809815

research-article2018
CRE0010.1177/0269215518809815Clinical RehabilitationConesa-Segura et al.

Técnica de espiración lenta

prolongada CLINICAL
Original Article REHABILITATION

Clinical Rehabilitation

Prolonged slow expiration 1­–12

© The Author(s) 2018
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DOI: 10.1177/0269215518809815
https://doi.org/10.1177/0269215518809815

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infants: FIBARRIX randomized

controlled trial

Enrique Conesa-Segura1, Susana B Reyes-Dominguez2,

José Ríos-Díaz3,4 , María Ángeles Ruiz-Pacheco5,
Cristina Palazón-Carpe5 and Manuel Sánchez-Solís6

Abstract
Objective: To examine the effect of prolonged slow expiration respiratory physiotherapy treatment on
the acute bronchiolitis severity scale and O2 saturation at short-time and at medical discharge in infants
and the hospital stay.
Design: Randomized controlled trial.
Setting: Infants’ unit of university hospital.
Participants: Infants with acute bronchiolitis (N = 80).
Intervention: Infants were randomized into respiratory treatment (RT) with prolonged slow expiration
or treatment as usual (control) for one-week period.
Main outcome measures: The primary outcomes were Acute Bronchiolitis Severity Scale score and
O2 saturation, recorded shortly after each intervention during the stay and at medical discharge, and the
hospital stay.
Results: The RT had a significantly lower Acute Bronchiolitis Severity Scale 10-minute after the first
intervention (mean difference −1.7 points, 95% confidence interval (CI) −3.0 to −0.38), 2 hours after (–2.0
points, 95% CI −3.2 to −0.86) and the last day before medical discharge (−1.3 points, 95% CI −2.1 to 0.51).
No changes were detected in O2 saturation. The survival analysis of time at medical discharge showed
decrease in the average number of days to achieve an Acute Bronchiolitis Severity Scale of less than 2
points (RT: 2.6 days, 95% CI 2.1–3.1; Control: 4.4 days, 95% CI 3.6–5.1).

