Heart & Lung: The Journal of Acute and Critical Care

© Mosby-Year Book Inc. 2000. All Rights Reserved.
Volume 29(2)             March/April 2000             pp 125-135
Bronchopulmonary hygiene physical therapy in bronchiectasis and chronic obstructive pulmonary disease: A systematic review
[Issues In Pulmonary Nursing]

Jones, Arthur EdD, RRTa; Rowe, Brian H. MD, MSc, CCFP(EM)b

San Antonio, Texas, and Edmonton, Alberta, Canada
From the aDepartment of Respiratory Care, University of Texas at San Antonio, and the bDivision of Emergency Medicine, University of Alberta, Edmonton.
Reprints not available from author.

Outline


Graphics

Abstract^

OBJECTIVES: This study had two objectives: (1) to examine the effects of bronchopulmonary hygiene physical therapy on patients with chronic obstructive pulmonary disease and bronchiectasis; (2) to determine any differences between manual and mechanical techniques for bronchopulmonary hygiene physical therapy.

DESIGN: The study design was a systematic review of the literature that used an exhaustive search for trials and review methods prescribed by the Cochrane Collaboration.

INCLUSION CRITERIA: Randomized controlled trials examined patient groups, interventions, and dependent variables.

PATIENTS: Patients included those with chronic obstructive pulmonary diseases (emphysema or chronic bronchitis) or bronchiectasis.

INTERVENTIONS: Any of the following interventions or combinations thereof were included: manual interventions, such as postural drainage, chest percussion, vibration, chest shaking, directed coughing, or forced exhalation technique.

CONTROLS: Controls of the study were as follows: no intervention; placebo; coughing; and mechanical interventions, such as mechanical vibration.

RESULTS: The search identified 99 potential trials; inclusion or exclusion analysis left 7, which examined a total of 126 patients. Mean score on trial quality was 1.4 (5 = greatest). Three separate trials (N = 51) found statistically significant effects for bronchopulmonary hygiene physical therapy on sputum production and radioaerosol clearance. No trials (N = 126) found statistically significant effects on pulmonary function variables or differences between manual and mechanical techniques.

CONCLUSIONS: Considering the small sizes, low quality, and mixed results from the trials, the research on bronchopulmonary hygiene physical therapy is inconclusive. There is a need for adequately sized, high-quality, randomized controlled trials with uniform patient populations to examine the effects of bronchopulmonary hygiene physical therapy.


Chest physical therapy (CPT) is an assortment of manual and mechanical interventions intended to improve patients' pulmonary condition. A subset of chest physical therapeutics that intends to mobilize secretions from patients' lungs is referred to here as bronchopulmonary hygiene physical therapy (BHPT). The purpose of this distinction is to separate these interventions from CPT interventions that have clinical goals other than secretion mobilization Specific maneuvers included within the realm of BHPT include chest percussion, postural drainage, chest wall vibration, chest wall shaking, directed coughing, and forced exhalation technique. Typically, nurses and therapists administer BHPT as a regimen, consisting of multiple techniques. Commonly, chest percussion and postural drainage have been combined into a regimen, sometimes including other techniques. The selection of techniques to include in a regimen varies among institutions as well as among practitioners.

Despite controversies in the literature regarding its efficacy,1-6 BHPT continues in a variety of clinical settings. In our experience, there are instances in which BHPT is administered routinely to patients on the basis of diagnosis, rather than specific clinical criteria. BHPT is labor intensive, therefore, expensive. Furthermore, it poses some risks to patients, such as decreased arterial oxygen tension 7 and forced expiratory volume in 1 second (FEV1).8 A 1994 delphi study 9 concluded that clarifying BHPT outcomes should be a high research priority.

To date, there have been numerous nonsystematic reviews on BHPT.1-6 However, there has been only 1 systematic review on the topic, the meta-analysis by Thomas et al 10 that examined the effects of BHPT on cystic fibrosis. Therefore, similar reviews for other patient populations, like this one, are warranted.

