Guy Postiaux PT,

Bruno Zwaenepoel PT,

Jacques Louis MD.

Groupe d’étude pluridisciplinaire

stéthacoustique &

Grand Hôpital de Charleroi, Dpt of

pediatrics.

6000 Charleroi-Belgium

CHEST PHYSICAL THERAPY IN ACUTE VIRAL

BRONCHIOLITIS: un updated REVIEW (*)

(*) Postiaux G, Zwaenepoel B, Louis J. Chest Physical Therapy in Acute Viral Bronchiolitis

- un updated Review. Respir Care 2013).

Postiaux G 2013 2

Chest Physical Therapy:

Aim: clearance of secretions, prevention of

atelectasis and hyperinflation

Debated from a long time

Cochrane review 2012: not recommended

Each november’s month: A MEDIA DRAMA DIN

BUT

Cochrane is not gospel: confusing analysis,

epidemiologits…mixing appels and pears

recent publications cast doubt on the Cochranes’ conclusion

Postiaux G 2013 3

The infant is not a small adult

Bronchial obstruction is the endpoint of various lower respiratory tract diseases with an allergic or infectious aetiology.

Inflammation triggers capillary dilation and extravasation of plasma into the bronchial wall leading to edema. Goblet cells hyperplasia develops with excess mucus production, resulting in narrowing or occlusion of the smaller airways with ventilation dysfunction

Infant peculiar mechanical features should be taken in account

Shaffer TH, Wolfson MR, Panitch HB. Airway structure, function and development in health and disease. Ped Anesth 2004;14:1046-

1060. DOI: 10.1046/j.1460-9592.2003.01207.x

Fahy JV, Dickey BF. Airway Mucus Function and Dysfunction. N Engl J Med 2010;363:2233-2247.

Grainge CL, Lau LC, Ward JA, Dukay V, Lahiff G, Wilson S. Effect of bronchoconstriction on airway remodeling on asthma. N Engl J

Med 2011;364:2006-2015.

Postiaux G 2013 4

Several PT methodologies have been proposed and

evaluated

In Anglo-saxon countries (Thomson 1968):

cCPT conventional Chest Physical Therapy

In France (Barthe 1972):

IET Increased Exhalation Technique

(Accélération du Flux Expiratoire – AFE)

In Belgium (Postiaux et al,1994, 2011, 2013) :

PSEt Prolonged Slow Expiration Technique – Expiration Lente

Prolongée)

ill-treating - maltraitance

does’nt work

Validated : 1 RCT study!

Postiaux Guy 2013 5

Which alternative ?

Postiaux G 2013 6

We propose an alternative PT protocol taking in account:

The Consensus conference Guidelines (Paris sept 2000)

The mutlifactorial components of bronchial obstruction

A physical maneuver attuned to the infant mechanical system

Grading the disease severity

Validated trials

Indications are symptom-based

Postiaux Guy 2013 7

Stagnara J, Balagny E, Cossalter B, et al. Management of bronchiolitis in the infant. Recommendations. Long text. Arch Pediatr 2001; 8 Suppl1:11S-

23S.

Postiaux G. Arch Ped 2001; 8 suppl. 1: 117-25. POSTIAUX G. Quelles sont les techniques de désencombrement bronchique et des voies

aériennes supérieures adaptées chez le nourrisson ? Rapport d'expertise Conférence de Consensus. Arch Ped 2001. POSTIAUX G. Rapport

d'expertise Conférence de Consensus sur les méthodes instrumentales en kinésithérapie. Place de l'auscultation pulmonaire dans l'évaluation de

l'encombrement bronchique. Lyon nov 2000.

Expert opinion:

- 95% des BVA ne requièrent pas l’hospitalisation

- il n’existe pas de consensus médicamenteux

- recommande ELPr (PSE + PC) en soins

ambulatoires

- des études cliniques doivent être entreprises ns ns Hs Hs

RL (hp/L/sec) vs TWh/TotT (%)

0

50

100

150

200

250

RL

pat n° 1 6 11 8 10 5 2 9 4 12 7 3

r = (tjrs pos) .97 .31 .80 .23 .05 .38 .84 .95 .80

Wh%

Wh

Adult, teenagers, infant: a good correlation between the wheezing rate and functional parameters

Baughman1982, Pasterkamp 1985, Postiaux 1987, Sanchez 1993, Postiaux 1997: infant

Postiaux G 2013 8

We propose an alternative PT protocol taking in account:

The Consensus conference Guidelines (Paris sept 2000)

The multifactorial components of bronchial obstruction

A physical maneuver attuned to the infant mechanical system

Grading the disease severity

Validated trials

Indications are symptom-based

Postiaux Guy 2013 9

Bronchiolitis is a disorder most commonly caused in infants (<2years) by viral lower respiratory tract infection. It is the most common LRI in this age group. It is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospam.

