Physiotherapy 122 (2024) 57–67

Development of a clinical practice guideline for

physiotherapy management of adults invasively ]] ]]
]]]]]]
ventilated with community-acquired pneumonia
Lisa van der Lee a,b,d,e, ,1,2, Shane Patman a,3, Anne-Marie Hill c,4,5
⁎

a
The University of Notre Dame Australia, School of Health Sciences and Physiotherapy, 19 Mouat Street (PO Box 1225), Fremantle, WA 6959, Australia
b
Fiona Stanley Hospital, Physiotherapy Department, Locked Bag 100, Palmyra DC, WA 6961, Australia
c
The University of Western Australia, School of Allied Health, Western Australia Centre for Health & Ageing, 35 Stirling Highway, Crawley, WA 6000,
Australia
d
Curtin University, School of Allied Health, 208 Kent St, Bentley, WA 6102, Australia
e
Sir Charles Gairdner Hospital, Physiotherapy Department, Hospital Avenue, Nedlands WA 6009, Australia

Abstract
Background and setting Patients hospitalised with community-acquired pneumonia (CAP) are frequently admitted to an intensive care
unit (ICU) for invasive mechanical ventilation and receive treatment by physiotherapists. However, clinical physiotherapy practice is
variable for this ICU cohort.
Objectives To develop a clinical practice guideline for physiotherapy management of adults invasively ventilated with CAP using the best
available evidence.
Methods Guideline development using evidence synthesis according to the GRADE and JBI approaches, incorporating findings from four
preceding phases of a mixed-methods research program: systematic review and meta-analysis, national survey of Australian ICU phy­
siotherapy practice, e-Delphi study to determine expert consensus, and multidisciplinary peer-review of the expert consensus statements by
senior ICU clinicians to determine validity and applicability of the statements for translation into practice.
Results The guideline comprises 26 recommendations, encompassing physiotherapy assessment, patient selection and prioritisation, and
treatment. Physiotherapy treatment covers domains of humidification, patient positioning, hyperinflation techniques, manual chest wall
techniques, normal saline instillation, active treatment, and mobilisation. Recommendations are rated as strong or conditional based on JBI
criteria, and certainty of evidence according to GRADE. Considerations for practice are provided within the guideline to enhance clarity and
practicality, particularly for conditional recommendations where evidence is limited or conflicting.
Conclusion This guideline, based on the best available evidence for clinical physiotherapy practice for adults invasively ventilated with
CAP, is intended to support clinicians with clinical decision making. Further research is required to evaluate guideline implementation into
clinical practice, and incorporate the values and preferences of ICU patients and their families.
Contribution of paper
• This world first clinical practice guideline was developed based on the best available evidence for physiotherapy management of adults
invasively ventilated with non-COVID-19 community-acquired pneumonia.
• The evidence-based guideline provides 26 recommendations across nine domains of physiotherapy assessment and treatment, to guide
best practice for this common ICU cohort.
© 2023 The Author(s). Published by Elsevier Ltd on behalf of Chartered Society of Physiotherapy. This is an open access article under the
CC BY license (http://creativecommons.org/licenses/by/4.0/).

⁎
Corresponding author at: Fiona Stanley Hospital, Physiotherapy Department, Locked Bag 100, Palmyra DC, WA 6961, Australia.
E-mail address: [email protected] (L. van der Lee).
1
ORCID:https://orcid.org/0000-0001-5527-1391
2
@lisa_vanderlee
3
ORCID:https://orcid.org/0000-0002-7476-1692
4
ORCID https://orcid.org/0000-0003-1411-6752
5
@amhill_physio

https://doi.org/10.1016/j.physio.2023.12.003
0031-9406/© 2023 The Author(s). Published by Elsevier Ltd on behalf of Chartered Society of Physiotherapy. This is an open access article under the CC BY
license (http://creativecommons.org/licenses/by/4.0/).
58 L.van der Lee et al. / Physiotherapy 122 (2024) 57–67

