus AAD or IPV and AAD versus IPV.

secretions from the respiratory tract in a short period of Although the setting in our control group was similar to
time. Unfortunately, there is no technique available to the one in the study of Luo et al.,30 we found a discrepancy
measure the amount of coughed up secretions in children, in length of hospital stay (4.5
1.9 days in our control
because they do not expectorate. Counting the number of group vs. 6.0
1.2 days in Luo’s study). A possible
coughs is inadequate, because dry coughs occur. explanations could be Wang scores at admission in Luo’s
Due to the bouncing, children appeared to tolerate well group (5.8
1.2) were slightly worse than in our control
both ACT’s during our study and displayed no crying or group (5.3
0.9).
distressed behavior with an increase of HR. Children even A fourth group combining AAD and IPV would have
showed a significant decrease of HR in the IPV group been of interest to detect a possible strengthening effect of
80 min after treatment at day 1. both techniques.
In our long experience, children felt “very threat- Both physiotherapy techniques used in this study are
ened” during respiratory physiotherapy, often leading to highly specialized and need a well-trained physiotherapist
resistance against or crying during therapy, which to perform. Equipment for IPV is unfortunately very
decreased the efficacy or the intended effects. A expensive and not available in every hospital to perform
significant association between crying, increased reflux these treatments.
episodes, and lower oxygen saturation has been
recorded in children with CF.35 Therefore, bouncing CONCLUSION
in a well-supported 908 upright position is used to
This study showed the effectiveness of AAD and IPV,
maximize the relaxation of the child.
combined with bouncing, in this well-defined group of
There are some limitations to this study:
hospitalized children with mild to moderate bronchiolitis.
Awell-defined group of children hospitalized with mild
Both ACT’s reduced significantly the length of hospital
to moderate bronchiolitis was selected. More research on
stay and some respiratory symptoms of bronchial
the effect of respiratory physiotherapy is necessary in
obstruction compared to no physiotherapy. It is important
children suffering from very mild bronchiolitis managed
to recall that these observations cannot be extended to
on an outpatient basis, or severely ill children, eventually
outpatients or critically ill children, whether admitted to
admitted to ICU.
ICU or not. Further research is necessary.
No significant differences between the three groups in
SaO2 at T20 and T80 were observed. Differences in
REFERENCES
SaO2 were probably wiped out by the scores of the
children receiving oxygen, because SaO2 remained 1. Bush A, Thomson AH. Acute bronchiolitis. BMJ 2007;335:
100% before, at T20 and T80 in 64% of the control 1037–1041.
2. Gajdos V, Katsahian S, Beydon N, Abadie V, de Pontual L, Larrar
group, 58% in the AAD group and 51% in the IPV
S, Epaud R, Chevallier B, Bailleux S, Mollet-Boudjemline A, et al.
group. Oxygen was administered if SaO2 was 92%. Effectiveness of chest physiotherapy in infants hospitalized with
The nursing staff recorded HR, respiratory frequency, acute bronchiolitis: a multicenter, randomized, controlled trial.
SaO2 and general well-being every 4 hr. Oxygen supply PLoS Med 2010;7:e1000345.
was decreased in a very conservative way depending on 3. Castro-Rodriguez JA, JR G, ER-M C. Principal findings of
the SaO2 and the general state of the child. It was the systematic reviews of acute asthma treatment in childhood.
J Asthma 2015;52:1038–1045.
observers opinion that in some children too much 4. Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP.
oxygen was administered for a too long period of time, Nebulised hypertonic saline solution for acute bronchiolitis in
resulting in 100% SaO2. infants. Cochrane Database Syst Rev 2013;7:CD006458.

Pediatric Pulmonology
 Airway Clearance Techniques in Bronchiolitis 231

5. Florin TA. Nebulised hypertonic saline does not reduce hospital ventilation improves the outcome of patients with acute
length of stay in acute bronchiolitis. Evid Based Med 2015; exacerbation of chronic obstructive pulmonary disease using a
20:106. helmet. Crit Care Med 2006;34:2940–2945.