OBJECTIVES^
The aim of this review was to examine the effects of BHPT on patients with chronic obstructive pulmonary disease (COPD) and bronchiectasis, respectively. Specifically, the study addressed the following questions:

• For patients with stable COPD, compared with control treatments, what are the effects of BHPT on physiologic outcomes, such as vital capacity (VC), FEV1, peak expiratory flow rate (PEFR), blood gases, pulmonary radioaerosol clearance, and sputum production?

• For patients with acute exacerbations of COPD, compared with control treatments, what are the effects of BHPT on physiologic outcomes, such as VC, FEV1, PEFR, blood gases, pulmonary radioaerosol clearance, and sputum production?

• For patients with bronchiectasis, compared with control treatments, what are the effects of BHPT on physiologic outcomes, such as VC, FEV1, PEFR, blood gases, pulmonary radioaerosol clearance, and sputum production?

METHODS^
Trial identification^
To identify relevant randomized controlled trials (RCTs), we used the following terms to search the Cochrane Airways Review Group Database: postural drainage OR physical therapy OR percussion OR physiotherapy. This is a database developed by, and for, the group that includes literature citations on asthma, bronchiectasis, bronchiolitis, COPD, sleep apnea, and wheezing. It is a composite of the MEDLINE database from 1966 to 1999, EMBASE from 1980 to 1999, and CINAHL (Cumulative Index of Nursing and Allied Health Literature) from 1982 to 1999.

Until 1990, the term randomized controlled trial was not listed as a publication type in MEDLINE. Therefore, computerized searches for RCTs would not detect those conducted before that year. Recognizing this, the Cochrane Collaboration undertook a massive effort, involving thousands of people, to search, page by page, through medical journals to identify RCTs for reclassification as RCTs by the National Library of Medicine. Members of the Cochrane Airways Review Group completed the task of hand searching 20 major respiratory journals. Those trials identified by hand searchers as RCTs were tagged as such in both databases so they could be located by subsequent searchers.

In addition to the computer search, we examined the reference lists of all retrieved articles for additional trials. First authors of included trials were contacted to verify their data and whether their trial was, indeed, randomized. Also, those authors were mailed a list of the included trials, with a request for information on RCTs on BHPT that were not listed.

One reviewer screened the original collection of abstracts and reference lists of trials and previous reviews to identify potential trials for this review. Any article whose title suggested that it was a potential trial or literature review was retrieved; that is, the full-text article was obtained for additional analysis. The search intended to locate all potential trials; therefore, only articles whose titles obviously excluded them were not retrieved. Examples of terms found in titles that constituted nonretrieval are pediatrics, case studies, exclusionary diagnostic groups, and interventions that did not include BHPT.

After the potential trials were retrieved, both reviewers applied the inclusion and exclusion criteria to those trials, which had been masked as to source and authorship. The purpose of masking is to prevent reviewer bias in the selection process. Masking was done by a clerical person who "whited out" the aforementioned information on the articles under consideration. The inclusion criteria were as follows:

Trial type: RCT

Patients: COPD, chronic bronchitis, or bronchiectasis

Interventions: Postural drainage; or postural drainage and percussion; or postural drainage, percussion, vibration, and shaking.

Outcomes: Physiologic measures-forced vital capacity and components thereof, respiratory rate, arterial oxygen tension or saturation, sputum production, and dysrhythmias.

General outcome measures: mortality rate change; and morbidity variables, such as resolution of chest radiograph, infection, length of hospital stay, and dyspnea.

Controls: Autogenic drainage; forced exhalation technique; positive expiratory pressure (PEP); chest oscillation; automatic rotating bed; deep breathing and coughing; therapeutic bronchoscopy; and no intervention.

