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The Cochrane Database of Systematic... Mar 2020Cystic fibrosis (CF) is the most common life-threatening, inherited disease in white populations which causes several dysfunctions, including postural abnormalities.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Cystic fibrosis (CF) is the most common life-threatening, inherited disease in white populations which causes several dysfunctions, including postural abnormalities. Physical therapy may help in some consequences of these postural abnormalities, such as pain, trunk deformity and quality of life.
OBJECTIVES
To determine the effects of a range of physical therapies for managing postural abnormalities in people with cystic fibrosis, specifically on quality of life, pain and trunk deformity.
SEARCH METHODS
We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches, hand-searched journals and conference abstract books. 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on ClinicalTrials.gov and on the WHO International Clinical Trials Registry Platform for any planned, ongoing and unpublished studies. Date of the last search: 19 March 2020.
SELECTION CRITERIA
Randomised controlled trials examining any modality of physical therapy considered relevant for treating postural disorders compared with each other, no physical therapy, sham treatment or usual care in people with CF (of any age or disease severity).
DATA COLLECTION AND ANALYSIS
Two review authors independently selected eligible trials, assessed the risk of bias in each trial and extracted the data. We contacted trial authors to obtain missing or additional information. We assessed the quality of the evidence using the GRADE criteria.
MAIN RESULTS
Two trials, involving a total of 50 participants with CF and postural abnormalities, were included in this review. One was in people with stable disease (lasting three months) and one in hospital inpatients experiencing an exacerbation (20 days). Both trials compared manual therapy comprising mobilizations to the rib cage and thoracic spine, treatment of specific muscle dysfunction or tight muscle groups; and postural awareness and education versus medical usual care. The age of participants ranged from 17 years to 58 years. Both trials were conducted in the UK. The following outcomes were measured: change in quality of life, change in pain, change in trunk deformity and change in pulmonary function. Manual therapy may make little or no difference to the change in trunk deformity compared to usual care (low-quality evidence). No results could be analysed for quality of life (very low-quality evidence) and pain outcomes (very low-quality evidence) because of the high heterogeneity between trials. It is uncertain whether the intervention improves lung function: forced vital capacity (very low-quality evidence); forced expiratory volume in one second (very low-quality evidence); or Tiffeneau's index (ratio of forced expiratory volume at one second (FEV) and forced vital capacity (FVC)). Only one trial (15 participants) measured functional capacity, and the change in walked distance seemed to favour intervention over usual care, but with the possibility of no effect due to wide confidence intervals. The same trial also reported that six participants in the intervention group had positive comments about the intervention and no adverse events were mentioned.
AUTHORS' CONCLUSIONS
Due to methodological limitations in the included trials, and in addition to the very low to low quality of the current evidence, there is limited evidence about the benefits of physical therapies on postural abnormalities in people with CF. Therefore, further well-conducted trials with robust methodologies are required considering a prior inclusion criterion to identify the participants who have postural abnormalities.
Topics: Cystic Fibrosis; Humans; Pain Management; Physical Therapy Modalities; Posture; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 32227599
DOI: 10.1002/14651858.CD013018.pub2 -
The Cochrane Database of Systematic... Mar 2020Breathing exercises have been widely used worldwide as a non-pharmacological therapy to treat people with asthma. Breathing exercises aim to control the symptoms of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Breathing exercises have been widely used worldwide as a non-pharmacological therapy to treat people with asthma. Breathing exercises aim to control the symptoms of asthma and can be performed as the Papworth Method, the Buteyko breathing technique, yogic breathing, deep diaphragmatic breathing or any other similar intervention that manipulates the breathing pattern. The training of breathing usually focuses on tidal and minute volume and encourages relaxation, exercise at home, the modification of breathing pattern, nasal breathing, holding of breath, lower rib cage and abdominal breathing.
OBJECTIVES
To evaluate the evidence for the efficacy of breathing exercises in the management of people with asthma.
