See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/261737040

The effects of a physiotherapy programme on patients with a pleural

effusion: A randomized controlled trial

Article  in  Clinical Rehabilitation · April 2014

DOI: 10.1177/0269215514530579 · Source: PubMed

CITATIONS READS

6 3,008

5 authors, including:

Gerald Valenza Marie Carmen Valenza

University of Granada University of Granada
48 PUBLICATIONS   178 CITATIONS    129 PUBLICATIONS   439 CITATIONS   

SEE PROFILE SEE PROFILE

Irene Cabrera-Martos Irene Torres Sánchez

University of Granada University of Granada
69 PUBLICATIONS   164 CITATIONS    62 PUBLICATIONS   130 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Psychological factors and cognitive impairment in COPD View project

All content following this page was uploaded by Marie Carmen Valenza on 06 July 2015.

The user has requested enhancement of the downloaded file.

 Clinical Rehabilitation
http://cre.sagepub.com/

The effects of a physiotherapy programme on patients with a pleural effusion: a randomized

controlled trial
G Valenza-Demet, MC Valenza, I Cabrera-Martos, I Torres-Sánchez and F Revelles-Moyano
Clin Rehabil published online 14 April 2014
DOI: 10.1177/0269215514530579

The online version of this article can be found at:

http://cre.sagepub.com/content/early/2014/04/11/0269215514530579

Published by:

http://www.sagepublications.com

Additional services and information for Clinical Rehabilitation can be found at:

Email Alerts: http://cre.sagepub.com/cgi/alerts

Subscriptions: http://cre.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

>> OnlineFirst Version of Record - Apr 14, 2014

What is This?

Downloaded from cre.sagepub.com at Biblioteca Universitaria de Granada on May 29, 2014

530579
research-article2014
CRE0010.1177/0269215514530579Clinical RehabilitationValenza et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

The effects of a physiotherapy 1­–9

© The Author(s) 2014
Reprints and permissions:
programme on patients with a sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0269215514530579

pleural effusion: a randomized cre.sagepub.com

controlled trial

G Valenza-Demet, MC Valenza, I Cabrera-Martos,

I Torres-Sánchez and F Revelles-Moyano

Abstract
Objective: To investigate the effects of a physiotherapy protocol on patients with pleural effusion.
Design: Randomized controlled trial.
Setting: University hospital.
Participants: A total of 104 consecutive inpatients with a medical diagnosis of pleural effusion.
Intervention: Patients were randomly allocated to a control group receiving standard treatment (medical
treatment and drainage) or an intervention group treated with physiotherapy added to standard treatment.
The physiotherapy programme included deep breathing exercises, mobilizations and incentive spirometry.
Main outcome measures: Spirometric predicted values and chest radiographs were measured before
treatment and at discharge and the length of hospital stay was recorded. Assessors were blinded to the
intervention.
Results: A comparative analysis showed a significant improvement of spirometric parameters in the
intervention group; pre-to-post hospitalization predicted values showed significant changes in vital capacity
(73.1 ± 12.6% to 72.13 ± 13.7 %, P<0.001 ), forced expiratory volume in first second (72.13 ± 13.7% to
78.98 ± 16.9%, P<0.001) and forced expiratory flow at 25-75 % (64.8 ± 35.1% to 76.78 ± 35.3%, P=0.198)
compared to the control group that showed no significant changes across treatment. The radiographic
findings showed better scores on the affected side of the thorax at discharge in the physiotherapy group.
Length of hospital stay was also significantly (P=0.014) shorter in the intervention group (26.7 ± 8.8 days)
compared to the control group (38.6 ± 10.7 days).
Conclusions: A physiotherapy programme added to standard treatment improves the spirometric
parameters and the radiological findings and reduces the hospital stay in patients with a pleural effusion.