Multifactorial obstruction

= BVA = CF = BPCO… Defining the targets

Diagnosis and management of Bronchiolitis. Subcommittee on diagnosis and management of Bronchiolitis. Pediatrics 2006;118;1774-1793.

http://www.pediatrics.org/cgi/content/full/118/4/1774

Signs and symptoms (Mc Intosh-

1973, Pediatrics-2006)

• Rhinitis (prodrome) - rhinorrhea

• Tachypnea – respiratory rate

• Wheezing

• Cough

• Crackles (high pitched)

• Use of accessory muscles

• And/or nasal flaring

• Grunting

• Intercostal and subcostal retractions

• Poor feeding, <12 weeks, hist of prematurity, underlying cardiopulmonary disease, immunodeficiency, apnea

Definition

Postiaux G 2013 10

1° Inflammation, Edema:

hypertonic saline 3% nebulization

Sarrel ZEM, Tal GT, Witzling M. et al. Chest 2002; 122:2015-2020.

AND OTHERS ………

Postiaux G 2013 11

Mandelberg et al. Ped Pulmonol 2010

normal moderate -mild RSV bronchiolitis

severe RSV bronchiolitis viral infection in CF

Postiaux G 2013 12

Sauvaget E, David M, Bresson V et al. Sérum salé hypertonique et bronchiolite aiguë du nourrisson: données

actuelles. Arch Ped 2012.

Postiaux G 2013 13

Stethacoustic and symtpom-based Algoritm in AVB

EXCESS BRONCHIAL

SECRETIONS

EDEMA

BRONCHOSPASM

Wheezes Crackles

NEBULIZATION HS3% PSE + PC

+ OTHERS STETACOUSTICAL PARAMETERS

Postiaux G 2013 14

We propose an alternative PT protocol taking in account:

The Consensus conference Guidelines (Paris sept 2000)

The mutlifactorial components of bronchial obstruction

A physical maneuver attuned to the infant mechanical system

Grading the disease severity

Validated trials

Indications are symptom-based

Postiaux G 2013 15

Considering the alveolar pressure equation and the

physico-mathematical Rorher model 1919, Otis 1926:

PA = Ppl + Pel

Δ Ppl = Δ V x E + Δ V' X R

Pham TMT, Yull M, Dakin C et al. Regional distribution in the first 6 months of life. Eur Respir J 2011;37:919-24.: Demont B et al. Effects of respiratory physical therapy and nasopharyngeal suction on GOR in infants less than a year of age, with or without

abnormal reflux. Arch Fr Ped 1991;48(9):621-25 Zwaenepoel B. UZ Gent-B. Données non publiées.2011

! GOR + ok

Postiaux G 2013 16

A chronological intervention is required (*)

1. HS 3% - hypertonic NaCl nebulization

2. PSET - ELPr: Prolonged Slow Expiration Technique

3. PC - TP: Provoked Cough

is a reflexive coughing

provoked triggered by a

brief tracheal pressure

applied just above the

sternal notch

a passive, and progressive bimanual

thoraco-abdominal pressure exerted

by the physiotherapist to obtain a

prolonged SLOW expiration into the

expiratory reserve volume – ERV

controlled by breath sounds at the

mouth

(*) Chest Physical Therapy in Acute Viral Bronchiolitis – an updated review. Respir Care in press 2013.

Postiaux G 2013 17

Prolonged Slow Expiration technique - PSE

key Words: lung deflation, squeezing

Postiaux G, Louis, Labasse HC, Gerroldt J, Kotik AC, Lemuhot A, Patte C.. Resp Care 2011; 56,7:989-94

Zhang L et al. Cochrane Data Base of Systematic Rev. 2008.

Lanza , Wandalsen G, Bianca AC, Cruz C, Postiaux G, Solé D. Prolonged slow expiration technique (PSE): description of pulmonary alterations in infants. Resp Care 2011 (in press).

