Chest physiotherapy for pneumonia in adults

Xiaomei Chen; Jiaojiao Jiang; Renjie Wang; Hongbo Fu; Jing Lu; Ming Yang

doi:10.1002/14651858.CD006338.pub4

Chest physiotherapy for pneumonia in adults

Declaraciones de intereses de los autores

Versión publicada: 06 septiembre 2022 Historial de versiones

https://doi.org/10.1002/14651858.CD006338.pub4

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Abstract

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Background

Despite conflicting evidence, chest physiotherapy has been widely used as an adjunctive treatment for adults with pneumonia. This is an update of a review first published in 2010 and updated in 2013.

Objectives

To assess the effectiveness and safety of chest physiotherapy for pneumonia in adults.

Search methods

We updated our searches in the following databases to May 2022: the Cochrane Central Register of Controlled Trials (CENTRAL) via OvidSP, MEDLINE via OvidSP (from 1966), Embase via embase.com (from 1974), Physiotherapy Evidence Database (PEDro) (from 1929), CINAHL via EBSCO (from 2009), and the Chinese Biomedical Literature Database (CBM) (from 1978).

Selection criteria

Randomised controlled trials (RCTs) and quasi‐RCTs assessing the efficacy of chest physiotherapy for treating pneumonia in adults.

Data collection and analysis

We used standard methodological procedures expected by Cochrane.

Main results

We included two new trials in this update (540 participants), for a total of eight RCTs (974 participants). Four RCTs were conducted in the United States, two in Sweden, one in China, and one in the United Kingdom. The studies looked at five types of chest physiotherapy: conventional chest physiotherapy; osteopathic manipulative treatment (OMT, which includes paraspinal inhibition, rib raising, and myofascial release); active cycle of breathing techniques (which includes active breathing control, thoracic expansion exercises, and forced expiration techniques); positive expiratory pressure; and high‐frequency chest wall oscillation.

We assessed four trials as at unclear risk of bias and four trials as at high risk of bias.

Conventional chest physiotherapy (versus no physiotherapy) may have little to no effect on improving mortality, but the certainty of evidence is very low (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.15 to 7.13; 2 trials, 225 participants; I² = 0%). OMT (versus placebo) may have little to no effect on improving mortality, but the certainty of evidence is very low (RR 0.43, 95% CI 0.12 to 1.50; 3 trials, 327 participants; I² = 0%). Similarly, high‐frequency chest wall oscillation (versus no physiotherapy) may also have little to no effect on improving mortality, but the certainty of evidence is very low (RR 0.75, 95% CI 0.17 to 3.29; 1 trial, 286 participants).

Conventional chest physiotherapy (versus no physiotherapy) may have little to no effect on improving cure rate, but the certainty of evidence is very low (RR 0.93, 95% CI 0.56 to 1.55; 2 trials, 225 participants; I² = 85%). Active cycle of breathing techniques (versus no physiotherapy) may have little to no effect on improving cure rate, but the certainty of evidence is very low (RR 0.60, 95% CI 0.29 to 1.23; 1 trial, 32 participants). OMT (versus placebo) may improve cure rate, but the certainty of evidence is very low (RR 1.59, 95% CI 1.01 to 2.51; 2 trials, 79 participants; I² = 0%).

OMT (versus placebo) may have little to no effect on mean duration of hospital stay, but the certainty of evidence is very low (mean difference (MD) −1.08 days, 95% CI −2.39 to 0.23; 3 trials, 333 participants; I² = 50%). Conventional chest physiotherapy (versus no physiotherapy, MD 0.7 days, 95% CI −1.39 to 2.79; 1 trial, 54 participants) and active cycle of breathing techniques (versus no physiotherapy, MD 1.4 days, 95% CI −0.69 to 3.49; 1 trial, 32 participants) may also have little to no effect on duration of hospital stay, but the certainty of evidence is very low. Positive expiratory pressure (versus no physiotherapy) may reduce the mean duration of hospital stay by 1.4 days, but the certainty of evidence is very low (MD −1.4 days, 95% CI −2.77 to −0.03; 1 trial, 98 participants).

Positive expiratory pressure (versus no physiotherapy) may reduce the duration of fever by 0.7 days, but the certainty of evidence is very low (MD −0.7 days, 95% CI −1.36 to −0.04; 1 trial, 98 participants). Conventional chest physiotherapy (versus no physiotherapy, MD 0.4 days, 95% CI −1.01 to 1.81; 1 trial, 54 participants) and OMT (versus placebo, MD 0.6 days, 95% CI −1.60 to 2.80; 1 trial, 21 participants) may have little to no effect on duration of fever, but the certainty of evidence is very low.

OMT (versus placebo) may have little to no effect on the mean duration of total antibiotic therapy, but the certainty of evidence is very low (MD −1.07 days, 95% CI −2.37 to 0.23; 3 trials, 333 participants; I² = 61%). Active cycle of breathing techniques (versus no physiotherapy) may have little to no effect on duration of total antibiotic therapy, but the certainty of evidence is very low (MD 0.2 days, 95% CI −4.39 to 4.69; 1 trial, 32 participants).

High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage (versus fibrobronchoscope alveolar lavage alone) may reduce the MD of intensive care unit (ICU) stay by 3.8 days (MD −3.8 days, 95% CI −5.00 to −2.60; 1 trial, 286 participants) and the MD of mechanical ventilation by three days (MD −3 days, 95% CI −3.68 to −2.32; 1 trial, 286 participants), but the certainty of evidence is very low.

One trial reported transient muscle tenderness emerging after OMT in two participants. In another trial, three serious adverse events led to early withdrawal after OMT. One trial reported no adverse events after positive expiratory pressure treatment.

Limitations of this review were the small sample size and unclear or high risk of bias of the included trials.

Authors' conclusions

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Plain language summary

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Chest physiotherapy for pneumonia in adults

Review question

Is chest physiotherapy effective and safe as a supportive treatment for adults with pneumonia?

Background

Pneumonia is one of the most common health problems affecting all age groups around the world. Antibiotics represent the mainstay of pneumonia treatment, whilst some other supportive therapies, such as supplementary oxygen, might also be beneficial in improving patient outcomes. Chest physiotherapy, an airway clearance technique, has been widely used as a supportive therapy for pneumonia in adults without reliable evidence.

Search date

The evidence is current to May 2022.

Study characteristics

We included eight studies involving a total of 974 participants. We included two new studies (540 participants) in this update. All studies included hospitalised patients. The studies looked at five types of chest physiotherapy, namely conventional chest physiotherapy (manual handling techniques to help clear sputum), active cycle of breathing techniques (a set of breathing exercises to help clear sputum), osteopathic manipulative treatment (OMT) (a therapeutic application of manually guided forces by a physiotherapist to improve respiratory function and sputum clearance), positive expiratory pressure (use of a device that increases airflow resistance to improve sputum clearance), and high‐frequency chest wall oscillation (chest wall vibration with a specialised device to promote sputum clearance).

Key results

1. Death

Conventional chest physiotherapy, OMT, and high‐frequency chest wall oscillation (versus no physiotherapy or placebo therapy) may have little to no effect on reducing death, but the certainty of evidence is very low.

2. Cure rate

OMT (versus placebo therapy) may improve cure rate as defined by the study authors, but the certainty of evidence is very low. Conventional chest physiotherapy (versus no physiotherapy) and active cycle of breathing techniques may have little to no effect on improving cure rate, but the certainty of evidence is very low.

3. Duration of hospital stay

Positive expiratory pressure (versus no physiotherapy) may reduce the duration of hospital stay by 1.4 days, but the certainty of evidence is very low. OMT, conventional chest physiotherapy, and active cycle of breathing techniques (versus placebo therapy or no physiotherapy) may have little to no effect on duration of hospital stay, but the certainty of evidence is very low.

4. Duration of fever

Positive expiratory pressure (versus no physiotherapy) may reduce the duration of fever by 0.7 days, but the certainty of evidence is very low. Conventional chest physiotherapy (versus no physiotherapy) or OMT (versus placebo therapy) may have little to no effect on duration of fever, but the certainty of evidence is very low.

5. Duration of antibiotic use

OMT (versus placebo therapy) and active cycle of breathing techniques (versus no physiotherapy) may have little to no effect on the duration of antibiotic use, but the certainty of evidence is very low.

6. Duration of intensive care unit (ICU) stay

High‐frequency chest wall oscillation (versus no physiotherapy) may reduce the duration of ICU stay by 3.8 days in people with severe pneumonia who received mechanical ventilation (use of a machine to help people breathe), but the certainty of evidence is very low.

7. Duration of mechanical ventilation

High‐frequency chest wall oscillation (versus no physiotherapy) may reduce the duration of mechanism ventilation by three days in people with severe pneumonia who received mechanical ventilation, but the certainty of evidence is very low.

8. Adverse events (unwanted events that cause harm to the patient)

One study reported three serious adverse events (not specified) that caused early withdrawal of participants after OMT. One study reported adverse events as short‐term muscle tenderness after treatment in two participants. Another study reported no adverse events.

Certainty of the evidence

In summary, the certainty of evidence is very low due to research limitations, the small number of participants, and/or imprecision of the results (estimated effects of the treatment were very imprecise). Very low certainty evidence suggests that some physiotherapies may slightly shorten hospital stays, fever duration, antibiotic treatment duration, and ICU stay, as well as mechanical ventilation, but this needs to be further explored.

Authors' conclusions

Implications for practice

The inclusion of two new trials in this update did not change the main conclusions of the original review. The current evidence is very uncertain about the effect of chest physiotherapy on improving mortality and cure rate in adults with pneumonia. Very low‐certainty evidence shows that positive expiratory pressure may reduce hospital stay and duration of fever. New, very low‐certainty evidence shows that high‐frequency chest wall oscillation may reduce mean duration of intensive care unit stay and mechanical ventilation in severe pneumonia patients who received mechanical ventilation. However, the current evidence does not support chest physiotherapy as a conventional adjunctive treatment for pneumonia in adults.