Exclusion criteria included the following:

* Studies limited to patients with cystic fibrosis
* Studies that include patients with bronchogenic carcinoma or congestive heart failure
* Pulmonary diagnosis unspecified or unsupported by pulmonary mechanics or imaging
* Nonspecification of intervention duration or frequency
Trial quality assessment^
Two reviewers assessed the methodologic quality of the RCTs using the Cochrane Collaboration scale for describing allocation concealment and a modified version of the 5-point scoring instrument proposed by Jadad et al.11 Table I shows both of these scales. The modification to the original scale of Jadad et al 11 includes the addition of 2 items that ask whether the methods for randomizing and blinding were described and appropriate. This is a modification commonly adopted by Cochrane reviewers. A weighted kappa (Kw) measured agreement between evaluators. This statistic, otherwise known as Cohen's Kappa, measures interobserver agreement, adjusted for chance.12


Table I Allocation concealment and quality assessment Scales
We established consensus on quality score by discussion. No trial was excluded on the basis of quality score. If the pooled data showed significant heterogeneity, we planned to use quality scores in a sensitivity analysis to determine whether trial quality influenced intervention effects. Moher et al 13 found a statistically significant and clinically important relationship between trial quality and intervention effects. Therefore we intended to control for trial quality as a potential spurious variable.

Data from the trials were extracted by one reviewer, recorded on the review data extraction form, which was a spreadsheet, then verified by the other reviewer. Table II lists the variables that were included in the extraction form.


Table II Variables extracted from trials
DATA ANALYSIS^
Cochrane Review Manager (Revman), Windows version 3.01, MetaView, and Lotus 1-2-3 Release 4 were used to compile and analyze the data. Revman and MetaView are software programs developed by, and for, Cochrane Collaborators to provide organization and analysis in systematic reviews. Where trials examined both early and late pulmonary function variables, those measured latest were used for this review because we consider the lasting effects more clinically relevant. All of the dependent variables were continuous; therefore, we used weighted mean differences with 95% confidence intervals for effects of individual studies. For each trial identified as a crossover, we used only the arm comparing BHPT with placebo or no intervention for our analysis. Three of the trials examined radioaerosol clearance from different portions of the lung. We used only radioaerosol clearance from the total lung as the more clinically relevant measure. Signs of effects were adjusted to reflect whether they represented clinical improvement or deterioration on the graphic representation of quantitative results (Fig 1).


Fig 1 Results of individual trials. FET, Forced exhalation technique; MV, mechanical vibration; NI, no intervention; P, percussion; PEP, positive expiratory pressure; PD, postural drainage; WMD, weighted mean difference. The blocks represent the weighted mean differences for each variable. Where the blocks overlap the midline, the effect magnitude is statistically nonsignificant. Common practice is for beneficial, or favorable, effects to appear on the left side of the midline, or "no effect" line.
The dependent variables from the trials were grouped into 3 specific categories for analysis. These were as follows:

* Pulmonary function: FEV1, PEFR, and FVC
* Oxygenation: PaO2
* Pulmonary clearance: sputum production and radioaerosol clearance
RESULTS^
Trial retrieval^
The search through the Cochrane Airways Review Group Database located 95 potential trials and reviews. We located 4 additional potential trials on reference lists of retrieved trials. On the basis of the abstracts, we retrieved 47 trials to consider for inclusion. Forty of these did not meet the inclusionary criteria (Appendix 1), which left 7 RCTs for the review. Table III includes a complete list of included trials and an overview of the trial characteristics.


Table III Characteristics of included trials

Table III No caption available.
Three authors of the included trials responded to the request to confirm their data. The low response rate was not surprising, considering that the oldest included trial was published in 1978, and the oldest trial considered for inclusion was published in 1964. The queries resulted in no additional trials for inclusion.

Trial quality^
Using Cochrane's system for categorizing trials with regard to allocation concealment, the Kw was 1.0. By use of the system of Jadad et al 11 for trial quality, our Kw was 0.31 and 0.26, respectively. Although the agreement was low, it is noteworthy that disagreements on trial quality were resolved through e-mail dialogue. Because of this procedure for gaining consensus, there is controversy among reviewers as to whether agreement should be measured at all.

The mean score of the trials on the scale of Jadad et al 11 was 1.4. Only 1 trial, that of Newton and Stephenson,14 described the methods for randomization and blinding. It was also the only trial that scored 3 out of a possible 5 on the quality scale.