SEARCH METHODS
To identify relevant studies we searched The Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL and AMED and performed handsearching of respiratory journals and meeting abstracts. We also consulted trials registers and reference lists of included articles. The most recent literature search was on 4 April 2019.
SELECTION CRITERIA
We included randomised controlled trials of breathing exercises in adults with asthma compared with a control group receiving asthma education or, alternatively, with no active control group.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed study quality and extracted data. We used Review Manager 5 software for data analysis based on the random-effects model. We expressed continuous outcomes as mean differences (MDs) with confidence intervals (CIs) of 95%. We assessed heterogeneity by inspecting the forest plots. We applied the Chi test, with a P value of 0.10 indicating statistical significance, and the I statistic, with a value greater than 50% representing a substantial level of heterogeneity. The primary outcome was quality of life.
MAIN RESULTS
We included nine new studies (1910 participants) in this update, resulting in a total of 22 studies involving 2880 participants in the review. Fourteen studies used Yoga as the intervention, four studies involved breathing retraining, one the Buteyko method, one the Buteyko method and pranayama, one the Papworth method and one deep diaphragmatic breathing. The studies were different from one another in terms of type of breathing exercise performed, number of participants enrolled, number of sessions completed, period of follow-up, outcomes reported and statistical presentation of data. Asthma severity in participants from the included studies ranged from mild to moderate, and the samples consisted solely of outpatients. Twenty studies compared breathing exercise with inactive control, and two with asthma education control groups. Meta-analysis was possible for the primary outcome quality of life and the secondary outcomes asthma symptoms, hyperventilation symptoms, and some lung function variables. Assessment of risk of bias was impaired by incomplete reporting of methodological aspects of most of the included studies. We did not include adverse effects as an outcome in the review. Breathing exercises versus inactive control For quality of life, measured by the Asthma Quality of Life Questionnaire (AQLQ), meta-analysis showed improvement favouring the breathing exercises group at three months (MD 0.42, 95% CI 0.17 to 0.68; 4 studies, 974 participants; moderate-certainty evidence), and at six months the OR was 1.34 for the proportion of people with at least 0.5 unit improvement in AQLQ, (95% CI 0.97 to 1.86; 1 study, 655 participants). For asthma symptoms, measured by the Asthma Control Questionnaire (ACQ), meta-analysis at up to three months was inconclusive, MD of -0.15 units (95% CI -2.32 to 2.02; 1 study, 115 participants; low-certainty evidence), and was similar over six months (MD -0.08 units, 95% CI -0.22 to 0.07; 1 study, 449 participants). For hyperventilation symptoms, measured by the Nijmegen Questionnaire (from four to six months), meta-analysis showed less symptoms with breathing exercises (MD -3.22, 95% CI -6.31 to -0.13; 2 studies, 118 participants; moderate-certainty evidence), but this was not shown at six months (MD 0.63, 95% CI -0.90 to 2.17; 2 studies, 521 participants). Meta-analyses for forced expiratory volume in 1 second (FEV1) measured at up to three months was inconclusive, MD -0.10 L, (95% CI -0.32 to 0.12; 4 studies, 252 participants; very low-certainty evidence). However, for FEV % of predicted, an improvement was observed in favour of the breathing exercise group (MD 6.88%, 95% CI 5.03 to 8.73; five studies, 618 participants). Breathing exercises versus asthma education For quality of life, one study measuring AQLQ was inconclusive up to three months (MD 0.04, 95% CI -0.26 to 0.34; 1 study, 183 participants). When assessed from four to six months, the results favoured breathing exercises (MD 0.38, 95% CI 0.08 to 0.68; 1 study, 183 participants). Hyperventilation symptoms measured by the Nijmegen Questionnaire were inconclusive up to three months (MD -1.24, 95% CI -3.23 to 0.75; 1 study, 183 participants), but favoured breathing exercises from four to six months (MD -3.16, 95% CI -5.35 to -0.97; 1 study, 183 participants).