Implications for research

Further well‐designed randomised controlled trials addressing the role of chest physiotherapy for pneumonia in adults may be warranted. The following key points should be considered in future studies: appropriate sample size with power to detect expected difference, clearly defined different types of pneumonia, rigorous standardisation of the method of chest physiotherapy, an appropriate comparator therapy, appropriate and standardised outcomes (the following categories might be included: mortality, cure rate, improvements in symptoms, improvements in laboratory results, duration of hospital stay, duration of antibiotic or other therapies, and quality of life), the cost‐effectiveness of the chest physiotherapy, and evaluation of patient satisfaction with physiotherapy.

Summary of findings

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Summary of findings 1. Conventional chest physiotherapy plus routine treatment compared to routine treatment alone for pneumonia

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Conventional chest physiotherapy plus routine treatment compared to routine treatment alone for pneumonia
Patient or population: people with pneumonia Settings: hospital Intervention: conventional chest physiotherapy plus routine treatment Comparison: routine treatment alone
	Assumed risk	Corresponding risk
	Routine treatment alone	Chest physiotherapy plus routine treatment
Mortality Follow‐up: during hospitalisation	17 per 1000	18 per 1000 (3 to 124)	RR 1.03 (0.15 to 7.13)	225 (2 studies)	⊕⊝⊝⊝ Very low^a,b	Both studies did not report the time point to measure this outcome.
Cure rate Follow‐up: during hospitalisation	930 per 1000	865 per 1000 (521 to 1000)	RR 0.93 (0.56 to 1.55)	225 (2 studies)	⊕⊝⊝⊝ Very low^a,b	Both studies did not report the time point to measure this outcome.
Duration of hospital stay Follow‐up: during hospitalisation	The mean duration of hospital stay in the control groups was 6.9 days.	The mean duration of hospital stay in the intervention groups was 0.70 higher (1.39 lower to 2.79 higher).	‐	54 (1 study)	⊕⊝⊝⊝ Very low^c,d
Duration of fever Follow‐up: during hospitalisation	The mean duration of fever in the control groups was 2.5 days.	The mean duration of fever in the intervention groups was 0.40 higher (1.01 lower to 1.81 higher).	‐	54 (1 study)	⊕⊝⊝⊝ Very low^c,d
Duration of total antibiotic therapy ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of ICU stay ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of mechanical ventilation ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; ICU: intensive care unit; RR: risk ratio
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aDowngraded one level due to high risk of bias (concerns regarding blinding of participants and personnel in one of the two studies) ^bDowngraded two levels because the total number of events was less than 300. ^cDowngraded two levels due to high risk of bias (concerns regarding blinding of participants and personnel in this study). ^dDowngraded one level due to small sample size.

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Summary of findings 2. Active cycle of breathing techniques plus routine treatment compared to routine treatment alone for pneumonia

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Active cycle of breathing techniques plus routine treatment compared to routine treatment alone for pneumonia
Patient or population: people with pneumonia Settings: hospital Intervention: active cycle of breathing techniques plus routine treatment Comparison: routine treatment alone
	Assumed risk	Corresponding risk
	Routine treatment alone	Active cycle of breathing techniques plus routine treatment
Mortality Follow‐up: during hospitalisation	See comment	See comment	Not estimable	32 (1 study)	⊕⊝⊝⊝ Very low^a,b	No participant died in either group during the study period.
Cure rate Follow‐up: during hospitalisation	700 per 1000	420 per 1000 (203 to 861)	RR 0.60 (0.29 to 1.23)	32 (1 study)	⊕⊝⊝⊝ Very low^a,b	The study did not clearly did not report the time point to measure this outcome.
Duration of hospital stay Follow‐up: during hospitalisation	The mean duration of hospital stay in the control groups was 5.27 days.	The mean duration of hospital stay in the intervention groups was 1.4 higher (0.69 lower to 3.49 higher).	‐	32 (1 study)	⊕⊝⊝⊝ Very low^a,b
Duration of fever ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of total antibiotic therapy Follow‐up: during hospitalisation	The mean duration of total antibiotic therapy in the control groups was 15.02 days.	The mean duration of total antibiotic therapy in the intervention groups was 0.15 higher (4.39 lower to 4.69 higher).	‐	32 (1 study)	⊕⊝⊝⊝ Very low^a,b
Duration of ICU stay ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of mechanical ventilation ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; ICU: intensive care unit; RR: risk ratio
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aDowngraded two levels due to high risk of bias (concerns regarding blinding of participants and personnel, blinding of outcome assessment, and incomplete outcome data). ^bDowngraded one level due to small sample size and wide confidence intervals.

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Summary of findings 3. Osteopathic manipulative treatment (OMT) plus routine treatment compared to placebo plus routine treatment for pneumonia

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Osteopathic manipulative treatment (OMT) plus routine treatment compared to placebo plus routine treatment for pneumonia
Patient or population: people with pneumonia Settings: hospital Intervention: OMT plus routine treatment Comparison: placebo plus routine treatment
	Assumed risk	Corresponding risk
	Placebo plus routine treatment	OMT plus routine treatment
Mortality Follow‐up: during hospitalisation	49 per 1000	21 per 1000 (6 to 73)	RR 0.43 (0.12 to 1.50)	327 (3 studies)	⊕⊝⊝⊝ Very low^a,b	These studies did not report the time point to measure this outcome.
Cure rate Follow‐up: during hospitalisation	375 per 1000	596 per 1000 (379 to 941)	RR 1.59 (1.01 to 2.51)	79 (2 studies)	⊕⊝⊝⊝ Very low^a,c	These studies did not report the time point to measure this outcome.
Duration of hospital stay Follow‐up: during hospitalisation	The mean duration of hospital stay in the control groups was 9.77 days.	The mean duration of hospital stay in the intervention groups was 1.08 lower (2.39 lower to 0.23 higher).	‐	333 (3 studies)	⊕⊝⊝⊝ Very low^a,b
Duration of fever Follow‐up: during hospitalisation	The mean duration of fever in the control groups was 1.6 days.	The mean duration of fever in the intervention groups was 0.6 higher (1.60 lower to 2.80 higher).	‐	21 (1 study)	⊕⊝⊝⊝ Very low^a,c
Duration of total antibiotic therapy Follow‐up: during hospitalisation	The mean duration of total antibiotic therapy in the control groups was 8.37 days.	The mean duration of total antibiotic therapy in the intervention groups was 1.07 lower (2.37 lower to 0.23 higher).	‐	333 (3 studies)	⊕⊝⊝⊝ Very low^a,b
Duration of ICU stay ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of mechanical ventilation ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; ICU: intensive care unit; RR: risk ratio
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aDowngraded two levels due to very wide confidence intervals and very low event rate. ^bDowngraded two levels due to small sample size and confidence intervals overlapping no effect and substantial benefit. ^cDowngraded two levels due to very small sample size.

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Summary of findings 4. Positive expiratory pressure plus routine treatment compared to routine treatment alone for pneumonia

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Positive expiratory pressure plus routine treatment compared to routine treatment alone for pneumonia
Patient or population: people with pneumonia Settings: hospital Intervention: positive expiratory pressure plus routine treatment Comparison: routine treatment alone
	Assumed risk	Corresponding risk
	Routine treatment alone	Positive expiratory pressure plus routine treatment
Mortality Follow‐up: during hospitalisation	See comment	See comment	Not estimable	98 (1 study)	⊕⊝⊝⊝ Very low^a,b	No participant died in either group during the study period.
Cure rate ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of hospital stay Follow‐up: during hospitalisation	The mean duration of hospital stay in the control groups was 5.3 days.	The mean duration of hospital stay in the intervention groups was 1.40 lower (2.77 to 0.03 lower).	‐	98 (1 study)	⊕⊝⊝⊝ Very low^a,c
Duration of fever Follow‐up: during hospitalisation	The mean duration of fever in the control groups was 2.3 days.	The mean duration of fever in the intervention groups was 0.7 lower (1.36 to 0.04 lower).	‐	98 (1 study)	⊕⊝⊝⊝ Very low^a,c
Duration of total antibiotic therapy ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of ICU stay ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of mechanical ventilation ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; ICU: intensive care unit; RR: risk ratio
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aDowngraded two levels due to high risk of bias (concerns regarding blinding of participants and personnel and blinding of outcome assessment). ^bDowngraded one level because total number of events was less than 300. ^cDowngraded one level due to small sample size.

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Summary of findings 5. High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage compared to fibrobronchoscope alveolar lavage alone for severe pneumonia and receiving mechanical ventilation

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage compared to fibrobronchoscope alveolar lavage alone for severe pneumonia and receiving mechanical ventilation
Patient or population: people with severe pneumonia and receiving mechanical ventilation Settings: intensive care unit Intervention: high‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage Comparison: fibrobronchoscope alveolar lavage alone
	Assumed risk	Corresponding risk
	Fiberbronchoscope alveolar lavage alone	High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage
Mortality Follow‐up: during hospitalisation	28 per 1000	21 per 1000 (5 to 92)	RR 0.75 (0.17 to 3.29)	286 (1 study)	⊕⊝⊝⊝ Very low^a,b	This study did not report the time point to measure this outcome.
Cure rate ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of hospital stay ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of fever ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of total antibiotic therapy ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of ICU stay Follow‐up: during hospitalisation	The mean duration of ICU stay in the control groups was 12.4 days.	The mean duration of ICU stay in the intervention groups was 3.8 lower (5 to 2.6 lower).	‐	286 (1 study)	⊕⊝⊝⊝ Very low^a,c
Duration of mechanical ventilation Follow‐up: during hospitalisation	The mean duration of mechanical ventilation in the control groups was 9.4 days.	The mean duration of mechanical ventilation in the intervention groups was 3 lower (3.68 to 2.32 lower).	‐	286 (1 study)	⊕⊝⊝⊝ Very low^a,c
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; ICU: intensive care unit; RR: risk ratio
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aDowngraded two levels due to high risk of bias (concerns regarding allocation concealment, blinding of participants and personnel, and blinding of outcome assessment). ^bDowngraded two levels due to very few events and very wide confidence intervals encompassing both substantial benefit and substantial harm. ^cDowngrade one level due to small sample size.