1Programa de Doctorado en Ciencias de la Salud, Universidad 6Paediatric

Católica de Murcia (UCAM), Murcia, Spain
2Virgen Arrixaca University Children’s Hospital, Murcia, Spain
3Centro Universitario de Ciencias de la Salud San Rafael,
Universidad Antonio de Nebrija, Madrid, Spain
4Fundación San Juan de Dios, Madrid, Spain
5MIR Pediatría, Virgen de la Arrixaca University Children’s
Hospital, Murcia, Spain
Neumology, Virgen Arrixaca University Children’s
Hospital, Murcia, Spain
Corresponding author:
José Ríos-Díaz, Centro Universitario de Ciencias de la Salud
San Rafael, Universidad Antonio de Nebrija, Paseo de la
Habana, 70bis. 28036 Madrid, Spain.
Email: jrios@nebrija.es
Twitter: @geyrivers; @FundSJDInvest
2 Clinical Rehabilitation 00(0)
Conclusion: A prolonged slow expiration physiotherapy reduces Acute Bronchiolitis Severity Scale
scores and does not change O2 saturation. Infants in RT group stay less days in hospital than infants in
control group and no adverse events were detected.
Keywords
Respiratory physiotherapy, prolonged slow exhalation, paediatrics, acute viral bronchiolitis, intensive
care unit
Date received: 9 May 2018; accepted: 8 October 2018
Introduction
Passive expiration techniques, such as prolonged
slow expiration, seem to have greater effectiveness
than conventional techniques.1,2 In prolonged slow
expiration, intrathoracic pressure increases slowly
by means of thoracoabdominal compression to pre-
vent bronchial collapse and disruption of the flow
that occurs during forced expirations.3 At pro-
longed slow expiration, intrathoracic pressure
increases slowly through thoracoabdominal com-
pression to prevent bronchial collapse and disrup-
tion of the flow that occurs during forced
expirations.4
The studies carried out until now are not conclu-
sive as regards the results of the different tech-
niques tested. Some of these studies do not consider
the special characteristics of these patients, such as
high compliance of the rib cage, or the diameter of
the airways, which produce a high resistance to air
flow. This should be considered when choosing
respiratory physiotherapy techniques.5
Respiratory physiotherapy has demonstrated its
efficacy in removing bronchial secretions, reduc-
ing breathlessness and improving oxygenation in
both adults and paediatric patients,6,7 and is recom-
mended in patients with cystic fibrosis,8 cerebral
palsy or spinal muscular atrophy,9 among other
neuromuscular diseases.10 However, there are no
reports on the application of this technique in chil-
dren with acute bronchiolitis admitted to infant
units.
Therefore, the object this randomized controlled
trial was to find answers to the following questions:
1. For children with acute bronchiolitis, does pro-
longed slow expiration respiratory physiotherapy
technique reduce the acute bronchiolitis sever-
ity score and O2 saturation at short-time and at
medical discharge?
2. Does prolonged slow expiration respiratory
physiotherapy treatment shorten the hospital
stay?
3. Is prolonged slow expiration respiratory phys-
iotherapy treatment safe?
Method
The study was conducted from December 2014
to March 2015 in the Infants’ Unit of ‘Virgen de
la Arrixaca’ University Hospital of Murcia
(Spain). This study followed the Helsinki
Declaration (64th WMA General Assembly,
Fortaleza, Brazil, October 2013) and was
approved by the Clinical Investigation Ethics
Committee (CEIC) of the ‘Virgen de la Arrixaca’
Hospital (2014/12/18). All parents or legal
guardian gave written informed consent before
data collection began.
This was a randomized controlled trial with
concealed allocation and assessor blinding. The
study protocol was registered in ClinicalTrials.gov
database with the code NCT02458300 (FIBARRIX)
and followed the Consolidated Standards of
Reporting Trials (CONSORT).
Patients
Infants were considered for inclusion in the
study if they met the following criteria: (1) aged
1–24 months,11 (2) admitted to Hospital for acute
viral bronchiolitis,12 (3) absence of congenital car-
diopathy6 and (4) no contraindications for thoracic
Conesa-Segura et al.
physiotherapy techniques such as gastroesopha-
geal reflux and laryngeal affections.6
After confirming which infants complied with
the eligibility criteria, a researcher did a simple
randomization by assigning subjects to either the
respiratory physiotherapy group or the control
group (Macro !RNDSEQ for SPSS Statistics.
Generation of Random Sequences [computer
programme]. V2011.09.09. Randomization
