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Chest physiotherapy for acute wheezing: an

inappropriate protocol in a misdiagnosed group
of patients

Article in Acta paediatrica · April 2014

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Jordi Vilaro Rodrigo Torres-Castro

Universitat Ramon Llull University of Chile
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Title
Chest physiotherapy for acute wheezing episodes: is the appropriate treatment?

Running head
Acute bronchiolitis is not only acute wheezing episodes

Authors

Vilaro, J1. Torres-Castro, R2. Postiaux, G3.

1
Health Sciences Faculty Blanquerna, Physiohterapy Research Group (GReFis), Ramon Llull University.
2 3
Barcelona, Spain; School of physiotherapy, Medicine Faculty. University of Chile. Santiago, Chile; Groupe

d’Etude pluridisciplinaire stéthacoustique, Grand Hôpital de Charleroi, Service des Soins Intensifs Site Notre-

Dame et Laboratoire de stéthacoustique appliquée. Charleroi, Belgium.

Abstract

Bronchiolitis is one of the most common respiratory infections in children. The lack of

specific treatment promotes the search new interventions that might improve patients

respiratory and general conditions. Chest physiotherapy could be one of these

interventions. Unfortunately, until now, most of the published studies have committed

two major errors: 1) try to treat diseases misdiagnosed that often cannot be treated by

physiotherapy, for example acute episodes of wheezing, such as the study of Castro-

Rodriguez or 2) use techniques or protocols that do not affect the problem to be

addressed. For example, to use mucus drainage techniques to treat an inflammatory

and/or bronchoespastic process. This letter aims to highlight these errors produced by the

study of Castro-Rodriguez and correctly pointed out specific points which should be

considered for future studies that want to validate chest physiotherapy in bronchiolitis
To the editor:

Recently, in your journal, Dr. Castro-Rodriguez published the article entitled “Chest

physiotherapy is not clinically indicated for infants receiving outpatient care for acute

wheezing episodes”( doi: 10.1111/apa.12578) (1). The authors evaluated the effectiveness

of slow and long expiratory flow and assisted cough techniques in 48 infants. 25 followed

CPT and 23 received only salbutamol MDI.

First of all, there is a poor description of the disease. Acute wheezing episodes are signs

that could involve a wide range of respiratory diseases, such as asthma or atopy, some of

which are not likely to be treated with physical maneuvers (2). Furthermore, wheezing is a

symptom not a clinical diagnosis. The lack of this information could lead to a

misinterpretation of the results, by introducing an important bias which implies wrong

conclusions. Therefore, the title and the conclusion should be redefined in order to be

adjusted with the real respiratory disease diagnosis thus avoiding wrongful clinical actions.

On the other hand, Castro-Rodriguez assumes that chest physiotherapy is not indicated

for these patients. In the study they evaluate three techniques (slow and long expiratory

flow, and assisted cough) that are not well defined in the paper, and not in accordance

with the literature (the genuine appellation of slow expirations is PSEt: prolonged slow

expiration technique), which are all used to increase mucus transportation and

expectoration. Wheezing symptoms are related to bronchial edema and bronchospasm.

Evidence shows that they must be treated by corticoids and bronchodilators previously to

any other treatment by using an adequate delivery system, mostly in children. In this case,

they used salbutamol administered by MDI with a valve spacer. Probably, this is not the

best recommended treatment and delivery system according to the American guidelines

(3). Furthermore, if the intention was to treat an acute episode of acute bronchiolitis

which produces a bronchial obstruction due to multifactorial features, the unique study

which has shown positive effects used a protocol combining PSEt preceded by hypertonic

saline nebulization (4). The procedure is to first reduce edema to facilitate the clearance

of secretions in excess. Moreover, frequently the wheezing infants are only secreting on

the second or third day after the initial symptom. Thus in this study, on the first day, the

aim of physiotherapy is missed. Chest physiotherapy has a wide range of techniques to

treat different respiratory problems and only few of them, could have impact on wheezes

(5). This is not the case of the techniques applied in the present study that are specifically

used for mucus drainage. Moreover, authors did not provide any information about the

evolution of mucus secretion before and after the intervention.

Methodologically, they initially calculated a sample of 32 subjects for each group (power

0.8, alpha level 0.05). At the end of the study they recruited only 23 and 25 per group. The

authors assume this as a limitation, but considering that there is not a significant

difference between the groups (p values do not appear on table 2), and showing a clear

tendency in favor of CPT (Initial score CPT 7.1 (6.7-7.6) without CPT 7.2 (6.7-7.7) and final

score CPT 2.8 (2.2-3.3) without CPT 3.4 (2.8-4.1), we hypothesizes that the difference
might be significant if the sample achieved 32 subjects. Furthermore, a post-hoc analysis

of subgroups by grouping patients according to the history of wheezing, as suggested by

Baillieux and coworkers (6), could show positive effects in CPT compared to the control

group.

Another aspect that might be taken in account when analyzing the results and the

intervention is the degree of concordance between the physiotherapists, who applied the

techniques, and the doctors that performed the assessments. Concordance is the degree

of agreement or disagreement between two or more professionals that participate in an

intervention (7) and it has not been evaluated in the study. Indeed, chest physical therapy

is a group of manual maneuvers. The training level of each participant is an important

factor that could interfere in the results. There is no information about the expertise of

the professionals or any kind of their training before the study.

Finally, the primary outcome is well described but there is a lack of information on the

secondary one (number of hospital admissions after the second hour of treatment).

Reviewing the literature, it is well established that chest physiotherapy produces post

treatment effects up to 24h (4, 8). For these reasons, it is surprising that the authors

expect good results in the outcomes with only one session applied during one hour.

Therefore, we might give an answer to what happened between the second hour and the

7th or the 28th day. Did all the patients enrolled in the CPT group follow the appropriate

treatment during this period? Did they follow only an isolated therapeutic session?
Considering that there is a cumulative effect of CPT (9), and that chest physical therapy is

a cornerstone of the national pediatric respiratory infection program in Chile (10), it is

difficult to accept that patients really followed only salbutamol treatment during post

intervention days. The treatment modalities applied during the follow-up period should be

clarified by the authors.

Indeed the Castro-Rodriguez study presents some important limitations, which are not

well reflected in the discussion. Then, there is an important discrepancy between an

affirmative title, the conclusion and those non mentioned limitations. To sum up, the

study tries to evaluate an inappropriate protocol, and not the efficiency of an isolated

physical maneuver. Given our comments, we believe that the study methodology is too

poor to conclude with such a categorical and risky statement.

Sincerely,

Bibliography

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Chest physiotherapy is not clinically indicated for infants receiving outpatient care

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