Chest physiotherapy for preventing morbidity in babies being
extubated from mechanical ventilation (Review)
Flenady V, Gray PH
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2010, Issue 10
http://www.thecochranelibrary.com
Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 1 Postextubation lobar
collapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Analysis 1.2. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 2 Reintubation within
24hrs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Analysis 1.3. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 3 Pneumonia. . . 19
Analysis 1.4. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 4 Bradycardia. . 19
Analysis 1.5. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 5 Intraventricular
haemorrhage-all grades. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Analysis 1.6. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 6 Intraventricular
haemorrhage - Grades 3 and 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Analysis 1.7. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 7 Death prior to
discharge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Analysis 1.8. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 8 Duration of mechanical
ventilation (days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Analysis 1.9. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 9 Duration of
nasopharyngeal CPAP( days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Analysis 1.10. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 10 Duration of
supplemental oxygen (days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Analysis 1.11. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 11 Duration of
neonatal intensive care stay (days). . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Analysis 2.1. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation, Outcome 1
Postextubation lobar collapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Analysis 2.2. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation, Outcome 2
Reintubation within 24hrs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Analysis 2.3. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation, Outcome 3
Bradycardia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Analysis 2.4. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation, Outcome 4
Intraventricular haemorrhage - all grades. . . . . . . . . . . . . . . . . . . . . . . . . 25
Analysis 2.5. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation, Outcome 5
Intraventricular haemorrhage - Grades 3 and 4. . . . . . . . . . . . . . . . . . . . . . . 25
Analysis 2.6. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation, Outcome 6 Death
prior to discharge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Analysis 2.7. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation, Outcome 7
Duration of mechanical ventilation (days). . . . . . . . . . . . . . . . . . . . . . . . . 26
Analysis 2.8. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation, Outcome 8
Duration of nasopharyngeal CPAP( days). . . . . . . . . . . . . . . . . . . . . . . . . 27
Analysis 2.9. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation, Outcome 9
Duration of supplemental oxygen (days). . . . . . . . . . . . . . . . . . . . . . . . . 27
iChest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.10. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation, Outcome 10
Duration of neonatal intensive care stay (days). . . . . . . . . . . . . . . . . . . . . . . 28
Analysis 3.1. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency),
Outcome 1 Post extubation lobar collapse. . . . . . . . . . . . . . . . . . . . . . . . . 28
Analysis 3.2. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency),
Outcome 2 Reintubation within 24 hours. . . . . . . . . . . . . . . . . . . . . . . . . 29
Analysis 3.3. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency),
Outcome 3 Pneumonia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Analysis 3.4. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency),
Outcome 4 Bradycardia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Analysis 3.5. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency),
Outcome 5 Intraventricular haemorrhage- all grades. . . . . . . . . . . . . . . . . . . . . 32
Analysis 3.6. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency),
Outcome 6 Intraventricular haemorrhage - Grades 3 and 4. . . . . . . . . . . . . . . . . . . 33
Analysis 3.7. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency),
Outcome 7 Death prior to discharge. . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Analysis 3.8. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency),
Outcome 8 Duration of mechanical ventilation (days). . . . . . . . . . . . . . . . . . . . . 35
Analysis 3.9. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency),
Outcome 9 Duration of nasopharyngeal CPAP( days). . . . . . . . . . . . . . . . . . . . . 35
Analysis 3.10. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency),
Outcome 10 Duration of supplemental oxygen (days). . . . . . . . . . . . . . . . . . . . . 36
Analysis 3.11. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency),
Outcome 11 Duration of neonatal intensive care stay (days). . . . . . . . . . . . . . . . . . . 37
37WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
37HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
39INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iiChest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Chest physiotherapy for preventing morbidity in babies beingextubated from mechanical ventilation
Vicki Flenady1, Peter H Gray2
1Mater Medical Research Institute, Mater Health Services, Wooloongabba, Australia. 2Newborn Services, University of Queensland,
South Brisbane, Australia
Contact address: Vicki Flenady, Mater Medical Research Institute, Mater Health Services, Level 2 Quarters Building, Annerley Road,
Wooloongabba, Queensland, 4102, Australia. [email protected].
Editorial group: Cochrane Neonatal Group.
Publication status and date: Edited (no change to conclusions), published in Issue 10, 2010.
Review content assessed as up-to-date: 9 November 2009.
Citation: Flenady V, Gray PH. Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation.
Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000283. DOI: 10.1002/14651858.CD000283.
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Chest physiotherapy has been used to clear secretions and help lung ventilation in newborns who have needed mechanical ventilation
for respiratory problems. However, there are concerns about the safety of some forms of chest physiotherapy.
Objectives
To determine the effects of active chest physiotherapy on infants being extubated from mechanical ventilation for respiratory failure.
Search strategy
The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of electronic databases: Oxford
Database of Perinatal Trials; Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2005);
MEDLINE (1966 to February 2009); CINAHL (1982 to February 2009); and EMBASE (2006 to February 2009), previous reviews
including cross references, abstracts, conferences, symposia proceedings, expert informants and journal hand searching.
Selection criteria
All trials utilising random or quasi-random patient allocation, in which active chest physiotherapy was compared with non-active
techniques (e.g. positioning and suction alone) or no intervention in the peri-extubation period.
Data collection and analysis
Assessment of methodological quality and extraction of data for each included trial was undertaken independently by the authors.
Subgroup analysis was performed on different treatment frequencies and gestational age less than 32 weeks. Meta-analysis was conducted
using a fixed effects model. Results are presented as relative risk (RR), risk difference (RD) and number needed to treat (NNT) for
categorical data and mean difference (MD) for data measured on a continuous scale. All outcomes are reported with the use of 95%
confidence intervals.
1Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results
In this review of four trials, two of which were carried out 15 and 23 years ago, no clear benefit of peri-extubation active chest
physiotherapy can be seen. Active chest physiotherapy did not significantly reduce the rate of postextubation lobar collapse [typical
RR 0.80 (95% CI 0.49,1.29)], though a reduction in the use of reintubation was shown in the overall analysis [typical RR 0.32 (95%
CI 0.13,0.82); typical RD -7% (95% CI-13, -2); NNT 14 (95% CI 8, 50)]. There is insufficient information to adequately assess
important short and longer term outcomes, including adverse effects.
Authors’ conclusions
Caution is required when interpreting the possible positive effects of chest physiotherapy of a reduction in the use of reintubation and
the trend for decreased post-extubation atelectasis as the numbers of babies studied are small, the results are not consistent across trials,
data on safety are insufficient, and applicability to current practice may be limited.
P L A I N L A N G U A G E S U M M A R Y
Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Active chest physiotherapy may not be helpful for all babies being taken off mechanical breathing support. Mechanical ventilation
(machine-assisted breathing) increases a baby’s lung secretions. Chest physiotherapy (tapping or vibrating on the chest) is thought to
clear the baby’s lungs, and is often done when taking the baby off the ventilator (extubation). Although this review found a benefit for
physiotherapy in terms of less babies needing to go back on the ventilator, no other benefits were shown. Also, this benefit was mainly
due to the results of studies conducted a long time ago before advances such as better humidification systems to moisten the air the
baby breaths and the drug surfactant. These advances may have reduced the risk of complications around the time of extubation so
these results may not apply to babies in today’s neonatal nurseries. This review did not show any evidence of harm for babies receiving
a short course of chest physiotherapy following extubation.
B A C K G R O U N D
Description of the condition
Endotracheal intubation and mechanical ventilation cause trauma
and inflammation to the airways and increase secretions in the
lungs. These effects may contribute to respiratory complications
following cessation of mechanical ventilation and extubation. Pos-
textubation complications range from problematic secretion build
up causing discomfort, agitation and distress (necessitating fre-
quent suctioning) to obstruction of major airways with resultant
lung collapse. The presence of lung collapse may require increased
support such as additional oxygen and occasionally reintubation
for further mechanical ventilation. These complications poten-
tially prolong the recovery phase and may impact on long term
outcomes.
The neonate is particularly at risk of respiratory complications due
to immaturity of the respiratory system. Decreasing birth weight
(Odita 1993), increasing duration of mechanical ventilation, high
oxygen concentrations, multiple intubations (Wyman 1977), pres-
ence of disease states such as sepsis and patent ductus arteriosus
(Odita 1993) and nasal intubation (Roper 1976; Spitzer 1982)
have been identified as risk factors for postextubation lobar col-
lapse (PEC). The incidence of neonatal PEC has been reported at
between 11 and 50% over the past decade (Halliday 1992; Odita
1993), with reintubation required in 10-30% of cases (Halliday
1992).
Description of the intervention
Respiratory physiotherapy techniques include chest percussion
and vibrations (often referred to as active chest physiotherapy).
How the intervention might work
Respiratory physiotherapy techniques such as chest percussion
and vibrations (often referred to as active chest physiotherapy) are
thought to reduce respiratory complications by promoting clear-
ance of secretions (Etches 1978), thus improving ventilation of the
2Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
lungs. Improvement in oxygenation following active physiother-
apy has been reported (Tudehope 1980). However, reports on the
effects of the different methods of active physiotherapy show con-
flicting results (Crane 1978; Curran 1979; Tudehope 1980). Sa-
fety in terms of stability of intracranial blood flow during suction
(Paratz 1994), no increase in the rate of cerebral lesions (Beeby
1998), and benefit in terms of reducing hypoxaemia during suc-
tion (Bradbury-Hough 1995) has been reported. However, con-
cerns have also been expressed regarding the safety of this inter-
vention. Reports of adverse effects include hypoxaemia (Holloway
1969; Fox 1978), rib fractures (Purohit 1975) and associated brain
lesions (Raval 1987; Cross 1992; Ramsay 1995; Coney 1995;
Harding 1998).