seed = –1987653.97). The allocation was concealed
by the primary researcher. The study was triple-
blind because neither the evaluating paediatricians,
parents nor statistician knew the group codes.
Intervention procedure
All infants were assessed daily at three time-points:
baseline (at 8.00 a.m.), and 10 minutes and 2 hours
after physiotherapy intervention in experimental
group and in the control group (without physiother-
apy). Finally, they were evaluated at discharge. To
ensure the homogeneous evaluation of patients, all
the physicians were previously trained in acute
bronchiolitis scoring. Fellow paediatricians/paedi-
atrician interns as well as senior permanent staff on
the ward took part in applying the scale.
All the physiotherapy interventions were devel-
oped by experienced and trained physiotherapists.
The prolonged slow expiration technique was
developed as follows: the therapist places the
hypothenar region of one hand under the sternal
notch of the infant’s chest and the hypothenar
region of the other hand below the umbilicus of the
infant’s abdomen. At the end of the expiratory
phase, gentle pressure is applied with both hands to
take the patient to expiratory reserve volume. The
hand on the chest moves in the cranio-caudal direc-
tion and the other in the opposite direction. This
pressure is kept for two or three breathing cycles
without exceeding five cycles. This technique is
repeated several times, with a rest time between
applications of about 5 or 10 spontaneous breaths.
After the application of prolonged slow expiration,
coughing is triggered by applying pressure with
the thumb just above the external clevis at the
end of the inspiratory phase.13 Then, a retrograde
rhinopharyngeal unclogging is performed, which is
a forced inspiratory manoeuvre that aims to clear
3
the nasopharynx.14 Finally, a nasal and oral aspira-
tion is realized in order to remove secretions. In our
intervention, the total duration of treatment was
about 15 minutes5 and was given once a day during
the stay in infant’s unit. Discharge from hospital
was performed when the patient presented clinical
stability, an adequate oral intake of fluids and a
SPO2 above 92% breathing ambient air for at least
4 hours including a period of sleep.
In both groups, a hypertonic saline nebulization
was administered, and the nasopharynx content
was aspirated.15,16 None drug was prohibited dur-
ing study and they were prescribed freely by pae-
diatricians. Infants allocated to the control group
were evaluated in the same way as those in the
experimental group.
Measures
The primary outcomes were change in Acute
Bronchiolitis Severity Scale (ABSS) and O2 satu-
ration shortly after respiratory physiotherapy treat-
ment and at medical discharge. The ABSS17 is a
validated scale in a Spanish population that com-
bines the evaluation of wheezing, crackles, respira-
tory effort and inspiration/exhalation ratio. The
scale has three levels of severity: mild from 0 to 4
points, moderate from 5 to 9 and severe from 10 to
13. Also, the time at which a score of 4 points and
2 points on the ABSS was reached during admis-
sion was noted.
Secondary outcomes were the items used to
calculate the total score on the ABSS: wheezing
(0–4 points), crackles (0–4 points), respiratory
effort (0–3 points), inspiration/exhalation ratio
(0–2), respiratory rate (0–2 points) and cardiac
rates (0–2 points). In addition, respiratory (0–2)
and cardiac rates (0–2) by age were registered. For
survival analysis of admission days in Infant’s
Unit, we considered an ABSS score of less than
two points as an event.
Data analysis
The sample size was calculated to detect differences
of 2.1 units in primary outcome ABSS, assuming a
type I error of 5% and type II error of 10% (power
of 90%) and bilateral contrast.18 The sample size
4 Clinical Rehabilitation 00(0)
estimated was 62 participants. We considered a
15% of loses, so the final sample size required was
of 80 participants.
Statistical analysis was performed using IBM
SPSS Statistics 19 software and data were analysed
according to their randomly assigned treatment
(intention-to-treat analysis). Significance was
accepted at an alpha level of 0.05.
The baseline characteristics of the infants and
the outcome measures at each assessment point
were summarized as median (interquartile range
[IQR]) and ranges, or number (%) as appropriate.
At baseline, we tested quantitative variables with a
Student’s t-test for independent samples and
