***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND : We proposed a new chest physiotherapy ( CPT ) secretion clearance method to treat respiratory syncytial virus bronchiolitis in infants . Our new CPT method consists of 15 prolonged slow expirations , then 5 provoked cough maneuvers . METHODS : We r and omized 20 infants ( mean age 4.2 months ) into 2 groups : 8 patients received 27 sessions of nebulization of hypertonic saline ; 12 patients received 31 sessions of nebulization of hypertonic saline followed by our new CPT method . We used the Wang clinical severity scoring system ( which assesses wheezing , respiratory rate , retractions , and general condition ) and measured SpO2 and heart rate before each CPT session ( T0 ) , immediately after the 30-min session ( T30 ) , and 120 min after the session ( T150 ) . RESULTS : Within the groups : in the first group , Wang score was significantly lower at T150 than at T0 : 4.6 vs 5.0 ( P = .008 ) . In the new- method -CPT group , Wang score was significantly lower at T30 ( 3.6 vs 4.3 , P = .001 ) and at T150 ( 3.7 vs 4.3 , P = .002 ) . Wheezing score was significantly lower at T150 than at T0 ( 1.1 vs 1.2 , P = .02 ) in the first group , and in the new- method -CPT group at T30 than at T0 ( 0.8 vs 1.3 , P = .001 ) and at T150 than at T0 ( 0.9 vs 1.3 , P = .001 ) . Between the groups : at T30 the improvement was significantly better in the new- method -CPT group for overall Wang score ( P = .02 ) , retractions ( P = .05 ) , respiratory rate ( P = .001 ) , and heart rate ( P < .001 ) . At T150 the Wang score was not significantly different between the groups . At T30 ( versus T0 ) the difference in percent gain between the groups was significant for Wang score ( P = .004 ) , wheezing ( P = .001 ) , and heart rate ( P = .02 ) . Over 5-hospital days , the daily baseline ( T0 ) Wang score decreased significantly in the new- method -CPT group ( P = .002 ) , whereas it did not in the first group . There were no adverse events . Average hospital stay was not significantly different between the groups . CONCLUSIONS : Our new CPT method showed short-term benefits to some respiratory symptoms of bronchial obstruction in infants with acute respiratory syncytial virus bronchiolitis Vincent Gajdos and colleagues report results of a r and omized trial conducted among hospitalized infants with bronchiolitis . They show that a physiotherapy technique ( increased exhalation and assisted cough ) commonly used in France does not reduce time to recovery in this population In the GRADE approach , r and omized trials start as high- quality evidence and observational studies as low- quality evidence , but both can be rated down if most of the relevant evidence comes from studies that suffer from a high risk of bias . Well-established limitations of r and omized trials include failure to conceal allocation , failure to blind , loss to follow-up , and failure to appropriately consider the intention-to-treat principle . More recently recognized limitations include stopping early for apparent benefit and selective reporting of outcomes according to the results . Key limitations of observational studies include use of inappropriate controls and failure to adequately adjust for prognostic imbalance . Risk of bias may vary across outcomes ( e.g. , loss to follow-up may be far less for all-cause mortality than for quality of life ) , a consideration that many systematic review s ignore . In deciding whether to rate down for risk of bias -- whether for r and omized trials or observational studies -- authors should not take an approach that averages across studies . Rather , for any individual outcome , when there are some studies with a high risk , and some with a low risk of bias , they should consider including only the studies with a lower risk of bias OBJECTIVE To compare the expiratory flow increase technique ( EFIT ) and vibration accompanied by postural drainage ( PD ) in terms of their effects on the heart rate ( HR ) , respiratory rate ( RR ) and SpO(2 ) of infants with acute viral bronchiolitis ( AVB ) . METHODS Infants with clinical and radiological diagnosis of AVB were analyzed . The HR , RR and SpO(2 ) were registered at four time points : prior to the procedure ; and at 10 , 30 and 60 min after the procedure . The patients were divided into three groups : su bmi tted to the EFIT ; su bmi tted to vibration/PD ; and control . RESULTS We included 81 infants , 27 per group , with a mean age of 4.52 years and a mean weight of 6.56 kg . Using ANOVA , we found that the EFIT and vibration/PD groups presented no significant differences in relation to the control group in terms of the mean values for HR , RR or SpO(2 ) ( p > 0.05 ) . Considering only the four time points evaluated , the mean RR was significantly lower in the EFIT and vibration/PD groups than in the control group ( p < 