Key Words 669

Chest physiotherapy,
bronchiolitis.
An Evaluation of Chest
by K J Nicholas
Physiotherapy in the M O Dhouieb
T G Marshall
Management of Acute A T Edmunds
Bronchiolitis M B Grant
Changing clinical practice

Summary
Aims A clinical trial was undertaken to test the hypothesis that CPT
may be of benefit to those infants with acute viral bronchiolitis
whether CPT was a necessary component in
whose disease on admission was severe enough to require the management of these patients. The
nasogastric or intravenous feeding. The clinical impression that clinical impression of the paediatricians and
CPT does not increase respiratory distress was also investigated. physiotherapists at RHSCE was that CPT
Method The treatment group (n = 26) receiving physiotherapy was reduced the intensity of the acute illness in
compared with a control group (n = 24). Subjects in the control those children whose disease was at the
severe end of the spectrum and did not
group were nursed in modified postural drainage positions with
increase their respiratory distress. This
suction as required. Outcome was assessed by comparison of impression was contrary to a previous trial
clinical score, duration of hospital stay, requirement for oxygen, (Webb et al, 1985), which found that CPT
and nasogastric feeding. had no effect on the natural course of the
Results There was no significant difference in overall outcomes illness and suggested that the handling
between the two groups. Analysis of clinical scores suggested that inherent in CPT increased the respiratory
distress of the infants treated.
less severely ill infants (score < 9.5 on admission) in the treatment
A subsequent article reviewing adult
group recovered at a slower rate than the equivalent infants in the chest physiotherapy (Sutton, 1988),
control group. recommended that the use of CPT should
Conclusions There was no increase in the respiratory distress of be limited to those patients with actual or
infants who received CPT according to the protocol, but chest potential sputum production. The question
physiotherapy is of no benefit in the management of acute viral asked in this trial was whether CPT was
required for infants producing secretions, or
bronchiolitis in the absence of other pathologies.
whether good nursing care, including
positioning and suctioning before feeds,
Introduction would relieve the airway obstruction with
Bronchiolitis is the most common acute minimal handling.
respiratory tract infection in infants. The aim of the RHSCE study was to
Epidemics tend to occur during winter investigate the clinical impression that CPT
months (Phelan, 1982). This infection, was of benefit to infants whose disease was at
predominantly due to respiratory syncytial the severe end of the spectrum and, as
virus, results in admission to hospital of performed by the RHSCE physiotherapists,
between 1% and 2% of all infants born in did not cause an increase in their respiratory
the United Kingdom (Milner, 1982, 1988). It distress.
is a self-limiting disease causing production
of secretions which may, in the age group Method
Nicholas, K J, Dhouieb, affected, require nasopharyngeal suction Sample
E M O, Marshall, T G, (Young, 1988). During the three years 1986 to 1989,
Edmunds, A T and The use of chest physiotherapy (CPT), October to April inclusive, infants were
Grant, M B (1999).
including the use of manual techniques, had identified for inclusion in the present study
An evaluation of chest
physiotherapy in the
in 1986 become common practice at the if they had been admitted to RHSCE with a
management of acute Royal Hospital for Sick Children, Edinburgh clinical diagnosis of acute bronchiolitis and
bronchiolitis: Changing (RHSCE), most infants suffering from acute their respiratory distress was so severe that
clinical practice, bronchiolitis being automatically referred clinical staff judged that they required
Physiotherapy, 85, for physiotherapy. The dilemma for the nasogastric tube feeding or intravenous
12, 669-674. referring physicians and physiotherapists was fluids. The requirement for nasogastric