Background

This is an updated version of a Cochrane Review first published in 2010 (Yang 2010), and first updated in 2013 (Yang 2013).

Description of the condition

The leading cause of death from infectious diseases (Ferreira‐Coimbra 2020), pneumonia is most commonly caused by bacteria, but occasionally is caused by viruses, fungi, parasites, and other infectious agents. Pneumonia is typically classified as community‐acquired pneumonia (CAP), hospital‐acquired pneumonia (HAP, also known as nosocomial pneumonia), and ventilator‐associated pneumonia (VAP, the most serious form of nosocomial pneumonia, infecting patients who are mechanically ventilated for other reasons) (Kalil 2016). Pneumonia is highly prevalent in adults worldwide and is one of the most commonly encountered conditions in clinical practice (Musher 2014). For example, the incidence of CAP in adults ranges from 5 to 11 per 1000 per year in European and North American countries (Lim 2009). The incidence of CAP increases with aging (Cao 2018). For example, Japanese researchers revealed that in the 15 to 64, 65 to 74, and ≥ 75‐year‐old populations, the incidence of CAP was 3.4/1000, 10.7/1000, and 42.9/1000 person‐years, respectively (Kalil 2016). In adults, pneumonia mortality also increases with advanced age (Zhang 2018). For example, according to a Japanese study, hospitalised CAP patients had a mortality rate of 1.4% in the 15 to 44 age group, 3.3% in the 45 to 64 age group, 6.9% in the 65 to 74 age group, and 9.3% in the 75 and older age group (Takayanagi 2006). In a large cohort of Chinese adults with CAP, 4.2% of patients died in 30 days, 6.3% were admitted to an intensive care unit (ICU), and 2.7% required invasive mechanical ventilation (Chen 2018). Pneumonia also induces a heavy disease burden (Prina 2015). According to a recent study (Tong 2018), in the United States, pneumonia costs were between USD 910 and USD 2621.9 for children, USD 2170.7 and USD 3478.1 for adults, and USD 4025.8 and USD 4923.0 for elderly adults.

Description of the intervention

Antibiotics are the cornerstone of pneumonia treatment (Metlay 2019), whilst other therapies are mostly supportive. These adjunctive therapies include supplementary oxygen, intravenous hydration, and chest physiotherapy (George 1995). Chest physiotherapy is an airway clearance technique that combines manual percussion of the chest wall by a caregiver, strategic positioning of the patient for mucous drainage, and teaching cough and breathing techniques.

Conventional chest physiotherapy includes postural drainage, percussion, chest shaking, huffing, and coughing. Recently, several new physiotherapy techniques have been developed, including the active cycle of breathing techniques (Lewis 2012), positive expiratory pressure (McIlwaine 2015), osteopathic manipulative treatment (OMT) (Jonas 2018), and high‐frequency chest wall oscillation (Nicolini 2013). Active cycle of breathing techniques includes active breathing control, thoracic expansion exercises and forced expiration technique, and sometimes postural drainage and chest clapping (Lewis 2012). Positive expiratory pressure uses a device to provide a positive expiratory pressure of 10 to 25 cmH₂0 during expiration. It may stabilise airways by keeping them open during expiration, which may facilitate airway clearance (McIlwaine 2015). OMT includes bilateral paraspinal inhibition, bilateral rib raising, diaphragmatic myofascial release, and soft myofascial release to the anterior thoracic inlet. It may improve chest wall mobility and enhance exercise tolerance (Jonas 2018). High‐frequency chest wall oscillation generally uses an inflatable jacket connected to an air pulse generator to compress the chest wall. By delivering an intermittent flow of air into the jacket, the chest wall can be compressed and released at various frequencies (Nicolini 2013). High‐frequency chest wall oscillation has been shown to facilitate mucus clearance centrally and peripherally (Nicolini 2013).

How the intervention might work

Chest physiotherapy assists in treating some of the symptoms of respiratory disorders, such as airflow obstruction, alterations in ventilatory pump functions, and impaired exercise performance. The aim is to improve the patient's respiratory status and expedite recovery by enhancing airway clearance in lung diseases associated with hypersecretion and reduced airway resistance. Increased airway clearance reduces airway resistance, enhances gas exchange, and reduces breathing effort (Chaves 2019; Wallis 1999).

Why it is important to do this review

Chest physiotherapies for cystic fibrosis and acute bronchiolitis have been reviewed (Roqué 2016; Warnock 2015). The Cochrane Review regarding chest physiotherapy for pneumonia in children has also been recently updated (Chaves 2019). However, the clinical effectiveness of chest physiotherapy for pneumonia in adults is controversial. Some clinical studies have reported that chest physiotherapy does not hasten the resolution of pneumonia (Graham 1978), or was not useful (Britton 1983; Britton 1985). Two studies suggested that larger or multicentre trials are needed to confirm the findings (Ntoumenopoulos 2002; Tydeman 1989). Other studies have concluded that chest physiotherapy has beneficial effects in patients with pulmonary infection (Marques 2020). On the other hand, chest physiotherapy may be ineffective and even harmful. It may cause an increase in oxygen consumption (Horiuchi 1997; Weissman 1991; Weissman 1993), bronchospasm (Campbell 1975), induce hypertension, increase oxygen demand (Horiuchi 1997; Weissman 1993), cause hypoxaemia (Connors 1980; Poelaert 1991), and even lead to rib fractures (Chalumeau 2002). It was therefore necessary to systematically summarise the evidence regarding chest physiotherapy for treating adult patients with pneumonia. The last version of this review was published in 2013 (Yang 2013), and did not support the routine application of chest physiotherapy for pneumonia in adults. Since more than eight years have passed and new relevant evidence may have become available, we updated the review to summarise all randomised controlled trials which examine the effectiveness and safety of chest physiotherapy for pneumonia in adults.

Objectives

To assess the effectiveness and safety of chest physiotherapy for pneumonia in adults.

Methods

Criteria for considering studies for this review

Types of studies

We considered all randomised controlled trials (RCTs), including cross‐over RCTs and cluster‐RCTs, and quasi‐RCTs assessing the efficacy of chest physiotherapy for adult participants with any type of pneumonia. We included trials that also included other basic respiratory diseases, once pneumonia was diagnosed; we analysed such trials separately. We excluded trials in which physiotherapy was administered for the prevention of pneumonia, as pneumonia can occur in many conditions, such as trauma, cerebral vessels disease, and postoperative conditions. We included both published and unpublished trials.

Types of participants

Adult participants (older than 18 years of age) of either gender, with any type of pneumonia. Pneumonia was defined by the original trial author. We included intubated or non‐intubated participants. We excluded trials if the participants had respiratory comorbidities, such as asthma, chronic obstructive pulmonary disease (COPD), or atelectasis. Some trials involved participants who suffered from different diseases (e.g. some had COPD, whereas others had pneumonia). In such a case, if the subgroup analysis data of participants with pneumonia could be extracted, we would include the trial. Otherwise, the trial was excluded.

Types of interventions

Chest physiotherapy of any type was compared with no chest physiotherapy. We included trials using traditional chest physiotherapy, as well as trials using mechanical devices which have the same effect as traditional chest physiotherapy. We considered the following methods: postural drainage, chest percussion, vibration, thoracic oscillation, chest shaking, huffing, directed coughing, thoracic expansion, forced exhalation or expiration techniques, and manual hyperinflation.

Types of outcome measures

We included the following outcomes.

Primary outcomes

Mortality.
Cure rate (the definitions of 'cure' and the 'time to cure' were determined by the original trial authors).

Secondary outcomes

Duration of hospital stay (days).
Healing time (days) (subjective or objective assessment of time to complete recovery).
Duration of fever (days) (fever defined as more than 37.5 °C).
Rate of improvement of chest X‐ray (chest X‐ray improvement was defined as any improvement on chest X‐ray after treatment compared with before treatment. The assessment could be made by radiologists or clinicians).
Duration of antibiotic therapy (days).
Duration of sputum production (days).
Duration of mechanical ventilation (days).
Duration of intensive care unit (ICU) stay (days).
Time to clinical stability (days).
Rate of in‐hospital respiratory failure.
Rate of 60‐day hospital readmission.
Duration of leukocytosis (days).
Change in leukocyte count.
Mean leukocyte count.
Inpatient sputum weight (g).

Adverse events

We defined serious adverse events according to the International Conference on Harmonisation (ICH) Guidelines as any event that: leads to death, is life‐threatening, requires inpatient hospitalisation or prolongation of existing hospitalisation, results in persistent or significant disability, and any important medical event which may harm the patient or requires intervention to prevent it (ICH 1997). We considered all other adverse events as non‐serious.

Search methods for identification of studies

Electronic searches

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 4, 2022) via OvidSP (November 2012 to 25 May 2022), MEDLINE via OvidSP (November 2012 to 25 May 2022), Embase via embase.com (November 2012 to 25 May 2022), Physiotherapy Evidence Database (PEDro) (November 2012 to 25 May 2022), Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO (2012 to 25 May 2022), and the Chinese Biomedical Literature Database (CBM) (2012 to 25 May 2022). Please see Appendix 1 and Appendix 2 for details of the previous searches.

We used the strategy in Appendix 3 to search MEDLINE and CENTRAL. We combined the MEDLINE search with the Cochrane Highly Sensitive Search Strategy for identifying randomised trials in MEDLINE: sensitivity‐ and precision‐maximising version (2008 revision), Ovid format (Lefebvre 2021). We adapted these search terms to search Embase (see Appendix 4), PEDro (see Appendix 5), and CINAHL (see Appendix 6).

Searching other resources

We handsearched the references of all included trials for any additional relevant studies. We did not impose any language or publication restrictions.

Data collection and analysis

Selection of studies

Two review authors (HBF, JL) independently searched the databases. Two review authors (XMC, JJJ) independently assessed the titles and abstracts of records identified by the search to determine potential relevance. Two review authors (RJW, JL) independently assessed the full texts of the publications deemed potentially relevant, excluding any trials that failed to meet the inclusion criteria. Any differences between review authors were resolved by the arbitrator (MY).