Pearson’s χ2 test for categorical variables.
Age, admission time/day, days of treatment,
ABSS and O2 saturation levels did not show a nor-
mal distribution (Kolmogorv-Smirnov test,
P < 0.05) and normal Q-Q plots showed some out-
lier data, so logarithmic transformation was used to
correct this point in parametric tests.
To assess the influence of the experimental
intervention on ABSS and on O2 saturation a 4 × 2
repeated measured analysis of variance (ANOVA)
with time (baseline, 10 minutes after first treat-
ment, 2 hours after first treatment and at basal
evaluation on the day of discharge) as the within-
participants factor, and group (experimental and
control) as the between participants factor was
applied. Also, a post hoc paired t-test with
Bonferroni’s correction (level of significance at
P < 0.0125 for four repeated measurements) was
performed. As the initial diagnosis and length of
stay in hospital may interact with the principal out-
come, an initial analysis of covariance (ANCOVA)
was used to check whether this was the case.
Hedges’ g statistic was calculated to evaluate
the effect sizes. As a guideline, we considered
that g < 0.2 corresponded to a small effect size,
around 0.5 to a medium effect size and more than
0.8 to a large effect size. Also, the percentage of
change was calculated as 1-(measure x/baseline)
in within group or 1 – (control/experimental)
between groups.
Likewise, the changes in ordinal variables
used to calculate the ABSS were analysed.
McNemar–Bowker’s test was used to analyse each
moment with respect to baseline in each group and
Goodman–Kruskal’s Gamma coefficient to check
differences between groups at each moment. These
tests were replaced by the chi-square test if some
cells of contingency tables cells that had no cases.
Finally, a survival analysis was performed with
the Kaplan–Meier method to check whether the
time to reach an ABSS of less than 2 points differed
between groups. The differences between groups
were analysed by Breslow’s test.
Results
Flow of participants during the study
Eighty participants were screened for eligibility
and three refused to participate: two because par-
ents did not sign the informed consent and one
because parents did not understand Spanish, French
or English language. One patient in the control
group and two in the experimental group were
excluded due to changes in diagnosis. At the end of
study, one patient in the control group and two in
the experimental group were eliminated from data-
base because erroneous data were detected that
could not be corrected. Finally, 32 patients in the
control group and 39 in the experimental group
were analysed (Figure 1).
Characteristics of participants
Baseline characteristics are reported in Table 1.
The groups appear to be well matched for age
(log δ = –0.12 year; 95% confidence interval
(CI) = –0.39 to 0.14; P = 0.36; Hedges’ g = 0.21),
length of O2 therapy (log δ = 0.15 hour.; 95%
CI = 0.89 to 1.20; P = 0.77; Hedges’ g = 0.07), O2
saturation (δ = –0.89%, 95% CI = –2.6 to 0.81;
P = 0.30; Hedges’ g = 0.25) and ABSS (log δ = 0.046;
95% CI = –0.13 to 0.23; P = 0.69; Hedges’ g = 0.12).
They are also well matched for sex (χ2 = 0.501;
d.f. = 1; P = 0.48; OR = 1.6; 95% CI = 0.61 to 4.1)
and oxygen therapy (χ2 = 0.003; d.f.= 1; P = 0.95;
OR = 0.87; 95% CI = 0.33 to 2.3).
Effect of intervention
Primary outcomes. The primary outcome, ABSS,
improved in the experimental group. Table 2 shows
Conesa-Segura et al.
Figure 1. Flowchart of the participants.
the results of the mixed-model linear analysis
(ANOVA) for ABSS. It revealed an interaction
between group and time (F(3, 207) = 6.44; P < 0.001;
ω p2 = 0.07 ), in which infants treated with physio-
therapy respiratory techniques experienced a
reduction of 46% in ABSS immediately after the
treatment with respect to the baseline (P < 0.001;
Hedges’ g = 0.73) with a large effect size (Figure 2).
However, in the control group, ABSS did not change
significantly (7%) immediately after treatment
5
(P = 0.87; Hedges’ g = 0.16). The differences
between groups at this moment were significant
with a moderate effect size (P = 0.01; Hedges’
g = 0.54) that represents a reduction of 46% in
experimental group.
The changes in ABSS 2 hours post-treatment
showed a reduction in both groups, but higher in
the experimental group (P < 0.001, Hedges’
g = 1.4) than in the control group (P < 0.001;
Hedges’ g = 0.37). This improvement was 108% in
6 Clinical Rehabilitation 00(0)

