Impact of physical therapy on different types of bronchiolitis, patients, and care settings: A systematic review

ABSTRACT

Bronchiolitis is defined as an acute episode of wheezing that occurs in the context of a respiratory condition, usually of viral origin, with a high incidence in children under 2 years of age. Considering that the role of physical therapy has been questioned in this context, it is paramount to clarify and differentiate the impact of different physical therapy techniques employed for each type of bronchiolitis, patient, and care settings. A systematic review was performed, searching the Science Direct, MEDLINE/PubMed, and SciELO databases on physical therapy techniques in children up to 2 years of age with a bronchiolitis episode. Six observational studies, 5 experimental studies without control group and 15 with control group, involving 3339 individuals were included. Fourteen studies use inpatient samples, six analyze hospital and ICU samples, and six studied outpatient samples. Among the most commonly used respiratory physical therapy techniques are the prolonged slow expiration (PSE) associated with provoked coughing (PC), expiratory flow increase (EFI), retrograde rhinopharyngeal clearance (RRC) and postural drainage (PD). Positive results were found regarding respiratory physical therapy techniques, namely RRC, PSE and EFI or PC, on airway permeabilization, promotion of bronchial hygiene, hospital stay, oxygen saturation, clinical score, heart rate, respiratory rate, and need for oxygen therapy. As limitations of the study, it is highlighted the lack of studies with robust and comparable methodologies to draw conclusions with greater certainty, especially regarding different severities of the pathology, thus supporting the personalization and adequacy of interventions in clinical practice.

Keywords:
Physical Therapy; Bronchiolitis; Infant

RESUMO

A bronquiolite é definida como um episódio agudo de sibilâncias que ocorre no contexto de um quadro respiratório, de origem normalmente viral, com elevada incidência nas crianças com menos de 2 anos. Considerando que o papel da Fisioterapia tem sido questionado nesse contexto, é extremamente importante esclarecer e diferenciar o impacto das diversas técnicas de fisioterapia empregadas em cada tipo de bronquiolite, paciente e local de atendimento. Foi realizada uma revisão sistemática, com busca nas bases de dados ScienceDirect, MEDLINE/PubMed e SciELO, sobre as técnicas de fisioterapia em crianças de até 2 anos de idade com episódio de bronquiolite. Foram incluídos seis estudos observacionais, cinco experimentais sem grupo de controle e 15 com grupo de controle, envolvendo 3.339 indivíduos. São 14 os estudos com amostras em internamento, seis em internamento e unidade de cuidados intensivos (UCI) e seis em ambulatório. Dentre as técnicas de fisioterapia respiratória mais utilizadas, destacam-se a técnica de expiração lenta e prolongada (ELPr) associada à tosse provocada (TP), a aumento do fluxo expiratório (AFE), a desobstrução rinofaríngea retrógrada (DRR) e a drenagem postural (DP). Encontraram-se resultados positivos em relação às técnicas de fisioterapia respiratória, nomeadamente DRR, ELPr e AFE ou TP, na permeabilização das vias aéreas, promoção da higiene brônquica, dias de hospitalização, saturação de oxigênio, pontuação clínica, frequência cardíaca, frequência respiratória e necessidade de oxigenoterapia. Como limitações do estudo, destaca-se o fato de não haver estudos suficientes com metodologias robustas e comparáveis que permitam chegar a conclusões com maior certeza, em especial em relação às diferentes severidades da patologia, e fundamentar assim a personalização e adequação das intervenções na prática clínica.

Descritores:
Fisioterapia; Bronquiolite; Lactente

RESUMEN

La bronquiolitis se define como un episodio agudo de sibilancia que resulta de una infección respiratoria, generalmente viral, con alta incidencia en niños con menos de 2 años de edad. Teniendo en cuenta que el papel de la Fisioterapia ha sido cuestionado en este contexto, es de suma importancia aclarar y diferenciar el impacto de las diferentes técnicas de fisioterapia utilizadas en cada tipo de bronquiolitis, paciente y lugar de atención. Se realizó una revisión sistemática, buscando en las bases de datos ScienceDirect, MEDLINE/PubMed y SciELO técnicas de fisioterapia en niños de hasta 2 años con un episodio de bronquiolitis. Se incluyeron seis estudios observacionales, cinco estudios experimentales sin grupo de control, y 15 con grupo de control, involucrando a 3.339 individuos. Son 14 estudios con muestras de pacientes hospitalizados, seis con pacientes hospitalizados y en unidades de cuidados intensivos (UCI), y seis con pacientes ambulatorios. Entre las técnicas de fisioterapia respiratoria más utilizadas destacan la técnica de espiración lenta y prolongada (ELPr) asociada a tos provocada (PT), flujo espiratorio aumentado (AFE), drenaje rinofaríngeo retrógrado (DRR) y drenaje postural (DP). Se encontraron resultados positivos con relación a las técnicas de fisioterapia respiratoria, como el DRR, ELPr y AFE o PT, en la permeabilización de las vías aéreas, promoción de la higiene bronquial, días de hospitalización, saturación de oxígeno, puntaje clínico, frecuencia cardíaca, frecuencia respiratoria y necesidad de oxigenoterapia. Las limitaciones de este estudio fueron los escasos estudios con metodologías robustas y comparables que permitan llegar a conclusiones más seguras, especialmente con relación a las diferentes severidades de la patología, y así apoyar la personalización y adecuación de las intervenciones en la práctica clínica.

Palabras clave:
Fisioterapia; Bronquiolitis; Lactante

INTRODUCTION

Bronchiolitis is defined as an acute episode of wheezing that occurs in the context of a respiratory condition, usually of viral origin, mainly affecting infants¹. It is estimated that the disease affects 30% of infants, who have at least one episode in their lifetime. Approximately 1 to 3% of respiratory syncytial virus (RSV) infections in children are associated with high morbidity and mortality^1),(2. The physical therapy approach differs substantially from the practices used in adults, and it must respect the patient’s age and relative anatomical and physiological factors³. The techniques are used to permeabilize the airways, promote comfort, and aid function recovery⁴. Interventions include combinations of very different techniques⁵, which are divided into two main approaches: one comprises percussion and postural drainage techniques, while the other acts by changing ventilatory flows⁶. The role of such techniques is still controversial and their recommendation, challenging^6),(7. Clinically, we commonly observe that children in severe or mild conditions do not benefit from the application of respiratory physiotherapy techniques, unlike those in moderate conditions⁷. We should note that while most studies are carried out with inpatients, most patients are never hospitalized^8),(9. Therefore, this review sought to clarify the impact of physical therapy on different types of bronchiolitis, patients, and care settings.

METHODOLOGY

This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and criteria¹⁰ and is registered in the International Prospective Register of Systematic Reviews (PROSPERO) under number CDR42021239709.

The search was carried out in the ScienceDirect, MEDLINE/PubMed, and SciELO databases, using the terms obtained via the PICO¹¹ questionnaire: Population: bronchiolitis, infants; Intervention: physical therapy; Comparison: severity, acute, chronic, home, outpatient and inpatient care; Outcome: (all) and their translation to Portuguese. Inclusion criteria consisted of observational or experimental studies on infants, bronchiolitis, and physical therapy intervention. Studies that addressed pathologies or conditions that affect the respiratory system were excluded.

Quality of the articles was assessed using the National Heart, Lung, and Blood Institute (NHLBI)¹² instruments: Quality Assessment of Controlled Intervention Studies, for controlled experimental studies, and Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, for observational studies (cohort and cross-sectional), both with 14 questions; and Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group, for experimental studies without control group, with 12 questions, resulting in the classification of studies as good, sufficient, or poor. Description of the article selection was made using the PRISMA¹⁰ flowchart, and the review evaluation was performed using the PRISMA checklist (Appendix I)¹⁰.

After search and article selection, two independent investigators assessed the methodological quality of each study. Results were presented in table form for each of the articles and a descriptive and exploratory analysis of such articles was carried out together. Finally, agreement analysis of the quality assessment of the articles was performed using the Kappa coefficient (0.05 significance level). Data and articles underwent exploratory and descriptive analysis.

RESULTS

From the database searches carried out in May 2021, we obtained 338 articles. After screening and careful analysis of study eligibility, the review included 26 articles (Figure 1), comprising a total of 3,339 individuals. Their methodological quality tended towards good (Appendix II), and the agreement between evaluators was almost perfect, at 80.77% (kappa=0.71, p=0.05). The studies (6 observational, 5 experimental without control group and 15 experimental with control group) were published between 1985 and 2020, comprising 14 with inpatient samples, six with inpatient and intensive care unit (ICU) samples, and six with outpatient samples. Table 1 summarizes the most relevant information for each article (author and year, sample, objective, procedures, evaluation methodology and results). Regarding physical therapy techniques, the results often did not reach a consensus. Prolonged slow expiration (PSE) reduced hospitalization days when associated with provoked cough (PC) and forced inspiration¹³, but not when associated with PC alone¹⁴. When associated with PC, the technique reduces the degree of severity, with normalization of respiratory rate (RR) and oxygen saturation (SpO₂)^15)-(17. A study on PSE application with PC, however, found no significant changes in Wang’s clinical severity score, nor in SpO₂¹⁷. Increase in expiratory flow (EF) showed significant changes in SpO₂¹⁸ and in the severity score¹⁹, with reduction of adventitious sounds, and retractions when associated with vibration and nasotracheal aspiration⁸.