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 670

feeding or intravenous fluids defines a band Procedure

of relative severity, as they are required Infants were randomly allocated to control
when infants are too ill to tolerate breast or (n = 24) and treatment (n = 26) groups
bottle feeding because of breathlessness, using a random sequence number generated
exhaustion, hypoxia, coughing or inability to by the Medical Statistics Unit of the
absorb nasogastric feeds. University of Edinburgh.
Following informed parental consent, 50 Both groups received similar nursing and
infants (23 boys, 27 girls) with a mean age of medical management. Standard RHSCE
2.8 months (range 0.4 to 7.6 months) were management included maintenance of
studied. normal blood gases, nasopharangeal suction
to clear secretions, maintenance of fluid
balance, temperature control, positioning,
Physiotherapy Protocol monitoring of vital signs, and antibiotics if
indicated.
Exit from the trial was automatic after five
Optimal treatment
Patient is treated on physiotherapist's knee; percussion and vibration days. Exit from the trial also occurred if
in right side lying, left side lying and sitting; suction performed after there was clinical deterioration to the point
each side if necessary until clear; no oxygen required during where the patient required admission to the
treatment. Two people to do physiotherapy and suction. intensive care unit. One infant came into
this category.
Modifications
General position: If unable to tolerate treatment on knee then on flat Treatment Protocol
cot, if unable to tolerate this then on head-up tipped cot (as nursed). A physiotherapy protocol was established
which identified both an optimal treatment,
Postural drainage: If patient is treated in cot then sitting modified to
CPT manual techniques of percussion and
supine lying with head-up tip. If not tolerating change of position,
vibrations performed in postural drainage
then as many as able in one session. If not handling well, then treated
in position found. Treatment timed with turning to concentrate on positions and the possible modifications
any area of collapse/consolidation. Treatment timed with nursing required (see panel).
procedures to create minimum disturbance. Physiotherapy input and suction were
responsive, ie balancing the need for
Techniques: If patient is unstable and unable to tolerate percussion secretion clearance with the infant's ability
then vibrations only. to tolerate intervention. The selection and
Suction: If not tolerated until clear then as often as able. sequence of techniques to be used were
based on the clinical judgement of the
Oxygen: An oxygen supply via mask or bag will be on hand during all physiotherapists working on the medical
treatment. If not tolerating treatment with no oxygen then it will be wards including on-call and weekend staff.
given during treatment. If not tolerating this then infant will remain Suction was performed by nurses during
in headbox with extra oxygen during treatment. physiotherapy and before feeds as necessary.
Oxygen saturation was measured using
Not tolerating is defined by respiratory distress, ie raised cyanosis, raised pulse oximetry before, during and after
recession and respiratory rate, raised heart rate to unacceptable levels for that
patient. physiotherapy sessions.
Infants in the control group were nursed
in modified postural drainage positions with
Table 1: Clinical scoring system suction performed by nurses as required.

0 - 0.5 1 - 1.5 2 Total Data Collection

Clinical Outcome Measures
Respiratory rate < 40 40 - 60 > 60 The effectiveness of CPT was evaluated using
Heart rate < 120 120 - 160 >160 a set of specific parameters, ie a clinical
Blood gases PCO2 kPa <6 6-8 >8 scoring system (Webb et al, 1985) to assess
Rhinitis Mild Moderate Severe change in clinical status, differences in
Hyperinflation Mild Moderate Severe length of hospital stay, provision of inspired
Use of accessory muscles Mild Moderate Severe oxygen and requirement for nasogastric
Recession Mild Moderate Severe feeding. A concurrent pilot study of changes
Cough Mild Moderate Severe in oxygen saturation (SaO 2 ) during
Wheeze Nil Auscultate Audible physiotherapy was initiated to evaluate the
Crackles Nil Local Widespread possibility of respiratory distress resulting
from physiotherapy handling.

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Professional articles 671

Clinical Status example prematurity, cardiac problems or

A validated scoring system (Dick, 1991) was a neurological condition.
used to assess any change in clinical status
over five days (table 1). The higher the Statistical Analysis
score, the more severe the clinical signs and In order to fulfil the aim of the present
symptoms. All components were scored study, the infants clinical scores were
individually, twice in 24 hours, so far as subjected to the Students t-test for matched
possible by a single observer -- ie two medical subjects in order to compare differences
staff in the first year (TM 84%, RH 16%) between the two groups. In addition the
and by one (TM) during the subsequent two pulse oximetry data from the two groups
years. were compared using the paired Students
t-test, and the Mann-Whitney U-test was used
Oxygen Saturation to compare differences in length of hospital
A pilot study using pulse oximetry to stay, provision of inspired oxygen and
measure oxygen saturation (SaO 2 ) ran requirement for nasogastric feeding. There
concurrently with the main trial. SaO2 was was retrospective descriptive analysis of chest
measured at three points during a physiotherapy. The alpha value was set at
physiotherapy session; five minutes before 0.05.
treatment (baseline), during treatment
(intervention) and ten minutes after the end Results
of treatment (recovery). A sensor was fixed A total of 50 infants (23 boys, 27 girls) with a
to the infant's toe or thumb, the basic mean age 2.8 months (range 0.4 to 7.6) were
requirement being the achievement of a studied over three years. The two groups
reliable signal. Patients who did not require were similar in regard to age, sex, admission
supplementary oxygen were treated and score, and the proportion who were
measured in air. Those patients who did not respiratory syncytial virus positive (table 2).
desaturate on the removal of oxygen were
treated and measured in air with oxygen to Table 2: Group characteristics of trial subjects
hand. The patients who did desaturate
received supplemental oxygen throughout
treatment and measurement. Characteristics Control (n = 24) Physiotherapy (n = 26)