Table 1. Baseline characteristics of participants.

Characteristic All (n = 71) Exp (n = 39) Con (n = 32)

Age (year), median (IQR) [range] 2.9 (1.8–5.4) [1.1, 20.0] 3.3 (1.8–7.0) [1.1, 20.0] 2.8 (1.8–5.1) [1.1, 11.7]
Gender (F), n (%) 31 (44) 19 (49) 12 (38)
Oxygen therapy (yes), n (%) 43 (61) 23 (53) 20 (46)
Hours of oxygen therapy, median 48 (0–72) [0, 240] 24 (0–72) [0-240] 48 (0–90) [0-192]
(IQR) [range]
Initial O2 saturation (%), median 97 (94–99) [85, 100] 97 (94.5–99) [91, 100] 96 (94–98.8) [85, 100]
(IQR) [range]
Time of stay (days), median (IQR) 5 (4–8) [10, 26] 5 (4–8) [1, 26] 5.5 (4–8) [1, 14]
[range]
Sessions of physiotherapy and/or 3 (2–3) [1, 8] 2 (1–3) [1, 6] 2 (3–4) [1, 8]
medical treatment (days), median
(IQR) [range]
Initial Acute Bronchiolitis Severe 6 (4–7) [1, 11] 5 (4–7) [2, 10] 6 (4–7) [1, 11]
Scale (0–13) median (IQR) [range]
Severe bronchiolitis, n (%)
Low (0–4) 21 (35) 15 (39) 10 (31)
Moderate (5–9) 41 (58) 23 (59) 18 (56)
Severe (10–13) 5 (7) 1 (3) 4 (13)

Exp: experimental group; Con: control group; F: female; IQR: interquartile range.