Keywords: Guideline; Pneumonia; Physical Therapy; Intensive Care

Introduction consensus to obtain and synthesise the evidence, which was

further developed into a clinical practice guideline using
Background guideline methodology from the Joanna Briggs Institute
(JBI) [18,19] and Grading of Recommendations Assess­
Community acquired pneumonia (CAP), was the fourth ment Development and Evaluation (GRADE) ap­
leading cause of death world-wide pre-pandemic in 2019 proach [20].
[1,2], with 1.23 million deaths in people aged over 70 years,
and over 1.6 million aged over 50 years [1]. This is sig­
nificant in the context of a global ageing population, with Objective and target audience
population aged over 60 years expected to double to 2.1
billion by 2050 [3]. In England, CAP due to Streptococcus This clinical practice guideline aims to provide clinically
pneumoniae is the most common respiratory cause of hos­ relevant and practical contemporary clinical guidance,
pitalisation, recently estimated at approximately £731 mil­ based on the best available evidence, to support phy­
lion per annum [4], with admissions requiring critical care siotherapists and other health care professionals working in
costing an additional £8000 [4]. In Australia, the estimated ICU with this patient population. This guideline may also
cost of CAP requiring hospitalisation is over AUD$ 55 be a useful tool to assist clinical training of physiotherapists
million, with ICU care also being very expensive at AUD $ new to ICU and in conceptualising future research.
4875 per stay-day [5]. These figures highlight the sig­
nificant global economic burden of CAP requiring ICU
care. Physiotherapists working in the ICU provide re­ Methods
spiratory treatments for patients who are intubated and
mechanically ventilated with acute respiratory illness, such Target population and scope
as CAP, as part of usual care [6–9]. The aims of these in­
terventions are to improve secretion clearance and re­ The scope of this clinical practice guideline, developed
spiratory mechanics and facilitate weaning from pre-pandemic, includes adult patients with CAP requiring
mechanical ventilation and restoration of functional in­ invasive mechanical ventilation in a Level 2 or 3 ICU [21].
dependence [6,8,10–12]. There has been limited evidence Patients whose condition progresses to the development of
available to guide respiratory physiotherapy treatment of moderate to severe Adult Respiratory Distress Syndrome
mechanically ventilated patients with specific respiratory (ARDS), as defined according to the Berlin Definition [22],
conditions, such as CAP. Furthermore, clinical practice of are outside the scope of this guideline, as the pathophy­
respiratory physiotherapy intervention for these patients siology is different, and clinical management requires a
admitted to ICU is variable [6,7,9,13]. This inconsistency in different approach. Pneumonia resulting from COVID-19
clinical practice has the potential to result in unfavourable requires special considerations and guidance due to specific
outcomes for some patients [9]. pathogenesis and high virus transmissibility. Therefore,
Clinical practice guidelines have been developed in physiotherapy for pneumonia due to COVID-19 is also
multiple areas of health care, to present a detailed synthesis outside of the scope of this guideline. This topic has been
of the best available evidence to clinicians to optimise pa­ specifically addressed elsewhere [23].
tient outcomes through reduction of unwanted variation in
clinical practice [14,15]. However, current clinical practice
guidelines for the management of CAP are medical, fo­ Guideline development process
cussed primarily on antibiotic therapy, and are silent on the
role of physiotherapy [16,17]. Development of a guideline This guideline was developed by further synthesising the
for the physiotherapy management of pneumonia, which findings of the previous four research phases, published
incorporates a multidisciplinary perspective, is important to elsewhere [7,8,12,24,25]. This synthesised evidence was
enhance evidence-based collaborative, interprofessional, used in the guideline development to formulate and grade
patient-centred care. each guideline recommendation. The level of certainty of
Therefore, to address this gap we conducted a program the evidence according to the GRADE approach was de­
of research to identify the best available evidence for termined by assessment of inconsistency, indirectness, im­
physiotherapy for CAP in ICU requiring invasive me­ precision, and risk of bias of the included studies [20,26]. A
chanical ventilation. Since there was limited clinical trials summary of the phases of the research is presented in
and no reviews, we conducted a systematic review and Fig. 1. Each phase of research and steps undertaken to
combined this with locally validated international expert develop the guideline are outlined below.
 L.van der Lee et al. / Physiotherapy 122 (2024) 57–67 59

Fig. 1. Guideline development methods.

Phase 1 treatment (MD 5.40 ml/cmH2O; 95% CI: 2.37, 8.43) and
following a 20–30 minutes delay (MD 6.86 ml/cmH2O;
A systematic review of the literature and meta-analysis 95% CI: 2.86, 10.86) in adults who are invasively ventilated
[12] was undertaken according to Cochrane methodology with pneumonia [12]. However, the certainty of this evi­
[27] to synthesise the best available evidence. The review dence according to GRADE was very low, due to small
indicated that short-term positive benefits favouring treat­ sample sizes and some subject groups being comprised of
ment involving an increase in tidal volume exists for phy­ mixed diagnoses other than pneumonia. Lack of standar­
siological outcomes of sputum clearance (MD 1.97 g; 95% disation of interventions and outcome measures used pre­
CI: 0.80, 3.14) and lung compliance, both immediately after cluded some studies from inclusion in meta-analysis. There
60 L.van der Lee et al. / Physiotherapy 122 (2024) 57–67