Keywords
Pleural effusion, physiotherapy, length of stay, spirometry

Received: 18 July 2013; accepted: 16 March 2014

Physiotherapy Department, Faculty of Health Sciences, Corresponding author:

University of Granada, Spain Marie Carmen Valenza, Faculty of Health Sciences, Av de
Madrid SN, Granada, 18071, Spain.
Email: [email protected]

Downloaded from cre.sagepub.com at Biblioteca Universitaria de Granada on May 29, 2014

2 Clinical Rehabilitation 

Introduction breathing control exercises, postural exercises and

mobilizations, sputum clearance techniques and
Pleural effusion is an accumulation of fluid in the education.8 It is recommended and should be
pleural space. It is a common medical condition applied during the first weeks of treatment. But
caused by an underlying disease. It often causes while some authors9,10 propose treatment with res-
dyspnea, pleuritic chest pain, non-productive piratory physiotherapy, no definitive conclusions
cough and fever, although their clinical manifesta- could be drawn about the success of this treatment
tions largely depend on the underlying disease. relative to improvement in pleural effusion symp-
Regardless of its cause, it has significant effects on toms. To date, the most common approach is medi-
the respiratory system, aggravating the normal age- cal treatment combined with pleural fluid removal
related changes.1 by thoracentesis.3
In the management of pleural effusion, the aim is The complexity of diagnosis and treatment of
to provide symptomatic relief by removing the fluid pleural effusion makes it challenging to plan and
from the pleural space and to allow the treatment of deliver care. The aim of the present study was to
the underlying disease. Management options often investigate the effects of a respiratory physiother-
depend on the pathophysiology of pleural effusion, apy protocol added to standard treatment on
its evolutionary stage and the underlying condition. patients with pleural effusion.
The most common care priorities in pleural effusion
include, but are not limited to dyspnea, localized
pain, ineffective breathing pattern, activity intoler- Methods
ance and anxiety.2 A randomized controlled trial was conducted in the
A number of treatment strategies for the pleural University Hospital San Cecilio (Granada, Spain).
effusion are currently discussed. The most com- The study was carried out from February 2009 to
mon treatment used when the amount of fluid is March 2012. It received ethical approval from the
more than 100 ml is to drain the liquid and antibi- University of Granada Ethics Committee and was
otic treatment. The total resolution of the effusion registered in www.clinicaltrials.gov, reference
with this treatment has been reported to range NCT01756742.
between 18 and 91%.3 Fibrinolitic agents com- One hundred and four consecutive inpatients
bined with the drainage are shown to be effective to with pleural effusion were screened and invited to
prevent the infections and the residual pleural participate on the basis of the following inclusion
fibrosis and to improve the pulmonary function.4,5 criteria: be clinically diagnosed with pleural effu-
Additionally, pleurodesis for the treatment of sion. The diagnosis was based on the presence of
pleural effusion offers the most effective control of consistent radiological findings in posteroanterior
fluid recurrence. It has been reported to have an and lateral chest radiographs in addition to the
overall success rate around 60-70%.6 When clinical presentation (dyspnea, pleuritic chest
attempting to explain this wide range of success pain, non-productive cough and fever, depending
rates cited in the literature for pleurodesis, some on the underlying disease), to be aged between 18
points to mention are the eligibility criteria for and 80 years and to have a life expectancy higher
patient selection, the pleura design agent used, the than three months. Patients were excluded if they
methods and the definition of success. had visual impairments, severe cognitive impair-
Physiotherapy has been previously proposed as ment or comprehension deficits that prevented
a possible therapeutic approach added to other sur- them from following verbal commands, other
gical and non-surgical treatments.7 This is an concomitant neurological or cardiorrespiratory
important intervention that prevents and reduces disease and recent trauma or surgery in the tho-
the negative effects of prolonged bed rest during racic spine.
hospitalization and improves the respiratory func- Before being included in the study, patients
tion. Respiratory physiotherapy usually includes were informed about the purpose and the course of

Downloaded from cre.sagepub.com at Biblioteca Universitaria de Granada on May 29, 2014

Valenza et al. 3

Enrollment Assessed for eligibility (n= 112 )

Excluded (n= 8 )
Not meeting inclusion criteria (n= 6 )
Declined to participate (n= 0 )
Other reasons (n= 2 )

Randomized (n= 104 )