the experimental group and 26% in the control
group. The differences between groups were also
of note (P < 0.001; Hedges’ g = 0.69), the reduction
being 57% lower in the experimental group than in
the control group.
Finally, in the basal state on the morning of
discharge, the experimental group showed a sig-
nificant reduction of 440% of the baseline
(P = 0.001; Hedges’ g = 2.0) compared with the
control group that showed significant reduction
of 152% (P < 0.001; Hedges’ g = 1.2). The dif-
ferences between groups were significant
(P = 0.002; Hedges’ g = 0.53) which represents a
19% higher reduction in the experimental group.
O2 saturation was similar in both groups (Figure
2) and no changes were detected during follow-
up (Table 2).
Secondary outcomes. Table 3 shows the change in
every secondary outcome after intervention and the
differences between groups. As can be appreciated,
all of them except cardiac and respiratory rates
showed a significantly greater improvement in the
experimental group.
The analysis (Supplementary Figure 1) shows
that the mean time to reach an ABSS below 2
points was significantly shorter (Breslow’s test
χ2 16.6, P < 0.001) in the experimental group
(2.6 days, 95% CI 2.1–3.1 days) than in the con-
trol group (4.4 days, 95% CI 3.69–5.1 days). The
median number of days of treatment necessary to
reach an ABSS score of below 2 points was
three days in the intervention group and four days
in the control group. In the experimental group,
75% of the children had an ABSS Score below 2
points after three days of treatment whereas the
control group needed six days for the same score to
be reached by 75% of the children.
Discussion
This study shows that the infants who receiving
respiratory physiotherapy on average reduced the
ABSS score by half with a single intervention and
no change in control group. The improvement
within 2 hours of the first intervention was
approximately 100% in the intervention group and
only 25% in the control. Also, the intervention
 Conesa-Segura et al.

Table 2. Mean (SD) of groups, mean (95% CI) difference within groups, and mean (95% CI) difference between groups and effect size and P-values for
Acute Bronchiolitis Severity Scale and O2 saturation.

Outcome Groups Difference within groups Difference between groups

Pre-test 10′ post- 2 hours Final 10′ minus pre-test 2 hours minus pre-test Final minus pre-test 10′ 2 hours Final
test post-test

Exp Con Exp Con Exp Con Exp Con Exp Con Exp Con Exp Con Exp–Con Exp–Con Exp–Con
(n = 39) (n = 32)

ABSS 5.4 5.8 3.7 5.4 2.6 4.6 1.0 2.3 −1.7 −0.44 −2.8 −1.2 −4.3 −3.5 −1.7 −2.0 −1.3
(0 to 13) (2.03) (2.6) (2.9) (2.66) (2.29) (2.53) (1.31) (2.09) (−2.4 to −0.96) (−1.24 to 0.37) (−3.4 to −2.1) (−1.9 to −0.5) (−5.3 to −3.4) (−4.5 to −2.4) (−3.0 to −0.38) (−3.2 to −0.86) (–2.1 to 0.51)
[0.73; <0.001] [0.16; 0.87] [1.3; <0.001] [0.37; <0.001] [2.0; 0.001] [1.2; <0.001] [0.54; 0.01] [0.69; 0.001] [0.53; 0.002]
O2 96.6 95.7 96.6 95.8 96.1 96.6 96.3 96.5 0.03 0.07 −0.55 0.93 −0.33 0.79 −0.85 −0.58 −0.23
saturation (3.01) (3.65) (2.75) (2.74) (2.97) (3.01) (2.71) (3.05) (–1.6 to 1.6) (–1.7 to 1.8) (–2.0 to 0.92) (–0.66 to 2.5) (–2.3 to 1.7) (–1.4 to 2.9) (–0.56 to 2.3) (–2.1 to 0.95) (–1.7 to 1.25)
(%) [0.01; 0.99] [0.02; 0.99] [0.08; 0.99] [0.15; 0.70] [0.09; 0.99] [0.12; 0.99] [0.21; 0.23] [0.09; 0.45] [0.07; 0.76]

Exp: experimental group; Con: control group; ABSS: Acute Bronchiolitis Severity Scale.
Hedges’ g for effect size and P-value are in square brackets. The significance tests were made with natural logarithms of the outcomes. Data are in natural scale for better interpretation. The level of
significance for multiple comparisons was corrected by Dunn–Bonferroni’s method.
7
8 Clinical Rehabilitation 00(0)