Data extraction and management

Two review authors (XMC, JJJ) independently extracted data using a standardised form. A third review author (MY) checked the extracted data. Extracted data included, where available:

description of participants (including age, gender, type of pneumonia);
severity of pneumonia;
basic conditions and setting;
description of intervention (details of chest physiotherapy, including type, frequency, intensity, and time);
description of control therapy;
methodological details (including design and recruitment);
method of randomisation;
sample size;
trial inclusion and exclusion criteria;
withdrawals;
description of outcomes (including mortality, duration of hospital stay, adverse events, cure, healing time, rate of clearing of X‐ray film, and duration of fever); and
source of funding.

Assessment of risk of bias in included studies

In this update, two review authors (XMC, JL) independently assessed the risk of bias for all included studies based on Cochrane’s risk of bias tool (RoB 1) in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2021). The arbitrator (MY) resolved any differences. We assessed the following domains.

Random sequence generation (selection bias)
Allocation concealment (selective bias)
Blinding of participants and personnel (performance bias)
Blinding of outcome assessment (detection bias)
Incomplete outcome data (attrition bias)
Selective reporting (reporting bias)
Other bias

We assessed each domain as one of three levels: low, high, or unclear risk of bias, and provided support for each judgement in the risk of bias table. We judged the overall risk of bias of each included trial as: low risk of bias (all domains were at low risk of bias); unclear risk of bias (at least one domain was at unclear risk of bias and no domain was at high risk of bias); or high risk of bias (at least one domain was at high risk of bias) (Higgins 2021).

Measures of treatment effect

We expressed dichotomous data, such as cure rate or mortality, as risk ratios (RR). We expressed continuous data, such as duration of fever, as mean differences (MD). We reported all outcomes with 95% confidence intervals (CIs).

Unit of analysis issues

The unit of analysis was the individual, as all included trials were simple parallel‐group trials in which participants were randomly allocated to several groups, and a single result for each outcome from each individual was collected and analysed. None of the included trials used complicated designs such as cross‐over or cluster randomisation.

Dealing with missing data

We attempted to contact trial authors by email to search for additional papers, and to confirm data extraction and obtain missing data where necessary, but obtained no further information. Only available data were analysed (i.e. ignoring missing data). We did not apply any statistical method to impute missing data.

Assessment of heterogeneity

We assessed heterogeneity in trial results by inspecting the forest plots to detect non‐overlapping CIs, applying the Chi² test with a P value of 0.10 indicating statistical significance, and implementing the I² statistic (considering a value of 50% as indicative of moderate heterogeneity). In the case of heterogeneity between studies, we attempted to explore possible sources due to various factors, such as type of pneumonia and type of physiotherapy.

Assessment of reporting biases

The small number of included studies precluded a funnel plot analysis to identify reporting biases.

Data synthesis

We used Review Manager 5 to combine some outcomes (Review Manager 2020). We used a fixed‐effect model for single‐study analyses, and a random‐effects model for multiple‐study meta‐analyses. When determining the precision of the CIs around the overall effect size, the random‐effects model takes into account both within‐study sampling error and between‐study variation, whereas the fixed‐effect model only considers within‐study variation.

Subgroup analysis and investigation of heterogeneity

Due to significant clinical heterogeneity, we reported different comparison results according to different types of chest physiotherapy. We performed subgroup analyses according to clinical settings (inpatient or outpatient) and different time durations (e.g. mean leukocyte count on Day 3 from admission, or on Day 5 from admission), if necessary.

Sensitivity analysis

The limited amount of data available for each outcome precluded sensitivity analyses.

Summary of findings and assessment of the certainty of the evidence

We included five summary of findings tables in this 2022 update using the following outcomes: mortality, cure rate, duration of hospital stay, duration of fever, duration of total antibiotic therapy, duration of ICU stay, and duration of mechanical ventilation (summary of findings Table 1; summary of findings Table 2; summary of findings Table 3; summary of findings Table 4; summary of findings Table 5). We used the GRADE system to evaluate the certainty of the evidence. Based on the GRADE Working Group guidelines, we assessed the certainty of evidence for the selected outcomes (Guyatt 2008). We used GRADEpro GDT software to develop the summary of findings tables (GRADEpro GDT).

Results

Description of studies

See Characteristics of included studies and Characteristics of excluded studies.

Results of the search

In this update, we identified a total of 8634 records from the electronic databases after removal of duplicates. After screening the titles and abstracts, we identified 12 publications of 11 studies for full‐text evaluation (Ahmed 2021; Cao 2020; Jose 2016; Lopez‐Lopez 2019; Martín‐Salvador 2016; NCT05007457; Noll 2010; Shi 2017; Valenza 2016; Wang 2020; Xu 2021). Of these, three publications of two trials, Noll 2010 and Shi 2017, met our inclusion criteria (see Characteristics of included studies), and one publication, NCT05007457, was an ongoing study (see Characteristics of ongoing studies). In addition, six publications identified in the 2012 version were assessed as awaiting classification because five of them were published in Russian (Kuznetsov 1976; Kuznetsov 1980a; Kuznetsov 1980b; Sedov 1975; Vorob'ev 1984), and one was published in 1947 (Facto 1947). In this 2022 update, we acquired and screened the full‐text copies of these trials. All six publications were excluded (see Characteristics of excluded studies).

In the 2012 update (Yang 2013), a total of 835 records were identified from the electronic databases after removal of duplicates. After title and abstract screening, two publications were considered to be potentially eligible (Dangour 2011; Noll 2008). However, both publications were finally excluded. Noll 2008 was grouped into Noll 2010 as a supplementary reference in the current update.

In the 2009 search (Yang 2010), 1329 articles were identified by electronic database searching. After title and abstract screening, 68 trials were selected as potentially relevant. Six of these trials met our inclusion criteria (see Characteristics of included studies) (Bjorkqvist 1997; Britton 1985; Graham 1978; Noll 1999; Noll 2000; Tydeman 1989).

A study flow diagram is shown in Figure 1.

Figure 1

Study flow diagram.

Included studies

We included a total of eight RCTs in the review (Bjorkqvist 1997; Britton 1985; Graham 1978; Noll 1999; Noll 2000; Noll 2010; Shi 2017; Tydeman 1989), of which four were conducted in the United States (Graham 1978; Noll 1999; Noll 2000; Noll 2010), two in Sweden (Bjorkqvist 1997; Britton 1985), one in China (Shi 2017), and one in the United Kingdom (Tydeman 1989). All of them were randomised, parallel‐group controlled trials. None of the trials was supported by pharmaceutical company funding. All included trials were conducted in inpatient settings.

Participants

The eight trials included a total of 974 participants (462 males, 512 females), with 484 participants in the treatment group and 490 participants in the control group. The included trials involved participants with acute pneumonia. Two trials included community‐acquired pneumonia (CAP) only (Bjorkqvist 1997; Tydeman 1989); three trials included CAP, nosocomial pneumonia, and nursing home‐acquired pneumonia (Noll 1999; Noll 2000; Noll 2010); and one trial included severe pneumonia patients receiving mechanical ventilation (Shi 2017). The remaining two trials did not describe the type of pneumonia (Britton 1985; Graham 1978). The severity of pneumonia was mild to moderate in two trials (Graham 1978; Tydeman 1989), severe in one trial (Shi 2017), mild to severe in one trial (Noll 2010), and not stated in the other four trials (Bjorkqvist 1997; Britton 1985; Noll 1999; Noll 2000). The baseline characteristics of the experiment and control groups of each included trial were comparable. Three included studies had missing data (13%, 4.7%, and 11% of the study populations, respectively) (Bjorkqvist 1997; Noll 2010; Tydeman 1989).

Interventions

Three trials compared chest physiotherapy and routine treatment to placebo and routine treatment (Noll 1999; Noll 2000; Noll 2010). In the other five trials (Bjorkqvist 1997; Britton 1985; Graham 1978; Shi 2017; Tydeman 1989), chest physiotherapy and routine treatment were compared with routine treatment alone. The types of chest physiotherapies used in the included trials differed, and included conventional chest physiotherapy, OMT, active cycle of breathing techniques, positive expiratory pressure, and high‐frequency chest wall oscillation. Both treatment and control groups were given routine treatments such as antibiotics, oxygen therapy, and other drug therapies, if necessary.

Outcome measures

The primary outcomes were mortality and cure rate. Mortality could be calculated from data from all included trials. However, the cure rate was calculated from five included trials (Britton 1985; Graham 1978; Noll 1999; Noll 2000; Tydeman 1989).

The following secondary outcomes were reported in some of the included trials.

Duration of hospital stay (Bjorkqvist 1997; Britton 1985; Graham 1978; Noll 1999; Noll 2000; Noll 2010; Shi 2017; Tydeman 1989).
Healing time (Britton 1985).
Duration of fever (Bjorkqvist 1997; Britton 1985; Graham 1978; Noll 1999).
Rate of improvement of chest X‐ray (Graham 1978; Noll 1999; Noll 2000; Tydeman 1989).
Duration of antibiotic therapy (Noll 1999; Noll 2000; Noll 2010; Tydeman 1989).
Duration of sputum production (Tydeman 1989).
Duration of mechanical ventilation (Shi 2017).
Duration of ICU stay (Shi 2017).
Time to clinical stability (Noll 2010).
Rate of in‐hospital respiratory failure (Noll 2010).
Rate of 60‐day hospital readmission (Noll 2010).
Duration of leukocytosis (Noll 1999).
Change in leukocyte count (Noll 2000).
Mean leukocyte count (Noll 2000).
Inpatient sputum weight (Tydeman 1989).

Additionally, several included trials reported adverse effects. Two trials reported adverse effects (Noll 2000; Noll 2010), another trial reported that there were no side effects during the study period (Bjorkqvist 1997), and the remaining trials did not address this outcome.

Excluded studies

For reasons for exclusion of the excluded studies, see Characteristics of excluded studies.