0.05 ) . CONCLUSIONS In terms of overall improvement of cardiorespiratory parameters , neither the EFIT nor vibration/PD provided any benefit to infants with BVA . However , over time , respiratory physical therapy seems to contribute to decreasing the RR in these patients In the GRADE approach , r and omized trials start as high- quality evidence and observational studies as low- quality evidence , but both can be rated down if a body of evidence is associated with a high risk of publication bias . Even when individual studies included in best- evidence summaries have a low risk of bias , publication bias can result in substantial overestimates of effect . Authors should suspect publication bias when available evidence comes from a number of small studies , most of which have been commercially funded . A number of approaches based on examination of the pattern of data are available to help assess publication bias . The most popular of these is the funnel plot ; all , however , have substantial limitations . Publication bias is likely frequent , and caution in the face of early results , particularly with small sample size and number of events , is warranted Chest physiotherapy ( CP ) using passive expiratory manoeuvres is widely used in Western Europe for the treatment of bronchiolitis , despite lacking evidence for its efficacy . We undertook an open r and omised trial to evaluate the effectiveness of CP in infants hospitalised for bronchiolitis by comparing the time to clinical stability , the daily improvement of a severity score and the occurrence of complications between patients with and without CP . Children < 1 year admitted for bronchiolitis in a tertiary hospital during two consecutive respiratory syncytial virus seasons were r and omised to group 1 with  CP ( prolonged slow expiratory technique , slow accelerated expiratory flow , rarely induced cough ) or group 2 without CP . All children received st and ard care ( rhinopharyngeal suctioning , minimal h and ling , oxygen for saturation ≥92 % , fractionated meals ) . Ninety-nine eligible children ( mean age , 3.9 months ) , 50 in group 1 and 49 in group 2 , with similar baseline variables and clinical severity at admission .  Time to clinical stability , assessed as primary outcome , was similar for both groups ( 2.9 ± 2.1 vs. 3.2 ± 2.8 days , P = 0.45 ) . The rate of improvement of a clinical and respiratory score , defined as secondary outcome , only showed a slightly faster improvement of the respiratory score in the intervention group when including stethoacoustic properties ( P = 0.044 ) . Complications were rare but occurred more frequently , although not significantly ( P = 0.21 ) , in the control arm . In conclusion , this study shows the absence of effectiveness of CP  using passive expiratory techniques in infants hospitalised for bronchiolitis . It seems justified to recommend against the routine use of CP in these patients AIM To measure the impact of French national consensus guidelines on the clinical practice s of primary care paediatricians and general practitioners . DESIGN Non-r and omized intervention study , with a first survey 1 year before the consensus development conference and a second survey 1 year after . INTERVENTION Implementation of bronchiolitis management guidelines through the medical press and the Internet . SUBJECTS Paediatricians and general practitioners treating infants 1 year of age and under consulting for a first-time episode of bronchiolitis . RESULTS Ninety-three doctors and 510 infants were included during the first phase of the study and 96 doctors and 394 infants during the second phase . This study showed a slight increase in adherence to the guidelines for non-vali date d drugs ( 6.6 % adherence before and 14.3 % after ) , general advice ( 29.0 % adherence before and 57.1 % after ) and  flow modulation respiratory physical therapy  ( 91.9 % adherence before and 98.8 % after ) . Increase in adherence to guidelines for other practice s , that is , hospitalization , prescribing antibiotics and complementary examinations , was not statistically significant . Adherence to the guidelines on providing general advice increased the most between the two studies . CONCLUSION The guidelines helped practitioners evolve slightly in their approach to the treatment of bronchiolitis . Non-vali date d drugs remain frequently used . Additional re sources for implementing the guidelines should be provided to improve primary care doctors ' practice Objective To evaluate and compare the effects of two chest physiotherapy interventions in patients hospitalized due to acute bronchiolitis . Methods Prospect i ve r and omized study with a sample of 83 calls for 29 patients aged between 3 months and 1 year hospitalized for acute bronchiolitis . Patients were distributed r and omly into two groups : Group 1 , su bmi tted to postural