Figure 2. Box plot for Acute Bronchiolitis Severity Scale (top) and O2 saturation (bottom) follow-up and between
groups. Boxes represent the median and first and third quartiles. When the notches of two plots do not overlap,
indicates strong evidence that the two medians differ. The dots represent the individual values.

with respiratory physiotherapy reduces the mean
recovery time than in control group. Three quar-
ters of the children who were treated with physio-
therapy achieved an ABSS of less than 2 points at
three days, while in the control group it took
six days to achieve the same score.
Respiratory physiotherapy has been tested in
several studies as a treatment for acute bronchioli-
tis, but the results have not provided clear evi-
dence in its favour.2 Classic techniques such as
vibration and percussion in patients suffering from
this illness were analysed in three randomized
Table 3. Number of participants (%) in Acute Bronchiolitis Severity Scale items and Bronchiolitis Severity for both groups.
Variable Levels Control (n = 32) Experimental (n = 39)

Initial 10 minutes 2 hours Final Initial 10 minutes 2 hours Final

Wheezing/ 0 2 (6.3%) 4 (12.5%) 4 (12.5%) 10 (31.3%) 2 (5.1%) 11 (28.2%) 14 (35.9%) 19 (48.7%)

crackles 1 5 (15.6%) 6 (18.8%) 7 (21.9%) 12 (37.5%) 12 (30.8%) 12 (30.8%) 12 (30.8%) 14 (35.9%)
2 9 (28.1%) 9 (28.1%) 11 (34.4%) 7 (21.9%) 12 (30.8%) 5 (12.8%) 8 (20.5%) 4 (10.3%)
3 5 (15.6%) 3 (9.4%) 3 (9.4%) 2 (6.3%) 4 (10.3%) 5 (12.8%) 5 (12.8%) 2 (5.1%)
Conesa-Segura et al.

4 11 (34.4%) 10 (31.3%) 7 (21.9%) 1 (3.1%) 9 (23.1%) 6 (15.4%) 0 (0%) 0 (0%)

P-value intra-groupa Ref 0.70 0.65 0.092 Ref 0.008 <0.001 0.05
P-value inter-groupb – – – – 0.151 0.023 0.001 0.068
Respiratory 0 6 (18.8%) 9 (28.1%) 10 (31.3%) 18 (56.3%) 2 (5.1%) 15 (38.5%) 17 (43.6%) 32 (82.1%)
effort 1 16 (50%) 15 (46.9%) 15 (46.9%) 13 (40.6%) 28 (71.8%) 17 (43.6%) 18 (46.2%) 6 (15.4%)
2 10 (31.3%) 8 (25%) 6 (18.8%) 1 (3.1%) 8 (20.5%) 5 (12.8%) 4 (10.3%) 1 (2.6%)
3 0 (0%) 0 (0%) 1 (3.1%) 0 (0%) 1 (2.6%) 2 (5.1%) 0 (0%) 0 (0%)
P-value intra-group Ref 0.082 <0.001 <0.001 Ref 0.005 0.001 <0.001
P-value inter-group – – – – 0.78 0.36 0.15 0.020
Inspiration 0 4 (12.5%) 6 (18.8%) 11 (34.4%) 25 (78.1%) 6 (15.4%) 20 (51.3%) 24 (61.5%) 37 (94.9%)
exhalation 1 21 (65.6%) 20 (62.5%) 14 (43.8%) 4 (12.5%) 25 (64.1%) 14 (35.9%) 13 (33.3%) 2 (5.1%)
ratio 2 7 (21.9%) 6 (18.8%) 7 (21.9%) 3 (9.4%) 8 (20.5%) 5 (12.8%) 2 (5.1%) 0 (0%)
P-value intra-group Ref 0.77 0.066 <0.001 Ref 0.001 <0.001 0.017
P-value inter-group – – – – 0.77 0.008 0.006 0.034
Cardiac rates 0 18 (56.3%) 15 (46.9%) 21 (65.6%) 24 (75%) 18 (46.2%) 24 (61.5%) 31 (79.5%) 37 (94.9%)
1 10 (31.3%) 14 (43.8%) 11 (34.4%) 7 (21.9%) 10 (31.3%) 15 (38.5%) 8 (20.5%) 2 (5.1%)
2 4 (12.5%) 3 (9.4%) 0 (0%) 1 (3.1%) 4 (12.5%) 0 (0%) 0 (0%) 0 (0%)
P-value intra-group Ref 0.39 0.006 0.046 Ref 0.009 <0.001 0.053
P-value inter-group – – – – 0.59 0.13 0.19 0.018
Respiratory 0 22 (68.8%) 21 (65.6%) 23 (71.9%) 28 (87.5%) 28 (71.8%) 30 (76.9%) 32 (82.1%) 39 (100%)
rates 1 5 (15.6%) 6 (18.8%) 6 (18.8%) 3 (9.4%) 9 (23.1%) 8 (20.5%) 7 (17.9%) 0 (0%)
2 5 (15.6%) 5 (15.6%) 3 (9.4%) 1 (3.1%) 2 (5.1%) 1 (2.6%) 0 (0%) 0 (0%)
P-value intra-group Ref 0.91 0.51 0.11 Ref 0.57 0.001 n/a
P-value inter-group – – – – 0.60 0.20 0.24 0.033
Bronchiolitis No 0 (0%) 1 (3.1%) 1 (3.1%) 3 (9.4%) 0 (0%) 6 (15.4%) 10 (25.6%) 17 (43.6%)
severity Mild 10 (31.3%) 10 (31.3%) 16 (50%) 26 (81.3%) 19 (48.7%) 19 (48.7%) 20 (51.3%) 20 (51.3%)
Moderate 18 (56.3%) 19 (59.4%) 14 (43.8%) 2 (6.3%) 19 (48.7%) 14 (35.9%) 9 (23.1%) 2 (5.1%)
Severe 4 (12.5%) 2 (6.3%) 1 (3.1%) 1 (3.1%) 1 (2.6%) 0 (0%) 0 (0%) 0 (0%)
P-value intra-group Ref <0.001 0.026 0.041 Ref 0.006 0.036 0.001
P-value inter-group – – – – 0.27 0.002 0.001 0.001