Qualitative description of results^
Commonly, the intent of a systematic review is to aggregate, or pool, the quantitative results from separate trials to generate a pooled effect magnitude. This aggregation of results is called meta-analysis. Certain conditions must be met by the trials for this aggregation to proceed with validity. First, the trials must address the same question, which includes interventions and subject groups. Furthermore, the trials must use similar dependent variables. When these conditions are not met, the trial results are not aggregable, which leaves qualitative analysis as the only option for the reviewers.

Within the 7 trials included in this review, there were 6 separate comparisons of interventions. Those comparisons used different dependent variables. The results of only 2 trials, those of Bateman et al 15 and Sutton et al,16 could be statistically aggregated because the remaining trials that addressed similar interventions used disparate patient groups or dependent variables. For example, there were 4 crossover trials having arms that compared BHPT with no intervention. However, the 2 trials that used pulmonary function variables used patients with stable 17 and acute COPD,14 respectively, making them statistically nonaggregable.

The other 2 trials comparing BHPT with no intervention used patients with bronchiectasis and examined pulmonary clearance variables, such as sputum production and radioaerosol clearance. These latter 2 trials, those of Bateman et al 15 and Sutton et al,16 were the only trials that were statistically combinable.

Only 1 study, that of Newton and Stephenson,14 examined the effects of BHPT on acute exacerbations of COPD. They found no statistically significant effects for BHPT on pulmonary function outcomes. Similarly, May and Munt 17 found no effects for BHPT on the pulmonary function of patients with stable COPD, although they found positive effects on sputum production. Neither study found statistically significant effects for BHPT on PaO2.

The trials by both Bateman et al 15 and Sutton et al 16 tested the effects of percussion, postural drainage, and forced exhalation technique, respectively, on patients with bronchiectasis. The sample of Sutton et al (N = 10) was contaminated by the inclusion of 1 patient with asthma and 4 patients with cystic fibrosis. Both of these trials found that BHPT improved pulmonary clearance, as measured by sputum production and radioaerosol clearance. Sutton et al reported, in text, that there were no statistically significant changes in PEFR following treatments but provided no quantitative results.

Oldenburg et al 18 conducted a crossover trial that examined the effects of postural drainage, exercise, and cough on pulmonary clearance, as measured by radioaerosol clearance. These study patients had chronic bronchitis.18 The researchers found that postural drainage, alone, did not improve pulmonary clearance, compared with no intervention.18 Furthermore, results illustrated that coughing, alone, was more effective in pulmonary clearance than postural drainage.18

Two trials addressed the issue of mechanical versus manual techniques. First, Mohsenifar et al,19 after comparing manual percussion and postural drainage with mechanical vibration, found no statistically significant differences between these techniques with respect to effects on pulmonary function variables or PaO2. Second, Olseni et al 20-who compared postural drainage and forced exhalation technique with PEP and forced exhalation technique-concluded that postural drainage and forced exhalation technique increased radioaerosol clearance more effectively than PEP and forced exhalation technique. However, our analysis of the data Olseni et al 20 indicated the confidence intervals of those effects to include the zero value.

No trials compared mechanical percussion with manual percussion. Furthermore, none of the trials examined clinical outcomes related to mortality or morbidity. One trial 19 reported a single incident of nausea and vomiting associated with BHPT. This was the only report of an adverse outcome.

Quantitative description of results^
Fig 1 plots the weighted mean differences for the comparisons and variables examined by the trials.

DISCUSSION^
The reader is cautioned that the results of these trials were found on the basis of a total of 126 patients. The state of the research on BHPT is characterized by the following attributes:

* Small samples (N = 6-35)
* Samples that are contaminated by mixing diagnostic groups that may affect trial findings
* Research methods or reporting that reflect uniformly low ratings on the quality scale of Jadad et al 11
* Measuring treatment effects based on one treatment only
* Lack of investigation into effects on variables related to mortality and morbidity.
As shown in Table III, the included trials were small, with a minimum and maximum of 6 and 35 subjects, respectively. Although this finding suggests that the trials may have been statistically underpowered, 2 of the small trials found statistically significant effects (Bateman 15 and Sutton 16). This result could be explained by the fact that those trials that found statistically significant effects used patients with bronchiectasis, which might confer greater effects for BHPT. In addition, this finding could have been magnified in the study of Sutton et al,16 which was contaminated by the inclusion of patients with cystic fibrosis.

