Chest physiotherapy for pneumonia in adults

Ming Yang; Yuping Yan; Xiangli Yin; Bin Y Wang; Taixiang Wu; Guan J Liu; Bi Rong Dong

doi:10.1002/14651858.CD006338.pub3

Fisioterapia torácica para la neumonía en adultos

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Referencias

Referencias de los estudios incluidos en esta revisión

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Bjorkqvist M, Wiberg B, Bodin L, Bárány M, Holmberg H. Bottle‐blowing in hospital‐treated patients with community‐acquired pneumonia. Scandinavian Journal of Infectious Diseases 1997;29(1):77‐82.

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Referencias de los estudios excluidos de esta revisión

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Schultz K, Bergmann KC, Kenn K, Petro W, Heitmann RH, Fischer R, et al. Effectiveness of inpatient pulmonary rehabilitation (AHB). Results of a multicenter prospective observation study [Effektivitat der pneumologischen Anschluss‐Rehabilitation (AHB). Ergebnisse einer multizentrischen prospektiven Beobachtungsstudie]. Deutsche Medizinische Wochenschrift 2006;131(33):1793‐8.

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Referencias de los estudios en espera de evaluación

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Referencias de los estudios en curso

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Referencias adicionales

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Bowton DL. Nosocomial pneumonia in the ICU: year 2000 and beyond. Chest 1999;115(Suppl):28‐33.

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Characteristics of studies

Characteristics of included studies [ordered by study ID]

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Bjorkqvist 1997

Methods	Randomised, parallel‐group trial
Participants	In‐patient setting; relevant details of health status of participants; age; sex; country 50 treatment, 48 control 16 to 95 years old (mean 65) Male/female: 84 /61 Conducted in Sweden
Interventions	The physiotherapy was positive expiratory pressure (PEP). In this study a bottle containing 10 cm of tap water was used. Patients were asked to sit up with their feet on the floor and blow bubbles at a calm speed into the bottle through a plastic tube (10 mm in diameter) with an air pressure just sufficient to overcome the resistance of the water. This method was used 20 times per hour from 9 am to 8 pm and continued after discharge. This study consisted of three group (A, B, C). Group A was control which underwent early mobilisation and "huffing". Group B members were given the same as A and deep breaths. Group C members were given the same as A and the method of bottle‐blowing
Outcomes	Primary outcomes: death Secondary outcomes: duration of hospital stay (days); fever clearance time; CRP; VC; FEV1; PEF
Notes	The study was supported financially by the Orebro County Council Research Committee and the Orebro Medical Center Research Foundation
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	The randomised method was not clearly reported
Allocation concealment (selection bias)	Low risk	"Sealed envelopes" were used
Blinding (performance bias and detection bias) All outcomes	High risk	No blinding
Incomplete outcome data (attrition bias) All outcomes	Low risk	19 (13%) patients were drop‐outs. However, ITT analysis was performed
Selective reporting (reporting bias)	Unclear risk	Insufficient information
Other bias	Unclear risk	Insufficient information

Britton 1985

Methods	Randomised, parallel‐group, single‐blind trial
Participants	In‐patient setting; relevant details of health status of participants; age; sex; country 83 treatment, 88 control 15 to 75 years old (control: 47.2, treatment: 47.4) Male/female: 74/97 Conducted in Sweden
Interventions	The chest physiotherapy consisted of postural drainage, external help with breathing, percussion and vibration. The placebo was to receive advice on expectoration, deep breathing and how to exercise to avoid thrombosis
Outcomes	Primary outcomes: death; cure rate Secondary outcomes: duration of hospital stay (days); healing time (days); fever clearance time; FEV1
Notes	The study was approved by the ethical committee of the Karolinska Hospital, Stockholm Sources of funding were not stated
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	The randomised method was not clearly reported
Allocation concealment (selection bias)	Low risk	"Sealed envelopes" were used
Blinding (performance bias and detection bias) All outcomes	Low risk	Outcome assessor was blinded
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Insufficient information
Selective reporting (reporting bias)	Unclear risk	Insufficient information
Other bias	High risk	The standard deviations of duration of hospital stay and fever were not reported