Gomez E. , Postiaux G, Medeiros DL , Monteiro KD, Costa D.Chest physiotherapy is effective in reducing the clinical score in bronchiolitis: A randomized clinical trial. BMC pediatrics

2011 (in press)

Box-plot dos valores percentuais de redução

no volume de reserva expiratório (VRE)

V

R

E

100

80

60

40

20

0

p < 0,001

p = 0,01

p = 0,04

Seq. A Seq. B Seq. C

VRE

(%)

32,0 ±

17,8

40,9 ± 23,9 53,0 ± 19,6

Laboratório de Função Pulmonar no Lactente da Disciplina de

Alergia, Imunologia Clínica e Reumatologia do Departamento

de Pediatria da UNIFESP. Lanza et al . Respir Care 2012.

Postiaux G 2013 19 Guy Postiaux 2012

PSET AFE-FET PC

- Flow is not increased - Tracheal collapse, air – secretions trapped - Exhaled volume lesser than spontaneous tidal volume - Derived pleural pressure curve non physiological

Which usefulness ?

Postiaux G. Ann Kinésithér 1992,t.19,n°8,pp. 411-427

19 19

Δ Ppl = Δ V x E + Δ V' X R (Rohrer-1919, Otis 1926)

Flow

Volume

Pleural

presure

Postiaux G 2013 20

We propose an alternative PT protocol taking in account:

The Consensus conference Guidelines (Paris sept 2000)

The mutlifactorial components of bronchial obstruction

A physical maneuver attuned to the infant mechanical system

Grading the disease severity

referring to a validated trial

Indications are symptom-based

Postiaux G 2013 21

CS: Wang’s Clinical Severity score

Scores

VARIABLES 0 1 2 3

Respiratory rate/min**

<30 31-45 46-60 >60

Wheezing None Terminal expiratory or only

with stethoscope

Entire expiration or audible on

expiration without stethoscope

Inspiration and expiration without

stethoscope

Retraction None Intercostal only Tracheosternal Severe with nasal

flaring

General Condition

Normal Irritable,

lethargic, poor feeding

SpO2 ≥ 95% 92-94% 90-91% <90%

HR/min <140 140-159 160-179 ≥180

The scoring system assigns a number from 0 to 3 to each variable with increased

severity receiving a higher score . Cs = sum. Wang EE et al. Arch Dis Child 1992,67:289-93.

Sarrell EM et al. Chest 2002; 122: 2015-2020.

Mandelberg A et al. Chest 2003; 123:481-487.

Beck R. Et al. BMC Pediatrics 2007;722-7.

Galdos V et al. BMC Pediatrics 2009.

Postiaux G 2013 22

Grading the disease according to the Wang severity score

and the literature

SEVERE :

CS 9-12, RR>60 c/min, SpO2<90%, suprasternal retraction,

in+ex wheezing, nasal flaring, somnolence, apnea, no feeding

MODERATE :

CS 4-8, RR 40-60 c/min, SpO2 90-93%, ex wheezing, intercostal

retraction, poor feeding

MILD :

CS 1-3, RR < 40 c/min, SpO2 ≥ 94%, minimal retraction, end ex

wheezing, normal feeding

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.

Rochat I, Leis P, Bouchardy M, Oberli C, Sourial H, Friedli-Burri M, Perneger T, Barazone Argiroffo C. Chest physiotherapy using passive

techniques does not reduce bronchiolitis severity: a randomised controlled trial. Eur J Pediatr 2011.

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.

Anil AB, Anil M, Saglam AB, Cetin N, bal A, Aksu N. Nebulized salbutamol, epinephrin, 3% saline and normal saline are equally effective in

mild bronchiolitis in pediatric emergency department. Pediatric Pulmonology 2009.

Postiaux G 2013 23

Managament of AVB : PT Decision Flow chart

AVB

CS : 9 to 12 CS : 4 to 8 CS : 1 to 3

SEVERE MODERATE MILD

Ambulatory

care Hospitalization

ICU Supportive

care

CPT :

Contraindicated

Consider

- Age

- Medical

history

- Social

condition

Home

monitoring,

supervision,

education

CPT :

[HS] + [PSE

+ CP]

CPT :

Not

necessary

(*) Chest Physical Therapy in Acute Viral Bronchiolitis – an updated review. Respir Care 2013, fig 1.

Postiaux G 2013 24

We propose an alternative PT protocol taking in account:

The Consensus conference Guidelines (Paris sept 2000)

The mutlifactorial components of bronchial obstruction

A physical maneuver attuned to the infant mechanical system

Grading the disease severity

Validated trials

Indications are symptom-based

Postiaux G 2013 25

A RCT: randomized controlled trial – RCT

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. Respir Care

2011;56,7:989-94.