Figure 1
PRISMA flowchart

Reason 1: physiotherapy is non-existent, not described or inseparable from other approaches; Reason 2: does not assess clinical or functional picture; Reason 3: sample with other pathologies; Reason 4: outside age range; Reason 5: not an article; Reason 6: article not accessible.

Table 1
Articles’ presentation

Author, year	Study type	Sample	Procedures	Evaluation	Results
Bailleux, 2011	RCT			Average recovery time (days)	CG
					Total population: 2.31 (1.99-2.73)
		AB			<2 months: 2.64 (2.25-3.08)
		Hospitalization			≥2 months: 2.01 (1.65-2.44)
		n=496 (238<2 months+258≥2 months)			VHR+2.34 (1.99-2.99)
		289 positive RSV	CG: Nasal aspiration		Hypoxemia: 2.73 (2.31-3.33)
		216 cases of hypoxemia	EG: EFI+PC		EG
					Total population: 2.02 (1.98-2.40)
					<2 months: 2.47 (1.98-3.31)
					≥2 months: 2.00 (1.51-2.25)
					VHR+2.33 (1.96-2.92)
					Hypoxemia: 2.47 (2.02-3.22)
Barbié, 2008	RCT	Severe AVB
		Outpatient clinic		Silverman's score (breathing difficulty): 3 or 4 (moderate), 5 or 6 (intense) and 7 or 8 (very intense)	Silverman's score:
		12 babies (7 ♂ + 5 ♀)	GAN: Nasopharyngeal Aspiration	SpO2 (%)	GAN: T0<T1 (p=0.029)
		Age from 29 days to 15 months	GDRR: RRC	Reassessment of the clinical picture after the technique (T0) and 5 min later (T5)	GDRR: T0=T1
		(average 5.4 months)			GAN>GDRR (p=0.002)
		GAN: 7 children
		GDRR: 5 children
Bernard-Narbonne, 2003	Clinical trial without control group				SpO2
					T0: 94.5±3.8;
					T1: 95.5±9.9
				SpO2 (%)	T2: 98±5.3 (p<0.05)
				Transcutaneous capnia (TcPCO2)(mmHg)	T3: 97.5±10.5(p<0.05)
				Inspiratory tidal volume (VTI)(ml)	VTI
		AB		Expiratory tidal volume (VTE)(ml)	T0: 55.4±16
		Hospitalization	EFI	T0: before tracheal aspiration	T1: 59.6±17
		57 infants hospitalized in the resuscitation service, ventilated.	Duration: 5-10 min depending on the infant's tolerance	T1: after tracheal aspiration	T2: 66.3±19(p<0.05)
				T2: after 1 RR session + tracheal aspiration	T3: 63.6±20(p<0.05)
				T3: 1 hour after RR	VTE:
					T0: 53.15±16
					T1: 59.1±17
					T2: 66.1±20(p<0.05)
					T3: 62.3±21(p<0.05)
Bohe, 2005	RCT				EG
					Clinical score
		32 patients			on admission: 5.56±1.96
		Hospitalization			after discharge: 3.25±1.27
		21♂ + 11♀		Clinical breathing difficulty score	Average hospital stay: 4.00±2
		Average age: 84.8 days	CG: Nasopharyngeal aspirations	Severity score based on HR, respiratory, auscultation, and use of accessory muscles (0 to 12 points)	CG
		Average length of stay: 3.9 days	EG: Same as control group + DP + Percussion + Vibrations	Length of hospital stay (days)	Clinical score on admission: 5.75±1.61
		25 with VHS+		Moments: admission and after discharge	Score after discharge: 3.12±1.15
		CG=16			Average hospital stay: 3.87 ± 1.3
		EG=16			Clinical score at admission (p=0.77)
					Score after discharge (p=0.76)
					Average hospital stay (p=0.84)
Carroll, 2016	Retrospective OBS				Time in the ICU
					BCH=48 (28-150)
					CCMC=104 (51-231)
					MFCH=52 (27-108)
					YNHCH=66 (36-105)
					Hospitalization time
					BCH=145 (98-239)
					CCMC=186 (118-358)
		AVB			MFCH=151 (90-205)
		ICU			YNHCH=118 (69-202)
		184 (57%) ♂ + 139 (43%)♀			Intubated:
		Age=68 days		Time in the ICU (hours)	BCH 20%
		Hospitals		Hospitalization time (hours)	CCMC 44%
		BCH		Use of:	MFCH 13%
		Age=67 (39-146) days		- Albuterol (76%)	YNHCH 19%
		35 (50%)		- RR	Average of all hospitals:
		CCMC		- Hypertonic saline solution	Time in the ICU=5.3±8.5 days
		Age=60 (34-118) days		- High-flow nasal cannula	76% Albuterol
		56 (54%) ♂		- Non-invasive ventilation	26% Intubated
		MFCH		- Intrapulmonary percurssive ventilation	Variations between hospitals:
		Age=73 (31-230) days		- Ipratropium	- Albuterol (p=0.002)
		44 (62%) ♂		- Systemic corticosteroids.	- RR (p<0.001)
		YNHCH		- Inhaled corticosteroids	- Hypertonic saline solution (p<0.001)
		Age=49 (63%)♂			- High-flow nasal cannula (p<0.001)
		88 (36-302) days			- Non-invasive ventilation (p<0.001)
					- Intrapulmonary percurssive ventilation (p<0.001)
					- Ipratropium (p<0.001)
					- Systemic corticosteroids (p<0.001)
					- Inhaled corticosteroids (p=0.01)
					Time in the ICU increased with:
					Invasive mechanical ventilation (p<0.001)
					Inhaled corticosteroid (p=0.0006)
					Intrapulmonary percurssive ventilation (p<0.001)
					RR (p=0.0005)
Castro, 2011	EXP without CG			Use of oxygen therapy
				Adventitious sounds (medium frequency crackles, high frequency crackles, WH, snoring)	Adventitious noises
				Retractions:	81.4% changed (2.1% worse+13.4% better) (p=0.001)
			RR Session: with 10 minutes of each technique:	Nasal flutter	Medium frequency crackles
		AB	-DP	Intercostal	15.27% changed (14.4% worse+22.8% better) (p=0.017)
		Hospitalization	-EFA	Subdiaphragmatic	WH
		29 children	-Percussion	Sternal	32.9% changed (12.7% worse+16.5% better) (p=0.010)
		13♂ + 16♀	-Vibration	SpO2 (%)	Retractions:
		4.6±3 months	-Nasotracheal aspiration	Downes' Score: Severity: Mild (1-3), Moderate (4-7), Severe (8-14)	21.6% changed (8.2% worse+26.8% better) (p=0.001)
				Moments:	Downes' score
				Before RR (Pre)	20% changed (4.1% worse+21.6% better) (p=0.001)
				15 to 45 min afterwards (Post)
Conesa-Segura, 2019	RCT	AVB			ABBS:
		Hospitalization and ICU		ABBS (mild 0-4, moderate 5-0, severe 10-13) with:	CG (PS/PR=−7%)
		CG:		WH (0-4)	EG (PS/PR=−46%) (p=0.01)
		12 (38%) ♀		Breathing effort (0-3)	CG < EG (p=0.001)
		2.8 (1.8-5.1) months		Ratio Ins/Exp (0-2)	CG (P2/PS=−26%) (p=0.001)
		20 with O2	CG:	HR (0-2)	EG (P2/PS=−108%) (p=0.001)
		48 (0-90) hours of O2	Hypertonic saline mist	RR (cycles/min)	CG<EG (p=0.001)
		ABBS=6 (31 mild, 56 moderate and 13 severe)	Nasopharyngeal aspiration	SpO2 (%)	CG (AM/PR=−1552%) (p=0.001)
		EG:	EG:	Moments:	EG (AM/PR=−440%) (p=0.001)
		19 (49%) ♀	CG + PSE + PC + RRC	Pre session (PR)	CG<EG (p=0.002)
		3.3 (1.8-7.0) months		10 minutes post session (PS)	Average time for ABBS<2:
		23 with O2		2 hours after session (P2)	CG (4.4)>EG (2.6) (p<0.0001)
		24 (0-72) hours of O2		Medical discharge (AM)	WH, Respiratory Effort and Insp/Exp Ratio:
		ABBS=5 (35 mild, 59 moderate and 3 severe)			EG (AM-PR)>CG (AM-PR) (p<0.05)
Evenou, 2017	Prospective OBS	AVB	Two daily sessions with EFI
		Outpatient clinic
		1st session: n=163:
		89 ♂ + 74 ♀			Wang's score (median)
		0-6 months: 89		Wang score	1st session: Pre=5; Post=4
		6-12 months: 55		Moments: Pre and Post sessions	2nd session: Pre=3; Post=2
		>12 months: 19			1st session Pre > 2nd session Post
		2nd session: n=160			(p <0.0001)
		0-6 months: 87
		6-12 months: 54
		>12 months: 19
Gajdos, 2010	RCT	AVB
		Hospitalization
		CG:
		141 (56,4%) ♂,
		2.0 (1.3-4.0) months
		39.1±1.65 Pregnancy
		69 in a tobacco environment
		100 with eczema or atopic
		37 in kindergarten
		36 used bronchodilators and 34 used corticosteroids before randomization
		222 with eating difficulties
		3.0 with respiratory symptoms	Session: 3× a day, 10-15min	Days of hospitalization	Adverse effects during the session:
		110 (44.2%) SpO2	Oxygen Therapy + Enteral Feeding + Bronchodilators + Corticosteroids	Adverse effects during the session	Vomiting CG (1) vs EG (10) (p<0.005)
		31 with atelectasis, 152 with RSV	CG: nasal suction	Effects 30 days later	Respiratory instability CG (3) vs EG (16) (p<0.002)
		37.2 ±0.7°C	EG: EFI + TA
		EG:
		134 (54.5%) ♂
		2.1 (1.3-3.8) months
		39.1±1.67 Pregnancy
		69 in a tobacco environment
		97 with eczema or atopic
		29 in kindergarten