Graham 1978

Methods	Randomised, parallel‐group trial
Participants	In‐patient setting; relevant details of health status of participants; age; sex; country 27 treatment, 27 control Age (mean ± SD): control: 63 ± 3 years old, treatment: 61 ± 4 years old Male/female: control 13/14, treatment 14/13 Conducted in Sweden
Interventions	The chest physiotherapy consisted of postural drainage, chest percussion and vibration, with encouragement of deep breathing and coughing. This therapy was used concomitantly with intermittent positive pressure breathing every 4 hours during the first 24 hours. Therapy was given for at least 3 days to all the treated participants, with an average duration of 5 days
Outcomes	Primary outcomes: death; cure rate Secondary outcomes: duration of hospital stay (days); rate of clearing of X‐ray film; fever clearance time
Notes	The study was supported by a grant (PHS 17292) to the Vermont Lung Center from the National Heart, Lung, and Blood Institute, National Institutes of Health Sources of funding not stated
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	The method of randomisation was not described
Allocation concealment (selection bias)	Low risk	"Sealed envelopes" were used
Blinding (performance bias and detection bias) All outcomes	Unclear risk	Insufficient information
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Insufficient information
Selective reporting (reporting bias)	Unclear risk	Insufficient information
Other bias	Unclear risk	Insufficient information

Noll 1999

Methods	Randomised, parallel‐group, double‐blind trial
Participants	In‐patient setting; relevant details of health status of participants; age; sex; country 11 in treatment group, 10 in control group The mean age was 78.7 in the control group, 82.5 in the treatment group Male/female: control 3/7, treatment 3/8 The trial was conducted in the United States
Interventions	Patients in the treatment group received a standardised osteopathic manipulative treatment protocol treatment consisting of 7 osteopathic manipulative techniques and non‐standardised osteopathic manipulative treatments from an osteopathic manipulative treatment specialist, while participants in the control group received a standardised light touch protocol treatment (sham treatment), with care taken not to move myofascial structures or to articulate joints. The session was 10 to 15 minutes, and the frequency of treatment was 2 sessions per day
Outcomes	Primary outcomes: death; cure rate Secondary outcomes: duration of hospital stay (days); rate of clearing of X‐ray film; duration of antibiotic therapy; duration of leukocytosis
Notes	—
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	The method of randomisation was not described
Allocation concealment (selection bias)	Unclear risk	Insufficient information
Blinding (performance bias and detection bias) All outcomes	Low risk	Patients and outcome assessors were blinded
Incomplete outcome data (attrition bias) All outcomes	Low risk	No drop‐outs
Selective reporting (reporting bias)	Unclear risk	Insufficient information
Other bias	Unclear risk	Insufficient information

Noll 2000

Methods	Randomised, double‐blind, parallel trial
Participants	In‐patient setting; relevant details of health status of participants; age; sex; country 28 in treatment group; 30 in control group Age (mean ± SD): control group: 77.0 ± 17.2 years old; treatment group: 77.7 ± 17.1 years old Male/female: control group: 16/14; treatment group: 14/14 The trial was conducted in the United States
Interventions	Patients in the treatment group received a standardised osteopathic manipulative treatment protocol treatment consisting of 7 osteopathic manipulative techniques and non‐standardised osteopathic manipulative treatments from an osteopathic manipulative treatment specialist, while participants in the control group received a standardised light touch protocol treatment (sham treatment), with care taken not to move myofascial structures or to articulate joints. The session was 10 to 15 minutes, and the frequency of treatment was 2 sessions per day
Outcomes	Primary outcomes: death; cure rate Secondary outcomes: duration of hospital stay (days); rate of clearing of X‐ray film; duration of antibiotic therapy; change in leukocyte count; mean leukocyte count
Notes	—
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	The method of randomisation was not described
Allocation concealment (selection bias)	Unclear risk	Insufficient information
Blinding (performance bias and detection bias) All outcomes	Low risk	Patients and outcome assessors were blinded
Incomplete outcome data (attrition bias) All outcomes	Low risk	No drop‐outs
Selective reporting (reporting bias)	Unclear risk	Insufficient information
Other bias	Unclear risk	Insufficient information