Risk of bias in included studies

Details on risk of bias of each trial are provided in Characteristics of included studies. We assessed four included trials as having high risk of bias due to at least one type of bias (Figure 2; Figure 3) (Bjorkqvist 1997; Britton 1985; Shi 2017; Tydeman 1989).

Figure 2

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

Figure 3

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

Allocation

All eight trials explicitly stated that randomisation was used in their studies. However, only two trials mentioned the method of randomisation (Noll 2010; Shi 2017). Only four trials clearly described the method of allocation concealment (Bjorkqvist 1997; Britton 1985; Graham 1978; Noll 2010).

Blinding

Participants and personnel were blinded in three trials (Noll 1999; Noll 2000; Noll 2010), but were not blinded in four other trials (Bjorkqvist 1997; Britton 1985; Shi 2017; Tydeman 1989). Outcome assessors were blinded in four trials (Britton 1985; Noll 1999; Noll 2000; Noll 2010), but were not blinded in three other trials (Bjorkqvist 1997; Shi 2017; Tydeman 1989).

In one study it was unclear whether blinding was used or not (Graham 1978).

Incomplete outcome data

In four trials information was insufficient to permit a judgement on attrition bias (Bjorkqvist 1997; Britton 1985; Graham 1978; Noll 2010). Three trials were at low risk of attrition bias (Noll 1999; Noll 2000; Shi 2017), and the remaining trial was at high risk of attrition bias (Tydeman 1989).

Selective reporting

One trial was at low risk of reporting bias (Noll 2010). Information was insufficient to determine reporting bias in the other trials.

Other potential sources of bias

Information was insufficient to determine other potential sources of bias in all included trials.

Effects of interventions

See: Summary of findings 1 Conventional chest physiotherapy plus routine treatment compared to routine treatment alone for pneumonia; Summary of findings 2 Active cycle of breathing techniques plus routine treatment compared to routine treatment alone for pneumonia; Summary of findings 3 Osteopathic manipulative treatment (OMT) plus routine treatment compared to placebo plus routine treatment for pneumonia; Summary of findings 4 Positive expiratory pressure plus routine treatment compared to routine treatment alone for pneumonia; Summary of findings 5 High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage compared to fibrobronchoscope alveolar lavage alone for severe pneumonia and receiving mechanical ventilation

Given the obvious clinical heterogeneity between different chest physiotherapies, we presented the results as comparisons between:

conventional chest physiotherapy plus routine treatment versus routine treatment alone;
active cycle of breathing techniques plus routine treatment versus routine treatment alone;
OMT plus routine treatment versus placebo plus routine treatment;
positive expiratory pressure plus routine treatment versus routine treatment alone; and
high‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage versus fibrobronchoscope alveolar lavage alone.

In the three trials evaluating OMT plus routine treatment (Noll 1999; Noll 2000; Noll 2010), the comparator was standardised light touch treatment as a placebo in addition to the routine treatment. In the remaining trials, participants in the control group received routine treatment alone.

1. Conventional chest physiotherapy plus routine treatment versus routine treatment alone

Two trials including a total of 225 participants (110 in treatment group and 115 in control group) evaluated the effect of conventional chest physiotherapy (Britton 1985; Graham 1978).

1.1 Primary outcomes

1.1.1 Mortality

Meta‐analysis of Britton 1985 and Graham 1978 using a random‐effects model indicated that there may be little or no difference between the use of conventional chest physiotherapy plus routine treatment and routine treatment alone in mortality (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.15 to 7.13; 2 trials, 225 participants; I² = 0%; very low‐certainty evidence; Analysis 1.1).

1.1.2. Cure rate

In one trial (Britton 1985), all participants were cured in both treatment and control group, whilst the other trial reported that cure rates in the treatment group and control group were 59.26% and 70.37%, respectively (Graham 1978). However, pooled data with a random‐effects model indicated that there may be little or no difference between conventional chest physiotherapy plus routine treatment and routine treatment alone in cure rate (RR 0.93, 95% CI 0.56 to 1.55; 2 trials, 225 participants; I² = 85%; very low‐certainty evidence; Analysis 1.2).

1.2 Secondary outcomes

1.2.1 Duration of hospital stay

We were unable to perform meta‐analysis, as one of the included trials did not report the standard deviation (SD) of the duration of hospital stay (Britton 1985). Britton 1985 found little or no difference between treatment and control groups (P value was unavailable; 1 trial, 171 participants; very low‐certainty evidence). Graham 1978 reached a similar result (mean difference (MD) 0.7 days, 95% CI −1.39 to 2.79; 1 trial, 54 participants; very low‐certainty evidence; Analysis 1.3).

1.2.2 Healing time

Britton 1985 reported healing time as a secondary outcome. The mean healing time was 30.6 days in the treatment group and 31.3 days in the control group. The study reported little or no difference between groups (P value was unavailable; 1 trial, 171 participants; very low‐certainty evidence).

1.2.3 Duration of fever

Britton 1985 did not report the SD of the duration of fever, therefore we could not perform a meta‐analysis. Britton 1985 reported mean duration of fever in the treatment group and control group as 6.8 and 4.9 days, respectively (P < 0.01). The other trial reported mean duration of fever in the treatment group and control group as 2.9 and 2.5 days, respectively (MD 0.4 days, 95% CI −1.01 to 1.81; 1 trial, 54 participants; very low‐certainty evidence; Analysis 1.4) (Graham 1978).

1.2.4 Rate of improvement of chest X‐ray

Only Graham 1978 reported this outcome, which indicated that conventional chest physiotherapy may have little or no benefit on improvement of chest X‐ray (RR 0.85, 95% CI 0.59 to 1.22; 1 trial, 54 participants; very low‐certainty evidence; Analysis 1.5).

1.2.5 Duration of antibiotic therapy

Not reported.

1.2.6 Duration of sputum production

Not reported.

1.2.7 Duration of mechanical ventilation

Not reported.

1.2.8 Duration of ICU stay

Not reported.

1.2.9 Time to clinical stability

Not reported.

1.2.10 Rate of in‐hospital respiratory failure

Not reported.

1.2.11 Rate of 60‐day hospital readmission

Not reported.

1.2.12 Duration of leukocytosis

Not reported.

1.2.13 Change in leukocyte count

Not reported.

1.2.14 Mean leukocyte count

Not reported.

1.2.15 Inpatient sputum weight

Not reported.

Adverse effects

Not reported.

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

Only one trial including 32 participants (12 in treatment group and 20 in control group) evaluated active cycle of breathing techniques (Tydeman 1989).

2.1 Primary outcomes

2.1.1 Mortality

No participants died during the study period.

2.1.2 Cure rate

There may be little or no difference between active cycle of breathing techniques plus routine treatment and routine treatment alone in cure rate (RR 0.60, 95% CI 0.29 to 1.23; 1 trial, 32 participants; very low‐certainty evidence; Analysis 2.1).

2.2 Secondary outcomes

2.2.1 Duration of hospital stay

Duration of hospital stay (mean ± SD) was 6.67 ± 3.26 days in the treatment group and 5.27 ± 2.26 days in the control group. However, there may be little or no difference between groups (MD 1.40 days, 95% CI −0.69 to 3.49; 1 trial, 32 participants; very low‐certainty evidence; Analysis 2.2).

2.2.2 Healing time

Not reported.

2.2.3 Duration of fever

Not reported.

2.2.4 Rate of improvement of chest X‐ray

Active cycle of breathing techniques may provide no benefit in rate of improvement of chest X‐ray (RR 0.60, 95% CI 0.29 to 1.23; 1 trial, 32 participants; very low‐certainty evidence; Analysis 2.3).

2.2.5 Duration of antibiotic therapy

Duration of antibiotic therapy (mean ± SD) was 15.17 ± 6.70 days in the treatment group and 15.02 ± 5.53 days in the control group. There may be little or no difference between groups (MD 0.2 days, 95% CI −4.39 to 4.69; 1 trial, 32 participants; very low‐certainty evidence; Analysis 2.4).

2.2.6 Duration of sputum production

There may be little or no differences in both inpatient and outpatient populations in duration of sputum production (MD 0.83 days, 95% CI −1.57 to 3.23; MD −1.20 days, 95% CI −3.28 to 0.88, respectively; 1 trial, 32 participants; very low‐certainty evidence; Analysis 2.5).

2.2.7 Duration of mechanical ventilation

Not reported.

2.2.8 Duration of ICU stay

Not reported.

2.2.9 Time to clinical stability

Not reported.

2.2.10 Rate of in‐hospital respiratory failure

Not reported.

2.2.11 Rate of 60‐day hospital readmission

Not reported.

2.2.12 Duration of leukocytosis

Not reported.

2.2.13 Change in leukocyte count

Not reported.

2.2.14 Mean leukocyte count

Not reported.

2.2.15 Inpatient sputum weight

There may be little or no difference between active cycle of breathing techniques plus routine treatment and routine treatment alone in inpatient sputum weight (MD 4.9 g, 95% CI −1.82 to 11.62; 1 trial, 32 participants; very low‐certainty evidence; Analysis 2.6).

Adverse effects

Not reported.

3. OMT plus routine treatment versus placebo plus routine treatment

The first publication of this review included two RCTs focusing on this technique (Noll 1999; Noll 2000). In this update, we included an additional RCT in which participants were randomly allocated to three groups (Noll 2010): the treatment group, the placebo treatment group, and the control group. To achieve comparable groups from the previous trials (Noll 1999; Noll 2000), we included only the results of the treatment group and the placebo group. We thus included three RCTs involving a total of 349 participants (174 in treatment group and 175 in control group) (Noll 1999; Noll 2000; Noll 2010).

3.1 Primary outcomes

3.1.1 Mortality

Three RCTs reported this outcome (Noll 1999; Noll 2000; Noll 2010). Pooled data with a random‐effects model indicated that there may be little to no difference between OMT plus routine treatment and placebo plus routine treatment in mortality (RR 0.43, 95% CI 0.12 to 1.50; 3 trials, 327 participants; I² = 0%; very low‐certainty evidence; Analysis 3.1).