Lanza , Wandalsen G, Bianca AC, Cruz C, Postiaux G, Solé D. Prolonged slow expiration technique

(PSE): description of pulmonary alterations in infants. Resp Care 2011 (in press).

Gomez EL, Postiaux G, De Medeiros DR, Monteiro KD, Costa D. Chest physiotherapy is effective in

reducing the clinical score in bronchiolitis : a randomized clinical trial. BMC Pediatrics (In press

2011).

Postiaux G 2013 26

Inclusion criteria

1st clinical episode of acute bronchiolitis or wheezing

Infant < 12 months

CS ≥ 3

Presence of RSV in the naso-pharyngeal secretions

Exclusion criteria

Parents refusal

RSV (–)

Underlying cardiac or neurologic disease

Previous episode of wheezing

Chronic lung disease (bronchodisplasia)

Immunodeficiency

Congenital anomaly

Patients needing ventilatory support

To evaluate during 3 winters seasons (2004/2005, 2005-2006, 2006-2007 the efficacy of a

newCPT protocol including PSE + PC (Prolonged Slow Expiration technique + Provoked

coughing) preceded by HS3% nebulization and salbutamol on the Wang clinical severity

score on hospitalized infants with RSB bronchiolitis.

Aim of the study

Baseline

characteristics

Group 1,

Control

(nebulisatio

n 3%

hypertonic

saline

solution, n=

8)

Group 2,

nCPT

(nebulisation 3%

hypertonic saline

solution +

physiotherapy,

n=12)

p Value

Age (months) 4.19 3.88 NS

Female/male

gender, No. 4/4 2/10

Baseline CS score 4,.96+/-2.71 4.32+/-2.69 NS

Total number of

sessions 27 31 NS

Length of hospital

stay 6.25 5.25 NS

Number of

sessions/patient 3.25 2.5 NS

Demographics

Postiaux G 2013 27

DESIGN OF THE STUDY a RCT

Group (1) 27 sessions

Nebulization

(3%HS/Salb)

+

Physios’ Smile

Group (2) 31 sessions

Nebulization (3%HS/Salb)

+

nCPT (PSET + CP)

Postiaux G. et al. Eur Resp J 2008; sept. n° 0126-2008,E-com ERS Berlin meeting.

Postiaux G, Louis J. et al. Respir Care 2011;vol 56, 7:989-94

Two uninformed evaluators (fellow pediatricians) at t0, (before the session), t30 (end of the session) and

t150: CS Wang, SpO2, HR

Winters seasons:2004-2005, 2005-2006, 2006-2007: 3 different caregivers

Postiaux G 2013 28

Session effects between 2 groups :

CS Wh

Control nCPT Control nCPT

t0 4.9±2.7 4.32±2.7 1.22±0.85 1.26±0.86

t30 5.11±2.3 ns 3.55±2.3 p=0.001 1.19±0.79 ns 0.84±0.78 p<0.002

t150 4.62±2.9 p=0,008 3.66±2.6 p<0.002 1.08±0.85 ns 0.90±0.82 p<0.001

CS Wh

Control nCPT Control nCPT

t30 vs t0 13,3 -22,5 p=0,004 1,1 -60,7 p=0,001

t150 vs t0 8,6 -3,2 NS -12,2 -20,8 NS

Session effects for t30 , t150 vs t0 (%):

Postiaux G 2013 29

n = 27 sessions/8 pat. = 31

sessions/12 pat.

nCPT

p = NS 0,008 = 0,001 <0,002

RESULTS (1): CS at t0, t30 and t150, for each patient. Comparison of

average vs t0

NS

Postiaux G 2013 30

RESULTS (2): Daily evolution of CS baseline values (t0) for both groups: a day-

to-day cumulative effect is observed and a shorter time (ns) for recovery

0

1

2

3

4

5

6

7

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

CS

Control

nCPT

p = 0,002

p = 0,056

Postiaux G 2013 31

We propose an alternative PT protocol taking in account:

The Consensus conference Guidelines (Paris sept 2000)

The mutlifactorial components of bronchial obstruction

A physical maneuver attuned to the infant mechanical system

Grading the disease severity

Validated trials

Indications are symptom-based

Postiaux G 2013 32

PT in AVB is mainly symptom-based.

Edema is the first target and HS should precede the

PT maneuvers.