Alternatively, the positive effects could be a result of the inverse relationship between trial quality and significant effects, as described by Moher et al.13 Regardless of the explanation, the reader is cautioned that the positive effects found in these trials applied to 51 subjects. Whether this is a sufficient number of subjects on which to base a practice is left to the discretion of the reader.

Trial quality is another important issue to address among the trials. The results here reported a mean trial quality of 1.4 out of a possible 5 on the scale of Jadad et al.11 Although the problem may lie in inadequate reporting rather than in trial methods, reviewers have only the published reports on which to base evaluation of quality. In general, the researchers did not report their methods for randomization or blinding. The low-quality scores raise additional questions about the validity of the trial results.

Related to trial quality is the fact that the results of each of the trials were found on the basis of 1 treatment session. One could reasonably question whether 1 session per subject is adequate to achieve measurable benefits. This has been contrary to clinical practice, which raises another question about the trials, that is, ecological validity. Did the conduct of the trials reflect clinical practice?

CONCLUSIONS^
Implications for practice^
The beneficial effects of BHPT, sputum production and radioaerosol clearance, were related to pulmonary clearance. However, the effect of these on lung function was not clear. In fact, none of the studies found statistically significant effects on pulmonary function measurements or arterial oxygen tension. In view of the lack of physiologic improvement and the low quality and small sample sizes of the trials, the research on BHPT is inconclusive. There is insufficient evidence to support or refute administration of BHPT to these patient groups.

Implications for further research^
There is an apparent need to conduct adequately sized, high-quality RCTs that examine the effects of BHPT. These RCTs should include power analysis to include adequate sample size to prevent a type II statistical error. Furthermore, such studies should test the effects of a course of BHPT, rather than a single treatment. Finally, the RCTs should use samples of patients with uniform pulmonary conditions.

We thank the following personnel for their effort: Dr Steve Milan, Anna Bara, and Dr Paul Jones of the Cochrane Airways Review Group for their logistical and editorial assistance; Dr Jay Peters for his service as an external reviewer; and the 3 anonymous reviewers for Heart & Lung.

Appendix 1^
Excluded trials (reasons for exclusion)

1. Agoston B, Biro Z, Hajos K, Kirchknopf M, Vadasz G. Cave therapy for respiratory diseases. Orvosi Hetilap 1968;109:640-2. [Medline Link] Intervention did not meet inclusion criteria.

2. Ambrosino N, Paggiaro P, Macchi M, Fillieri M, Toma G, Aghini Lombardi F, et al. A study of short-term effect of rehabilitative therapy in chronic obstructive pulmonary disease. Respiration 1981;41:40-4. [Medline Link] Intervention did not meet inclusion criteria.

3. Anthonisen P, Riis P. The value of lung physiotherapy in the treatment of acute exacerbations of chronic bronchitis. Acta Med Scand 1964;175:715-9. Not an RCT.

4. Belcastro M, Backes C, Chila A. Bronchiolitis: a pilot study of osteopathic manipulative treatment, bronchodilators, and other therapy. J Am Osteopath Assoc 1984;83:672-6. [Medline Link] Not an RCT.

5. Boksha V, Sokolov S, Grabil'tseva T, Sveshnikova E, Shatrov A. The physiotherapy of patients with chronic bronchitis. Vopr Kurortol Fizioter Lech Fiz Kult 1989;3:31-6. [Medline Link] Intervention did not meet inclusion criteria.

6. Boye N, Ottersen I, Refsum H. Fysioterapi ved kronisk obstruktiv lungeskydom med og uten masketrening. Tidsskr Nor Laegeforen 1994;22:2606-8. Intervention did not meet inclusion criteria.

7. Castillo R, Haas A. Chest physical therapy: comparative efficacy of preoperative and postoperative in the elderly. Arch Phys Med Rehab 1985;66:376-9. [Medline Link] [CINAHL Link] Inappropriate patient population.

