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Physiotherapy xxx (2015) xxx–xxx

Systematic review

What is the role of the physiotherapist in paediatric intensive

care units? A systematic review of the evidence for
respiratory and rehabilitation interventions for mechanically
ventilated patients
Ellie Hawkins, Anne Jones ∗
Discipline of Physiotherapy, School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University,
Townsville, Australia

Abstract
Background Physiotherapy in intensive care units (ICU) has traditionally focussed on the respiratory management of mechanically ventilated
patients. Gradually, focus has shifted to include rehabilitation in adult ICUs, though evidence of a similar shift in the paediatric ICU (PICU)
is limited.
Objectives Review the evidence to determine the role of physiotherapists in the management of mechanically ventilated patients in PICU.
Data sources A search was conducted of: PEDro, CINAHL, Medline, PubMed and the Cochrane Library.
Eligibility criteria Studies involving PICU patients who received physiotherapy while invasively ventilated were included in this review.
Those involving neonatal or adult ICU patients, or patients on non-invasive or long-term ventilation, were not included in the study.
Study appraisal All articles were critically appraised by two reviewers and results were analysed descriptively.
Results Six studies on chest physiotherapy (CPT) met the selection criteria. Results support the use of the expiratory flow increase technique
and CPT, especially manual hyperinflation and vibrations, for secretion clearance. Evidence does not support the routine use of either CPT or
suction alone. No studies investigating rehabilitation in PICU met selection criteria.
Limitations A lack of high level evidence was available to inform this review.
Conclusion Evidence indicates that CPT is still the focus of physiotherapy intervention in PICU for mechanically ventilated patients, and
supports its use for secretion clearance in this setting.
PROSPERO register for systematic reviews (registration no. CRD42014009582).
Crown Copyright © 2015 Published by Elsevier Ltd on behalf of The Chartered Society of Physiotherapy. All rights reserved.

Keywords: Intensive care; Pediatrics; Physical therapy specialty; Physical therapists; Ventilators; Mechanical

Introduction patients to secondary complications such as respiratory infec-

Paediatric intensive care unit (PICU) admissions are usu-
ally due to acute medical illness, accidents, or life-threatening
surgical conditions [1]; a high percentage of these patients
require mechanical ventilation for more than 24 hours [2,3].
Resultant airway clearance compromise predisposes these
∗ therapy (CPT) is usually the main focus of treatment for
Corresponding author. Tel.: +61 747816280; fax: +61 747816868.
E-mail addresses: ellie.hawkins@my.jcu.edu.au (E. Hawkins),
anne.jones@jcu.edu.au (A. Jones).
tions and acute lobar atelectasis [4,5]. Evidence in adult
populations also demonstrates that the long periods of immo-
bility associated with mechanical ventilation often result in
muscle atrophy and weakness [6]. As respiratory and func-
tion specialists, physiotherapists are an important part of the
multi-disciplinary team in most intensive care units (ICU)
in Australia and throughout the world [7,8]. Chest physio-
physiotherapists in ICU, and forms part of the standard
care for both adult and paediatric mechanically ventilated

http://dx.doi.org/10.1016/j.physio.2015.04.001
0031-9406/Crown Copyright © 2015 Published by Elsevier Ltd on behalf of The Chartered Society of Physiotherapy. All rights reserved.