was no evidence available regarding whether a treatment techniques, and patient safety for head down tilt posi­
benefit exists for long-term, patient centred outcomes, such tioning. These statements required three rounds to achieve
as length of stay, functional recovery, quality of life or consensus.
mortality [12].
Phase 4
Phase 2
Multidisciplinary clinical validation of the expert con­
A national survey of Australian ICU physiotherapists sensus statements was established through qualitative re­
(n = 75) from 73 hospitals regarding current clinical prac­ search with multidisciplinary ICU clinicians (n = 26) to
tice was conducted [7,24]. Results indicated that substantial determine clinical applicability of expert consensus state­
variability in clinical practice regarding treatment mode and ments for clinical practice, and to explore clinician stake­
dosage exists for adults intubated and mechanically venti­ holder values and preferences to aid translation [25].
lated with CAP in Australian ICUs. Results indicated that Clinicians concurred that the consensus statements were
senior ICU physiotherapists believe there is a strong ratio­ relevant and provided valuable guidance for practice. Nine
nale for delivery of respiratory physiotherapy in this patient of the statements (24%) were deemed to require modifica­
cohort, with hyperinflation techniques, positioning and tion to enhance clinical utility. Clinicians indicated that
manual chest wall techniques commonly employed. A patient safety, teamwork and communication, and the in­
treatment duration between 16–30 minutes was reported by fluences of culture on local practice were important factors
70% of respondents, with longer treatment times reported which could influence clinical application of the statements.
by those who worked in ICUs with greater staffing levels Head down tilt positioning was again identified as a con­
available over the 24-hour period (p = 0.03). Respondents flicting area of practice, influenced by local culture, with
reported that frequency of treatment was usually once practicality and safety concerns raised.
(44%) or twice (44%) daily. Staffing levels were found to
impact on reported duration and frequency of treatment, and Phase 5
in addition patients were more likely to receive more fre­
quent treatment when there was a beneficial response, the The guideline development process consisted of: (i)
patient was medically stable, or sputum volume was in­ modification of the expert consensus statements according
creased [7]. Furthermore, patients invasively ventilated to clinician stakeholder feedback, (ii) synthesis of the best
with CAP were more likely to receive two or more treat­ available evidence from the systematic review, and (iii)
ments a day when an after-hours physiotherapy service was rating the statements according to the JBI approach of
reported to be available (p = 0.018), however, an after-hours evidence-based healthcare and evidence implementation
physiotherapy service was reported to be available by less [18,19], based on principles of: best available current evi­
than half of participants (49%) [24]. dence; the health care context; individual patient context;
and professional judgement and expertise of the healthcare
Phase 3 professional, to inform the considerations of feasibility,
appropriateness, meaningfulness and effectiveness of the
Due to the large variability in clinical practice found in intervention [19] to determine the strength and wording of
Phase 2 an e-Delphi technique, with an a priori consensus the recommendations. Each guideline recommendation was
threshold of 70%, was conducted to determine international then evaluated for certainty of the best available evidence
consensus by clinical and academic experts in ICU phy­ according to GRADE [20,26]. Where more than one level
siotherapy (n = 29) from eight countries [8]. The outcome of corroborating evidence is available to strengthen a re­
of this study was the development of 38 expert consensus commendation, each level of evidence is listed separately,
statements covering the seven domains of physiotherapy and references are provided [18,19].
assessment, patient selection and prioritisation, patient po­
sitioning, hyperinflation techniques, manual chest wall Grading of recommendations
techniques, normal saline instillation and active treatment
and mobilisation. Twenty-eight statements (74%) provided The JBI Grades of Recommendations criteria in­
consensus on recommended clinical practice, two state­ corporate the “FAME” framework [19] for consideration of
ments (7%) provided consensus disagreement for what the factors “feasibility”, “appropriateness”, “mean­
practice is not recommended, and eight statements (21%) ingfulness” and “effectiveness”, to guide the wording of
indicated which treatments may be beneficial. Statements recommendations. Considerations for practice were pro­
regarding use of manual chest wall techniques, such as vided within the guideline to enhance clarity and practi­
chest wall vibrations and percussion, and head down tilt cality, particularly for conditional recommendations where
positioning were identified as controversial areas of prac­ evidence is limited or conflicting [19]. In this context, de­
tice, with concerns raised by the panel regarding lack of cision making will depend on values and preferences, and
research evidence of efficacy for manual chest wall where deemed necessary through clinical stakeholder
 L.van der Lee et al. / Physiotherapy 122 (2024) 57–67 61