8. Cegla U, Retzow A. Physical therapy with VRP1 in chronic obstructive respiratory tract diseases-results of a multicenter comparative study. Pneumologie 1993;11:636-9. [Medline Link] Intervention did not meet inclusion criteria.

9. Cegla U. Symptomatic therapy in lung emphysema. Atemwegs und Lungenkrankheiten 1994;20:199-203. Intervention did not meet inclusion criteria.

10. Christensen E, Nedergaard T, Dahl R. Long-term treatment of chronic bronchitis with pulmonary physiotherapy with and without positive expiratory pressure. Ugeskr Laeger 1991;153:113-6. [Medline Link] Intervention did not meet inclusion criteria.

11. Christensen H, Simonsen K, Lange P, Clementsen J, Viskum K, Heideby J, Koch U. PEEP masks in patients with severe obstructive pulmonary disease: a negative report. Eur Respir J 1990;3:267-72. [Medline Link] Intervention did not meet inclusion criteria.

12. Clark N, Feldman C, Evans D, Levison M, Wasilewski Y, Mellins R. The impact of health education on frequency and cost of health care use by low income children with asthma. J Allergy Clin Immunol 1986;78:108-15. [Medline Link] Intervention did not meet inclusion criteria.

13. Conway J, Fleming J, Perring S, Holgate S. Humidification as an adjunct to chest physiotherapy in aiding tracheobronchial clearance in patients with bronchiectasis. Respir Med 1992;86(2):109-14. [Medline Link] Intervention did not meet inclusion criteria.

14. Craven J, Evans G, Davenport P, Williams R. The evaluation of the incentive spirometer in the management of postoperative pulmonary complications. Br J Surg 1974;61:793-7. [Medline Link] Intervention did not meet inclusion criteria.

15. Edenbrandt L, Olseni L, Svenonius E, Jonson B. Effect of physiotherapy in asthmatic children-a one-year follow up after physical training once a week. Acta Paediatr Scand 1990;79:973-5. [Medline Link] Intervention did not meet inclusion criteria.

16. Feldman J, Traver G, Taussig L. Maximal expiratory flows after postural drainage. Am Rev Respir Dis 1979;119:239-45. [Medline Link] Not an RCT.

17. Foglio C, Vitacca M, Quadri A, Scalvini S, Marangoni S, Ambrosino N. Acute exacerbations in severe COLD patients: treatment using positive pressure ventilation by nasal mask. Chest 1992;101:1533-8. [Medline Link] [CINAHL Link] Not an RCT.

18. Gallon A. Evaluation of chest percussion in the treatment of patients with copious sputum production [see comments]. Respir Med 1991;85(1):45-51. [Medline Link] No nonintervention or mechanical arm.

19. Hasani A, Pavia D, Agnew J, Clarke S. Regional lung clearance during cough and forced expiration technique (FET): effects of flow and viscoelasticity. Thorax 1994;49:557-61. [Medline Link] Intervention did not meet inclusion criteria.

20. Hansen L, Warwick W. High-frequency chest compression system to aid in clearance of mucus from the lung. Biomed Instrum Technol 1990;24:289-94. [Medline Link] Not an RCT.

21. Lorin M, Denning C. Evaluation of postural drainage by measurement of sputum volume and consistency. Am J Phys Med 1971;50:215-9. [Medline Link] Inappropriate patient population.

22. Kraszko P, Jonas J, Szoboszlay F. Results of cave climate therapy in the obstructive respiratory syndrome. Orvosi Hetlap 1973;114:4-7. Intervention did not meet inclusion criteria.

23. Luttmann H, Gromping U, Kreienbrock L, Treiber-Klotzer C, Wolf-Ostermann K, Wichmann H. Cohort study of respiratory tract diseases and lung function in school children in southwest Germany. 2. Regional influences on respiratory tract diseases in Mannheim and the Freiburg area. Zentralbl Hyg Umweltmed 1994;196:114-38. [Medline Link] Not an RCT.