Please cite this article in press as: Hawkins E, Jones A. What is the role of the physiotherapist in paediatric intensive care units? A
systematic review of the evidence for respiratory and rehabilitation interventions for mechanically ventilated patients. Physiotherapy
(2015), http://dx.doi.org/10.1016/j.physio.2015.04.001
PHYST-823; No. of Pages 7
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2 E. Hawkins, A. Jones / Physiotherapy xxx (2015) xxx–xxx
patients [9,10]. The aims of CPT surround the removal of
excess secretions, and in PICU usually involves positioning,
percussions, vibrations, saline instillation, oropharyngeal or
endotracheal suction, and manual hyperinflation [4,9,11].
However, overall the evidence base for physiotherapy in pae-
diatric acute care is limited [12].
In recent years improvements in neonatal medicine has
resulted in an increasing number of very premature infants
surviving the neonatal period [3,13]. With this population at
greater risk of morbidities, such as reduced lung function
and developmental delay, the prevalence of chronic co-
morbidities among PICU and neonatal ICU (NICU) patients
has increased [14–16]. As a result, focus has shifted to include
rehabilitation as part of standard physiotherapy intervention
in NICU’s, as well as in adult intensive care units, for mechan-
ically ventilated patients [9]. Documented benefits of early
rehabilitation in adult ICU’s include improved quality of life
and function, and reduced length of stay [17,18]. In NICUs,
initial evidence shows that infants receiving developmental
care had significantly improved functional outcomes, com-
pared to those infants who did not receive such care [19]. In
contrast, a large gap exists in this area among the mechani-
cally ventilated PICU population. The aim of this study was
to determine the role of physiotherapists in the management
of mechanically ventilated patients in the paediatric intensive
care unit, with regards to both rehabilitation and respiratory
management.
Method
Protocol and registration
A systematic review was conducted using a PRISMA
approach in order to determine the research objective [20].
The review was registered on the PROSPERO register for
systematic reviews (registration no. CRD42014009582).
Search strategy
Five databases were selected through James Cook Uni-
versity (JCU) to be used for searches: PEDro, CINAHL,
MEDLINE, PubMed, and the Cochrane Library. A prelimi-
nary search of Google Scholar, JCU’s One Search, and the
five databases was conducted to determine the depth of the
evidence base and inform the selection of search terms. The
final search was conducted using keywords and MeSH terms,
with or without truncation, as appropriate for the database.
The search terms used can be seen in Appendix A. Articles
yielded from the search were screened by title and abstract;
those which met the selection criteria were obtained in full
text and further screened for eligibility. Studies which met
all inclusion and exclusion criteria following full text review
were included in the study. Reference lists of full text arti-
cles were also screened to ensure a comprehensive search of
potential evidence.
Please cite this article in press as: Hawkins E, Jones A. What is the role of the physiotherapist in paediatric intensive care units? A
systematic review of the evidence for respiratory and rehabilitation interventions for mechanically ventilated patients. Physiotherapy
(2015), http://dx.doi.org/10.1016/j.physio.2015.04.001
Inclusion and exclusion criteria
Studies were included in the review if the sample included
invasively ventilated patients who were admitted to PICU,
and receiving some form of physiotherapy intervention from
a physiotherapist. Both qualitative and quantitative articles
were included provided they were available in full text
English. Article types which were excluded include: let-
ters to the editor, editorials, comments, presentations, studies
on animals or artificial models, and systematic or literature
reviews. Studies were also excluded if the sample included
adults (older than 18 years), patients admitted to an adult or
neonatal ICU, patients on non-invasive ventilation or being
discharged from ICU on mechanical ventilation, and those
not receiving intervention from a physiotherapist. No restric-
tions were applied to the year published or methodological
quality based on a critical appraisal tool score.
Data collection and analysis
Due to the variation in study protocols and data collected
between studies, and so the lack of comparable quantitative
data, outcomes were collected in a descriptive manner. Study
specific terms regarding study characteristics and significant
findings were used to answer the research question. These
were collected in accordance with the research aims: demo-
graphics of the population, treatments performed and their
protocols, adverse events, and the evidence behind inter-
ventions (see Table 1). Results were presented in tables to
allow comparison of protocols and results, and highlight any
similarities.
Risk of bias
To minimise the risk of selection bias, the eligibility of the
studies for inclusion was agreed upon by two assessors based
on the defined inclusion and exclusion criteria. The Crowe
Critical Appraisal Tool (CCAT) was used to determine the
methodological quality of all studies, including risk of bias
within studies [21]; this was also completed independently
Table 1
Descriptive data using objective outcomes from individual studies.
PICO Descriptive data/objective measures used
Population Number of participants, age (months and years), and
demographics primary and associated conditions
Treatments Treatments performed e.g. manual hyperinflation,
and protocols suction, vibrations, postural drainage etc. Treatment
duration, number of techniques, passes of suction,
cycles of treatment etc.
