J Pediatr Intensive Care
DOI: 10.1055/s-0041-1732448
Review Article

Chest Physiotherapy for Mechanically Ventilated Children: A Systematic Review

1   Physiotherapy Department, Hospital for Children NHS Foundation Trust, London, United Kingdom
Jo Wray
2   Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
Mark Peters
3   Infection, Immunity and Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
Harriet Shannon
3   Infection, Immunity and Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
› Author Affiliations
Funding This study was funded by the National Institute for Health Research (ICA-CDRF-2018-ST2–018). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.


The aim of this study was to appraise and summarize the effects of chest physiotherapy in mechanically ventilated children. A systematic review was completed by searching Medline, Embase, Cinahl Plus, PEDro, and Web of Science from inception to February 9, 2021. Studies investigating chest physiotherapy for mechanically ventilated children (0–18 years), in a pediatric intensive care unit were included. Chest physiotherapy was defined as any intervention performed by a qualified physiotherapist. Measurements of effectiveness and safety were included. Exclusion criteria included preterm infants, children requiring noninvasive ventilation, and those in a nonacute setting. Thirteen studies met the inclusion criteria: two randomized controlled trials, three randomized crossover trials, and eight observational studies. The Cochrane risk of bias and the Critical Appraisal Skills Program tools were used for quality assessment. Oxygen saturations decreased after physiotherapy involving manual hyperinflations (MHI) and chest wall vibrations (CWV). Although statistically significant, these results were not of clinical importance. In contrast, oxygen saturations improved after the expiratory flow increase technique; however, this was not clinically significant. An increase in expiratory tidal volume was demonstrated 30 minutes after MHI and CWV. There was no sustained change in tidal volume following a physiotherapy-led recruitment maneuver. Respiratory compliance and dead-space increased immediately after MHI and CWV. Atelectasis scores improved following intrapulmonary percussive ventilation, and MHI and CWV. Evidence to support chest physiotherapy in ventilated children remains inconclusive. There are few high-quality studies, with heterogeneity in interventions and populations. Future studies are required to investigate multiple physiotherapy interventions and the impact on long-term outcomes.

Publication History

Received: 26 April 2021

Accepted: 12 June 2021

Article published online:
17 August 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
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  • References