Deleterious and unvalidated methods should be

discarded (ethics!)

Contra-indications of PT (??? To be confirmed)

TIREDNESS

Severe AVB

Chronic lung disease (bronchodisplasia)

Immunodeficiency

Congenital anomaly

Patients needing ventilatory support

Underlying cardiac or neurologic disease

Postiaux G 2013 33

Conclusions:

This study is the first scientific argument in favour of physiotherapy nCPT in acute RSV bronchiolitis

The nCPT protocol including PSET + CP can be a safe complement and a relevant alternative to the presently limited options to treat infants with acute RSV bronchiolitis

nCPT contributes to an economically relevant reduction in the lenght of hospital stay – LOS

In infants < 12 months, a part of wheezes is the clinical sign of the presence of secretions in the mid and proximal airways

Given the observed dataset of 20 subjects, those results are to be considered as preliminary and a way for future larger trials

A swallow doesn’t make the summer

But in any case, CPT research walks round and

round and needs a new paradigme (in press)

next…..

……..

Postiaux G 2013 34

Postiaux G 2013 35

Thanks for your attention

Postiaux Guy 2013 36

Trois méthodes de KR ont été proposées

Dans les pays Anglo-saxon (Thomson 1968):

cCPT conventional Chest Physical Therapy

En France (Barthe 1972):

IET Increased Exhalation Technique

(Accélération du Flux Expiratoire – AFE)

En Belgique (Postiaux 1987-ELTGOL, 1994, 2011, 2013) :

PSEt Prolonged Slow Expiration Technique – Expiration Lente

Prolongée Respir Care 2011)

NE MARCHE PAS

MATRAITANCE

UNE (!) ETUDE

VALIDANTE

Postiaux G 2013 37

cCPT (FET + Clapping + Postural Drainage +

Suctioning)

Controversial, not supported by controlled studies (Prasad, Arch Dis Child 1999)

Banned, deleterious (Purchit, Am J Dis Child 1975; Harding, J Pediatr 1998)

Not recommended (Cincinnati Med Cent 2001)

Has failed to show any benefit (Webb, Arch Dis Child 1985; Bohe, Medicina 2004)

Has shown several drawbacks: rib fractures, GOR, tachypnea, tachycardy, hypoxemia, central nervous troubles…)

Not recomended (Cochrane 2005,2007,2012)

Thomson, Australia;1968

D.L. FROWNFELTER. Chest Physical Therapy and pulmonary rehabilitation.

Year Book Medical Publishers, INC. Chicago 1978.

Postiaux G 2013 38

IET - increased exhalation technique (AFE =passive FET):

Widely used on various (13!) appellations in France

Several mechanical drawbacks:

Vigorous, robust – mimics FET!

Rib fractures (Chalumeau 2002, Berquier 2004, Gorincourt 2004)

Interrupting mouth breath sounds, tracheal collapse, air-secretions trapping (Postiaux 1992)

3 controlled studies (Pupin 2009, Gajdos 2010-Bronkinou study, Sanchez 2012, Rochat 2012): No effect on the hospital stay nor cardio-respiratory parameters, with several side-effects: vomiting, transient respiratory dysfunction, bouts of hypotonia, tracheal collapse, interruption of the procedure. But improves auscultation

Barthe, Hennequet, EMC,26052,10. 1970

Barthe et al. J .Pédiatr. Puéri. 1988

Postiaux G e al. Ann Kinésithér 1992, 1995

Chalumeau et al. Pediatr radiol 2002

Berquier J. et al Arch Ped 2004

Gorincourt G et al. ArchDis Child 2004

Gajdos et al. BMC 2010

Lalieux et al. Arch Ped 2011

Postiaux G 2013 39

Cochrane’s conclusion:

Does not reduce length of hospital stay, oxygen requirements, nor improves the severity clinical score (C. Perrotta, M. Roque et al – Cochrane Rev 2005,2007, 2012, + FEEDBACK DEC 2012 (issue2))

The Cochrane conclusion is univocal, methodologist and partial

An other analysis is possible physiopathologicallyy based.

The Cochrane is not the Gospel

WHICH ALTERNATIVE ? Postiaux G, Louis J. Chest physiotherapy for acute bronchiolitis in paediatric patients

between 0 and 24 months old, 5. March 2012, Feedback Issue2, dec 2012.

