Chest physiotherapy for pneumonia in adults

Pneumonia is a form of acute infection that affects the lungs and can be broadly classified as community-acquired (CAP) and hospital-acquired pneumonia (HAP). Epidemiologic studies show that the incidence of CAP in adults ranges from 5 to 11 per 1,000 per year in European and North American countries, increasing with age, together with mortality. People with pneumonia usually have dyspnea, mucus hypersecretion, increased airway resistance and airflow obstruction, and decreased exercise performance and tolerance. In this scenario, rehabilitation aims to enhance mucus clearance, reduce airway resistance, enhance gas exchange, improve the patient's respiratory status, and accelerate recovery. Pneumonia treatment is mainly based upon antibiotics and is supported by oxygen supplementation, intravenous hydration, and chest physiotherapy. Modern physiotherapy applies many different techniques such as manual percussion, chest shaking, postural drainage, expectoration, and breathing techniques. Recently new techniques have been introduced like the active cycle of breathing techniques, positive expiratory pressure, osteopathic manipulation, and chest-wall oscillation. Chest physiotherapies have been analyzed for cystic fibrosis and acute bronchiolitis; however, their use in adults with pneumonia is still debated.

This review investigated whether chest physiotherapy was safe and effective to treat adults with pneumonia.

This review is important for

People with pneumonia, their loved ones/caregivers, health professionals caring for this population, general practitioners, researchers, and policymakers.

Outcomes of this review

This is an update of Cochrane Systematic Reviews (CSRs) published in 2010 and in 2013. The outcomes analyzed were: mortality, cure rate; duration of hospitalization; complete recovery time; rate of chest X-ray improvement; duration of fever, antibiotic treatment; and leukocytosis, sputum production and its weight. Moreover, further outcomes were: duration of mechanical ventilation; days in intensive care unit; days to reach clinical stability, rate of respiratory failure during hospitalization, and rate of readmission; and change in leukocyte count and in its mean.

The CSR included a total of eight trials published and/or registered up to May 2022, with 974 participants.

For all of the outcomes, results showed that it is uncertain whether, compared to no physiotherapy or placebo, chest physiotherapy, osteopathic manipulative treatment (OMT), high-frequency chest wall oscillation, and active cycle of breathing techniques lead to any improvement because the certainty of evidence was very low. A slight, non-statistically significant improvement was observed for duration of hospital stay, fever, antibiotic treatment, and mechanical ventilation. No studies assessed the effectiveness or safety of chest physiotherapy for treating HAP or ventilation acquired pneumonia.

These results must be interpreted with caution because of (i) the small sample size affecting the power of the included trials. (ii) Most studies analyzed CAP, whereas in others the distinction between CAP and HAP was unclear. (iii) The duration, the types of techniques, and the quality of treatment sessions varied greatly, limiting the reproducibility of the results. (iv) Information on physiotherapist training was not available. (v) The duration of the intervention period varied across trials. (vi) Only two trials specified the randomization method. (vii) Few studies were double blinded or single blinded, leading to overestimation bias. (viii) Half of the studies had more than a 10% dropout rate, but none used an intention-to-treat (ITT) analysis.

Author’s conclusion of the review

The authors are uncertain whether chest physiotherapy improved mortality and cure rate in adults with pneumonia. Some physiotherapies may slightly improve length of hospitalization and ICU care, fever duration, and mechanical ventilation. The evidence for all of the outcomes was estimated as very low quality; therefore, further analysis is required.

Future recommendations

The authors recommended that further large-scale, well-designed randomized controlled trials are necessary, particularly to find out (a) the role of chest physiotherapy on the different types of pneumonia, not only for CAP. (b) Chest physiotherapy treatment should be standardized as well as the outcomes and the comparator therapy. (c) Cost-effectiveness analysis should be performed and, lastly, it would be appropriate to (d) analyze outcomes such as patients’ subjective satisfaction with the treatment.

Robin Kuruvila Sentinella