AUTHORS' CONCLUSIONS
Breathing exercises may have some positive effects on quality of life, hyperventilation symptoms, and lung function. Due to some methodological differences among included studies and studies with poor methodology, the quality of evidence for the measured outcomes ranged from moderate to very low certainty according to GRADE criteria. In addition, further studies including full descriptions of treatment methods and outcome measurements are required.
Topics: Adult; Asthma; Breathing Exercises; Disease Progression; Health Education; Humans; Hyperventilation; Quality of Life; Randomized Controlled Trials as Topic; Respiratory Function Tests; Yoga
PubMed: 32212422
DOI: 10.1002/14651858.CD001277.pub4 -
JAMA Otolaryngology-- Head & Neck... Apr 2020Augmentation rhinoplasty requires adding cartilage to provide enhanced support to the structure of the nose. Autologous costal cartilage and irradiated homologous costal... (Comparative Study)
Comparative Study Meta-Analysis
IMPORTANCE
Augmentation rhinoplasty requires adding cartilage to provide enhanced support to the structure of the nose. Autologous costal cartilage and irradiated homologous costal cartilage (IHCC) are well-accepted rhinoplasty options. Tutoplast is another alternative cartilage source. No studies, to our knowledge, have definitively demonstrated a higher rate of complications with IHCC grafts compared with autologous costal cartilage grafts.
OBJECTIVE
To compare rates of outcomes in the published literature for patients undergoing septorhinoplasty with autologous costal cartilage vs IHCC grafts vs Tutoplast grafts.
DATA SOURCES
For this systematic review and meta-analysis, the MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched for articles published from database inception to February 2019 using the following keywords: septorhinoplasty, rhinoplasty, autologous costal cartilage graft, cadaveric cartilage graft, and rib graft.
STUDY SELECTION
Abstracts and full texts were reviewed in duplicate, and disagreements were resolved by consensus. Only patients who underwent an en bloc dorsal onlay graft were included for comparison to ensure a homogenous study sample. A total of 1308 results were found. After duplicate records were removed, 576 unique citations remained. Studies were published worldwide between January 1, 1990, and December 31, 2017.
DATA EXTRACTION AND SYNTHESIS
Independent extraction by 2 authors was performed. Data were pooled using a random-effects model.
MAIN OUTCOMES AND MEASURES
All reported outcomes after septorhinoplasty and rates of graft warping, resorption, infection, contour irregularity, and revision surgery among patients receiving autologous grafts vs IHCC vs Tutoplast cartilage grafts.
RESULTS
Of 576 unique citations, 54 studies were included in our systematic review; 28 studies were included after applying inclusion and exclusion criteria. Our search captured 1041 patients of whom 741 received autologous grafts and 293 received IHCC grafts (regardless of type). When autologous cartilage (n = 748) vs IHCC (n = 153) vs Tutoplast cartilage (n = 140) grafts were compared, no difference in warping (5%; 95% CI, 3%-9%), resorption (2%; 95% CI, 0%-2%), contour irregularity (1%; 95% CI, 0%-3%), infection (2%; 95% CI, 0%-4%), or revision surgery (5%; 95% CI, 2%-9%) was found.
CONCLUSIONS AND RELEVANCE
No difference was found in outcomes between autologous and homologous costal cartilage grafts, including rates of warping, resorption, infection, contour irregularity, or revisions, in patients undergoing dorsal augmentation rhinoplasty. En bloc dorsal onlay grafts are commonly used in augmentation rhinoplasty to provide contour and structure to the nasal dorsum.
Topics: Costal Cartilage; Humans; Postoperative Complications; Reoperation; Rhinoplasty; Transplantation, Autologous; Transplantation, Homologous; Treatment Outcome
PubMed: 32077916
DOI: 10.1001/jamaoto.2019.4787 -
The Cochrane Database of Systematic... Jul 2019Vertebral fractures are associated with increased morbidity (e.g. pain, reduced quality of life) and mortality. Therapeutic exercise is a non-pharmacological...