Assessments:

Rx, Pulmonary function test

Allocation
Allocated to PT Group (n= 52 ) Allocated to n-PT Group (n= 52 )
Received allocated intervention (n= 52 ) Received allocated intervention (n= 49 )
Did not complete the intervention (n= 3 )
Reason: decided not to continue (n=1)
Complications (n=2)

Assessments: Rx, Pulmonary function test

and analysis

Analysed (n= 52 ) Analysed (n= 49 )

Figure 1.  Flow diagram representing the recruitment, inclusion, assignment and subsequent follow-up of the study
patients.

the study, after which they gave their informed process. The randomization sequence was drawn
written consent to participate. up and kept off-site by an independent body, using
Patients were randomized to the intervention a random number generator in blocks of eight with
group (physical therapy added to standard treat- no stratification. The sequence of subjects included
ment) or to the control group (medical treatment in every treatment group was mailed from the inde-
and drainage). To ensure concealment of alloca- pendent body to the recruiter. The design of the
tion, eligibility was determined by a blinded asses- study and participants’ distribution between groups
sor (a nurse) not involved in the randomization is shown in Figure 1.11

Downloaded from cre.sagepub.com at Biblioteca Universitaria de Granada on May 29, 2014

4 Clinical Rehabilitation 

After the allocation, baseline measures were more than eight years of experience graded the
taken. All the data were collected by an independ- pleural effusion severity from 0 (no pleural effu-
ent researcher who was blinded to the allocation sion) to 10 (massive pleural effusion).
group of the patients.
The assessment included a complete clinical
Length of hospital stay
history review and a physical examination.
The outcome measures recorded were the Length of hospital stay (LOS) is defined as the
spirometry and the chest radiograph at baseline and number of days between hospital admission and
at discharge and the length of hospital stay. discharge. Over recent years, LOS has been shown
to be an outcome variable in several therapeutic
strategies and practical guidelines.19
Spirometry All the patients included in the study received
Spirometry was used to assess the severity of indi- standard treatment. This was based on medical
vidual patients’ respiratory disease and their treatment including management and clinical care,
response to therapy.12 It is regarded as the gold pharmacologist approach and drainage (if neces-
standard measure of respiratory function.13 A sary) during the hospital stay.
Medical International Research (MIR) Spirolab II Patients allocated in the intervention group
spirometer was used to collect data using Knudson received physiotherapy added to standard treat-
et al.14 predicted spirometric values as the normal ment. The physiotherapy programme started when
reference values. The following variables were the patient was considered clinically stable by the
recorded: 1) forced vital capacity (FVC), 2) forced medical doctor. A trained physiotherapist provided
expiratory volume achieved in the first second 40–60 minute sessions five times per week during
(FEV1), and 3) forced expiratory flow at 25 -75 % the hospital stay. The physiotherapy protocol was
(FEF25-75). These variables were calculated supervised and individually adapted, according to
according to the methods defined in the Medical the patient response to treatment. Patients were
International Research manual.15 monitored during the exercise performance in
order to detect increased pain, severe dyspnea,
desaturation and/or increased skin temperature at
Chest radiographs each session.
Posteroanterior and lateral chest radiographs The physiotherapy protocol included mobiliza-
were used to confirm the diagnosis at baseline tion techniques and exercises, deep breathing exer-
and as an outcome measure of severity. Lateral cises and incentive spirometry. The proposed
radiographs are able to identify a small amount of exercises have been reported to increase strength,
fluid. The diagnosis criteria was based on some flexibility, and range of motion.20,21
radiological findings including the following fea-
tures: on the lateral chest radiograph, pleural
Mobilization techniques and
effusions became visible as a meniscus at a vol-
ume of approximately 50 ml.16 At a volume of exercises
200 ml, the meniscus is also identified on the Limb exercises (i.e., passive, active assisted, or
posteroanterior radiograph and at a volume of active) were performed in bed or in a seated posi-
about 500 ml the hemidiaphragm appear to be tion, depending on medical advice, with the aim of
obscured. Other radiologic findings are blunting maintaining joint range of motion, improving soft-
of the costophrenic angle and in case of a large tissue length, muscle strength and function, and
volume of fluid a mediastinal shift could be decreasing the risk of thromboembolism. The deep
appreciated.17 breathing programme included pursed lips breath-
The severity was scored using a numeric scale ing, active expiration and incentive spirometry, as
as shown in previous studies.18 A radiologist with follows:

