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Chest physiotherapy for acute bronchiolitis in paediatric patients

between 0 and 24 months old (Review)
Roqué-Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C, Vilaró J
Roqué-Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C, Vilaró J.

Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old.
Cochrane Database of Systematic Reviews 2023, Issue 4. Art. No.: CD004873.
DOI: 10.1002/14651858.CD004873.pub6.
www.cochranelibrary.com
Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old (Review)
Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews
TABLE OF CONTENTS
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
SUMMARY OF FINDINGS.............................................................................................................................................................................. 4
BACKGROUND.............................................................................................................................................................................................. 7
OBJECTIVES.................................................................................................................................................................................................. 8
METHODS..................................................................................................................................................................................................... 8
Figure 1.................................................................................................................................................................................................. 10
RESULTS........................................................................................................................................................................................................ 13
Figure 2.................................................................................................................................................................................................. 14
Figure 3.................................................................................................................................................................................................. 15
Figure 4.................................................................................................................................................................................................. 17
DISCUSSION.................................................................................................................................................................................................. 21
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 23
ACKNOWLEDGEMENTS................................................................................................................................................................................ 23
REFERENCES................................................................................................................................................................................................ 25
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 31
DATA AND ANALYSES.................................................................................................................................................................................... 54
Analysis 1.1. Comparison 1: Slow passive expiratory technique versus control, Outcome 1: Severity clinical score...................... 55
Analysis 2.1. Comparison 2: Slow passive expiratory techniques versus instrumental techniques, Outcome 1: Severity clinical 55
score.......................................................................................................................................................................................................
Analysis 3.1. Comparison 3: Forced passive expiration technique versus control, Outcome 1: Severity clinical score................... 56
ADDITIONAL TABLES.................................................................................................................................................................................... 56
APPENDICES................................................................................................................................................................................................. 58
FEEDBACK..................................................................................................................................................................................................... 61
WHAT'S NEW................................................................................................................................................................................................. 64
HISTORY........................................................................................................................................................................................................ 64
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 65
DECLARATIONS OF INTEREST..................................................................................................................................................................... 65
SOURCES OF SUPPORT............................................................................................................................................................................... 65
DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 65
INDEX TERMS............................................................................................................................................................................................... 66
Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old (Review) i
Informed decisions.
[Intervention Review]
Chest physiotherapy for acute bronchiolitis in paediatric patients

between 0 and 24 months old
Marta Roqué-Figuls1, Maria Giné-Garriga2, Claudia Granados Rugeles3, Carla Perrotta4, Jordi Vilaró5
1Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública
(CIBERESP), Barcelona, Spain. 2Department of Physical Activity and Sport Sciences, Faculty of Psychology, Education and Sport Sciences
(FPCEE) Blanquerna, Universitat Ramon Llull, Barcelona, Spain. 3Department of Clinical Epidemiology and Biostatistics, Faculty of
Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia. 4School of Public Health, University College Dublin, Dublin, Ireland.
5Blanquerna Faculty of Health Sciences. GRoW, Global Research on Wellbeing, Ramon Llull University, Barcelona, Spain
Contact: Jordi Vilaró, [email protected].
Editorial group: Cochrane Acute Respiratory Infections Group.

Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 4, 2023.
Citation: Roqué-Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C, Vilaró J. Chest physiotherapy for acute bronchiolitis in
paediatric patients between 0 and 24 months old. Cochrane Database of Systematic Reviews 2023, Issue 4. Art. No.: CD004873. DOI:
10.1002/14651858.CD004873.pub6.
ABSTRACT
Background
Acute bronchiolitis is the leading cause of medical emergencies during winter months in infants younger than 24 months old. Chest
physiotherapy is sometimes used to assist infants in the clearance of secretions in order to decrease ventilatory effort. This is an update
of a Cochrane Review first published in 2005 and updated in 2006, 2012, and 2016.
Objectives
To determine the efficacy of chest physiotherapy in infants younger than 24 months old with acute bronchiolitis. A secondary objective was
to determine the efficacy of different techniques of chest physiotherapy (vibration and percussion, passive exhalation, or instrumental).
Search methods
We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, Web of Science, PEDro (October 2011 to 20 April 2022), and two trials registers
(5 April 2022).
Selection criteria
Randomised controlled trials (RCTs) in which chest physiotherapy was compared to control (conventional medical care with no
physiotherapy intervention) or other respiratory physiotherapy techniques in infants younger than 24 months old with bronchiolitis.
Data collection and analysis

We used standard methodological procedures expected by Cochrane.
Main results
Our update of the searches dated 20 April 2022 identified five new RCTs with 430 participants. We included a total of 17 RCTs (1679
participants) comparing chest physiotherapy with no intervention or comparing different types of physiotherapy.
Five trials (246 participants) assessed percussion and vibration techniques plus postural drainage (conventional chest physiotherapy), and
12 trials (1433 participants) assessed different passive flow-oriented expiratory techniques, of which three trials (628 participants) assessed
forced expiratory techniques, and nine trials (805 participants) assessed slow expiratory techniques. In the slow expiratory subgroup,
Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old (Review) 1
Informed decisions.
two trials (78 participants) compared the technique with instrumental physiotherapy techniques, and two recent trials (116 participants)
combined slow expiratory techniques with rhinopharyngeal retrograde technique (RRT). One trial used RRT alone as the main component
of the physiotherapy intervention. Clinical severity was mild in one trial, severe in four trials, moderate in six trials, and mild to moderate
in five trials. One study did not report clinical severity. Two trials were performed on non-hospitalised participants.
Overall risk of bias was high in six trials, unclear in five, and low in six trials.
The analyses showed no effects of conventional techniques on change in bronchiolitis severity status, respiratory parameters, hours with
oxygen supplementation, or length of hospital stay (5 trials, 246 participants).
Regarding instrumental techniques (2 trials, 80 participants), one trial observed similar results in bronchiolitis severity status when
comparing slow expiration to instrumental techniques (mean difference 0.10, 95% confidence interval (C) −0.17 to 0.37).
Forced passive expiratory techniques failed to show an effect on bronchiolitis severity in time to recovery (2 trials, 509 participants; high-
certainty evidence) and time to clinical stability (1 trial, 99 participants; high-certainty evidence) in infants with severe bronchiolitis.
Important adverse effects were reported with the use of forced expiratory techniques.
Regarding slow expiratory techniques, a mild to moderate improvement was observed in bronchiolitis severity score (standardised mean
difference −0.43, 95% CI −0.73 to −0.13; I2 = 55%; 7 trials, 434 participants; low-certainty evidence). Also, in one trial an improvement in
time to recovery was observed with the use of slow expiratory techniques. No benefit was observed in length of hospital stay, except for
one trial which showed a one-day reduction. No effects were shown or reported for other clinical outcomes such as duration on oxygen
supplementation, use of bronchodilators, or parents' impression of physiotherapy benefit.
Authors' conclusions
We found low-certainty evidence that passive slow expiratory technique may result in a mild to moderate improvement in bronchiolitis
severity when compared to control. This evidence comes mostly from infants with moderately acute bronchiolitis treated in hospital. The
evidence was limited with regard to infants with severe bronchiolitis and those with moderately severe bronchiolitis treated in ambulatory
settings.
We found high-certainty evidence that conventional techniques and forced expiratory techniques result in no difference in bronchiolitis
severity or any other outcome. We found high-certainty evidence that forced expiratory techniques in infants with severe bronchiolitis do
not improve their health status and can lead to severe adverse effects.
Currently, the evidence regarding new physiotherapy techniques such as RRT or instrumental physiotherapy is scarce, and further trials are
needed to determine their effects and potential for use in infants with moderate bronchiolitis, as well as the potential additional effect of
RRT when combined with slow passive expiratory techniques. Finally, the effectiveness of combining chest physiotherapy with hypertonic
saline should also be investigated.
PLAIN LANGUAGE SUMMARY
Chest physiotherapy for acute bronchiolitis in children younger than two years of age
Key messages
Chest physiotherapy based on slow expiratory techniques may improve disease severity in infants with moderately severe acute
bronchiolitis.
What is acute bronchiolitis, and what is the role of chest physiotherapy in this condition?
Acute bronchiolitis is a viral respiratory infection that frequently occurs in infants younger than two years old. Most infants have a mild
disease and do not require specific medical treatments or hospitalisation. However, those with moderate or severe disease may present
with a build-up of fluid in the airways (mucus secretion), as well as swollen (oedema) or constricted (bronchospasm) airways, that make
it difficult to clear phlegm.
Chest physiotherapy may assist in the clearance of respiratory secretions and improve breathing. There are three established types of
chest physiotherapy techniques to manage airway clearance: vibration and percussion techniques, forced expiratory techniques, and
slow passive expiratory techniques. Additionally, there is emerging evidence on rhinopharyngeal retrograde clearance techniques and
instrumental clearance techniques, alone or in combination with other physiotherapy techniques.
What did we want to find out?
The aim of the review was to determine the effectiveness of chest physiotherapy in relieving acute bronchiolitis in infants between 0 and
24 months old, as well as to determine the effectiveness of the different techniques of chest physiotherapy.
What did we do?

Informed decisions.
We searched for all randomised controlled trials (a type of study where participants are randomly assigned to one of two or more treatment
groups) comparing chest physiotherapy interventions against a control or other types of physiotherapy, and looked at their effectiveness
by type of technique and bronchiolitis severity.
What did we find?
We included 17 trials with a total of 1679 infants. Five trials (246 infants) tested vibration and percussion techniques (conventional chest
physiotherapy); three trials (628 infants) tested forced expiratory techniques; and nine trials (805 infants) tested slow expiratory techniques.
Two trials (80 infants) tested instrumental physiotherapy techniques, and three trials (216 infants) tested the rhinopharyngeal retrograde
clearance technique (two combined with slow expiratory technique in 116 infants). Disease severity of infants was mild in one trial, severe
in four trials, moderate in six trials, and a mix of mild to moderate in five trials. One trial did not report disease severity of infants. Two trials
were performed in ambulatory (non-hospitalised) infants, and the rest were performed in hospitalised infants.
We found no effect of conventional physiotherapy on disease severity of infants with moderate bronchiolitis. Forced expiratory techniques
also failed to show an effect on bronchiolitis severity in infants with severe disease, while important adverse effects were reported. We
have high confidence in this evidence, and new trials are unlikely to challenge these results. Slow expiratory techniques showed a mild
to moderate improvement in bronchiolitis severity, mostly in infants with moderate bronchiolitis, based on low-certainty evidence (future
studies may challenge this result). Also, one study showed an improvement in time to recovery with slow expiratory techniques in infants
with moderate bronchiolitis. No effects were shown or reported for other clinical outcomes such as length of hospital stay, duration of
oxygen supplementation, use of bronchodilators, or parents' impression of a benefit from the physiotherapy.
What are the limitations of the evidence?
Despite the positive effects found for some types of chest physiotherapy, most of the trials were poorly designed, which has a direct impact
on the certainty and reliability of the results. For some techniques, the evidence for the effect is of low certainty. Furthermore, a larger
number of participants, longer interventions, and well-reported adverse events are needed before any firm conclusions can be reached.
The evidence is robust for the older or more established types of physiotherapy (vibration and percussion and forced expiratory techniques)
administered to hospitalised infants. The evidence is limited for slow expiratory techniques, and only anecdotal for the newest techniques
(rhinopharyngeal retrograde clearance and instrumental clearance techniques), which have been explored in few trials. There is little
evidence on the effectiveness of chest physiotherapy in non-hospitalised infants.
How up-to-date is this evidence?
The evidence is current to 20 April 2022.
SUMMARY OF FINDINGS
Summary of findings 1. Slow passive expiration versus control for acute bronchiolitis
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Slow passive expiration versus control for acute bronchiolitis
Patient or population: paediatric participants between 0 and 24 months old with acute bronchiolitis
Settings: hospital
Better health.
Informed decisions.
Trusted evidence.
Intervention: slow passive expiration
Comparison: control
Outcomes Illustrative comparative risks* (95% CI) Relative effect No. of partici- Certainty of Comments
(95% CI) pants the evidence
Assumed risk Corresponding risk (studies) (GRADE)
Control Physiotherapy
Time to recovery/time Mean time to recov- Mean time to recovery NA 71 (1 trial) ⊕⊕⊝⊝ Participants with mild to moder-
to clinical stability ery 4.4 days (3.7 to 2.6 days (2.1 to 3.1 days) Lowa ate bronchiolitis
5.1 days)
Recovery defined as at- (Conesa-Segura 2018)
taining an ABSS clinical
score below 2.
(follow-up until hospital

discharge)
Change in the severity Mean Wang score of The mean severity score SMD −0.43 434 (7 trials) ⊕⊕⊝⊝ Participants with mild to moder-
status of bronchiolitis 7.5 (Gomes 2012)b in the intervention (−0.73 to −0.13) Lowc ate bronchiolitis
group was 0.7 lower (1.2
Assessed using a variety lower to 0.3 lower).b (Conesa-Segura 2018; Gomes

of scales 2012; Gomes 2016; Lopez Gal-
bany 2004; Postiaux 2011;
(follow-up ranging from Ramos-Pinto 2021; Van Gin-
1 hour to hospital dis- derdeuren 2017)
charge)
Adverse events 4 studies reported no adverse events. 565 (6 trials) ⊕⊝⊝⊝ Participants with severe bronchi-
Very lowd olitis
(follow-up until hospital 1 study reported more episodes of nasal bleeding (28 vs 1) and vom-
discharge) iting (11 vs 7) in the control aspiration group than the clearance (Sanchez Bayle 2012)
physiotherapy group.
Participants with mild to moder-
ate bronchiolitis
4
1 study reported no direct complications (respiratory deterioration (Conesa-Segura 2018; Gomes
with oxygen desaturation, bradycardia, vomiting) due to treatment 2016; Postiaux 2011; Ramos-Pin-
in any participant. There were 4.3% cases (2 controls and 2 experi- to 2021; Sanchez Bayle 2012; Van
mental) of complications due to bronchiolitis severity. Ginderdeuren 2017)
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*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is
based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
ABSS: Acute Bronchitis Severity Score; CI: confidence interval; NA: not applicable: SMD: standardised mean difference
Better health.
Informed decisions.
Trusted evidence.
GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is
substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
aDowngraded for unclear risk of bias and serious imprecision of estimates due to small sample size.
bAssumed risk was taken from the baseline mean severity of the control group in Gomes 2012, which was measured with the Wang severity score and presented low risk of bias
in the meta-analysis. SMD was back-transformed into a mean difference multiplying the standard deviation of the Gomes 2012 control group (mean change from baseline to end
of study) by the pooled SMD.
cDowngraded for unclear risk of bias and imprecision of estimates. Inconsistency of results (I2 = 55%) did not result in reduced certainty of the evidence because the sensitivity
analysis reached similar results with no inconsistency.
dDowngraded for unclear risk of bias, serious imprecision of estimates, and serious indirectness of assessments because in 4 of the 6 trials it was unclear what adverse effects
were assessed, and 1 of the trials only assessed participants in the intervention group.
Summary of findings 2. Forced expiration versus control for acute bronchiolitis
Forced expiration versus control for acute bronchiolitis
Patient or population: paediatric participants between 0 and 24 months old with acute bronchiolitis

Settings: hospital
Intervention: forced expiration
Comparison: control
Outcomes Illustrative comparative risks* (95% CI) Relative effect No. of partici- Certainty of Comments
(95% CI) pants the evidence
Assumed risk Corresponding risk (studies) (GRADE)
Control Physiotherapy
5
Time to recov- Median time to re- Median time to re- 3 studies reported no differences 628 ⊕⊕⊕⊕ Participants with severe
ery/time to clini- covery was 2.31 days covery was 2.02 days between intervention and con- (3 trials) High bronchiolitis
cal stability (1.97 to 2.73) (Gajdos (1.96 to 2.34) (Gajdos trol in time to recovery/clinical
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2010).a 2010). stability. (Gajdos 2010; Rochat
(follow-up un- 2010)
til hospital dis-
charge) Participants with mild-
moderate bronchiolitis
(Remondini 2014)
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Informed decisions.
Trusted evidence.
Change in the Mean RDAI severi- Mean RDAI severity 2 studies reported no differences 132 (2 trials) ⊕⊝⊝⊝ Participants with severe
severity status ty score of 3.13 (SD score was 3.26 (SD between forced expiration and Verylowc bronchiolitis
of bronchiolitis 1.81) (Remondini 1.96).b control or standard physiothera-
2014)b py (including tapping). (Rochat 2010)
Assessed using a
variety of scales Participants with mild-
moderate bronchiolitis
(Remondini 2014)
Adverse events Adverse events reported in Gajdos 2010: 599 ⊕⊕⊕⊕ Participants with severe
(2 trials) High bronchiolitis
(follow-up un- • bradycardia with desaturation (RR 1.0, 95% CI 0.2 to 5.0)
til hospital dis- • bradycardia without desaturation (RR 3.6, 95% CI 0.7 to 16.9) (Gajdos 2010; Rochat
charge) • transient respiratory destabilisation (RR 5.4, 95% CI 1.6 to 18.4) 2010)
• vomiting during procedure (RR 10.2, 95% CI 1.3 to 78.8)
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is
based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; NA: not applicable; RDAI: Respiratory Distress Assessment Instrument; RR: risk ratio; SD: standard deviation
GRADE Working Group grades of evidence

High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.

Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is
substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
aIllustrative comparative risks (assumed and corresponding risks) have been taken from the mean time to recovery assessed in Gajdos 2010, which has a large sample size and
low risk of bias in the comparison.
bIllustrative comparative risks (assumed and corresponding risks) have been taken from the mean severity score RDAI reported in Remondini 2014.
cDowngraded for unclear risk of bias and very serious imprecision of estimates.
6
Informed decisions.
BACKGROUND not recommend their use (Cavaye 2018; Ralston 2014a). There is
no evidence to support the use of glucocorticoids or antibiotics
Description of the condition (Farley 2014; Fernandes 2013), and although there is some poor-
quality evidence that bronchodilators, nebulised hypertonic saline,
Acute bronchiolitis is the leading cause of emergency department
epinephrine, and heliox therapy may have some benefit in terms
visits during winter months in children younger than two years
of improving clinical scores (Gadomski 2014; Hartling 2011; Liet
of age. It results in high use of healthcare resources, and
2015; Umoren 2011; Zhang 2017), this benefit must be weighed
is an increasing burden on outpatient practices, emergency
against the lack of benefit in reducing the duration or severity
departments, and hospitals (Carroll 2008). Between 2% and 3%
of illness, costs, and adverse effects. Furthermore, non-invasive
of children younger than 12 months of age are hospitalised with
nasal airways clearance is also recommended for bronchiolitis in
a diagnosis of bronchiolitis, which accounts for between 57,000
order to decrease nasal obstruction (Norris 2018), and could have
and 172,000 hospitalisations annually in the USA; it also results
an impact on length of hospital stay (Mussman 2013). However,
in significant morbidity in infants (Meissner 2016). Infant mortality
there is still controversy over the effects of nasal aspiration versus
rates vary depending on geographical region and the economic
nasopharyngeal suctioning (Ringer 2020).
status of the family (Scheltema 2017).
Chest physiotherapy has been proposed to assist in the clearance
In high-income countries, the incidence of bronchiolitis-associated
of tracheobronchial, and, recently, nasal secretions. The main goal
deaths is low, and occurs mainly in infants with severe
is to decrease airway obstruction produced by secretions; reduce
comorbidities (e.g. congenital heart disease) and prematurity.
airway resistance; enhance gas exchange; and reduce the work
However, for low-income or lower-middle-income countries, only
of breathing. Different techniques are used in paediatric patients:
28% of deaths were associated with comorbidities, compared with
1) conventional chest physical therapy (cCPT) such as chest
47% in upper-middle-income and 70% in high-income countries
percussion and vibration in combination with postural drainage
(Holman 2003; Panickar 2005; Scheltema 2017). Furthermore, there
positions, chest shaking, and directed coughing; 2) flow-based
is strong evidence of irreversible airway damage and reduced
techniques: slow or forced passive expiration, which may help
lung function in adults who were hospitalised with bronchiolitis
to mobilise secretions from bronchioles or bronchi, respectively,
in infancy (Backman 2014; Sigurs 2010). Children who have had
towards the trachea and trigger coughing which helps to remove
respiratory syncytial virus (RSV) disease in early life have been
secretions; 3) instrumental techniques based on thorax vibration,
shown to have a higher incidence of asthma/wheezing in later
intrapulmonary percussive ventilation, and high-frequency chest
life (odds ratio 3.84, Fauroux 2017; Régnier 2013). Increasing
wall compression, which produce an airway's oscillation that
evidence suggests that RSV is a significant risk factor for respiratory
improves mucus transportation by modifying its rheology and
morbidity, and is a predisposition to asthma and allergies within
improving cilia beating; and recently 4) rhinopharyngeal retrograde
the first decade of life and possibly into adulthood. The increased
technique (RRT), which uses forced nasal inspiration to remove
respiratory morbidity may lead to a reduced quality of life and
secretions from the nasal cavity towards the mouth. However, there
increased healthcare costs (Fauroux 2017).
may be drawbacks to conventional chest physiotherapy and forced
In 2014, the American Academy of Pediatrics published a statement passive expiration techniques. It has been claimed that they might
on the diagnosis and treatment of bronchiolitis (Ralston 2014a). cause distress to the infant, and concerns have arisen about the
However, the criteria for diagnosing acute bronchiolitis vary safety of the procedures, especially in relation to rib fractures in
greatly. Most doctors agree that the case definition for an episode at-risk patients (Beeby 1998; Chalumeau 2002; Chanelière 2006).
of acute bronchiolitis should include children aged 24 months or Ensuring safety and reducing adverse effects should also be a
younger who have a first episode of acute wheezing accompanied priority when assessing the efficacy of new chest physiotherapy
by physical findings of viral infection (e.g. coryza, cough and fever) techniques.
(González Caballero 2001; Wainwright 2003).
How the intervention might work
Most cases of acute bronchiolitis are mild and can be treated on Chest physiotherapy should decrease airway obstruction and
an outpatient basis, while 1% to 3% (depending on the severity reduce flow resistance and the work of breathing by enhancing the
of the disease) will require hospitalisation (Ralston 2014b). Risk mucociliary transportability. Initially, airway clearance techniques
factors associated with the need for hospitalisation are young age, were based on the effects of the airflow over the mucus in which the
premature birth, chronic lung disease, congenital heart disease, airflow friction improved mucus transportation. However, current
and a compromised immune system (Ralston 2014a). In low- evidence explores the effects produced at the biomechanical and
income countries, the most frequent risk factors associated with biochemical levels. The mechanical stress produced by airflow,
hospitalisation and severe disease include living in a low-income airways stretching and pressure during chest physiotherapy
family, malnutrition, low birthweight, age of the mother, mother's generates changes in mucus rheology (Button 2008; Button 2013);
education level, being bottle-fed, and premature birth (Scheltema increases ciliary beat frequency (Button 2018); and increases
2017; Smyth 2006; Spencer 1996). the water volume in secretions, all of which means the mucus
becomes more fluid and transportable (Button 2013). Considering
Description of the intervention this evidence-based approach, chest physiotherapy might be used
The aim when treating acute bronchiolitis is to ensure adequate only when there is an indication of airway obstruction due to
oxygenation, fluid intake, nasal airway clearance, and feeding of the mucus secretions, ideally in children with moderate or mild acute
infant (NICE 2021; PREDICT 2019; Ralston 2014a). Pharmacological bronchiolitis, because their severity level indicates the need for
strategies include bronchodilators, antibiotics, and steroids, but manual and mechanical clearance techniques in order to avoid
their effectiveness remains uncertain, and current guidelines do adverse effects. Finally, the physiological effects are not immediate,
Informed decisions.
and can take up to three hours before maximum benefit is realised. METHODS
This delay must be considered when assessing postintervention
effects of chest physiotherapy for acute bronchiolitis. Criteria for considering studies for this review
Why it is important to do this review Types of studies
When this review was first published, there was uncertainty about We included randomised controlled trials (RCTs) evaluating chest
the efficacy of conventional physiotherapy techniques (vibration, physiotherapy in paediatric patients with acute bronchiolitis.
percussion and postural drainage). The review challenged their
Types of participants
use in daily practice, prompting the recommendation that chest
physiotherapy based on vibration and percussion should not be Infants younger than 24 months of age with acute bronchiolitis, as
routinely used in hospitals (BGT 2005; Ralston 2014a; SIGN 2006). defined by the trial authors, in all settings.
However, chest physiotherapy is still being used in outpatient
and inpatient settings (Barben 2008; González 2010a). Parents' Types of interventions
expectations and demands for chest physiotherapy in clinical daily We included trials that compared any type of chest physiotherapy
practice may explain its widespread use (Sanchez 2007). (postural drainage, chest percussion, vibration, chest shaking,
directed coughing, slow or forced expiration techniques,
New and gentler passive expiratory physiotherapy techniques have
rhinopharyngeal retrograde clearance technique, and instrumental
become mainstream in many countries. In Chile, the Health Ministry
techniques) versus control (conventional medical care with no
introduced the slow expiratory technique into clinical guidelines
physiotherapy intervention) or other respiratory physiotherapy
for bronchiolitis management in outpatient and inpatient settings
techniques.
(Ministerio de Salud Chile 2013). This Chilean guideline points
to the fact that the physiotherapy intervention is linked to the We classified the interventions into four main categories:
severity score, mild or moderate, and must always be followed positioning + vibration and percussion, passive flow expiratory
up with a strict assessment after the intervention, to determine techniques, rhinopharyngeal retrograde clearance technique, and
clinical efficacy. In France, forced expiratory techniques are not instrumental techniques. We further subdivided passive expiratory
recommended by the health authority for the first bronchiolitis techniques into slow passive expiratory techniques and forced
episode due to their adverse effects, except for those children passive expiratory techniques.
who have chronic respiratory comorbidities or poor cough reflex
(Haute Autorité de Santé: HAS-FR 2019). However, forced expiratory We considered the following four comparisons.
techniques are widely used in outpatient settings in France (David
2010; Halna 2005; Touzet 2007). In other countries such as the 1. Slow passive expiratory techniques versus control.
UK (NICE 2021), the USA (Ralston 2014a), and Spain (Ministerio 2. Slow passive expiratory techniques versus instrumental
Sanidad 2011), chest physiotherapy is only recommended for techniques.
people with comorbidities or for those with atelectasis due to 3. Forced passive expiratory techniques versus control.
airway obstruction. 4. Positioning plus percussion and vibration (conventional
The use of chest physiotherapy varies around the world. Differences techniques) versus control.
could be attributed to the intervention approach and the Types of outcome measures
techniques used to assess and treat the physiopathological
condition of the airway obstruction of the infant. Results differ Primary outcomes
depending on the technique used.
1. Time to recovery.
Given what seems to be contrary evidence on routine use of 2. Change in the severity status of bronchiolitis.
chest physiotherapy in infants with acute bronchiolitis, we were
motivated to shift the focus of this review to assess the efficacy Secondary outcomes
and safety of passive expiratory techniques, and to explore the 1. Respiratory parameters (oxygen saturation levels,
differential effects of chest physiotherapy, depending on the transcutaneous carbon dioxide partial pressure (PaCO2)).
technique used, severity of the disease, and the setting of the
2. Duration of oxygen supplementation.
physiotherapy.
3. Length of hospital stay in hospitalised infants.
OBJECTIVES 4. Avoidance of hospitalisations or emergency visits in ambulatory
patients.
To determine the efficacy of chest physiotherapy in infants younger 5. Use of bronchodilators and steroids.
than 24 months old with acute bronchiolitis. A secondary objective
6. Parents' impression of physiotherapy benefit.
was to determine the efficacy of different techniques of chest
physiotherapy (vibration and percussion, passive exhalation, or 7. Adverse events, defined as any undesired outcome due to
instrumental). the intervention, e.g. rib fractures, bradycardia, respiratory
instability, vomiting, or long-term neurological disabilities. We
took all outcomes into consideration. We described the methods
used to measure any adverse events.
Informed decisions.
Search methods for identification of studies and ClinicalTrials.gov (www.clinicaltrials.gov/) trials registers with
the search terms bronchiolitis AND "chest physiotherapy" for
Electronic searches completed and ongoing trials (5 April 2022).
In this update we searched the Cochrane Central Register of
Controlled Trials (CENTRAL 2022, Issue 4) (accessed 20 April 2022), In the first publication of this review, we examined the reference
the Cochrane Acute Respiratory Infections Group's Specialised lists of general paediatric, infectious diseases, pneumatology, and
Register (October 2011 to 20 April 2022), MEDLINE and MEDLINE In- physiotherapy textbooks. We reviewed the reference lists of all
Process and Other Non-Indexed Citations (October 2011 to 20 April selected articles and recent review articles and also examined
2022), Embase (October 2011 to 20 April 2022), CINAHL (Cumulative published abstracts from the Pediatric Academic Societies' Annual
Index to Nursing and Allied Health Literature) (October 2011 to 20 Meetings (US) (1999 to 2003). We handsearched the French journals
April 2022), LILACS (Latin American and Caribbean Health Science Journal Pédiatrie Puériculture (1999 to May 2004) and Archives de
Information database) (October 2011 to 20 April 2022), Web of Pédiatrie (1994 to 1997; 2000 to May 2004).
Science (October 2011 to 20 April 2022), and PEDro (October 2011
Data collection and analysis
to April 2022).
Selection of studies
We used the search strategy described in Appendix 1 to search
CENTRAL and MEDLINE. We did not combine the search strategy Three review authors (CG, MG, MR) independently screened the
with a filter for identifying randomised trials, as there were too results from the initial search of all the databases and reference
few results. We adapted the search strategy to search MEDLINE lists to identify potentially relevant citations. We obtained the full-
In-Process (Appendix 2), Embase (Appendix 3), CINAHL (Appendix text articles of those abstracts or titles deemed potentially relevant.
4), LILACS (Appendix 5), and Web of Science (Appendix 6). See Four review authors (CG, MG, MR, JV) independently decided on
Appendix 7 for details of previous searches. which trials to include using a standardised form. There were no
disagreements regarding which trials to include in the review. We
Searching other resources recorded the selection process in sufficient detail to complete a
PRISMA flow diagram (Figure 1) (Moher 2009).
We searched the World Health Organization (WHO) International
Clinical Trials Registry Platform (ICTRP) (trialsearch.who.int/)
Informed decisions.
Figure 1. Study flow diagram.
530 records
identified
through
database
searching after
removal of 1 record identified through
duplicates other sources (Lopez
Prior to 2011: Galbany 2004)
101
2011 to 2015: 64
2015 to 2022:
365
531 records 508 records

screened excluded
9 full-text
studies
excluded, with
reasons:
1 RCT unclear
whether
participants had
bronchiolitis
2
28 full-text non-randomised
articles controlled
assessed for clinical trial
eligibility
3 uncontrolled
intervention
study
2 observational
non-intervention
studies
1 paper in a
predatory
journal
17 studies (19
articles)
included in
qualitative
synthesis
Informed decisions.
Figure 1. (Continued)
17 studies (19
articles)
included in
qualitative
synthesis
7 studies
included in
quantitative
synthesis
(meta-analysis)
Data extraction and management during recruitment, or changed after assignment. We assessed the
methods as:
Two review authors (MR, MG) independently extracted data from
the included studies. We used a standardised form to extract the 1. low risk of bias (e.g. telephone or central randomisation;
following data. consecutively numbered, sealed, opaque envelopes);
1. Characteristics of the study (design, method of randomisation, 2. high risk of bias (open random allocation; unsealed or non-
withdrawals, dropouts). opaque envelopes, alternation; date of birth); or
2. Participants (age, gender, low birthweight or normal weight, 3. unclear risk of bias.
ambulatory or hospital patients, disease severity, nutritional
3. Blinding (performance and detection bias)
status).
3. Intervention (type of chest physiotherapy, administration, co- We assessed the combined risk of performance and detection
interventions) and its comparator. bias based on the blinding procedures implemented in the
4. Outcomes (types of outcome measures, timing of outcomes, studies to prevent families, healthcare personnel treating the
adverse effects). participants, and outcome assessors from knowledge of the
treatment participants received. For each included study we
5. Results.
described all the methods used, if any, to blind families, study
Assessment of risk of bias in included studies and healthcare personnel, and outcome assessors from knowledge
of which intervention a participant received. We also provided
Two review authors (MG, MR) independently assessed the risk of information on whether the intended blinding was effective. Where
bias for each included study using the criteria outlined in the blinding was not possible, we assessed whether the lack of blinding
Cochrane Handbook for Systematic Reviews of Interventions (Higgins was likely to have introduced bias. We assessed the methods as:
2011). Any disagreements were resolved by discussion.
1. low risk of bias;
1. Sequence generation (selection bias) 2. high risk of bias; or
We described for each included study the methods used to generate 3. unclear risk of bias.
the allocation sequence in sufficient detail to allow an assessment
of whether it should produce comparable groups. We assessed the 4. Incomplete outcome data (attrition bias through
methods as: withdrawals, dropouts, and protocol deviations)
We described for each included study and for each outcome or
1. low risk of bias (any truly random process, e.g. random number
class of outcomes the completeness of data including attrition
table; computer random number generator);
and exclusions from the analysis. We stated whether attrition and
2. high risk of bias (any non-random process, e.g. odd or even date exclusions were reported, the numbers included in the analysis
of birth; hospital or clinic record number); or at each stage (compared with the total randomised participants),
3. unclear risk of bias. reasons for attrition or exclusion where reported, and whether
missing data were balanced across groups or were related to
2. Allocation concealment (selection bias) outcomes. We assessed whether each study was at:
We described for each included study the method used to conceal
1. low risk of bias;
the allocation sequence in sufficient detail to determine whether
intervention allocation could have been foreseen in advance of, or 2. high risk of bias; or
3. unclear risk of bias.
Informed decisions.
5. Selective reporting bias secondary intention-to-treat (ITT) sensitivity analysis would be

performed for dichotomous outcomes. The ITT subanalysis would
We described for each included study how we examined the
use imputation, assuming that all missing data corresponded to a
possibility of selective outcome reporting bias and what we found.
negative outcome.
We assessed the methods as:
Assessment of heterogeneity
1. low risk of bias (where it was clear that all of the study's
prespecified outcomes and all expected outcomes of interest to We planned to assess statistical heterogeneity using the I2 statistic,
the review were reported); considering values I2 ≥ 50% as indicative of moderate to high
2. high risk of bias (where not all of the study's prespecified heterogeneity if the included trials were similar enough to perform
outcomes were reported; one or more reported primary a quantitative analysis (Higgins 2003).
outcomes were not prespecified; outcomes of interest were
reported incompletely and so could not be used; the study Assessment of reporting biases
failed to include results of a key outcome that would have been We did not explore publication bias and other reporting biases
expected to have been reported); or statistically or graphically due to the lack of statistical data in the
3. unclear risk of bias. included trials.
6. Other sources of bias Data synthesis
We described for each included study any important concerns we We did not perform a meta-analysis for the comparisons
had about other possible sources of bias, in particular regarding of positioning plus percussion and vibration (conventional
contamination. We assessed each study as at: techniques) and forced passive expiratory technique, due to clinical
heterogeneity and statistical considerations. We were able to
1. low risk of bias; meta-analyse the results for severity of bronchiolitis clinical score
2. high risk of bias; or outcome for the slow passive expiratory techniques comparison.
3. unclear risk of bias. We conducted a narrative synthesis describing the individual
results with the effect measures reported in the original trials.
Measures of treatment effect We conducted a meta-analysis through a statistical pooling of
We estimated the effect of treatment by mean differences (MDs) and effect measures with a random-effects model, applying the inverse-
standardised mean differences (SMD) for continuous outcomes, variance method. We wrote the review using Review Manager 5
and risk ratios (RRs) for dichotomous outcomes, with their (Review Manager 2020).
corresponding confidence intervals (CIs). We estimated the effect
Subgroup analysis and investigation of heterogeneity
of treatment with SMD when continuous outcomes were measured
with different scales across trials. We considered that SMD < 0.2 We proposed two subgroup analyses for the main outcomes
corresponded to a small effect size; around 0.5 to a medium effect based on the hypothesis that performance of slow flow chest
size; and more than 0.8 to a large effect size. physiotherapy techniques could depend on disease severity
and, consequently, on setting (inpatient versus outpatient). We
Unit of analysis issues introduced a subgroup analysis by disease severity, classifying
Had cluster-randomised trials been included in the review, we trials into severe, mild to moderate, and unknown categories
would have assessed their data analysis in search of possible unit of depending on the inclusion criteria of the trial or the characteristics
analysis errors, and combined them with individually randomised of the included participants. We proposed a second subgroup
trials if no errors were observed. We did not expect to identify any analysis by setting, classifying trials into inpatient/outpatient
cross-over randomised trials on this topic given the short course of categories, under the hypothesis that infants with more severe
bronchiolitis. bronchiolitis would be seen in inpatient settings, while infants with
mostly moderate or mild bronchiolitis severity would be treated in
A trial with three arms was meta-analysed in the 'slow passive outpatient settings.
expiratory technique versus control' comparison by pooling the
data from the two active arms (Van Ginderdeuren 2017), and In this update, we added a new, post hoc subgroup analysis to
comparing these pooled data against the control arm to avoid the slow passive expiratory techniques comparison, to show results
incurring unit of analysis errors (Higgins 2011). In the 'slow passive separately for those trials using physiotherapy techniques with
expiratory technique versus instrumental techniques' comparison, and without RRT. We classified the trials into three categories,
the two active arms of the trial were compared against each other. depending on whether the physiotherapy techniques incorporated
RRT or not. This subgroup analysis was a purely descriptive
Dealing with missing data exploration, and we did not consider the meta-analysed results
separately by subgroup as the evidence was too scarce for the
We assessed the impact of missing data on the results of the results to be reliable.
risk of bias assessment, considering the magnitude of missing
data for each trial and how the missing data were dealt with. We Sensitivity analysis
tried to assess how many participants were excluded from the
analysis, to which treatment group they belonged, the reasons for We planned that if a quantitative analysis of dichotomous
excluding them, and whether their exclusion biased the results. outcomes was performed, we would carry out an ITT sensitivity
We planned that if a quantitative analysis was performed, the analysis for dichotomous outcomes, imputing all missing data as a
main analysis would be based on the available data, and a negative outcome.
Informed decisions.
Summary of findings and assessment of the certainty of the (216 participants) used a rhinopharyngeal retrograde technique
evidence (RRT) as a component of their physiotherapy intervention,
which consists of a forced nasal inspiratory manoeuvre based
We included two summary of findings tables for the comparisons
on the inspiratory reflex that follows a slow and prolonged
of 'slow passive expiration techniques versus control' and 'forced
expiration (Conesa-Segura 2018; Gomes 2016; Ramos-Pinto 2021).
expiration techniques versus control', including the following
The majority of trials compared chest physiotherapy against a
outcomes: time to recovery/clinical stability, changes in severity
control, which was described generally as 'no intervention' (Aviram
status, and adverse effects. Illustrative comparative risks are
1992; Bohe 2004; Conesa-Segura 2018; Lopez Galbany 2004;
presented in the tables, taking the values observed in the control
Nicholas 1999; Ramos-Pinto 2021; Rochat 2010; Webb 1985), or a
groups as the assumed risks. We assessed the certainty of evidence
conventional approach that was defined differently across trials,
using the GRADE approach (Guyatt 2008), which is based on the
and included postural drainage and tracheal aspiration, and was
extent to which users can be confident that an association reflects
in some cases combined with tapping and percussion (De Córdoba
the item being evaluated (Guyatt 2008). Assessment of the certainty
2008; Gajdos 2010; Gomes 2012; Gomes 2016; Postiaux 2011;
of evidence is based on the five GRADE considerations (risk of bias,
Remondini 2014; Sanchez Bayle 2012).
heterogeneity, directness of the evidence, risk of publication bias,
and precision of effect estimates) (Guyatt 2011a; Guyatt 2011b; Two of the included trials assessed the effect of slow passive
Guyatt 2011c; Guyatt 2011d; Guyatt 2011e; Guyatt 2011f; Guyatt expiratory techniques against an active instrumental comparator:
2011g; Guyatt 2011h). For outcomes where no meta-analysis was intrapulmonary percussive ventilation (IPV), Van Ginderdeuren
possible, we followed guidelines for rating the certainty of evidence 2017, or high frequency chest wall compression (HFCWC), González-
in a narrative synthesis (Murad 2017). We developed summary of Bellido 2020.
findings tables using GRADEpro GDT software (GRADEpro GDT).
Fifteen of the included trials evaluated the efficacy of chest
RESULTS physiotherapy in hospitalised infants with a clinical diagnosis of
acute bronchiolitis. We classified the trials by the clinical severity
Description of studies of the disease, as reported in the papers or as estimated by the
Results of the search review authors. Clinical severity of participants was mild in one
trial (De Córdoba 2008 1.9 mean Silverman-Anderson score at
We updated the searches on 20 April 2022. We retrieved 365 baseline, out of 10 maximum score); mild to moderate in nine trials
records, and included five new trials (Conesa-Segura 2018; Gomes (Bohe 2004 5.7 mean Wang score at baseline; Gomes 2012 75% of
2016; González-Bellido 2020; Ramos-Pinto 2021; Van Ginderdeuren participants with a four to eight points in the Wang score; Postiaux
2017). We excluded three new trials (Evenou 2017; Sebban 2017; 2011 5.75 mean Wang score at baseline; Webb 1985 11 mean clinical
Sebban 2019), and identified five new ongoing trials (NCT02708147; score at admission over 30 maximum score; Lopez Galbany 2004 5.6
NCT02853838; NCT03738501; NCT03753802; NCT04553822). mean Wang score at baseline; Remondini 2014 5.8 mean respiratory
distress assessment instrument (RDAI) score at baseline; Conesa-
Included studies Segura 2018 92% had Acute Bronchiolitis Severe Scale (ABSS)
See Characteristics of included studies table. <= 9; Gomes 2016 72% had Wood score <= 7; Van Ginderdeuren
2017 restricted inclusion to Wang score >= 3 and <= 8); and severe in
We included 17 RCTs (1679 participants) in the review (Aviram 1992; four trials (Gajdos 2010; Nicholas 1999; Rochat 2010; Sanchez Bayle
Bohe 2004; Conesa-Segura 2018; De Córdoba 2008; Gajdos 2010; 2012). The trials of infants with severe bronchiolitis also included
Gomes 2012; Gomes 2016; González-Bellido 2020; Lopez Galbany infants who required nasogastric feeding or intravenous fluid. The
2004; Nicholas 1999; Postiaux 2011; Ramos-Pinto 2021; Remondini severity of bronchiolitis in one trial was unknown (Aviram 1992).
2014; Rochat 2010; Sanchez Bayle 2012; Van Ginderdeuren 2017;
Webb 1985). Two trials were performed on ambulatory, non-hospitalised infants
(González-Bellido 2020; Ramos-Pinto 2021). In both cases disease
A description of included trials by type of intervention is shown severity was mild to moderate, by either the Wang or the
in Table 1. Regarding the intervention type, we classified the Kristjansson score. In González-Bellido 2020, infants received only
intervention groups as follows: 1) use of classic techniques such as one physiotherapy session. In Ramos-Pinto 2021, infants received
percussion and vibration (without any modifications in the current five sessions during the first week and three sessions during the
update); 2) forced expiration techniques; 3) slow flow techniques second week. No adverse events were observed in either trial.
including the retrograde rhinopharyngeal clearance technique; and
4) instrumental techniques (González-Bellido 2020; group 2 of Van The trials were carried out in the UK (Nicholas 1999; Webb
Ginderdeuren 2017). 1985), Spain (Conesa-Segura 2018; González-Bellido 2020; Lopez
Galbany 2004; Sanchez Bayle 2012), Brazil (De Córdoba 2008;
Five trials (246 participants) assessed percussion and vibration Gomes 2012; Gomes 2016; Remondini 2014), France (Gajdos
techniques (Aviram 1992; Bohe 2004; De Córdoba 2008; 2010), Belgium (Postiaux 2011; Van Ginderdeuren 2017), Israel
Nicholas 1999; Webb 1985), and 12 trials (1433 participants) (Aviram 1992), Argentina (Bohe 2004), Portugal (Ramos-Pinto
assessed different passive flow-oriented expiratory techniques, of 2021), and Switzerland (Rochat 2010). Two of the included trials
which three trials (628 participants) assessed forced expiratory were unpublished, and we contacted the trial authors for further
techniques (Gajdos 2010; Remondini 2014; Rochat 2010), and clarification and data gathering (Aviram 1992; Lopez Galbany 2004).
nine trials (805 participants) assessed slow expiratory techniques We contacted the authors of several trials asking for clarification
(Conesa-Segura 2018; Gomes 2012; Gomes 2016; González-Bellido and additional information, with positive responses (Aviram 1992;
2020; Lopez Galbany 2004; Postiaux 2011; Ramos-Pinto 2021; Gomes 2012; Lopez Galbany 2004; Postiaux 2011; Rochat 2010;
Sanchez Bayle 2012; Van Ginderdeuren 2017). The most recent trials Sanchez Bayle 2012).
Informed decisions.
Only three trials specifically reported funding from governmental Details for the two non-randomised comparative trials were as
organisations (Gajdos 2010; González-Bellido 2020; Rochat 2010). follows.
Four trials declared no conflicts of interest (Postiaux 2011; Ramos-
Pinto 2021; Sanchez Bayle 2012; Van Ginderdeuren 2017), and the Belcastro 1984 was a pilot study with 12 patients that compared:
other trials did not report on conflicts of interest.
1. osteopathic manipulative treatment to postural drainage in
Excluded studies a non-randomised fashion (first three participants received
osteopathy, and the rest received postural drainage); and
See Characteristics of excluded studies table.
2. bronchodilators to placebo in a randomised, double-blind
We excluded nine trials after full-text screening. One trial was a fashion.
single-blind randomised clinical trial including infants under two
The endpoints were number of hospital days and mean daily
years of age with moderate acute wheezing episodes attending an
respiratory rates.
outpatient clinic (Castro 2014). We excluded two trials due to being
non-randomised comparative trials (Belcastro 1984; Pupin 2009), Pupin 2009 was a comparative controlled intervention trial that
three trials that were uncontrolled intervention trials (Bernard- included 81 infants with clinically and radiologically diagnosed
Narbonne 2003; Postiaux 2004; Quitell 1988), and two trials that acute viral bronchiolitis. Infants were non-randomly allocated
were observational non-intervention trials (Evenou 2017; Sebban to receive forced expiratory flow technique (FET), vibration plus
2017). We excluded one trial because it was published in a postural drainage, or a control procedure (no respiratory therapy,
predatory journal (Sebban 2019). only manual contact of the physical therapist on the thorax). Each
procedure consisted of a single therapeutic session performed
One excluded trial randomised 48 participants to receive
in the morning for 10 minutes. Heart rate, respiratory rate, and
salbutamol with or without chest physiotherapy using slow and
SpO2 were assessed before the procedure and at 10, 30, and
long expiratory flow and assisted cough techniques (Castro 2014).
After inclusion of the participant by a family physician, those infants 60 minutes afterwards. The authors concluded that "In terms of
in the chest physiotherapy group received physiotherapy for one overall improvement of cardiorespiratory parameters, neither the
hour. Afterwards the infant was assessed by the family physician, FET nor vibration/PD provided any benefit to infants with acute
who was blinded to intervention status, for re-evaluation of his viral bronchiolitis. However, over time, respiratory physical therapy
or her clinical status, clinical score, and oxygen saturation (SpO2) seems to contribute to decreasing the respiratory rate in these
patients".
level. If the infant met the criteria of improvement, they were
discharged. Otherwise, the participant received a second hour of Risk of bias in included studies
treatment, according to their original randomised group. After the
second hour, the infant was assessed again by the original family The overall risk of bias for the comparison vibration and percussion
physician and referred to the hospital for admission if the criteria techniques was unclear or high, because of the lack of description
of improvement based on the clinical score was still not achieved. and limitations associated with the assessment of risk of bias in
The study endpoints were clinical score, SpO2, number of hospital the five trials (Aviram 1992; Bohe 2004; De Córdoba 2008; Nicholas
admissions, and parents' satisfaction. 1999; Webb 1985) (Figure 2; Figure 3).
Figure 2. Risk of bias graph: review authors' judgements about each methodological quality item presented as
percentages across all included studies.
Random sequence generation (selection bias)