		47 used bronchodilators and 25 used corticosteroids before randomization
		207 with eating difficulties
		3.0 with respiratory symptoms
		18 with atelectasis, 137 with RSV
		37.2±0.6°C
Ginderdeuren, 2017	RCT	Mild and moderate bronchiolitis			CG-B:
		Hospitalization			Days of hospitalization: 4.5±1.9
		CG-B (Control with Bouncing):			Wang:
		18♀ +13♂; 160±143 days			(T0-T20): 0.2±0.3
		6.4±2.5 (kg)			(T0-T80): 0.5±0.4
		23 (74%) with VSR; 20 to O2			GAAD:
		2.0±0.8 coryza symptoms			Days of hospitalization: 3.6±1.4
		12±6 time admission and inclusion (hours)			Wang:
		5.3±0.9 Wang		Days of hospitalization	(T0-T20): 0.5±0.5
		GAAD (assisted autogenic drainage):		Wang's score (0 to 12)	(T0-T80): 0.8±0.6
		15♀ +16♂; 121±118 months	20min/day session	SpO2 (%)	GIPV:
		6.2±2.4 (kg)	CG-B: PC every 5min if there is no spontaneous cough + sitting on a pilates ball, with support, without anterior flexion of the spine, promoting vertical detachments of about 4 to 6cm in amplitude + 3 inhalations of 10min/day	RR (ppm)	Days of hospitalization: 3.5±1.3
		22 (71%) with RSV; 23 to O2	GAAD: CG-B + PSE	Moments:	Wang:
		2.0±0.8 coryza symptoms	GIPV: CG-B + 4 5-min cycles of intrapulmonary ventilation at 100 to 300 cycles/min and with 6 to 10 mbar, applied by a mask	T0: pre-treatment	(T0-T20): 0.7±0.5
		14±5 admission and inclusion time (hours)		T20:– 20min after treatment	(T0-T80): 0.9 ± 0.5
		5.3±1.2 Wang		T80: 1 hour after T20	p-value:
		GIPV (intrapulmonary percussive ventilation):			CG-B – GAAD
		16♀+15♂; 135±132 months			Days of hospitalization: 0.05
		6.6 ± 2.2 (kg)			Wang: (T0-T20): 0.04, (T0-T80): 0.03
		23 (74%) with RSV; 18 to O2			CG-B – GIPV
		2.0±0.8 coryza symptoms			Days of hospitalization: 0.03
		15±6 time admission and inclusion (hours)			Wang: (T0-T20): <0.01, (T0-T80): <0.01
		5.5±0.9 Wang			GAAD – GIPV
					Wang: (T0-T20): 0.03
Gomes, 2012	RCT	AVB			Pre/Post
		Hospitalization and ICU			2 hours
		Age: 4.08±3.12 months		Wheezing (WH)	G1:
		G1:		Investigate the primary outcome (CS)	CS 7.0 (5-11)/4.0(2-7) (p<0.05)
		6♀ + 4♂		RR (bpm)	WH 1.0 (0-3)/0(0-1) (p<0.05)
		days: 126.1±125.8		Retractions (RE)	RE 2.0 (2-3)/1.0(0-2) (p<0.05)
		Wang's Score: 7.0 (5.0-11)		GenC (general conditions)(min-max)	G2:
		5.896±2.473 kg	G1: PSE+RRC	Intra-Friedman Test	CS 7.5 (3-10)/5.5(1-7) (p<0.05)
		G2:	G2: modified DP + expiratory compression + vibration + percussion	SpO2 (%)	48 hours:
		3♀ +7♂	G3: upper airway aspiration	Moments:	G1:
		days: 157.5±99.26		G1 and G2:	CS 5.5 (1-7)/3.0(1-5) (p<0.05)
		Wang's score: 7.5 (3.0-10)		Admission	RE 2.0 (2-3)/1.0(0-2) (p<0.05)
		7.317±1.987 kg		2 hours, 48 and 72 hours after admission	G2:
		G3:		1 hour before discharge	CS 4.0 (1-7)/2.0(1-6) (p<0.05)
		5♀ + 5♂		G3:	RE 2.0 (2-3)/1.0(0-2) (p<0.05)
		days: 102.1±56.16		Admission	72 hours:
		Wang's score: 7.5 (4.0-11)			G1:
		5.822±1.029 kg			CS 2.0 (0-6)/1.0(0-4) (p<0.05)
Gomes, 2016	RCT	AVB
		Hospitalization and ICU
		GA (aspiration):
		48.4♂, 4.78±2.98 months		Evaluation	No significant differences between groups pre session HR:
		Weight: 6.89±2.03 kg		HR (ppm)	M1: GD<GA at 10 min (p=0.002) and at 30 min (p=0.02)
		0.33±1.34 percentile		RR (bpm)	M2: GD<GA at 10 min (p=0.038) and at 30 min (p=0.02)
		Birth weight: 3.20±0.57 kg	1 session	SpO2 (%)	Adverse effects (GA vs GD):
		First episode: 68%	Saline solution at 0.9%	Adverse effects	nosebleeds: 28 vs 1
		SpO2: 95.3±3.7%	GA: nasal aspiration	Signs and respiratory distress	vomiting: 11 vs 7
		RR 51.7±11.3 cycles/min	GD: RRC	Clinical severity score (HR, RR, chest retractions, presence of wheezing, cyanosis and auscultation)	retractions: 100% vs 84.6%
		DG (clearance):		Moments:	Moderate severity score (GA vs GD)
		51.6♂, 4.80±2.92 months		Pre: 10 and 30 min after	retractions (100% vs 84.6%) (p<0.05)
		Weight: 6.70±1.87 kg		M1: early morning	nosebleeds (44.8% vs 0%) (p<0.05)
		Percentile 0.08±1.27(		M2: early afternoon	High severity score (GA vs GD)
		Birth weight: 3.21±0.63 kg		M3: night	nosebleeds (63.6% vs 8.3%) (p<0.05)
		First episode: 72.0%
		RR: 51.6±11.0 cycles/min
Gonçalves, 2014	Cross-sectional OBS		Pulmonary re-expansion maneuvers, manual vibration and postural drainage		RR:
		AVB		Evaluation:	Pre (62.1±14) <P3 (66.6±11) (p<0.05)
		Hospitalization		HR (bpm)	P6 (63.1±11)>P3 (p<0.05)
		30 neonates		SpO2 (%)	P9 (60.7±12)<P3 (p<0.05)
		66.6% ♂		RR (ppm)	SpO2
		3.4±1.63 months		Moments:	Pre (94.9±1.5) <P3 (95.2±1.3) (p<0.05)
		3 with antibiotics		before treatment (pre)	P6 (63.1±11)>Pre (p<0.05)
				post treatment at 3 (P3), 6 (P6) and 9 (P9) min	P9 (97.3±0.5)>P3 (p<0.05)
González-Bellido, 2020	RCT	AVB (light and moderate)
		Outpatient clinic			PRE
		G1 (airway clearance technique):		Evaluation:	No significant differences between groups
		n=44		Wang's score	PRE-POST 20
		17 (38.6%) ♀		RR (cycles/min)	Wang's score
		7.5±2.7 months	1 session only	HR (ppm)	G1 and G2: F (2.46.811)=6.09 (p=0.004)
		8.1±1.5 kg	G1: PSE 20min + PC	SpO2 (%)	GACT (0.14±0.46) vs GHFCWC (0.28±0.54) (n2=0.007)
		68.9±7.8 cm	Medication use: 33	Mucus (dry volume) (ml)	RR
		95.3±2.3% SpO2	Bronchodilator: 38	Adverse effects:	G1 and G2: F (2.46.938)=6.0584 (p=0.004)
		48.6±8.0 RR	G2: PSE SmartVest (12Hz frequency and 2-4cm H2O pressure) 15 min	Petechiae;	G1 (27.89±1.93) vs G2 (28.11±2.40) (n2=0.007)
		G2 (high frequency wall compression):	Medication use: 39	Tachycardia	HR
		n=47	No: 8 (17.0)	Vomiting	G1 and G2: F (2.46.571)=5.943 (p=0.005)
		15 (31.9%) ♀	Bronchodilator: 2	Moments:	G1 (111.0±13.0) vs G2 (116.6±20.0) (n2=0.006)
		8.2±2.4 months		Pre (admission)	Mucus: G1(19)>G2(30)(p<0.001)
		8.2±1.2 kg		After 10 min	PRE-POST 10-POST 20
		69.7±6.6 cm		After 20 min	Wang's score
		95.4±2.0% SpO2			G1 (54.5 to 9.1%) vs G2 (61.7 to 23.4%) (p=0.009)
		45.5±6.6 RR
Postiaux, 2006	EXP without CG				CS (n=19):
					Before:
					1st day: 4.3±2
					2nd day: 3.7±1.8
					Last day: 2.1±1.3
					After RR:
					1st day: 2.1±0.8
					2nd day: 1.8±1.1
					Last day: 0.9±0.6 (p<0.001)
					SpO2 (n=18):
		AVB			Before:
		Hospitalization			1st day: 96.2±2.2
		19 infants:		CS: score from 0 to 3 for each variable, with increasing severity receiving an increasingly higher score.	2nd day: 96.8±2.4
		10 ♂ + 9 ♀	Daily sessions of 20/30 min (average number of 20 maneuvers applied)	SpO2 (%)	Last day: 97.1±1.4
		7.75±6.6 months	Techniques: PSE + PC	HR (ppm)	After RR:
		32% history of bronchiolitis	Positioning: DD, head elevation (35º)	Previous episodes of bronchiolitis (AB)	1st day: 97.67±1.57
		26% history of prematurity		Assessment on the 1st, 2nd and last day of session (57 sessions):	2nd day: 98.28±1.56
		47% positive radiological signs		before and after 15 min	Last day: 98.67±1.27 (p<0.001)
					HR (n=16):
					Before RR:
					1st day: 149.4±17.4
					2nd day: 148.7±17.4
					Last day: 145.1±16.4
					After RR:
					1st day: 142.2±16.4
					2nd day: 138.7±14.4
					Last day: 134.4±13.1 (p<0.001)
					Average number of sessions (NS): 3.8±1.7
					A daytime effect is observed in CS (p<0.028), and session effect differs in D1 and JD for AB in CS (p=0.020) and SpO2 (p<0.039).
Postiaux, 2011	RCT				CG:
					Days of hospitalization: 6.3±2.0
					T150 <T0: (4.6 vs 5.0, p=0.008)
					T150<T0 (1.1 vs 1.2, p=0.02)
		AVB			GCPT:
		Hospitalization	CG:	Before each session (T0):	Days of hospitalization: 5.3±1.8
		CG (n=8):	27 sessions	Wang;	T30: (3.6 vs 4.3, p=0.001)
		4♀ + 4♂	3.3 sessions/patient	SpO2;	T150: (3.7 vs 4.3, p=0.002)