Downloaded from cre.sagepub.com at Biblioteca Universitaria de Granada on May 29, 2014

Valenza et al. 5

•• Pursed lips breathing: Pursed lips breathing was used to perform such comparisons with non-
works to improve expiration, requiring active parametric data. Differences between groups were
and prolonged expiration and to prevent airway analyzed with the independent t-test for parametric
collapse.22 It has been found to have a more data and the Mann-Whitney U-test for non-para-
marked increase of tidal volume and a decrease metric data. The alpha level was set at 0.05.
of breathing frequency.23
•• Active expiration: The active expiration length-
Results
ens the diaphragm and contributes to make it
operate close to its optimal length.24,25 In addi- A total of 112 patients who fulfilled the criteria
tion, active expiration increases elastic recoil for pleural effusion were included in the study.
pressure of the diaphragm and the rib cage.25 Finally, a total of 104 patients were enrolled and
•• Incentive spirometry: Incentive spirometry was randomly assigned to the intervention or to the
used as a lung expansion therapy, and it was control group. Figure 111 shows the recruitment,
administered supervised by a physiotherapist inclusion, assignment, and subsequent follow-up
during 10 to 15 minutes per day.26,27 The device of the patients.
used was the Coach spirometer (Kendall; Demographic and clinical data for the study
Neustadt, Germany) groups are shown in Table 1. No significant differ-
ences between-groups were found for any of the
The inpatients allocated to the control group did variables. Most participants had left side and exu-
not receive any physiotherapy. They received only date pleural effusion (Table 1).
the standard treatment. No significant differences were found between
Sample size calculation was based on the pri- the two groups for the dependant variables of
mary outcomes: spirometry results and radio- severity and the spirometric values at baseline.
graphic score. An increase in FVC and FEV1 (Table 1).
(-12±3.3 and -15±8.2) was expected in the control Table 2 shows the outcome measures (radio-
group, as previously reported28 and a greater posi- graphic pleural effusion score, spirometric values
tive effect (-3 in FVC and -5 in FEV1) was antici- and length of hospital stay) at baseline and at
pated in the intervention group. discharge.
Hence, in order to have 80% power using a two- The intervention group showed a significant
sided α=0.05 and a hypothetical dropout rate of pre-to-post hospital stay improvement (P<0.001)
10%, 48 patients in each group were required to in spirometric values (FVC and FEV1) and in
show statistically significant differences between radiographic severity. Student’s t-test showed a
both groups in FVC and FEV1. significant difference between groups in length of
Data were entered into Statistical Package for hospital stay, being shorter in the physiotherapy
the Social Sciences, version 20.0 (SPSS Inc., group.
Chicago, IL, USA) for analysis. Descriptive statis-
tics (mean ± standard deviation) were used to
Discussion
determine participant characteristics. Prior to sta-
tistical analysis, the Kolmogorov-Smirnov test was The objective of this study was to investigate the
performed to assess the normality of continuous effects of a respiratory physical therapy programme
data. The statistical distribution of the data was ini- added to standard treatment on spirometric param-
tially analyzed using the Shapiro Wilks test. The eters, chest radiographs and length of hospital stay
demographic data and initial assessment results in inpatients with a pleural effusion.
were compared using the Student’s t-test. The t-test Our results show greater improvement in all the
for paired samples was used to compare the results variables measured in the physiotherapy interven-
of the assessment before and after treatment for tion group. More specifically, this group improved
parametric data. The Wilcoxon signed rank test the pulmonary function, decreased the severity and

Downloaded from cre.sagepub.com at Biblioteca Universitaria de Granada on May 29, 2014

6 Clinical Rehabilitation 

Table 1.  Characteristics of the subjects included in the study.