BACKGROUND
Vertebral fractures are associated with increased morbidity (e.g. pain, reduced quality of life) and mortality. Therapeutic exercise is a non-pharmacological conservative treatment that is often recommended for patients with vertebral fractures to reduce pain and restore functional movement. This is an update of a Cochrane Review first published in 2013.
OBJECTIVES
To assess the effects (benefits and harms) of exercise intervention of four weeks or greater (alone or as part of a physical therapy intervention) versus non-exercise/non-active physical therapy intervention, no intervention or placebo among adults with a history of vertebral fractures on incident fragility fractures of the hip, vertebra or other sites. Our secondary objectives were to evaluate the effects of exercise on the following outcomes: falls, pain, physical performance, health-related quality of life (disease-specific and generic), and adverse events.
SEARCH METHODS
We searched the following databases until November 2017: the Cochrane Library (Issue 11 of 12), MEDLINE (from 2005), Embase (from 1988), CINAHL (Cumulative Index to Nursing and Allied Health Literature, from 1982), AMED (from 1985), and PEDro (Physiotherapy Evidence Database, from 1929). Ongoing/recently completed trials were identified by searching the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. Conference proceedings were searched via ISI and SCOPUS, and targeted searches of proceedings of the American Congress of Rehabilitation Medicine and American Society for Bone and Mineral Research. Search terms or MeSH headings included terms such as vertebral fracture AND exercise OR physical therapy. For this update, the search results were limited from 2011 onward.
SELECTION CRITERIA
We included all randomized controlled trials and quasi-randomized trials comparing exercise or active physical therapy interventions with placebo/non-exercise/non-active physical therapy interventions or no intervention implemented in individuals with a history of vertebral fracture.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected trials and extracted data using a pre-tested data extraction form. Disagreements were resolved by consensus, or third-party adjudication. We used Cochrane's tool for assessing risk of bias to evaluate each study. Studies were grouped according to duration of follow-up (i.e. a) 4-12 weeks; b) 16-24 weeks; c) 52 weeks); a study could be represented in more than one group depending on the number of follow-up assessments. For dichotomous data, we reported risk ratios (RR) and corresponding 95% confidence intervals (95% CI). For continuous data, we reported mean differences (MD) of the change from baseline and 95% CI. Data were pooled for Timed Up and Go test, self-reported physical function measured by the QUALEFFO-41 physical function subscale score (scale of zero to 100; lower scores indicate better self-reported physical function), and disease-specific quality of life measured by the QUALEFFO-41 total score (scale of zero to 100; lower scores indicate better quality of life) at 12 weeks using a fixed-effect model.
MAIN RESULTS
Nine trials (n = 749, 68 male participants; two new trials in this review update) were included. Substantial variability across the trials prevented any meaningful pooling of data for most outcomes. Risk of bias across all studies was variable; low risk across most domains in four studies, and unclear/high risk in most domains for five studies. Performance bias and blinding of subjective outcome assessment were almost all high risk of bias.One trial reported no between-group difference in favor of the effect of exercise on incident fragility fractures after 52 weeks (RR 0.54, 95% CI 0.17 to 1.71; very low-quality evidence with control: 184 per 1000 and exercise: 100 per 1000, 95% CI 31 to 315; absolute difference: 8%, 95% CI 2 to 30). One trial reported no between-group difference in favor of the effect of exercise on incident falls after 52 weeks (RR 1.06, 95% CI 0.53 to 2.10; very low-quality evidence with control: 262 per 1000 and exercise: 277 per 1000; 95% CI 139 to 550; absolute difference: 2%, 95% CI -12 to 29). These findings should be interpreted with caution because of the very serious risk of bias in these studies and the small sample sizes resulting in imprecise estimates.We are uncertain that exercise could improve pain, self-reported physical function, and disease-specific quality of life, because certain studies showed no evidence of clinically important differences for these outcomes. Pooled analyses revealed a small between-group difference in favor of exercise for Timed Up and Go (MD -1.13 seconds, 95% CI -1.85 to -0.42; studies = 2), which did not change following a sensitivity analysis (MD -1.09 seconds, 95% CI -1.78 to -0.40; studies = 3; moderate-quality evidence). Exercise improved QUALEFFO-41 physical function score (MD -2.84 points, 95% CI -5.57 to -0.11; studies = 2; very low-quality evidence) and QUALEFFO-41 total score (MD -3.24 points, 95% CI -6.05 to -0.43; studies = 2; very low-quality evidence), yet it is unlikely that we observed any clinically important differences. Three trials reported four adverse events related to the exercise intervention (costal cartilage fracture, rib fracture, knee pain, irritation to tape, very low-quality evidence).