		4.2±3.1 months	Nebulization with 3ml albuterol in hypertonic saline solution for 8 to 10 minutes	HR (T0)	SoB:
		6.0±3.2 Wang	GNMF	Shortness of breath (SoB)	T30<T0 (0.8 vs 1.3, p=0.001)
		GNMF (n=12):	31 sessions	After the session:	T150<T0 (0.9 vs 1.3, p=0.001)
		2♀ + 10♂	2.5 sessions/patient	30min (T30)	CG vs GCPT:
		3.9±2.4 months	Nebulization followed by 10 to 15 minutes of PSE and PC	120min (T150)	T30:
		5.5 ± 2.9 Wang			RR (p=0.001)
					HR (p<0.001)
					T30 vs T0:
					Wang: (p=0.004)
					SoB: (p=0.001)
					HR: (p=0.2)
Pupin, 2009	RCT				GAD, GDP and CG without significant differences in T1
					GAD:
					HR
					T1 55.59±10.12, T2 54.19±8.88,
					T3 50.26±8.65, T4 47.89±8.54
					T1 vs T3 (p=0.0171)
		AVB			T2 vs T3 (p=0.0016)
		Outpatient clinic			T2 vs T4 (p=0.0137)
		EFI and RRC Group (GAD)			RR
		18♂ + 9♀			T1 147.67±17.75, T2 151.89±16.19,
		4.59±2.75 months			T3 144.00±17.35, T4 146.78±18.97
		7 comorbidity			T2 vs T3 (p=0.0023)
		6 premature			T2 vs T4 (p=0.0066)
		13 oxygen support	Positioning: bench press with headboard elevation	HR (ppm)	GDP:
		DP Group (GDP)	GAD: EFI + RRC	RR (cycles/min)	HR
		15♂ + 12♀	Repeated up to a maximum of 40 compressions.	SpO2 (%)	T1 55.11±11.30, T2 54.85±9.84,
		4.19±2.22 months	GDP: Vibration + –PC + DP	T1: before the procedure	T3 51.22±8.67, T4 49.11±10.81
		5 comorbidity	10min	T2: 10min after	T1 vs T3 (p=0.0171)
		8 premature	Untreated CG: manual chest contact	T3: 30min after	T2 vs T3 (p=0.0016)
		10 oxygen support	10min	T4: 60min fater	T2 vs T4 (p=0.0137)
		Control group (CG)			RR
		15♂ + 11♀			T1 155.11±21.46, T2 156.15±24.55,
		4.78±2.98 meses			T3 147.81±16.85, T4 147.11±21.50
		7 comorbidity			T1 vs T4 (p=0.0066)
		4 premature			T2 vs T3 (p=0.0126)
		15 with oxygen support			CG:
					HR
					T1 56.37±10.06, T2 56.37±9.68,
					T3 54.41±10.17, T4 55.00±8.66
					T1 vs T3 (p=0.0171)
					T2 vs T3 (p=0.0016)
					T2 vs T4 (p=0.0137)
Remondini, 2014	RCT				G1:
		AVB	G1 and G2: bronchodilators and DP		Location: Ward 39 (81%) + ICU 9
		Hospitalization and ICU	G1:		Antibiotics: 48 (100%)
		G1:	puncture	Location (ward or ICU)	SpO2:
		14 (29.2%) ♀ + 34 (70.8%) ♂	tracheal aspiration	SpO2 (%)	<92%: 6 (0) vs 2 (10) vs 5 (60) (p=0.307)
		5.47 months	Antibiotics: 31 (64.6%) no	Severity of Lower Respiratory Tract Infection (LRTI) (1 to 17), where <4 is considered mild	>92%: 42 (0) vs 46 (10) vs 43 (60) (p=0.307)
		39 ICU + 9 hospitalization	Corticosteroids: 29 (60.4%) no	Moments:	LRTI: 5.02 (0) vs 3.06 (10) vs 3.13 (60) (p<0.001)
		SpO2<92%: 6 and ≥92:42	G2:	Before (0)	G2:
		G2:	expiratory flow acceleration	10min after session (10)	Location: Ward 34 (97%) + ICU 1
		7 (20.0%) ♀ + 28 (80.0%) ♂	tracheal aspiration.	60min after session (60)	Antibiotics: 35 (100%)
		6.28 months	Antibiotic: 19 (54.3%) no		SpO2:
		34 ICU + 1 hospitalization	Corticosteroids: 13 (37.1%) no		<92%: 7 (0) vs 3 (10) vs 3 (60) (p=0.234)
		SpO2<92: 7 and ≥92:28			>92%: 28 (0) vs 32 (10) vs 32 (60) (p=0.234)
					LRTI: 5.8 (0) vs 3.6 (10) vs. (660) (p<0.001)
Rochat, 2012	RCT				EG:
					Clinical score: 0.73 (0.91)
					Respiratory score: 9.5 (3.6)
		AVB			RR: 53.2 (12.7)
		Hospitalization	Sessions two times per day		SpO2: 91.9 (4.5)
		EG:	CG:	-Clinical score (feeding, vomiting, sleep quality)	pH: 7.37 (0.06)
		27♂ + 23♀	- rhinopharyngeal suction after administration of saline solution	-Respiratory score (RR, SpO2, presence and severity of retractions, adventitious respiratory sounds, presence of vesicular murmur, chest distention)	PCO2: 5.73 (1.72)
		110 (95) days	-oxygen to reach SpO2≥92%	-RR (cycles/min)	Bicarbonates: 23.1 (2.5)
		37 at first episode of bronchiolitis	-fractionated meals	-SpO2 (%)	CG:
		37 with RSV ELISA	-nasal drops (xylometazoline)	-pH of capillary blood	Clinical score: 0.73 (0.96)
		1 with another type of virus	-antibiotics in cases of infection	-capillary PCO2 (kPa)	Respiratory score: 9.5 (3.6)
		CG:	EG:	-Bicarbonates (mmol/l)	SpO2: 92.4 (4.8)
		28♂ + 21♀	-Same as the control group	Daily clinical assessments before physiotherapy sessions (in the EG)	pH: 7.37 (0.05)
		108 (86) days	-PSE		PCO2: 6.11 (1.30)
		42 at first episode of bronchiolitis	-EFA		Bicarbonates: 24.3 (2.1)
		37 with RSV ELISA	-PC		Clinical score:
		1 with another type of virus			p=0.37
					Respiratory score:
					p=0.044
Sánchez, 2004	Prospective OBS	AVB
		Hospitalization
		n=223 of 2 hospitals
		HUC: n=93	-supplemental oxygen		HUC vs HRS
		56% ♂ + 44% ♀	-common adrenaline		Age: 6.6 vs 2.5 (p<0.001)
		6.6 months	-salbutamol nebulization	Length of stay (days)	Hospital days: 3 vs 4 (p<0.018)
		26.9% with chronic respiratory pathology	-systemic corticosteroid	Difference in treatments in different centers (%)	-common adrenaline: 44% vs 81% (p < 0.0001)
		HSR: n=130	-antibiotics		-salbutamol nebulization: 90.3% vs 31.5% (p<0.0001)
		54% ♂ + 46% ♀	-RR		-RR: 54% vs 86% (p<0.0001)
		2.5 ± 0.2 months
		2.3% with chronic respiratory pathology
Sánchez-Bayle, 2012	RCT	AVB
		Hospitalization	10min sessions, 2× a day
		CG:	CG:
		41♀ + 59♂	Placebo maneuvers (postural changes)
		2.48±1.57 months	Initial medication:
		80% with respiratory stress	-Adrenaline (54% of the sample)		Hospitalization days:
		90% with exams	-Salbutamol (27%)		EG (4.56±2.07) vs CG (4.54±1.72)
		67% with RSV	-Ipratropium bromide (5%)	Hospitalization days	Hours of oxygen therapy:
		37±1 ºC	-Antibiotics (37%)	Hours of oxygen therapy	GR (49.98±37.1) vs CG (53.53±38.87) (p=0.042).
		95±4% SpO2	-Adrenaline (50%)	Final medication (% of sample)	Final medication:
		EG:	EG:		-Adrenaline: EG (50%) vs CG (54%)
		55♀ + 81♂	PSE + Vibration + PC		-Salbutamol: EG (29.41%) vs CG (27%)
		2.61±1.53 months	Initial medication:		-Ipratropium bromide: EG (5.14%) vs CG (5%)
		85% with respiratory stress	-Adrenaline (50% of the sample)		-Antibiotics: EG (38.97%) vs CG (37%)
		88% with exams	-Salbutamol (29%)
		67% with RSV	-Ipratropium bromide (5%)
		37±1ºC	-Antibiotics (39%)
		95±3% SpO2	-Adrenaline (54%)
Sebban, 2017	Prospective OBS	AVB
		Outpatient clinic		Stratified Wang:	Wang of 4 [2-6] before and 2 [0-3] after RR (p < 0.01).
		19 (6♀ + 13♂)	1 physiotherapy session (2 hours and 30 minutes) consisting of techniques:	<4: class 1: benign bronchiolitis (BB)	BB: Before (31.6%) and after RR (94.7%) (p<0.0001)
		Age (months)	RRC + Flow demodulation maneuver practice + PC	<9: class 2: moderate bronchiolitis (MB)	MB: before (63.2%) and after RR (5.3%) (p<0.0001)
		From 1 to 3: 8 (42.1%)	Other treatments received: Bronchodilator, Corticotherapy, Antibiotics	<12: class 3: severe bronchiolitis related to hospitalization decision (SB)	SB: before (5.3%) and after RR (0%) (p<0.001)
		From 3 to 6: 7 (36.8%)		Hospitalization	Hospitalization before RR: 6
		From 6 to 9: 3 (15.8%)		Before and after (RR)	Hospitalization after RR: 0
		From 9 to 12: 1 (5.3%)
Webb, 1985	RCT	Acute viral bronchiolitis
		Hospitalization	CG: without RR		CG vs EG
		90 infants (CG=46; EG=44)	EG: with RR	Clinical score (maximum score: 30)	admission (46): 12 vs (44): 10
		54♂ + 36♀	-Cupped hand percussion (3min)	HR, RR, hyperinflation, use of accessory muscles, recession, rhinitis, wheezing, coughing, crackling and snoring	day 1 (45): 10 vs (42): 7
		4 – 6 months	-5 postural drainages	On admission, 1-5 days later	day 2 (39): 8 vs (38): 7
		69% RSV positive	-assisted coughing		day 3 (31): 6 vs (28): 7
		36% family history of atopy	-oropharyngeal suction (2× daily)		day 4 (21): 6 vs (16): 4
		66% with smokers at home			day 5 (18): 5 vs (11): 6