Allocation concealment (selection bias)
Blinding (performance bias and detection bias): All outcomes
Incomplete outcome data (attrition bias): All outcomes
Selective reporting (reporting bias)
Other bias
0% 25% 50% 75% 100%
Low risk of bias Unclear risk of bias High risk of bias
Informed decisions.
Figure 3. Risk of bias summary: review authors' judgements about each methodological quality item for each
included study.
Blinding (performance bias and detection bias): All outcomes

Incomplete outcome data (attrition bias): All outcomes
Random sequence generation (selection bias)
Allocation concealment (selection bias)
Selective reporting (reporting bias)

Other bias
Aviram 1992 ? ? ? ? ? −
Bohe 2004 ? + − ? ? +
Conesa-Segura 2018 + + + ? ? +
De Córdoba 2008 ? + ? − ? +
Gajdos 2010 + + + + + +
Gomes 2012 + + + + ? +
Gomes 2016 ? ? − − ? +
González-Bellido 2020 + + ? ? + +
Lopez Galbany 2004 ? ? ? ? ? −
Nicholas 1999 + ? ? ? ? +
Postiaux 2011 ? ? + + ? +
Ramos-Pinto 2021 + + ? − + +
Remondini 2014 ? ? ? + ? +
Rochat 2010 + + ? + ? +
Sanchez Bayle 2012 + ? + ? ? +
Van Ginderdeuren 2017 + + + ? ? +
Webb 1985 ? ? − − ? +
Informed decisions.
The overall risk of bias for the comparison forced expiratory González-Bellido 2020; Ramos-Pinto 2021). Assessment of selective
techniques was unclear. Two trials comparing forced expiration reporting bias was not possible for the remaining trials due to the
techniques were at low risk of bias (Gajdos 2010; Rochat 2010), and scarcity of available data.
one trial was at unclear risk of bias (Remondini 2014).
Other potential sources of bias
The comparison of slow flow techniques (including the retrograde
Two trials were at high risk of other potential biases because they
rhinopharyngeal clearance technique) has four trials at low risk
were only published as abstracts (Aviram 1992; Lopez Galbany
of bias (Conesa-Segura 2018; Gomes 2012; González-Bellido 2020;
2004). We identified no other potential sources of bias for the
Van Ginderdeuren 2017), four trials at unclear risk of bias (Lopez
remaining trials.
Galbany 2004; Postiaux 2011; Ramos-Pinto 2021; Sanchez Bayle
2012), and one trial at high risk of bias (Gomes 2016). Effects of interventions
Allocation See: Summary of findings 1 Slow passive expiration versus control
Scant information was provided regarding randomisation methods for acute bronchiolitis; Summary of findings 2 Forced expiration
and allocation concealment. Ten trials described adequate versus control for acute bronchiolitis
sequence generation procedures (Conesa-Segura 2018; Gajdos
The inclusion of trials with valid data and similar assessments
2010; Gomes 2012; Gomes 2016; González-Bellido 2020; Nicholas
permitted the pooling of data for change in the severity status
1999; Ramos-Pinto 2021; Rochat 2010; Sanchez Bayle 2012; Van
of bronchiolitis for slow passive expiratory technique. We have
Ginderdeuren 2017). Seven trials either described procedures
summarised all other outcomes for all comparisons narratively.
to conceal allocation (De Córdoba 2008; Gajdos 2010; Gomes
2012; Rochat 2010; Van Ginderdeuren 2017), or claimed to have Comparison 1: slow passive expiratory techniques versus
concealed allocation (Bohe 2004; Conesa-Segura 2018). control
Blinding Primary outcomes
Six trials reported masking of families or healthcare personnel, or A summary or results is presented in Summary of findings 1.
both, describing having implemented measures to prevent them
from knowledge of the treatment allocation (Conesa-Segura 2018; 1. Time to recovery
Gajdos 2010; Gomes 2012; Postiaux 2011; Sanchez Bayle 2012; Van One study (71 infants) reported data on time to recovery. Conesa-
Ginderdeuren 2017). Segura 2018 assessed time to recovery as the mean time to reach
an ABSS (Acute Bronchiolitis Severe Scale) clinical score value
Masking of outcome assessment was most likely absent in all below two points. The authors report that mean recovery time
but two of the included trials. Eight trials implemented rigorous was statistically significantly shorter in the experimental group (2.6
procedures to mask outcome assessments (Conesa-Segura 2018; days, 95% confidence interval (CI) 2.1 to 3.1 days) than in the control
Gajdos 2010; Gomes 2012; González-Bellido 2020; Postiaux 2011; group (4.4 days, 95% CI 3.69 to 5.1 days). Also, the mean time when
Rochat 2010; Sanchez Bayle 2012; Van Ginderdeuren 2017), but 75% of the children reached an ABSS below two was also shorter
the other trials were admittedly open (Bohe 2004; Rochat 2010; in the experimental group (after three days of treatment) than in
Webb 1985), or most likely so (Aviram 1992; De Córdoba 2008; the control group (after six days). The certainty of evidence was low,
Gomes 2016; Lopez Galbany 2004; Nicholas 1999; Ramos-Pinto due to unclear risk of bias and serious imprecision of estimates.
2021). Even though some outcomes were objective and not subject
to bias (oxygen saturation, heart rate), other outcomes depended 2. Change in the severity status of bronchiolitis
on observation and could be more vulnerable (clinical scores and
Seven trials analysing 482 infants assessed severity of bronchiolitis
respiratory discomfort questionnaire).
through clinical scores (Conesa-Segura 2018; Gomes 2012; Gomes
Incomplete outcome data 2016; Lopez Galbany 2004; Postiaux 2011; Ramos-Pinto 2021; Van
Ginderdeuren 2017). Time of assessment ranged from one to three
A single trial had a large sample size and an adequate description hours after treatment, Postiaux 2011; Van Ginderdeuren 2017, to
of attrition of participants, as well as a description of how they discharge from hospital (Conesa-Segura 2018). One ambulatory
were handled (ITT analysis) (Gajdos 2010). Another trial had a large study conducted the intervention also after emergency department
sample and an adequate description of attrition of participants discharge, assessing participants at 15 days postdischarge (Ramos-
(Rochat 2010). In the rest of the included trials the attrition of Pinto 2021). Severity status was assessed with different scales,
participants was either null (Gomes 2012; Postiaux 2011; Ramos- although in all of them higher values indicated higher severity:
Pinto 2021), or low and unclearly dealt with (Bohe 2004; Conesa- Wang clinical score (Gomes 2012; Postiaux 2011; Van Ginderdeuren
Segura 2018; De Córdoba 2008; Gomes 2016; González-Bellido 2020; 2017), Wood score (Gomes 2016), modified Bierman Pierson score
Nicholas 1999; Sanchez Bayle 2012; Webb 1985; Van Ginderdeuren (Lopez Galbany 2004), Kristjansson score (Ramos-Pinto 2021), and
2017). the ABSS (Conesa-Segura 2018). Results are presented in Figure
4 organised by use of RRT as part of the physiotherapy intervention.
Selective reporting
Three trials had a low risk of selective reporting bias, as shown by
comparing the trial protocol with the published paper (Gajdos 2010;
Informed decisions.
Figure 4. Forest plot of comparison: 1 Slow flow versus control, outcome: 1.1 Severity clinical score.
Chest physiotherapy Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.1.1 Slow expiratory technique with no RRT

Gomes 2012 -3.1 2.02 10 -2.4 1.58 10 8.0% -0.37 [-1.26 , 0.52]
Lopez Galbany 2004 -3.39 3.33 26 -2.5 3.33 24 13.9% -0.26 [-0.82 , 0.29]
Postiaux 2011 3.7 2.7 29 4.6 2.9 26 14.6% -0.32 [-0.85 , 0.22]
Van Ginderdeuren 2017 -0.85 0.55 62 -0.5 0.4 31 17.0% -0.69 [-1.13 , -0.24]
Subtotal (95% CI) 127 91 53.5% -0.45 [-0.73 , -0.18]
Heterogeneity: Tau² = 0.00; Chi² = 1.80, df = 3 (P = 0.62); I² = 0%
Test for overall effect: Z = 3.21 (P = 0.001)
1.1.2 Slow expiratory technique with RRT

Conesa-Segura 2018 1 1.31 39 2.3 2.09 32 15.8% -0.75 [-1.24 , -0.27]
Ramos-Pinto 2021 0.3 0.5 28 1.2 1.5 17 12.3% -0.89 [-1.52 , -0.25]
Subtotal (95% CI) 67 49 28.1% -0.80 [-1.19 , -0.42]
Test for overall effect: Z = 4.09 (P < 0.0001)
1.1.3 Only RRT

Gomes 2016 5.12 1.45 50 4.88 2.1 50 18.4% 0.13 [-0.26 , 0.52]
Subtotal (95% CI) 50 50 18.4% 0.13 [-0.26 , 0.52]
Heterogeneity: Not applicable
Total (95% CI) 244 190 100.0% -0.43 [-0.73 , -0.13]

Test for overall effect: Z = 2.83 (P = 0.005) -1 -0.5 0 0.5 1
Test for subgroup differences: Chi² = 11.42, df = 2 (P = 0.003), I² = 82.5% Favours CP Favours control
Overall, slow passive expiratory techniques reduced the severity We conducted a post hoc sensitivity analysis excluding Gomes
status of bronchiolitis more than the control (standardised mean 2016, as the active intervention in this study was exclusively RRT,
difference (SMD) −0.43, 95% CI −0.73 to −0.13; P = 0.03, I2 = 55%; 7 and the results corroborated the benefit observed in the main
trials, 434 participants; low-certainty evidence; Analysis 1.1). analysis, with no signs of heterogeneity (SMD −0.57, 95% CI −0.80 to
−0.35; I2 = 0%; 6 trials, 334 participants).
In Postiaux 2011, a significant small improvement in the Wang
clinical score was observed immediately after the intervention Secondary outcomes
in the group receiving slow flow physiotherapy and salbutamol
1. Respiratory parameters
(3.6 versus 5.1, analysis of variance (ANOVA) P = 0.02), which
disappeared two hours later (4.6 versus 3.7, ANOVA P = 0.21). The No data were presented for this outcome.
authors report a "day-to-day baseline improvement in Wang score
significantly better [in the CPT group] than that in the control 2. Duration of oxygen supplementation
group", but this conclusion is based on within-group tests on a One trial (236 infants) compared the average hours with oxygen
diminishing sample due to discharge of patients ("After 5 days, 6 of supplementation in the physiotherapy and control groups, which
the 8 control group patients had been discharged, whereas all 12 of showed no statistically significant differences (Sanchez Bayle
the new-method-CPT group had been discharged"). 2012). Mean hours of oxygen therapy needed were 49.98 ± 37.10 in
the physiotherapy group and 53.53 ± 38.87 in the control group.
We could not conduct subgroup analyses by severity, as all trials
in this comparison included participants with mild to moderate 3. Length of hospital stay
bronchiolitis.
This outcome was assessed in four trials (345 infants), and only
Subgroup analyses by setting: when considering only interventions one of them detected statistically significant differences in length
delivered in-hospital, slow passive expiratory techniques reduced of hospital stay between the physiotherapy and control groups.
the severity status of bronchiolitis more than control (SMD −0.37, Mean length of stay in Sanchez Bayle 2012 was 4.56 ± 2.07 days
95% CI −0.68 to −0.06; P = 0.04, I2 = 54%; 6 trials, 389 participants). in the physiotherapy group and 4.54 ± 1.72 days in the control
A single study in an ambulatory setting assessed the effect at 15 group. Mean length of stay in Lopez Galbany 2004 was 6.18
days after emergency department discharge (end of intervention), days in the physiotherapy group and 5.88 in the control group.
and the results suggested that slow passive expiratory techniques Average hospital stay in Postiaux 2011 was 5.3 ± 1.8 days in the
may slightly reduce the severity status of bronchiolitis compared to physiotherapy group and 6.3 ± 2 days in the control group (Mann-
control (mean difference (MD) −0.9, 95% CI −1.6 to −0.3; 1 study, 45 Whitney U test P = 0.25).
participants).
Van Ginderdeuren 2017 assessed as primary outcome the time to
clinical stability and discharge from hospital, measured as length
Informed decisions.
of hospital stay in days. Since no explicit criteria were reported on assisted autogenic drainage (AAD) and intrapulmonary percussive
what defined clinical stability, we have reported the data as length ventilation (IPV). We did not attempt to pool data, as the
of hospital stay. Average time to discharge was significantly shorter instrumental physiotherapy techniques were different.
in the physiotherapy groups (3.6 ± 1.4 days in assisted autogenic
drainage (AAD) and 3.5 ± 1.3 days in intrapulmonary percussive Primary outcomes
ventilation (IPV)) than in the control group (4.5 ± 1.9 days) (analysis 1. Time to recovery
of covariance (ANCOVA) test P = 0.05 for AAD, and P = 0.03 for IPV).
There were no differences between physiotherapy groups. No trials reported estimates of time to recovery between study
arms. González-Bellido 2020 reported a higher percentage of
4. Avoidance of hospital admission or emergency visits in ambulatory participants returning to a normal status by the Wang score at 20
patients minutes in the slow expiratory group (90.9%) than in the HFCWC
A single study in outpatients (45 infants) indirectly assessed the group (76.6%). Results at 10 minutes were 77.3% and 53.2%,
need for hospital admission, as it was one criterion for withdrawal respectively.
of included participants (Ramos-Pinto 2021). Five infants were 2. Change in the severity status of bronchiolitis
withdrawn from the study due to hospital admission following
clinical worsening (intervention group, n = 2; control group, n = Van Ginderdeuren 2017 found a similar effect on clinical scores
1) or other clinical problems (gastroenteritis or vascular disease between AAD and IPV (MD 0.10, 95% CI −0.17 to 0.37). In González-
(intervention group, n = 2)). Bellido 2020, the slow flow intervention had a slightly larger effect
on the Wang clinical score than HFCWC (MD 0.14, 95% CI 0.07 to
5. Use of bronchodilators and steroids 0.35) at 20 minutes.
One trial including 236 infants recorded the percentages of
Secondary outcomes
participants that received salbutamol, ipratropium bromide,
or antibiotics, showing no statistical differences between the 1. Respiratory parameters
intervention and control groups (Sanchez Bayle 2012). González-Bellido 2020 reported a minimal reduction in respiratory
6. Parents' impression of physiotherapy benefit rate (MD 0.277 breaths/min, 95% CI 0.47 to 1.34) and heart rate
(MD 5.87 beats/min, 95% CI 0.72 to 13.2) in the slow flow group
No data were presented for this outcome. compared to the HFCWC group.
7. Adverse events 2. Duration of oxygen supplementation
Six trials (565 infants) reported on the safety of the procedures No data were presented for this outcome.
explored. The study by Gomes 2016 reported higher number of
episodes of nasal bleeding and vomiting in the control aspiration 3. Length of hospital stay
group (28 and 11 episodes, respectively) when compared with the The two trials were conducted in outpatient participants, therefore
clearance physiotherapy group (1 and 7 episodes, respectively). Van this outcome was not applicable.
Ginderdeuren 2017 reported no direct complications (respiratory
deterioration with oxygen desaturation, bradycardia, vomiting) 4. Avoidance of hospital admission or emergency visits in ambulatory
due to the treatment, although it reported complications due to patients
bronchiolitis severity in 4.3% cases (two in the control group,
No data were presented for this outcome.
and one in each physiotherapy group), requiring high-flow oxygen
therapy, antibiotics, and/or corticosteroids. We could not pool data 5. Use of bronchodilators and steroids
for these two trials given that the units of analysis were episodes in
one study and participants in the other. No data were presented for this outcome.
6. Parents' impression of physiotherapy benefit

Three in-hospital trials explicitly stated that no adverse events
were observed, but there is no definition of the events considered No data were presented for this outcome.
(Conesa-Segura 2018; Postiaux 2011; Sanchez Bayle 2012).
7. Adverse events
A single study conducted in 45 ambulatory participants explicitly
González-Bellido 2020 reported that in the majority of infants
stated that no relevant adverse events were observed in the
(airway clearance techniques group: 42/44, 95.5%; HFCWC group:
intervention group, but there is no definition of the events
39/47, 83.0%), no adverse events were present after 20 minutes.
considered (Ramos-Pinto 2021). No mention is made regarding
Tachycardia was observed in two infants in the airway clearance
adverse events in the control group. The certainty of the evidence
group and six in the HFCWC group; petechiae and vomiting were
for adverse events was very low.
observed in one infant in the HFCWC group.
Comparison 2: slow passive expiratory techniques versus
Comparison 3: forced passive expiratory techniques versus
instrumental techniques
control
Two trials compared passive expiratory techniques (slow
Primary outcomes
passive expiratory techniques) to instrumental physiotherapy
(González-Bellido 2020; Van Ginderdeuren 2017). González-Bellido A summary of results is presented in Summary of findings 2.
2020 compared slow flow versus high-frequency chest wall
compression (HFCWC), and Van Ginderdeuren 2017 compared
Informed decisions.
1. Time to recovery Subgroup analyses by setting: these could not be conducted

Three trials (628 infants) assessed resolution of bronchiolitis in because all trials were in hospitalised infants.
terms of time to recovery, Gajdos 2010; Remondini 2014, and Secondary outcomes
time to clinical stability (Rochat 2010). Overall, there were no
significant differences between groups in any of these trials. We One trial comparing the addition of forced passive expiratory
did not perform a meta-analysis due to clinical heterogeneity physiotherapy to postural drainage did not observe differences
considerations given the differences in how the outcome was in SpO2 during and after the intervention (Remondini 2014).
defined, assessed, and reported in the individual trials. There were no data on secondary outcomes such as duration
of oxygen supplementation, length of hospital stay, and use of
In Gajdos 2010, the physiotherapy intervention (forced expiratory bronchodilators and steroids.
technique with assisted cough) had no significant effect on time
to recovery as assessed by the logrank test and a Cox regression. 1. Respiratory parameters
The median time to recovery was 2.31 days (95% CI 1.97 to 2.73)
In Rochat 2010, the rate of improvement of a respiratory
for the control group and 2.02 days (95% CI 1.96 to 2.34) for the
score, defined as secondary outcome, only showed a slightly
physiotherapy group (hazard ratio 1.09, 95% CI 0.91 to 1.31; P =
faster improvement of the respiratory score in the prolonged
0.33). In Rochat 2010, time to clinical stability, assessed as a primary
slow expiration technique group when including stethacoustic
outcome, was similar for forced expiratory technique and placebo
properties (mixed linear model P = 0.044). No differences were
(2.9 ± 2.1 versus 3.2 ± 2.8 days, logrank test P = 0.45).
observed in oxygen saturation (SpO2) (mixed linear models P = 0.85)
In Remondini 2014, discharge was conducted when recovery was or respiratory rates (mixed linear models P = 0.24).
achieved, defined as a disease severity score respiratory distress
2. Duration of oxygen supplementation
assessment instrument (RDAI) ≤ 4 with adequate oxygenation on
room air (SpO2 ≥ 92%). The median time to discharge was three No data were presented for this outcome.
days (range two to five days) in the physiotherapy group, and
3. Length of hospital stay
two days (range one to five days) in the control group, with no
statistically significant difference between the two groups (P = No data were presented for this outcome.
0.408).
4. Avoidance of hospital admission or emergency visits in ambulatory
The certainty of the evidence was high. patients
Subgroup analyses by severity: results for the mild-moderate All trials were conducted on hospitalised infants, therefore this
subgroup, Remondini 2014, and the severe subgroup, Gajdos 2010; outcome was not applicable.
Rochat 2010, were qualitatively similar, as there were no differences 5. Use of bronchodilators and steroids
between the intervention and control in any of them.
Subgroup analyses by setting: these could not be conducted, as all
trials in this comparison included hospitalised infants. 6. Parents' impression of physiotherapy benefit
Remondini 2014 presented data on parents' impression on the