Postiaux G 2013 40

We propose an alternative PT protocol taking in account:

The Consensus conference Guidelines (Paris sept 2000)

The mutlifactorial components of bronchial obstruction

A physical maneuver attuned to the infant mechanical system

Grading the disease severity

Validated trials

Indications are symptom-based

Postiaux G 2013 41

Guy P

ostia

ux 2

012

Stagnara J, Balagny E, Cossalter B, et al. Management of bronchiolitis in the infant.

Recommendations. Long text. Arch Pediatr 2001; 8 Suppl1:11S-23S.

Postiaux G. Arch Ped 2001; 8 suppl. 1: 117-25.

Given an expert opinion:

- 95% of AVB does not require hospitalization

- no consensus on medical treatment (medications)

- recomends PSE + CP in ambulatory care

- more validated trials are needed

ns ns Hs Hs

RL (hp/L/sec) vs TWh/TotT (%)

0

50

100

150

200

250

RL

pat n° 1 6 11 8 10 5 2 9 4 12 7 3

r = (tjrs pos) .97 .31 .80 .23 .05 .38 .84 .95 .80

Wh%

Wh

In adults, adolescents and infants, there is a good relationship between the Wheezing rate and funcional parameters. Baughman1982, Pasterkamp 1985, Postiaux 1987, Sanchez 1993, Postiaux 1997.

Wheezing is the cardinal sign of infants’ bronchial obstruction

Postiaux G 2013 42

We propose an alternative PT protocol taking in account:

The Consensus conference Guidelines (Paris sept 2000)

The mutlifactorial components of bronchial obstruction

A physical maneuver attuned to the infant mechanical system

Grading the disease severity

Validated trials

Indications are symptom-based

Postiaux G 2013 43

Definition

Bronchiolitis is a disorder most commonly caused in infants (<2years) by viral lower respiratory tract infection. It is the most common LRI in this age group. It is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospam.

= Multifactorial obstruction:

a common feature of

bronchial secreting diseases

Diagnosis and management of Bronchiolitis. Subcommittee on diagnosis and management of Bronchiolitis. Pediatrics 2006;118;1774-1793.

http://www.pediatrics.org/cgi/content/full/118/4/1774

• Rhinitis (prodrome) - rhinorrhea

• Tachypnea – respiratory rate

• Wheezing

• Cough

• Crackles (high pitched)

• Use of accessory muscles

• And/or nasal flaring

• Grunting

• Intercostal and subcostal retractions

• Poor feeding, <12 weeks, hist of prematurity, underlying cardiopulmonary disease, immunodeficiency, apnea

Postiaux G 2013 44

PSET(ELPr) ≠ FETecniques

presumed mechanisms:

Proximal action

! ! ! Airway instability

Gas-liquid interaction

Flow

High lung volume

From IRV

Peripheral effects

Squeezing (small

airways)

Milking effects (lung

tissue)

Lung deflation

Low Lung volume

Into the ERV

Postiaux G 2013 45

EFFETS D’UN TRAITEMENT ISOLÉ DE KINÉSITHÉRAPIE PAR ELPR + TP CHEZ DES ENFANTS HOSPITALISÉS

POUR BRONCHIOLITE VIRALE AIGUË DE GRAVITÉ MOYENNE (CS MOY = 4,26)

Session effects on CS

0,0

1,0

2,0

3,0

4,0

5,0

6,0

7,0

Day 1 Day 2 Last day

Sessions

Clin

ical S

co

re

Before nCPT

After nCPT Guy P

ostia

ux 2

012

Session effects of nCPT on CS at D1, D2 and DL. CS differed significantly (p<0,001) before and after nCPT at each day. The day effect was significant (p=0,028). N=57 S.

Postiaux et al. Chest physiotheapy in bronchilolitis. Proc 6th Internat Congress on Pediatric Pulmonology. Lisboa Feb. 2004.

Perrotta et al. Cochrane Collaboration issue 2007. Rev Mal Respir 2005; 22: 1S30-1S111.

A prospective longitudinal study of 19 infants (7,75 +/- 6,6 months, mean +/- SD), nCPT protocol including: PSEt + CP. Before and after 57 nCPT sessions, once daily until discharge. Wang's Clinical Severity score (CS), pulse oximetry (SpO2), heart rate (HR), previous episodes of bronchiolitis (AB), prematurity (AP) and presence of Rx abnormalities (Rx) were calculated for sessions and day effects at D1, D2, DL (last day).

BUT : NOT CONTROL GROUP for ethical reasons (?) a RCT is NEEDED TO EVALUATE nCPT