• AB: acute bronchiolitis; EFI: expiratory flow increase; AVB: acute viral bronchiolitis; GenC: general conditions; PD: postural drainage; RRC: retrograde rhinopharyngeal clearance; PSE: prolonged slow expiration; CG: control group; EG: experimental group; HR: heart rate; RR: Respiratory rate; OBS: observational; RE: retractions; RCT: randomized controlled trial; SpO₂: oxygen saturation; AC: assisted cough; PC: provoked cough; ICU: intensive care unit; RSV: respiratory syncytial virus; WH: Wheezing.
• Values are presented as mean±standard deviation. The results presented are those significant (with p-value), unless considered pertinent.

Retrograde rhinopharyngeal clearance (RRC) reduced wheezing and retractions²⁰; when associated with PSE, it reduced retractions and increased SpO₂¹⁷, and when associated with PC²¹ it decreased hospitalization days and Wang’s score. RRC showed no changes in Silverman’s score²². Postural drainage (PD) associated with percussion and vibration did not decrease hospitalization days, supplemental oxygen or nasogastric feeding^23),(24; when associated with PC and oropharyngeal suction, it improved heart rate (HR), RR and SpO₂²², and when associated with EFI and tracheal aspiration, it improved SpO₂, reduced the number of infants in ICU and reduced the severity of the condition⁹. Assisted autogenic drainage associated with intrapulmonary percussive ventilation was shown to be statistically significant in terms of days to discharge, Wang’s clinical severity score, and heart rate⁹.

Only two studies addressed mild and moderate viral bronchiolitis, with a decrease in hospitalization days and pathology severity²⁰, heart rate, respiratory rate, and Wang’s score¹⁷.

Regarding the care setting, 54% of the articles performed inpatient physiotherapy and of these, 64% showed fewer hours of oxygen therapy²¹, hospitalization days^16),(20),(25, improved Wang’s score^15),(16),(20, decrease HR^{15),(16),(20),(22}, RR^16),(22),(26, adventitious sounds (reduction of retractions) and Downes’ score⁸, and increased SpO₂^{15),(18),(22),(26}.

As for the studies (23%) that encompassed both inpatient and ICU settings, most showed positive results regarding hospitalization days²⁷, SpO₂^9),(28),(29, reduction in the number of infants in the ICU⁹, reduction in disease severity⁹, reduction in wheezing and retractions^28),(30 and respiratory rate²⁹.

In studies (23%) with outpatient intervention, most (83%) showed some statistically significant positive outcome, namely in RR¹⁷, HR^17),(31, hospitalization days²¹ and clinical severity scores^14),(19),(32.

DISCUSSION

There is no consensus on which physical therapy techniques are most suitable for the benefit of infants with acute viral bronchiolitis (ABV), despite positive results^33),(34. Only two studies found an improved HR with EFI associated with vibrating RRC, PC and PD³¹ and autogenic drainage with intrapulmonary percussive ventilation²⁰, reinforcing the results of other authors⁵.

