Safety and Impacts of Chest Physiotherapy During High-Frequency Oscillatory Ventilation: A Systematic Review and Meta-Analysis

About the Study

This study is the first systematic review and attempted meta-analysis to evaluate the role of chest physiotherapy (CPT) in intubated patients receiving high-frequency oscillatory ventilation (HFOV). While CPT is a standard adjunct in conventional mechanical ventilation, its use during HFOV is less documented due to concerns about safety, physiologic stability, and potential interference with oscillatory pressure delivery.

The review followed PRISMA 2020 guidelines, with a protocol based on a structured PICO framework. Searches were conducted across five major databases (PubMed, Scopus, Web of Science, CINAHL, Cochrane Library), screening over 2200 records. After rigorous screening, four studies were included:
• One adult ICU study (Ntoumenopoulos 2014): Directly evaluated CPT (manual assisted cough, postural drainage, suction, saline instillation) during HFOV. Results showed CPT was well tolerated, with no significant changes in oxygenation or hemodynamics, though transient decreases in oscillatory amplitude (ΔPaw) were observed.
• Three additional studies (Papazian 2005, Demory 2007, Brederlau 2006): Explored prone positioning as a physiotherapy-related intervention during HFOV, reporting improved oxygenation but mixed results compared with conventional ventilation.

Key findings:
• CPT during HFOV appears safe and does not cause major adverse physiologic effects.
• Evidence of clinical benefit is limited, as only one direct CPT study exists.
• Pediatric and neonatal evidence is lacking, despite HFOV being commonly used in these populations.
• Certainty of evidence was rated very low (GRADE) across all outcomes due to small sample sizes, heterogeneity, and indirectness.

Implications:
• Clinically, CPT can be considered feasible in HFOV with close ventilator monitoring, particularly for ΔPaw.
• Policymakers and ICU directors (e.g., in Israel and globally) should consider developing protocolized guidelines for CPT in HFOV settings.
• Research priorities include large multicenter trials, especially in neonatal and pediatric ICUs where HFOV is most often applied.