Multimodality respiratory physiotherapy reduces mortality but may not prevent ventilator-associated pneumonia or reduce length of stay in the intensive care unit: a systematic review

Abstract

Question: In intubated adult patients receiving mechanical ventilation, does multimodality respiratory physiotherapy prevent ventilator-associated pneumonia, shorten length of intensive care unit (ICU) stay, and reduce mortality? Design: A systematic review with meta-analysis of randomised controlled trials. Participants: Intubated adult patients undergoing mechanical ventilation who were admitted to an intensive care unit. Intervention: More than two respiratory physiotherapy techniques such as positioning or postural drainage, manual hyperinflation, vibration, rib springing, and suctioning. Outcomes measures: Incidence of ventilator-associated pneumonia (VAP), duration of ICU stay, and mortality. Results: Five trials were included in the meta-analysis. Random-effects models were used to calculate pooled weighted mean difference (WMD) for length of ICU stay and pooled risk ratio (RR) for incidence of VAP, and fixed-effects model was used to calculate pooled RR for mortality. The effect on the incidence of VAP was unclear (RR 0.73 in favour of multimodality respiratory physiotherapy, 95% CI 0.38 to 1.07). The effect on length of stay was also unclear (WMD –0.33 days shorter with multimodality respiratory physiotherapy, 95% CI –2.31 to 1.66). However, multimodality respiratory physiotherapy significantly reduced mortality (RR 0.75, 95% CI 0.58 to 0.92). Conclusion: Multimodality respiratory physiotherapy appeared to reduce mortality in ICU patients. It was unclear whether this occurred via a reduction in the incidence of VAP and/or length of stay because the available data provided very imprecise estimates of the effect of multimodality respiratory physiotherapy on these outcomes. These very imprecise estimates include the possibility of very worthwhile effects on VAP incidence and length of ICU stay; therefore, these outcomes should be the focus of further investigation in rigorous trials. Registration: PROSPERO CRD42018094202. [Pozuelo-Carrascosa DP, Torres-Costoso A, Alvarez-Bueno C, Cavero-Redondo I, López Muñoz P, Martínez-Vizcaíno V (2018) Multimodality respiratory physiotherapy reduces mortality but may not prevent ventilator-associated pneumonia or reduce length of stay in the intensive care unit: a systematic review. Journal of Physiotherapy 64: 222–228]