Following the publication of a small trial in 1979 (Finer 1979),
the use of active chest physiotherapy techniques for the prevention
of postextubation lung collapse became a part of routine care in
many neonatal nurseries. However, a growing body of conflicting
literature on the effects of active chest physiotherapy has resulted in
differences of opinion about the risk/benefit ratio of many neonatal
physiotherapy techniques, and also differences in practice (Lewis
1992; Flenady 1997).
Why it is important to do this review
This review updates the existing review “Chest physiotherapy for
preventing morbidity in babies being extubated from mechanical
ventilation” published in the Cochrane Database of Systematic
Reviews Flenady 2002.
O B J E C T I V E S
To determine the effects of active chest physiotherapy on infants
being extubated from mechanical ventilation for neonatal respi-
ratory failure on outcomes of post-extubation lobar collapse, the
use of reintubation and adverse effects such as bradycardia, hypox-
aemia and the incidence of intracranial lesions.
A priori sub-group analyses:
Different treatment intervals - frequent (one and two hourly) ver-
sus four hourly.
Different treatment methods - vibrations versus percussion.
Preterm < 28 weeks gestation or < 1000 g birthweight.
Preterm < 32 weeks gestation or <1500 g birthweight.
M E T H O D S
Criteria for considering studies for this review
Types of studies
All trials utilising random or quasi-random patient allocation, in
which active chest physiotherapy was compared with non-active
techniques (e.g. positioning and suction alone) or no intervention
in the peri-extubation period.
Types of participants
All infants being extubated following a period of mechanical ven-
tilation for neonatal respiratory failure.
Types of interventions
Active chest physiotherapy techniques including the use of vibra-
tions or percussion with or without the use of devices such as face
masks and electric vibrators.
Types of outcome measures
Primary outcomes
Lobar collapse of the lung shortly after extubation.
Use of reintubation.
Hypoxaemic episodes.
Bradycardia.
Duration of oxygen therapy.
Intracranial haemorrhage.
Cerebral cystic lesions (Periventricular leukomalacia, poren-
cephalic cysts).
Long term neurosensory impairment.
Death prior to hospital discharge.
Secondary outcomes
Pulmonary air leak.
Duration of mechanical ventilation (days).
Duration of nasopharyngeal CPAP (days).
Chronic lung disease: oxygen use at 28 days of age; oxygen use at
36 weeks postmenstrual age.
Frequency of suctioning and handling.
Duration of neonatal intensive care unit stay (days).
Duration of hospital stay (days).
Search methods for identification of studies
The standard search strategy for the Cochrane Neonatal Review
Group was used.
3Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Electronic searches
We searched the following electronic databases for published
manuscripts: Oxford Database of Perinatal Trials; Cochrane Cen-
tral Register of Controlled Trials (CENTRAL, The Cochrane Li-
brary, Issue 1, 2005); MEDLINE (1966 to January 2005); and
CINAHL (1982 to January 2005) using MeSH term infant-new-
born and text terms extubat*; atelectasis; lung collapse; lobar col-
lapse; chest physiotherapy; respiratory therapy, chest physical ther-
apy.
In 2009, the search was updated as follows: MEDLINE (search via
PubMed), CINAHL, EMBASE and The Cochrane Library were
search from 2006 to 2009.
Search terms: extubat* OR atelectasis OR lung collapse OR lobar
collapse OR chest physiotherapy OR respiratory therapy OR chest
physical therap. Limits: human, newborn infant and clinical trial.
No language restrictions were applied. The bibliography cited in
each publication obtained was searched in order to identify addi-
tional relevant articles.
Searching other resources
In addition we searched previous reviews including cross refer-
ences, abstracts, conference and symposia proceedings, expert in-
formants, journal hand searching in the English language.
Clinical trials registries were also searched for ongoing or re-
cently completed trials (clinicaltrials.gov; controlled-trials.com;
and who.int/ictrp)
Data collection and analysis
The standard methods of the Cochrane Collaboration and its
Neonatal Review Group were used.
Selection of studies
All randomised and quasi-randomized controlled trials fulfilling
the selection criteria described in the previous section were in-
cluded. The authors reviewed the results of the search and sep-
arately selected the studies for inclusion. The review authors re-
solved any disagreement by discussion.
Data extraction and management
Each author independently extracted data then compared and re-
solved differences. For the 2002 update, extraction of data from
the previously included trials was conducted for the additional
outcomes specified.
Additional data on neonatal morbidity were sought from the in-
vestigators of three trials (V- Beresford 1987; Al-Alaiyan 1996;
Bagley 2005). One trial (Bagley 2005) provided additional data.
Data were received on outcomes for one infant excluded following
randomisation in Al-Alaiyan 1996. In Bagley 2005, there were four
post randomisation exclusions for the outcome of postextubation
collapse (PEC), two for intraventricular haemorrhage (IVH) and
one for the outcome of duration of oxygen therapy. In this review,
all infants randomised into this trial were included in the denom-
inator for the outcomes of PEC and IVH. Bagley 2005 also pro-
vided additional data on the outcome of cerebral cystic lesions at
six weeks of age; however, due to large number of losses to follow-
up (20 and 30% in the two groups), this outcome has not been
included in the review. Data for the outcomes of the duration of
mechanical ventilation, oxygen therapy, CPAP and neonatal in-
tensive care stay came from one trial (Bagley 2005). In this trial,
these outcomes were calculated for the period from admission to
the nursery (not from the time of random allocation) to discharge
from hospital.
Two trials included study groups of differing treatment frequencies
(Al-Alaiyan 1996; V- Beresford 1987). In the analysis, the hourly,
two hourly and four hourly physiotherapy groups in V- Beresford
1987 and the two hourly and four hourly groups in Al-Alaiyan
1996 were combined for the overall comparison.
Assessment of risk of bias in included studies
All included studies were assessed for blinding of randomisation,
blinding of intervention, completeness of follow-up, and blinding
of outcome assessment. The authors independently undertook
this assessment and assigned a rating of either Yes (Adequate),
Can’t Tell (Unclear), or No (Inadequate) for each. Differences were
resolved by discussion. Information was also sought and received
on methods of random allocation for two trials (V- Beresford
1987; Al-Alaiyan 1996). This information was added to the table
’Characteristics of Included Studies’.
In addition, following issues were evaluated and entered into the
Risk of Bias Table:
1. Sequence generation: Was the allocation sequence adequately
generated?
2. Allocation concealment: Was allocation adequately concealed?
3. Blinding of participants, personnel and outcome assessors: Was
knowledge of the allocated intervention adequately prevented dur-
ing the study? At study entry? At the time of outcome assessment?
4. Incomplete outcome data: Were incomplete outcome data ad-
equately addressed?
5. Selective outcome reporting: Are reports of the study free of
suggestion of selective outcome reporting?
6. Other sources of bias: Was the study apparently free of other
problems that could put it at a high risk of bias?.
Measures of treatment effect
Statistical analyses were performed using Review Manager soft-
ware. Categorical data were analyzed using relative risk (RR), risk
difference (RD) and the number needed to treat (NNT). Contin-
uous data were analyzed using weighted mean difference (WMD).
The 95% Confidence interval (CI) was reported on all estimates.
4Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Assessment of heterogeneity
We estimated the treatment effects of individual trials and exam-
ined heterogeneity between trials by inspecting the forest plots and
quantifying the impact of heterogeneity using the I2 statistic. If we
detected statistical heterogeneity, we explored the possible causes
using the subgroups noted below.
Assessment of reporting biases
Reporting bias was investigated by examining the degree of asym-
metry of the funnel plot. Information was also sought and received
on methods of random allocation for two trials (V- Beresford 1987;
Al-Alaiyan 1996).
Data synthesis
Meta-analysis was performed using Review Manager software
(RevMan 5) supplied by the Cochrane Collaboration. Meta-anal-
ysis was conducted using the fixed effect model. Mean Differences
(MD) were used for outcome data measured on a continuous scale
and relative risk, risk difference and number needed to treat as
appropriate for categorical data. 95% Confidence Intervals (CI)
are presented for all reported outcomes.
Subgroup analysis and investigation of heterogeneity
Different treatment intervals: frequent (one and two hourly) versus
four hourly.
Different treatment methods: vibrations versus percussion.
Preterm < 28 weeks gestation or < 1000 g birthweight.
Preterm < 32 weeks gestation or <1500 g birthweight.
R E S U L T S
Description of studies
See: Characteristics of included studies.
Results of the search
Four randomised trials addressing the issue of active chest physio-
therapy in the peri-extubation period were identified and included
in this review ( Finer 1979; V- Beresford 1987; Al-Alaiyan 1996;
Bagley 2005). A full description of each is included in the table,
Characteristics of Included Studies.
Included studies
Participants
The participants of the four trials differed somewhat with respect
to primary diagnosis and gestational ages. The groups in Finer
1979 and Al-Alaiyan 1996 were more mature than in V- Beresford
1987 and Bagley 2005. Mean gestational age in was 35 weeks in
Finer 1979, 33-35 weeks across the groups in Al-Alaiyan 1996,
29-32 weeks in V- Beresford 1987 and 30 weeks in Bagley 2005.
Nine babies had multiple intubations (maximum of three) prior
to enrolment in Finer 1979. Two trials randomised infants under-
going extubation from a primary course of ventilation only (V-
Beresford 1987; Bagley 2005). The number of courses of mechan-
ical ventilation prior to randomisation is unknown for infants in
Al-Alaiyan 1996. The main diagnosis of babies enrolled in the
four trials was respiratory distress syndrome, however Al-Alaiyan
1996 enrolled a higher proportion of babies with thoracoabdom-
inal surgery (30%) and only Finer 1979 included infants with
meconium aspiration and bacterial pneumonia.