Evidence Significant effects on oxygenation, dead space, tidal
behind volumes, peak expiratory flows/peak expiratory flow
treatments ratios, airway compliance, airway resistance, forces
applied during manual techniques e.g. suction produced
significant reductions in airway compliance.
Adverse Haemodynamic stability (heart rate, blood pressure),
events oxygenation (SpO2 )
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by the two assessors. Discrepancies in scores were discussed,
and a third assessor consulted if required. For the purpose of
quality appraisal, a high score on the CCAT was considered to
be >80% (that is, at least four out of five in all categories). The
level of evidence was also used to further determine the rigour
of the studies reviewed and used when drawing conclusions
[22]. To limit the risk of bias associated with access to articles,
all potentially relevant articles were paid for where access
through James Cook University was not available. However,
to ensure studies were adequately critically appraised, those
not available in full text English were excluded.
Results
Study selection
The search conducted on the 27th April 2014 initially
yielded 539 results. Following removal of those which did not
meet selection criteria, a resultant six studies were included
in the review (see Fig. S1).
Study characteristics
All studies focussed on CPT, and a summary of study char-
acteristics and findings can be seen in Table 2. The addition of
manual techniques to a baseline intervention of suction, saline
instillation, and pre-oxygenation usually distinguished CPT
from control and intervention groups. However, Main et al.
[5] and Main and Stocks [11] included manual hyperinflation
(MHI) in both control and intervention groups. Furthermore,
Morrow et al. [23] investigated the effects of suction alone,
without manual techniques, in a single sample group. Set pro-
tocols were used in two studies [23,24]; in the remaining four,
the intervention group received treatment based on clinical
assessment of the patient.
With the exception of Almeida et al. [24], all studies had a
similar mix of patients: primary respiratory, secondary respi-
ratory (including neurological and other medical conditions),
and non-surgical and surgical cardiac conditions (see Table 2)
Four studies reported on adverse events: two reported no
adverse events [24,25], while the other two reported adverse
events surrounding oxygenation and haemodynamic stability
[5,23]. Main et al. [5] also reported an undefined respiratory
deterioration in one third of patients receiving both CPT and
suction.
Effects of manual techniques
Increases in peak expiratory flows following MHI, and the
creation of an expiratory flow bias with the addition of vibra-
tions, were demonstrated by Gregson et al. [4,25]. Patients
receiving CPT were also more likely to show improve-
ments in pulmonary compliance and resistance, and tidal
volume [5]. Almeida et al. [24] found statistically significant
improvements in respiratory rate and oxygenation measures
Please cite this article in press as: Hawkins E, Jones A. What is the role of the physiotherapist in paediatric intensive care units? A
systematic review of the evidence for respiratory and rehabilitation interventions for mechanically ventilated patients. Physiotherapy
(2015), http://dx.doi.org/10.1016/j.physio.2015.04.001
3
following the expiratory flow increase technique (EFIT)
and suction. An increase in dead space, accompanied by
improvements in tidal volume and unchanged carbon dioxide
elimination levels, was also demonstrated post-CPT [11].
Effects of suction
A reduction in pulmonary compliance post-suction was
found in two studies [5,23]. This was accompanied by a
reduction in tidal volume following suction alone [23]. In
the second study, the suction intervention also included MHI
[5]. Contrastingly, improvements in pulmonary compliance,
airway resistance, and tidal volume were found post-suction
in a select group whom had increased oxygenation index and
reduced pulmonary compliance at baseline [23].
Methodological quality and risk of bias
The studies reviewed were not of a high level of evi-
dence, but were high quality (see Table 2) Most studies
involved single intervention groups, however two randomised
crossover studies by the same author group were included
[5,11]. Though individual studies did not comment on risk
of bias, all scored at least four for “design” on the CCAT
which includes assessment of risk of bias within the study.
No discrepancies in critical appraisal scoring were evident
between the two assessors, nor in the selection of studies to
be included in the review. Only one potentially relevant arti-
cle could not be obtained in full text English and so was not
included, potentially affecting the results.
Rehabilitation in paediatric intensive care unit
No studies specific to the population were found that
investigated rehabilitation and also met inclusion and exclu-
sion criteria. Two studies investigating rehabilitation were
excluded because they included other professions and non-
invasively ventilated patients [26,27].
Discussion
The objective of this study was to review the evidence
to determine the role of physiotherapists in the manage-
ment of mechanically ventilated PICU patients. A search of
five databases revealed six studies which met all inclusion
and exclusion criteria, all of which were focussed on CPT
interventions. Overall, findings support the use of CPT for
secretion clearance and improving oxygenation. No studies
included in the review reported on rehabilitation interven-
tions.
Effects on expiratory flow and tidal volume
Gregson et al. [4,25] demonstrated increased peak expira-
tory flows with the addition of MHI compared to mechanical
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4 E. Hawkins, A. Jones / Physiotherapy xxx (2015) xxx–xxx