2. Change in the severity status of bronchiolitis
benefit of physiotherapy compared to conventional physiotherapy.
Two trials (132 infants) assessed severity of bronchiolitis using Parents in both groups reported satisfaction related to
three non-comparable clinical scores, therefore we did not attempt improvements of breathing, feeding, and nasal congestion, but no
to pool results. difference was observed between the intervention groups. Gajdos
2010 reported not observing any significant difference in the way
One trial (103 infants) evaluated severity of bronchiolitis through a the parents rated the influence of physiotherapy on respiratory
clinical score assessing feeding, vomiting, and sleep (Rochat 2010). status (risk ratio (RR) 0.99, 95% CI 0.90 to 1.08; P = 0.89) or comfort
No differences were observed in daily change in the clinical score (RR 0.99, 95% CI 0.94 to 1.05; P = 0.84).
between the physiotherapy and the control groups (MD −0.21, 95%
CI −0.26 to −0.16); mixed linear models P = 0.37. 7. Adverse events
One trial (29 infants) compared the addition of two chest Two trials (599 infants) assessed adverse events or complications.
physiotherapy techniques (either forced passive expiratory In Gajdos 2010, there were no significant differences between
techniques or manual percussion or tapping) to postural drainage. groups in the proportion of children who experienced one episode
The trial assessed severity of bronchiolitis using the RDAI of bradycardia with desaturation (RR 1.0, 95% CI 0.2 to 5.0; P =
(Remondini 2014). Both groups showed an RDAI decrease 10 1.00) or without desaturation (RR 3.6, 95% CI 0.7 to 16.9; P = 0.10).
minutes after the intervention (P < 0.001) and maintained these Conversely, in the increased exhalation technique physiotherapy
values after 60 minutes. However, no differences were found group, a higher proportion of children had transient respiratory
between groups at 60 minutes (MD −0.13, 95% CI −0.96 to 0.70). destabilisation (RR 5.4, 95% CI 1.6 to 18.4; P = 0.002) or vomited
during the procedure (RR 10.2, 95% CI 1.3 to 78.8; P = 0.005).
The certainty of evidence was very low.
Regarding the physiotherapy technique, in Rochat 2010,
Subgroup analyses by severity: these could not be conducted complications were defined as concomitant bacterial infection
because no pooling was attempted. or transfer to the intensive care unit due to respiratory fatigue.
The trial authors state that complications related to bronchiolitis
Informed decisions.
severity were rare and occurred more frequently in the control groups (P = 0.02, Kruskal Wallis test). Respiratory discomfort
group, albeit not significantly (12 in the control group, 7 in the was assessed by means of the Silverman-Andersen Questionnaire
intervention group; RR 0.56, 95% CI 0.24 to 1.30; P = 0.21). Also, (Silverman 1956), and significantly improved (P < 0.05, Friedman
the trial authors state that no direct complications of physiotherapy analysis of variance) post-15 minutes with respect to baseline in the
such as respiratory deterioration occurred. two treatment groups, but not in the control group. It is not clear
from the paper whether differences across the groups were tested,
Remondini 2014 did not report any adverse events. but it can be assumed that the lack of data means that there were
not significant differences across groups.
For adverse events, the certainty of evidence was high.
2. Duration of oxygen supplementation
Comparison 4: positioning plus percussion and vibration
(conventional techniques) versus control Nicholas 1999 found that the mean number of hours with
supplemental oxygen was 63 (range 2.3 hours to 128 hours) in the
Primary outcomes control group compared with 86 (range 36 hours to 148 hours) in the
1. Time to recovery physiotherapy group. Differences were reported as not significant
using a non-parametric test.
3. Length of hospital stay
2. Change in the severity status of bronchiolitis
In Bohe 2004, mean length of hospital stay was 4 days (SD 2) in
Five trials (241 analysed infants) assessed the severity of the treatment group, and 3.9 days (SD 1.3) in the control group.
bronchiolitis by means of clinical scores, with none of them There were no statistically significant differences between groups
showing statistical differences between groups at day five (Aviram (MD 0.13, 95% CI −1.00 to 1.26). In Nicholas 1999, mean length of
1992; Bohe 2004; De Córdoba 2008; Nicholas 1999; Webb 1985). hospital stay was 6.6 days (range 2.3 days to 11.5 days) in the control
Nicholas 1999 and Webb 1985 used a common clinical score. group, and 6.7 days (range 3 days to 9.5 days) in the physiotherapy
In Webb 1985, there were no statistically significant differences group. Webb 1985 showed a median length of hospital stay of 4 days
between groups in relation to the clinical score or to the proportion (range 1 day to 15 days) in the control group, and 4 days (range 2
of infants who remained in hospital at day five. The clinical score days to 11 days) in the physiotherapy group.
was similar in both groups at baseline and on each of the first five 4. Avoidance of hospital admission or emergency visits in ambulatory
days of assessment at the hospital. The median score on admission patients
was 12 (range 4 to 24) in 46 infants in the control group, and
10 (range 4 to 22) in 44 infants in the physiotherapy group. On All trials were conducted on hospitalised participants, therefore
the fifth day, 18 infants who remained in hospital had a median this outcome was not applicable.
score of 5 (range 1 to 11) in the control group, and 11 infants had 5. Use of bronchodilators and steroids
a median score of 6 (range not presented in the original article)
in the physiotherapy group. The study also assessed the length No data were presented for this outcome.
of illness, which was not significantly different between groups
6. Parents' impression of physiotherapy benefit
(Mann-Whitney test) (Mann 1947). The median length of illness was
14 (range 4 to 27) in the control group, and 13 (range 7 to 26) in the No data were presented for this outcome.
physiotherapy group. Nicholas 1999 expressed clinical scores using
means but did not report standard deviations (SDs). There were 7. Adverse events
no differences in the admission mean clinical scores (intervention In Bohe 2004, one case of atelectasis was reported in the control
group 9.1 versus control group 10.9) between groups. The trial arm. The infant was withdrawn from the trial and assigned to
authors reported that clinical scores did not show any statistically receive chest physiotherapy.
significant differences between groups during the five-day trial.
Data were provided on a graph but could not be extracted. Bohe Subgroup analyses
2004 used a different clinical severity score to the one used in the
other two trials. The score at day five or the day of discharge was The subgroup analysis by participant severity was confounded
3.25 (SD 1.27) in the physiotherapy group, and 3.12 (SD 1.15) in the by the different chest physiotherapy techniques. Four trials
control group (MD 0.13, 95% CI −0.71 to 0.97). The unpublished trial included infants with severe bronchiolitis, corresponding to the
did not describe the clinical score used, and also failed to show comparisons of vibration and percussion (Nicholas 1999), slow
differences between treatment groups (Aviram 1992). passive expiration (Sanchez Bayle 2012), and forced expiration
(Gajdos 2010; Rochat 2010). Five trials included infants with
Secondary outcomes moderate bronchiolitis, corresponding to the comparisons of slow
passive expiration, Gomes 2012; Lopez Galbany 2004; Postiaux
1. Respiratory parameters 2011, and vibration and percussion (Bohe 2004; Webb 1985).
Data for respiratory parameters were available in only one of One trial of vibration and percussion techniques included infants
the included trials, assessed immediately after treatment and at with mild bronchiolitis (De Córdoba 2008). While no formal meta-
15 minutes (De Córdoba 2008). No significant differences were analysis or test of subgroups could be conducted due to lack of
observed in oxygen saturation levels or in respiratory frequency data, it became clear that the evidence for the slow flow chest
between treatment groups in their 15-minute results (Kruskal physiotherapy techniques was unevenly distributed, with slow
Wallis test) (Kruskal 1952). The amount of aspirated secretions was flow techniques studied in less severe participants than forced
significantly smaller in the control group than in the intervention expiratory techniques.
Informed decisions.
For conventional techniques, it was not possible to conduct direct effect on airway obstruction resulting in improved mucus
subgroup analysis by setting, since all trials included hospitalised transportability.
infants.
In analysing the results according to the type of technique
Subgroup analysis performed in the included trials used, it is clear that two airways clearance techniques are not
beneficial (conventional and forced expiratory). However, slow
Sanchez Bayle 2012 conducted subgroup analyses of the effect
passive expiratory techniques, alone or in combination, could
of physiotherapy on length of hospital stay, and duration of
provide a relief in disease severity.
oxygen supplementation by subgroups of respiratory syncytial
virus (RSV) status. They found statistical differences in the number The included trials did not report severe adverse events for
of hours with oxygen supplementation in the subgroup of RSV- most of the techniques used. However, Gajdos 2010 observed a
positive infants that received physiotherapy compared to those significant risk of vomiting (RR > 10) and respiratory instability (RR
RSV-positive infants in the control group (mean hours 48.80 ± 37.70 > 5) with forced expiratory technique. Few or no complications
versus 58.68 ± 36.78; P = 0.042, Mann-Whitney test). There were no related to bronchiolitis severity were observed in trials using slow
other statistical differences. passive expiratory techniques (Conesa-Segura 2018; González-
Bellido 2020; Postiaux 2011; Ramos-Pinto 2021; Rochat 2010;
Gajdos 2010 performed subgroup analyses by personal eczema
Sanchez Bayle 2012). For infants with nasal obstruction, no nasal
or history of atopy, RSV-positive infection and hypoxaemia at
bleeding was observed and fewer vomiting episodes were reported
randomisation. There was no statistically significant quantitative
with RRT compared to nasal aspiration (Gomes 2016).
interaction on time to recovery between any of these subgroups.
Nicholas 1999 performed a subgroup analysis between infants who

Overall completeness and applicability of evidence
had more than 10 points on the baseline clinical score and those Based on the evidence provided in this review, the following four
with a baseline clinical score below 9.5. There were no differences points must be considered when airway clearance techniques are
between the physiotherapy and control groups in this subgroup used for infants with acute bronchiolitis.
analysis.
First, infants with severe acute bronchiolitis are unlikely to
Webb 1985 reported that there were no differences between benefit from chest physiotherapy due to their critical respiratory
treatments in daily scores or length of illness in the subset of status (distress, airways inflammation, etc.) and severe symptoms
participants with some degree of collapse/consolidation on chest (exhaustion, apnoea, cyanosis, poor fluid intake, etc.) or possible
X-rays. comorbidities (Meissner 2016). In infants with mild acute
bronchiolitis, respiratory symptoms should rapidly decrease, and
DISCUSSION chest physiotherapy helps to accelerates this. Infants who benefit
the most are those with a moderate exacerbation, as airway
Summary of main results clearance techniques have an impact in reducing the severity
This review included 17 trials (1679 infants) exploring the of acute bronchiolitis (Conesa-Segura 2018; Gomes 2012; Lopez
efficacy of five physiotherapy techniques (vibration and percussion Galbany 2004; Ramos-Pinto 2021; Van Ginderdeuren 2017). Chest
(conventional techniques), slow passive expiratory techniques, physiotherapy should therefore target infants with moderate
forced passive expiratory techniques, and rhinopharyngeal exacerbation of acute bronchiolitis.
retrograde inspiratory technique), compared to control
Second, only slow passive expiratory techniques, alone or in
(conventional medical care with no physiotherapy intervention) or
combination with RRT, can improve the severity score compared to
other respiratory physiotherapy techniques, in hospitalised or non-
control infants with moderate bronchiolitis (Conesa-Segura 2018;
hospitalised infants with acute bronchiolitis not under mechanical
Gomes 2012; Lopez Galbany 2004; Postiaux 2011; Ramos-Pinto
ventilation.
2021; Van Ginderdeuren 2017). Similar results, but not as high, were
The slow expiratory techniques showed a mild-to-moderate observed using instrumental techniques, González-Bellido 2020;
significant benefit in change of disease severity, which was higher Van Ginderdeuren 2017, or RRT, Gomes 2016, when applied alone,
when combined with RRT. However, there was no significant producing a decrease in length of hospital stay in one trial (Van
effect on length of hospital stay, except for in one study (Van Ginderdeuren 2017). However, some techniques such as forced
Ginderdeuren 2017), nor for oxygen requirements. Regarding RRT passive expiratory techniques have adverse effects and should be
applied in infants with acute moderate bronchiolitis (Gomes 2016), avoided (Gajdos 2010).
a decrease in severity clinical score was observed compared to
Third, related to the setting where the intervention should be
nasal aspiration. Instrumental techniques showed improvements
used, two trials were conducted in non-hospitalised infants (i.e.
in severity score immediately after the intervention, although less
outpatients) and achieved positive results in infants with moderate
than slow passive expiratory techniques. For conventional or forced
acute bronchiolitis (González-Bellido 2020; Ramos-Pinto 2021).
expiratory techniques, no effect was observed in any variable.
For the first time, chest physiotherapy for acute bronchiolitis has
In this 2022 update, we reported a meta-analysis with positive not been linked to the hospital environment, probably because
effects produced by the airways clearance techniques slow the infants had moderately severe acute bronchiolitis, and chest
expiratory techniques alone or combined with RRT in severity physiotherapy was effective in this non-clinical setting.
score of infants with acute bronchiolitis. These techniques should
Fourth, a new chest physiotherapy intervention, RRT, which
be considered in infants with acute moderate bronchiolitis as a
removes nasopharynx secretions, was explored (Gomes 2016). This
co-adjuvant intervention along with medical treatment, due to a
is a common site of mucus obstruction in bronchiolitis (Norris
Informed decisions.
2018). When comparing RRT to nasal aspiration, this non-invasive A methodological issue in the trials was the implementation of
technique demonstrated an immediate decrease in severity score, a valid placebo. Because the majority of the trials had a non-
and had few adverse events and complications in infants with intervention group, usually control groups received standard care,
moderate acute bronchiolitis. and the researchers would have been expected to establish an
outcome assessment procedure that prevented bias. Again, this
Certainty of the evidence was effectively and imaginatively established in Conesa-Segura
2018, Gajdos 2010, Gomes 2016, Postiaux 2011, Sanchez Bayle
The certainty of the evidence in the review varied, depending on
2012, and Van Ginderdeuren 2017. Gajdos 2010 and Sanchez
the comparison being considered. While there is high-certainty
Bayle 2012 compared chest physiotherapy with nasal suctioning
evidence for forced expiration techniques, the certainty of evidence
or postural changes, respectively. Postiaux 2011 administered an
is low for slow passive expiration techniques, and very low for
aerosol composed of albuterol (3 mL) and hypertonic saline (3%
vibration and percussion. The GRADE assessments rely heavily on
NaCl) in both groups and added the slow passive expiration
the risk of bias of the trials, and the imprecision of their results,
techniques to the intervention group. Conesa-Segura 2018 applied
mainly due to small sample sizes. For adverse effects, there were
similar actions, hypertonic saline nebulisation (3% NaCl) plus
concerns regarding indirectness of assessments for trials that were
nasopharynx aspiration. The same nasopharyngeal aspiration was
unclear on how the adverse effects were assessed.
carried out in the Gomes 2016 control group. Van Ginderdeuren
The high-certainty evidence for forced expiration techniques in 2017 applied the more original placebo intervention by bouncing
infants with severe bronchiolitis stems from the overall low risk of infants from the control group on a fit ball, as a sort of "shaking"
bias of the trials, the large number of participants included, and technique. However, none of these alternatives were shown to
the consistency of the results of the trials. Although the three trials have an impact on the overall trial results, as this lack of placebo
assessed recovery with two different measures (time to recovery alternative will usually overestimate the results, favouring the
and time to clinical stability), the results were homogeneous intervention.
and led to similar conclusions of no effect of the physiotherapy
It is important to consider that a limitation of the majority of
techniques. One of the trials had a very large sample size and good
included trials was that they did not analyse the effectiveness of
methodological quality, and was designed to detect a 20% decrease
the techniques in terms of duration of oxygen supplementation,
in time to recovery, assessed eight-hourly (Gajdos 2010). Since this
time to recovery or other treatments used, such as hypertonic
adequately powered trial was negative, our confidence in the lack
saline nebulisation. Due to their importance in terms of disease
of effect observed with this physiotherapy technique is high. Also,
improvement, future research should take these variables into
the negative results are consistent in all the assessed outcomes,
account.
including respiratory parameters, which are more sensitive to the
treatment and do not show a statistical benefit. There are also
Potential biases in the review process
negative results in length of hospital stay, a less relevant outcome
since it is a crude measure of length of illness, and is sensitive to To avoid biases in the review process, we applied robust methods
unrelated factors (i.e. hospital discharge practices, day of the week, for searching, study selection, data collection, and risk of bias
parental wishes, etc.). assessment. To guarantee the comprehensiveness of the search,
we sought both published and unpublished trials and contacted
The low-certainty evidence for the slow flow techniques in trial authors where possible to gather additional information about
moderate/severe cases stems from the unclear risk of bias, unpublished trials. While pooling of data was not possible for some
moderate sample sizes, and methodological limitations in the interventions, conventional techniques, we have considered the
adverse effects assessment in the included studies. The included potential impact of this and have performed a careful assessment
trials used different measures of clinical severity, and some of of individual trials. In addition, we performed a rigorous risk of bias
them presented incomplete data. Although most data on clinical assessment of the included trials.
efficacy were positive overall, most of the effects were not explored
for a long time period, except for in Ramos-Pinto 2021, and Agreements and disagreements with other studies or
could therefore be considered as transient. The largest trial in the reviews
comparison (and second-largest trial in the review) did not perform
an a priori sample size estimation, thus we cannot assess the The first publication of this review in 2005, Perrotta 2005,
power of the trial or the potential lack of power of the conclusions prompted the recommendation that chest physiotherapy based on
(Sanchez Bayle 2012). The very low certainty of evidence on the vibration and percussion should not be used routinely in hospital
safety of slow passive expiration techniques stems from doubts settings (BGT 2005; Ralston 2014a; SIGN 2006). Recently, some
regarding how safety was assessed in the included trials. The safety systematic reviews and clinical guidelines have been published
issues observed with forced expiratory techniques are related to on this topic based on the same evidence, and reached similar
the intrinsic characteristics of forcing expiration, and it could be conclusions to the previous Cochrane Review (Roqué i Figuls
argued that these issues would be minor or non-existent in the slow 2016a) (systematic reviews: Bourke 2010; Castro-Rodriguez 2015;
passive expiration procedures due to their gentler nature. González 2010b; Kirolos 2020; Schechter 2007; Wainwright 2010;
and clinical guidelines: Ministerio de Salud Chile 2013; NICE 2021;
The very low-certainty evidence for vibration and percussion Norris 2018; PREDICT 2019; Ralston 2014a). Chest physiotherapy
techniques stems from the high risk of bias and small sample does not have to be routinely recommended, except when infants
sizes in the included studies. However, the consistency between present with comorbidities or with nasopharyngeal obstructions.
trials in showing a lack of effect and the external reports on safety Due to the findings of our Cochrane Review and the previously
of the procedures strengthen a negative conclusion (Beeby 1998; mentioned evidence (Roqué i Figuls 2016a), in France, two trials
Chalumeau 2002; Harding 1998; Knight 2001). were conducted to analyse the use of forced expiratory technique
Informed decisions.
(AFE in French) in clinical settings. They observed a decrease Implications for research
in chest physiotherapy prescription (Branchereau 2013; HAS-FR
2019), and a recommendation to not systematically prescribe Based on the results of this review, it seems clear that conventional
chest physiotherapy based on forced expiratory technique for and forced expiratory techniques will not change the course of the
ambulatory infants (Verstraete 2014). As a consequence, this disease in hospitalised infants with severe bronchiolitis. Further
updated review includes the most recent RCTs; introduces two new trials using these techniques in this population should therefore
interventions, instrumental and nasopharyngeal techniques; and not be a research priority.
remains the main source of evidence on chest physiotherapy for
There is evidence to suggest that passive slow expiratory technique
acute bronchiolitis.
may result in a mild to moderate improvement in severity of the
disease, when compared to control. This evidence comes mostly
AUTHORS' CONCLUSIONS
from infants with moderately acute bronchiolitis treated in a in-
Implications for practice hospital setting; however, the available evidence is of low certainty,
and further trials with more rigorous methodology are needed
Conventional chest physiotherapy (postural drainage plus to reach stronger conclusions. On the other hand, the evidence
percussion and vibration techniques) has not been shown to is very limited with regard to infants with severe bronchiolitis,
improve the severity of bronchiolitis, and is associated with adverse and in infants with moderate severity bronchiolitis treated in
effects. For these reasons, conventional techniques must not be ambulatory settings; these two populations should therefore be
used in clinical practice for infants with bronchiolitis. further studied. Other questions that remain unanswered relate to
the minimum duration and dose of physiotherapy that are needed
Results for chest physiotherapy using passive flow-oriented to achieve persistent benefits. Any research conducted on this topic
expiratory techniques (which includes both forced expiratory should include a specific and thorough assessment of adverse
techniques and slow flow techniques) have differed. For the effects and reported infant satisfaction and harms.
forced expiratory technique, no improvements on severity scores,
nor a reduction in time to recovery or length of hospital stay, Currently, the evidence regarding new physiotherapy techniques
was observed. However, for slow expiratory techniques, a mild such as rhinopharyngeal retrograde technique or instrumental
to moderate significant benefit in severity score - higher when physiotherapy is very scarce, and more trials are needed to
combined with rhinopharyngeal retrograde technique - was shown. determine the effectiveness of the these techniques, alone or
Furthermore, in only one study evaluating slow passive expiratory in combination with slow passive expiratory techniques. Other
techniques, a significant decrease in length of hospital stay was questions to be clarified refer to the role of rhinopharyngeal
observed. No benefits in oxygen requirements were reported with retrograde technique in acute bronchiolitis with nasal obstruction
any intervention. in comparison to nasal aspiration or nasopharyngeal suctioning.
For rhinopharyngeal retrograde technique applied in infants We recommend exploring the effects of these techniques in non-
with moderate bronchiolitis, a decrease in severity score was hospitalised infants with moderate bronchiolitis. At present, only
observed in comparison to nasal aspiration, but not in infants with two trials have been conducted in non-hospitalised infants, and the
severe bronchiolitis. Instrumental techniques showed moderate generalisation of the review's body of evidence to non-hospitalised
improvements in severity score immediately after intervention. infants may not be straightforward due to differences in the
health conditions and severity of disease between hospitalised and
By considering the severity of the disease, it is notable that only ambulatory infants.
moderate acute bronchiolitis infants could benefit from chest
physiotherapy, slow expiration, rhinopharyngeal, or instrumental ACKNOWLEDGEMENTS
techniques applied in-hospital or ambulatory, as shown in two
trials. This is important to take into account when considering these We thank Dr Gadjós, Dr Asher Tal, Ms Núria Lopez, Dr Postiaux,
techniques as a co-adjuvant to medical treatment. Dr Gomes, Dr Rochat, Dr Sanchez Bayle, and Dr Gomes for their
help in providing information regarding their studies. We thank the
There is high-certainty evidence that forced expiratory techniques following people for commenting on the 2016 update: Eman Sobh,
in infants with severe bronchiolitis do not improve their health Martin Chalumeau, Mark Jones, and Hans van der Wouden.
status and can lead to severe adverse effects. Consequently,
there are no arguments in favour of routine use of these The following people conducted the editorial process for this 2022
techniques as standard clinical practice for hospitalised infants update.
with severe bronchiolitis. Few or no complications were observed
when applying slow expiratory techniques, nor for instrumental • Sign-off Editors (final editorial decision): Mark Jones (Bond
techniques. For those infants with nasal obstruction, some University, Australia); Mieke van Driel (The University of
adverse effects were observed when applying the rhinopharyngeal Queensland, Australia).
technique, but fewer than with nasal aspiration. • Managing Editors (provided editorial guidance to authors,
edited the review, selected peer reviewers, collated peer-
There is low-certainty evidence that slow flow techniques may reviewer comments): Liz Dooley (Bond University, Australia);
temporarily decrease severity of disease in infants with moderate Fiona Russell (Bond University, Australia).
acute bronchiolitis, and for this reason we conclude that, under • Contact Editor (assessed peer-review comments and
clinical judgement, these techniques may be considered in specific recommended an editorial decision): Johannes van der Wouden
situations to improve respiratory performance. (Amsterdam UMC, Vrije Universiteit, Amsterdam, Netherlands).
Informed decisions.
• Statistical Editor (provided comments): Robert S Ware (Griffith • Consumer review: Mohamed A Gouda (Menoufia University,
University, Australia). Egypt); Eman Sobh (Al-Azhar University, Cairo, Egypt; College of
• Copy Editor (copy-editing and production): Lisa Winer, Cochrane Medical Rehabilitations Sciences, Medina, Saudi Arabia).
Copy Edit Support. • Methods review: Leslie Choi (Evidence Synthesis Development
Editor, Cochrane Central Executive Team, UK).
Peer reviewers (provided comments and recommended an • Search review: Justin Clark (Institute for Evidence-Based
editorial decision): Healthcare, Bond University, Australia); Jo Platt (Information
• Clinical/content review: Francis Gilchrist (Keele University and Specialist Cochrane Cochrane Gynaecological, Neuro-Oncology
Staffordshire Children's Hospital at Royal Stoke, UK). and Orphan Cancers Review Group, UK).
Informed decisions.
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* Indicates the major publication for the study
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Aviram 1992
Study characteristics
Methods Randomised, single-blinded controlled trial
Clinical scoring was performed in a blinded manner.
Participants 50 young infants with acute bronchiolitis, paired by age and severity of disease. Diagnostic criteria not
described. Country: Israel.
Age range 1 to 5 months. There was no information on percentage of RSV+ participants.
Interventions Group 1: chest physiotherapy. Although there is no information on the physiotherapy technique ap-
plied, it is assumed to be based on vibration and percussion (N = 25).
Group 2: no intervention (N = 25)
All participants were treated with fluids, oxygen (when SpO2 in room < 92%), and received inhaled
salbutamol every 6 hours.
Outcomes Length of stay in hospital
Improvement in clinical score (12 hours) (Tal 1983)
Changes in SpO2
Notes Unpublished study.
No information on funding.
Authors confirmed trial unpublished (July 2010) and provided additional information.
Personal communication: the decision to discharge was based on improvement of the infant to a score
of < 5 and no need for oxygen. There was no difference between the 2 groups.
Risk of bias
Bias Authors' judgement Support for judgement
Informed decisions.
Aviram 1992 (Continued)
Random sequence genera- Unclear risk No information available.