Responsive Physiotherapy Age

The selection of chest physiotherapy Mean (months) 3.2 2.4
techniques, length of treatment and number Range (months) 0.4 - 8.3 0.4 - 6.9
of treatments was based on the clinical
Sex M : F 10 : 14 13 : 13
judgement of the physiotherapists according
to the optimal protocol (see panel). Admission clinical score
All selected components were recorded Mean 9.1 10.86
on a data collection sheet to allow for Minimum 5 4
retrospective analysis. Maximum 17 14.5
The components of CPT to be selected
were listed on the data collection sheet and Virology
include general and specific postural RSV positive 19 ( 79% ) 22 ( 85% )
drainage positions and manual techniques; RSV negative 3 ( 13% ) 3 ( 12% )
large and small amplitude vibrations and No result 2 ( 8% ) 1 (4% )
percussion. The data collection sheet was
completed during each treatment session Supplemental oxygen
and the data analysed retrospectively (Dick, Mean (hours) 63 86
1991). Range (hours) 2.3 - 128 36 - 148
Patient numbers 17 ( 70.8% ) 17 ( 65.3%)
Ethical Approval
Nasogastric feeds
Ethical approval was obtained before the
Mean (hours) 92 86
trial from the Paediatric/ Reproductive
Range (hours) 8 - 225 18 - 161
Medicine Ethics Group, RHSCE. Patients
were excluded from the trial if parental Hospital stay
permission was refused or if they had Mean (days) 6.6 6.7
another underlying pathological condition Range (days) 2.3 - 11.5 3 - 9.5
compromising respiratory status, for

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12
in five daily scores for those infants with
admission scores greater than 9.5 (control 9,
10
physiotherapy 16). Analysis of daily scores in
those with admission scores less than 9.5
8 (control 15, physiotherapy 9), suggested that
the infants in the treatment group recovered
Mean scores

at a slower rate than their equivalents in the

6
control group. There was a statistically
significant difference in scores 7, 8, and 9
4 corresponding to days 4 and 5 (see figure).
The results were not significant when
2
using the Mann-Whitney U test to compare
the observed differences between the two
groups in provision of oxygen and the
0
1 2 3 4 5 6 7 8 9 10
requirement for nasogastric or intravenous
Data collection points (5 days) feeding. Hospital stays in both groups were
Treatment group (n = 9) + 2SD very similar. Exit from the trial was required
for one infant owing to admission to
Control group (n = 15) 2SD
intensive care.
Fig 1: Sequential clinical scores for infants with admission score < 9.5
Oxygen Saturation
The paired Students t-test was used to
compare the progressive result of CPT on
SaO2 in air or oxygen in the same subjects.
100
This group (n = 28) included two infants
98 excluded from the trial as they had not been
clinically scored. The baseline (before
96
physiotherapy) readings were compared
94 against intervention (physiotherapy) and
92
recovery (after physiotherapy) readings (fig
2). Intervention readings were similarly
(SaO2)

90
compared with recovery readings. There was
88 a decrease in SaO 2 between baseline and
intervention which was not statistically
86
significant. A subsequent rise in SaO 2
84 between inter vention and recovery
82
was significant at the 0.05 level.

80
Responsive Physiotherapy
Before physiotherapy Physiotherapy After physiotherapy
Descriptive analysis of these data indicated
Fig 2: Mean oxygen saturation (SaO2) 1 SD in air and supplementary that, in keeping with the protocol, the
oxygen (N = 28) treatments generally progressed from the
least stressful postural drainage position, eg
On analysis of the sequential clinical one position on a tipped bed, to the most
scores over five days in all 50 cases (control stressful, eg all postural drainage positions
group n = 24, physiotherapy group n = 26), on a physiotherapist's knee. Subjective
the mean scores were higher in the obser vation of the physiotherapists
physiotherapy group than in the controls. treatment during the trial indicated that if a
The differences were not, however, patient was unable to tolerate a full
statistically significant. Subsequently, on the treatment, the response was to decrease the
basis of the mean clinical score on treatment time and increase the number of
admission, the infants were divided into two treatments, ie the physiotherapists appeared
groups: those scoring 9.5 or below on to modify their treatment in response to the
admission (n = 24) and those scoring 10 or patients ability to withstand the handling
above (n = 26); the higher scoring of the inherent in CPT.
second group reflecting a greater illness
severity on admission. Discussion
Using the Students t-test for matched The trial did not confirm the clinical
subjects there were no significant differences impression that CPT reduced the intensity of