3.1.2 Cure rate

Two RCTs evaluated this outcome (Noll 1999; Noll 2000). Pooled data with a random‐effects model showed that OMT plus routine treatment may increase cure rate compared to placebo plus routine treatment (RR 1.59, 95% CI 1.01 to 2.51; 2 trials, 79 participants; I² = 0%; very low‐certainty evidence; Analysis 3.2).

3.2 Secondary outcomes

3.2.1 Duration of hospital stay

3.2.2 Healing time

Not reported.

3.2.3 Duration of fever

Only one RCT with 21 participants assessed this outcome (Noll 1999), finding that OMT plus routine treatment may have little to no effect on duration of fever in comparison with placebo plus routine treatment (MD 0.6 days, 95% CI −1.60 to 2.80; 1 trial, 21 participants; very low‐certainty evidence; Analysis 3.4).

3.2.4 Rate of improvement of chest X‐ray

Two RCTs reported this outcome (Noll 1999; Noll 2000). Pooled data with a random‐effects model showed that OMT plus routine treatment may provide little to no benefit on improvement of chest X‐ray in comparison with placebo plus routine treatment (RR 1.21, 95% CI 0.84 to 1.74; 2 trials, 75 participants; I² = 0%; very low‐certainty evidence; Analysis 3.5).

3.2.5 Duration of antibiotic therapy

Three RCTs reported this outcome (Noll 1999; Noll 2000; Noll 2010). Pooled data with a random‐effects model showed that OMT plus routine treatment may have little to no effect on mean duration of total (intravenous + oral) antibiotic therapy in comparison with placebo plus routine treatment (MD −1.07 days, 95% CI −2.37 to 0.23; 3 trials, 333 participants; I² = 61%; very low‐certainty evidence; Analysis 3.6). Pooled data with a random‐effects model showed that OMT plus routine treatment may have little to no effect on mean duration of intravenous antibiotic therapy in comparison with placebo plus routine treatment (MD −1.28 days, 95% CI −2.97 to 0.41; 3 trials, 333 participants; I² = 74%; very low‐certainty evidence; Analysis 3.7). Additionally, based on Noll 1999 and Noll 2000, pooled data with a random‐effects model showed that OMT plus routine treatment may have little to no effect on mean duration of oral antibiotic therapy in comparison with placebo plus routine treatment (MD 0.97 days, 95% CI −1.25 to 3.20; 2 trials, 79 participants; I² = 78%; very low‐certainty evidence; Analysis 3.8).

3.2.6 Duration of sputum production

Not reported.

3.2.7 Duration of mechanical ventilation

Not reported.

3.2.8 Duration of ICU stay

Not reported.

3.2.9 Time to clinical stability

Noll 2010 reported time to clinical stability, which was defined as "the hospital calendar day when all seven clinical parameters first met criteria for stability (i.e., lowest systolic blood pressure ≥ 90 mmHg, highest heart rate ≤ 100 beats/min, highest respiratory rate ≤ 24 breaths/min, highest temperature ≤ 38°C, lowest oxygen saturation ≥ 90%, ability to eat food by mouth or by a feeding tube, and mental status back to pre‐pneumonia baseline)". There may be little to no difference between OMT plus routine treatment and placebo plus routine treatment in time to clinical stability (MD 0 days, 95% CI −0.38 to 0.38; 1 trial, 239 participants; very low‐certainty evidence; Analysis 3.9).

3.2.10 Rate of in‐hospital respiratory failure

Noll 2010 reported this outcome. Compared with placebo plus routine treatment, OMT plus routine treatment may have little to no effect on rate of in‐hospital respiratory failure (RR 1.00, 95% CI 0.26 to 3.91; 1 trial, 248 participants; very low‐certainty evidence; Analysis 3.10).

3.2.11 Rate of 60‐day hospital readmission

Noll 2010 reported this outcome. Compared with placebo plus routine treatment, OMT plus routine treatment may have little to no effect on rate of 60‐day hospital readmission (RR 0.83, 95% CI 0.46 to 1.49; 1 trial, 189 participants; very low‐certainty evidence; Analysis 3.11).

3.2.12 Duration of leukocytosis

Only one RCT assessed this outcome (Noll 1999), finding that OMT plus routine treatment may have little to no effect on mean duration of leukocytosis in comparison with placebo plus routine treatment (MD −0.90 day, 95% CI −7.02 to 5.22; 1 trial, 21 participants; very low‐certainty evidence; Analysis 3.12).

3.2.13 Change in leukocyte count

One RCT assessed change in leukocytosis count (Noll 2000). Between Days 1 and 3 from admission, OMT may improve leukocyte count changes (MD 3599.8, 95% CI 1121.22 to 6078.38; 1 trial, 58 participants; very low‐certainty evidence; Analysis 3.13). However, by Day 5, OMT may have little to no effect on leukocyte count changes (MD 2271.5, 95% CI −1287.07 to 5830.07; 1 trial, 58 participants; very low‐certainty evidence; Analysis 3.13).

3.2.14 Mean leukocyte count

One RCT also assessed mean leukocyte count on Days 3 and 5 after admission (Noll 2000), finding that there may be little to no difference between groups in mean white blood cell count on Days 3 and 5 (Day 3: MD 1383, 95% CI −1072 to 3838; Day 5: MD 1210, 95% CI −1052 to 3472, respectively; 1 trial, 58 participants; very low‐certainty evidence; Analysis 3.14).

3.2.15 Inpatient sputum weight

Not reported.

Adverse events

Noll 2000 reported transient muscle tenderness emerging after treatment in two participants during the period of study. Noll 2010 reported three serious adverse events (not specified) in the OMT group, which resulted in early withdrawal.

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

One trial including 98 participants (50 in treatment group and 48 in control group) evaluated this technique (Bjorkqvist 1997).

4.1 Primary outcomes

4.1.1 Mortality

No participants died during the period of study.

4.1.2 Cure rate

Not reported.

4.2 Secondary outcomes

4.2.1 Duration of hospital stay

Compared with routine treatment alone, positive expiratory pressure plus routine treatment may reduce mean duration of hospital stay by 1.4 days (MD −1.4 days, 95% CI −2.77 to −0.03; 1 trial, 98 participants; very low‐certainty evidence; Analysis 4.1).

4.2.2 Healing time

Not reported.

4.2.3 Duration of fever

Positive expiratory pressure may reduce mean duration of fever by 0.7 days (MD −0.7 days, 95% CI −1.36 to −0.04; 1 trial, 98 participants; very low‐certainty evidence; Analysis 4.2).

4.2.4 Rate of improvement of chest X‐ray

Not reported.

4.2.5 Duration of antibiotic therapy

Not reported.

4.2.6 Duration of sputum production

Not reported.

4.2.7 Duration of mechanical ventilation

Not reported.

4.2.8 Duration of ICU stay

Not reported.

4.2.9 Time to clinical stability

Not reported.

4.2.10 Rate of in‐hospital respiratory failure

Not reported.

4.2.11 Rate of 60‐day hospital readmission

Not reported.

4.2.12 Duration of leukocytosis

Not reported.

4.2.13 Change in leukocyte count

Not reported.

4.2.14 Mean leukocyte count

Not reported.

4.2.15 Inpatient sputum weight

Not reported.

Adverse effects

No side effects were found during the study period (Bjorkqvist 1997).

5. High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage versus fibrobronchoscope alveolar lavage alone

We included a new RCT focusing on this technique in this update (Shi 2017). Shi 2017 included 286 severe pneumonia patients receiving mechanical ventilation (143 in treatment group and 143 in control group).

5.1 Primary outcomes

5.1.1 Mortality

Compared with fibrobronchoscope alveolar lavage alone, high‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage may have little to no effect on mortality (RR 0.75, 95% CI 0.17 to 3.29; 1 trial, 286 participants; very low‐certainty evidence; Analysis 5.1).

5.1.2 Cure rate

Not reported.

5.2 Secondary outcomes

5.2.1 Duration of hospital stay

Not reported.

5.2.2 Healing time

Not reported.

5.2.3 Duration of fever

Not reported.

5.2.4 Rate of improvement of chest X‐ray

Not reported.

5.2.5 Duration of antibiotic therapy

Not reported.

5.2.6 Duration of sputum production

Not reported.

5.2.7 Duration of mechanical ventilation

Compared with fibrobronchoscope alveolar lavage alone, high‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage may reduce mean duration of mechanical ventilation by Day 3 (MD −3.0 days, 95% CI −3.68 to −2.32; 1 trial, 286 participants; very low‐certainty evidence; Analysis 5.2).

5.2.8 Duration of ICU stay

Compared with the fibrobronchoscope alveolar lavage alone, high‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage may reduce mean duration of ICU stay by 3.8 days (MD −3.8 days, 95% CI −5.00 to −2.60; 1 trial, 286 participants; very low‐certainty evidence; Analysis 5.3).

5.2.9 Time to clinical stability

Not reported.

5.2.10 Rate of in‐hospital respiratory failure

Not reported.

5.2.11 Rate of 60‐day hospital readmission

Not reported.

5.2.12 Duration of leukocytosis

Not reported.

5.2.13 Change in leukocyte count

Not reported.

5.2.14 Mean leukocyte count

Not reported.

5.2.15 Inpatient sputum weight

Not reported.

Adverse effects

Not reported.

Discussion

Summary of main results

We included eight RCTs with 974 participants in this review. We included two new RCTs (540 participants) in this 2022 update. The included RCTs looked at five types of chest physiotherapies: conventional chest physiotherapy, active cycle of breathing techniques, OMT, positive expiratory pressure, and high‐frequency chest wall oscillation. None of these techniques was found to improve mortality in adult patients with pneumonia. Very uncertain evidence indicated that OMT might improve the cure rate of pneumonia, but not the rate of chest X‐ray improvement. Conventional chest physiotherapy and active cycle of breathing techniques did not increase the cure rate of pneumonia or the rate of chest X‐ray improvement. Positive expiratory pressure did reduce the mean duration of hospital stay by 1.4 days, whereas OMT, conventional chest physiotherapy, and active cycle of breathing techniques did not. Positive expiratory pressure may reduce the duration of fever, whilst OMT may not. Furthermore, this update found new evidence that high‐frequency chest wall oscillation combined with fibrobronchoscope alveolar lavage, compared with fibrobronchoscope alveolar lavage alone, may reduce the mean duration of ICU stay and the mean duration of mechanical ventilation in participants with severe pneumonia who are receiving mechanical ventilation.