Intervention
The intervention differed in that Finer 1979 and Al-Alaiyan 1996
used vibrations whereas V- Beresford 1987 and Bagley 2005 used
percussion. Al-Alaiyan 1996 used an electric vibrator to deliver
the chest wall vibrations. The frequency of treatments differed
among the three trials. Al-Alaiyan 1996 and V- Beresford 1987
enrolled babies into groups of differing treatment frequencies. V-
Beresford 1987 and Finer 1979 commenced active physiotherapy
1 hour prior to extubation whereas Al-Alaiyan 1996 and Bagley
2005 commenced the treatments following extubation.
Outcomes
The outcomes of postextubation lobar collapse and the use of en-
dotracheal reintubation within 24 hours of extubation were as-
sessed in all trials. Adverse effects were assessed in Bagley 2005
(short term neonatal morbidity and mortality) and V- Beresford
1987 (bradycardia only). Bagley 2005 reported on duration of
respiratory support (mechanical ventilation, oxygen therapy and
CPAP) and also for neonatal intensive care and hospital stay for
the period from admission to the nursery to the initial discharge
from hospital.
Excluded studies
None noted.
Risk of bias in included studies
Details of each study appear in the table, Characteristics of In-
cluded Studies.
Allocation
Concealment of allocation:
5Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
All of the included trials assigned babies to study groups by ran-
dom allocation. Adequate concealment of treatment allocation by
the use of sealed envelopes was undertaken in three trials (Finer
1979; Al-Alaiyan 1996; Bagley 2005). Concealment of treatment
allocation was not achieved in V- Beresford 1987. In this trial,
four treatment allocations (one for each of the four groups) were
included in one sealed envelope.
Blinding
Blinding of the intervention: Blinding of the intervention was not
possible.
Blinding of outcome: Diagnosis of post-extubation collapse was
performed by an assessor blinded to the treatment allocation in all
included trials.
Incomplete outcome data
Completeness of follow-up:
Finer 1979 and V- Beresford 1987 reported on outcomes for all
randomised babies. In the Al-Alaiyan 1996 trial one baby who
failed extubation was excluded; this baby has been included in this
review following personal communication with the investigator.
Bagley 2005 excluded four infants for the outcome of post extu-
bation collapse as chest radiography was not performed, and two
infants for the outcome of intraventricular haemorrhage as head
ultrasonography was not performed; greater than 20% loss to fol-
low-up was reported for the outcome of cerebral cystic lesions at
six weeks.
Effects of interventions
Active chest physiotherapy vs. no active chest physiotherapy
(Comparison 1):
Primary outcomes:
Post extubation collapse (PEC) and reintubation were the only
outcomes reported in all of the included trials. The overall analysis
shows a trend towards a reduction in the rate of PEC with active
chest physiotherapy which is not statistically significant [(typical
RR 0.80 (95% CI 0.49, 1.29)]. A significant reduction in the use
of reintubation within 24 hours of extubation was shown for ba-
bies receiving active chest physiotherapy [(typical RR 0.32 (95%
CI 0.13, 0.82); typical RD -7% (95% CI -13, -2)]. Thus, number
needed to treat (NNT) to expect to prevent one baby receiving
reintubation is 14 (95% CI 8, 50). There was insufficient infor-
mation to adequately assess the outcomes of bradycardia, duration
of oxygen therapy, cerebral haemorrhage, cerebral cystic lesions,
long term neurosensory impairment or death.
Secondary outcomes:
No statistically significant differences were shown in any other
short term outcomes (duration of CPAP and mechanical venti-
lation, duration of neonatal intensive care) reported by one trial
(Bagley 2005).
Subgroup analysis by gestation age (Comparison 2):
No significant effect of chest physiotherapy on the following out-
comes was shown in sub-group analyses of infants born less than
32 weeks gestation reported by one trial (Bagley 2005): postextu-
bation collapse, use of reintubation, duration of oxygen therapy,
cerebral haemorrhage, bradycardia, duration of CPAP and me-
chanical ventilation, duration of neonatal intensive care stay and
death. Although no trend to a reduction in PEC was shown as
for the overall analysis [RR 1.09 (95% CI 0.45, 2.63)], the trend
to a reduction in reintubation remained [RR 0.64 (95% CI 0.11,
3.72)].
Sub-group analyses of differing treatment frequencies (Com-
parison 3):
Four trials contributed to the comparison of more frequent treat-
ment (one and two hourly groups combined) with no treatment.
In keeping with the overall analysis, there was a non significant re-
duction in the rate of PEC [typical RR 0.76 (95% CI 0.47, 1.24)]
and a significant reduction in the use of reintubation [typical RR
0.24 (95% CI 0.08, 0.72); typical RD -8% (95% CI -14, -3);
NNT 13 (95% CI 7, 33)]. Less frequent treatment (4 hourly) was
compared to no treatment. Two trials were included in this analysis
(V- Beresford 1987; Al-Alaiyan 1996), which showed an increase
in PEC with active physiotherapy which is not statistically signif-
icant [(typical RR 1.45; (95% CI 0.51, 4.09)]. The reduction in
the use of reintubation is also not statistically significant [(typical
RR 0.80; 95% CI 0.21, 2.99)].
D I S C U S S I O N
Summary of main results
This review identified several important limitations of the
presently available evidence from randomised trials:
Small sample sizes
Due to small numbers of infants in the four included trials, all
estimates of effect are imprecise resulting in the inability to ade-
quately assess the effects of this intervention.
Inconsistency of results
Some of the effects, particularly the effect on postextubation alve-
olar collapse, are inconsistent across trials. In the case of PEC,
there is some evidence of a secular trend in that the rates in the
control groups of the different trials fell from 38% (Finer 1979) to
25% (V- Beresford 1987) to 13% (Al-Alaiyan 1996) and 20% in
Bagley 2005. The size and the direction of treatment effect varies
with control event rate, so that the point estimates for risk dif-
ference are -38% (Finer 1979), -13% (V- Beresford 1987), +16%
6Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Al-Alaiyan 1996) and -2% (Bagley 2005). Thus, a source of the
heterogeneity of treatment effect on PEC may be the level of risk
for PEC in the absence of chest physiotherapy. A similar trend
across time, again correlated with size of treatment effect, is shown
for reintubation. The rate of reintubation and the risk difference
in the control groups are as follows: Finer 1979 33% (RD -33%),
V- Beresford 1987 25% (RD -21%), Al-Alaiyan 1996 8.7% (RD
-1.4%) and Bagley 2005 3.4% (RD -1.1%).
Overall completeness and applicability ofevidence
Lack of safety data
Over the past decade, concerns regarding the safety of chest phys-
iotherapy, particularly in the small preterm infant, have been re-
ported. Information on possible adverse effects was inadequate in
these trials to allow assessment of safety.
Although no difference was found in the number of infants with
bradycardia following extubation reported by two trials, the num-
bers of infants studied are too small to be confident about this
outcome or other more important adverse short term outcomes
such as hypoxaemia and cerebral haemorrhage or cysts. None of
the included trials reported measures of the important longer term
outcome of neurodevelopmental impairment.
Quality of the evidence
Applicability to present day practice
Two of the four trials were conducted 15 and 23 years ago. Ap-
plicability of the results of the review to current practice may be
compromised due to advancements in neonatal care which have
occurred over the interval since the earlier trials were performed.
Relevant improvements in neonatal care include better techniques
for humidification of inspired gases, introduction of exogenous
surfactant, strategies to reduce trauma during endotracheal suc-
tioning (less frequent suctioning and the use of measured smaller
bore catheters) and the use of prophylactic post-extubation nasal
continuous positive airway pressure (NCPAP). These innovations
may well have changed the nature of post-extubation complica-
tions considerably. For example, the use of prophylactic post-ex-
tubation NCPAP has been shown to reduce the rate of post-extu-
bation complications (Davis 2001). Only one trial (Bagley 2005)
used routine post-extubation NCPAP prophylactically for preterm
infants. Therefore, the results of this review may overestimate the
rates of PEC and reintubation in nurseries where prophylactic
post-extubation NCPAP is now being used.
Potential biases in the review process
Caution is required in interpreting the results of this review and
applying them to current practice. Although the number needed
to treat of 14 to avoid reintubation shown in the overall analysis
of this review suggests that active chest physiotherapy in this situ-
ation may be a worthwhile intervention, this finding was heavily
weighted by the two trials conducted some time ago (Finer 1979;
V- Beresford 1987) and was not supported by the results of the two
more recent trials in this review. No benefit for chest physiother-
apy was shown in one trial (Bagley 2005) in terms of the duration
of mechanical ventilation, NCPAP, oxygen therapy or neonatal
intensive care nursery stay. However, adequate assessment of the
effects of chest physiotherapy on these outcomes is difficult due
to insufficient data and also as the outcomes were measured from
admission to the nursery not from randomisation and institution
of the allocated treatment.
Agreements and disagreements with otherstudies or reviews
Although data in this review are insufficient to permit adequate
assessment of this intervention, the lack of clear benefit for postex-
tubation active chest physiotherapy shown is supported by other
recent reports. A similar rate of PEC and no evidence for benefit of
postextubation physiotherapy in terms of PEC was reported in a
recent before-and-after study assessing active postextubation phys-
iotherapy (Bloomfield 1998). Furthermore, the low risk of pos-
textubation complications (PEC and reintubation) evident in the
more recent trials in this review (Al-Alaiyan 1996; Bagley 2005)
is also supported by a recent retrospective study. Davies 1998 re-
ported a very low risk of PEC with no requirement for reintuba-
tion in these infants. Bagley 2005 reported no use of reintubation
for any infant with PEC (unpublished data).
Care providers need to consider the role of active postextuba-
tion chest physiotherapy in the light of the lack of clear evidence
for benefit, recent reports of severe adverse outcome associated
with active chest physiotherapy in some situations (Ramsay 1995;
Harding 1998) and the need to avoid unnecessary distress in the
care of sick newborn infants from interventions which may not be
beneficial. There are challenges in obtaining robust evidence for
physiotherapy interventions due to the difficulties with blinding
the intervention, and defining and measuring clinically meaning-
ful outcomes (Wallis 1999).