drainage , tapping and tracheal aspiration ; and Group 2 , su bmi tted to postural drainage , expiratory acceleration flow and tracheal aspiration . Assessment s were made before and 10 and 60 minutes after the end of therapy . Patients also underwent drug treatment . The endpoint was to compare two physical therapy interventions as to clinical improvement in infants with acute bronchiolitis by means of oxygen saturation and the Respiratory Distress Assessment Instrument score . The parents/guardians was requested to answer a question naire about the treatment applied before the last evaluation in order to measure their satisfaction related to the interventions made . Results The groups were similar regarding the use of antibiotics and bronchodilators . A greater number of patients used corticosteroids in Group 2 . A relevant improvement was observed on Respiratory Distress Assessment Instrument score with physical therapy , with reduction of the score 10 minutes after interventions , and the same score 60 minutes later , with no differences between techniques applied . There was no significant variation of pulse oximetry after chest physiotherapy . Most items assessed by the question naire had satisfactory answers . Conclusion No differences were observed between groups regarding the items assessed ( time required to discharge from study , pulse oximetry in room air and disease severity according to the Respiratory Distress Assessment Instrument score ) . Parents answered positively about the effects of therapy in the majority of items in the question naire , both for the expiratory acceleration flow technique and for tapping BACKGROUND The treatment of infants with bronchiolitis is largely supportive . The role of bronchodilators is controversial . Most studies of the use of bronchodilators have enrolled small numbers of subjects and have examined only short-term outcomes , such as clinical scores . METHODS We conducted a r and omized , double-blind , controlled trial comparing nebulized single-isomer epinephrine with placebo in 194 infants admitted to four hospitals in Queens-l and , Australia , with a clinical diagnosis of bronchiolitis . Three 4-ml doses of 1 percent nebulized epinephrine or three 4-ml doses of normal saline were administered at four-hour intervals after hospital admission . Observations were made at admission and just before , 30 minutes after , and 60 minutes after each dose . The primary outcome measures were the length of the hospital stay and the time until the infant was ready for discharge . The secondary outcome measures were the degree of change in the respiratory rate , the heart rate , and the respiratory-effort score and the time that supplemental oxygen was required . RESULTS There were no significant overall differences between the groups in the length of the hospital stay ( P=0.16 ) or the time until the infant was ready for discharge ( P=0.86 ) . Among infants who required supplemental oxygen and intravenous fluids , the time until the infant was ready for discharge was significantly longer in the epinephrine group than in the placebo group ( P=0.02 ) . The need for supplemental oxygen at admission had the greatest influence on the score for severity of illness and strongly predicted the length of the hospital stay and the time until the infant was ready for discharge ( P<0.001 ) . There were no significant changes in the respiratory rate , blood pressure , or respiratory-effort scores from before each treatment to after each treatment . The heart rate was significantly increased after each treatment with epinephrine ( P=0.02 to P<0.001 ) . CONCLUSIONS The use of nebulized epinephrine did not significantly reduce the length of the hospital stay or the time until the infant was ready for discharge among infants admitted to the hospital with bronchiolitis OBJECTIVE To evaluate the effectiveness of chest physical therapy ( CP ) in reducing the clinical score in infants with acute viral bronchiolitis ( AVB ) . METHODS R and omized controlled trial of 30 previously healthy infants ( mean age 4.08 SD 3.0 months ) with AVB and positive for respiratory syn 
    Output:
    
This evidence is of high quality and corresponds to patients with severe bronchiolitis .
None of the chest physiotherapy techniques analysed in this review ( conventional , slow passive expiratory techniques or forced expiratory techniques ) have demonstrated a reduction in the severity of disease .
For these reasons , these techniques can not be used as st and ard clinical practice for hospitalised patients with severe bronchiolitis .
There is high quality evidence that forced expiratory techniques in severe patients do not improve their health status and can lead to severe adverse events .
Slow passive expiratory techniques provide an immediate and transient relief in moderate patients without impact on duration .