24. Marcq M, Minette A. Cardiorespiratory function in young bronchitis patients, mostly mineworkers, before and after kinesitherapy and exertion training. Comparison with a control group (Preliminary results). Revue Institut Hyg Mines (Hasselt) 1981;36:5-31. Intervention did not meet inclusion criteria.

25. Mazzoco M, Owens G, Kiriloff L, Rogers R. Chest percussion and postural drainage in patients with bronchiectasis. Chest 1985;88:360-3. [Medline Link] Not an RCT.

26. Newton D, Bevans H. Physiotherapy and intermittent positive-pressure ventilation of chronic bronchitis. Br Med J 1978;2:1525-8. [Medline Link] Intervention did not meet inclusion criteria.

27. Nichols P, Howell B. Routine pre- and post-operative physiotherapy. Results of a trial. Rheumatol Phys Med 1970;10:321-36. [Medline Link] Inappropriate patient population.

28. Nichols P, Howell B. Routine pre- and post-operative physiotherapy. A preliminary trial. Physiother 1970;56:356-9. Inappropriate patient population.

29. Pavia D, Thomson M, Phillipakos D. A preliminary study of the effect of a vibrating pad on bronchial clearance. Am Rev Respir Dis 1976;113:92-5. [Medline Link] Intervention unspecified.

30. Petersen E, Esmann V, Honcke P, Munkner C. A controlled study of the effect of treatment on chronic bronchitis. An evaluation using pulmonary function tests. Acta Med Scand 1967;182:293-305. [Medline Link] Intervention unspecified.

31. Pryor J, Webber B, Hodson M, Batten J. Evaluation of the forced expiration technique as an adjunct to postural drainage in treatment of cystic fibrosis. Br Med J 1979;18:417-8. Inappropriate patient population.

32. Rivington-Law B, Epstein S, Thompson G, Corey P. Effect of chest wall vibrations on pulmonary function in chronic bronchitis. Chest 1984;85:378-81. [Medline Link] [CINAHL Link] Not an RCT.

33. Sutton P, Lopez-Vidriero M, Pavia D, Newman S, Clay M, Webber B, et al. Assessment of percussion, vibratory shaking, and breathing exercises in chest physical therapy. Eur J Respir Dis 1985;66:147-52. [Medline Link] No nonintervention or mechanical arm.

34. Toevs C, Kaplan R, Atkins C. The costs and effects of behavioral programs in chronic obstructive pulmonary disease. Med Care 1984;22:1088-1100. [Medline Link] Intervention did not meet inclusion criteria.

35. Tonnesen P, Kelstrup M. Self-administered positive end-expiratory pressure (PEEP) using a face mask as an alternative to conventional lung. Ugeskr Laeger 1982;144(21):1532-6. [Medline Link] Intervention did not meet inclusion criteria.

36. Van Hengstum M, Festen J, Beurskens C, Hankel M, Beekman F, Corstens F. Effect of positive expiratory pressure mask physiotherapy (PEP) versus forced expiration technique (FET/PD) on regional lung clearance in chronic bronchitis. Eur Respir J 1991;4:651-4. [Medline Link] Intervention did not meet inclusion criteria.

37. Van Hengstum M, Festen J, Beurskens C, Hankel M, van den Broek W, Buijs W, Corstens F. The effect of positive expiratory pressure versus forced expiration technique on tracheobronchial clearance in chronic bronchitics. Scand J Gastroenterol 1988;143 Suppl:114-8. Intervention did not meet inclusion criteria.

38. Van der Schans C, Piers D, Beekhuis H, Koeter G, van der Mark W, Postma D. Effect of forced expirations on mucus clearance in patients with chronic airflow obstruction: effect of lung recoil pressure. Thorax 1990;45:623-7. [Medline Link] Intervention did not meet inclusion criteria.

39. Van der Schans C, Piers D, Postma D. Effect of manual percussion on tracheobronchial clearance in patients with chronic airflow obstruction and excessive tracheobronchial secretion. Thorax 1986;41(6):448-52. [Medline Link] Not an RCT.