Overall completeness and applicability of evidence

Despite the fact that nearly 10 years have passed since the 2012 version of this review, only two relevant RCTs were included in this update. The remaining six included RCTs were conducted around 20 to 40 years ago. The main positive conclusions (a decrease in duration of hospital stay, fever, antibiotic treatment, and mechanical ventilation) were based on four trials with small sample sizes. There have been advances in chest physiotherapies that have not yet been evaluated in people with pneumonia in RCTs. For example, in this review, most included studies addressed CAP, whereas Noll 2010 included some nursing home‐acquired pneumonia patients (81/387). Shi 2017 included severe pneumonia patients receiving mechanical ventilation in ICU, but the types of pneumonia (CAP or hospital‐acquired pneumonia (HAP)) were unclear. We did not find any studies assessing the effectiveness or safety of chest physiotherapy for treating HAP or ventilation‐acquired pneumonia.

It has been reported that the duration, sessions, and quality of chest physiotherapies vary from case to case (Guessous 2008). Misleading results may occur if the treatments are administered by unskilled practitioners. However, information on the experience and training of the physiotherapists who implemented the treatments was not available in most of the included trials. The techniques, the number and duration of sessions, and the duration of the intervention period also varied across trials. Consequently, caution is advised when interpreting the results of this review and applying them to current practice.

Certainty of the evidence

We assessed the evidence for all outcomes in this review as of very low certainty. Firstly, although all trials stated that randomisation was used, only two trials mentioned the method of randomisation (Noll 2010; Shi 2017). Secondly, only three of the eight studies were double‐blinded trials (in which participants and outcome assessors were blinded) (Noll 1999; Noll 2000; Noll 2010), and one study was a single‐blinded trial (Britton 1985). Lack of blinding may cause overestimation of the effects. It should be noted that chest physiotherapy was performed by a physiotherapist, so it might be difficult to blind the practitioners. Thirdly, four of the eight studies had more than 10% dropout, but none used an intention‐to‐treat (ITT) analysis, which aims to maintain the unbiased group comparison afforded by randomisation and to resolve the problem of non‐compliance (Bjorkqvist 1997; Britton 1985; Graham 1978; Tydeman 1989). The absence of an ITT analysis might lead to potential biases. Finally, the sample sizes of the eight trials were too small to permit adequate assessment of the intervention being evaluated. Moreover, there were challenges in obtaining high‐certainty evidence for physiotherapy interventions because of the difficulties in blinding the intervention, standardising the method of chest physiotherapy, and defining clinically meaningful outcomes.

Potential biases in the review process

We were unable to perform a funnel plot analysis to assess potential publication bias because of the limited number of trials for each outcome. The publication date of the included studies varied from 1978 to 2017, which implies that definitions of care and cure, plus medical management (including the methods of chest physiotherapy), may have differed across trials significantly. For these reasons, clinical heterogeneity was inevitable, which may have led to bias when we combined the results of different studies in a meta‐analysis.

Most of the included trials had small sample sizes. If studies are small, skewed data can lead to misleading results when analysing continuous outcomes. Unfortunately, the included trials did not provide sufficient information for us to evaluate the probability of skewed outcome data.

Agreements and disagreements with other studies or reviews

Although chest physiotherapy has been widely used in pneumonia, there is little evidence of any benefit (Guessous 2008). To our knowledge, this is the first systematic review to examine chest physiotherapy for pneumonia in adults. We did not find any systematic reviews or meta‐analyses that addressed this issue when we screened the search results from the major medical databases. According to our results, chest physiotherapy has no benefit for mortality and cure rate. Chest physiotherapy can be costly, as it requires equipment and experienced respiratory therapists, physiotherapists, or clinicians to perform (Guessous 2008). We therefore advise caution when prescribing chest physiotherapy for adults with pneumonia, especially for mild to moderate pneumonia.

Figure 1

Study flow diagram.

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Figure 2

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 3

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

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Analysis 1.1

Comparison 1: Conventional chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 1: Mortality

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Analysis 1.2

Comparison 1: Conventional chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 2: Cure rate

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Analysis 1.3

Comparison 1: Conventional chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 3: Duration of hospital stay

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Analysis 1.4

Comparison 1: Conventional chest physiotherapy plus routine treatment versus routine treatment alone, Outcome 4: Duration of fever

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Analysis 1.5

Comparison 1: Conventional 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: Inpatient sputum weight

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Analysis 3.1

Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 1: Mortality

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Analysis 3.2

Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 2: Cure rate

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Analysis 3.3

Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 3: Duration of hospital stay

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Analysis 3.4

Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 4: Duration of fever

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Analysis 3.5

Comparison 3: OMT 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: OMT plus routine treatment versus placebo plus routine treatment, Outcome 6: Duration of total antibiotic therapy

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Analysis 3.7

Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 7: Duration of intervenous antibiotic therapy

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Analysis 3.8

Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 8: Duration of oral antibiotic therapy

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Analysis 3.9

Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 9: Time to clinical stability

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Analysis 3.10

Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 10: Rate of in‐hospital respiratory failure

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Analysis 3.11

Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 11: Rate of 60‐day hospital readmission

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Analysis 3.12

Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 12: Duration of leukocytosis

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Analysis 3.13

Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 13: Change in leukocyte count

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Analysis 3.14

Comparison 3: OMT plus routine treatment versus placebo plus routine treatment, Outcome 14: 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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Analysis 5.1

Comparison 5: High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage versus fibrobronchoscope alveolar lavage alone, Outcome 1: Mortality

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Analysis 5.2

Comparison 5: High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage versus fibrobronchoscope alveolar lavage alone, Outcome 2: Duration of mechanical ventilation

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Analysis 5.3

Comparison 5: High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage versus fibrobronchoscope alveolar lavage alone, Outcome 3: Duration of ICU stay

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Summary of findings 1. Conventional chest physiotherapy plus routine treatment compared to routine treatment alone for pneumonia

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Conventional chest physiotherapy plus routine treatment compared to routine treatment alone for pneumonia
Patient or population: people with pneumonia Settings: hospital Intervention: conventional chest physiotherapy plus routine treatment Comparison: routine treatment alone
	Assumed risk	Corresponding risk
	Routine treatment alone	Chest physiotherapy plus routine treatment
Mortality Follow‐up: during hospitalisation	17 per 1000	18 per 1000 (3 to 124)	RR 1.03 (0.15 to 7.13)	225 (2 studies)	⊕⊝⊝⊝ Very low^a,b	Both studies did not report the time point to measure this outcome.
Cure rate Follow‐up: during hospitalisation	930 per 1000	865 per 1000 (521 to 1000)	RR 0.93 (0.56 to 1.55)	225 (2 studies)	⊕⊝⊝⊝ Very low^a,b	Both studies did not report the time point to measure this outcome.
Duration of hospital stay Follow‐up: during hospitalisation	The mean duration of hospital stay in the control groups was 6.9 days.	The mean duration of hospital stay in the intervention groups was 0.70 higher (1.39 lower to 2.79 higher).	‐	54 (1 study)	⊕⊝⊝⊝ Very low^c,d
Duration of fever Follow‐up: during hospitalisation	The mean duration of fever in the control groups was 2.5 days.	The mean duration of fever in the intervention groups was 0.40 higher (1.01 lower to 1.81 higher).	‐	54 (1 study)	⊕⊝⊝⊝ Very low^c,d
Duration of total antibiotic therapy ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of ICU stay ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of mechanical ventilation ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; ICU: intensive care unit; RR: risk ratio
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aDowngraded one level due to high risk of bias (concerns regarding blinding of participants and personnel in one of the two studies) ^bDowngraded two levels because the total number of events was less than 300. ^cDowngraded two levels due to high risk of bias (concerns regarding blinding of participants and personnel in this study). ^dDowngraded one level due to small sample size.

Summary of findings 1. Conventional chest physiotherapy plus routine treatment compared to routine treatment alone for pneumonia

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Summary of findings 2. Active cycle of breathing techniques plus routine treatment compared to routine treatment alone for pneumonia

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Active cycle of breathing techniques plus routine treatment compared to routine treatment alone for pneumonia
Patient or population: people with pneumonia Settings: hospital Intervention: active cycle of breathing techniques plus routine treatment Comparison: routine treatment alone
	Assumed risk	Corresponding risk
	Routine treatment alone	Active cycle of breathing techniques plus routine treatment
Mortality Follow‐up: during hospitalisation	See comment	See comment	Not estimable	32 (1 study)	⊕⊝⊝⊝ Very low^a,b	No participant died in either group during the study period.
Cure rate Follow‐up: during hospitalisation	700 per 1000	420 per 1000 (203 to 861)	RR 0.60 (0.29 to 1.23)	32 (1 study)	⊕⊝⊝⊝ Very low^a,b	The study did not clearly did not report the time point to measure this outcome.
Duration of hospital stay Follow‐up: during hospitalisation	The mean duration of hospital stay in the control groups was 5.27 days.	The mean duration of hospital stay in the intervention groups was 1.4 higher (0.69 lower to 3.49 higher).	‐	32 (1 study)	⊕⊝⊝⊝ Very low^a,b
Duration of fever ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of total antibiotic therapy Follow‐up: during hospitalisation	The mean duration of total antibiotic therapy in the control groups was 15.02 days.	The mean duration of total antibiotic therapy in the intervention groups was 0.15 higher (4.39 lower to 4.69 higher).	‐	32 (1 study)	⊕⊝⊝⊝ Very low^a,b
Duration of ICU stay ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of mechanical ventilation ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; ICU: intensive care unit; RR: risk ratio
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aDowngraded two levels due to high risk of bias (concerns regarding blinding of participants and personnel, blinding of outcome assessment, and incomplete outcome data). ^bDowngraded one level due to small sample size and wide confidence intervals.