tion (selection bias)
Allocation concealment Unclear risk No information available.

(selection bias)
Blinding (performance Unclear risk "Clinical scoring was done by a physician who was blinded to the [chest phys-
bias and detection bias) iotherapy] therapy"
All outcomes
Personal communication: "Patient's condition was monitored using our clini-
cal score by one of two physicians, twice a day, blinded to the yes or no chest
physiotherapy done by a third person, who was blinded to the scores."
Incomplete outcome data Unclear risk 50 infants were randomised and analysed.
(attrition bias)
All outcomes
Selective reporting (re- Unclear risk No information available.

porting bias)
Other bias High risk Trial reported as abstract, no peer review of full publication.
Bohe 2004
Methods Randomised, open controlled trial
Participants Infants admitted to the hospital with a clinical diagnosis of acute bronchiolitis defined as acute respira-
tory tract infection, preceded or simultaneous to fever and/or rhinitis, plus tachypnoea, wheezing, and
increased respiratory effort. Country: Argentina.
N = 32 participants randomised and participants analysed: 16 allocated to the control group and 16 to
the intervention arm. Mean age 2.8 months, and 78.1% of participants were positive for RSV. There was
no information on the percentage of RSV+ participants or participants with atelectasis/consolidation at
baseline or during the trial.
Interventions Group 1: drainage, percussion, vibration, and nasopharyngeal aspiration twice a day (N = 16)
Group 2: nasopharyngeal aspiration (N = 16)
All participants received nebulised B2 adrenergic and inhaled and intravenous corticoids.
Outcomes Primary outcome: clinical score with range 0 to 12 (Wood 1972), scoring 0 to 3 to heart rate, respiratory
rate, auscultation, use of accessory muscles. Assessment at discharge
Secondary outcome: length of stay (days)
Notes 1 participant in the control group developed atelectasis at day 4 and was withdrawn and received chest
respiratory physiotherapy.
Children were assessed every evening up to discharge or day 5.
No information on funding
Risk of bias
Informed decisions.
Bohe 2004 (Continued)
Random sequence genera- Unclear risk Participant allocation was random, by means of concealed allocation accord-
tion (selection bias) ing to admission number, independently assigned by the hospital admission
centre.
Allocation concealment Low risk Allocation was described as concealed.

(selection bias)
Blinding (performance High risk Study described as open.

bias and detection bias)
All outcomes
Incomplete outcome data Unclear risk 32 participants were randomised and analysed. A child included in Group 2
(attrition bias) presented right basal atelectasis by 4th day of hospitalisation; he received res-
All outcomes piratory physiotherapy and was excluded from the trial. It is not clear how the
data were treated.
Selective reporting (re- Unclear risk Not described

porting bias)
Other bias Low risk No other biases identified.
Conesa-Segura 2018
Methods Randomised, double-blind controlled clinical trial
Participants Children under the age of 2 years, admitted to hospital for acute viral bronchiolitis, absence of congen-
ital cardiopathy, and no contraindication for thoracic physiotherapy techniques. Diagnostic criteria
were not reported; however, they cited a study (Scarfone RJ. Controversies in the treatment of bronchi-
olitis. Curr Opin Pediatr 2005; 17: 62–6). Country: Spain.
N = 77 participants randomised and 71 participants analysed: 42 allocated to the respiratory physio-

therapy group, and 35 to the control group. Mean age was 2.9 months (range 1.8 to 5.4). There was no
information on percentage of RSV+ participants.
Interventions Group 1: respiratory physiotherapy group. Slow expiration technique + coughing + retrograde
rhinopharyngeal unclogging (forced inspiratory manoeuvre) + nasal and oral aspiration in order to re-
move secretions. The treatment was given once a day during the stay in infant’s unit, and total duration
of treatment was about 15 minutes (N = 39).
Group 2 (control group): no physiotherapy (N = 32)
All participants received hypertonic saline nebulisation, and the nasopharynx content was aspirated.
No drug was prohibited during study and they were prescribed freely by paediatricians.
Outcomes Primary outcome: Acute Bronchiolitis Severity Scale score and O2 saturation, recorded shortly after
each intervention during the stay and at medical discharge, and the hospital stay. Higher values indi-
cate increased severity.
Secondary outcomes: subjective opinion of parents or tutors at the end of treatment
Notes All infants were assessed daily at 3 time points: baseline (at 8.00 a.m.) and 10 minutes and 2 hours after
physiotherapy intervention in Groups 1 and 2, until discharge. They were also evaluated at discharge.
Informed decisions.
Conesa-Segura 2018 (Continued)

Authors report no funding.
ClinicalTrials.gov identifier: NCT02458300
Risk of bias
Random sequence genera- Low risk A researcher did a simple randomisation by assigning participants to either
tion (selection bias) the respiratory physiotherapy group or the control group (Macro!RNDSEQ
for SPSS Statistics. Generation of Random Sequences [computer program].
V2011.09.09. Randomisation seed = –1987653.97)
Allocation concealment Low risk The allocation was concealed by the primary researcher.
(selection bias)
Blinding (performance Low risk Evaluating paediatricians, parents, and statistician were unaware of the group
bias and detection bias) codes.
All outcomes
Incomplete outcome data Unclear risk 6 out of 77 participants excluded from analysis. Flow of participants described.
(attrition bias) Number of participants excluded from analysis unlikely to impact on results or
All outcomes conclusions.
Selective reporting (re- Unclear risk Study protocol was published in ClinicalTrials.gov, and methods agree with
porting bias) publication. However, publication presents oxygen saturation as a primary
outcome, when it was not reported as such in the protocol, and omits a sec-
ondary outcome established in protocol (subjective opinion). Regardless, we
considered that these changes did not bias reporting.
De Córdoba 2008
Participants were allocated by opaque, sealed envelopes.
Participants Children below 2 years admitted to the hospital and emergency department, with clinical and radiolog-
ical diagnosis of acute viral bronchiolitis, presenting with bronchial hypersecretion (pulmonary auscul-
tation). Country: Brazil.
N = 24 participants randomised, 19 participants analysed: 5 in Group 1, 8 in Group 2, and 6 in Group 3.

Exclusions due to haemodynamic instability (2), heart disease (1), non-invasive mechanical ventilation
(1), prematurity (1)
Mean age: 93 days in Group 1, 131 days in Group 2, 125 days in Group 3. There was no information on
percentage of RSV+ participants or participants with lung collapse/consolidation at baseline or during
the trial.
Interventions Group 1: vibration + postural drainage + bronchial aspiration in dorsal decubitus (N = 5)
Group 2: percussion + postural drainage + bronchial aspiration in dorsal decubitus (N = 8)
Group 3: bronchial aspiration in dorsal decubitus (N = 6)
Informed decisions.
De Córdoba 2008 (Continued)

Postural drainage for 5 minutes in each decubitus (right and left lateral randomly chosen) + bronchial
aspiration in dorsal decubitus. All participants received nasotracheal aspiration with saline solution.
Outcomes The primary outcome is not clear. Outcomes assessed were: saturation of oxygen pulse, cardiac fre-
quency, respiratory frequency, Silverman-Andersen score of respiratory discomfort (Silverman 1956),
amount of inhaled secretion.
Notes Treatment was delivered once. Outcomes were assessed immediately after treatment and after 15 min-
utes.
Risk of bias
Random sequence genera- Unclear risk Not described

Allocation concealment Low risk Participants were randomised by means of opaque, sealed envelopes.
(selection bias)
Blinding (performance Unclear risk Not described

All outcomes
Incomplete outcome data High risk 24 randomised participants and 5 exclusions described with reasons, but not
(attrition bias) the groups to which they belonged: 2 haemodynamic instability, 1 heart dis-
All outcomes ease, 1 non-invasive mechanical ventilation, and 1 preterm baby. Results are
presented for 19 participants.

porting bias)
Gajdos 2010
Methods Randomised, double-blind controlled trial
All interventions were administered with the physiotherapist staying alone with the infant in a room
with a covered window pane. The therapists were not involved in the evaluation of time to recovery.
Participants Children aged 15 days to 24 months with first acute bronchiolitis and indication of hospitalisation, and
1 or more of the following criteria at admission: toxic aspect; apnoea or cyanosis; respiratory rate > 60/
minute; pulse oxymetry < 95%; alimentary intake < 2/3 of the needs. Bronchiolitis was diagnosed on the
basis of a history of upper respiratory tract infection and clinical findings consistent with bronchiolitis,
including wheezing or wheezing with crackles and respiratory distress. Country: France.
N = 496 participants randomised and analysed: 246 allocated to the control group and 250 to the inter-
vention group. Mean age 2 months, range 1.3 to 3.9 months. The control group presented with a high-
er proportion of RSV+ infants than the intervention group (76.4% vs 73.3%), as well as the proportion of
cases of lung atelectasis diagnosed on chest X-ray (12.9% vs 7.6%). Survival analyses of time to recov-
ery were adjusted for prognostic baseline covariates, including atelectasis at randomisation and RSV
infection.
Informed decisions.
Gajdos 2010 (Continued)
Interventions Group 1: chest physiotherapy with increased exhalation technique plus assisted cough plus nasopha-
ryngeal aspiration (N = 246)
Group 2: nasopharyngeal aspiration (N = 250)
Increased exhalation technique involved the generation of synchronised thoracic-abdominal move-

ment by the hands of the physiotherapist at the beginning of expiration with 1 hand on the thorax,
meanwhile with the other on the abdomen, centred on the umbilicus, the physiotherapist applied an
abdominal counterweight. The manoeuvre began at the end of the inspiratory plateau and was pur-
sued until the end of expiration, according to the infant's thoraco-pulmonary compliance and up to
his or her chest wall and lung resistance limits. The procedure was repeated until meeting ausculta-
tion-efficacy criteria (decrease or disappearance of wheezing and/or increase of rhonchi), but did not
last longer than 10 to 15 minutes. The procedure was stopped in the case of respiratory status aggrava-
tion. If no spontaneous coughing occurred, coughing could be triggered by pressure on the supraster-
nal notch.
All interventions were administered 3 times a day.
Outcomes Primary outcome: time to recovery, defined in the study protocol as verifying, for at least 8 hours in a
row, the following requirements: pulse oxymetry >= 95% AND normal feeding AND specific respiratory
distress score lower than 1 as described in the protocol AND normal respiratory rate
Secondary outcomes: safety of the forced expiratory technique; comparison of pulse oxymetry be-
fore/after chest physiotherapy; quality of life scale
Notes ClinicalTrials.gov identifier: NCT00125450
Study received funding from governmental organisations.
Risk of bias
Random sequence genera- Low risk "random allocation computer generated with SAS software packages in ad-
tion (selection bias) vance by the biostatistician", "permutation blocks with a block size of four"
Allocation concealment Low risk "physiotherapist opening a sealed sequentially numbered envelope" "block
(selection bias) size of four that was not mentioned to the physicians involved in the patient
recruitment"
Blinding (performance Low risk "all paediatric department staff, parents and guardians were blind to treat-
bias and detection bias) ment assignment." "Those involved in the evaluation of primary outcome or in
All outcomes the decision of the co interventions were blinded to group assignment." "The
treatment was performed by the physiotherapist staying alone with the infant,
in a room with a covered window pane"
Incomplete outcome data Low risk "Analysis was performed on an intent-to-treat basis and all patients includ-
(attrition bias) ed in the study were analysed, including the two lost to follow-up (one in each
All outcomes group)"
Selective reporting (re- Low risk Protocol available and consistent with report.
porting bias)
Informed decisions.
Gomes 2012
Assessors were blinded to the treatment groups.
Participants Infants aged from 28 days to 24 months, previously healthy, with a clinical diagnosis of acute bronchi-
olitis infection and positive outcome of RSV in nasopharyngeal aspirate detected by immunofluores-
cence technique. Country: Brazil.
N = 30 participants randomised, 30 participants analysed at baseline, 20 analysed at 48 hours, 17

analysed at 72 hours
Mean age 125 days. % RSV+ 100%
Interventions Group 1: new physiotherapy group received prolonged slow expiration (slow passive and progres-
sive expiration from the functional residual capacity into the expiratory reserve volume) and clearance
rhinopharyngeal retrograde (forced inspiratory manoeuvre) (N = 10)
Group 2: conventional physiotherapy group received vibrations, expiratory compression, modified
postural drainage only in the lateral decubitus position, and clapping (N = 10)
Group 3: control group received suction of the upper airways (N = 10). The control group was only as-
sessed at admission, and afterwards followed the standard chest physiotherapy regimen in the hospi-
tal; we did not consider this group in the review.
Outcomes Primary outcome: Wang's clinical score. Higher values indicate increased severity.
Secondary outcomes: transcutaneous PCO2
Notes Assessments performed at 2 hours, 48 hours, and 72 hours after admission and again 1 hour prior to
discharge.
Authors contacted and provided information (21 March 2014).
Risk of bias
Random sequence genera- Low risk "Infants were randomised by using sealed opaque envelopes containing the
tion (selection bias) instructions to be followed in each of three groups"
Allocation concealment Low risk "Infants were randomised by using sealed opaque envelopes containing the
(selection bias) instructions to be followed in each of three groups"
Blinding (performance Low risk "Assessors were blinded to the treatment groups. These raters were trained
bias and detection bias) specifically for this assessment. The time spent caring for children was similar
All outcomes in all groups and parents were unaware of their child's group allocation."
Incomplete outcome data Low risk 3 participants lost at 72 hours (1 in new physiotherapy group and 2 in conven-
(attrition bias) tional physiotherapy group) due to hospital discharge.
All outcomes
Selective reporting (re- Unclear risk Study protocol was published on ClinicalTrials.gov, and methods agree with
porting bias) publication. The protocol describes the study as single-blind (investigator), al-
though the publication states that parents were also blinded to the interven-
tion assignment.
Informed decisions.
Gomes 2012 (Continued)
Gomes 2016
Methods Randomised, open controlled clinical trial
Participants Children ≤ 12 months old with a clinical diagnosis of acute viral bronchiolitis, and hospitalised. Chil-
dren were excluded if 1 of the following criteria was present: history of lung disease related to prematu-
rity (bronchopulmonary dysplasia), heart disease, chronic lung diseases (cystic fibrosis), bronchopneu-
monia or associated pneumonia, unstable haemodynamics (ARDS or sepsis), subcutaneous oedema,
admission to the ICU, tracheostomy, or the need for mechanical ventilation and associated neurologi-
cal disease. Country: Brazil.
N = 114 participants randomised and 100 participants analysed. Mean age in months by group: Group 1:
4.80 (SD 2.92); Group 2: 4.78 (SD 2.98). RSV was identified in 68% of cases in Group 1 and 54% in Group
2.
Interventions Group 1: nasopharyngeal aspiration group: 3 times a day for 5 minutes, in early morning, early after-
noon, and evening, separated by approximately 4 h. A sterile aspiration catheter connected to an ex-
tension was introduced; the technician introduced it through the nasal orifice of the participant. A neg-
ative (vacuum) pressure promoted the suction of secretion from the airways (N = 50).
Group 2: clearance group: retrograde rhinopharyngeal clearance technique performed 3 times a day
for 5 minutes, in early morning, early afternoon, and evening, separated by approximately 4 h (N = 50).
All participants received a 0.9% physiological solution instillation before the procedure.
Outcomes Primary outcome: chest retractions, wheezing, nasal bleeding, vomit episodes
Secondary outcomes: heart rate, respiratory rate, oxygen saturation (SpO2) with oxygen use, SaO2 in
room air, and Wood clinical score. Wood clinical severity score includes the evaluation of heart rate,
breathing frequency, chest retractions, presence of wheezing, pulmonary auscultation, and cyanosis.
Each variable is graded from 0 (absent) to 3 (severe), and the final score is categorised into 3 levels:
mild (1 to 3), moderate (4 to 7), and high (8 to 14). Higher values indicate increased severity.
Notes In both groups, there were 3 evaluations on the same day.
Risk of bias
Random sequence genera- Unclear risk Participants were randomly assigned using computer software.
Allocation concealment Unclear risk Not reported