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
The results of this review do not give a clear direction for the
role of active chest physiotherapy for infants being extubated from
mechanical ventilation in today’s neonatal intensive care settings.
Evidence for benefit of this intervention is conflicting and it was
7Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
not possible to identify subgroups of babies who may benefit. No
benefit for more vs. less frequent treatment is evident.
Concerns regarding the safety of active chest physiotherapy for
preterm neonates have been reported. Information on adverse ef-
fects is inadequate in the trials included in this review to allow
assessment of safety. In view of this and the lack of clear evidence
for benefit, it would seem wise to use this intervention cautiously.
Implications for research
Further randomised controlled trials addressing the role of pro-
phylactic active chest physiotherapy for neonates in the postextu-
bation period may be unwarranted.
A C K N O W L E D G E M E N T S
The authors would like to acknowledge Catherine Bagley, Phys-
iotherapy Department, Mater Hospital, Brisbane, Australia; Dr
Saleh Al-Alaiyan, Department of Pediatrics, King Faisal Specialist
Hospital and Research Center, Riyadh, Saudi Arabia and Ann Vi-
vian-Beresford, Children’s Rehabilitation Centre, St John’s, New-
foundland, Canada for providing further information regarding
their trials.
We would also like to acknowledge Katie Welsh for assistance with
literature searching and formatting the review.
R E F E R E N C E S
References to studies included in this review
Al-Alaiyan 1996 {published data only}
Al-Alaiyan S, Dyer D, Khan B. Chest physiotherapy and post-
extubation atelectasis in infants. Pediatric Pulmonology 1996;21:
227–30.
Bagley 2005 {published data only}
Bagley C, Flenady V, Tudehope D, Gray P. The role of
postextubation chest physiotherapy: A randomised controlled trial.
Proceedings of the Perinatal Society of Australia and New Zealand
4th Annual Congress. Brisbane, 1999.
Bagley CE, Gray PH, Tudehope DI, Flenady V, Shearman AD,
Lamont A. Routine neonatal postextubation chest physiotherapy: a
randomized controlled trial. Journal of Paediatrics and Child Health
2005;41(11):592–7.
Finer 1979 {published data only}
Finer N, Moriartey R, Boyd J, Phillips H, Stewart A, Ulan O. Post-
extubation atelectasis: A retrospective review and a prospective
controlled study. Journal of Pediatrics 1979;94:110–3.
V- Beresford 1987 {published data only}
Vivian-Beresford A, King C, Macauley H. Neonatal post-
extubation complications: the preventive role of physiotherapy.
Physiotherapy Canada 1987;39:184–90.
Additional references
Beeby 1998
Beeby PJ, Henderson-Smart DJ, Lacey JL, Rieger I. Short- and
long-term neurological outcomes following neonatal chest
physiotherapy. Journal of Paediatrics and Child Health 1998;34:
60–2.
Bloomfield 1998
Bloomfield FH, Teele RL, Voss M, Knight DB, Harding J. The role
of neonatal chest physiotherapy in preventing postextubation
atelectasis. Journal of Pediatrics 1998;133:269–71.
Bradbury-Hough 1995
Bradbury-Hough JB. Cupping: The effect of this respiratory
physiotherapy technique on the cardiorespiratory function of the neonate
with idiopathic respiratory distress syndrome [Masters of Physiotherapy
thesis]. Australia: University of Queensland, 1995.
Coney 1995
Coney S. Physiotherapy technique banned in Auckland. Lancet
1995; Vol. 345:510.
Crane 1978
Crane LD, Zombek M, Krauss AN, Auld PAM. Comparison of
chest physiotherapy techniques in infants with HMD. Pediatric
Research 1978;12:559.
Cross 1992
Cross JH, Harrison CJ, Preston PR, Rushton DI, Newell SJ,
Morgan MEI, et al.Postnatal encephaloclastic porencephaly - a new
lesion?. Archives of Disease in Childhood 1992;67:307–11.
Curran 1979
Curran LC, Kachoyeanos MK. The effects on neonates of two
methods of chest physical therapy. Mothercraft Nursing 1979;4:
309–13.
Davies 1998
Davies MW, Cartwright DW. Postextubation chest X-rays in
neonates: A routine no longer necessary. Journal of Paediatrcs and
Child Health 1998;34:147–50.
Davis 2001
Davis PG, Henderson-Smart DJ. Prophylactic post-extubation
nasal CPAP in preterm infants. Cochrane Database of Systematic
Reviews 2002, Issue 1. [DOI: 10.1002/14651858.CD000143]
Duara 1983
Duara S, Bessard K, Keszier L, Artes D, Batzer K. Evaluation of
different percussion time intervals of chest physiotherapy on
neonatal pulmonary function parameters [abstract]. Pediatric
Research 1983;17:310A.
Etches 1978
Etches PC, Scott B. Chest physiotherapy in the newborn: Effects
on secretions removed. Pediatrics 1978;62:713–5.
Finer 1978
Finer NN, Boyd DPT. Chest physiotherapy in the neonate: A
controlled study. Pediatrics 1978;61:282–5.
8Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Flenady 1997
Flenady VJ, Bagley C, Tudehope DT. Active chest physiotherapy
practices in neonatal intensive care: A survey of units in Australia
and New Zealand. Proceedings of the Perinatal Society of Australia
and New Zealand Congress. Fremantle, 1997.
Fox 1978
Fox WH, Schwartz JG, Shaffer TH. Pulmonary physiotherapy in
neonates: Physiologic changes and respiratory management.
Journal of Pediatrics 1978;92:977–81.
Halliday 1992
Halliday HL. Other acute lung disorders. In: Sinclair JC, Bracken
MB editor(s). Effective Care of the Newborn Infant. Oxford: Oxford
University Press, 1992:359–384.
Harding 1998
Harding JE, Miles FKI, Becroft DMO, Allen BC, Knight DB.
Chest physiotherapy may be associated with brain damage in
extremely premature babies. Journal of Pediatrics 1998;132:440–4.
Higgins 2008
Higgins JPT, Green S, editors. Cochrane Handbook for Systemic
Reviews of Interventions Version 5.0.0 [updated February 2008].
The Cochrane Collaboration, 2008. Available from
www.cochrane–handbook.org.
Holloway 1969
Holloway R, Adams EB, Desai SD, Thambian AK. Effect of chest
physiotherapy on blood gases of neonates treated by intermittent
positive pressure respiration. Thorax 1969;24:421–6.
Lewis 1992
Lewis JA, Lacey JL, Henderson-Smart DJ. A review of chest
physiotherapy in neonatal intensive care units in Australia. Journal
of Paediatrics and Child Health 1992;28:297–303.
Odita 1993
Odita JC, Kayyali M, Ammari A. Post-extubation atelectasis in
newborn infants. Pediatric Radiology 1993;23:183–5.
Paratz 1994
Paratz JD. The effect of respiratory physiotherapy on intracranial
dynamics in preterm and term infants [Doctor of Philosophy thesis].
Australia: University of Queensland, 1994.
Purohit 1975
Purohit DM, Caldwell C, Levkoff AH. Multiple rib fractures due
to physiotherapy in a neonate with hyaline membrane disease.
American Journal of Disease of Children 1975;129:1103–4.
Ramsay 1995
Ramsay S. The Birmingham experience. Lancet 1995;345:510.
Raval 1987
Raval D, Yeh TF, Mora A, Cuevas D, Pyati S, Pildes RS. Chest
physiotherapy in preterm infants with RDS in the first 24 hours of
life. Journal of Perinatology 1987;7:301–4.
Roper 1976
Roper PC, Vonwiller JB, Fisk GC, Gupta JM. Lobar atelectasis
after nasotracheal intubation in newborn infants. Australian
Paediatric Journal 1976;12:272–5.
Spitzer 1982
Spitzer AR, Fox WW. Post-extubation atelectasis - the role of oral
versus nasal endotracheal tubes. Journal of Pediatrics 1982;100:
806–10.
Tudehope 1980
Tudehope DI, Bagley C. Techniques of physiotherapy in intubated
babies with respiratory distress syndrome. Australian Paediatric
Journal 1980;16:226–8.
Wallis 1999
Wallis C, Prasad A. Who needs chest physiotherapy? Moving from
anecdote to evidence. Archives of Disease in Childhood 1999;80:
393–7.
Wyman 1977
Wyman L, Kuhns L. Lobar opacification of the lung after tracheal
extubation in neonates. Journal of Pediatrics 1977;91:109–12.
References to other published versions of this review
Flenady 1998
Flenady VJ, Gray PH. Chest physiotherapy for preventing
morbidity in babies being extubated from mechanical ventilation.
Cochrane Database of Systematic Reviews 1998, Issue 1. [DOI:
10.1002/14651858.CD000283]
Flenady 2002
Flenady VJ, Gray PH. Chest physiotherapy for preventing
morbidity in babies being extubated from mechanical ventilation.
Cochrane Database of Systematic Reviews 2002, Issue 2. [DOI:
10.1002/14651858.CD000283]∗ Indicates the major publication for the study
9Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Al-Alaiyan 1996
Methods Blinding of randomisation: yes
Blinding of intervention: no
Complete follow-up: yes
Blinding of outcome measure: yes for primary outcome (PEC)
Participants Electively extubated infants who were intubated for more than 24 hours.
Exclusions were atelectasis prior to extubation, meconium aspiration or pneumonia.
Main diagnoses were respiratory distress syndrome (52%) and thoracoabdominal surgery
(30%).
Mean gestational age across the groups was 33 - 35 weeks.
