***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: Expectoration of mucus is important in preventing the development of airway inflammation in patients with diffuse panbronchiolitis ( DPB ) . To evaluate the clinical efficacy of the FLUTTER device in clearing mucus from the airways of patients with DPB who have difficulty expectorating , we assessed pulmonary function and symptoms in patients treated with FLUTTER . Eight patients in a stable clinical condition with DPB were included in the study . The study was divided into two consecutive , 1-week periods . The initial week was an observation week . During the following week , patients used FLUTTER four times daily . Expectorated sputum was collected in a container and weighed every day during 2 weeks . Pulmonary function , partial oxygen pressure and partial carbon dioxide pressure in arterial blood were measured in all patients on the last day of the observation week and the FLUTTER treatment week . A symptom score for difficulty of expectoration was determined by question naire . A pneumothorax developed in one patient during using FLUTTER . The mean daily sputum weight and peak expiratory flow rate increased significantly after treatment with FLUTTER ( P < 0.04 and P < 0.02 , respectively ) . Symptom score improved significantly after using FLUTTER ( P < 0.02 ) . We conclude that the use of FLUTTER is effective in clearing mucus from the airways . However , the development of a pneumothorax may complicate use of the procedure in some cases Pneumonia in elderly patients is a major public health concern because of greater morbidity and mortality and longer hospital stays relative to younger population s. Based on the premise that osteopathic manipulative treatment ( OMT ) is beneficial in the management of pulmonary infections , the Multicenter Osteopathic Pneumonia Study in the Elderly ( MOPSE ) was design ed as a prospect i ve r and omized controlled trial to evaluate the efficacy of OMT as an adjunct to the current pharmacologic treatment of elderly patients hospitalized for pneumonia . The protocol developed for MOPSE has its origins in early osteopathic medical literature at a time when effective antibiotic therapy was unavailable and osteopathic physicians relied on physical examination and empiric reasoning to develop treatment strategies and OMT techniques to improve host defenses against pneumonia . The present paper review s the early osteopathic medical literature to identify the reasoning behind the OMT techniques that are the basis for the design of the MOPSE protocol . Likewise , the contemporary medical literature relevant to the protocol is review ed . Finally , a description of the study design and the OMT and light touch ( sham ) protocol s used in MOPSE are provided Ventilator-associated pneumonia results from bacterial colonisation of the aerodigestive tract or aspiration of contaminated secretions into the lower airways . As a consequence of infection of the lung parenchyma and alveolitis , accumulation of inflammatory exu date s and infiltration of airway mucosa can lead to unfavourable respiratory mechanics in ventilator-associated pneumonia . Tracheal suction is often employed by nursing staff in the management of mechanically ventilated patients with ventilator-associated pneumonia but this technique has the potential to increase respiratory resistance .  Manual hyperinflation is used by physiotherapists to improve lung volume and mobilise secretions and has been shown to increase lung compliance . The effect of manual hyperinflation on airway resistance has not been studied . This study aims to demonstrate an additional mechanical benefit to the respiratory system when manual hyperinflation and suction techniques are combined , by comparing the application of manual hyperinflation and suction with suction alone on static lung compliance ( C(L ) ) and inspiratory resistance ( R(AW ) ) in mechanically ventilated patients with ventilator-associated pneumonia . Fifteen adult patients with ventilator-associated pneumonia were recruited and acted as their own controls . Manual hyperinflation followed by suction ( manual hyperinflation plus suction ) and suction alone were applied consecutively , in r and om order , on two occasions , four hours apart . Respiratory variables , C(L ) and R(AW ) , were measured five times and the averaged value documented . Data were recorded before , immediately after , and 30 minutes after each intervention protocol . C(L ) increased by 22 % and R(AW ) decreased by 21 % , up to 30 minutes after manual hyperinflation plus suction , but not after suction alone . This study suggests that manual hyperinflation in conjunction with suction induces beneficial changes in respiratory mechanics in mechanically ventilated patients with ventilator-associated pneumonia While osteopathic manipulative treatment ( OMT ) is thought to be beneficial for patients with pneumonia , there have been few clinical trials -- especially in the elderly . The authors ' pilot study suggested that duration of intravenous antibiotic use and length of hospital stay were promising measures of outcome . Therefore , a larger r and omized controlled study was conducted . Elderly patients hospitalized with acute pneumonia were recruited and r and omly placed into two groups : 28 in the treatment group and 30 in the control group . The treatment group received a st and ardized OMT protocol , while the control group received a light touch protocol . There was no statistical difference between groups for age , sex , or simplified acute physiology scores . The treatment group had a significantly shorter