(selection bias)
Blinding (performance High risk Open-label study

All outcomes
Informed decisions.
Gomes 2016 (Continued)
Incomplete outcome data High risk It is not clear how many participants were assessed (in Table 2, data were on-
(attrition bias) ly reported for 42 of 50 participants in the aspiration group and 40 of 50 par-
All outcomes ticipants in the clearance group). There is no clear information for the remain-
ing outcomes: oxygen saturation, breathing frequency, heart rate, and clinical
score.
Selective reporting (re- Unclear risk Study protocol was published on ClinicalTrials.gov, and methods agree with
porting bias) publication.
González-Bellido 2020
Methods Randomised, open controlled clinical trial
Participants 91 non-hospitalised infants with mild to moderate acute viral bronchiolitis were randomised.
Interventions Group 1: airway clearance techniques (20 min of prolonged slow expiration and provoked cough) (N =
44)
Group 2: high-frequency chest wall compression (HFCWC) for 15 minutes (N = 47)
In both groups, all children received 1 inhalation with 4 mL hypertonic saline (NaCl 3%), nebulised at a
flow of 8 L/min over 10 min (Phillips, Murrysville, Pennsylvania).
Outcomes Primary outcomes: Wang clinical severity score; oxygen saturation
Secondary outcomes: use of BD; respiratory rate (bpm); heart rate (bpm); SaO2 20 min post-treatment;
sputum volume (mL)
Adverse events, including the presence of petechiae, tachycardia, and vomiting, were monitored dur-
ing both treatments and recorded at baseline and at 10 min and 20 min.
Notes One of the authors, Dr Donadio, is supported in part by Coordenaçao de Aperfeiçoamento de Pessoal
de Nıvel Superior and Conselho Nacional de Desenvolvimento Cientifico e Tecnologico, Brasil. No other
authors claimed any conflicts of interest.
Risk of bias
Random sequence genera- Low risk "Assignment numbers were generated by simple random sequences using R
tion (selection bias) 5.3.1"
Allocation concealment Low risk "An independent investigator allocated subjects to the airway clearance tech-
(selection bias) niques or HFCWC group in a concealed manner, using sealed opaque en-
velopes."
Blinding (performance Unclear risk Open study. Nevertheless, "a medical evaluator, blinded to the group alloca-
bias and detection bias) tion, was responsible for all evaluations in both groups".
All outcomes
Informed decisions.
González-Bellido 2020 (Continued)
Incomplete outcome data Unclear risk All randomised participants were included in the analysis. However, there was
(attrition bias) an unexpectedly large number of exclusions due to lack of consent to partici-
All outcomes pate.
Selective reporting (re- Low risk Main outcome and time points in published study agree with ClinicalTrials.gov
porting bias) registration (NCT03835936).
Other bias Low risk None detected.
Lopez Galbany 2004

Methods Randomised, single-blind controlled trial
Participants Pilot study enrolled 30 hospitalised infants less than 1 year old with RSV+ bronchiolitis. Country: Spain.
N = 32 participants randomised, 32 participants analysed: 16 allocated to the control group and 16 to

the intervention group.
There was no information on age or percentage of RSV+ participants.
Interventions Group 1: forced expiratory technique for 10 minutes, single daily session during the first 5 days of hos-
pitalisation
Group 2: no intervention
Outcomes Severity clinical score (Bierman Pierson modified score) (Bierman 1974; Tal 1983). Higher values indi-
cate increased severity.
Length of stay
Notes Unpublished study
Authors confirmed trial unpublished (July 2010).
Risk of bias
Random sequence genera- Unclear risk No information

Allocation concealment Unclear risk No information

(selection bias)
Blinding (performance Unclear risk Unpublished data report blinded data assessment.
All outcomes
Incomplete outcome data Unclear risk No information

(attrition bias)
All outcomes
Informed decisions.
Lopez Galbany 2004 (Continued)
Selective reporting (re- Unclear risk No information

porting bias)
Other bias High risk Trial reported as abstract, no peer review of full publication.
Nicholas 1999

Participants were randomly allocated to control and treatment groups using a random sequence num-
ber.
Participants Infants admitted to the hospital with a clinical diagnosis of acute bronchiolitis and with respiratory dis-
tress severe enough to require nasogastric tube feeding or intravenous fluids
N = 50 participants randomised and analysed: 24 were allocated to control group and 26 to treatment
group. Mean age of control group: 3.2 (range 0.4 to 8.3); intervention group 2.4 (range 0.4 to 6.9). RSV+:
control 79%, intervention 85%
Interventions Group 1: vibration and postural drainage techniques twice a day (N = 26)
In the physiotherapy arm, the infant was treated on the physiotherapist's knee, percussion and vibra-
tion lying on right side, lying on the left side, and sitting; suction performed after on each side, if neces-
sary, until clear; no oxygen required during treatment. Modifications were allowed if infant could not
tolerate the procedure. Oxygen was allowed depending on infant tolerability.
Outcomes Primary outcome: validated clinical score (Dick 1991) with values 0 to 20, assigning scores 0 to 2 to
heart rate, respiratory rate, blood gases, rhinitis, hyperinflation, use of accessory muscles, recession,
cough, wheeze, crackles
Secondary outcomes: length of stay (days); provision of inspired oxygen; requirement for nasogastric
feeding; oxygen saturation
Notes The study ended at 5 days or if the infant was transferred to the ICU.
Authors did not report SD.
Risk of bias
Random sequence genera- Low risk "random sequence number generated by the Medical Statistics Unit of the
tion (selection bias) University of Edinburgh"
Allocation concealment Unclear risk Not described

(selection bias)

All outcomes
Incomplete outcome data Unclear risk 50 participants were randomised and assessed, although 1 child was exclud-
(attrition bias) ed from the trial after being admitted to the ICU. It is not clear how these data
Informed decisions.
Nicholas 1999 (Continued)

All outcomes were treated. Saturation of oxygen pulse assessments comprised 2 excluded
children who were not assessed for clinical outcomes.

porting bias)
Other bias Low risk No other biases detected.
Postiaux 2011
Both of the paediatric evaluators were blinded to the applied treatment and goals. Physiotherapists in
charge of administering the treatments were instructed to ignore the results of each evaluation until
the end of the study. The participants' parents were unaware of the group to which their child had been
assigned. In both groups, the periods of time spent in the room were identical, so outside observers
were blinded to the applied treatment.
Participants Hospitalised infants less than 1 year of age presenting with acute RSV bronchiolitis and a clinical Wang
score >= 3. Country: Belgium.
N = 20 infants randomised and analysed: 8 allocated to the control group and 12 to the intervention
group. Mean age: 4.19 months. % RSV+: 100%
Interventions Group 1: 3% hypertonic saline solution and salbutamol (HS therapy) (n = 8, totalling 27 sessions)
Group 2: HS therapy followed by 1 session of 10 to 15 minutes of prolonged slow expiration technique

and coughing provoked (n = 12, totalling 31 sessions). Sessions lasted 30 minutes.
Outcomes Primary outcome: Wang's clinical score (respiratory rate, wheezing, retraction, general appearance).
The maximum Wang score is 12; higher score indicates a worse condition.
Secondary outcomes: SaO2; heart rate
Notes Outcomes were evaluated at time point 0 before the session, time point 30 at end of the session, and
time point 150.
Authors report no conflict of interest/funding.
Risk of bias


(selection bias)
Blinding (performance Low risk "Both of our paediatrician evaluators were blinded to the applied treatment
bias and detection bias) and goals"; "Physiotherapists in charge of administering the treatments were
All outcomes instructed to ignore the results of each evaluation until the end of the study.
The patient' parents were unaware of the group in which their child was in-
cluded. In both groups the periods of time spent in the room were identical, so
outside observers were blinded to the applied treatment."
Informed decisions.
Postiaux 2011 (Continued)
Incomplete outcome data Low risk 20 participants were randomised and assessed.
(attrition bias)
All outcomes

porting bias)
Ramos-Pinto 2021
Methods Randomised, single-blind controlled clinical trial
Participants Non-hospitalised children under 2 years of age, diagnosed with mild-moderate acute viral bronchioli-
tis. Exclusion criteria: severe bronchiolitis; need for admission to the inpatient department; chronic
pulmonary or neuromuscular diseases, congenital heart diseases, trisomy 21 or other congenital mal-
formations; no contraindication for thoracic physiotherapy techniques
A total of 45 children completed the study (n = 28, IG) (n = 17, CG). Mean age was 11.5 months (SD 6.7).
There was no information on percentage of RSV+ participants.
Interventions Group 1: outpatient respiratory physiotherapy group. Slow expiration technique + coughing + retro-
grade rhinopharyngeal unclogging (forced inspiratory nasal manoeuvre). 20 min/session, 5 sessions
during 1st week, 3 alternating sessions during 2nd week (total 8 sessions)
Group 2: control group, no physiotherapy.
Both groups received similar recommendations on general support measures and were medicated, as
needed.
Outcomes Primary outcome: respiratory status, assessed by Kristjansson Respiratory Score (KRS) on days 15 and
7
Secondary outcome: peripheral oxygen saturation and adverse events
Notes Authors report no conflict of interest/funding.
Risk of bias
Random sequence genera- Low risk Randomisation was conducted by permuted blocks.
Allocation concealment Low risk Allocation envelopes were stored in sequentially numbered (from 1 to 6),
(selection bias) opaque, sealed envelopes, prepared by a person not involved in the study, and
opened after the inclusion of a new case.
Blinding (performance Unclear risk A double-blind assessment was not possible, as both physiotherapist and par-
bias and detection bias) ents were aware of the intervention.
All outcomes
Incomplete outcome data High risk 80 cases randomised, only 45 finished the study. Differing rates of attrition in
(attrition bias) control and intervention groups (52.6% and 23.8% by lack of adherence)
Informed decisions.
Ramos-Pinto 2021 (Continued)

All outcomes
Selective reporting (re- Low risk Main outcome and time points in published study agree with ClinicalTrials.gov
porting bias) registration (NCT04260919).
Remondini 2014
Methods Randomised controlled trial
Participants Hospitalised infants younger than 1 year with a clinical diagnosis of bronchiolitis. Country: Brazil.
N = 29 infants randomised into 2 groups. Group 1 = 16 infants, 48 sessions; Group 2 = 13 infants, 35 ses-
sions. The trial authors considered the participant ready to be discharged from the study when they
presented a lower disease severity score (RDAI score ≤ 4) associated with adequate oxygenation on RA
(SpO2 ≥ 92%).
Participants that presented with congenital heart diease, neuropathy, underlying lung disease, indica-
tion for ventilatory support, or RDAI score ≤ 4 associated to SpO2 ≥ 92% were excluded. Mean age was
5.81 months. There was no information on percentage of RSV+ participants.
Interventions Group 1: underwent postural drainage associated with expiratory acceleration flow (EAF) and tracheal
aspiration (N = 13)
Group 2: underwent postural drainage associated with tapping or percussion and tracheal aspiration
(N = 16)
The total number of sessions was 83: 48 in the conventional group and 35 in the forced expiratory
group. The physiotherapist in charge of the infant determined the number of sessions according to the
disease severity. The number of sessions ranged from 1 to 4 a day.
Outcomes Primary outcome: Respiratory Distress Assessment Instrument (RDAI) score system and oxygen satura-
tion (SpO2)
Secondary outcomes: time required to discharge, and parents' perception of treatment
Notes Participants were assessed before, 10 minutes after, and 60 minutes after the physical therapy inter-
vention, by the same therapist.
Risk of bias


(selection bias)

All outcomes
Informed decisions.
Remondini 2014 (Continued)
Incomplete outcome data Low risk 4 participants were excluded because of refusal of parents to accept AEF ma-
(attrition bias) noeuvre.
All outcomes
Participants were assessed before, 10 minutes after, and 60 minutes after the
physical therapy intervention.

porting bias)
Rochat 2010
Methods Randomised open clinical trial
Participants Infants <= 1 year admitted with diagnosis of RSV+ bronchiolitis during 2 consecutive RSV seasons (2005
to 2006 and 2006 to 2007). Country: Switzerland.
N = 103 children randomised, 99 analysed. 51 allocated to physiotherapy and 52 to control. Mean age
was 109 days (3.9 months). RSV test positive: 74% intervention, 75.5% control
Interventions Group 1: physiotherapy group received 2 daily physiotherapy sessions at least 2 hours after feeds (pro-
longed slow expiratory technique obtained by slow manual pressure over the abdomen, exerted at the
start of the expiratory phase down to the residual volume and maintained for 2 to 3 respiratory cycles;
manual vibration exerted at the start of the expiratory phase; induced cough) plus same treatment as
control group (N = 51)
Group 2: control group received rhinopharyngeal suctioning after instillation of normal saline solution
if needed; minimal handling; oxygen to achieve SpO2 ≥ 92% and fractionated meals (N = 52)
Topical bronchodilators and steroids were not routinely used. Nasal drops such as xylometazoline were
often employed to decrease nasal congestion. Antibiotics were administered when concomitant bacte-
rial infection was suspected (prolonged fever, otitis media, and increased white cell count).
Outcomes Primary outcome: time to clinical stability, defined by feeding more than 50% of the required amount,
absence of vomiting, undisrupted sleep, and SpO2 ≥ 92% for more than 10 hours
Secondary outcomes: change in clinical state, measured by a general score made of 3 well-being items
(feeding, vomiting, and quality of sleep); change in respiratory state, measured by a respiratory score
made of 7 items (respiratory rate, pulse oximetry oxygen saturation SaO2, presence and severity of re-
tractions, adventitious respiratory sounds, presence of vesicular murmur, thoracic distension); occur-
rence of complications (such as transfer to the ICU)
Notes Study received funding from governmental organisations.
Outcomes assessed daily at a fixed time point prior to physiotherapy sessions.
Authors contacted and provided information (March 2014).
Risk of bias
Random sequence genera- Low risk "Randomisation list in blocks of random length (8, 10 or 12) by the study epi-
tion (selection bias) demiologist, not involved in the clinical phase of the study."
Informed decisions.
Rochat 2010 (Continued)
Allocation concealment Low risk "Randomisation was done by the attribution of a number contained in a
(selection bias) sealed opaque envelope opened following the inclusion consent. Envelopes
were prepared according to a randomisation list in blocks of random length (8,
10 or 12) by the study epidemiologist, not involved in the clinical phase of the
study (TP)."
Blinding (performance Unclear risk Open trial. Nevertheless, "All children underwent daily clinical evaluations at
bias and detection bias) a fixed time point prior to the physiotherapy sessions when allocated to the
All outcomes group with CP. Evaluations were performed by a study physiotherapist who
was different from the physiotherapist administering the treatment".
Incomplete outcome data Low risk 103 randomised infants, 4 of whom were later excluded (1 in physiotherapy,
(attrition bias) 3 in control) for the following reasons: parental withdrawal of consent, er-
All outcomes roneous initial diagnosis and direct admission to intensive care, or age > 12
months. Results presented for the 99 remaining eligible infants.
Selective reporting (re- Unclear risk An abstract presented to a scientific meeting in 2010 focuses its conclusions
porting bias) on the daily improvement of a severity score, while the published paper re-
ports time to clinical stability as the primary outcome. Nevertheless, we be-
lieve this change does not introduce bias into the results since both outcomes
were related and non-significant.
Sanchez Bayle 2012

Methods Randomised, single-blinded, controlled trial
Participants were randomised before checking of inclusion criteria and signing of informed consent,
leading to the exclusion of 40 randomised participants not meeting the criteria, and 16 participants
that refused consent because of blinding of intervention received. Only the physiotherapists were
aware of the allocation groups of the infants. Parents, doctors, and nurses were unaware of the treat-
ment allocations during the study.
Participants Infants < 7 months with a first episode of acute bronchiolitis diagnosed by McConnochie 1993 criteria,
admitted in a paediatric hospital during 2 consecutive winter seasons. Country: Spain.
293 children where randomised (149 to physiotherapy and 144 to control) and 236 participants were
analysed. Mean age was 2.77 months. RSV test positive: 66% intervention, 67% control
Interventions Group 1: physiotherapy group received 2 daily physiotherapy sessions of 10 minutes (prolonged slow
expiratory technique obtained by slow manual pressure over the abdomen, exerted at the start of the
expiratory phase down to the residual volume and maintained for 2 to 3 respiratory cycles; manual vi-
bration exerted at the start of the expiratory phase; induced cough) plus oxygen therapy until SpO2 >=
94% (N = 136)
Group 2: control group received postural changes plus oxygen therapy until SaO2 >= 94% (N = 100)
All interventions were administered twice a day.
Outcomes Primary outcome: duration of oxygen supplementation, length of hospital stay
Secondary outcomes: salbutamol use, ipratropium bromide use, antibiotics use, adrenaline use, pneu-
monia
Informed decisions.
Sanchez Bayle 2012 (Continued)
Notes Outcomes were assessed at discharge.
Authors reported no conflicts of interest/funding.
Authors contacted and provided information (March 2014).
Risk of bias
Random sequence genera- Low risk Random number table used.

Allocation concealment Unclear risk No information provided.

(selection bias)
Blinding (performance Low risk "Only the physiotherapists were aware of the allocation group of the infants",
bias and detection bias) "The placebo group received postural changes, so parents, doctors and nurses
All outcomes couldn't guess the allocation group"
Incomplete outcome data Unclear risk 236 analysed participants of 293 initially recruited. 40 initially recruited partic-
(attrition bias) ipants (10 in treatment and 30 in control) did not meet inclusion criteria. The
All outcomes unequal distribution may be related to selection bias.
Selective reporting (re- Unclear risk No information provided.

porting bias)
Van Ginderdeuren 2017

Methods Randomised controlled clinical trial
Participants Children under 2 years of age, hospitalised with a first episode of bronchiolitis. Bronchiolitis was diag-
nosed on the basis of clinical findings, including wheezing or wheezing with crackles and respiratory
distress. Children were eligible within 24 h of admission if they presented as a mild to moderate bron-
chiolitis with a Wang clinical severity score ≥ 3 and ≤ 8. Country: Belgium.
N = 103 participants randomised and 93 participants analysed: 34 allocated to the assisted autogenic
drainage group, 33 to the intrapulmonary percussive ventilation group, and 36 to the bouncing con-
trol group. Mean age in days by group: 121 (SD 118) in Group 1; 135 (SD 132) in Group 2; 160 (SD 143) in
Group 3. Percentages of RSV+ participants were 71% in Group 1, 74% in Group 2, and 74% in Group 3.
Interventions Group 1: assisted autogenic drainage (AAD). Treatment began at least 2 h after the latest inhalation
and feeds, 1 session daily of 20 minutes (N = 31).
Group 2: intrapulmonary percussive ventilation (IPV). Treatment began at least 2 h after the latest in-
halation and feeds, 1 session daily. Each child received 4 cycles of 5 min of IPV (N = 31).
Group 3 (control group): bouncing at low amplitude (4 to 6 cm), a gentle up-and-down movement on
a physiotherapy ball; 1 session daily of 20 minutes (N = 31).
AAD and IPV were combined with bouncing, and if no spontaneous coughing occurred, coughing was
triggered every 5 min by a gentle pressure on the suprasternal notch.
Informed decisions.
Van Ginderdeuren 2017 (Continued)

All participants received 3 inhalations daily with 0.5 mL salbutamol dissolved in 4 mL hypertonic (3%)
saline (NaCl 3%), nebulised over 10 min with a Sidestream Nebuliser at a flow of 6 L/min. Rhinopharyn-
geal rinsing with normal saline was applied to all participants if needed. Oxygen supplementation was
administered if SaO2 was ≤ 92%. Orogastric feeding was offered to children spontaneously ingesting
less than 50% of their daily needs.
Outcomes Primary outcome: mean time to discharge, measured as length of hospital stay in days
Secondary outcomes: the impact of the treatment and the daily improvement with a validated clinical
and respiratory severity score (Wang score), heart rate, and oxygen saturation (SaO2)
Notes Outcomes were assessed before, after, and 1 h after treatment.
Authors reported no conflicts of interest/funding.
Risk of bias
Random sequence genera- Low risk Children were randomised to the different treatment modalities by the attribu-
tion (selection bias) tion of a computer-generated number (Randomisation.com, 2011), using the
method of randomly permuted blocks.
Allocation concealment Low risk Each number was contained in a sealed, opaque envelope opened by the
(selection bias) physiotherapist after inclusion. Envelopes were prepared by a physiotherapist
not involved in the clinical phase of the study.
Blinding (performance Low risk The publication describes the study as blinded in performance ("All pediatric
bias and detection bias) department staff and parents were blind to treatment assignment") and out-
All outcomes come detection ("[assessors] were blinded to the applied treatment").
Incomplete outcome data Unclear risk 10% of losses, similarly distributed across arms
(attrition bias)
All outcomes
Selective reporting (re- Unclear risk Study protocol was published in ClinicalTrials.gov, and methods agree with
porting bias) publication. However, the protocol describes the study as "single blind (out-
come assessor)", while the publication states that paediatric department staff
and parents were also blinded.
Webb 1985
Methods Randomised, open, controlled trial
Participants Infants admitted with a clinical diagnosis of acute bronchiolitis. Unreported diagnostic criteria. Coun-
try: UK.
N = 90 participants randomised and analysed: 46 allocated to the control group and 44 to the interven-
tion arm
Informed decisions.
Webb 1985 (Continued)

Mean age 46 months (range 0.5 to 15). 69% had RSV; 36% had a first-degree family history of atopy; 66%
had smokers in the household; 24.5% had some degree of atelectasis/consolidation on chest X-rays.
Interventions Group 1: chest physiotherapy comprising standard techniques applied by a trained paediatric phys-
iotherapist. Chest percussion was performed with a cupped hand for 3 minutes in each of 5 postural
drainage positions followed by assisted coughing or gentle oropharyngeal suction twice a day (N = 44).
Outcomes Primary outcome: clinical score, with values 0 to −30, assigning scores 0 to 3 to heart rate, respirato-
ry rate, hyperinflation, use of accessory muscles, recession, rhinitis, wheeze, cough, crepitations and
rhonchi
Secondary outcome: length of stay (days), total length of illness (days)
Notes Clinical assessment of severity illness made at a fixed time each day for 5 days. At hospital discharge,
parents were asked to maintain a symptom record diary, and children were reviewed in outpatient clin-
ics after 2 weeks.
Authors did not report mean and SD of the mean. When contacted, the trial author was unable to pro-
vide the mean and SD of each parameter because the raw data were no longer available. Results were
expressed as median values and range.
Risk of bias


(selection bias)
Blinding (performance High risk "Strictly speaking, [assessments] could not be ‘blind' with respect to treat-
bias and detection bias) ment status though in practice that status was not obvious at each assess-
All outcomes ment"
Incomplete outcome data High risk 90 analysed participants, but it is not clear how many were randomised, or if
(attrition bias) there was any attrition of participants
All outcomes

porting bias)
ADD: assisted autogenic drainage

AEF: forced expiratory technique (augmentation expiratoire du flux)
ARDS: acute respiratory distress syndrome
AVB: acute viral bronchiolitis
BD: bronchodilation
bpm: beats per minute
CG: control group
EAF: eosinophilic angiocentric fibrosis
ELISA: enzyme-linked immunosorbent assay
HFCWC: high-frequency chest wall oscillation
HS: hypertonic saline solution and salbutamol
Informed decisions.
ICU: intensive care unit

