Postural drainage in infants and young children with cystic fibrosis

Review question

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 (includes head-down tilt) with modified postural drainage (includes horizontal positions and head-up tilt). This is an update of a previously published review.

Background

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. However, there is a risk of gastroesophageal reflux (the return of stomach contents back up into the oesophagus (throat area)) associated with this technique.

Search date

The evidence is current to: 19 June 2017.

Study characteristics

The review included two studies concerning 40 children with cystic fibrosis up to six years of age. One included study used a 20° head-down tilt and head-up tilt of 20 degrees and the other used modified postural drainage (30° head-up tilt) compared to standard postural drainage (using a 30° 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 was funded by the Sydney Children’s Hospital Foundation and the other by the Royal Children’s Hospital Research Foundation and Physiotherapy Research Foundation of Australia.

Key results

One included study using a 20° head-down tilt and 20° 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 (30° head-up tilt) was associated with fewer number of reflux episodes and fewer respiratory complications than standard postural drainage (using a 30° 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. However, the use of a 30° head-up tilt seems to result in fewer reflux episodes and respiratory complications than a 30° 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. We do not envisage that there will be any new trials undertaken that will affect the conclusions of this review; therefore, we do not plan to update this review.

Quality of the evidence

Both studies were of moderate (so we think further research could have an important impact on the results) quality and appeared to be well run and we do not think any factors will influence the results in a negative way.

Authors' conclusions: 

The limited 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 20° head-down postural drainage position was not found to be significantly different from the 20° 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. We do not envisage that there will be any new trials undertaken that will affect the conclusions of this review; therefore, we do not plan to update this review.

Read the full abstract...
Background: 

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.

This is an update of a review published in 2015.

Objectives: 

To compare the effects of standard postural drainage (15º to 45º head-down tilt) with modified postural drainage (15º to 30º 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.

Search strategy: 

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: 19 June 2017.

Selection criteria: 

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.

Data collection and analysis: 

We used standard methodological procedures expected by Cochrane. Two review authors independently identified studies for inclusion, extracted outcome data and assessed risk of bias. We resolved disagreements by consensus or by involving a third review author. We contacted study authors to obtain missing or additional information. The quality of the evidence was assessed using GRADE.

Main results: 

Two studies, involving a total of 40 participants, were eligible for inclusion in the review. We included no new studies in the 2018 update. The included 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 in this study reached the upper oesophagus (moderate-quality evidence). The second included study reported that modified postural drainage (30° head-up tilt) was associated with fewer number of gastroesophageal reflux episodes and fewer respiratory complications than standard postural drainage (30° head-down tilt) (moderate-quality evidence). The included studies had an overall low risk of bias. One included study was funded by the Sydney Children’s Hospital Foundation and the other by the Royal Children’s Hospital Research Foundation and Physiotherapy Research Foundation of Australia. Data were not able to be pooled by meta-analysis due to differences in the statistical presentation of the data.

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