AUTHORS' CONCLUSIONS
In conclusion, we do not have sufficient evidence to determine the effects of exercise on incident fractures, falls or adverse events. Our updated review found moderate-quality evidence that exercise probably improves physical performance, specifically Timed Up and Go test, in individuals with vertebral fracture (downgraded due to study limitations). However, a one-second improvement in Timed Up and Go is not a clinically important improvement. Although individual trials did report benefits for some pain and disease-specific quality of life outcomes, the findings do not represent clinically meaningful improvements and should be interpreted with caution given the very low-quality evidence due to inconsistent findings, study limitations and imprecise estimates. The small number of trials and variability across trials limited our ability to pool outcomes or make conclusions. Evidence regarding the effects of exercise after vertebral fracture in men is scarce. A high-quality randomized trial is needed to inform safety and effectiveness of exercise to lower incidence of fracture and falls and to improve patient-centered outcomes (pain, function) for individuals with vertebral fractures (minimal sample size required is approximately 2500 untreated participants or 4400 participants if taking anti-osteoporosis therapy).
Topics: Exercise; Exercise Therapy; Humans; Osteoporotic Fractures; Postural Balance; Quality of Life; Randomized Controlled Trials as Topic; Spinal Fractures; Time and Motion Studies
PubMed: 31273764
DOI: 10.1002/14651858.CD008618.pub3 -
BMJ Open Apr 2019Multiple systematic reviews have reported on the impact of rib fracture fixation in the presence of flail chest and multiple rib fractures, however this practice remains...
OBJECTIVES
Multiple systematic reviews have reported on the impact of rib fracture fixation in the presence of flail chest and multiple rib fractures, however this practice remains controversial. Our aim is to synthesise the effectiveness of surgical rib fracture fixation as evidenced by systematic reviews.
DESIGN
A systematic search identified systematic reviews comparing effectiveness of rib fracture fixation with non-operative management of adults with flail chest or unifocal non-flail rib fractures. MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and Science Citation Index were last searched 17 March 2017. Risk of bias was assessed using the Risk Of Bias In Systematic reviews (ROBIS) tool. The primary outcome was duration of mechanical ventilation.
RESULTS
Twelve systematic reviews were included, consisting of 3 unique randomised controlled trials and 19 non-randomised studies. Length of mechanical ventilation was shorter in the fixation group compared with the non-operative group in flail chest; pooled estimates ranged from -4.52 days, 95% CI (-5.54 to -3.5) to -7.5 days, 95% CI (-9.9 to -5.5). Pneumonia, length of hospital and intensive care unit stay all showed a statistically significant improvement in favour of fixation for flail chest; however, all outcomes in favour of fixation had substantial heterogeneity. There was no statistically significant difference between groups in mortality. Two systematic reviews included one non-randomised studies of unifocal non-flail rib fracture population; due to limited evidence the benefits with surgery are uncertain.
CONCLUSIONS
Synthesis of the reviews has shown some potential improvement in patient outcomes with flail chest after fixation. For future review updates, meta-analysis for effectiveness may need to take into account indications and timing of surgery as a subgroup analysis to address clinical heterogeneity between primary studies. Further robust evidence is required before conclusions can be drawn of the effectiveness of surgical fixation for flail chest and in particular, unifocal non-flail rib fractures.