We observed opposite results regarding the relationship between SpO₂ and severity (Wang), which had already been noted by Roqué i Figuls⁶.The studies included in this systematic review did not report any improvement when using PD associated with vibration and percussion^23),(35, unlike a 2008 study in which it is associated with vibrocompression³⁶. Regarding the Silverman’s score, only one study obtained significant results when using RRC¹⁴. Studies show that application of the RRC technique in infants with acute viral bronchiolitis has immediate positive effects on the occurrence of complications and signs of respiratory effort when compared to nasopharyngeal aspiration. RRC seems to be a safe technique and can therefore be considered a possible alternative for treating infants with AVB and upper airway obstruction²⁰. In agreement with the literature, RRC achieved significant improvements in airway auscultation and significantly decreased respiratory rate³⁷. Finally, regarding the Downes’ score, only one study showed significant improvements when performing EFI associated with vibration and nasotracheal aspiration⁸. According to Almeida-Júnior³⁸, when evaluating the effects of EFI on lung function in infants, significant improvements were found in all parameters. Although moderate bronchiolitis is less frequently addressed, studies reported significant improvements in hospitalization days and severity of the pathology²⁰, as well as in HR, RR and Wang’s score¹⁷, confirming that in moderate cases there is benefit in applying physical therapy⁷. There is no consensus regarding its effectiveness in reducing clinical severity, which can be explained by the fact, in the most severe cases, it is common not to use physical therapy⁷. Of the 26 selected articles, 54% were carried out in inpatient settings, with 64% reporting significant changes, and 23% in both inpatient and ICU settings and 23% in outpatient settings, with 83% observing significant changes, corroborating an outpatient study that showed that physical therapy had a positive impact on this population³⁹.

CONCLUSION

Evidence suggests good results of physical therapy techniques, namely RRC, PSE and EFI or PC, in airway permeabilization, promotion of bronchial hygiene, and comfort and recovery of functions in the population studied, regardless of disease severity and the care setting. It also showed positive results on hospitalization days, SpO₂, clinical score, HR, RR, and the need for oxygen therapy. A limitation of this systematic review is the lack of studies with robust and comparable methodologies, especially regarding the different severities of the pathology, to clarify the adequacy of interventions. We suggest that studies be carried out on patients with mild to moderate bronchiolitis who are not hospitalized.

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• ¹
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  van Ginderdeuren F, Vandenplas Y, Deneyer M, Vanlaethem S, Buyl R, Kerckhofs E. Effectiveness of airway clearance techniques in children hospitalized with acute bronchiolitis. Pediatr Pulmonol. 2017;52(2):225-31. doi: 10.1002/ppul.23495.
  » https://doi.org/10.1002/ppul.23495
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  Sánchez Bayle M, Martín Martín R, Cano Fernández J, Martínez Sánchez G, Gómez Martín J, Chullen GY, 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. 2012;77(1):5-11. doi: 10.1016/j.anpedi.2011.11.026.
  » https://doi.org/10.1016/j.anpedi.2011.11.026
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  Jacinto CP, Gastaldi AC, Aguiar DY, Maida KD, Souza HCD. Physical therapy for airway clearance improves cardiac autonomic modulation in children with acute bronchiolitis. Braz J Phys Ther. 2013;17(6):533-40. doi: 10.1590/S1413-35552012005000120.
  » https://doi.org/10.1590/S1413-35552012005000120
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  Nicholas KJ, Dhouieb MO, Marshall TG, Edmunds AT, Grant MB. An evaluation of chest physiotherapy in the management of acute bronchiolitis. Physiotherapy. 1999;85(12):669-74. doi: 10.1016/S0031-9406(05)61230-8.
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  Bohé L, Ferrero ME, Cuestas E, Polliotto L, Genoff M. Indicación de la fisioterapia respiratoria convencional en la bronquiolitis aguda. Medicina (B Aires). 2004;64(3):198-200.
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  Sánchez Díaz I, Monge M, Córdova P, Fuentes P, Carrasco JA, Cavagnaro P. Factores epidemiológicos y evolución clínica de pacientes hospitalizados por bronquiolitis aguda en dos hospitales de Santiago. Rev Chil Pediatr. 2004;75(Suppl.1):25-31. doi: 10.4067/S0370-41062004000700005.
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  Rochat I, Leis P, Bouchardy M, Oberli C, Sourial H, Friedli-Burri M, et al. Chest physiotherapy using passive expiratory techniques does not reduce bronchiolitis severity: a randomised controlled trial. Eur J Pediatr. 2012;171:457-62. doi: 10.1007/s00431-011-1562-y.
  » https://doi.org/10.1007/s00431-011-1562-y
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  Carroll CL, Faustino EVS, Pinto MG, Sala KA, Canarie MF, Li S, et al. A regional cohort study of the treatment of critically ill children with bronchiolitis. J Asthma. 2016;53(10):1006-11. doi: 10.1080/02770903.2016.1180697.
  » https://doi.org/10.1080/02770903.2016.1180697
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  Gomes ELFD, Postiaux G, Medeiros DRL, Monteiro KKDS, Sampaio LMM, Costa D. Chest physical therapy is effective in reducing the clinical score in bronchiolitis: randomized controlled trial. Braz J Phys Ther. 2012;16(3):241-7. doi: 10.1590/s1413-35552012005000018.
  » https://doi.org/10.1590/s1413-35552012005000018
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  Gonçalves RAS, Feitosa S, Selestrin CC, Valenti VE, Sousa FH, Siqueira AAF, et al. Evaluation of physiological parameters before and after respiratory physiotherapy in newborns with acute viral bronchiolitis. Int Arch Med. 2014;7(1):3.
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  Gomes GR, Calvete FPG, Rosito GF, Donadio MVF. Rhinopharyngeal retrograde clearance induces less respiratory effort and fewer adverse effects in comparison with nasopharyngeal aspiration in infants with acute viral bronchiolitis. Respir Care. 2016;61(12):1613-9. doi: 10.4187/respcare.04685.
  » https://doi.org/10.4187/respcare.04685
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  Pupin MK, Riccetto AGL, Ribeiro JD, Baracat ECE. Comparison of the effects that two different respiratory physical therapy techniques have on cardiorespiratory parameters in infants with acute viral bronchiolitis. J Bras Pneumol. 2009;35(9):860-7. doi: 10.1590/s1806-37132009000900007.
  » https://doi.org/10.1590/s1806-37132009000900007
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  Sebban S, Pull L, Smail A, Menier I, Berthaud C, Boulkedid R, et al. Influence de la kinésithérapie respiratoire sur la décision d'hospitalisation du nourrisson de moins d'un an atteint de bronchiolite aux urgences pédiatriques. Kinésithérapie, la Revue. 2017;17(183):3-8. doi: 10.1016/j.kine.2016.11.011.
  » https://doi.org/10.1016/j.kine.2016.11.011
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  Giné-Garriga M, Roqué-Fíguls M, Coll-Planas L, Sitjà-Rabert M, Salvà A. Physical exercise interventions for improving performance-based measures of physical function in community-dwelling, frail older adults: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2014;95(4):753-69. doi: 10.1016/j.apmr.2013.11.007.
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  Castro AT, Silva SF, Palhau L. Cinesiterapia respiratória na bronquiolite aguda. Revista da Sociedade Portuguesa de Medicina Física e de Reabilitação. 2009;17(1):33-8. doi: 10.25759/spmfr.58.
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  Webb MSC, Martin JA, Cartlidge PHT, Ng YK, Wright NA. Chest physiotherapy in acute bronchiolitis. Arch Dis Child. 1985;60(11):1078-9. doi: 10.1136/adc.60.11.1078.
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  Oliveira TRS, Santos CA, Viviani AG. Efeitos da fisioterapia respiratória em lactentes prematuros. Movimenta. 2013;6(2):456-62.
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  Almeida-Júnior AA, Silva MTN, Almeida CCB, Jácomo ADN, Nery BM, Ribeiro JD. Associação entre índice de ventilação e tempo de ventilação mecânica em lactentes com bronquiolite viral aguda. J Pediatr. 2005;81(6):466-70. doi: 10.1590/s0021-75572005000800010.
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  Pinto FR, Alexandrino AS, Correia-Costa L, Azevedo I. Ambulatory chest physiotherapy in mild-to-moderate acute bronchiolitis in children under two years of age - a randomized control trial. Hong Kong Physiother J. 2021;41(2):99-108. doi: 10.1142/S1013702521500098.
  » https://doi.org/10.1142/S1013702521500098