IG: intervention group
IPV: intrapulmonary percussive ventilation
NaCl: sodium chloride
PCO2: partial pressure of carbon dioxide
RDAI: respiratory distress assessment index
RSV: respiratory syncytial virus
SaO2: oxygen saturation in room air
SD: standard deviation
SpO2: oxygen saturation with oxygen use
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Belcastro 1984 Controlled clinical trial of osteopathic intervention compared with postural drainage and bron-
chodilator therapy
Bernard-Narbonne 2003 Uncontrolled intervention study
Castro 2014 To be included, patients had to present an acute wheezing episode, which is not necessarily corre-
lated to bronchiolitis.
Evenou 2017 Observational study
Postiaux 2004 Uncontrolled intervention study
Pupin 2009 Controlled clinical trial: no participants randomised
Quitell 1988 Uncontrolled intervention study
Sebban 2017 Observational study
Sebban 2019 Published in a predatory journal
Characteristics of ongoing studies [ordered by study ID]
ACTR12608000601336
Study name Comparison of effectiveness between Anglo-Saxon chest physiotherapy techniques and European
chest physiotherapy techniques in infants diagnosed with acute bronchiolitis
Methods Blinded randomised clinical trial
Participants Infants aged between 0 and 24 months, with a recent acute bronchiolitis diagnostic attested by a
physician and a posteroanterior thorax X-ray incidence
Interventions Group 1: Anglo-Saxon chest physiotherapy techniques: aerosol therapy, vibration, postural
drainage, percussion and induced cough
Group 2: European chest physiotherapy techniques: aerosol therapy, ELPr (French: expiration
length prolonged-passive, slow expiration) induced cough
Outcomes Wang severity clinical score, hospitalisation period, pulse oxymetry, heart rate
Starting date 1 July 2008 (start of enrolment)
Informed decisions.
ACTR12608000601336 (Continued)
Contact information Alice Bella Lisbôa. Rua Abolição, 1827, Swift, Campinas-SP, Brazil. Phone: +55 19 32373878 +55 19
92475175. E-mail: [email protected]
Notes
NCT02708147
Study name Impact of respiratory physiotherapy in children with bronchiolitis in the first 2 years of life
Methods Randomised clinical trial, parallel, open
Participants 52 children up to 2 years of age, with medical diagnostic for 1st or 2nd episode of bronchiolitis and
who were healthy 3 days before the current diagnosis of bronchiolitis
Interventions Group 1: forced expiratory physiotherapy + conventional treatment
Group 2: conventional treatment, only contact with physician/paediatrician and maybe drugs pre-
scription
Outcomes 1. Computerised lung sounds

2. Wang severity scale
Starting date 15 March 2016
Contact information Alda S Marques, PhD
+351234 372 462
[email protected]
Notes clinicaltrials.gov/ct2/show/NCT02708147
NCT02853838
Study name Chest physiotherapy in infants between 0 and 12 months old with acute bronchiolitis SRV(+)
Methods Randomised, parallel open trial
Participants Children up to 12 months years of age, both genders, with a diagnosis of acute bronchiolitis, RSV+
in direct immunofluorescence assay, a Wang clinical severity score ≥ 4 points, not receiving supple-
mentary oxygen and with no contraindications to physiotherapy (N = 204)
Interventions Group 1: slow flow physiotherapy and standard care: prolonged slow expiration + provoked cough-
ing
Group 2 (control): vibration
All participants received standard care consisting of nasopharyngeal suction, oxygen therapy, flu-
ids administration, and 0.5% adrenaline nebulisation.
Outcomes Primary outcome: Wang clinical score assessed at 48 h after baseline
Informed decisions.
NCT02853838 (Continued)
Secondary outcomes: hours of supplementary oxygen, peripheral blood oxygen level, heart rate,
respiratory rate, wheezing, rib cage retractions, general clinical condition, transfer to high com-
plexity unit
Starting date March 2015
Contact information Patricio Gomolan Gonzalez, Universidad del Desarrollo, Chile
NCT03738501
Study name Slow expiratory technique to improve alimentation in children with bronchiolitis (BRONCHIOL-EAT)
Methods Randomised clinical trial with parallel assignment and triple masking (participant, investigator,
outcomes assessor)
Participants 42 children under 12 months hospitalised for bronchiolitis, with a chest physiotherapy prescrip-
tion, and bronchial obstruction confirmed by physician and respiratory physiotherapist
Interventions Group 1: chest physiotherapy where airway clearance technique is slow expiratory technique. Ex-
perimental group will also benefit for standard medical and non-pharmacological care (e.g. stan-
dard treatment).
Group 2: standard treatment: medical treatment, health education for parents, rhinopharyngeal
clearance using isotonic saline solution, advices
Outcomes 1. Food ingestion

2. Sleep quality
3. Oxygen saturation
4. Respiratory rate
5. Heart rate
6. Respiratory distress
Starting date 13 November 2018
Contact information Yann Combret, PT, MSc
+33786952577
[email protected]
NCT03753802
Study name Multicentre, randomised controlled trial: evaluation of the effects of respiratory physiotherapy,
placebo-controlled, in infants with moderate acute bronchiolitis
Methods Randomised, quadruple-blind, controlled clinical trial
Participants Infants aged 3 to 24 months, suffering a first or second episode of acute viral bronchiolitis of mod-
erate severity (Wang's score > 3 and < 9), treated on an outpatient basis (N = 168)
Informed decisions.
Interventions Group 1: chest physiotherapy: chest physiotherapy treatment using slow extended and passive ex-
piratory manoeuvres
Group 2 (control): no physiotherapy
Outcomes Primary outcomes: change of the Wang's Respiratory score between day 4 and day 1, time to im-
provement (up to 4 days), defined as an increase of 10 points from the QUALIN score (for child un-
der 24 months of age) compared to the initial score. The QUALIN total score quotes the quality of
life of the child from −68 to +68, with a negative score meaning that the child has a poor general
health condition and quality of life, and a positive score meaning that the child has a good general
health condition and quality of life.
Secondary outcome measures: change in oxygen saturation
Starting date December 2019
Contact information Aurore Trebuchet, Réseau Kinésithérapie Bronchiolite Essonne, France
clinicaltrials.gov/ProvidedDocs/02/NCT03753802/Prot_SAP_ICF_002.pdf
NCT04553822
Study name Mucociliary clearance techniques in moderate bronchiolitis
Methods Randomised clinical trial, parallel, single masking (outcomes assessor)
Participants 165 participants between 2 and 12 months of age, with medical diagnosis of a first episode of acute
viral bronchiolitis of moderate degree of severity (Wang clinical severity score ≥ 4 and ≤ 8; modified
Wood-Downes Scale score ≥ 4 and ≤ 5; acute bronchiolitis severity scale ≥ 5 and ≤ 9; Hospital Sant
Joan de Déu scale ≥ 6 and ≤ 10; ReSVinet Scale ≥ 7 and ≤ 13), had not previously received respirato-
ry physiotherapy since diagnosis, and oxygen saturation (SaO2) ≥ 94%
Interventions Group 1: assisted autogenous drainage group (DAA)
Group 2: prolonged slow expiration (ELPr)
Group 3: nebulisation with 4 mL Muconeb 3% hypertonic serum, for 8 minutes in a Philips vibrating
mesh nebuliser
Outcomes Primary outcome measures:
1. Modified Wang clinical severity scale [ Time Frame: 48 hours ]
Secondary outcome measures:
1. Wood-Downes scale modified by Ferres [ Time Frame: 48 hours ]

2. Acute Bronchiolitis Severity Scale [ Time Frame: 48 hours ]
3. Scale of the Sant Joan de Déu Hospital [ Time Frame: 48 hours ]
4. ReSVinet Scale [ Time Frame: 48 hours ]
Starting date 1 July 2022
Contact information Juan Nicolas Mr Cuenca Zaldívar
+34 639 96 29 35
Informed decisions.
[email protected]
RSV: respiratory syncytial virus

SaO2: oxygen saturation
DATA AND ANALYSES
Comparison 1. Slow passive expiratory technique versus control
Outcome or subgroup title No. of studies No. of partici- Statistical method Effect size
pants
1.1 Severity clinical score 7 434 Std. Mean Difference (IV, Random, -0.43 [-0.73, -0.13]
95% CI)
1.1.1 Slow expiratory tech- 4 218 Std. Mean Difference (IV, Random, -0.45 [-0.73, -0.18]
nique with no RRT 95% CI)
1.1.2 Slow expiratory tech- 2 116 Std. Mean Difference (IV, Random, -0.80 [-1.19, -0.42]
nique with RRT 95% CI)
1.1.3 Only RRT 1 100 Std. Mean Difference (IV, Random, 0.13 [-0.26, 0.52]
95% CI)
Informed decisions.
Analysis 1.1. Comparison 1: Slow passive expiratory technique versus control, Outcome 1: Severity clinical score
Chest physiotherapy Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.1.1 Slow expiratory technique with no RRT

Gomes 2012 -3.1 2.02 10 -2.4 1.58 10 8.0% -0.37 [-1.26 , 0.52]
Lopez Galbany 2004 -3.39 3.33 26 -2.5 3.33 24 13.9% -0.26 [-0.82 , 0.29]
Postiaux 2011 3.7 2.7 29 4.6 2.9 26 14.6% -0.32 [-0.85 , 0.22]
Van Ginderdeuren 2017 -0.85 0.55 62 -0.5 0.4 31 17.0% -0.69 [-1.13 , -0.24]
Subtotal (95% CI) 127 91 53.5% -0.45 [-0.73 , -0.18]
1.1.2 Slow expiratory technique with RRT

Conesa-Segura 2018 1 1.31 39 2.3 2.09 32 15.8% -0.75 [-1.24 , -0.27]
Ramos-Pinto 2021 0.3 0.5 28 1.2 1.5 17 12.3% -0.89 [-1.52 , -0.25]
Subtotal (95% CI) 67 49 28.1% -0.80 [-1.19 , -0.42]
Test for overall effect: Z = 4.09 (P < 0.0001)
1.1.3 Only RRT

Gomes 2016 5.12 1.45 50 4.88 2.1 50 18.4% 0.13 [-0.26 , 0.52]
Subtotal (95% CI) 50 50 18.4% 0.13 [-0.26 , 0.52]
Heterogeneity: Not applicable
Total (95% CI) 244 190 100.0% -0.43 [-0.73 , -0.13]

Test for overall effect: Z = 2.83 (P = 0.005) -1 -0.5 0 0.5 1
Test for subgroup differences: Chi² = 11.42, df = 2 (P = 0.003), I² = 82.5% Favours CP Favours control
Comparison 2. Slow passive expiratory techniques versus instrumental techniques
pants
2.1 Severity clinical score 2 Mean Difference (IV, Random, 95% Subtotals only
CI)
Analysis 2.1. Comparison 2: Slow passive expiratory techniques

versus instrumental techniques, Outcome 1: Severity clinical score
CP 1 CP 2 Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total IV, Random, 95% CI IV, Random, 95% CI
González-Bellido 2020 0.14 0.46 44 0.28 0.54 47 -0.14 [-0.35 , 0.07]

Van Ginderdeuren 2017 -0.8 0.6 31 -0.9 0.5 31 0.10 [-0.17 , 0.37]
Test for subgroup differences: Not applicable -1 -0.5 0 0.5 1

Favours Intervention 1 Favours Intervention 2
Informed decisions.
Comparison 3. Forced passive expiration technique versus control
pants
3.1 Severity clinical score 2 Std. Mean Difference (IV, Fixed, 95% Totals not select-
CI) ed
Analysis 3.1. Comparison 3: Forced passive expiration technique versus control, Outcome 1: Severity clinical score
Experimental Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total IV, Fixed, 95% CI IV, Fixed, 95% CI
Remondini 2014 3.26 1.96 35 3.13 1.81 48 0.07 [-0.37 , 0.50]

Rochat 2010 -0.12 0.126 50 0.09 0.125 49 -1.66 [-2.12 , -1.20]
-4 -2 0 2 4
Favours CP Favours control
ADDITIONAL TABLES
Table 1. Chest physiotherapy studies grouped by the applied technique

Chest physiotherapy technique (EG) Participant Setting Comparison N ran-
disease (CG) domised
severity
De Córdoba Conventionala vibration + percussion + Mild Hospital Percussion + PD 24 (19

2008 PD (CG1) analysed)
Suctioning (CG2) EG: 5
CG1: 8
CG2: 6
Bohe 2004 Conventional: vibration + percussion + PD Moderate Hospital No interventionb 32

+ suctioning
EG: 16
CG: 16
Nicholas 1999 Conventional: vibration + percussion + PD Severe Hospital No intervention 50
EG: 24
CG: 25
Aviram 1992 Conventional: vibration + percussion + PD Not reported Hospital No intervention 50
EG: 25
CG: 25
Webb 1985 Conventional: vibration + percussion + PD Moderate Hospital No intervention 90
EG: 44
Informed decisions.
Table 1. Chest physiotherapy studies grouped by the applied technique (Continued)

CG: 46
Ramos-Pinto Slow expiration technique and rhinopha- Mild-moder- Outpatient No intervention 45

2021 ryngeal retrograde clearance technique + ate
provoked cough EG: 28
CG: 17
González-Bel- Slow expiration technique + induced Mild-moder- Outpatient High-frequency 91

lido 2020 cough ate chest wall com-
pression EG: 44
CG: 47
Conesa-Segu- Slow expiration technique + coughing + Mild-moder- Hospital No intervention 77

ra 2018 rhinopharyngeal retrograde technique + ate (93%)
nasal and oral aspiration EG: 42
CG: 35
Van Gin- Slow expiration technique (assisted au- Moderate Hospital Bouncing + 103
derdeuren togenic drainage) + bouncing + induced salbutamol 0.5
2017 cough + salbutamol 0.5 mL (EG1) mL EG1: 34
Intrapulmonary percussive ventilation + EG2: 33

bouncing + induced cough + salbutamol
CG: 36
0.5 mL (EG2)
Sanchez Bayle Slow expiration technique Severe Hospital Postural changes 293
2012 (sham)
EG: 149
CG: 144
Gomes 2012 Slow expiration technique + nasal Moderate Hospital Conventional 30

drainage (CG1)
EG: 10
Suctioning (CG2)
CG1: 10
CG2: 10
Postiaux 2011 Slow expiration technique + induced Moderate Hospital Albuterol 3 mL + 20

cough + albuterol 3 mL + 3% NaCl 3% NaCl
EG: 12
CG: 8
Lopez Gal- Slow expiration technique Moderate Hospital No intervention 32

bany 2004
EG: 16
CG: 16
Gomes 2016 Rhinopharyngeal retrograde technique + Mild-moder- Hospital Nasopharyngeal 114 (100
0.9% physiological solution ate (72%) aspiration + 0.9% analysed)
physiological so-
lution EG: 50
CG: 50
Informed decisions.
Table 1. Chest physiotherapy studies grouped by the applied technique (Continued)
Remondini Conventional physiotherapy (postural Mild-moder- Hospital Conventional 29

2014 drainage + percussion and tracheal aspi- ate
ration) + forced expiration technique EG: 16
CG: 13
Rochat 2010 Slow + forced expiration technique + in- Severe Hospital No intervention 103
duced cough
EG: 51
CG: 52
Gajdos 2010 Forced expiration technique + assisted Severe Hospital Nasal suctioning 496
cough
EG: 246
CG: 250
aConventional: conventional chest physical therapy (postural drainage, percussion, vibration, and suctioning).
bNo intervention: usual medical care (bronchodilators + corticoids + oxygen therapy if needed + nasal suctioning).
Abbreviations: CG: control group; EG: experimental group; NaCl: hypertonic saline solution; PD: postural drainage
APPENDICES
Appendix 1. MEDLINE (Ovid) search strategy

1 exp Bronchiolitis/
2 bronchiolit*.tw.
3 exp Respiratory Syncytial Viruses/
4 Respiratory Syncytial Virus Infections/
5 (repiratory syncytial virus* or rsv).tw.
6 or/1-5
7 exp Physical Therapy Modalities/
8 (chest adj2 (physiotherap* or physical therap*)).tw.
9 Drainage, Postural/
10 (postural adj2 drainage*).tw.
11 Percussion/
12 (chest* adj3 percuss*).tw.
13 Vibration/
14 vibrat*.tw.
15 (chest* adj3 shak*).tw.
16 directed cough*.tw.
17 forced exhalation.tw.
18 forced expiration.tw.
19 Breathing Exercises/
20 breathing exercise*.tw.
21 or/7-20
22 6 and 21
Appendix 2. MEDLINE (Ovid) In-Process and Other Non-Indexed Citations

1 bronchiolit*.tw.
2 (repiratory syncytial virus* or rsv).tw.
3 (chest adj2 (physiotherap* or physical therap*)).tw.
4 (postural adj2 drainage*).tw.
5 (chest* adj3 percuss*).tw.
6 vibrat*.tw.
7 (chest* adj3 shak*).tw.
8 directed cough*.tw.
Informed decisions.
9 forced exhalation.tw.
10 forced expiration.tw.
11 breathing exercise*.tw.
12 (physiotherap* or physical therap*).tw.
13 1 or 2
14 or/3-12
15 13 and 14
Appendix 3. EMBASE (Elsevier) search strategy

21. #6 AND #20
20. #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19
19. (breathing NEAR/2 exercise*):ab,ti
18. 'breathing exercise'/de
17. 'forced exhalation':ab,ti OR 'forced expiration':ab,ti
16. 'directed coughing':ab,ti
15. (chest* NEAR/3 shak*):ab,ti
14. vibrat*:ab,ti
13. 'vibration'/de
12. (chest* NEAR/3 percuss*):ab,ti
11. 'percussion'/de
10. 'postural drainage':ab,ti
9. 'postural drainage'/de
8. (physiotherapy NEAR/4 chest):ab,ti
7. 'physiotherapy'/exp
6. #1 OR #2 OR #3 OR #4 OR #5
5. 'respiratory syncytial virus':ab,ti OR 'respiratory syncytial viruses':ab,ti OR rsv:ab,ti
4. 'respiratory syncytial virus infection'/de
3. 'respiratory syncytial pneumovirus'/de
2. bronchiolit*:ab,ti
1. 'bronchiolitis'/exp
Appendix 4. CINAHL (EBSCO) search strategy

S24 S6 and S23
S23 S21 or S22
S22 S7 or S8 or S9 or S10 or S11 or S12 or S13
S21 S14 or S15 or S16 or S17 or S18 or S19 or S20
S20 TI breathing exercise* or AB breathing exercise*
S19 (MH "Breathing Exercises+")
S18 TI ( "forced exhalation" or "forced expiration" ) or AB ( "forced exhalation" or "forced expiration" )
S17 TI directed N3 cough* or AB directed N3 cough*
S16 TI chest N3 shak* or AB chest N3 shak*
S15 TI vibrat* or AB vibrat*
S14 (MH "Vibration")
S13 TI chest N3 percuss* or AB chest N3 percuss*
S12 (MH "Percussion")
S11 TI "postural drainage" or AB "postural drainage"
S10 TI chest N3 "physical therapy" or AB chest N3 "physical therapy"
S9 TI chest N3 physiotherap* or AB chest N3 physiotherap*
S8 (MH "Chest Physical Therapy+")
S7 (MH "Physical Therapy")
S6 S1 or S2 or S3 or S4 or S5
S5 TI ( respiratory syncytial virus* or rsv ) or AB ( respiratory syncytial virus* or rsv )
S4 (MH "Respiratory Syncytial Virus Infections")
S3 (MH "Respiratory Syncytial Viruses")
S2 TI bronchiolit* or AB bronchiolit*
S1 (MH "Bronchiolitis+")
Appendix 5. LILACS (BIREME) search strategy

(MH:bronchiolitis OR MH:C08.127.446.135$ OR MH:C08.381.495.146.135$ OR MH:C08.730.099.135$ OR bronchiolit$ OR Bronquiolitis OR
Bronquiolite OR MH:"Respiratory syncytial viruses" OR "respiratory syncytial virus" OR "respiratory syncytial viruses" OR "Virus Sincitiales
Informed decisions.
Respiratorios" OR MH:"respiratory syncytial virus infections" OR "Infecciones por Virus Sincitial Respiratorio" OR rsv OR "Infecciones por
Virus Sincitial Respiratorio" OR "Infecções por Vírus Respiratório Sincicial") AND (MH:"physical therapy modalities" OR MH:E02.779$ OR
"physical therapy" OR "physical therapies" OR "Modalidades de Terapia Física" OR "Modalidades de Fisioterapia" OR physiotherap$ OR
Fisioterap$ OR Fisioterápicas OR "Terapia Física" OR MH:"Drainage, Postural" OR "postural drainage" OR "Drenaje Postural" OR "Drenagem
Postural" OR MH:Percussion OR Percusión OR Percussão OR percus$ OR MH:vibration OR vibrat$ OR Vibración OR Vibração OR shak$ OR
"directed coughing" OR "directed cough" OR "forced exhalation" OR "forced expiration" OR expiración OR Expiração OR MH:"Breathing
exercises" OR "breathing exercise" OR "breathing exercises" OR "Ejercicios Respiratorios" OR "Exercícios Respiratórios")
Appendix 6. Web of Science (Thomson Reuters) search strategy

Topic=(bronchiolit* or rsv or respiratory syncytial virus*) AND Topic=(chest physical therap* or chest physiotherap* or postural drainage or
chest percussion or chest vibration or chest shaking or directed coughing or forced exhalation or breathing exercises)
Timespan=2006-2009. Databases=SCI-EXPANDED, CPCI-S.
Appendix 7. Details of previous searches