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Professional articles 673

the acute illness in these patients. It is the airways of infants whose bronchiolitis is Authors
possible that that the inclusion of CPT slows uncomplicated by any other pathology. In Kate Nicholas (ne Dick)
the normal recovery in patients who on these circumstances excess mucus may be MCSP DipTP BA MPhil
admission are moderately ill, but does not cleared by nursing positioning and suction. was a senior lecturer in
significantly affect the course of the illness of The major limitations of this study arise physiotherapy at Queen
severely ill patients. The inclusion of CPT partly from the effects of study design and Margaret College. This
had no statistically significant effect on the partly from the lack of reliable and valid trial was part of her thesis
length of hospital stay, the requirement for tools to evaluate CPT. The low number (50) submitted for the degree
of Master of Philosophy.
supplemental oxygen or nasogastric feeding. of infants recruited to a three-year trial may
However, the degree of handling which be explained by entry to the trial being Elaine Dhouieb MCSP is
these patients received during CPT did not limited to those patients with moderate to a senior physiotherapist
appear to increase their respiratory distress severe bronchiolitis as evidenced by the at Edinburgh Sick
Children's NHS Trust and
and it is possible that the suggestion by need for nasogastric or intravenous feeding.
was principal clinical
Webb et al (1985) that CPT increases the The selection of a responsive approach to
physiotherapist on the
respiratory distress of infants may be treatment poses obvious problems for others trial.
explained by the difference in CPT wishing to replicate this study, though an
Tom Marshall is a
interventions, and that respiratory distress attempt was made in this case to define an
consultant paediatrican
was avoided in the RHSCE trial by the use optimal protocol with modifications.
at Edinburgh Sick
of responsive CPT. Analysis of oxygen A further limitation was common to a Children's NHS Trust.
saturation readings indicated that responsive number of bronchiolitis trials (Henry et al, At the time of the study
CPT as per formed did not cause desat- 1983; Webb et al, 1985; Barry et al, 1986), ie he was senior registrar
uration. The Webb trial had described a the use of a non-validated clinical score and clinically scored the
standard CPT treatment for all infants system. This limitation was addressed in this patients.
admitted with bronchiolitis which had trial by using a questionnaire circulated to Trevor Edmunds is a
resulted in a total of 30 minutes daily consultant paediatricians and senior consultant paediatrican
treatment. registrars with responsibility for infants with and Mo Grant MCSP is
Discussion during the design stage of this bronchiolitis, to validate the most common head of physiotherapy at
trial had revealed conflicts present between clinical markers used in bronchiolitis. Edinburgh Sick
a clinical and a research approach to the As the trial did not confirm the clinical Children's NHS Trust.
evaluation of CPT. The RHSCE physio- impression that CPT reduced the intensity of
therapists felt that a standard treatment acute viral bronchiolitis, the report was not The trial was designed
and run as a collaborative
removed elements which were an essential offered for publication in 1989 or 1990. In
effort between the staff of
part of their practice. They wished to be able the meantime, the concomitant finding that the Royal Hospital for
to respond to any changing clinical situation chest physiotherapy is of no benefit in the Sick Children and the
and felt that a standard treatment dose absence of other pathologies has added Department of
increased the possibility of over-treatment value to the study. Physiotherapy, Queen
and with it the chance of increasing The results of the trial have changed Margaret College.
respiratory distress. clinical practice for both medical and
The functional requirement for naso- physiotherapy staff at the RHSCE. Patients This article was received
gastric feeding as a criterion for entry to the with acute viral bronchiolitis and no other on July 21, 1997, and
accepted on July 29, 1998.
RHSCE trial had allowed the selection of pathology are no longer being referred for
those infants whose disease was at the severe physiotherapy, and the resulting change
end of the spectrum. In the previous study in medical clinical practice has decreased
Address for
(Webb et al, 1985) there was no apparent the overall physiotherapy departmental
Correspondence
selection, all infants admitted with workload in the epidemic winter months,
bronchiolitis during the study period being and enabled a more effective use of Mrs K J Nicholas,
Department of
eligible for inclusion. paediatric physiotherapy resources in the
Physiotherapy, Queen
In spite of these trial design differences, paediatric setting. Previously staff had had
Margaret University
the combined results of this and the to be relocated from other duties during College, Leith Campus,
previous bronchiolitis trial (Webb et al, the week, taking resources from other Duke Street, Edinburgh
1985), indicate that CPT does not affect the physiotherapy areas, and a second on-call EH6 8HF.
progress of any infant with uncomplicated physiotherapist was required.
acute bronchiolitis. The results of ongoing clinical monitoring
The explanation for the conclusions of give no reason to reverse the decision to
both of these trials may be that the inclusion change practice. There has been no increase
of percussion and vibration -- manual in the numbers of infants with uncom-
techniques to mobilise adherent secretions plicated acute viral bronchiolitis developing
(Gallon, 1992 ) -- are unnecessary in the lobar consolidation or collapse, or requiring
presence of generally free-moving mucus in admission to intensive care.