Table 2
Characteristics and findings of those studies included in the review.
Study Design CCAT Scorea Sample Intervention Statistically significant Adverse events
NHMRC (N, age, conditions) outcomes
levelb
Gregson et al. Observational: 93% N = 105 MHI, vibrations, saline, MHI increases PEF & Not reported
[4] single group, pre- LIII-2 7 days to 15.9 years ETT suction; protocol tidal volumes;
& post-test Mixc determined by vibrations cause further
assessment increases and create an
expiratory flow bias
Gregson et al. 93% N = 55 No adverse
[25] LIII-2 7 days to 13.7 years events
Mixc
Morrow et al. 90% N = 78 1 pass of ETT suction Overall reduction in Self-limiting O2
[23] LIII-2 0.3 to 25 months with pre-oxygenation compliance and tidal desaturations
Mixc volume and episodes of
bradycardia
Almeida et al. 98% N = 22 40 EFITs, ETT suction Statistically significant No adverse
[24] LIII-2 1 to 11 months improvements in events
Obstructive acute oxygenation
respiratory failure
Main and Randomised 93% N = 75 “Suction” (MHI, Significant increases in Not reported
Stocks [11] crossover (quasi- LIII-1 3 days to 16 years suction, saline, dead space post-CPT
experimental) Mix pre-oxygenation)
“CPT” (“suction”,
vibrations, percussions,
compressions, or
postural drainage)
Protocol determined by
assessment
Main et al. [5] 95% N = 83 Significant reduction in O2 desaturations
LIII-1 3 days to 16 years airway resistance and low blood
Mix post-CPT; reduction in pressure;
airway compliance respiratory
post-suction deterioration
MHI, manual hyperinflation; ETT, endotracheal tube; PEF, peak expiratory flows; EFIT, expiratory flow increase technique; CPT, chest physiotherapy; O2 ,
oxygen.
a Crowe Critical Appraisal Tool Score [21]. A score of 80% or more was considered to indicate high methodological quality.
b Based on NHMRC’s hierarchy of evidence [22].
c Mix of patients included: primary respiratory, secondary respiratory (including neurological and other medical conditions), and non-surgical and surgical

