Thread by @WellingtonICU

Chest physiotherapy is a mainstay in routine care and management of ventilated patients with particular roles in respiratory weaning from mechanical ventilation and clearing of secretions.

This includes deep breathing exercises, gravity-assisted drainage, chest wall percussion or vibrations, bagging (manual hyperinflation), suctioning, rib springing, intra-pulmonary percussive ventilation, aerosol therapy (to name a few)

This meta-analysis aims to address the potential role of chest physio in preventing VAP in mechanically ventilated patients.

Search terms: chest physiotherapy; manual hyperinflation; chest vibrations; respiratory physiotherapy; AND pneumonia.

Statistical analysis expressed as relative risk or weighted mean differences with 95% confidence intervals. Heterogeneity tested using the I-squared statistic (moderate to high for included studies). Publication bias not assessed (low number of studies).

Six RCTs were included in the analysis. Trial sizes from n=46 to 173. Total patients n=704.

Varied definitions for VAP: Clinical pulmonary infection scores vs. positive non-bronchoscopic alveolar lavage vs. new radiographic infiltrate with 2-3 of pyrexia, raised WCC, purulent sputum with bacteria on gram stain, positive culture

Primary outcome: incidence of VAP (6 trials reported)
Secondary outcomes: ICU (3 trials) and hospital (5 trials) mortality, length of ICU stay (6 trials), duration of MV (5 trials)

Main findings were that chest physiotherapy did not result in a statistically significant reduction in the incidence of VAP, nor did it significantly reduce hospital mortality, ICU mortality or length of stay, or duration of MV.

Limitations: Small number of studies included, with moderate heterogeneity (though most of this came from single trial with quite different interventions & patient population; Zeng et al ncbi.nlm.nih.gov/pubmed/28524027, seemed to suggest benefits of multimodal chest physiotherapy)

No trials reported complications or adverse effects – possible micro-aspirations, haemodynamic disturbances and increased oxygen consumption suggested. Do these outweigh the benefits in some patients?

Side note from @dogICUma
- The number of patients studied in trials is small & 95% CIs encompass effects that are both clinically important & biologically plausible
- It is interesting to see that that such entrenched clinical practice is supported by such a poor evidence base

@threadreaderapp unroll please