PROSPERO REGISTRATION NUMBER
CRD42016053494.
Topics: Adult; Flail Chest; Fracture Fixation, Internal; Humans; Length of Stay; Pneumonia; Randomized Controlled Trials as Topic; Respiration, Artificial; Rib Fractures; Systematic Reviews as Topic
PubMed: 30940753
DOI: 10.1136/bmjopen-2018-023444 -
Journal of Cardiothoracic Surgery Feb 2019Rib fractures are common injuries sustained by patients who experience high-impact chest trauma, and they result in severe respiratory compromise because of the altered... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Rib fractures are common injuries sustained by patients who experience high-impact chest trauma, and they result in severe respiratory compromise because of the altered mechanics of respiration. Several studies have shown that the ventilation requirements and incidence of pulmonary complications may be decreased with operative intervention. The purpose of this study was to evaluate the effect of surgical fixation treatments for rib fractures through systematic review and meta-analysis.
METHODS
A literature search was performed in the PubMed, EMBASE, Web of Science and Cochrane Library databases for information from February 1958 to April 2018. Studies comparing the benefits of surgical management with that of non-surgical management of rib fractures were included. Statistical heterogeneity was evaluated by the X test with the significance set to P < 0.10 or I > 50%.
RESULTS
Fourteen studies consisting of 839 patients were included (407 patients in the surgical management group; 432 patients in the non-surgical management group). The results showed that the surgical management group experienced a significant decrease in hospitalization time, intensive care time, mechanical ventilation time, mortality rate, pulmonary infection rate and tracheotomy rate compared with the non-surgical management group. However, the surgical management group incurred extra costs, and there was no significant difference in the duration of antibiotic use between the two groups.
CONCLUSIONS
Compared with non-surgical management, surgical management methods are of great value in the treatment of rib fractures despite the added expense.
Topics: Conservative Treatment; Female; Flail Chest; Fracture Fixation; Humans; Length of Stay; Male; Respiration, Artificial; Rib Fractures; Tracheostomy; Treatment Outcome
PubMed: 30813961
DOI: 10.1186/s13019-019-0865-3 -
Respiratory Care Nov 2018Chest wall motion is a vital component of the respiratory system. Body position changes disturb joint orientation around the chest wall and results in performance... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Chest wall motion is a vital component of the respiratory system. Body position changes disturb joint orientation around the chest wall and results in performance modifications of respiratory muscles and movement surrounding the rib cage and the abdomen. Body position is a priority treatment for preserving and promoting chest wall motion. The objective of the study was to conduct a meta-analysis to provide insight into which body position most effectively improves chest wall motion.
METHODS
Medical literature databases were systemically searched up to January 31, 2018. Methodological quality was evaluated by using a checklist for measuring quality. A meta-analysis was performed to evaluate the effects of body positions on chest wall motion. The quality of evidence was judged by using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.
RESULTS
Six studies (5 high- and 1 low-quality) were identified. Our results showed that the sitting position provided greater improvement in chest-wall diameter changes and volume related to rib-cage function versus other body positions (very low to moderate evidence). The supine position demonstrated greater enhancement of chest-wall-diameter changes and volume in the part of the abdomen than the other body positions with very low to moderate evidence.
CONCLUSIONS
The results of this review indicated that the sitting position improved the rib-cage compartment of the chest wall, whereas the supine position resulted in the superior enhancement in the part of the abdomen relative to other body positions. These changes in the body position could have some effect on the movements of the rib cage and abdomen and the variations in lung volumes, which need to be interpreted with caution when considering implementation in the clinical setting.
Topics: Healthy Volunteers; Humans; Movement; Posture; Thoracic Wall
PubMed: 30327334
DOI: 10.4187/respcare.06344 -
European Journal of Trauma and... Aug 2019The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled... (Meta-Analysis)
Meta-Analysis
PURPOSE
The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies.
METHODS
MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy.
RESULTS
Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies.
CONCLUSIONS
Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs.