Table 1
Guideline Recommendations.
Recommendations for Physiotherapy Assessment
1. We recommend a high priority is given to respiratory physiotherapy assessment during the acute intubated phase, when the patient is
unconscious.
Strength: STRONG JBI Level of Evidence 5b(1−5) GRADE Certainty of Evidence: Very Low
2. We recommend these patients receive a respiratory physiotherapy assessment within 24 hours of intubation to establish a baseline regarding
disease severity and presence of problems amenable to physiotherapy intervention.
Strength: STRONG Level of Evidence 5b(1−5) GRADE Certainty of Evidence: Very Low
3. We recommend these patients receive a respiratory physiotherapy assessment at least daily whilst in ICU to monitor for changes in condition
and problems amenable to physiotherapy intervention.
Strength: STRONG Level of Evidence 5b(1−3) GRADE Certainty of Evidence: Very Low
4. We conditionally recommend, as staffing resources allow, that these patients receive timely, frequent assessment, more than once a day whilst
in ICU to identify changes when assessment and treatment findings indicate that physiotherapy amenable problems and treatment benefit
from intervention exist.
Strength: CONDITIONAL Level of Evidence 5b(1−3) GRADE Certainty of Evidence: Very Low
5. We recommend that physiotherapy assessment includes:
• Ventilation settings: ventilation mode, respiratory rate, tidal volume, breath type (spontaneous, mandatory, assisted), PEEP, pressure support and
peak pressure.
• Gas exchange parameters: ABG, FiO2, SpO2.
• Work of breathing: minute ventilation, observation of respiratory rate, respiratory pattern, ventilator synchrony.
• Signs of atelectasis: CXR interpretation, auscultation, chest expansion
• Signs of secretion retention: CXR interpretation, auscultation, tactile fremitus, inspiratory capacity, and cough quality and effectiveness.
• Pre-morbid status: presence of respiratory disease, respiratory medication use, functional ability and smoking history.
• Cardiovascular stability: arterial BP, MAP, HR and basic ECG rhythm, rate and dosage of inotropic and vasoactive medications.
• Current neurological function: Glasgow Coma Score, Richmond Agitation-Sedation Scale, (4) sedative medication and dosage.
• Current musculoskeletal function: Joint range of motion, manual muscle strength testing.
Strength: STRONG Level of Evidence 5b(1−5) GRADE Certainty of Evidence: Very Low
Consideration: Interprofessional communication with senior clinicians from physiotherapy, nursing and medicine should occur if there are concerns
regarding CVS stability, to enable to facilitate delivery of the required treatment whilst ensuring patient safety.
6. We conditionally recommend, based on availability of the following parameters from the ventilator display, that mean airway pressure,
plateau airway pressure, and lung compliance are also included in assessment to provide information for aiding risk stratification.
Strength: CONDITIONAL Level of Evidence 5c(6) GRADE Certainty of Evidence: Very Low
Recommendations for physiotherapy patient selection and prioritisation
7. We recommend a high priority is given to physiotherapy intervention in the acute, intubated phase when there are identifiable problems such
as atelectasis and secretion retention which are impairing gas exchange and amenable to physiotherapy intervention for the following types of
patients:
- Unconscious.
- Conscious and able to actively participate.
- Conscious but unable or insufficient participation due to neurological dysfunction, weakness, or fatigue.
Strength: STRONG Level of Evidence 5b(2−5) GRADE Certainty of Evidence: Very Low
8. We recommend that regular airway suctioning by nursing staff should not be a substitute for respiratory physiotherapy treatment.
Strength: STRONG Level of Evidence 5b(1) GRADE Certainty of Evidence: Very Low
Consideration 1: In some instances when secretion load is low, cough reflex is effective, there are no other physiotherapy amenable problems needing
to be addressed and nurses can dedicate sufficient time to secretion management, then respiratory physiotherapy intervention may not be necessary.
Consideration 2: Changes in the patient’s respiratory condition may necessitate escalation of respiratory physiotherapy involvement therefore regular
assessment by a physiotherapist (minimum daily), communication with the bedside nurse regarding assessment findings and any physiotherapy
recommendations for respiratory care plans is important.
9. We recommend that patients who have evidence of secretion retention and/or high sputum load and/or impaired gas exchange which is
amenable and responsive to physiotherapy intervention receive frequent respiratory physiotherapy assessment and treatment.
Strength: STRONG Level of Evidence 5b(1, 3) GRADE Certainty of Evidence: Very Low
Recommendations for Physiotherapy Treatment
a) Humidification
10. We recommend that measures to increase airway humidification, such as use of heated humidifiers, regular saline nebulisers and fluid
optimisation are used when sputum viscosity is high.
Strength: STRONG Level of Evidence 5b(1, 3−5) GRADE Certainty of Evidence: Very Low
b) Patient Positioning
11. We recommend that patients should be positioned in full side-lying with the affected lung uppermost for respiratory physiotherapy treatment
when the lung pathology is unilateral.
Strength: STRONG Level of Evidence 1c(7−9) and 5b(1, 3−5) GRADE Certainty of Evidence: Very Low
12. We recommend that when the pathology is bilateral, and alveolar recruitment or secretion clearance is the goal of treatment, multiple
positions, including alternate full side-lying, should be used with the target area for treatment uppermost.
Strength: STRONG Level of Evidence 1c(10, 11) and 5b(1, 3−5) GRADE Certainty of Evidence: Very Low
62 L.van der Lee et al. / Physiotherapy 122 (2024) 57–67