Variables Intervention group Control group P-value

(n=52) (n=49)
Sex 15 (28.84) 19 (38.77) 0.072
n (%) males
Age (years) 56.4 ± 16.2 57.04 ± 17.0 0.683
mean ± SD
Weight (kg) 68.3 ± 13.03 67.6 ± 13.2 0.741
(mean ± SD)
Height (cm) 164 ± 22.14 166.8 ± 15.3 0.322
(mean ± SD)
BMI (kg/cm2) 25 ± 11.9 27.5 ± 18.3 0.567
(mean ± SD)
Effusion side, n (%): 0.188
Right side 19 (36.5) 16 (32.65)
Left side 28 (53.8) 29 (59.18)
Bilateral 5 (9.7) 4 (8.27)
Type of pleural effusion, n (%): 0.206
Malignancy 25 (48.07) 23 (46.93)
Parapneumonia 11 (21.15) 9 (18.36)
Tuberculosis 8 (15.38) 6 (12.24)
Other exudates 5 (9.61) 7 (14.28)
Transudates 3 (5.82) 4 (8.19)
Severity of pleural effusion 4.84 ± 1.73 4.79 ± 1.61 0.810
(mean ± SD)
Drainage n (%) 31 (59.62) 29 (59.18) 0.859
Spirometric values 0.667
(% predicted values)
(mean±SD):
FVC 73.1 ± 12.6 72.7 ± 13.1
FEV1 72.13 ± 13.7 72.5 ± 11.8
FEF 25-75% 64.8 ± 35.1 61.8 ± 30.2

FVC %: predicted forced vital capacity, FEV1%: predicted forced expiratory volume in first second, FEF25-75: forced expiratory flow
25%-75%, SD: standard deviation, BMI: body mass index, n: number of subjects allocated in a group.

the length of hospital stay was shorter compared effusion regardless of the etiology. In fact, various
with the control group. studies33,34 have suggested that patients with pleu-
Several studies have shown physical therapy to ral effusion should be included in a respiratory
be effective in the treatment of various respiratory physiotherapy programme as early as possible. Yet,
conditions.9,10,29,30 The general aim of a physiother- to our knowledge, no clinical trials focused on the
apy programme in critical areas is to apply effects of a physiotherapy programme in hospital-
advanced and cost-effective therapeutic modali- ized patients due to a pleural effusion are available
ties, decrease the dependence of patients, improve in the literature.
residual function, reduce the risk of new hospitali- One of the most important goals of physical ther-
zation and improve the quality of life.31 apy related to hospitalization due to respiratory
Physiotherapy has been proposed by some pathologies, even in highly compromised patients is
authors32-34 as part of the treatment of a pleural to enhance their functional capacity and to decrease

Downloaded from cre.sagepub.com at Biblioteca Universitaria de Granada on May 29, 2014

Valenza et al. 7

the risks associated with intensive care and bed

Between groups

FVC: forced vital capacity, FEV1: forced expiratory volume in first second, FEF25-75: forced expiratory flow 25%-75%, LOS: length of hospital stay, n: number of subjects allocated in a group, CI: confi-
rest.35 In order to that, we included mobilization
techniques and exercises to reduce the musculo-
P-value 
skeletal complications due to the bed rest, and res-

0.001
0.198
0.001
0.042

0.014
piratory exercises to improve respiratory function.

 
The standard treatment includes drainage of the
Within group

fluid accumulated in the pleural space. The aspira-

tion of pleural fluid is associated with increase in the
P-value

0.062
0.952
0.114
0.221
static lung volumes which were lower than the vol-

–
ume of fluid removed.23,35 This indicates that pleural
3.04 (–0.76, 6.80)
0.068 (–2.3, 2.2)
Mean difference

effusion cause a decrease in lung volume and chest

1.1(–2.3, 0.065)

1.94 (1.28, 2.6)

wall expansion.36 According to that, pulmonary
(95% CI)

function was included as a main outcome measure.