Duration of MV at randomisation:
Physio groups: 11.2 (16.7), and 11.4 (13.8)
Control group: 8.3 (11.2)
Mean (SD) days
Interventions Active chest physio n=41: Postural drainage(lateral decubitus) and bilateral chest wall
vibration (using a neo-cussor) were commenced immediately following extubation and
continued for a 24 hour period. Two active chest physio groups: a 2 hourly and a 4
hourly treatment frequency group.
All treatments were performed by a physiotherapist.
Controls n=23: No active chest physiotherapy.
Outcomes Atelectasis on chest radiography performed at 24 hours post-extubation, the use of
reintubation and nasopharyngeal CPAP up to 24 hours postextubation.
Notes All infants enrolled received active chest physiotherapy for postextubation collapse de-
tected on the chest radiography at 24 hrs postextubation. Additional outcome data were
received from the author for one infant excluded following randomisation.
Risk of bias
Item Authors’ judgement Description
Adequate sequence generation? Unclear Uncertain method of randomisation
Allocation concealment? Yes Blinding of randomisation: yes
Blinding?
All outcomes
No Blinding of intervention: no
Blinding of outcome measure: yes for pri-
mary outcome (PEC)
10Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Al-Alaiyan 1996 (Continued)
Incomplete outcome data addressed?
All outcomes
Yes Complete follow-up: yes
Free of selective reporting? Yes Additional information received from au-
thor
Free of other bias? Unclear Insufficient information
Bagley 2005
Methods Blinding of randomisation: yes
Blinding of intervention: no
Complete follow-up: no
Blinding of outcome measure: yes for primary outcome (PEC)
Participants 177 infants receiving a primary course of MV deemed ready for extubation. Exclusions:
MV <24 hrs, unstable infants, infants with GA <28 weeks in the first week of life. Main
diagnosis was RDS (94%).
97% of extubations were elective.
At randomisation:
Duration of MV (days): physio-7.3 (7.7) Control- 6.5 (8.5)
Postnatal age (days):
Physio: 8.7 (8.6)
Control: 7.2 (7.8)
GA (weeks):
Physio- 30.1 (3.4), Controls- 30.5 (3.69) [mean(SD)]
Interventions Active chest physio n= 88: Percussion with a Laerdal or Bennetts face mask 2nd hourly
for 6 hrs starting 2 hrs post extubation
Majority of physio performed by physiotherapists.
Controls n=89: No active chest physiotherapy Positioning and suctioning program as
for the physio group.
Outcomes Lobar collapse on chest radiography performed at 6 and 24 hrs post- extubation, rein-
tubation and bradycardia within 24 hrs of extubation, total episodes of MV, duration of
MV, oxygen treatment and NICU stay, IVH, intracranial haemorrhage, other cerebral
lesions, hypoxia measured by continuous pulse oximetry (subgroup only).
Notes Routine nursery practice included: oropharyngeal intubation, 4 hourly & prn ETT
suction using 6 gauge catheter,
prophylactic post extubation NCPAP for GA <32 weeks.
Infants remained in the original study group for each subsequent extubation episode.
The outcomes of PEC and reintubation for the initial extubation episode only were
included in the analysis
Additional data to that in the published abstract were included for Bagley 2005 as follows:
durations of mechanical ventilation, oxygen therapy, CPAP, neonatal intensive care and
hospital stay.
Sample size calculation: 430 needed to detect a 50% reduction in PEC from 40% in
11Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Bagley 2005 (Continued)
control group. Trial stopped at interim analysis due to no difference in the rates of PEC.
Risk of bias
Item Authors’ judgement Description
Adequate sequence generation? Unclear Uncertain method of randomisation
Allocation concealment? Yes Blinding of randomisation: yes
Blinding?
All outcomes
No Blinding of intervention: no
Blinding of outcome measure: yes for pri-
mary outcome (PEC)
Incomplete outcome data addressed?
All outcomes
No Complete follow-up: no
Free of selective reporting? Yes
Free of other bias? Yes
Finer 1979
Methods Blinding of randomisation: yes
Blinding of intervention: no
Complete follow-up: yes
Blinding of outcome measure: yes for primary outcome (PEC)
Participants Mechanically ventilated for greater than 24 hours. Exclusion criteria are not mentioned.
The mean gestational age was 35 weeks.
Respiratory Distress Syndrome was the most common diagnosis (60%); other diag-
noses included meconium aspiration, bacterial pneumonia, asphyxia, thoracoabdominal
surgery and apnoea.
Duration of MV at randomisation (mean days):
Physio: 6
Controls: 6
Interventions Active chest physio n=21: Postural drainage and chest wall vibrations commenced one
hour prior to extubation and continued for a period of 48 hours as follows:
Hourly for 8 hours, 2 hourly for a further 16 hrs and 3 hourly until 48 hrs postextubation.
A physiotherapist performed all the treatments for the first 8 hours and nurses for the
remainder.
Controls n=21: Hourly positioning program for upper lobe drainage.
Outcomes Atelectasis on chest radiographs performed at 8 or 24 hours post-extubation.
Notes All infants enrolled received active chest physiotherapy for postextubation collapse de-
tected on the chest radiography at 8 or 24 hrs postextubation.
12Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Finer 1979 (Continued)
Risk of bias
Item Authors’ judgement Description
Adequate sequence generation? Unclear Uncertain method of randomisation
Allocation concealment? Yes Blinding of randomisation: yes
Blinding?
All outcomes
No Blinding of intervention: no
Blinding of outcome measure: yes for pri-
mary outcome (PEC)
Incomplete outcome data addressed?
All outcomes
Yes Complete follow-up: yes
Free of selective reporting? Unclear Insufficient information
Free of other bias? Unclear Insufficient information
V- Beresford 1987
Methods Blinding of randomisation: no
Blinding of intervention: no
Complete follow-up: yes
Blinding of outcome measurement: yes for primary outcome (PEC)
Participants Preterm infants with Respiratory Distress Syndrome undergoing a planned extubation
from a primary course of extubation were eligible. Exclusions were babies with severe
pulmonary oedema, apnoea or bradycardia, tachycardia or other signs of distress. Addi-
tional diagnoses were transient tachypnoea and pneumonia.
Mean gestational age across the groups was 29 - 32 weeks.
Duration of MV at randomisation (days):
Physio groups: 7, 9 and 16.
Control group: 16
Mean (SD) days
Interventions Active chest physio n=24: Chest wall percussion was given in three study groups of differ-
ent frequency: 4 hourly, 2 hourly and 1 hourly. Commencing at one hour pre-extubation
until 24 hrs post-extubation. The treatments were carried out by either physiotherapists
or nurses.
Controls n=8: No active chest physiotherapy. Similar positioning program as for inter-
vention.
Outcomes Atelectasis (detected on chest radiographs at 24 hours post-extubation), pneumonia,
bradycardia, respiratory distress and intolerance of treatment up to 24 hours post-extu-
bation.
13Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
V- Beresford 1987 (Continued)
Notes Sample size calculation required 60 babies in total; 15 in each arm. Sample size not
achieved due to poor recruitment rate.
Risk of bias
Item Authors’ judgement Description
Adequate sequence generation? Unclear Uncertain method of randomisation
Allocation concealment? No Blinding of randomisation: no
Blinding?
All outcomes
No Blinding of intervention: no
Blinding of outcome measurement: yes for
primary outcome (PEC)
Incomplete outcome data addressed?