6. Everard ML, Hind D, Ugonna K, Freeman J, Bradburn M, Cooper 20. Vargas F, Bui HN, Boyer A, Salmi LR, Gbikpi-Benissan G,
CL, Cross E, Maguire C, Cantrill H, Alexander J, et al. SABRE: a Guenard H, Gruson D, Hilbert G. Intrapulmonary percussive
multicentre randomised control trial of nebulised hypertonic ventilation in acute exacerbations of COPD patients with mild
saline in infants hospitalised with acute bronchiolitis. Thorax respiratory acidosis: a randomized controlled trial
2014;69:1105–1112. [ISRCTN17802078]. Crit Care 2005;9:R382–R389.
7. Teunissen J, Hochs AH, Vaessen-Verberne A, Boehmer AL, 21. Clini EM, Antoni FD, Vitacca M, Crisafulli E, Paneroni M,
Smeets CC, Brackel H, van Gent R, Wesseling J, Logtens-Stevens Chezzi-Silva S, Moretti M, Trianni L, Fabbri LM. Intrapulmonary
D, de Moor R, et al. The effect of 3% and 6% hypertonic saline in percussive ventilation in tracheostomized patients: a randomized
viral bronchiolitis: a randomised controlled trial. Eur Respir J controlled trial. Intensive Care Med 2006;32:1994–2001.
2014;44:913–921. 22. Homnick DN, White F, de Castro C. Comparison of effects of an
8. Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, intrapulmonary percussive ventilator to standard aerosol and chest
Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, physiotherapy in treatment of cystic fibrosis. Pediatr Pulmonol
et al. Clinical practice guideline: the diagnosis, management, and 1995;20:50–55.
prevention of bronchiolitis. Pediatrics 2014;134:e1474–e1502. 23. Natale JE, Pfeifle J, Homnick DN. Comparison of intrapulmonary
9. Roque i Figuls M, Gine-Garriga M, Granados Rugeles C, Perrotta percussive ventilation and chest physiotherapy. A pilot study in
C. Chest physiotherapy for acute bronchiolitis in paediatric patients with cystic fibrosis. Chest 1994;105:1789–1793.
patients between 0 and 24 months old. Cochrane Database Syst 24. Wang EE, Milner RA, Navas L, Maj H. Observer agreement for
Rev 2012;2:CD004873. respiratory signs and oximetry in infants hospitalized with lower
10. Postiaux G, Louis J, Labasse HC, Gerroldt J, Kotik AC, Lemuhot respiratory infections. Am Rev Respir Dis 1992;145:106–109.
A, Patte C. Evaluation of an alternative chest physiotherapy 25. Matts JP, Lachin JM. Properties of permuted-block randomization
method in infants with respiratory syncytial virus bronchiolitis. in clinical trials. Control Clin Trials 1988;9:327–344.
Respir Care 2011;56:989–994. 26. Fornasa E, Ajcevic M, Accardo A. Characterization of the
11. Lannefors L, Button BM, McIlwaine M. Physiotherapy in infants mechanical behavior of intrapulmonary percussive ventilation.
and young children with cystic fibrosis: current practice and future Physiol Meas 2013;34:1583–1592.
developments. J R Soc Med 2004;97:8–25. 27. Kallet RH. Adjunct therapies during mechanical ventilation:
12. Van Ginderdeuren F, Verbanck S, Van Cauwelaert K, Vanlaethem airway clearance techniques, therapeutic aerosols, and gases.
S, Schuermans D, Vincken W, Malfroot A. Chest physiotherapy in Respir Care 2013;58:1053–1073.
cystic fibrosis: short-term effects of autogenic drainage preceded 28. Van Ginderdeuren F, Kerckhofs E, Deneyer M, Vanlaethem S,
by wet inhalation of saline versus autogenic drainage preceded by Buyl R, Vandenplas Y. Influence of intrapulmonary percussive
intrapulmonary percussive ventilation with saline. Respiration ventilation in upright position on gastro-oesophageal reflux
2008;76:175–180. in infants. Pediatr Pulmonol 2016. doi: 10.1002/ppul.23400.