In the first version of this review we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2004,
Issue 2), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (January 1966 to June 2004);
EMBASE (1990 to June 2004); PASCAL, SCISEARCH, LILACS and Cumulative Index to the Nursing & Allied Health Literature (CINAHL) (1982
to May 2004).
In June 2006 we updated the searches of CENTRAL (The Cochrane Library 2006, Issue 2); MEDLINE (2004 to May Week 4 2006); EMBASE (July
2004 to December 2005) and CINAHL (1982 to May Week 4 2006).
In 2011 we searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2011, Issue 4, part of The Cochrane
Librarywww.thecochranelibrary.com (accessed 13 December 2011), which includes the Cochrane Acute Respiratory Infections Group's
Specialised Register, MEDLINE (May 2006 to November week 3, 2011), MEDLINE in-process and other non-indexed citations (8 December
2011), EMBASE.com (December 2005 to December 2011), CINAHL (2006 to December 2011), LILACS (2006 to December 2011) and Web of
Science (2006 to December 2011).
In 2015 we conducted a top-up search. We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 6) (accessed 8
July 2015), the Cochrane Acute Respiratory Infections Group's Specialised Register (October 2011 to July 2015), MEDLINE and MEDLINE in-
process and other non-indexed citations (October 2011 to July 2015), EMBASE (October 2011 to July 2015), CINAHL (October 2011 to July
2015), LILACS (October 2011 to July 2015), Web of Science (October 2011 to July 2015) and Pedro (October 2011 to July 2015).
We used the following search strategy to search MEDLINE and CENTRAL in June 2006. The highly sensitive search strategy filter (Dickersin
1994) was combined with the search strategy and run over MEDLINE. The MEDLINE search was modified slightly to search CINAHL. No
language restrictions were applied.
MEDLINE (OVID)
1 exp BRONCHIOLITIS
2 exp Bronchiolitis, Viral/
3 bronchiolitis.mp.
4 exp Respiratory Syncytial Viruses/
5 exp Respiratory Syncytial Virus Infections/
6 respiratory syncytial virus$.mp.
7 exp Physical Therapy Techniques/
8 chest physiotherapy.mp.
9 exp Drainage, Postural/
10 postural drainage.mp.
11 chest percussion.mp.
12 exp VIBRATION/
13 vibration.mp.
14 chest shaking.mp.
15 directed coughing.mp.
16 forced exhalation.mp.
17 exp Breathing Exercises/
18 breathing exercise$.mp.
19 or/1-6
20 or/7-18
21 19 and 20
EMBASE (WebSpirs)
#1 explode 'bronchiolitis-' / all subheadings in DEM,DER,DRM,DRR
Informed decisions.
#2 (bronchiolitis in ti) or (bronchiolitis in ab)

#3 explode 'Respiratory-syncytial-pneumovirus' / all subheadings in DEM,DER,DRM,DRR
#4 (respiratory syncytial virus* or RSV) in ti
#5 #1 or #2 or #3 or #4
#6 explode 'physiotherapy-' / all subheadings in DEM,DER,DRM,DRR
#7 (physiotherapy in ti) or (physiotherapy in ab)
#8 explode 'postural-drainage' / all subheadings in DEM,DER,DRM,DRR
#9 (postural drainage in ti) or (postural drainage in ab)
#10 (chest percussion in ti) or (chest percussion in ab)
#11 explode 'vibration-' / all subheadings in DEM,DER,DRM,DRR
#12 (vibration in ti) or (vibration in ab)
#13 (chest shaking in ti) or (chest shaking in ab)
#14 (directed coughing in ti) or (directed coughing in ab)
#15 (forced exhalation in ti) or (forced exhalation in ab)
#16 explode 'breathing-exercise' / all subheadings in DEM,DER,DRM,DRR
#17 (breathing exercise* in ti) or (breathing exercise* in ab)
#18 #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17
#19 #5 and #18
FEEDBACK
Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old, 5 March 2012
Summary
We have read with much interest the last Cochrane review devoted to Chest Physiotherapy for acute bronchiolitis in paediatric patients
between 0 and 24 months. (1) M. Roqué and her co-authors have reported the most recent publications in this field.
We would like to present some remarks:
1. The study of Postiaux et al. has been performed in Belgium, and not in France as mentioned in the Cochrane publication. (2) Even if this
aspect is not scientifically relevant, it implies different methodological PT approaches.
2. M. Roqué et al. have merged two different PT approaches in a same appellation “forced expiration techniques”, adding to the confusion
concerning the PT techniques. Indeed, their different functional features are essential. The first one is the Increased Exhalation
Technique - IET (augmentation/accélération du flux expiratoire) mainly used in France (see the Gajdos and Sanchez studies (3, 4)), which
is a passive forced (i.e. rapid, robust) expiration technique - FET, and the second one is the Prolonged Slow (i.e. progressive) Expiration
technique – PSE (prlonge slow expiration technique) proposed by our group in 1992 to avoid the mechanical drawbacks of the IET -
(Increased Exhalation Technique) such as the tracheal collapse. (5) PSE is more attuned to the infant’s specific ventilatory mechanics. (6)
3. It is important to stress that the therapeutic regimens are different. In the Postiaux’ study, PT is preceded by a hypertonic saline solution
nebulization NaCL3% – HS3%, while it is not in the other studies. HS3% dilutes the bronchial secretions and helps the mucociliary
transport. (7) Both, HS3% and PSE act in synergy.
4. The Cochrane Review states that in the Postiaux’ study, the effect of the treatment “disappeared two hours later”. However the study has
shown that the effect of the treatment lasted at least two hours and that a significant day-to-day cumulative effect had been observed.
These results envision a long term effect of such a treatment.
5. Explaining the apparent controversial results are also the different levels of severity of the patients samples. The Gajdos’, Sanchez’
and Rochat’ (8) studies were dealing with severe bronchiolitis while the Postiaux’ study dealt with moderate bronchiolitis. Severe
bronchiolitis are known to be poorly tolerating any handling procedure, probably explaining the lack ok positive outcome of IET in this
group.
We think that those elements are likely to clarify the PT methods and better define the indications/contraindications of PT in RSVB.
1. Roqué I Figuls M, Giné-garriga M, Granados Rugeles C, Perrotta C. Chest physiotherapy for acute bronchiolitis in
paediatric patients between 0 and 24 months old. Cochrane database of Systematic Review 2012 Issue 2.Art No.:CD004873,
DOI:10.1002/14651858.CD004873.pub4.
2. Postiaux G, Louis J, Labasse HC, Patte C, Gerroldt J, Kotik AC, Lemuhot A. Effects of an alternative chest physiotherapy regimen protocol
in infants with RSB bronchiolitis. Resp Care 2011;56,7:989-94.
3. Gajdos V, Katsahian S, Beydon N, et al. Effectiveness of Chest Physiotherapy in Infants Hospitalized with Acute Bronchiolitis : A
Multicenter, randomized, Controlled Trial. PLoS Med 2010;7(9) : e1000345.doi:10.1371/journal.pmed.1000345.
4. Sánchez Bayle M, et al. Estudio de la eficacia y utilidad de la fisioterapia respiratoria en la bronquiolitis aguda del lactante hospitalizado.
Ensayo clínico aleatorizado y doble ciego. An Pediatr (Barc). 2012. doi:10.1016/j.anpedi.2011.11.026 5. Postiaux G., Lens E. De ladite
Accélération du Flux Expiratoire…où forced is fast
Informed decisions.
Submitter agrees with default conflict of interest statement: I certify that I have no affiliations with or involvement in any organization or
entity with a financial interest in the subject matter of my feedback.
Reply
Dear Dr Postiaux, thank you for your comments that allow us to improve our work. In response to your feedback, we would like to formulate
the following remarks:
1. We apologise for the confusion regarding countries, and we have amended the review accordingly.
2. Throughout the text we have tried to clarify the differences between these techniques, grouped now as passive expiratory techniques
instead of forced expiratory techniques. Efficacy and safety results for both techniques have been clearly labelled in the results and
discussion sections.
3. We have clarified this point in the discussion and conclusions sections.
4. We have added a quote in the results section mentioning the day-to-day cumulative effect. Nevertheless, we've considered that this
result is inconclusive and doesn't change the overall results and conclusions of the review. The reasons are that this apparent cumulative
effect is based on 1) within group comparisons and not between group comparisons, and 2) assessment of a reduced number of patients
due to discharges during follow-up.
5. We have added specific mentions to the severity of patients.
After careful consideration of this feedback we have introduced several changes in the review with the aim to clarify the differences between
the diverse passive expiratory techniques, and to highlight their respective efficacy and safety results. This greater detail has lead to amend
the implications for research section, given that the prolonged slow expiration technique appears to be safe and that it may be related to
(at least) a transient effect. Nevertheless, the overall conclusion of the review and its implications for practice have not changed.
Contributors
Guy Postiaux. Occupation: An author cited in the Review
Jacques Louis.
Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old, 29 April 2016
Summary
I noticed the values of relative risk etc related to ‘vomiting during procedure’ or ‘respiratory destabilisation’ published in the Cochrane
review (from the Gajdos 2010 paper) have been incorrectly reversed – this is important in terms of readers understanding the actual
consequences of treatment... The mistake is consistent throughout the text of the Cochrane review.
Reply
Thanks for pointing out this transcription error. The text and tables have been modified to show the correct risk values for respiratory
destabilisation (RR 5.4, 95% CI 1.6 to 18.4, P = 0.002) and vomiting during the procedure (RR 10.2, 95% CI 1.3 to 78.8, P = 0.005). These values
had been interchanged during transcription.
Contributors
Professor Eleanor Main FCSP (BSc, BA, MSc, PhD) Programme Director: UCL MSc, Diploma & Certificate in Physiotherapy
Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old, 4 May 2017
Summary
In the Cochrane review “Chest physiotherapy for acute bronchiolitis in pediatric patients between 0 and 24 months old (Review)”, published
on Cochrane Database of Systematic Reviews 2016, Issue 2. Art. No.: CD004873. DOI: 10.1002/14651858.CD004873.pub5., you analyse,
among other studies, one study from our authorship (Remondini R, Santos AZ, Castro G, Prado C, Silva Filho LV. Comparative analysis of the
effects of two chest physical therapy interventions in patients with bronchiolitis during hospitalization period. Einstein. 2014;12(4):452-8).
After a thoughtful review of your review, we identified some conclusions reached by you that do not fit with our study.
Under “Summary of findings for the main comparison”: In our study, we didn't compare expiratory acceleration flow with no-physiotherapy
for acute bronchiolitis, but the comparison was made between expiratory acceleration flow and conventional physiotherapy (manual
percussion or tapping).
Under “Results – Included studies”: It classifies the study as forced expiration techniques, but the study compares expiratory acceleration
flow and conventional techniques (manual percussion or tapping).
Under “Passive expiratory techniques - forced passive expiratory techniques - Primary outcomes - Change in the severity status of
bronchiolitis”: It mentions that “They observed significant differences immediately after forced passive expiratory physiotherapy + postural
Informed decisions.
drainage (10 and 60 minutes post intervention; P <0.001). However, when compared to conventional physiotherapy (postural drainage),
no differences were found”, nevertheless the conventional physiotherapy is defined as postural drainage + manual percussion or tapping,
not postural drainage only.
Under "Results – Postural drainage percussion and vibration techniques – Primary outcomes 1 – Change in the severity status of
bronchiolitis": Our study should be cited as “One trial (29 participants) compared the addition tapping to postural drainage. The trial
assessed severity of bronchiolitis using respiratory distress assessment instrument (RDAI) (Remondini 2014). They observed significant
differences immediately after conventional physiotherapy (tapping + postural drainage (10 and 60 minutes post intervention; P<0.001), the
same result was observed after forced passive expiratory physiotherapy + postural drainage)”.
Under "Parents’ impression of physiotherapy benefit": it was mentioned “No trial presented data on parents’ impression of physiotherapy
benefit except Gajdos”, however our study presented that parents answered positively about the effects of therapy in the majority of items
in the questionnaire about the treatment applied, both for the expiratory acceleration flow technique and for tapping.
In summary, in our study we compare the effects of two chest physiotherapy interventions in patients hospitalised due to acute
bronchiolitis, with randomised patients and two groups (Group 1, submitted to postural drainage, tapping and tracheal aspiration;
and Group 2, submitted to postural drainage, expiratory acceleration flow and tracheal aspiration). We never compared Forced Passive
Expiratory Physiotherapy with just postural drainage.
A relevant improvement was observed on the Respiratory Distress Assessment Instrument score with physical therapy, with reduction
of the score 10 minutes after interventions, and the same score 60 minutes later, with no differences between techniques applied. No
differences were observed between groups regarding the items assessed (time required to discharge from study, pulse oximetry in room
air and disease severity according to the Respiratory Distress Assessment Instrument score).
We are available for any clarification.

Best Regards,
Renata Remondini PT (on behalf of the authors)
Reply
Under “Summary of findings for the main comparison” we changed the term “no-physiotherapy” to “standard care” and deleted
"(excluding chest physiotherapy)".
Under “Results – Included studies”: Remondini et al used the conventional terminology used by Gajdos 2010 for describing a type of
technique commonly used in France. The “expiratory acceleration flow” AFE in France, is related to a manual chest compression during
the expiratory phase that produces a high increase of flow in order to help mucus expectoration. This type of manoeuvre is globally called,
force expiration technique.
We changed the name in the review as suggested by Remondini in order to better fit with their original work but kept it in the same
classification group.
These changes also are made to the Table Remondini 2014 - Interventions.
Under “Passive expiratory techniques - forced passive expiratory techniques - Primary outcomes - Change in the severity status of
bronchiolitis”: we agree with the feedback and followed their suggestion.
Under Results – Postural drainage percussion and vibration techniques – Primary outcomes 1 – Change in the severity status of
bronchiolitis: again we agreed with the feedback
Under "Parents’ impression of physiotherapy benefit": we agree with the feedback. Firstly, we changed in “Postural drainage plus
percussion and vibration techniques - Secondary Outcomes”, outcome 5. Parents' impression of physiotherapy benefit "No trial presented
data on parents' impression of physiotherapy benefit in this comparison. except Gajdos (Gajdos 2010). In it, they did not observe any
significant difference in the way the parents rated the influence of physiotherapy on respiratory status (risk ratio (RR) 0.99, 95% CI 0.90 to
1.08, P = 0.89) or comfort (RR 0.99, 95% CI 0.94 to 1.05, P = 0.84).
Secondly, we changed in “Passive expiratory techniques – forced passive expiratory techniques - Secondary outcomes”, Outcome 5.
Parents' impression of physiotherapy benefitTwo trials provided data on the parents' impression on the benefit of chest physiotherapy.
Remondini 2014 presented data on the parents' impression on the benefit of physiotherapy compared to conventional physiotherapy
postural drainage alone. Parents' in both groups reported satisfaction related to improvements of breathing, feeding and nasal congestion,
but, no difference was observed between the intervention groups. Gajdos 2010 reported they did not observe any significant difference in
the way the parents rated the influence of physiotherapy on respiratory status (risk ratio (RR) 0.99, 95% CI 0.90 to 1.08, P = 0.89) or comfort
(RR 0.99, 95% CI 0.94 to 1.05, P = 0.84).
We did not compare forced passive expiratory physiotherapy with just postural drainage.
Informed decisions.
Contributors
Jordi Vilaró and Marta Roqué i Figuls
WHAT'S NEW
Date Event Description
3 April 2023 New search has been performed We included five new trials in this update (Conesa-Segura 2018;
Gomes 2016; González-Bellido 2020; Ramos-Pinto 2021; Van Gin-
derdeuren 2017), and excluded three new trials (Sebban 2017;
Sebban 2019; Evenou 2017). We identified five ongoing stud-
ies (NCT02708147; NCT02853838; NCT03738501; NCT03753802;
NCT04553822).
3 April 2023 New citation required and conclusions Positive effects were observed for slow expiratory techniques.
have changed The meta-analysis of the effects of slow expiratory technique on
clinical severity score showed mild but significant effects in de-
creasing the severity of the infant's condition after the interven-
tion. These positive effects were increased when slow expiratory
technique was combined with rhinopharyngeal retrograde tech-
nique.
HISTORY
Protocol first published: Issue 3, 2004
Review first published: Issue 2, 2005
29 June 2017 Feedback has been incorporated Feedback comment and response from authors added to the re-
view.
10 October 2016 Amended Acknowledgement statement edited.
19 May 2016 Amended Data transcription error corrected in Abstract.
19 May 2016 Feedback has been incorporated Data transcription error reported and corrected.
4 May 2016 Feedback has been incorporated Reader feedback and authors' responses and corrections incor-
porated.
8 July 2015 New search has been performed Searches updated. We included three new trials (Gomes 2012;
Remondini 2014; Sanchez Bayle 2012), and excluded one
new trial (Castro 2014). We identified one ongoing trial (AC-
TR12608000601336).
8 July 2015 New citation required and conclusions Review amended to add a finer classification of interventions
have changed and to introduce the analysis of severity of disease. Dr Jordi Vi-
laró joined the review team to update this review.
New evidence is presented for slow passive expiratory tech-

niques. The role of respiratory syncytial virus (RSV) and severi-
ty of disease are discussed as potential modifiers of the effect of
chest physiotherapy.
Informed decisions.
9 November 2012 Feedback has been incorporated Reply to feedback comment added to the review.
3 July 2012 Feedback has been incorporated Feedback comment added to the review.
13 December 2011 New search has been performed Searches conducted. Six new trials were included in this update
(Aviram 1992; De Córdoba 2008; Gajdos 2010; Lopez Galbany
2004; Postiaux 2011; Rochat 2010), and one trial was excluded
(Pupin 2009).
13 December 2011 New citation required and conclusions New evidence shows no benefit of forced expiratory techniques.
have changed A new review author joined the original author team to update
the review.
14 May 2008 Amended Converted to new review format
19 July 2006 New search has been performed Updated review Issue 1, 2007
9 June 2004 New search has been performed First published Issue 2, 2005
CONTRIBUTIONS OF AUTHORS
Marta Roqué was responsible for updating the review.
Marta Roqué, Maria Giné, and Jordi Vilaró performed the risk of bias assessment and data extraction, interpretation of results, and drafting
of the updated review text.
Carla Perrotta and Claudia Granados conducted reference screening.
All authors commented on the interpretation of results and the text of the review, and contributed to the final version of the review.
DECLARATIONS OF INTEREST
Marta Roqué i Figuls: declares that they have no conflict of interest.
Maria Giné-Garriga: declares that they have no conflict of interest.
Claudia Granados Rugeles: declares that they have no conflict of interest.
Carla Perrotta: declares that they have no conflict of interest.
Jordi Vilaró: declares that they have no conflict of interest.
SOURCES OF SUPPORT
Internal sources
• No source of support, Spain
No sources of support were obtained.
External sources
• No source of support, Spain
No sources of support were obtained.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW
2022 update
In the current update, we reorganised the reporting of results, presenting first the interventions where research is currently more active,
and then the interventions used in practice progressively less (vibration and percussion). We added a new subgroup analysis to the slow
expiratory comparison, to show results separately for those studies using physiotherapy techniques with and without rhinopharyngeal
retrograde technique. We added two new interventions in the current update: instrumental techniques and rhinopharyngeal retrograde
technique. Finally, we conducted a meta-analysis for slow expiratory techniques comparing their effects on clinical severity score.
Informed decisions.
We added one outcome specifically for ambulatory patients, related to avoidance of hospital admission or emergency visits.
2016 update
In the 2016 update, we classified the trials by type of physiotherapy technique into vibration and percussion techniques and passive
expiratory techniques. We further subdivided the latter subgroup into slow passive expiratory techniques and forced passive expiratory
techniques. We changed respiratory parameters, which were previously primary outcomes, to secondary outcomes in the 2016 update.
We added subgroup analyses by disease severity of participants and setting, after feedback received on previous versions made it clear
that the review included trials of participants with wide-ranging severity, and there was a plausible hypothesis that the efficacy of the
interventions varied with severity and setting (a covariate highly correlated with severity of participants). We added summary of findings
tables for the comparisons of 'forced expiration versus standard care for acute bronchitis' and 'slow passive expiration versus standard care
for acute bronchitis'. To better reflect the secondary objective of determining the efficacy of different techniques of chest physiotherapy
(e.g. vibration and percussion and passive forced exhalation), we modified the 'Types of interventions' section to explicitly allow inclusion
of studies with active comparators.
INDEX TERMS
Medical Subject Headings (MeSH)

*Bronchiolitis [drug therapy]; Bronchodilator Agents [therapeutic use]; Drainage, Postural; Oxygen; Physical Therapy Modalities;
*Respiratory Therapy [methods]
MeSH check words

Child; Child, Preschool; Humans; Infant; Infant, Newborn

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Cochrane

Chest physiotherapy for acute bronchiolitis in paediatric patients

Roqué-Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C, Vilaró J

Roqué-Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C, Vilaró J.

Chest physiotherapy for acute bronchiolitis in paediatric patients

Contact: Jordi Vilaró, [email protected].

Editorial group: Cochrane Acute Respiratory Infections Group.

Data collection and analysis

PLAIN LANGUAGE SUMMARY

What did we want to find out?

What did we do?

What did we find?

What are the limitations of the evidence?

How up-to-date is this evidence?

The evidence is current to 20 April 2022.

(follow-up until hospital

Cochrane Database of Systematic Reviews

Summary of findings 2. Forced expiration versus control for acute bronchiolitis

Forced expiration versus control for acute bronchiolitis

Cochrane Database of Systematic Reviews

Intervention: forced expiration

GRADE Working Group grades of evidence

Cochrane Database of Systematic Reviews

Why it is important to do this review Types of studies

Figure 1. Study flow diagram.

531 records 508 records

5. Selective reporting bias secondary intention-to-treat (ITT) sensitivity analysis would be

Random sequence generation (selection bias)

0% 25% 50% 75% 100%

Low risk of bias Unclear risk of bias High risk of bias

Blinding (performance bias and detection bias): All outcomes

Selective reporting (reporting bias)

Chest physiotherapy Control Std. Mean Difference Std. Mean Difference

1.1.1 Slow expiratory technique with no RRT

1.1.2 Slow expiratory technique with RRT

1.1.3 Only RRT

Total (95% CI) 244 190 100.0% -0.43 [-0.73 , -0.13]

6. Parents' impression of physiotherapy benefit

1. Time to recovery Subgroup analyses by setting: these could not be conducted

Remondini 2014 presented data on parents' impression on the

Nicholas 1999 performed a subgroup analysis between infants who

Postiaux 2004 {unpublished data only} NCT03753802 {published data only}

Additional references Button 2018

Fernandes 2013 Guyatt 2011c

González 2010a Guyatt 2011e

González Caballero 2001 Guyatt 2011h

GRADEpro GDT [Computer program] Halna 2005

hascnpp_bronchiolite_texte_recommandations_2019.pdf ambulatorio en menores de 5 años]. www.minsal.cl/portal/url/

Review Manager 2020 [Computer program] Spencer 1996

Ringer 2020 Tal 1983

Sanchez 2007 Verstraete 2014

* Indicates the major publication for the study

Characteristics of included studies [ordered by study ID]

Methods Randomised, single-blinded controlled trial

Clinical scoring was performed in a blinded manner.

Age range 1 to 5 months. There was no information on percentage of RSV+ participants.

Group 2: no intervention (N = 25)

Outcomes Length of stay in hospital

Improvement in clinical score (12 hours) (Tal 1983)

Notes Unpublished study.