All outcomes
Yes Complete follow-up: yes
Free of selective reporting? Unclear Insufficient information
Free of other bias? Unclear Insufficient information
14Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
D A T A A N D A N A L Y S E S
Comparison 1. Active chest physiotherapy vs no active chest physiotherapy
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Postextubation lobar collapse 4 315 Risk Ratio (M-H, Fixed, 95% CI) 0.80 [0.49, 1.29]
2 Reintubation within 24hrs 4 315 Risk Ratio (M-H, Fixed, 95% CI) 0.32 [0.13, 0.82]
3 Pneumonia 1 32 Risk Ratio (M-H, Fixed, 95% CI) 1.0 [0.12, 8.31]
4 Bradycardia 2 209 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.66, 1.53]
5 Intraventricular haemorrhage-all
grades
1 177 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.58, 1.78]
6 Intraventricular haemorrhage -
Grades 3 and 4
1 177 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
7 Death prior to discharge 1 177 Risk Ratio (M-H, Fixed, 95% CI) 0.25 [0.03, 2.22]
8 Duration of mechanical
ventilation (days)
1 177 Mean Difference (IV, Fixed, 95% CI) 1.74 [-1.26, 4.74]
9 Duration of nasopharyngeal
CPAP( days)
1 177 Mean Difference (IV, Fixed, 95% CI) 1.83 [-0.54, 4.20]
10 Duration of supplemental
oxygen (days)
1 176 Mean Difference (IV, Fixed, 95% CI) 9.73 [-0.69, 20.15]
11 Duration of neonatal intensive
care stay (days)
1 177 Mean Difference (IV, Fixed, 95% CI) 3.91 [-2.85, 10.67]
Comparison 2. Active chest physiotherapy vs no active physiotherapy - <32 wks gestation
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Postextubation lobar collapse 1 120 Risk Ratio (M-H, Fixed, 95% CI) 1.09 [0.45, 2.63]
2 Reintubation within 24hrs 1 120 Risk Ratio (M-H, Fixed, 95% CI) 0.64 [0.11, 3.72]
3 Bradycardia 1 120 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.63, 1.64]
4 Intraventricular haemorrhage -
all grades
1 120 Risk Ratio (M-H, Fixed, 95% CI) 0.91 [0.52, 1.60]
5 Intraventricular haemorrhage -
Grades 3 and 4
1 120 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
6 Death prior to discharge 1 120 Risk Ratio (M-H, Fixed, 95% CI) 0.24 [0.03, 2.10]
7 Duration of mechanical
ventilation (days)
1 120 Mean Difference (IV, Fixed, 95% CI) 1.5 [-2.59, 5.59]
8 Duration of nasopharyngeal
CPAP( days)
1 120 Mean Difference (IV, Fixed, 95% CI) 2.20 [-0.91, 5.31]
9 Duration of supplemental
oxygen (days)
1 119 Mean Difference (IV, Fixed, 95% CI) 9.84 [-3.91, 23.59]
10 Duration of neonatal intensive
care stay (days)
1 120 Mean Difference (IV, Fixed, 95% CI) 4.79 [-4.02, 13.60]
15Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 3. Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Post extubation lobar collapse 4 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
1.1 1 and 2 hourly active
physiotherapy vs no active
physiotherapy
4 285 Risk Ratio (M-H, Fixed, 95% CI) 0.76 [0.47, 1.24]
1.2 4 hourly active
physiotherapy vs no active
physiotherapy
2 61 Risk Ratio (M-H, Fixed, 95% CI) 1.45 [0.51, 4.09]
2 Reintubation within 24 hours 4 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
2.1 1 and 2 hourly active
physiotherapy vs no active
physiotherapy
4 285 Risk Ratio (M-H, Fixed, 95% CI) 0.24 [0.08, 0.72]
2.2 4 hourly active
physiotherapy vs no active
physiotherapy
2 61 Risk Ratio (M-H, Fixed, 95% CI) 0.80 [0.21, 2.99]
3 Pneumonia 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 1 and 2 hourly active
physiotherapy vs no active
physiotherapy
1 24 Risk Ratio (M-H, Fixed, 95% CI) 2.0 [0.14, 27.99]
3.2 4 hourly active
physiotherapy vs no active
physiotherapy
1 16 Risk Ratio (M-H, Fixed, 95% CI) 2.0 [0.22, 17.89]
4 Bradycardia 2 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
4.1 1 and 2 hourly active
physiotherapy vs no active
physiotherapy
2 201 Risk Ratio (M-H, Fixed, 95% CI) 1.03 [0.67, 1.58]
4.2 4 hourly active
physiotherapy vs no active
physiotherapy
1 16 Risk Ratio (M-H, Fixed, 95% CI) 0.4 [0.11, 1.49]
5 Intraventricular haemorrhage-
all grades
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
5.1 1 and 2 hourly active
physiotherapy vs no active
physiotherapy
1 177 Risk Ratio (M-H, Fixed, 95% CI) 1.01 [0.58, 1.78]
5.2 4 hourly active
physiotherapy vs no active
physiotherapy
0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
6 Intraventricular haemorrhage -
Grades 3 and 4
1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
6.1 1 and 2 hourly active
physiotherapy vs no active
physiotherapy
1 177 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
6.2 4 hourly active
physiotherapy vs no active
physiotherapy
0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
7 Death prior to discharge 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
16Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
7.1 1 and 2 hourly active
physiotherapy vs no active
physiotherapy
1 177 Risk Ratio (M-H, Fixed, 95% CI) 0.25 [0.03, 2.22]
7.2 4 hourly active
physiotherapy vs no active
physiotherapy
0 0 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
8 Duration of mechanical
ventilation (days)
1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
8.1 1 and 2 hourly active
physiotherapy vs no active
physiotherapy
1 177 Mean Difference (IV, Fixed, 95% CI) 1.74 [-1.26, 4.74]
8.2 4 hourly active
physiotherapy vs no active
physiotherapy
0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
9 Duration of nasopharyngeal
CPAP( days)
1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
9.1 1 and 2 hourly active
physiotherapy vs no active
physiotherapy
1 177 Mean Difference (IV, Fixed, 95% CI) 1.83 [-0.54, 4.20]
9.2 4 hourly active
physiotherapy vs no active
physiotherapy
0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
10 Duration of supplemental
oxygen (days)
1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
10.1 1 and 2 hourly active
physiotherapy vs no active
physiotherapy
1 176 Mean Difference (IV, Fixed, 95% CI) 9.54 [0.42, 18.66]
10.2 4 hourly active
physiotherapy vs no active
physiotherapy
0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
11 Duration of neonatal intensive
care stay (days)
1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
11.1 1 and 2 hourly active
physiotherapy vs no active
physiotherapy
1 177 Mean Difference (IV, Fixed, 95% CI) 3.91 [-2.85, 10.67]
11.2 4 hourly active
physiotherapy vs no active
physiotherapy
0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
17Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.1. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 1
Postextubation lobar collapse.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 1 Active chest physiotherapy vs no active chest physiotherapy
Outcome: 1 Postextubation lobar collapse
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Al-Alaiyan 1996 12/41 3/23 11.9 % 2.24 [ 0.71, 7.14 ]
Bagley 2005 15/88 17/89 52.4 % 0.89 [ 0.48, 1.67 ]
Finer 1979 0/21 8/21 26.4 % 0.06 [ 0.00, 0.96 ]
V- Beresford 1987 3/24 2/8 9.3 % 0.50 [ 0.10, 2.48 ]
Total (95% CI) 174 141 100.0 % 0.80 [ 0.49, 1.29 ]
Total events: 30 (Treatment), 30 (Control)
Heterogeneity: Chi2 = 6.87, df = 3 (P = 0.08); I2 =56%
Test for overall effect: Z = 0.93 (P = 0.35)
0.002 0.1 1 10 500
Favours treatment Favours controls
Analysis 1.2. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 2
Reintubation within 24hrs.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 1 Active chest physiotherapy vs no active chest physiotherapy
Outcome: 2 Reintubation within 24hrs
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Al-Alaiyan 1996 3/41 2/23 16.0 % 0.84 [ 0.15, 4.67 ]
Bagley 2005 2/88 3/89 18.6 % 0.67 [ 0.12, 3.94 ]
Finer 1979 0/21 7/21 46.7 % 0.07 [ 0.00, 1.10 ]
V- Beresford 1987 1/24 2/8 18.7 % 0.17 [ 0.02, 1.60 ]
Total (95% CI) 174 141 100.0 % 0.32 [ 0.13, 0.82 ]
Total events: 6 (Treatment), 14 (Control)
Heterogeneity: Chi2 = 3.42, df = 3 (P = 0.33); I2 =12%
Test for overall effect: Z = 2.38 (P = 0.017)
0.005 0.1 1 10 200
Favours treatment Favours controls
18Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.3. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 3
Pneumonia.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 1 Active chest physiotherapy vs no active chest physiotherapy
Outcome: 3 Pneumonia
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
V- Beresford 1987 3/24 1/8 100.0 % 1.00 [ 0.12, 8.31 ]
Total (95% CI) 24 8 100.0 % 1.00 [ 0.12, 8.31 ]
Total events: 3 (Treatment), 1 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P = 1.0)
0.1 0.2 0.5 1 2 5 10
Favours treatment Favours controls
Analysis 1.4. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 4
Bradycardia.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 1 Active chest physiotherapy vs no active chest physiotherapy
Outcome: 4 Bradycardia
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Bagley 2005 26/88 22/89 74.5 % 1.20 [ 0.74, 1.94 ]
V- Beresford 1987 7/24 5/8 25.5 % 0.47 [ 0.20, 1.06 ]
Total (95% CI) 112 97 100.0 % 1.01 [ 0.66, 1.53 ]
Total events: 33 (Treatment), 27 (Control)
Heterogeneity: Chi2 = 3.84, df = 1 (P = 0.05); I2 =74%
Test for overall effect: Z = 0.04 (P = 0.97)
0.1 0.2 0.5 1 2 5 10
Favours treatment Favours controls
19Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.5. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 5
Intraventricular haemorrhage-all grades.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 1 Active chest physiotherapy vs no active chest physiotherapy
Outcome: 5 Intraventricular haemorrhage-all grades
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Bagley 2005 19/88 19/89 100.0 % 1.01 [ 0.58, 1.78 ]
Total (95% CI) 88 89 100.0 % 1.01 [ 0.58, 1.78 ]
Total events: 19 (Treatment), 19 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.04 (P = 0.97)
0.1 0.2 0.5 1 2 5 10
Favours treatment Favours control
Analysis 1.6. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 6
Intraventricular haemorrhage - Grades 3 and 4.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 1 Active chest physiotherapy vs no active chest physiotherapy
Outcome: 6 Intraventricular haemorrhage - Grades 3 and 4
Study or subgroup Treatment Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Bagley 2005 0/88 0/89 0.0 [ 0.0, 0.0 ]
Total (95% CI) 88 89 0.0 [ 0.0, 0.0 ]
Total events: 0 (Treatment), 0 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.1 0.2 0.5 1 2 5 10
Favours treatment Favours control
20Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.7. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 7 Death
prior to discharge.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 1 Active chest physiotherapy vs no active chest physiotherapy
Outcome: 7 Death prior to discharge
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Bagley 2005 1/88 4/89 100.0 % 0.25 [ 0.03, 2.22 ]
Total (95% CI) 88 89 100.0 % 0.25 [ 0.03, 2.22 ]
Total events: 1 (Treatment), 4 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.24 (P = 0.21)
0.02 0.1 1 10 50
Favours treatment Favours control
Analysis 1.8. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 8
Duration of mechanical ventilation (days).
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 1 Active chest physiotherapy vs no active chest physiotherapy
Outcome: 8 Duration of mechanical ventilation (days)
Study or subgroup Treatment Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Bagley 2005 88 9.72 (9.94) 89 7.98 (10.4) 100.0 % 1.74 [ -1.26, 4.74 ]
Total (95% CI) 88 89 100.0 % 1.74 [ -1.26, 4.74 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.14 (P = 0.26)
-10 -5 0 5 10
Favours treatment Favours control
21Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.9. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 9
Duration of nasopharyngeal CPAP( days).