n/a: not applicable

Data are n (%).
The level of confidence was 95% for all tests. In this case, all patients are in category 0.
9

aChi-square McNemar–Bowker’s test with initial time as reference category (ref).

bChi-square Kruskal’s Gamma coefficient with control group as reference category.
10
controlled trials and no clear clinical benefits were
observed.19–21
Several studies have evaluated other techniques
such as ‘passive exhalation’, which includes pas-
sive prolonged slow expiratory flow and forced
passive expiratory flow. Lanza et al.5 considered
prolonged slow expiration to be superior to con-
ventional physiotherapy techniques because it
deflates the lungs until they reach the expiratory
reserve volume and thus mobilizes secretions from
the distal areas of the lung. Younger babies had
higher exhaled volumes, probably because their
ribcages are more compliant.22
While not recommending chest physiotherapy
in patients with bronchiolitis, Cochrane 2015
recorded a clinical trial in which the prolonged
slow expiration technique combined with salbuta-
mol provided temporary relief and a decreased
need for oxygen in children with moderate bron-
chiolitis, although there was no long-term impact.11
Postiaux et al.23 also stated that the prolonged slow
expiration could be considered the technique of
choice to facilitate removal of the distal secretions
in patients with acute viral bronchiolitis.
On the other hand, Rochat et al.24 concluded that
the technique of passive expiratory flow accelera-
tion was not effective in hospitalized infants with
severe bronchiolitis, so did not recommend it
should be routinely prescribed. Likewise, there is
high-quality evidence that forced expiration tech-
niques in severe patients do not improve their
health and may lead to serious adverse effects
(vomiting, bradycardia, desaturation, transient res-
piratory destabilization).11
Therefore, the severity of the disease may be
limiting in the application of this respiratory physi-
otherapy technique and may be effective in chil-
dren with moderate bronchiolitis. Our study points
to the beneficial effects of slow flow techniques on
various respiratory parameters and on the ABSS.
Most of these patients were suffering from moder-
ate bronchiolitis. No adverse effects were detected
in these patients because they are likely to be able
to tolerate physiotherapy better as they have less
respiratory involvement.24,25
In the present study, respiratory physiotherapy
is complemented using retrograde rhinopharyngeal
Clinical Rehabilitation 00(0)
unclogging and hypertonic nebulization. The aim
of unclogging is to reduce nasal aspirations to pre-
vent swelling or bleeding of the mucosa of the
patient.17 When the effect of nebulized hypertonic
saline was assessed in patients with cystic fibrosis,
the following findings were made: improvement in
the muco-ciliary clearance, decreased mucosal
oedema, decreased concentration of inflammatory
mediators, induction of cough and sputum produc-
tion. The combination of physiotherapy with
hypertonic saline prior nebulization can be more
effective than either technique used separately,
especially if the secretions are thick.16,26
With patients of both groups suffering a similar
degree of severity, Table 3 shows that the improve-
ments observed in the experimental group were
greater than in the control at all the stages of devel-
opment measured in the study. Improvements in
the ABSS score are directly related to the parame-
ters on which conventional techniques may have
some effect such as wheezing or crackles, respira-
tory effort, the inspiration/exhalation ratio and
respiratory rates. In addition, conventional tech-
niques have no effect on bronchospasm or oedema,
both of which are associated with acute viral
bronchiolitis9,27 But in the case of oedema, nebu-
lized hypertonic saline is effective if used before
applying chest physiotherapy manoeuvres, enhanc-
ing the potential effect of bronchial drainage.
Oxygen therapy was administered according to
patients’ needs to maintain a target O2 saturation
(SPO2) above 94%, which would explain why
there was no difference between the groups.
National Collaborating Centre for Women’s and
Children’s Health28 criteria guideline (clinical sta-
bility, adequate intake of oral fluids and SPO2
above 92% with ambient air for at least 4 hours,
including a period of sleep) for patient discharge
were used. As these criteria may be influenced by
several variables (social, distance to the hospital in
case of worsening attacks, difficulties in under-
standing the language and self-confidence of car-
egivers in home care situations), it was considered
unacceptable to evaluate the effects of a technique
based on average stay of patients in hospital.28
Instead, the recovery time to drop below 2 points
on the paediatric assessment scale was chosen. No
Conesa-Segura et al.
adverse effect was observed during this study by
the physiotherapists and paediatric physicians
who evaluated the patients.
Limitations of the study include the limited
number of patients who could be evaluated and
treated because of the epidemic nature of the dis-
ease. In addition, the techniques of manual chest
physiotherapy may vary in strength, duration, tim-
ing and other aspects at the discretion of the physi-
otherapist, depending on the age and condition of
the patient. However, it is important to remark that
the sessions were performed by an experienced
therapist previously trained to optimize the appli-
cation of the technique and to seek the greatest
benefit with the minimum risk.
This study evaluated a single daily intervention
in patients, but it is possible that increasing the
number of interventions would improve the results
by reducing respiratory symptoms. Nevertheless,
the possible bias of clinical evaluation was reme-
died using a scale previously validated for the
severity of acute bronchiolitis.17
The most important clinical implication is that
although bronchiolitis is an acute pathology and
usually resolves in a few days, respiratory physio-
therapy intervention accelerates the recovery of
children and reduces the stay in intensive care units
without side-effects. The addition of a physiothera-
pist to the medical team may be cost-effective and
this aspect could be addressed in future studies
Clinical Messages
•• Respiratory physiotherapy reduces re-
covery times in children with acute bron-
chiolitis. Three quarters of the children
who received physiotherapy recovered in
three days compared to six days in the
group that did not receive it.
•• The prolonged slow expiration technique
is safe without adverse effects
Acknowledgements
The authors thank the staff of the Virgen Arrixaca
University Children’s Hospital and all participants and
their parents in the study and thank Professor Sonia de
Marco (Centro de Ciencias de la Salud San Rafael.
11
Universidad Antonio de Nebrija, Madrid, Spain) for
reviewing the manuscript and for her advices on how to
improve it.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship and/or publica-
tion of this article.
Funding
The author(s) received no financial support for the
research, authorship and/or publication of this article.
Trial registration
Clinical trial registration number: NCT02458300.
ORCID iD
José Ríos-Díaz https://orcid.org/0000-0002-4786
-3351
Supplemental Material
Supplemental material for this article is available online.
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