Tydeman 1989

Methods	Randomised, parallel‐group trial
Participants	In‐patient setting; relevant details of health status of participants; age; sex; country 12 treatment, 20 control Age (mean ± SD): control: 36.80 ± 16.91 years old, treatment: 42.08 ± 15.59 years old Male/female: control 10/10, treatment 9/3 Conducted in UK
Interventions	The physiotherapy was active cycle of breathing techniques, which consisted of breathing control using the diaphragm; localised expansion exercises; postural drainage; thoracic expansion exercises with vibrations on expiration; percussion. The first 2 methods were continued to discharge and the other methods were used when participants became productive of sputum. The dose of the therapy was dependent on the patient's tolerance and the sputum production
Outcomes	Primary outcomes: death; cure rate Secondary outcomes: duration of hospital stay (days); rate of clearing of X‐ray film; duration of all antibiotic therapy; duration of production of sputum; in‐patient sputum weight
Notes	This study was under the funding of Norwich Health Authority and the East Anglian Regional Health Authority Research Committee
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	The method of randomisation was not described
Allocation concealment (selection bias)	Unclear risk	Insufficient information
Blinding (performance bias and detection bias) All outcomes	High risk	Blinding was not performed
Incomplete outcome data (attrition bias) All outcomes	Low risk	Only 4 (11%) patients did not complete the study. Among them, 1 patient died, 2 patients were re‐diagnosed as having other disease and 1 patient could not attend sufficient assessments
Selective reporting (reporting bias)	Unclear risk	Insufficient information
Other bias	Unclear risk	Insufficient information

CRP: C‐reactive protein
VC: vital capacity
FEV1: forced expiratory volume in the first second
ITT: intention‐to‐treat
PEF: peak expiratory flow
OMT: osteopathic manipulative treatment

Characteristics of excluded studies [ordered by study ID]

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Study	Reason for exclusion
Barkov 1987	Physical agent; no control
Britton 1983a	Secondary publications under Britton 1985
Britton 1983b	Secondary publications under Britton 1985
Burioka 1998	The participants had diffuse panbronchiolitis
Cheng 2004	This study was not a RCT or quasi‐RCT. It covered mechanical ventilation for patients with acute respiratory failure caused by pneumonia
Choi 2005	Study was about mechanical ventilation for patients with pneumonia
Confalonieri 1998a	Study was about respiratory failure caused by pneumonia
Confalonieri 1998b	Study was about respiratory failure caused by pneumonia
Dangour 2011	It was a prevention study
Fu 2005	In addition to pneumonia, the participants also had asthma, chronic bronchitis or bronchiectasis. Not a RCT or quasi‐RCT
Holody 1981	In addition to pneumonia, the participants had atelectasis. Not a RCT or quasi‐RCT
Jolliet 2001	Not a RCT or quasi‐RCT
Li 2005	Some participants with pneumonia also had congestive heart failure or diabetes mellitus. Not a RCT or quasi‐RCT
Mo 2004	Some participants with pneumonia also had COPD or asthma. A before‐and‐after study in the same participants
Noll 2008	It was a study protocol
Patman 2009	Some participants in the study were less than 18 years old. There was no subgroup analysis for adults provided in the study
Schultz 2006	The participants also had asthma, lung cancer, COPD or pulmonary embolism
Wan 2004	Participants had lower respiratory tract infections, not only pneumonia. Not a RCT or quasi‐RCT
Wang 1997	The participants also had chronic bronchitis or acute bronchitis, not only pneumonia. Not a RCT or quasi‐RCT
Wu 2005a	Participants had a pulmonary infection, not only pneumonia. Not a RCT or quasi‐RCT
Wu 2005b	Participants had a pulmonary infection, not only pneumonia. Not a RCT or quasi‐RCT
Wu 2005c	Participants had pneumonia caused by chronic bronchitis. Not a RCT or quasi‐RCT
Xia 2005	Participants had a pulmonary infection, not only pneumonia. Not a RCT or quasi‐RCT
Xu 2004	Participants had lower respiratory tract infections, not only pneumonia. Not a RCT or quasi‐RCT
Zha 2004	The participants had acute lung abscesses. Not a RCT or quasi‐RCT
Zhang 2004	Participants had pneumonia caused by COPD, not only pneumonia. Not a RCT or quasi‐RCT

COPD: chronic obstructive pulmonary disease
RCT: randomised controlled trial

Characteristics of studies awaiting assessment [ordered by study ID]

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Facto 1947

Methods	Unclear
Participants	Unclear
Interventions	Unclear
Outcomes	Unclear
Notes	—

Kuznetsov 1976

Methods	Unclear
Participants	Unclear
Interventions	Unclear
Outcomes	Unclear
Notes	—

Kuznetsov 1980a

Methods	Unclear
Participants	Unclear
Interventions	Unclear
Outcomes	Unclear
Notes	—