No previous study has demonstrated that physio-
–

therapy added to medical treatment and drainage

intervention

improve the spirometric values. These results might

73.6 ± 13.3
72.9 ± 12.6
58.7 ± 29.8
2.85 ± 1.39

38.6±10.7

be attributed to the effect of respiratory exercises on

Control group (n=49)

Post-

lung volume and chest wall expansion. The physical

therapy intervention also induces an intrathoracic
intervention

pressure generated in pursed lip breathing and in the

72.7 ± 13.1
72.5 ± 11.8
61.8 ± 30.2
4.79 ± 1.61

incentive spirometry that may help the drainage.23 It

was shown a significant improvement in the severity
Within group Pre-

of the pleural effusion based on chest radiographic

findings in the intervention group.
Another point to mention is related to the length
p<0.001
p<0.001
0.198
p<0.001
P-value

of hospital stay. Our study showed a reduced hos-

pital stay in the intervention group compared with
–
Table 2.  Outcome measures at baseline and after the intervention.

a control group. According to a number of studies,

73.1 ± 12.6 81.66 ± 13.7 8.9 (–11.4, –6.47)
72.13 ± 13.7 78.98 ± 16.9 6.77 (–9.6, –3.8)

2.78 ± 1.98 2.05 (1.35, 2.76)

64.8 ± 35.1 76.78 ± 35.3 14.8 (–39.3, 9.5)
Mean difference

the reported mean length of hospital stay of patients

with different pleural effusion etiologies ranges
intervention (95% CI)

from 17 to 37 days.37-39
Ferguson et al.37 analyzed 119 patients with
26.7 ± 8.8 –

purulent fluid; the mean time to discharge was 21

Intervention group (n=52)

days when the drainage tube or the aspiration inter-

vention was successful and 26 days when treatment
Post-

was unsuccessful. Alfageme et al.39 studied 82

patients with purulent or non-purulent fluid with a
intervention

4.84 ± 1.73

positive culture. The mean length of stay was 37

dence interval, SD: standard deviation.

days, but patients with nosocomial infections or a

Pre-

bronchopleural fistula required significantly longer

–

hospitalization. Interestingly, Ruiza et al.5 explained

X-ray severity of pleural

the differences between the length of hospital stay

(%predicted values)
Spirometric values

in the different studies. The first important point to

Clinical variables 

mention is the duration of the drainage and the sec-

efusión (0-10)
LOS (days)

ond is the underlying and associated diseases.

FEF25-75

Although no studies have assessed the influence

FEV1
FVC

of a physiotherapy intervention in length of stay,

Downloaded from cre.sagepub.com at Biblioteca Universitaria de Granada on May 29, 2014