Table 1 (Continued)
13. We conditionally recommend that patients may be positioned with head down tilt to target drainage of the lower lobes, provided there are no
contraindications, the patient’s condition is stable enough to tolerate this position, and the following considerations are met.
Strength: CONDITIONAL Level of Evidence 1c(8, 12) and 5b(1, 3−5) GRADE Certainty of Evidence: Very Low
Consideration 1: This recommendation is to be read in conjunction with recommendation 14.
Consideration 2: Assess patient for contraindications to use of head-down position; including (but not limited to) pregnancy, poor gastric feed
absorption, vomiting, paralytic ileus, known or suspected gastro-oesophageal reflux disorder (GORD), other conditions resulting in distended abdomen,
raised intra-cranial pressure.
Consideration 3: In ICUs where use of head-down positioning is not standard practice and is deemed necessary by the physiotherapist to optimise
treatment, a conversation should occur between the physiotherapist, bedside nurse and senior medical staff to discuss appropriateness of position, risk
stratification and mitigation due to minimal evidence to guide safe practice.
Consideration 4: Monitor the patient closely throughout for signs of adverse events, such as aspiration of gastric contents.
14. We conditionally recommend that if the head down tilt position is used, the enteral feed should either be withheld for at least 30 min prior to
treatment and/or the nasogastric tube aspirated to empty the stomach, to minimise risk of aspiration of gastric contents into the lungs.
Strength: CONDITIONAL Level of Evidence 5b(1) GRADE Certainty of Evidence: Very Low
Consideration 1: This recommendation is to be read in conjunction with recommendation 13.
Consideration 2: Patients with abdominal distension, vomiting, poor feed absorption or known/suspected GORD are contraindicated from use of head-
down tilt position due to greater risk of aspiration of gastric contents.
Consideration 3: A conversation should occur between the physiotherapist, bedside nurse and senior medical staff to discuss management of
continuous enteral feed with use of HDT positioning, due to minimal evidence to guide safe practice.
Consideration 4: Monitor the patient closely throughout for signs of adverse events, such as aspiration of gastric contents.
c) Hyperinflation Techniques
15. We recommend that lung hyperinflation techniques are used to treat unconscious patients with increased sputum volume.
Strength: STRONG Level of Evidence 1a(13), 1c(7−10, 12, 14, 15) and GRADE Certainty of Evidence: Very Low
5b(1−5)
16. We recommend that lung hyperinflation techniques are used in conjunction with measures to increase airway humidification for patients with
increased sputum viscosity.
Strength: STRONG Level of Evidence 5b(1, 3−5) GRADE Certainty of Evidence: Very Low
17. We recommend that lung hyperinflation techniques are used to improve alveolar recruitment when signs of atelectasis are present on CXR or
auscultation, when the cause is amenable to respiratory physiotherapy treatment i.e., sputum retention/mucous plugging versus consolidation/
effusion.
Strength: STRONG Level of Evidence 1a(13), 1c(7−10, 14, 16, 17) and GRADE Certainty of Evidence: Very Low
5b(1−5)
Consideration 1: Conscious patients who are insufficiently able to actively generate increase in tidal volumes or sustain these for treatment to be
effective may also benefit from hyperinflation techniques (e.g. Presence of neuromuscular weakness or fatigue).
d) Manual Chest Wall Techniques
18. We conditionally recommend that manual chest wall techniques (such as percussion or chest wall vibrations/expiratory rib cage compressions)
may be used for patients with high sputum viscosity in conjunction with measures to increase airway humidification.
Strength: CONDITIONAL Level of Evidence 1a(13) and 5b(1−5) GRADE Certainty of Evidence: Very Low
19. We conditionally recommend that a combination of manual chest wall techniques (such as percussion or chest wall vibrations/expiratory rib
cage compressions) and lung hyperinflation techniques may be used for patients with high sputum viscosity in conjunction with measures to
increase airway humidification.
Strength: CONDITIONAL Level of Evidence 1a(13) and 5b(1−5) GRADE Certainty of Evidence: Very Low
20. We conditionally recommend that a combination of manual chest wall techniques (such as percussion or chest wall vibrations/expiratory rib
cage compressions) and lung hyperinflation techniques may be used for patients with large sputum volume, to assist secretion clearance.
Strength: CONDITIONAL Level of Evidence 1a(13) and 5b(1−5) GRADE Certainty of Evidence: Very Low
21. We conditionally recommend that manual chest wall techniques (such as percussion, chest wall vibrations/expiratory rib cage compressions)
may be used to assist secretion clearance when hyperinflation techniques cannot be used or tolerated, in combination with positioning,
provided they are not also contraindicated.
Strength: CONDITIONAL Level of Evidence 5b(1) GRADE Certainty of Evidence: Very Low
e) Normal Saline Instillation
22. We recommend that normal saline should not be routinely instilled in the airway prior to airway suctioning during respiratory physiotherapy
treatment.
Strength: STRONG Level of Evidence 1a(18) and 5b(1−3, 19, 20) GRADE Certainty of Evidence: Very Low
23. We conditionally recommend that normal saline may be instilled prior to endotracheal suctioning only when the secretions are very tenacious
and unable to be cleared using other respiratory physiotherapy techniques.
Strength: CONDITIONAL Level of Evidence 1a(18) and 5b(1, 19) GRADE Certainty of Evidence: Very Low
f) Active Treatment and Mobilisation
24. We recommend that once the patient is conscious and able to participate, active modes of respiratory treatment should be used (e.g., deep
breathing exercises, active cycle of breathing techniques, forced expiratory technique) rather than passive treatment modes such as
hyperinflation and/or manual chest wall techniques.
Strength: STRONG Level of Evidence 5b(1, 2, 4, 5) GRADE Certainty of Evidence: Very Low
25. We recommend that patients should be mobilised out of bed as soon as they are haemodynamically stable.
Strength: STRONG Level of Evidence 1a(21), 3e(22), 5b(1, 2, 4, 5, 23−25) GRADE Certainty of Evidence: Very Low
Consideration 1: The patient has an appropriate conscious state (RASS +2 to −2) to ensure safety.(22)
 L.van der Lee et al. / Physiotherapy 122 (2024) 57–67 63