Kuznetsov 1980b

Methods	Unclear
Participants	Unclear
Interventions	Unclear
Outcomes	Unclear
Notes	—

Sedov 1975

Methods	Unclear
Participants	Unclear
Interventions	Unclear
Outcomes	Unclear
Notes	—

Vorob'ev 1984

Methods	Unclear
Participants	Unclear
Interventions	Unclear
Outcomes	Unclear
Notes	—

Characteristics of ongoing studies [ordered by study ID]

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Noll

Trial name or title	Multi‐Center Osteopathic Pneumonia Study in the Elderly (MOPSE)
Methods	Randomised, double‐blind, placebo‐controlled trial
Participants	Inclusion criteria: 50 years old or older Patient is hospitalised in an acute care facility Patient must exhibit at least 2 of the classic symptoms of pneumonia, to include: respiration rate greater than or equal to 25 respirations per minute new or increased cough fever greater than or equal to 100.4 degrees F (38 degrees C) pleuritic chest pain worsening of mental or functional status leukocytosis (WBC greater than 12,000 cells per cubic millimetre) new or increased physical findings (rales, wheezing, bronchial breath sounds) Exclusion criteria: Lung abscess Advancing pulmonary fibrosis Bronchiectasis Pulmonary tuberculosis Lung cancer Metastatic malignancy Uncontrolled metabolic bone disease that places subject at risk of pathologic bone fracture (i.e. Paget's disease or hypoparathyroidism) Acute or unhealed rib or vertebral fracture History of pathologic bone fracture Previous participation in the study Respiratory failure (intubation)
Interventions	The first group: osteopathic manipulative treatment (OMT) The second group: light touch control The third group: conventional care only
Outcomes	Primary outcome measures: length of hospital stay, time to clinical stability, rate of symptomatic and functional recovery Secondary outcome measures: duration of IV and oral antibiotic usage in the hospital, number of complications and deaths secondary to pneumonia, duration and severity of fever, duration and severity of leukocytosis, patient satisfaction
Starting date	March 2004
Contact information	Not available
Notes	The trial had been completed when we were drafting this review, however it has not yet been published

IV: intravenous
WBC: white blood cell

Data and analyses

Open in table viewer

Comparison 1. Chest physiotherapy plus routine treatment versus routine treatment alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality Show forest plot	2	225	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.15, 7.13]
Open in figure viewer Analysis 1.1 Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 1 Mortality.
2 Cure rate Show forest plot	2	225	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.91, 1.04]
Open in figure viewer Analysis 1.2 Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 2 Cure rate.
3 Duration of hospital stay Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.3 Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 3 Duration of hospital stay.
4 Duration of fever Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.4 Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 4 Duration of fever.
5 Rate of improvement of chest X‐ray Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.5 Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 5 Rate of improvement of chest X‐ray.

Open in table viewer

Comparison 2. Active cycle of breathing techniques plus routine treatment versus routine treatment alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Cure rate Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.1 Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 1 Cure rate.
2 Duration of hospital stay Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.2 Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 2 Duration of hospital stay.
3 Rate of improvement of chest X‐ray Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.3 Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 3 Rate of improvement of chest X‐ray.
4 Duration of antibiotic therapy Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.4 Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 4 Duration of antibiotic therapy.
5 Duration of sputum production Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.5 Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 5 Duration of sputum production.
5.1 In‐patient	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 Out‐patient	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.3 Total	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 In‐patient sputum weight Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.6 Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 6 In‐patient sputum weight.