8 Clinical Rehabilitation 

our results showed a positive effect of respiratory Funding

physiotherapy on fluid removal and respiratory This research received no specific grant from any fund-
function and consequently, the length of stay was ing agency in the public, commercial, or not-for-profit
reduced. sectors.
A number of factors limit the general applicabil-
ity of our study’s findings regarding the efficacy of References
physiotherapy in patients with a pleural effusion. 1. Chung J and Perrot MD. Pleural effusion and empyema
First, the diagnosis and evolution of pleural effu- thoracis. In: Bope ET, Rakel RE and Kellerman RD (eds)
sion was based on the presence of consistent radio- Conn’s Current Therapy. Philadelphia: Saunders Elsevier,
logical findings in posteroanterior and lateral chest 2010, pp. 263–265.
and decubitus lateral radiographs16,17 evaluated by 2. Light RW. Pleural effusions. Medical Clinics of North
America 2011; 95: 1055–1070.
a trained radiologist. However, previous research 3. Heffner JE. Indications for draining a parapneumonic
has shown this method to be accurate and reliable. effusion: an evidence-based approach. Semin Respir Infect
A second limitation of our study was the lack of 1999; 14: 48–58.
drainage duration and surgical procedures data. A 4. Robinson LA, Moulton AL, Fleming WH, Alonso A and
third limitation of the current study was the absence Galbraith TA. Intrapleural fibrinolytic treatment of multi-
loculated thoracic empyemas. Ann Thorac Surg 1994; 57:
of follow up after discharge. It is only reported the 803–814.
effectiveness pre to post intervention during the 5. Ruiza EM, Taloub MD, Álvareza JL and Ahijadoa CH.
hospital stay. Tratamiento con fibrinolisis intrapleural del empiema y el
In conclusion, this study shows that physio- derrame pleural complicado. Med Clin (Barc) 2003; 121:
therapy (deep breathing exercises, and mobili- 98–99.
6. Lee YCG, Baumann MH, Maskell NA, Whaterer GW,
zation techniques) combined with medical Eaton TE, Davies RJ, et al. Pleurodesis practice for malig-
treatment and drainage in inpatients with a pleu- nant pleural effusions in five English-speaking countries:
ral effusion was associated to a reduced length survey of pulmonologists. Chest 2003; 124: 2229–2238.
of hospital stay and a better recovery (i.e., radi- 7. Neragi-Miandoab S. Malignant pleural effusion, current
ological repercussions and pulmonary function). and evolving approaches for its diagnosis and manage-
ment. Lung cancer 2006; 54: 1–9.
These differences should be taken into account 8. Bott J, Blumenthal S, Buxton M, Ellum S, Falconer C,
because they are both significant and clinically Garrod R, et al. Guidelines for the physiotherapy man-
relevant. agement of the adult, medical, spontaneously breathing
patient. Thorax 2009; 64 (Suppl 1): i1-i51.
9. Britton S, Bejstedt M and Vedin L. Chest physiotherapy
in primary pneumonia. Br Med J (Clin Res Ed) 1985; 290:
Clinical messages 1703–1704.
10. Graham WG and Bradley DA. Efficacy of chest physiother-
• A physiotherapy treatment based on mobi- apy and intermittent positive-pressure breathing in the reso-
lizations, deep breathing exercises and lution of pneumonia. N Engl J Med 1978; 299: 624–627.
incentive spirometry, added to the stand- 11. Schulz KF, Altman DG and Moher D; CONSORT
ard treatment is feasible for patients with a Group. CONSORT 2010 Statement: updated guidelines
for reporting parallel group randomised trials. Int J Surg
pleural effusion, increasing the pulmonary 2011; 9: 672–677.
function and reducing the hospital stay. 12. American Thoracic Society. Standardization of spirom-
• There is an evidence of radiographic ben- etry. Am J Respir Crit Care Med 1995; 152: 1107–1136.
efit of treatment with physiotherapy in 13. Finkelstein SM, Lindgren B, Prasad B, Snyder M, Edin
patients with pleural effusion, decreasing C, Wielinski C, et al. Reliability and validity of spirom-
etry measurements in a paperless home monitoring diary
the severity of this condition. program for lung transplantation. Heart Lung 1993; 22:
523–533.
14. Knudson RJ, Lebowitz MD, Holberg CJ and Burrows B.
Changes in the normal maximal expiratory flow-volume
Conflict of interest curve with growth and aging. Am Rev Respir Dis 1983;
The authors declare that there is no conflict of interest. 127: 725–734.

Downloaded from cre.sagepub.com at Biblioteca Universitaria de Granada on May 29, 2014