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 1 Active chest physiotherapy vs no active chest physiotherapy
Outcome: 9 Duration of nasopharyngeal CPAP( days)
Study or subgroup Treatment Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Bagley 2005 88 7.09 (8.32) 89 5.26 (7.77) 100.0 % 1.83 [ -0.54, 4.20 ]
Total (95% CI) 88 89 100.0 % 1.83 [ -0.54, 4.20 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.51 (P = 0.13)
-10 -5 0 5 10
Favours treatment Favours control
Analysis 1.10. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 10
Duration of supplemental oxygen (days).
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 1 Active chest physiotherapy vs no active chest physiotherapy
Outcome: 10 Duration of supplemental oxygen (days)
Study or subgroup Treatment Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Bagley 2005 87 35.3 (39.65) 89 25.57 (30.11) 100.0 % 9.73 [ -0.69, 20.15 ]
Total (95% CI) 87 89 100.0 % 9.73 [ -0.69, 20.15 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.83 (P = 0.067)
-20 -10 0 10 20
Favours treatment Favours control
22Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.11. Comparison 1 Active chest physiotherapy vs no active chest physiotherapy, Outcome 11
Duration of neonatal intensive care stay (days).
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 1 Active chest physiotherapy vs no active chest physiotherapy
Outcome: 11 Duration of neonatal intensive care stay (days)
Study or subgroup Treatment Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Bagley 2005 88 25.16 (24.15) 89 21.25 (21.62) 100.0 % 3.91 [ -2.85, 10.67 ]
Total (95% CI) 88 89 100.0 % 3.91 [ -2.85, 10.67 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.13 (P = 0.26)
-20 -10 0 10 20
Favours treatment Favours control
Analysis 2.1. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation,
Outcome 1 Postextubation lobar collapse.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation
Outcome: 1 Postextubation lobar collapse
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Bagley 2005 9/61 8/59 100.0 % 1.09 [ 0.45, 2.63 ]
Total (95% CI) 61 59 100.0 % 1.09 [ 0.45, 2.63 ]
Total events: 9 (Treatment), 8 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.19 (P = 0.85)
0.1 0.2 0.5 1 2 5 10
Favours treatment Favours controls
23Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.2. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation,
Outcome 2 Reintubation within 24hrs.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation
Outcome: 2 Reintubation within 24hrs
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Bagley 2005 2/61 3/59 100.0 % 0.64 [ 0.11, 3.72 ]
Total (95% CI) 61 59 100.0 % 0.64 [ 0.11, 3.72 ]
Total events: 2 (Treatment), 3 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.49 (P = 0.62)
0.1 0.2 0.5 1 2 5 10
Favours treatment Favours controls
Analysis 2.3. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation,
Outcome 3 Bradycardia.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation
Outcome: 3 Bradycardia
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Bagley 2005 22/61 21/59 100.0 % 1.01 [ 0.63, 1.64 ]
Total (95% CI) 61 59 100.0 % 1.01 [ 0.63, 1.64 ]
Total events: 22 (Treatment), 21 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.05 (P = 0.96)
0.1 0.2 0.5 1 2 5 10
Favours treatment Favours controls
24Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.4. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation,
Outcome 4 Intraventricular haemorrhage - all grades.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation
Outcome: 4 Intraventricular haemorrhage - all grades
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Bagley 2005 17/61 18/59 100.0 % 0.91 [ 0.52, 1.60 ]
Total (95% CI) 61 59 100.0 % 0.91 [ 0.52, 1.60 ]
Total events: 17 (Treatment), 18 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.32 (P = 0.75)
0.1 0.2 0.5 1 2 5 10
Favours treatment Favours control
Analysis 2.5. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation,
Outcome 5 Intraventricular haemorrhage - Grades 3 and 4.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation
Outcome: 5 Intraventricular haemorrhage - Grades 3 and 4
Study or subgroup Treatment Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Bagley 2005 0/61 0/59 0.0 [ 0.0, 0.0 ]
Total (95% CI) 61 59 0.0 [ 0.0, 0.0 ]
Total events: 0 (Treatment), 0 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
0.1 0.2 0.5 1 2 5 10
Favours treatment Favours control
25Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.6. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation,
Outcome 6 Death prior to discharge.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation
Outcome: 6 Death prior to discharge
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Bagley 2005 1/61 4/59 100.0 % 0.24 [ 0.03, 2.10 ]
Total (95% CI) 61 59 100.0 % 0.24 [ 0.03, 2.10 ]
Total events: 1 (Treatment), 4 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.29 (P = 0.20)
0.02 0.1 1 10 50
Favours treatment Favours control
Analysis 2.7. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation,
Outcome 7 Duration of mechanical ventilation (days).
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation
Outcome: 7 Duration of mechanical ventilation (days)
Study or subgroup Treatment Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Bagley 2005 61 11.77 (10.61) 59 10.27 (12.16) 100.0 % 1.50 [ -2.59, 5.59 ]
Total (95% CI) 61 59 100.0 % 1.50 [ -2.59, 5.59 ]
Heterogeneity: not applicable
Test for overall effect: Z = 0.72 (P = 0.47)
-10 -5 0 5 10
Favours treatment Favours control
26Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.8. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation,
Outcome 8 Duration of nasopharyngeal CPAP( days).
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation
Outcome: 8 Duration of nasopharyngeal CPAP( days)
Study or subgroup Treatment Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Bagley 2005 61 9.72 (8.72) 59 7.52 (8.66) 100.0 % 2.20 [ -0.91, 5.31 ]
Total (95% CI) 61 59 100.0 % 2.20 [ -0.91, 5.31 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.39 (P = 0.17)
-10 -5 0 5 10
Favours treatment Favours control
Analysis 2.9. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation,
Outcome 9 Duration of supplemental oxygen (days).
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation
Outcome: 9 Duration of supplemental oxygen (days)
Study or subgroup Treatment Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Bagley 2005 60 44.32 (42.7) 59 34.48 (33.36) 100.0 % 9.84 [ -3.91, 23.59 ]
Total (95% CI) 60 59 100.0 % 9.84 [ -3.91, 23.59 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.40 (P = 0.16)
-20 -10 0 10 20
Favours treatment Favours control
27Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.10. Comparison 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation,
Outcome 10 Duration of neonatal intensive care stay (days).
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 2 Active chest physiotherapy vs no active physiotherapy - <32 wks gestation
Outcome: 10 Duration of neonatal intensive care stay (days)
Study or subgroup Treatment Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Bagley 2005 61 32.77 (25.43) 59 27.98 (23.8) 100.0 % 4.79 [ -4.02, 13.60 ]
Total (95% CI) 61 59 100.0 % 4.79 [ -4.02, 13.60 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.07 (P = 0.29)
-10 -5 0 5 10
Favours treatment Favours control
Analysis 3.1. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by
frequency), Outcome 1 Post extubation lobar collapse.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)
Outcome: 1 Post extubation lobar collapse
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 1 and 2 hourly active physiotherapy vs no active physiotherapy
Al-Alaiyan 1996 6/19 3/23 8.8 % 2.42 [ 0.70, 8.41 ]
Bagley 2005 15/88 17/89 54.9 % 0.89 [ 0.48, 1.67 ]
Finer 1979 0/21 8/21 27.6 % 0.06 [ 0.00, 0.96 ]
V- Beresford 1987 2/16 2/8 8.7 % 0.50 [ 0.09, 2.93 ]
Subtotal (95% CI) 144 141 100.0 % 0.76 [ 0.47, 1.24 ]
Total events: 23 (Treatment), 30 (Control)
Heterogeneity: Chi2 = 7.00, df = 3 (P = 0.07); I2 =57%
Test for overall effect: Z = 1.08 (P = 0.28)
2 4 hourly active physiotherapy vs no active physiotherapy
Al-Alaiyan 1996 6/22 3/23 59.5 % 2.09 [ 0.60, 7.35 ]
0.005 0.1 1 10 200
Favours treatment Favours control
(Continued . . . )
28Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(. . . Continued)Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
V- Beresford 1987 1/8 2/8 40.5 % 0.50 [ 0.06, 4.47 ]
Subtotal (95% CI) 30 31 100.0 % 1.45 [ 0.51, 4.09 ]
Total events: 7 (Treatment), 5 (Control)
Heterogeneity: Chi2 = 1.23, df = 1 (P = 0.27); I2 =19%
Test for overall effect: Z = 0.70 (P = 0.49)
0.005 0.1 1 10 200
Favours treatment Favours control
Analysis 3.2. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by
frequency), Outcome 2 Reintubation within 24 hours.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)
Outcome: 2 Reintubation within 24 hours
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 1 and 2 hourly active physiotherapy vs no active physiotherapy
Al-Alaiyan 1996 0/19 2/23 14.7 % 0.24 [ 0.01, 4.71 ]
Bagley 2005 2/88 3/89 19.3 % 0.67 [ 0.12, 3.94 ]
Finer 1979 0/21 7/21 48.6 % 0.07 [ 0.00, 1.10 ]
V- Beresford 1987 1/16 2/8 17.3 % 0.25 [ 0.03, 2.36 ]
Subtotal (95% CI) 144 141 100.0 % 0.24 [ 0.08, 0.72 ]
Total events: 3 (Treatment), 14 (Control)
Heterogeneity: Chi2 = 2.11, df = 3 (P = 0.55); I2 =0.0%
Test for overall effect: Z = 2.56 (P = 0.011)
2 4 hourly active physiotherapy vs no active physiotherapy
Al-Alaiyan 1996 3/22 2/23 43.9 % 1.57 [ 0.29, 8.51 ]
V- Beresford 1987 0/8 2/8 56.1 % 0.20 [ 0.01, 3.61 ]
Subtotal (95% CI) 30 31 100.0 % 0.80 [ 0.21, 2.99 ]
Total events: 3 (Treatment), 4 (Control)
Heterogeneity: Chi2 = 1.49, df = 1 (P = 0.22); I2 =33%
Test for overall effect: Z = 0.33 (P = 0.74)
0.002 0.1 1 10 500
Favours treatment Favours control
29Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.3. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by
frequency), Outcome 3 Pneumonia.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)
Outcome: 3 Pneumonia