13. Pryor JA, Tannenbaum E, Scott SF, Burgess J, Cramer D, Gyi K, [Epub ahead of print].
Hodson ME. Beyond postural drainage and percussion: airway 29. Gajdos V, Beydon N, Bommenel L, Pellegrino B, de Pontual L,
clearance in people with cystic fibrosis. J Cyst Fibros 2010;9: Bailleux S, Labrune P, Bouyer J. Inter-observer agreement
187–192. between physicians, nurses, and respiratory therapists for
14. McIlwaine M, Wong LT, Chilvers M, Davidson GF. Long-term respiratory clinical evaluation in bronchiolitis. Pediatr Pulmonol
comparative trial of two different physiotherapy techniques; 2009;44:754–762.
postural drainage with percussion and autogenic drainage, in the 30. Luo Z, Liu E, Luo J, Li S, Zeng F, Yang X, Fu Z. Nebulized
treatment of cystic fibrosis. Pediatr Pulmonol 2010;45: 1064–1069. hypertonic saline/salbutamol solution treatment in hospitalized
15. Langenderfer B. Alternatives to percussion and postural drainage. children with mild to moderate bronchiolitis. Pediatr Int 2010;52:
A review of mucus clearance therapies: percussion and postural 199–202.
drainage, autogenic drainage, positive expiratory pressure, flutter 31. Rochat I, Leis P, Bouchardy M, Oberli C, Sourial H, Friedli-Burri
valve, intrapulmonary percussive ventilation, and high-frequency M, Perneger T, Barazzone Argiroffo C. Chest physiotherapy using
chest compression with the ThAIRapy vest. J Cardiopulm Rehabil passive expiratory techniques does not reduce bronchiolitis
1998;18:283–289. severity: a randomised controlled trial. Eur J Pediatr 2012;171:
16. Savci S, Ince DI, Arikan H. A comparison of autogenic drainage 457–462.
and the active cycle of breathing techniques in patients with 32. Van Ginderdeuren F, Kerckhofs E, Deneyer M, Vanlaethem S,
chronic obstructive pulmonary diseases. J Cardiopulm Rehabil Vandenplas Y. Influence of respiratory physiotherapy on
2000;20:37–43. gastro-oesophageal reflux in infants: a systematic review. Pediatr
17. Toussaint M, De Win H, Steens M, Soudon P. Effect of Pulmonol 2015;50:936–944.
intrapulmonary percussive ventilation on mucus clearance in 33. Lapin CD. Airway physiology, autogenic drainage, and active
duchenne muscular dystrophy patients: a preliminary report. cycle of breathing. Respir Care 2002;47:778–785.
Respir Care 2003;48:940–947. 34. Cambonie G, Milesi C, Jaber S, Amsallem F, Barbotte E, Picaud JC,
18. Deakins K, Chatburn RL. A comparison of intrapulmonary Matecki S. Nasal continuous positive airway pressure decreases
percussive ventilation and conventional chest physiotherapy for respiratory muscles overload in young infants with severe acute
the treatment of atelectasis in the pediatric patient. Respir Care viral bronchiolitis. Intensive Care Med 2008;34: 1865–1872.
2002;47:1162–1167. 35. Button BM, Heine RG, Catto-Smith AG, Phelan PD, Olinsky A.
19. Antonaglia V, Lucangelo U, Zin WA, Peratoner A, De Simoni L, Chest physiotherapy, gastro-oesophageal reflux, and arousal in
Capitanio G, Pascotto S, Gullo A. Intrapulmonary percussive infants with cystic fibrosis. Arch Dis Child 2004;89:435–439.

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