Open in table viewer

Comparison 3. Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality Show forest plot	2	79	Risk Ratio (M‐H, Fixed, 95% CI)	0.27 [0.05, 1.57]
Open in figure viewer Analysis 3.1 Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 1 Mortality.
2 Cure rate Show forest plot	2	79	Risk Ratio (M‐H, Fixed, 95% CI)	1.54 [0.97, 2.46]
Open in figure viewer Analysis 3.2 Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 2 Cure rate.
3 Duration of hospital stay Show forest plot	2	79	Mean Difference (IV, Fixed, 95% CI)	‐2.02 [‐3.46, ‐0.58]
Open in figure viewer Analysis 3.3 Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 3 Duration of hospital stay.
4 Duration of fever Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.4 Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 4 Duration of fever.
5 Rate of improvement of chest X‐ray Show forest plot	2	75	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.77, 1.73]
Open in figure viewer Analysis 3.5 Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 5 Rate of improvement of chest X‐ray.
6 Duration of oral antibiotic therapy Show forest plot	2	79	Mean Difference (IV, Random, 95% CI)	0.97 [‐1.25, 3.20]
Open in figure viewer Analysis 3.6 Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 6 Duration of oral antibiotic therapy.
7 Duration of intervenous therapy Show forest plot	2	79	Mean Difference (IV, Fixed, 95% CI)	‐2.11 [‐3.36, ‐0.87]
Open in figure viewer Analysis 3.7 Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 7 Duration of intervenous therapy.
8 Duration of total antibiotic therapy Show forest plot	2	79	Mean Difference (IV, Fixed, 95% CI)	‐1.93 [‐3.12, ‐0.74]
Open in figure viewer Analysis 3.8 Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 8 Duration of total antibiotic therapy.
9 Duration of leukocytosis Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.9 Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 9 Duration of leukocytosis.
10 Change in leukocyte count Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.10 Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 10 Change in leukocyte count.
10.1 Change between Day 3 and 1 from admission	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.2 Change between Day 5 and 1 from admission	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Mean leukocyte count Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.11 Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 11 Mean leukocyte count.
11.1 Day 3 from admission	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11.2 Day 5 from admission	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Open in table viewer

Comparison 4. Positive expiratory pressure plus routine treatment versus routine treatment alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Duration of hospital stay Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 4.1 Comparison 4 Positive expiratory pressure plus routine treatment versus routine treatment alone, Outcome 1 Duration of hospital stay.
2 Duration of fever Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 4.2 Comparison 4 Positive expiratory pressure plus routine treatment versus routine treatment alone, Outcome 2 Duration of fever.

Figure 1

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Forest plot of comparison: 1 Chest physiotherapy plus routine treatment versus routine treatment alone, outcome: 1.1 Mortality.

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Figure 4

Forest plot of comparison: 1 Chest physiotherapy plus routine treatment versus routine treatment alone, outcome: 1.2 Cure rate.

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Figure 5

Forest plot of comparison: 3 OMT plus routine treatment versus placebo plus routine treatment, outcome: 3.1 Mortality.

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Figure 6

Forest plot of comparison: 3 OMT plus routine treatment versus placebo plus routine treatment, outcome: 3.2 Cure rate.

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Analysis 1.1

Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 1 Mortality.

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Analysis 1.2

Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 2 Cure rate.

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Analysis 1.3

Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 3 Duration of hospital stay.

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Analysis 1.4

Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 4 Duration of fever.

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Analysis 1.5

Comparison 1 Chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 5 Rate of improvement of chest X‐ray.

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Analysis 2.1

Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 1 Cure rate.

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Analysis 2.2

Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 2 Duration of hospital stay.

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Analysis 2.3

Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 3 Rate of improvement of chest X‐ray.

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Analysis 2.4

Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 4 Duration of antibiotic therapy.

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Analysis 2.5

Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 5 Duration of sputum production.

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Analysis 2.6

Comparison 2 Active cycle of breathing techniques plus routine treatment versus routine treatment alone, Outcome 6 In‐patient sputum weight.

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Analysis 3.1

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 1 Mortality.

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Analysis 3.2

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 2 Cure rate.

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Analysis 3.3

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 3 Duration of hospital stay.

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Analysis 3.4

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 4 Duration of fever.

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Analysis 3.5

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 5 Rate of improvement of chest X‐ray.

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Analysis 3.6

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 6 Duration of oral antibiotic therapy.

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Analysis 3.7

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 7 Duration of intervenous therapy.

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Analysis 3.8

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 8 Duration of total antibiotic therapy.

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Analysis 3.9

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 9 Duration of leukocytosis.

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Analysis 3.10

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 10 Change in leukocyte count.

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Analysis 3.11

Comparison 3 Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment, Outcome 11 Mean leukocyte count.

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Analysis 4.1

Comparison 4 Positive expiratory pressure plus routine treatment versus routine treatment alone, Outcome 1 Duration of hospital stay.

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Analysis 4.2

Comparison 4 Positive expiratory pressure plus routine treatment versus routine treatment alone, Outcome 2 Duration of fever.