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 1 and 2 hourly active physiotherapy vs no active physiotherapy
V- Beresford 1987 1/8 1/16 100.0 % 2.00 [ 0.14, 27.99 ]
Subtotal (95% CI) 8 16 100.0 % 2.00 [ 0.14, 27.99 ]
Total events: 1 (Treatment), 1 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.51 (P = 0.61)
2 4 hourly active physiotherapy vs no active physiotherapy
V- Beresford 1987 2/8 1/8 100.0 % 2.00 [ 0.22, 17.89 ]
Subtotal (95% CI) 8 8 100.0 % 2.00 [ 0.22, 17.89 ]
Total events: 2 (Treatment), 1 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.62 (P = 0.54)
0.02 0.1 1 10 50
Favours treatment Favours control
30Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.4. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by
frequency), Outcome 4 Bradycardia.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)
Outcome: 4 Bradycardia
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 1 and 2 hourly active physiotherapy vs no active physiotherapy
Bagley 2005 26/88 22/89 76.6 % 1.20 [ 0.74, 1.94 ]
V- Beresford 1987 5/16 5/8 23.4 % 0.50 [ 0.20, 1.23 ]
Subtotal (95% CI) 104 97 100.0 % 1.03 [ 0.67, 1.58 ]
Total events: 31 (Treatment), 27 (Control)
Heterogeneity: Chi2 = 2.82, df = 1 (P = 0.09); I2 =65%
Test for overall effect: Z = 0.15 (P = 0.88)
2 4 hourly active physiotherapy vs no active physiotherapy
V- Beresford 1987 2/8 5/8 100.0 % 0.40 [ 0.11, 1.49 ]
Subtotal (95% CI) 8 8 100.0 % 0.40 [ 0.11, 1.49 ]
Total events: 2 (Treatment), 5 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.37 (P = 0.17)
0.1 0.2 0.5 1 2 5 10
Favours treatment Favours control
31Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.5. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by
frequency), Outcome 5 Intraventricular haemorrhage- all grades.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)
Outcome: 5 Intraventricular haemorrhage- all grades
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 1 and 2 hourly active physiotherapy vs no active physiotherapy
Bagley 2005 19/88 19/89 100.0 % 1.01 [ 0.58, 1.78 ]
Subtotal (95% CI) 88 89 100.0 % 1.01 [ 0.58, 1.78 ]
Total events: 19 (Treatment), 19 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.04 (P = 0.97)
2 4 hourly active physiotherapy vs no active physiotherapy
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Treatment), 0 (Control)
Heterogeneity: not applicable
Test for overall effect: not applicable
0.1 0.2 0.5 1 2 5 10
Favours treatment Favours control
32Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.6. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by
frequency), Outcome 6 Intraventricular haemorrhage - Grades 3 and 4.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)
Outcome: 6 Intraventricular haemorrhage - Grades 3 and 4
Study or subgroup Treatment Control Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 1 and 2 hourly active physiotherapy vs no active physiotherapy
Bagley 2005 0/88 0/89 0.0 [ 0.0, 0.0 ]
Subtotal (95% CI) 88 89 0.0 [ 0.0, 0.0 ]
Total events: 0 (Treatment), 0 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P < 0.00001)
2 4 hourly active physiotherapy vs no active physiotherapy
Subtotal (95% CI) 0 0 0.0 [ 0.0, 0.0 ]
Total events: 0 (Treatment), 0 (Control)
Heterogeneity: not applicable
Test for overall effect: not applicable
0.1 0.2 0.5 1 2 5 10
Favours treatment Favours control
33Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.7. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by
frequency), Outcome 7 Death prior to discharge.
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)
Outcome: 7 Death prior to discharge
Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 1 and 2 hourly active physiotherapy vs no active physiotherapy
Bagley 2005 1/88 4/89 100.0 % 0.25 [ 0.03, 2.22 ]
Subtotal (95% CI) 88 89 100.0 % 0.25 [ 0.03, 2.22 ]
Total events: 1 (Treatment), 4 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.24 (P = 0.21)
2 4 hourly active physiotherapy vs no active physiotherapy
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Treatment), 0 (Control)
Heterogeneity: not applicable
Test for overall effect: not applicable
0.02 0.1 1 10 50
Favours treatment Favours control
34Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.8. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by
frequency), Outcome 8 Duration of mechanical ventilation (days).
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)
Outcome: 8 Duration of mechanical ventilation (days)
Study or subgroup Treatment Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 1 and 2 hourly active physiotherapy vs no active physiotherapy
Bagley 2005 88 9.72 (9.94) 89 7.98 (10.4) 100.0 % 1.74 [ -1.26, 4.74 ]
Subtotal (95% CI) 88 89 100.0 % 1.74 [ -1.26, 4.74 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.14 (P = 0.26)
2 4 hourly active physiotherapy vs no active physiotherapy
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
-10 -5 0 5 10
Favours treatment Favours control
Analysis 3.9. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by
frequency), Outcome 9 Duration of nasopharyngeal CPAP( days).
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)
Outcome: 9 Duration of nasopharyngeal CPAP( days)
Study or subgroup Treatment Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 1 and 2 hourly active physiotherapy vs no active physiotherapy
Bagley 2005 88 7.09 (8.32) 89 5.26 (7.77) 100.0 % 1.83 [ -0.54, 4.20 ]
Subtotal (95% CI) 88 89 100.0 % 1.83 [ -0.54, 4.20 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.51 (P = 0.13)
2 4 hourly active physiotherapy vs no active physiotherapy
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
-10 -5 0 5 10
Favours treatment Favours control
35Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.10. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by
frequency), Outcome 10 Duration of supplemental oxygen (days).
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)
Outcome: 10 Duration of supplemental oxygen (days)
Study or subgroup Treatment Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 1 and 2 hourly active physiotherapy vs no active physiotherapy
Bagley 2005 87 39.65 (35.3) 89 30.11 (25.57) 100.0 % 9.54 [ 0.42, 18.66 ]
Subtotal (95% CI) 87 89 100.0 % 9.54 [ 0.42, 18.66 ]
Heterogeneity: not applicable
Test for overall effect: Z = 2.05 (P = 0.040)
2 4 hourly active physiotherapy vs no active physiotherapy
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
-20 -10 0 10 20
Favours treatment Favours control
36Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.11. Comparison 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by
frequency), Outcome 11 Duration of neonatal intensive care stay (days).
Review: Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation
Comparison: 3 Active chest physiotherapy vs no active chest physiotherapy (subgrouped by frequency)
Outcome: 11 Duration of neonatal intensive care stay (days)
Study or subgroup Treatment Control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 1 and 2 hourly active physiotherapy vs no active physiotherapy
Bagley 2005 88 25.16 (24.15) 89 21.25 (21.62) 100.0 % 3.91 [ -2.85, 10.67 ]
Subtotal (95% CI) 88 89 100.0 % 3.91 [ -2.85, 10.67 ]
Heterogeneity: not applicable
Test for overall effect: Z = 1.13 (P = 0.26)
2 4 hourly active physiotherapy vs no active physiotherapy
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Heterogeneity: not applicable
Test for overall effect: not applicable
-20 -10 0 10 20
Favours treatment Favours control
W H A T ’ S N E W
Last assessed as up-to-date: 9 November 2009.
Date Event Description
7 September 2010 Amended Reference to included study Bagley CE updated from Abstract to full publication.
H I S T O R Y
Protocol first published: Issue 1, 1997
Review first published: Issue 1, 1998
Date Event Description
10 November 2009 New search has been performed This review updates the existing review “Chest phys-
iotherapy for preventing morbidity in babies being ex-
tubated from mechanical ventilation” published in the
Cochrane Database of Systematic Reviews (Flenady
37Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)
2002).
Updated search found no new trials.
No changes to conclusions.
13 February 2009 Amended Updated contact details
16 October 2008 Amended Converted to new review format.
28 January 2005 New search has been performed This is an update of the existing review “Chest physio-
therapy for preventing morbidity in babies being extu-
bated from mechanical ventilation” published in The
Cochrane Library, Issue 1, 1998 and updated in Issue
2, 2002 (Flenady 2002).
No new trials were identified in the search updated to
January 2005, and as a result no substantive changes
were made to the review.
31 January 2002 New citation required and conclusions have changed Substantive amendment
C O N T R I B U T I O N S O F A U T H O R S
Vicki Flenady prepared the protocol for the review, initial review and subsequent updates. Peter Gray provided comment.
Vicki Flenady (VF) wrote the original review and updated the review in 2002 and 2006.
The 2009 update was conducted centrally by the Cochrane Neonatal Review Group staff (Yolanda Montagne, Roger Soll, Diane
Haughton) and reviewed and approved by VF.
D E C L A R A T I O N S O F I N T E R E S T
The authors were investigators on the trial Bagley 2005.
S O U R C E S O F S U P P O R T
Internal sources
• JP Kelly Research Foundation, Mater Hospital, Sth Brisbane, Queensland, Australia.
• Mater Mother’s Research Centre - Mater Hospital, Sth Brisbane, Queensland, Australia.
• Department of Neonatology, Mater Mothers’ Hospital, South Brisbane, Queensland, Australia.
38Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
External sources
• Department of Health and Ageing, Commonwealth Government, Canberra, ACT, Australia.
I N D E X T E R M S
Medical Subject Headings (MeSH)
∗Respiration, Artificial; Drainage, Postural; Infant, Newborn; Intubation, Intratracheal; Physical Therapy Modalities [adverse effects];
Respiratory Insufficiency [∗therapy]; Suction; Thorax
MeSH check words
Humans
39Chest physiotherapy for preventing morbidity in babies being extubated from mechanical ventilation (Review)
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.