Table 1 (Continued)
Consideration 2: The feasibility to safely mobilise and position a patient with reduced consciousness out of bed will depend on the availability of
suitable seating/equipment to ensure patient and staff safety.
26. We recommend that respiratory physiotherapy treatment should still be provided once the patient is able to commence active mobilisation,
when problems of reduced ventilation/alveolar recruitment and sputum retention impairing gas exchange persist, to optimise exercise capacity
and cardiorespiratory reserve.
Strength: STRONG Level of Evidence 5b(1−3, 24) GRADE Certainty of Evidence: Very Low
Consideration: Respiratory treatment and mobilisation are likely to complement one another in facilitating achievement of functional goals, until the
patent has sufficient cardiorespiratory reserve and can achieve alveolar recruitment and/or airway clearance with mobilisation alone.
Notes: Level of Evidence; 1a, systematic review of randomized controlled trials (RCT); 1b, systematic review of RCTs and other study designs; 1c, RCT; 3e,
observational study without a control group; 5b, expert consensus; 5c, bench research/single expert opinion.
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25. Hodgson CL, Stiller K, Needham DM, Tipping CJ, Harrold M, Baldwin CE, et al. Expert consensus and recommendations on safety criteria for active
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64 L.van der Lee et al. / Physiotherapy 122 (2024) 57–67

feedback, further commentary has been provided to opti­ synthesis of findings from a rigorous five phase program of
mise patient safety and/or quality of practice [19]. The level research which incorporated scientific evidence, expert
of certainty which clinicians can place on the evidence was knowledge and experience, and clinician stakeholder opi­
rated on a scale of high, moderate, low, very low, using the nions, beliefs, values and preferences. Evidence-based
GRADE criteria [28], which consider the presence of im­ practice importantly considers evidence from expert opi­
precision, inconsistency, indirectness, and risk of bias of nion and the values and preferences of patients in addition
studies. The levels and certainty of the evidence are pre­ to findings from clinical trials when available and appro­
sented for each guideline recommendation to provide priate [18,19,31]. At present, there are limited clinical stu­
transparent guidance for end-user clinicians, to effectively dies which directly investigate the effect of respiratory
support clinical decision making. An evidence-to-synthesis physiotherapy on outcomes for patients invasively venti­
framework, incorporating the FAME ratings has also been lated with CAP, as highlighted by a recent systematic re­
provided as a separate document (see Online Supplement view [12]. Therefore, expert consensus provided the highest
Appendix A) to provide further information to the end-user level of evidence available for most recommendations in
regarding how the recommendations were derived. The the guideline.
Agree Reporting Checklist [29], which outlines the pro­ Evolution of evidence development and synthesis into
cesses and steps involved for development of the guideline, guideline recommendations, utilising GRADE metho­
was used to ensure guideline trustworthiness and transpar­ dology for the systematic review, and both GRADE and JBI
ency of reporting [30] (See Online Supplement Appendix B approaches [18–20,26,28] to grade the guideline re­
for details). commendations ensures rigour and trustworthiness of the
guideline. Furthermore, provision of the evidence to
Ethical considerations synthesis framework used to derive recommendations
(Online Supplement Appendix A) for the end-user also
Ethics approval was obtained for research conducted in improves credibility and enhances clinical decision making
the development of this guideline from the human and re­ [19,26,30].
search ethics committee of The University of Notre Dame
Australia. (Approval number 014130F). Important considerations for clinical translation