  • 1 PICANet, Paediatric Intensive Care Audit Network Annual Report 2019. The University of Leeds, University of Leicester and the Healthcare Quality Improvement Partnership. Accessed 2019 at: https://www.picanet.org.uk/wp-content/uploads/sites/25/2021/02/PICANet2020_AnnualReportAppendices_v1.0.pdf
  • 2 Pryor JA, Prasad SA. Physiotherapy for Respiratory and Cardiac Problems. 4th ed.. United Kingdom: Churchill Livingstone Elsevier; 2008
  • 3 Morrow BM, Argent AC. A comprehensive review of pediatric endotracheal suctioning: effects, indications, and clinical practice. Pediatr Crit Care Med 2008; 9 (05) 465-477
  • 4 Mietto C, Pinciroli R, Patel N, Berra L. Ventilator associated pneumonia: evolving definitions and preventive strategies. Respir Care 2013; 58 (06) 990-1007
  • 5 Hedenstierna G, Edmark L. Effects of anesthesia on the respiratory system. Best Pract Res Clin Anaesthesiol 2015; 29 (03) 273-284
  • 6 Ozturk E, Tanidir IC, Haydin S, Onan IS, Odemis E, Bakir I. The use of dornase alpha for post-operative pulmonary atelectasis after congenital heart surgery. Cardiol Young 2014; 24 (05) 807-812
  • 7 PICS. Quality Standards for the Care of Critically Ill Children. Paediatric Intensive Care Society. 2015
  • 8 Kneyber MCJ, de Luca D, Calderini E. et al; Respiratory Failure of the European Society for Paediatric and Neonatal Intensive Care. Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC). Intensive Care Med 2017; 43 (12) 1764-1780
  • 9 Van der Lee L, Hill A, Jacques A, Patman S. Efficacy of respiratory physiotherapy interventions for intubated and mechanically ventilated adults with pneumonia: a systematic review and meta-analysis. Physiother Can 2020; DOI: 10.3138/ptc-2019-0025.
  • 10 Chaves GSS, Freitas DA, Santino TA, Nogueira PAM, Fregonezi GAF, Mendonça KM. Chest physiotherapy for pneumonia in children. Cochrane Database Syst Rev 2019; 1: CD010277
  • 11 Roqué i 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 Syst Rev 2016; 2: CD004873
  • 12 Hough JL, Flenady V, Johnston L, Woodgate PG. Chest physiotherapy for reducing respiratory morbidity in infants requiring ventilatory support. Cochrane Database Syst Rev 2008; (03) CD006445
  • 13 Hawkins E, Jones A. What is the role of the physiotherapist in paediatric intensive care units? A systematic review of the evidence for respiratory and rehabilitation interventions for mechanically ventilated patients. Physiotherapy 2015; 101 (04) 303-309
  • 14 Blackwood B, Ringrow S, Clarke M. et al. A core outcome set for critical care ventilation trials. Crit Care Med 2019; 47 (10) 1324-1331
  • 15 CASP randomized controlled trial checklist. Critical appraisal skills programme. Accessed February 28, 2020 at: https://casp-uk.net/casp-tools-checklists/
  • 16 CASP cohort study checklist. Critical Appraisal Skills Programme. Accessed February 28, 2020 at: https://casp-uk.net/casp-tools-checklists/
  • 17 Deakins K, Chatburn RL. A comparison of intrapulmonary percussive ventilation and conventional chest physiotherapy for the treatment of atelectasis in the pediatric patient. Respir Care 2002; 47 (10) 1162-1167
  • 18 Morrow B, Futter M, Argent A. A recruitment manoeuvre performed after endotracheal suction does not increase dynamic compliance in ventilated paediatric patients: a randomised controlled trial. Aust J Physiother 2007; 53 (03) 163-169
  • 19 Main E, Castle R, Newham D, Stocks J. Respiratory physiotherapy vs. suction: the effects on respiratory function in ventilated infants and children. Intensive Care Med 2004; 30 (06) 1144-1151
  • 20 Main E, Stocks J. The influence of physiotherapy and suction on respiratory deadspace in ventilated children. Intensive Care Med 2004; 30 (06) 1152-1159
  • 21 Shannon H, Stocks J, Gregson RK, Dunne C, Peters MJ, Main E. Clinical effects of specialist and on-call respiratory physiotherapy treatments in mechanically ventilated children: a randomised crossover trial. Physiotherapy 2015; 101 (04) 349-356
  • 22 Almeida CCB, Ribeiro JD, Almeida-Júnior AA, Zeferino AMB. Effect of expiratory flow increase technique on pulmonary function of infants on mechanical ventilation. Physiother Res Int 2005; 10 (04) 213-221
  • 23 Bernard-Narbonne F, Daoud P, Castaing H, Rousset A. [Effectiveness of chest physiotherapy in ventilated children with acute bronchiolitis]. Arch Pediatr 2003; 10 (12) 1043-1047