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 674

Acknowledgements Conclusion Hospital for Sick Children in Edinburgh that

We thank the parents While numbers in the study were limited, it patients with acute viral bronchiolitis and
who consented to their appears that chest physiotherapy has no no other pathology are no longer being
child's entry to the trial. effect on the course of recovery in severely referred for physiotherapy. This change
Thanks are also due to Dr ill infants and appeared to slow down the has not resulted in an increase in the
Robin Prescott, Director recovery of moderately ill infants who had complications of this disease. Patients with
of the Medical Statistics acute viral bronchiolitis with no other additional pathology compromising resp-
Unit, Edinburgh iratory function, eg neurological conditions,
underlying pathology. Chest physiotherapy
University, for his help heart defects, lung pathology, are still
per formed using the protocol did not
with statistical analysis; to
appear to increase respiratory distress in the assessed by the physiotherapists for chest
the Avenol Trust for its
patients treated, perhaps because CPT was physiotherapy, as are those requiring
financial support, and to
all the on-call responsive to the patients clinical state. It is admission to intensive care and ventilation.
physiotherapists who now standard clinical practice at the Royal
added pulse oximetry to
their workload. References Henry, R L, Milner, A D and Stokes, G M (1983).
Ineffectiveness of ipratropium bromide in acute
Barry, W, Cockburn, F, Cornall, R, Price, J F,
bronchiolitis, Archives of Diseases of Childhood, 58,
Sutherland, G and Vardag, A (1986). Ribavirin
925-926.
aerosol for acute bronchiolitis, Archives of Disease
in Childhood, 61, 593-597. Hough, A (1996). Physiotherapy in Respiratory Care,
Chapman and Hall, London.
Dick, K J (1991). Investigation and evaluation of
physiotherapy intervention in acute bronchiolitis of Milner, A D (1982 ). Acute airway obstruction in
infancy, Masters Thesis, Department of children under five, Thorax, 37, 641-645.
Physiotherapy, Queen Margaret College, Milner, A D (1988). Acute bronchiolitis in infants,
Edinburgh. Booth Hall Childrens Postgraduate Centre,
Etches, P C and Scott, B (1978). Chest July 15, Update.
physiotherapy in the newborn: Effect on Phelan, P D (1982). Respiratory Illness in Children,
secretions removed, Paediatrics, 61, 713-715. Blackwell, Oxford, 2nd edn.
Finer, N N, Boyd, J and Grace, M G (1978). Sutton, P P (1988). Chest physiotherapy: A time
Chest physiotherapy in the neonate: for reappraisal, British Journal of Diseases of the
A controlled study, Pediatrics, 61, 282-285. Chest, 82, 127-137.
Finer, N N, Moriarty, R R, Boyd, J, Phillips, H J, Webb, M, Martin, J, Cartiledge, P, Ng, Y and
Stewart, A R and Ulan, O (1979). Postextubation Wright, N (1985). Chest physiotherapy in acute
atelectasis: A retrospective review and prospective bronchiolitis, Archives of Diseases of Childhood, 60,
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Gallon, A (1992). The use of percussion, Young, C S (1988).Airway suctioning: A study of
Physiotherapy, 78, 2, 85-89. physiotherapy practice, Physiotherapy, 74, 1,
13-15.

Key Messages tolerate intervention, is effective in

The presence of secretions does not minimising any respiratory distress which
inevitably mean that chest physiotherapy may be caused by the handling inherent
is indicated. in chest physiotherapy

In infants, the requirement for Clinical team research is an effective way

nasogastric feeding or intravenous fluids to change clinical practice. Leads to a
is a useful functional measure to define a general acceptance of results, and
band of relative severity. consequent changing of practice.

A responsive approach to physiotherapy,

ie balancing the need for suction
clearance with the infants ability to

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