This guideline was developed to support clinical deci­

Results sion making and does not replace the need for individual
clinician skill, judgement, and clinical liaison with health
The guideline development process resulted in 26 care workers from other disciplines involved in the care
guideline recommendations encompassing physiotherapy of adult patients critically ill with CAP. The treating
assessment, patient selection and prioritisation, and treat­ physiotherapist should always assess for contraindications
ment. Physiotherapy treatment covers the domains of hu­ to treatment to ensure patient safety. The guideline has
midification, patient positioning, hyperinflation techniques, been designed for use within the multidisciplinary ICU
manual chest wall techniques, normal saline instillation, environment where interprofessional teamwork is essential
and active treatment and mobilisation. Most recommenda­ to ensure optimisation of clinical care and patient safety.
tions (n = 17, 65%) were deemed strong, and nine (35%) Therefore, it is essential that these recommendations for
were deemed conditional. However, a lack of large clinical physiotherapy practice are used in conjunction with effec­
trials specifically investigating respiratory physiotherapy tive multidisciplinary communication. This is particularly
for this common ICU cohort resulted in downgrading of the important for conditional recommendations where evidence
certainty of the available evidence to very low according to is low, conflicting and/or clinical practice is guided by local
GRADE for most recommendations [26,28]. cultural influences. This will ensure appropriate, high
Table 1 outlines each guideline recommendation, the quality clinical care is delivered to meet the needs of
strength of the recommendation, a summary of the evidence individual patients, families, and the clinical environment.
level, and evaluation of certainty of the evidence according The influence of culture on local clinical practice was
to GRADE. incorporated into the guideline as it was highlighted by
clinician stakeholders as an important consideration for
clinical practice translation [25], especially for areas of
Discussion clinical practice where evidence is limited, conflicting, or of
low quality. This allows flexibility within the guideline for
This guideline is the first to provide a comprehensive values and preferences of the clinician, patient, and their
framework synthesising the best available evidence to fa­ families to be included in the clinical decision-making
cilitate clinical decision making for physiotherapy man­ process, for delivery of care to be patient-centred
agement of invasively ventilated adults with CAP in ICU. [18,19,26]. Organisational and professional culture have
The guideline recommendations were developed through been identified as both potential barriers and facilitators to
 L.van der Lee et al. / Physiotherapy 122 (2024) 57–67 65

the translation of guidelines into practice [14,15]. There­ Future development and review
fore, guidelines which are patient-centred and pay specific
consideration to values, preferences and cultural influences The values and preferences of patients with pneumonia
are likely to have better adherence [14,15,19,26]. and their families regarding respiratory physiotherapy in­
tervention is currently being investigated for incorporation
into the guideline [18,26,30]. Also, further work is required
Strengths and limitations for evaluation and endorsement of the guideline by pro­
fessional bodies, such as Cardiorespiratory Physiotherapy
A strength of the guideline is its development using a Australia and The International Confederation of Cardior­
framework of mixed-methods research to gain a holistic espiratory Physical Therapists.
understanding. Each subsequent phase of research was de­ It is important that the guideline is revised when any new
signed to build on the findings of preceding phases to fur­ evidence becomes available to ensure currency and re­
ther investigate areas of enquiry [32]. This enabled the levance. It is recommended that clinical practice guidelines
synthesised evidence to evolve with each phase to con­ in critical care are updated every 3–5 years, due to the rapid
tribute to the final development of a clinical practice development of new evidence within the field which may
guideline that was evidence-based and clinically relevant. potentially be practice changing [36].
Using an e-Delphi method for the expert consensus panel
allowed eight countries to be represented, enabling the
findings to be generalised further afield than Australia. Si­
Recommendations for future research
milarities in service delivery models and minimum standard
skill sets have been found between ICU physiotherapists
A future prospective observational study would be
practicing in Australia [33], Europe [34] and the UK [13],
beneficial to evaluate the application of this guideline into
which further strengthens the generalisability of the
clinical practice, establish its validity and relevance for all
guideline. Incorporation of multidisciplinary input into the
types of non-COVID-19 pneumonia requiring invasive
guideline development process was a further strength of the
mechanical ventilation, and to provide useful groundwork
methodology, as it provided clinical validation of the expert
for future clinical trials required to provide higher levels of
consensus statements by senior ICU clinician stakeholders
evidence.
from a multidisciplinary medical, nursing and phy­
Multicentre clinical trials comparing different re­
siotherapy perspective. This step enhances the trustworthi­
spiratory physiotherapy treatment modalities and dosages in
ness of the guideline through establishing the practicality
patients invasively ventilated with pneumonia are required,
and appropriateness of the expert consensus statements for
to determine clinical efficacy and impact on: patient out­
translation into the “real world” ICU environment from the
comes, such as increased ventilator free days, functional
perspective of each discipline involved in the care of the
recovery, quality of life and mortality; healthcare utilisation
patient with CAP in ICU during the acute, intubated period.
costs, such as ICU and hospital length of stay; and effi­
Finally, the use of the GRADE approach for both the Phase
ciency of physiotherapy service utilisation [12].
1 systematic review and Phase 5 guideline development
process provided strong methodological rigour and cred­
ibility to the guideline [35,36]. Incorporation of the JBI
approach for the guideline development provided a frame­ Conclusion
work to assess feasibility, acceptability, meaningfulness,
and effectiveness of the evidence. This enabled the influ­ Through a program of research, evidence has been es­
ence of local culture and the values and preferences of tablished and synthesised to produce a contemporary, evi­
clinicians to be considered for conditional recommenda­ dence-based guideline, comprising 26 recommendations for
tions to enhance translatability into clinical practice [35,36]. clinical physiotherapy practice. This guideline provides
The values and preferences of critically ill patients are clinical decision-making support for clinical ICU phy­
difficult to ascertain, however the perspective of the patient siotherapists to implement evidence-based physiotherapy
and their family is an important aspect to consider when practice for adults intubated and mechanically ventilated
balancing the desirable and undesirable effects of the with CAP. Further research is required to explore the values
treatment being considered, especially when there is limited and preferences of patients who have received invasive
or conflicting evidence regarding its efficacy [18,26]. The mechanical ventilation for CAP, and their families, re­
development of this guideline did not incorporate the values garding respiratory physiotherapy intervention, and to
and preferences of patients or their families which is a evaluate implementation of this guideline in clinical
limitation. practice.
66 L.van der Lee et al. / Physiotherapy 122 (2024) 57–67