• 3
  Financing source: nothing to declare

APPENDIX

I) PRISMA checklist

Section and Topic Item Checklist item Location where item is reported TITLE Title 1 Identify the report as a systematic review. Cover ABSTRACT Abstract 2 See the PRISMA 2020 for Abstracts checklist. INTRODUCTION Rationale 3 Describe the rationale for the review in the context of existing knowledge. 2 Objectives 4 Provide an explicit statement of the objective(s) or question(s) the review addresses. 2 METHODS Eligibility criteria 5 Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses. 2 Information sources 6 Specify all databases, registers, websites, organisations, reference lists and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted. 2 Search strategy 7 Present the full search strategies for all databases, registers and websites, including any filters and limits used. x Selection process 8 Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process. 2 Data collection process 9 Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process. 2 Data items 10a List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect. 2 10b List and define all other variables for which data were sought (e.g. participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information. 2 Study risk of bias assessment 11 Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process. 2 Effect measures 12 Specify for each outcome the effect measure(s) (e.g. risk ratio, mean difference) used in the synthesis or presentation of results. x Synthesis methods 13a Describe the processes used to decide which studies were eligible for each synthesis (e.g. tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)). 2 13b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions. x 13c Describe any methods used to tabulate or visually display results of individual studies and syntheses. 2 13d Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used. x 13e Describe any methods used to explore possible causes of heterogeneity among study results (e.g. subgroup analysis, meta-regression). x 13f Describe any sensitivity analyses conducted to assess robustness of the synthesized results. x Reporting bias assessment 14 Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases). x Certainty assessment 15 Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome. x RESULTS Study selection 16a Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram. 2 - Figure 1 16b Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded. 2 Study characteristics 17 Cite each included study and present its characteristics. Table 1 Risk of bias in studies 18 Present assessments of risk of bias for each included study. 2+Annex II Results of individual studies 19 For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g. confidence/credible interval), ideally using structured tables or plots. x Results of syntheses 20a For each synthesis, briefly summarie the characteristics and risk of bias among contributing studies. x 20b Present results of all statistical syntheses conducted. If meta-analysis was done, present for each the summary estimate and its precision (e.g. confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect. Table 1 20c Present results of all investigations of possible causes of heterogeneity among study results. x 20d Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results. x Reporting biases 21 Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed. x Certainty of evidence 22 Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed. x DISCUSSION Discussion 23a Provide a general interpretation of the results in the context of other evidence. 3-4 23b Discuss any limitations of the evidence included in the review. 4 23c Discuss any limitations of the review processes used. x 23d Discuss implications of the results for practice, policy, and future research. 4 OTHER INFORMATION Registration and protocol 24a Provide registration information for the review, including register name and registration number, or state that the review was not registered. 2 24b Indicate where the review protocol can be accessed, or state that a protocol was not prepared. 2 24c Describe and explain any amendments to information provided at registration or in the protocol. x Support 25 Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review. Submission form Competing interests 26 Declare any competing interests of review authors. Declaration Availability of data, code and other materials 27 Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review. y

Section and Topic	Item	Checklist item	Location where item is reported
TITLE
Title	1	Identify the report as a systematic review.	Cover
ABSTRACT
Abstract	2	See the PRISMA 2020 for Abstracts checklist.
INTRODUCTION
Rationale	3	Describe the rationale for the review in the context of existing knowledge.	2
Objectives	4	Provide an explicit statement of the objective(s) or question(s) the review addresses.	2
METHODS
Eligibility criteria	5	Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses.	2
Information sources	6	Specify all databases, registers, websites, organisations, reference lists and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted.	2
Search strategy	7	Present the full search strategies for all databases, registers and websites, including any filters and limits used.	x
Selection process	8	Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.	2
Data collection process	9	Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.	2
Data items	10a	List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect.	2
	10b	List and define all other variables for which data were sought (e.g. participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information.	2
Study risk of bias assessment	11	Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.	2
Effect measures	12	Specify for each outcome the effect measure(s) (e.g. risk ratio, mean difference) used in the synthesis or presentation of results.	x
Synthesis methods	13a	Describe the processes used to decide which studies were eligible for each synthesis (e.g. tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)).	2
	13b	Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.	x
	13c	Describe any methods used to tabulate or visually display results of individual studies and syntheses.	2
	13d	Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.	x
	13e	Describe any methods used to explore possible causes of heterogeneity among study results (e.g. subgroup analysis, meta-regression).	x
	13f	Describe any sensitivity analyses conducted to assess robustness of the synthesized results.	x
Reporting bias assessment	14	Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases).	x
Certainty assessment	15	Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome.	x
RESULTS
Study selection	16a	Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.	2 - Figure 1
	16b	Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.	2
Study characteristics	17	Cite each included study and present its characteristics.	Table 1
Risk of bias in studies	18	Present assessments of risk of bias for each included study.	2+Annex II
Results of individual studies	19	For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g. confidence/credible interval), ideally using structured tables or plots.	x
Results of syntheses	20a	For each synthesis, briefly summarie the characteristics and risk of bias among contributing studies.	x
	20b	Present results of all statistical syntheses conducted. If meta-analysis was done, present for each the summary estimate and its precision (e.g. confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect.	Table 1
	20c	Present results of all investigations of possible causes of heterogeneity among study results.	x
	20d	Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results.	x
Reporting biases	21	Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed.	x
Certainty of evidence	22	Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed.	x
DISCUSSION
Discussion	23a	Provide a general interpretation of the results in the context of other evidence.	3-4
	23b	Discuss any limitations of the evidence included in the review.	4
	23c	Discuss any limitations of the review processes used.	x
	23d	Discuss implications of the results for practice, policy, and future research.	4
OTHER INFORMATION
Registration and protocol	24a	Provide registration information for the review, including register name and registration number, or state that the review was not registered.	2
	24b	Indicate where the review protocol can be accessed, or state that a protocol was not prepared.	2
	24c	Describe and explain any amendments to information provided at registration or in the protocol.	x
Support	25	Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review.	Submission form
Competing interests	26	Declare any competing interests of review authors.	Declaration
Availability of data, code and other materials	27	Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review.	y

II) QUALITY ASSESSMENT

Observational studies:

reviewer Evenou 2017 Sebban 2017 Carroll, 2016 Gonçalves, 2014 1 2 both 1 2 both 1 2 both 1 2 both 1 Y Y Y Y Y Y Y Y 2 Y Y Y Y Y Y NR Y 3 Y NR Y N Y Y NR Y 4 Y Y Y Y Y Y N N 5 N N NR N NR N Y Y 6 Y Y Y Y Y Y Y Y 7 Y Y Y N Y Y N N 8 N NA N Y NO N N N 9 Y Y Y Y Y N Y Y 10 Y Y N Y NO NA Y Y 11 Y Y Y Y Y Y Y Y 12 N N N N NR N N Y 13 N N N N NR NA Y NR 14 NR N NR N NR N N N Quality Rating G G G F F F G F F G G G

reviewer	Evenou 2017			Sebban 2017			Carroll, 2016			Gonçalves, 2014
	1	2	both	1	2	both	1	2	both	1	2	both
1	Y	Y		Y	Y		Y	Y		Y	Y
2	Y	Y		Y	Y		Y	Y		NR	Y
3	Y	NR		Y	N		Y	Y		NR	Y
4	Y	Y		Y	Y		Y	Y		N	N
5	N	N		NR	N		NR	N		Y	Y
6	Y	Y		Y	Y		Y	Y		Y	Y
7	Y	Y		Y	N		Y	Y		N	N
8	N	NA		N	Y		NO	N		N	N
9	Y	Y		Y	Y		Y	N		Y	Y
10	Y	Y		N	Y		NO	NA		Y	Y
11	Y	Y		Y	Y		Y	Y		Y	Y
12	N	N		N	N		NR	N		N	Y
13	N	N		N	N		NR	NA		Y	NR
14	NR	N		NR	N		NR	N		N	N
Quality Rating	G	G	G	F	F	F	G	F	F	G	G	G

Experimental Studies with no Control Group:

reviewer Postiaux, 2006 Barbie, 2009 Bernard-Narbonne, 2003 Castro, 2011 Halna, 2005 Sanchez, 2004 1 2 both 1 2 both 1 2 both 1 2 both 1 2 both 1 2 both 1 Y Y Y Y Y Y Y Y Y Y Y Y 2 Y Y Y N Y Y Y Y Y Y Y Y 3 Y NR Y NR Y NR Y NR Y Y Y Y 4 N NR Y N Y Y Y Y Y Y Y Y 5 N NR N NR NR NR NR NR Y Y Y Y 6 Y Y Y Y Y Y Y Y Y Y Y N 7 Y Y Y Y Y Y Y Y Y Y Y Y 8 NR N N N NR NR NR Y NR N NR NA 9 Y Y NR NR NR NR NR Y NR NR NR NR 10 Y Y Y Y Y Y Y Y Y Y NO NA 11 Y N N N Y Y Y Y Y Y NO NA 12 NA NA Y Y Y Y Y Y Y N NO N Quality Rating F F F F P P G G G G G G G F G P P P

reviewer	Postiaux, 2006			Barbie, 2009			Bernard-Narbonne, 2003			Castro, 2011			Halna, 2005			Sanchez, 2004
	1	2	both	1	2	both	1	2	both	1	2	both	1	2	both	1	2	both
1	Y	Y		Y	Y		Y	Y		Y	Y		Y	Y		Y	Y
2	Y	Y		Y	N		Y	Y		Y	Y		Y	Y		Y	Y
3	Y	NR		Y	NR		Y	NR		Y	NR		Y	Y		Y	Y
4	N	NR		Y	N		Y	Y		Y	Y		Y	Y		Y	Y
5	N	NR		N	NR		NR	NR		NR	NR		Y	Y		Y	Y
6	Y	Y		Y	Y		Y	Y		Y	Y		Y	Y		Y	N
7	Y	Y		Y	Y		Y	Y		Y	Y		Y	Y		Y	Y
8	NR	N		N	N		NR	NR		NR	Y		NR	N		NR	NA
9	Y	Y		NR	NR		NR	NR		NR	Y		NR	NR		NR	NR
10	Y	Y		Y	Y		Y	Y		Y	Y		Y	Y		NO	NA
11	Y	N		N	N		Y	Y		Y	Y		Y	Y		NO	NA
12	NA	NA		Y	Y		Y	Y		Y	Y		Y	N		NO	N
Quality Rating	F	F	F	F	P	P	G	G	G	G	G	G	G	F	G	P	P	P

