Nursing Case Study Memo

Citation: Freitas DA, Dias FA, Chaves GS, Ferreira GM, Ribeiro CT, Guerra RO, Mendonça
KM. Standard (head-down tilt) versus modified (without head-down tilt) postural drainage in infants and young children with cystic fibrosis. Cochrane Database Syst Rev. 2015 Mar 10;3:CD010297. doi: 10.1002/14651858.CD010297.pub2. Review. PubMed PMID: 25756796.

Brief Description of patient: The patient is a 5 year old female diagnosed with cystic fibrosis and presents with difficulty breathing and difficulty clearing secretions. She is unable to walk or run long periods of time, has difficulty breathing in certain positions, and is unable to participate in physical activities at school.
PICO Question: For young children with cystic fibrosis, will standard
postural drainage (head down tilt) as compared to modified postural drainage (head up tilt) result in less potential for gastroesophageal reflux exacerbation?
Databases Searched and Key Words: Pubmed: Cystic Fibrosis AND Drainage, Postural AND Drainage, Postural/methods; PEDro: Cystic Fibrosis, Postural Drainage, Gastroesophageal Reflux
Question Type: Therapy intervention
Methods: This systematic review assessed a randomized control study and cross over study comparing two postural drainage positions, standard postural drainage (SPD) (greater (30° to 45° head down tilt) and lesser (15° to 20° head down tilt) with modified postural drainage (MPD) (greater (30° head up tilt) or lesser (15° to 20° head up tilt)), while taking into account exacerbations of gastroesophageal reflux in patients with Cystic Fibrosis (CF).1 In order to be included within the review, studies had to be randomized control trials regardless of year or language. Participants included children diagnosed with CF from birth to the age of six. Diagnosis was based on clinical criteria, sweat testing, and genotype analysis. Two studies were included within this review with one having a cross over design and the other consisted of two parts which included a cross over study and a parallel designed study period. The studies were performed in Australia within the hospital setting. Each study had 20 participants whose ages varied. Randomization was computer generated and allocation was concealed via opaque sealed envelopes for the first study by Button.1 Randomization was peformed using block randomization and allocation was concealed by sealed opaque envelopes in the study by Doumit.2 Participants in the first study were randomly assigned to SPD (30° head down tilt) or MPD (30° head up tilt) groups and went through a two day cross over study.
SPD and MPD were analyzed two times for better statistical power. Participants within this study continued the treatment for the following five years. Participants assigned to SPD were positioned supine horizontal, prone, left side down, and right side down. For those assigned to MPD the previous four positions were modified to supine 30° head up, prone horizontal, left side down horizontal, and right side down horizontal.1 Manual percussion was performed for two minutes followed by six vibrations for 30 minutes. The next session began with participants inhaling 2mL of nebulized normal saline for 5 to 10 minutes. In the second study each participant received two sessions of chest therapy, each 20 minutes long. Session one consisted of percussion with vibrations in four MPD positions for five minutes. Session two consisted of percussion with vibrations in four
gravity minimized postions for five minutes. The primary outcomes included the appearance or exacerbation of gastroesophageal reflux episodes (number and duration) by evaluation of clinical tests and pulmonary tests. Secondary outcomes included airway clearance measured by sputum weight and volume, the percentage of peripheral oxygen saturation, the number of exacerbations of upper respiratory tract symptoms, the number of days on antibiotics for acute exacerbations, hospital stays for repiratory problems (number and duration), chest x-ray scores, high resolution computed tomography scores, pulmonary function tests (immediate and long term) via spirometry, lung clearance index index derived from multiple breath washout via plethysmography, and adverse events. Participants of the first study were followed for five years; however, gastroesophageal reflux was said to decline over the first 12 months of life. The follow up time of the second study was not mentioned. It was noted that the difference in the median ages between both studies may have affected the results due to the inability of data to be pooled and analyzed.
Validity: Investigators included two studies in this systematic review.
The first study was designed as a randomized control trial and the second study was designed as a cross over study. Investigators did incorporate details regarding the search process and selection of the studies. Two authors reviewed the abstracts of several studies selected during the primary search to determine if they followed the inclusion criteria. They then read the full text of the studies to establish their admissibility. A third author was consulted to determine the final selection. Review Manager 5 was used to obtain data and any disagreements among the investigators was resolved via discussion and compromise. The following is a list of information collected by the investigators: methods, participants, interventions, outcomes, and risk of bias. The second study had a low risk of bias due to suitable reporting for outcome data; however, the first study had an unclear risk of bias due to the unavailability of its protocol in trial registers. This systematic review was not a meta-analysis and did not include individual patient data in the
analysis.
Results: Both studies analyzed the primary outcome of the appearance or exacerbation of gastroesophageal reflux with postural drainage positions in children with CF, but only one study included a few of the secondary outcomes. In the first study, after the data was assessed individually, authors inferred the postrual drainage position of 30° head up tilt was correlated to less gastroesophageal exacerbations and a decrease in long term respiratory complications. With regards to the lesser (15° to 20°) head up and head down tilt, it was indicated to use this postural drainage position with caution due to the increased potential for aspiration. The second study stated a lack of difference between the amount of reflux occcurences in 20° head up tilt or 20° head down tilt postural drainage positions.
Critical Appraisal: This systematic review was considered weak due to the lack of studies included, small sample size, and the inability to perform a meta-analysis with the data obtained. Furthermore, participant age could have interfered with gastroesphageal exacerbations due to the reduced occurrence of these events after the first 12 months of life. This review could have been weakened further due to the fact that one one study was carried out over 24 hours while the other was carried out over two days with a five year follow up.
Applicability to the patient: The study population characteristics do apply to my patient. The decreased occurrence of gastroesophageal reflux with 30° head up tilt could indicated implementation in my patients rehabilitation program. However, it was determined that methodological limitations and lack of study inclusion reduced the strength of the study and therefore its clinical applicability.
Clinical Bottom line: There is a need for further research regarding the SPD compared to MPD for this particular patient population. Furthermore, a larger patient population could improve the data obtained and therefore further strengthen this systematic review by allowing a meta-analysis to be conducted. The decline in gastroesophageal reflux after 12 months of life could have been controlled for by including studies with older children.
Author of CAT (Date): Annia Olivares (March 31, 2016)