Summary of findings 2. Active cycle of breathing techniques plus routine treatment compared to routine treatment alone for pneumonia

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Summary of findings 3. Osteopathic manipulative treatment (OMT) plus routine treatment compared to placebo plus routine treatment for pneumonia

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Osteopathic manipulative treatment (OMT) plus routine treatment compared to placebo plus routine treatment for pneumonia
Patient or population: people with pneumonia Settings: hospital Intervention: OMT plus routine treatment Comparison: placebo plus routine treatment
	Assumed risk	Corresponding risk
	Placebo plus routine treatment	OMT plus routine treatment
Mortality Follow‐up: during hospitalisation	49 per 1000	21 per 1000 (6 to 73)	RR 0.43 (0.12 to 1.50)	327 (3 studies)	⊕⊝⊝⊝ Very low^a,b	These studies did not report the time point to measure this outcome.
Cure rate Follow‐up: during hospitalisation	375 per 1000	596 per 1000 (379 to 941)	RR 1.59 (1.01 to 2.51)	79 (2 studies)	⊕⊝⊝⊝ Very low^a,c	These studies did not report the time point to measure this outcome.
Duration of hospital stay Follow‐up: during hospitalisation	The mean duration of hospital stay in the control groups was 9.77 days.	The mean duration of hospital stay in the intervention groups was 1.08 lower (2.39 lower to 0.23 higher).	‐	333 (3 studies)	⊕⊝⊝⊝ Very low^a,b
Duration of fever Follow‐up: during hospitalisation	The mean duration of fever in the control groups was 1.6 days.	The mean duration of fever in the intervention groups was 0.6 higher (1.60 lower to 2.80 higher).	‐	21 (1 study)	⊕⊝⊝⊝ Very low^a,c
Duration of total antibiotic therapy Follow‐up: during hospitalisation	The mean duration of total antibiotic therapy in the control groups was 8.37 days.	The mean duration of total antibiotic therapy in the intervention groups was 1.07 lower (2.37 lower to 0.23 higher).	‐	333 (3 studies)	⊕⊝⊝⊝ Very low^a,b
Duration of ICU stay ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of mechanical ventilation ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; ICU: intensive care unit; RR: risk ratio
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aDowngraded two levels due to very wide confidence intervals and very low event rate. ^bDowngraded two levels due to small sample size and confidence intervals overlapping no effect and substantial benefit. ^cDowngraded two levels due to very small sample size.

Summary of findings 3. Osteopathic manipulative treatment (OMT) plus routine treatment compared to placebo plus routine treatment for pneumonia

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Summary of findings 4. Positive expiratory pressure plus routine treatment compared to routine treatment alone for pneumonia

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Positive expiratory pressure plus routine treatment compared to routine treatment alone for pneumonia
Patient or population: people with pneumonia Settings: hospital Intervention: positive expiratory pressure plus routine treatment Comparison: routine treatment alone
	Assumed risk	Corresponding risk
	Routine treatment alone	Positive expiratory pressure plus routine treatment
Mortality Follow‐up: during hospitalisation	See comment	See comment	Not estimable	98 (1 study)	⊕⊝⊝⊝ Very low^a,b	No participant died in either group during the study period.
Cure rate ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of hospital stay Follow‐up: during hospitalisation	The mean duration of hospital stay in the control groups was 5.3 days.	The mean duration of hospital stay in the intervention groups was 1.40 lower (2.77 to 0.03 lower).	‐	98 (1 study)	⊕⊝⊝⊝ Very low^a,c
Duration of fever Follow‐up: during hospitalisation	The mean duration of fever in the control groups was 2.3 days.	The mean duration of fever in the intervention groups was 0.7 lower (1.36 to 0.04 lower).	‐	98 (1 study)	⊕⊝⊝⊝ Very low^a,c
Duration of total antibiotic therapy ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of ICU stay ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of mechanical ventilation ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; ICU: intensive care unit; RR: risk ratio
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aDowngraded two levels due to high risk of bias (concerns regarding blinding of participants and personnel and blinding of outcome assessment). ^bDowngraded one level because total number of events was less than 300. ^cDowngraded one level due to small sample size.

Summary of findings 4. Positive expiratory pressure plus routine treatment compared to routine treatment alone for pneumonia

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Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Certainty of the evidence (GRADE)	Comments
High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage compared to fibrobronchoscope alveolar lavage alone for severe pneumonia and receiving mechanical ventilation
Patient or population: people with severe pneumonia and receiving mechanical ventilation Settings: intensive care unit Intervention: high‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage Comparison: fibrobronchoscope alveolar lavage alone
	Assumed risk	Corresponding risk
	Fiberbronchoscope alveolar lavage alone	High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage
Mortality Follow‐up: during hospitalisation	28 per 1000	21 per 1000 (5 to 92)	RR 0.75 (0.17 to 3.29)	286 (1 study)	⊕⊝⊝⊝ Very low^a,b	This study did not report the time point to measure this outcome.
Cure rate ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of hospital stay ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of fever ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of total antibiotic therapy ‐ not reported	See comment	See comment	Not estimable	‐	See comment	This outcome was not reported.
Duration of ICU stay Follow‐up: during hospitalisation	The mean duration of ICU stay in the control groups was 12.4 days.	The mean duration of ICU stay in the intervention groups was 3.8 lower (5 to 2.6 lower).	‐	286 (1 study)	⊕⊝⊝⊝ Very low^a,c
Duration of mechanical ventilation Follow‐up: during hospitalisation	The mean duration of mechanical ventilation in the control groups was 9.4 days.	The mean duration of mechanical ventilation in the intervention groups was 3 lower (3.68 to 2.32 lower).	‐	286 (1 study)	⊕⊝⊝⊝ Very low^a,c
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; ICU: intensive care unit; RR: risk ratio
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aDowngraded two levels due to high risk of bias (concerns regarding allocation concealment, blinding of participants and personnel, and blinding of outcome assessment). ^bDowngraded two levels due to very few events and very wide confidence intervals encompassing both substantial benefit and substantial harm. ^cDowngrade one level due to small sample size.

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Comparison 1. Conventional chest physiotherapy plus routine treatment versus routine treatment alone

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

1.2 Cure rate Show forest plot	2	225	Risk Ratio (M‐H, Random, 95% CI)	0.93 [0.56, 1.55]

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

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

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

Comparison 1. Conventional 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
2.1 Cure rate Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

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

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

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

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

2.5.1 Inpatient	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.5.2 Outpatient	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.6 Inpatient 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. OMT plus routine treatment versus placebo plus routine treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 Mortality Show forest plot	3	327	Risk Ratio (M‐H, Random, 95% CI)	0.43 [0.12, 1.50]

3.2 Cure rate Show forest plot	2	79	Risk Ratio (M‐H, Random, 95% CI)	1.59 [1.01, 2.51]

3.3 Duration of hospital stay Show forest plot	3	333	Mean Difference (IV, Random, 95% CI)	‐1.08 [‐2.39, 0.23]

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

3.5 Rate of improvement of chest X‐ray Show forest plot	2	75	Risk Ratio (M‐H, Random, 95% CI)	1.21 [0.84, 1.74]

3.6 Duration of total antibiotic therapy Show forest plot	3	333	Mean Difference (IV, Random, 95% CI)	‐1.07 [‐2.37, 0.23]

3.7 Duration of intervenous antibiotic therapy Show forest plot	3	333	Mean Difference (IV, Random, 95% CI)	‐1.28 [‐2.97, 0.41]

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

3.9 Time to clinical stability Show forest plot	1	239	Mean Difference (IV, Fixed, 95% CI)	0.00 [‐0.38, 0.38]

3.10 Rate of in‐hospital respiratory failure Show forest plot	1	248	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.26, 3.91]

3.11 Rate of 60‐day hospital readmission Show forest plot	1	189	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.46, 1.49]

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

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

3.13.1 Change between Day 3 and 1 from admission	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.13.2 Change between Day 5 and 1 from admission	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.14 Mean leukocyte count Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.14.1 Day 3 from admission	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.14.2 Day 5 from admission	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

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

4.2 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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Comparison 5. High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage versus fibrobronchoscope alveolar lavage alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
5.1 Mortality Show forest plot	1	286	Risk Ratio (IV, Fixed, 95% CI)	0.75 [0.17, 3.29]

5.2 Duration of mechanical ventilation Show forest plot	1	286	Mean Difference (IV, Fixed, 95% CI)	‐3.00 [‐3.68, ‐2.32]

5.3 Duration of ICU stay Show forest plot	1	286	Mean Difference (IV, Fixed, 95% CI)	‐3.80 [‐5.00, ‐2.60]

Comparison 5. High‐frequency chest wall oscillation plus fibrobronchoscope alveolar lavage versus fibrobronchoscope alveolar lavage alone

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Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

PICO

PICO

Population

Intervention

Comparison

Outcome

Plain language summary

Chest physiotherapy for pneumonia in adults

Resumen visual

Authors' conclusions

Implications for practice

Implications for research

Summary of findings

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Primary outcomes

Secondary outcomes

Adverse events

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

Summary of findings and assessment of the certainty of the evidence

Results

Description of studies

Results of the search

Included studies

Participants

Interventions

Outcome measures

Excluded studies

Risk of bias in included studies

Allocation

Blinding

Incomplete outcome data

Selective reporting

Other potential sources of bias

Effects of interventions

1. Conventional chest physiotherapy plus routine treatment versus routine treatment alone

1.1 Primary outcomes

1.1.1 Mortality

1.1.2. Cure rate

1.2 Secondary outcomes

1.2.1 Duration of hospital stay

1.2.2 Healing time

1.2.3 Duration of fever

1.2.4 Rate of improvement of chest X‐ray

1.2.5 Duration of antibiotic therapy

1.2.6 Duration of sputum production