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Comparison 1. Chest physiotherapy plus routine treatment versus routine treatment alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality Show forest plot	2	225	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.15, 7.13]

2 Cure rate Show forest plot	2	225	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.91, 1.04]

3 Duration of hospital stay Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4 Duration of fever Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5 Rate of improvement of chest X‐ray Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 1. Chest physiotherapy plus routine treatment versus routine treatment alone

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Comparison 2. Active cycle of breathing techniques plus routine treatment versus routine treatment alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Cure rate Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2 Duration of hospital stay Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Rate of improvement of chest X‐ray Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4 Duration of antibiotic therapy Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5 Duration of sputum production Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.1 In‐patient	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 Out‐patient	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.3 Total	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 In‐patient sputum weight Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 2. Active cycle of breathing techniques plus routine treatment versus routine treatment alone

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Comparison 3. Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality Show forest plot	2	79	Risk Ratio (M‐H, Fixed, 95% CI)	0.27 [0.05, 1.57]

2 Cure rate Show forest plot	2	79	Risk Ratio (M‐H, Fixed, 95% CI)	1.54 [0.97, 2.46]

3 Duration of hospital stay Show forest plot	2	79	Mean Difference (IV, Fixed, 95% CI)	‐2.02 [‐3.46, ‐0.58]

4 Duration of fever Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5 Rate of improvement of chest X‐ray Show forest plot	2	75	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.77, 1.73]

6 Duration of oral antibiotic therapy Show forest plot	2	79	Mean Difference (IV, Random, 95% CI)	0.97 [‐1.25, 3.20]

7 Duration of intervenous therapy Show forest plot	2	79	Mean Difference (IV, Fixed, 95% CI)	‐2.11 [‐3.36, ‐0.87]

8 Duration of total antibiotic therapy Show forest plot	2	79	Mean Difference (IV, Fixed, 95% CI)	‐1.93 [‐3.12, ‐0.74]

9 Duration of leukocytosis Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

10 Change in leukocyte count Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

10.1 Change between Day 3 and 1 from admission	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
10.2 Change between Day 5 and 1 from admission	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Mean leukocyte count Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

11.1 Day 3 from admission	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11.2 Day 5 from admission	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 3. Osteopathic manipulative treatment plus routine treatment versus placebo plus routine treatment

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Comparison 4. Positive expiratory pressure plus routine treatment versus routine treatment alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Duration of hospital stay Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Duration of fever Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 4. Positive expiratory pressure plus routine treatment versus routine treatment alone

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Referencias

Referencias de los estudios incluidos en esta revisión

Bjorkqvist 1997 {published data only}

Britton 1985 {published data only}

Graham 1978 {published data only}

Noll 1999 {published data only}

Noll 2000 {published data only}

Tydeman 1989 {published data only}

Referencias de los estudios excluidos de esta revisión

Barkov 1987 {published data only}

Britton 1983a {published data only}

Britton 1983b {published data only}

Burioka 1998 {published data only}

Cheng 2004 {published data only}

Choi 2005 {published data only}

Confalonieri 1998a {published data only}

Confalonieri 1998b {published data only}

Dangour 2011 {published data only}

Fu 2005 {published data only}

Holody 1981 {published data only}

Jolliet 2001 {published data only}

Li 2005 {published data only}

Mo 2004 {published data only}

Noll 2008 {published data only}

Patman 2009 {published data only}

Schultz 2006 {published data only}

Wan 2004 {published data only}

Wang 1997 {published data only}

Wu 2005a {published data only}

Wu 2005b {published data only}

Wu 2005c {published data only}

Xia 2005 {published data only}

Xu 2004 {published data only}

Zha 2004 {published data only}

Zhang 2004 {published data only}

Referencias de los estudios en espera de evaluación

Facto 1947 {published data only}

Kuznetsov 1976 {published data only}

Kuznetsov 1980a {published data only}

Kuznetsov 1980b {published data only}

Sedov 1975 {published data only}

Vorob'ev 1984 {published data only}

Referencias de los estudios en curso

Noll {published data only}

Referencias adicionales

Bowton 1999

Britton 1983

Campbell 1975

Chalumeau 2002

Cochrane 1977

Colice 2004

Connors 1980

Fine 1990

Flenady 2010

George 1995

Guessous 2008

Hanying 2005

Horiuchi 1997

ICH 1997

Lefebvre 2011

Niederman 2001

Ntoumenopoulos 2002

Poelaert 1991

RevMan 2011 [Computer program]

Roqué i Figuls 2012

Van der Schans 2009

Wallis 1999

Weissman 1991

Weissman 1993

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Characteristics of excluded studies [ordered by study ID]

Characteristics of studies awaiting assessment [ordered by study ID]

Characteristics of ongoing studies [ordered by study ID]

Data and analyses

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