40. Wollmer P, Ursing K, Midgren B, Eriksson L. Inefficiency of chest percussion in the physical therapy of chronic bronchitis. Eur J Respir Dis 1985;66(4):233-9. [Medline Link] No nonintervention or mechanical arm. [Context Link]

REFERENCES^
1. Orlandi O, Perino B, Testi R. Old and new in chest physiotherapy. Eur Respir J 1989;7 Suppl:595-8. [Context Link]

2. Eid N, Bucheit J, Neuling M, Phelps H. Chest physiotherapy in review. Respir Care 1991;36:270-82. [CINAHL Link] [Context Link]

3. Pavia D. The role of chest physiotherapy in mucus hypersecretion. Lung 1990;168 Suppl:614-21. [Context Link]

4. Hardy KA. A review of airway clearance: new techniques, indications and recommendations. Respir Care 1994;39:440-52. [CINAHL Link] [Context Link]

5. Clarke SW. Rationale for airway clearance. Eur Respir J 1989;7 Suppl:599s-603s. [Context Link]

6. Clarke SW. Management of mucus hypersecretion. Eur J Resp Dis 1987;153 Suppl:136-44. [Context Link]

7. Connors A, Hammon W, Martin R. Rogers RM. Chest physical therapy: the immediate effect on oxygenation in acutely ill patients. Chest 1980;78:559-64. [Medline Link] [Context Link]

8. Campbell AH, Oconnell JM. The effect of chest physiotherapy upon FEV. Med J Aust 1975;1(2):33-5. [Medline Link] [Context Link]

9. Cullen DL. Delineating clinical effective research priorities for the respiratory care profession. AARC Times 1994;18:16-20. [CINAHL Link] [Context Link]

10. Thomas J, Cook DJ, Brooks D. Chest physical therapy management of patients with cystic fibrosis: a meta-analysis. Am J Respir Crit Care Med 1995;151:846-50. [Medline Link] [Context Link]

11. Jadad A, Moore RA, Carroll D, Jenkinson C, Reynolds JM, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17:1-12. [Medline Link] [Context Link]

12. Frick T. Semmel MI. Observer agreement and reliabilities of classroom observational measures. Rev Edu Res 1978;48:157-84. [Context Link]

13. Moher D, Pham B, Jones A, Cook DJ, Jadad AR, Moher M, et al. Does quality of reports of randomized trials affect estimates of intervention efficacy reported in meta-analyses? Lancet 1998;352:609-13. [Fulltext Link] [Medline Link] [CINAHL Link] [Current Contents Link] [Context Link]

14. Newton D, Stephenson A. Effect of physiotherapy on pulmonary function. Lancet 1978;29:228-9. [Medline Link] [Context Link]

15. Bateman J, Newman S, Daunt K, Sheahan N, Pavia D, Clarke S. Is cough as effective as chest physiotherapy in the removal of excessive tracheobronchial secretions? Thorax 1981;36:683-7. [Medline Link] [Context Link]

16. Sutton P, Parker R, Webber B, Newman S, Garland N, Lopez-Vidriero M, et al. Assessment of the forced expiration technique, postural drainage, and directed coughing in chest physiotherapy. Eur J Respir Dis 1983;64:62-8. [Medline Link] [Context Link]

17. May B, Munt P. Physiologic effects of chest percussion and postural drainage in patients with stable chronic bronchitis. Chest 1979;75:29-32. [Medline Link] [Context Link]

18. Oldenburg F, Dolovich M, Montgomery J, Newhouse M. Effects of postural drainage, exercise and cough on mucous clearance in chronic bronchitis. Am Rev Respir Dis 1979;120:739-45. [Medline Link] [Context Link]

19. Mohsenifar Z, Rosenburg N, Goldberg H, Koerner S. Mechanical vibration and conventional chest physiotherapy in outpatients with stable chronic obstructive lung disease. Chest 1985;87:483-5. [Medline Link] [CINAHL Link] [Context Link]

20. Olseni L, Midgren B, Hornblad Y, Wollmer P. Chest physiotherapy in chronic obstructive pulmonary disease: forced expiratory technique combined with either postural drainage or positive expiratory pressure breathing. Respir Med 1994;88:435-40. [Medline Link] [Context Link]


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