cardiac conditions.

ventilation alone. Though the peak expiratory flows gen-
erated during a cough far exceed those generated during
MHI, it was the expiratory flow bias, created by the fur-
ther addition of vibrations, which was considered important
[4,28]. As evidenced by an increase in peak expiratory
flow to peak inspiratory flow ratio, this bias is thought to
facilitate secretion clearance by contributing to the central
movement of secretions, allowing for removal by suc-
tion or cough [4]. The accompanying increase in tidal
volumes may also suggest secretion removal, where pre-
viously secretion filled/atelectatic airways are re-ventilated
following CPT [4]. There is an apparent lack of con-
crete evidence to confirm these hypotheses, for example
measurement of the volume of secretions removed. How-
ever, this too has potential confounders to measurement,
where secretions may be swallowed or mixed with saline
[11,29].
Effects on pulmonary compliance and airway resistance
Increased pulmonary compliance and airway resistance
are often related to the presence of secretions; improve-
ments in these parameters post-CPT therefore support its
use for secretion removal [30]. Main et al. [5] conducted a
randomised crossover study, in which the control group (“suc-
tion”) received a combination of pre-oxygenation, saline,
MHI, and endotracheal suction. In the CPT group, whom
received additional manual techniques, a significant drop
in airway resistance was demonstrated [5]. Furthermore,
patients whom received CPT were twice as likely to show
improvements in airway resistance, pulmonary compliance,
and tidal volume, compared to those post-suction [5]. In 96%
of cases, vibrations were the additional manual technique
of choice [5]. Findings are therefore comparable to those
of the study previously mentioned investigating MHI and