 Valenza et al. 9

15. Medical International Research. Spirolab II: User’s on postoperative pulmonary complications: a systematic
Manual. Italy, 2001, p. 26. review. Chest. 2001;120: 971–978.
16. Kocijancic I. Diagnostic imaging of small amounts of 27. Pryor JA. Physiotherapy for airway clearance in adults.
pleural fluid: pleural effusion vs. physiologic pleural Eur Respir J 1999; 14: 1418–1424.
fluid. Coll Antropol 2007; 31: 1195–1199. 28. Wang JS and Tseng CH. Changes in pulmonary mechan-
17. Blackmore CC, Black WC, Dallas RV and Crow HC. ics and gas exchange after thoracentesis in patients with
Pleural fluid volume estimation: a chest radiograph pre- hemidiaphragm inversion secondary to large pleural effu-
diction rule. Acad Radiol 1996; 3: 103–109. sion. Chest 1995;107: 1610–1614.
18. Zimmer PW, Hill M, Casey K, Harvey E and Low DE. 29. Varela G, Ballesteros E, Jiménes MF, Novoa N and
Prospective randomized trial of talc slurry vs bleomycin in Aranda JL. Cost-effectiveness analysis of prophylactic
pleurodesis for symptomatic malignant pleural effusions. respiratory physiotherapy in pulmonary lobectomy. Eur J
Chest 1997; 112: 430–434. Cardiothorac Surg 2006; 29: 216–220.
19. Weingarten SR, Riedinger MS, Hobson P, Noah MS, 30. Samuels S. Physiotherapy for suppurative lung disease.
Johnson B, Giugliano G, et al. Evaluation of a pneumonia In: Southall D, Coulter B, Ronald C, Nicholson S and
practice guideline in an interventional trial. Am J Respir Parke S (eds). International Health Care: A practical
Crit Care Med 1996; 153: 1110–1115. manual for hospitals worldwide. London: BMJ Books,
20. Wallin D, Ekblom B, Grahn R and Nordenborg T. 2002, pp. 161–163.
Improvement of muscle flexibility: a comparison between 31. Stiller K. Physiotherapy in intensive care. Towards
two techniques. Am J Sports Med 1985; 13: 263–268 an evidence-based practice. Chest 2000; 118: 1801–1813.
21. DiNubile NA. Strength training. Clin Sports Med 1991; 32. Wing S. Pleural effusion: nursing care challenge in the
10: 33–62. elderly. Geriatr Nurs 2004; 25: 348–354.
22. Mueller RE, Petty TL and Filley GF. Ventilation and arte- 33. Ferrer J. Pleural tuberculosis. Eur Resp J 1997; 10:
rial blood gas changes induced by pursed lips breathing. J 942–947.
Appl Physiol 1970; 28: 784–789. 34. Katariya K and Thurer RJ. Surgical management of empy-
23. Van der Schans CP, De Jong W, Kort E, Wijkstra PJ, ema. Clin Chest Med 1998; 19: 395–406.
Koeter GH, Postma DS, et al. Mouth pressures during 35. Topp R, Ditmyer M, King K, Doherti K and Hornyak J.
pursed lip breathing. Physiotherapy Theory & Practice The effect of bed rest and potential of rehabilitation on
1995; 11: 29–34. patients in the Intensive Care Unit. AACN Clin Issues
24. Gorman RB, McKenzie DK, Pride NB, Tolman JF and 2002; 13: 263–276.
Gandevia SC. Diaphragm length during tidal breath- 36. Mitrouska I, Klimathianaki M and Siafakas NM. Effects
ing in patients with chronic obstructive pulmonary of pleural effusion on respiratory function. Can Respir J.
disease. Am J Respir Crit Care Med 2002; 166: 1461– 2004; 11: 499–503
1469. 37. Ferguson AD, Prescott RJ, Selkon JB, Watson D and
25. Kleinman BS, Frey K, VanDrunen M, Sheikh T, DiPinto Swinburn CR. The clinical course and management of
D, Mason R, et al. Motion of the diaphragm in patients thoracic empyema. QJM 1996; 89: 285–289.
with chronic obstructive pulmonary disease while spon- 38. Lindstrom ST and Kolbe J. Community-acquired par-
taneously breathing versus during positive pressure apneumonic thoracic empyema: Predictors of outcome.
breathing after anesthesia and neuromuscular blockade. Respirology 1999; 4: 173–179.
Anesthesiology 2002; 97: 298–305. 39. Alfageme I, Muñoz F, Peña N and Umbría S. Empyema of
26. Overend TJ, Anderson CM, Lucy SD, Bhatia C, Jonsson the thorax in adults: etiology, microbiologic findings and
BI and Timmermans C. The effect of incentive spirometry management. Chest 1993; 103: 839–843.

Downloaded from cre.sagepub.com at Biblioteca Universitaria de Granada on May 29, 2014

View publication stats