Experimental Studies with Control Group:

reviewer Nicholas, 1999 Pupin, 2009 Webb,1985 Rochat,2012 Bailleux, 2011 Bohé, 2004 1 2 both 1 2 both 1 2 both 1 2 both 1 2 both 1 2 both 1 Y Y Y N Y N Y Y Y Y Y Y 2 Y Y NO Y NR NA Y Y NR N Y Y 3 NR Y NR N NR N Y Y NR NR Y Y 4 NR N NR N NR N Y N NR Y NR NR 5 NR N NR NR NR N NR Y NR Y NR NR 6 Y Y Y Y Y Y Y Y Y Y Y Y 7 Y Y NO Y NR Y NR Y NR NR NR Y 8 Y Y NO Y NR Y NR Y NR NR NR Y 9 Y Y Y Y Y Y Y Y Y NR Y Y 10 Y N NO N Y Y Y Y NR Y Y Y 11 Y Y Y Y Y Y Y Y NR Y NR Y 12 NR N NR NR NR NR NR NR NR NR NR NR 13 Y Y NO Y Y Y Y Y NR Y Y N 14 NR Y NO Y Y Y Y Y NR Y Y Y Quality Rating F F F P F F P P P G G G P P P G F F

reviewer	Nicholas, 1999			Pupin, 2009			Webb,1985			Rochat,2012			Bailleux, 2011			Bohé, 2004
	1	2	both	1	2	both	1	2	both	1	2	both	1	2	both	1	2	both
1	Y	Y		Y	N		Y	N		Y	Y		Y	Y		Y	Y
2	Y	Y		NO	Y		NR	NA		Y	Y		NR	N		Y	Y
3	NR	Y		NR	N		NR	N		Y	Y		NR	NR		Y	Y
4	NR	N		NR	N		NR	N		Y	N		NR	Y		NR	NR
5	NR	N		NR	NR		NR	N		NR	Y		NR	Y		NR	NR
6	Y	Y		Y	Y		Y	Y		Y	Y		Y	Y		Y	Y
7	Y	Y		NO	Y		NR	Y		NR	Y		NR	NR		NR	Y
8	Y	Y		NO	Y		NR	Y		NR	Y		NR	NR		NR	Y
9	Y	Y		Y	Y		Y	Y		Y	Y		Y	NR		Y	Y
10	Y	N		NO	N		Y	Y		Y	Y		NR	Y		Y	Y
11	Y	Y		Y	Y		Y	Y		Y	Y		NR	Y		NR	Y
12	NR	N		NR	NR		NR	NR		NR	NR		NR	NR		NR	NR
13	Y	Y		NO	Y		Y	Y		Y	Y		NR	Y		Y	N
14	NR	Y		NO	Y		Y	Y		Y	Y		NR	Y		Y	Y
Quality Rating	F	F	F	P	F	F	P	P	P	G	G	G	P	P	P	G	F	F

reviewer Jacinto, 2013 Sánchez Bayle, 2012 Ginderdeuren, 2017 Gadjos, 2010 Conesa-Segura, 2019 Remondini, 2014 1 2 both 1 2 both 1 2 both 1 2 both 1 2 both 1 2 both 1 Y N Y Y Y Y NR Y Y Y Y Y 2 NR NA Y Y Y Y Y Y Y Y Y NR 3 NR NA Y Y Y Y Y Y Y Y Y NR 4 NR NA N N N Y N N N N Y N 5 NR N Y N Y Y Y Y Y Y NR N 6 Y N Y Y Y Y Y Y Y Y NR N 7 NR Y N N Y Y Y Y Y Y Y Y 8 NR Y N N Y Y Y Y Y Y Y Y 9 Y NR Y Y N Y N Y Y Y NR Y 10 Y Y N Y N Y Y Y Y Y Y Y 11 Y Y Y Y Y Y Y Y Y Y Y Y 12 NR NR N Y Y NR N N Y Y Y NR 13 NR N Y Y Y Y Y Y Y Y Y Y 14 NR NA Y Y Y Y Y Y Y Y Y Y Quality Rating P P P G G G G G G G G G G G G F F F

reviewer	Jacinto, 2013			Sánchez Bayle, 2012			Ginderdeuren, 2017			Gadjos, 2010			Conesa-Segura, 2019			Remondini, 2014
	1	2	both	1	2	both	1	2	both	1	2	both	1	2	both	1	2	both
1	Y	N		Y	Y		Y	Y		NR	Y		Y	Y		Y	Y
2	NR	NA		Y	Y		Y	Y		Y	Y		Y	Y		Y	NR
3	NR	NA		Y	Y		Y	Y		Y	Y		Y	Y		Y	NR
4	NR	NA		N	N		N	Y		N	N		N	N		Y	N
5	NR	N		Y	N		Y	Y		Y	Y		Y	Y		NR	N
6	Y	N		Y	Y		Y	Y		Y	Y		Y	Y		NR	N
7	NR	Y		N	N		Y	Y		Y	Y		Y	Y		Y	Y
8	NR	Y		N	N		Y	Y		Y	Y		Y	Y		Y	Y
9	Y	NR		Y	Y		N	Y		N	Y		Y	Y		NR	Y
10	Y	Y		N	Y		N	Y		Y	Y		Y	Y		Y	Y
11	Y	Y		Y	Y		Y	Y		Y	Y		Y	Y		Y	Y
12	NR	NR		N	Y		Y	NR		N	N		Y	Y		Y	NR
13	NR	N		Y	Y		Y	Y		Y	Y		Y	Y		Y	Y
14	NR	NA		Y	Y		Y	Y		Y	Y		Y	Y		Y	Y
Quality Rating	P	P	P	G	G	G	G	G	G	G	G	G	G	G	G	F	F	F

reviewer Gomes, 2016 Postiaux, 2011 Gomes, 2012 González-Bellido, 2021 1 2 both 1 2 both 1 2 both 1 2 both 1 Y Y Y Y Y Y Y Y 2 Y Y Y Y Y Y Y N 3 Y Y Y Y Y Y Y N 4 N NR N N N N N N 5 Y NR Y Y Y Y Y Y 6 Y Y Y Y Y Y Y Y 7 Y Y Y Y Y Y Y Y 8 N Y N Y N N N Y 9 Y Y Y Y Y Y Y Y 10 N N Y Y N N N NR 11 Y Y Y Y Y Y Y Y 12 Y Y Y NR Y NR Y NR 13 Y Y Y Y Y Y Y Y 14 Y Y Y Y Y Y Y Y Quality Rating G G G G G G G G G G G G Quality Rating: G: Good; F: Fair; P: Poor.

reviewer	Gomes, 2016			Postiaux, 2011			Gomes, 2012			González-Bellido, 2021
	1	2	both	1	2	both	1	2	both	1	2	both
1	Y	Y		Y	Y		Y	Y		Y	Y
2	Y	Y		Y	Y		Y	Y		Y	N
3	Y	Y		Y	Y		Y	Y		Y	N
4	N	NR		N	N		N	N		N	N
5	Y	NR		Y	Y		Y	Y		Y	Y
6	Y	Y		Y	Y		Y	Y		Y	Y
7	Y	Y		Y	Y		Y	Y		Y	Y
8	N	Y		N	Y		N	N		N	Y
9	Y	Y		Y	Y		Y	Y		Y	Y
10	N	N		Y	Y		N	N		N	NR
11	Y	Y		Y	Y		Y	Y		Y	Y
12	Y	Y		Y	NR		Y	NR		Y	NR
13	Y	Y		Y	Y		Y	Y		Y	Y
14	Y	Y		Y	Y		Y	Y		Y	Y
Quality Rating	G	G	G	G	G	G	G	G	G	G	G	G

• Quality Rating: G: Good; F: Fair; P: Poor.

Publication Dates

• Publication in this collection
  11 Mar 2022
• Date of issue
  Oct-Dec 2021

History

• Received
  20 Aug 2021
• Accepted
  22 Nov 2021