Acknowledgements [9] Skinner EH, Haines KJ, Berney S, Warrillow S, Harrold M, Denehy
L. Usual care physiotherapy during acute hospitalization in subjects
The authors would like to acknowledge the contribution admitted to the ICU: An observational cohort study. Respir Care
2015;60(10):1476–85. https://doi.org/10.4187/respcare.04064
of time and expertise of the local and international ICU [10] Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M,
clinicians and academic experts involved at each phase of et al. Physiotherapy for adult patients with critical illness: re­
the research program for development of this guideline. commendations of the European Respiratory Society and European
Ethical approval: Ethics approval was obtained for research Society of Intensive Care Medicine Task Force on Physiotherapy for
Critically Ill Patients. Intensive Care Med 2008;34(7):1188–99.
conducted in the development of this guideline from the
https://doi.org/10.1007/s00134-008-1026-7
human and research ethics committee of XXXX. (Approval [11] Hanekom S, Berney S, Morrow B, Ntoumenopoulos G, Paratz J,
number 014130F). Professor Anne-Marie Hill is supported Patman S, et al. The validation of a clinical algorithm for the pre­
by a National Health and Medical Research Council of vention and management of pulmonary dysfunction in intubated
Australia Investigator Grant (EL2 award) and the Royal adults – a synthesis of evidence and expert opinion. J Eval Clin Pr
2011;17(4):801–10. https://doi.org/10.1111/j.1365-2753.2010.
Perth Hospital Research Foundation. Funding did not
01480.x
influence the content of the guideline. [12] van der Lee L, Hill AM, Jacques A, Patman S. Efficacy of respiratory
physiotherapy interventions for intubated and mechanically venti­
lated adults with pneumonia: a systematic review and meta-analysis.
Funding: No direct funding was obtained to conduct the Physiother Can 2021;73(1):6–18. https://doi.org/10.3138/ptc-2019-
research to develop this guideline. 0025
[13] Twose P, Jones U, Cornell G. Minimum standards of
Conflict of interest: The authors have no conflicts of interest clinical practice for physiotherapists working in critical care set­
to declare. tings in the United Kingdom: A modified Delphi technique. J
Intensive Care Soc 2019;20(2):118–31. https://doi.org/10.1177/
1751143718807019
[14] Cleary-Holdforth J, O’Mathúna D, Fineout-Overholt E. Evidence-
Appendix A. Supporting information
based practice beliefs, implementation, and organizational culture
and readiness for EBP among nurses, midwives, educators, and
Supplementary data associated with this article can be students in the Republic of Ireland. World Evid Based Nurs
found in the online version at doi:10.1016/j.physio.2023. 2021;18(6):379–88. https://doi.org/10.1111/wvn.12543
12.003. [15] Sharplin G, Adelson P, Kennedy K, Williams N, Hewlett R, Wood J,
et al. Establishing and sustaining a culture of evidence-based prac­
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