Topics: Aged; Conservative Treatment; Critical Care; Female; Flail Chest; Fracture Fixation; Humans; Length of Stay; Male; Middle Aged; Observational Studies as Topic; Pneumonia; Randomized Controlled Trials as Topic; Respiration, Artificial; Rib Fractures; Tracheostomy
PubMed: 30276722
DOI: 10.1007/s00068-018-1020-x -
Clinical Orthopaedics and Related... Jan 2019Multiple rib fractures are common in trauma patients, who are prone to trauma-associated complications. Surgical or nonsurgical interventions for the aforementioned... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Multiple rib fractures are common in trauma patients, who are prone to trauma-associated complications. Surgical or nonsurgical interventions for the aforementioned conditions remain controversial.
QUESTIONS/PURPOSES
The purpose of our study was to perform a meta-analysis to evaluate the clinical prognosis of surgical fixation of multiple rib fractures in terms of (1) hospital-related endpoints (including duration of mechanical ventilation, ICU length of stay [LOS] and hospital LOS), (2) complications, (3) pulmonary function, and (4) pain scores.
METHODS
We screened PubMed, Embase, and Cochrane databases for randomized and prospective studies published before January 2018. Individual effect sizes were standardized; the pooled effect size was calculated using a random-effects model. Primary outcomes were duration of mechanical ventilation, intensive care unit length of stay (ICU LOS), and hospital LOS. Moreover, complications, pulmonary function, and pain were assessed.
RESULTS
The surgical group had a reduced duration of mechanical ventilation (weighted mean difference [WMD], -4.95 days; 95% confidence interval [CI], -7.97 to -1.94; p = 0.001), ICU LOS (WMD, -4.81 days; 95% CI, -6.22 to -3.39; p < 0.001), and hospital LOS (WMD, -8.26 days; 95% CI, -11.73 to -4.79; p < 0.001) compared with the nonsurgical group. Complications likewise were less common in the surgical group, including pneumonia (odds ratio [OR], 0.41; 95% CI, 0.27-0.64; p < 0.001), mortality (OR, 0.24; 95% CI, 0.07-0.87; p = 0.030), chest wall deformity (OR, 0.02; 95% CI. 0.00-0.12; p < 0.001), dyspnea (OR, 0.23; 95% CI, 0.09-0.54; p < 0.001), chest wall tightness (OR, 0.11; 95% CI, 0.05-0.22; p < 0.001) and incidence of tracheostomy (OR, 0.34; 95% CI, 0.20-0.57; p < 0.001). There were no differences between the surgical and nonsurgical groups in terms of pulmonary function, such as forced vital capacity (WMD, 6.81%; 95% CI: -8.86 to 22.48; p = 0.390) and pain scores (WMD, -11.41; 95% CI: -42.09 to 19.26; p = 0.470).
CONCLUSIONS
This meta-analysis lends stronger support to surgical fixation, rather than conservative treatment, for multiple rib fractures. Nevertheless, additional trials should be conducted to investigate surgical indications, timing, and followup for quality of life.
LEVEL OF EVIDENCE
Level I, therapeutic study.
Topics: Critical Care; Fracture Fixation; Fracture Healing; Fractures, Multiple; Humans; Length of Stay; Postoperative Complications; Respiration, Artificial; Rib Fractures; Risk Assessment; Risk Factors; Treatment Outcome
PubMed: 30247228
DOI: 10.1097/CORR.0000000000000495 -
Journal of Physiotherapy Oct 2018In intubated adult patients receiving mechanical ventilation, does multimodality respiratory physiotherapy prevent ventilator-associated pneumonia, shorten length of... (Meta-Analysis)
Meta-Analysis
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.
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 -0.33days 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].
Topics: Adult; Hospital Mortality; Humans; Intensive Care Units; Length of Stay; Physical Therapy Modalities; Pneumonia, Ventilator-Associated
PubMed: 30220625
DOI: 10.1016/j.jphys.2018.08.005