Please cite this article in press as: Hawkins E, Jones A. What is the role of the physiotherapist in paediatric intensive care units? A
systematic review of the evidence for respiratory and rehabilitation interventions for mechanically ventilated patients. Physiotherapy
(2015), http://dx.doi.org/10.1016/j.physio.2015.04.001
PHYST-823; No. of Pages 7
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E. Hawkins, A. Jones / Physiotherapy xxx (2015) xxx–xxx
vibrations, and further support the use of CPT for secretion
clearance [4,25].
Effects on regional ventilation distribution
Main and Stocks [11] found a transient ventilation-
perfusion mismatch post-CPT, manifested in the results
as an increase in physiological and alveolar dead space.
However no concurrent compromise in CO2 elimination
occurred, as evident by unchanged “gold standard” measures
of partial pressure of arterial CO2 (PaCO2 ) and CO2 elim-
ination (VCO2 ) [11]. The authors therefore conclude that
the increase in dead space was likely due to an alteration
in ventilation distribution. Accompanying improvements in
pulmonary compliance and resistance potentially indicate
secretion removal: a possible cause for this ventilation re-
distribution [5,12]. Concurrent increases in tidal volume and
a reduction in end tidal CO2 , also indicate recruitment of pre-
viously atelectatic airways, further supporting this hypothesis
[11]. That is, if increases in ventilation were not matched
by increased pulmonary perfusion, it may have presented as
dead space. With some patients only reaching statistical sig-
nificance for changes in respiratory parameters at 30 minutes,
it is possible that this last follow-up time was inadequate to
determine the final effects of the interventions [11].
Patient selection for chest physiotherapy
In most studies, the benefits of CPT for secretion clear-
ance were not experienced by the majority, raising the issue
of appropriate patient selection. The primary indicator for
CPT should be evidence of secretion retention. Main et al.
[5] and Main and Stocks [11] selected their sample based
upon clinical assessment; however, further details of this
selection were not provided, and a third of patients experi-
enced respiratory deterioration. Almeida et al. [24] conducted
a study on a small sample of 22 infants with obstructive
acute respiratory failure (acute bronchiolitis) where clinical
signs indicated secretion retention. Following treatment of
40 EFITs and suction, statistically significant improvements
in oxygenation were found [24]. These findings were con-
firmed in a French study on a similar population, though
the study was excluded as it was not accessible in full text
English [31]. Contrarily, past studies have found no benefit
of CPT for non-ventilated patients with acute bronchiolitis
[30,32]. However, more severe cases often show signs of lung
consolidation on chest X-ray, thus potential for secretions
retention–an indication for CPT [30].
Effects of suction
Though suction is often performed routinely by nursing
staff, only studies where suction was performed by a
physiotherapist were included in the review. Suction was
included in all intervention groups, however only Morrow
et al. [23] investigated the effects of one pass of suction
Please cite this article in press as: Hawkins E, Jones A. What is the role of the physiotherapist in paediatric intensive care units? A
systematic review of the evidence for respiratory and rehabilitation interventions for mechanically ventilated patients. Physiotherapy
(2015), http://dx.doi.org/10.1016/j.physio.2015.04.001
5
alone. A reduction in pulmonary compliance and tidal
volumes was found post-suction [5,23]. In both studies,
patients with endotracheal tube leaks greater than 20%
were excluded, airway pressure and chest wall compliance
remained unchanged, patients had low to normal baseline
compliance, and no signs of air trapping [5,23]. This reduc-
tion in compliance was therefore considered to be indicative
of a loss of lung volume, and so the authors conclude
that suction alone should not be used routinely [23,33].
Contrastingly, Main et al. [5] supports the use of routine
suction over routine CPT. However, their suction group
included MHI which would compensate for the unintended
volume loss associated with suction alone [5,23]. Therefore,
like CPT, signs of secretion retention are required for safe
and effective suction intervention. This is supported by the
improvements in pulmonary compliance, airway resistance,
and tidal volumes found in the portion of patients (31.5%)
whom had signs of secretion retention at baseline [23].
Safety of chest physiotherapy
Following treatments of EFIT with suction and CPT, no
adverse events were recorded [24,25]. However, in two stud-
ies adverse events did occur in a small percentage of patients
[5,23]. Three self-limiting desaturations below 85% and one
episode of bradycardia was recorded post-suction in a sam-
ple of 78 [23]. Self-limiting was defined within the study
as fraction of inspired oxygen returning to pre-suction lev-
els within one minute [23]. Main et al. [5] also reported
short-lived oxygen desaturations and hypotensive episodes;
this was greater in the suction group (13%) compared to the
CPT group (7%), though the significance of this difference
was not commented upon. However, one third of patients in
both groups experienced an undefined respiratory deteriora-
tion; though not explicitly defined, the authors’ conclude that
this probably relates to metabolic changes including reduced
bicarbonate [5]. Overall, the adverse events experienced by
patients following CPT and suction alone do not raise signif-
icant concerns regarding the use of these interventions in the
studied population.
Methodological quality
Though the studies reviewed are not of high level evi-
dence, they are of a relatively high quality: the lowest CCAT
score was 90% (see Table 2). All studies used the CO2SMO
Plus! to record respiratory data, and two used the Novel Pli-
ance mat to record forces during manual techniques; both had
been validated prior to use in the studies [11,25]. Potential for
more rigour in study design was evident where control groups
in the two randomised crossover studies included MHI. The
patients therefore received more than minimal intervention
and, ethically, a randomised controlled trial may have been
permitted [5,11]. The literature presents evidence that sample
size is at the expense of homogeneity. No studies included
sample size calculations; however Almeida et al. [24], whom
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6 E. Hawkins, A. Jones / Physiotherapy xxx (2015) xxx–xxx
had a relatively homogenous population of patients with
acute bronchiolitis, had an apparently small sample of just
22 patients. Conversely, Gregson et al. [4] had a sample of
105 patients, but a range of ages and conditions (see Table 2).
Furthermore, there were large variations in the number of
physiotherapists delivering treatments, with 19 therapists in
one study [4]. This has implications for conclusions drawn
from the results, due to the differences in force application
between therapists [25], and more significantly because clin-
ical reasoning and experience potentially comes into play.
Limitations
Access to articles was only limited on one occasion: a
study that was inaccessible in full text English [31]. The
nature of the study however, limits control over treatment
protocols and data collection. Comparability between stud-
ies was therefore limited, due to a large variation in study
characteristics. This reduces the strength and validity of the
conclusions drawn in this review. Furthermore, the inclusion
and exclusion criteria of individual studies means that most
findings are only transferrable to a sedated, muscle-relaxed
population. Based on patient populations in individual stud-
ies, the age range of the PICU population is large, with most
including patients whom are technically considered neonates
[30]. Only one study excluded patients under one month old
[24]. In seems that in reality, neonates with respiratory condi-
tions or requiring surgery following discharge from hospital
at birth are often admitted to PICU [1]. This has implications
for research, especially with regards to rehabilitation, where
the focus for neonates surrounds growth and development
– a physiotherapy specialty in itself. Overall, the relatively
low levels of evidence available to inform this study thereby
reduce the strength of this review. There is also limited insight
into the effects of CPT based on monitoring of clinically
practical assessments such as auscultation or chest X-ray
changes.
Future research
With regards to CPT, future research should be direct
towards investigating the best practice for patient selection,
to ensure effective treatment and reduction of adverse events.
Furthermore, at present, the heterogeneity of study proto-
cols and data collection means that several studies’ findings
are undisputed. Confirmation of the findings of the stud-
ies reviewed, investigation into the long term benefits of
CPT, and comparisons of CPT to distinctively different con-
trols, is required. In terms of rehabilitation, evidence among
the mechanically ventilated PICU patients is limited. Two
studies, a retrospective chart review and survey, investigat-
ing rehabilitation in PICU were excluded from the review
[26,27]. Further research regarding the effects and safety
of specific rehabilitation interventions is required to inform
Please cite this article in press as: Hawkins E, Jones A. What is the role of the physiotherapist in paediatric intensive care units? A
systematic review of the evidence for respiratory and rehabilitation interventions for mechanically ventilated patients. Physiotherapy
(2015), http://dx.doi.org/10.1016/j.physio.2015.04.001
guidelines which may assist physiotherapists in providing
rehabilitation interventions to this population.
Conclusion
The role of physiotherapists in mechanically ventilated
patients in PICU still primarily surrounds CPT. Evidence
supports the use of CPT as a safe and effective treatment
for secretion clearance, and usually involves MHI, vibra-
tions, and suction. In PICU, physiotherapists are required
to treat patients with a variety of conditions, and of a range
of ages including those younger than one month old. This
research therefore has implications for physiotherapy among
full term neonates in NICU. Evidence in the area of rehabil-
itation among the mechanically ventilated PICU population
is still lacking and requires further research.
Conflict of interest
None declared.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/
j.physio.2015.04.001.
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