We reviewed the evidence about how different postural drainage positions affect gastroesophageal reflux in infants and young children up to six years old with cystic fibrosis. We compared standard postural drainage (greater (30° to 45° head-down tilt) and lesser (15° to 20° head-down tilt)) with modified postural drainage (greater (30º head-up tilt) or lesser (15º to 20º head-up tilt)).
Although cystic fibrosis is a disorder that affects many organs, pulmonary disease is the most common cause of illness and death. Chest physiotherapy is recommended to clear the airways and improve lung function. Postural drainage is a type of chest physiotherapy used to treat children with cystic fibrosis. There are two different techniques: standard postural drainage (which includes a lesser and greater head-down tilt of 15° to 20° and 30° to 45°, respectively); and modified postural drainage (which includes lesser and greater head-up tilt of 15º to 20º and 30º, respectively). However, there is a risk of gastroesophageal reflux (the return of stomach contents back up into the oesophagus (throat area)) associated with this technique. Given that children with cystic fibrosis are more likely to suffer from gastroesophageal reflux than healthy children, it is important to find out which of the two techniques is the best and most safe for people with cystic fibrosis.
The evidence is current to: 20 January 2015.
The review included two studies with 40 children with cystic fibrosis up to six years of age. One included study used a 20º head-down tilt and head-up tilt and the other used modified postural drainage (30º head-up tilt) compared to standard postural drainage (using a 30º head-down tilt). Children were randomly selected for one treatment or the other. One study was carried out over a 24-hour period and the second over two days, but with a five-year follow-up period. The age range of the participants varied from three weeks to 34 months.
One included study using a 20º head-down tilt and head-up tilt did not find differences regarding the number of gastroesophageal reflux episodes between the two postural drainage regimens whereas the other study found that modified postural drainage (30º head-up tilt) was associated with fewer number of reflux episodes and fewer respiratory complications than standard postural drainage (using a 30º head-down tilt) in infants with cystic fibrosis. The age of participants, angle of tilt, reported outcomes, number of sessions and study duration differed between the two studies. The evidence provided by this review is weak; however, the use of a 30º head-up tilt seems to result in fewer reflux episodes and respiratory complications than a 30º head-down tilt position. Even though one study did not find differences between two techniques, in most of the reflux episodes stomach contents reached the upper oesophagus with a potential for choking. This should make physiotherapists carefully consider their choice of technique.
Quality of the evidence
Both studies appeared to be well run and we do not think any factors will influence the results in a negative way.
The available evidence regarding the comparison between the two regimens of postural drainage is still weak due to the small number of included studies, the small number of participants assessed, the inability to perform any meta-analyses and some methodological issues with the studies. However, it may be inferred that the use of a postural regimen with a 30° head-up tilt is associated with a lower number of gastroesophageal reflux episodes and fewer respiratory complications in the long term. The 20º head-down postural drainage position was not found to be significantly different from the 20º head-up tilt modified position. Nevertheless, the fact that the majority of reflux episodes reached the upper oesophagus should make physiotherapists carefully consider their treatment strategy.
Postural drainage is used primarily in infants with cystic fibrosis from diagnosis up to the moment when they are mature enough to actively participate in self-administered treatments. However, there is a risk of gastroesophageal reflux associated with this technique.
To compare the effects of standard postural drainage (greater (30° to 45° head-down tilt) and lesser (15° to 20° head-down tilt)) with modified postural drainage (greater (30º head-up tilt) or lesser (15º to 20º head-up tilt)) with regard to gastroesophageal reflux in infants and young children up to six years old with cystic fibrosis in terms of safety and efficacy.
We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register. We also searched the reference lists of relevant articles and reviews. Additional searches were conducted on ClinicalTrials.gov and on the WHO International Clinical Trials Registry Platform for any planned, ongoing and unpublished studies.
The date of the most recent literature searches: 20 January 2015.
We included randomised controlled studies that compared two postural drainage regimens (standard and modified postural drainage) with regard to gastroesophageal reflux in infants and young children (up to and including six years old) with cystic fibrosis.
Two review authors independently selected the studies to be included in the review, assessed their risk of bias and extracted data.
Two studies, including 40 participants, were eligible for inclusion in the review. The studies were different in terms of the age of participants, the angle of tilt, the reported outcomes, the number of sessions and the study duration. The following outcomes were measured: appearance or exacerbation of gastroesophageal reflux episodes; percentage of peripheral oxygen saturation; number of exacerbations of upper respiratory tract symptoms; number of days on antibiotics for acute exacerbations; chest X-ray scores; and pulmonary function tests. One study reported that postural drainage with a 20° head-down position did not appear to exacerbate gastroesophageal reflux. However, the majority of the reflux episodes reached the upper oesophagus. The second included study reported that modified postural drainage (30º head-up tilt) was associated with fewer number of gastroesophageal reflux episodes and fewer respiratory complications than standard postural drainage (30º head-down tilt). The included studies had an overall low risk of bias. Data were not able to be pooled by meta-analysis due to differences in the statistical presentation of the data.