  • 24 Demont B, Vincon C, Bailleux S, Cambas CH, Dehan M, Lacaze-Masmonteil T. Chest physiotherapy using the expiratory flow increase procedure in ventilated newborns: a pilot study. Physiotherapy 2007; 93 (01) 12-16
  • 25 Gregson RK, Shannon H, Stocks J, Cole TJ, Peters MJ, Main E. The unique contribution of manual chest compression-vibrations to airflow during physiotherapy in sedated, fully ventilated children. Pediatr Crit Care Med 2012; 13 (02) e97-e102
  • 26 Gregson RK, Stocks J, Petley GW. et al. Simultaneous measurement of force and respiratory profiles during chest physiotherapy in ventilated children. Physiol Meas 2007; 28 (09) 1017-1028
  • 27 Hussey J, Hayward L, Andrews M, Macrae D, Elliott M. Chest physiotherapy following paediatric cardiac surgery: the influence of mode of treatment on oxygen saturation and haemodynamic stability. Physiother Theory Pract 1996; 12 (02) 77-85
  • 28 Lanza FC, Rocha FM, Favaro GC, Silva RM, Corso SD. Analysis of respiratory mechanics after physiotherapy in mechanically ventilated pediatric patients - physiological aspects of the respiratory system. Rev Terapia Manual 2011; 9 (46) 774-779
  • 29 Soundararajan LRA, Thankappan SM. Effect of manual hyperinflation on arterial oxygenation in paediatric patients with upper lobe collapse after cardiac surgery. Eur J Gen Med 2015; 12 (04) 313-318
  • 30 Morrow BM. Chest physiotherapy in the pediatric intensive care unit. J Pediatr Intensive Care 2015; 4 (04) 174-181
  • 31 McCarren B, Alison J, Lansbury G. The use of vibration in public hospitals in Australia. Physiother Theory Pract 2003; 19 (02) 87-98
  • 32 Freynet A, Gobaille G, Joannes-Boyau O. et al. Effects of chest physiotherapy by expiratory flow increase on secretion removal and lung mechanics in ventilated patients: a randomized crossover study. Intensive Care Med 2016; 42 (06) 1090-1091
  • 33 Salim A, Martin M. High-frequency percussive ventilation. Crit Care Med 2005; 33 (03) S241-S245
  • 34 Peters MJ, Jones GAL, Wiley D. et al; Oxy-PICU Investigators for the Paediatric Intensive Care Society Study Group (PICS-SG). Conservative versus liberal oxygenation targets in critically ill children: the randomised multiple-centre pilot Oxy-PICU trial. Intensive Care Med 2018; 44 (08) 1240-1248
  • 35 Shannon H, Stiger R, Gregson RK, Stocks J, Main E. Effect of chest wall vibration timing on peak expiratory flow and inspiratory pressure in a mechanically ventilated lung model. Physiotherapy 2010; 96 (04) 344-349
  • 36 Kim CS, Iglesias AJ, Sackner MA. Mucus clearance by two-phase gas-liquid flow mechanism: asymmetric periodic flow model. J Appl Physiol (1985) 1987; 62 (03) 959-971
  • 37 Chiumello D, Gotti M, Guanziroli M. et al. Bedside calculation of mechanical power during volume- and pressure-controlled mechanical ventilation. Crit Care 2020; 24 (01) 417
  • 38 Giosa L, Busana M, Pasticci I. et al. Mechanical power at a glance: a simple surrogate for volume-controlled ventilation. Intensive Care Med Exp 2019; 7 (01) 61
  • 39 Parke RL, McGuinness SP, Milne D, Jull A. A new system for assessing atelectasis on chest X-ray after sternotomy for cardiac surgery. Med Imag Radiol 2014. Available at: http://dx.doi.org/10.7243/2054-1945-2-2
  • 40 Balk DS, Lee C, Schafer J. et al. Lung ultrasound compared to chest X-ray for diagnosis of pediatric pneumonia: a meta-analysis. Pediatr Pulmonol 2018; 53 (08) 1130-1139
  • 41 Singh Y, Tissot C, Fraga MV. et al. International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). Crit Care 2020; 24 (01) 65
  • 42 Hayward SA, Janssen J. Use of thoracic ultrasound by physiotherapists: a scoping review of the literature. Physiotherapy 2018; 104 (04) 367-375
  • 43 Vieira R, Segura-Grau E, Magalhães J, Dos Santos J, Patrão L. Lung ultrasound as a tool to guide respiratory physiotherapy. J Clin Ultrasound 2020; 48 (07) 431-434
  • 44 Pozuelo-Carrascosa DP, Torres-Costoso A, Alvarez-Bueno C, Cavero-Redondo I, López Muñoz P, Martínez-Vizcaíno V. Multimodality respiratory physiotherapy reduces mortality but may not prevent ventilator-associated pneumonia or reduce length of stay in the intensive care unit: a systematic review. J Physiother 2018; 64 (04) 222-228