duration of intravenous antibiotic treatment and a shorter hospital stay To evaluate the benefit of osteopathic manipulative treatment in the elderly with pneumonia , the authors recruited 21 individuals older than 60 years who were hospitalized with acute pneumonia . Eleven patients were r and omly assigned to the treatment group and ten to the control group . The treatment group received specific osteopathic manipulative treatment for somatic dysfunction and a st and ardized treatment protocol . Both groups received conventional therapy , and the attending physician was blind to group assignments . No significant difference existed between groups for age , sex , or severity of illness . Although the mean duration of leukocytosis , intravenous antibiotic treatment , and length of stay were shorter for the treatment group , these measures did not reach statistical significance . However , the mean duration of oral antibiotic use did reach statistical significance at 3.1 days for the treatment group and 0.8 day for the control group . Osteopathic manipulative treatment may reduce antibiotic use and length of stay ; however , a larger study is needed to clarify this outcome A study was carried out to determine whether bottle-blowing has any positive effects in patients with pneumonia . In a prospect i ve open study 145 adults with untreated community-acquired pneumonia requiring hospitalization were r and omized to early mobilization ( group A ) , to sit up and take 20 deep breaths on 10 occasions daily ( group B ) , or to sit up and to blow bubbles in a bottle containing 10 cm water through a plastic tube 20 times on 10 occasions daily ( group C ) . Peak expiratory flow ( PEF ) , vital capacity ( VC ) , forced expiratory volume in 1 sec ( FEV1 ) and serum concentration of C-reactive protein ( CRP ) were determined on admission , and on days 4 and 42 . Fever duration and hospital stay were recorded . In a subset of 16 patients , single breath diffusion capacity of carbon monoxide was measured on 3 occasions . The patients in group A were hospitalized for a mean of 5.3 days , group B for 4.6 days and group C for 3.9 days . Treatment was a significant factor ( p = 0.037 ) in a Cox regression model , with group C significantly better than group A ( p = 0.01 ) . The number of days with fever was 2.3 , 1.7 and 1.6 in groups A , B and C respectively . These differences were not significant ( p = 0.28 ) . No significant differences were found between the groups regarding CRP , PEF , VC , FEV1 , or diffusion capacity . Intensive bottle-blowing shortens the hospital stay in patients with pneumonia . The underlying mechanism is not clear Abstract Objective : To explore three aspects of non-invasive pressure support ventilation ( NIPSV ) applied by face mask to patients with acute respiratory failure ( ARF ) due to severe community-acquired pneumonia ( CAP ) : ( 1 ) the initial acute effects on respiratory rate , gas exchange and hemodynamics , ( 2 ) the clinical course and outcome during ICU and hospital stay , ( 3 ) the nursing workload as measured by the daily PRN 87 ( Project Research in Nursing ) score . Setting : Medical ICU , University Hospital . Design : Prospect i ve , observational study . Patients : Patients without any prior history of chronic lung disease , consecutively admitted to the ICU to receive NIPSV for ARF due to severe CAP . Measurements and results ( means ± SD ) : Twenty-four patients aged 49±17 years , admission APACHE II 13±5 , were included . Admission PaO2/FIO2 , alveolar-arterial oxygen difference ( DA-aO2 ) and PaCO2 were 104±48 , 447±120 and 40±10 mmHg , respectively . All patients were normotensive . During the initial NIPSV  trial respiratory rate decreased from 34±8 to 28±10 breaths/min ( p<0.001 ) and arterial oxygenation improved ( PaO2/FIO2 104±48 vs 153±49 , DA-aO2 447±120 vs 370±180 mmHg , p<0.001 ) while PaCO2 remained unchanged . There were no hemodynamic effects . Subsequently , a total of 133 NIPSV trials were performed ( median duration 55 min , range 30–540 min ) over 1–7 days . No complication occurred during NIPSV . Sixteen patients were intubated ( 66 % ) 1.3±1 days after inclusion . Upon inclusion , the patients who were subsequently intubated were older ( 55±15 vs 37±12 years ) and more severely hypoxemic ( 63±11 vs 80±15 mmHg , p<0.05 ) than those not requiring intubation . Eight patients died ( 33 % ) , all in the intubated group . Median lengths of stay in the ICU and hospital were longer in intubated patients ( ICU 16 days , range 3–64 vs 6 days , range 3–7 , p<0.05 ; hospital 23 days , range 9–77 vs 9.5 days , range 4–42 , p<0.05 ) . Mean daily total PRN points were stable throughout the NIPSV period and were not different between the groups . Only 14 % of PRN points result ed from respiratory therapy interventions . PRN score was higher during the first 24 h following intubation than during the first 24 h of NIPSV ( 278±55 vs 228±24 points , p<0.05 ) . Conclusion : Despite initial improvement in arterial oxygenation with NIPSV in patients with ARF due to severe CAP , the intubation rate is high . However , the more favorable outcome and shorter ICU and hospital stays when intubation is avoided , as well as the short delay required to assess the success or failure of NIPSV warrants a trial of NIPSV in this setting . The nursing workload remains stable during NIPSV and does not result predominantly from respiratory therapy interventions Objective To investigate the effect of respiratory physiotherapy on the prevention and treatment of ventilator-associated pneumonia ( VAP ) for adults in an intensive care unit ( ICU ) with an acquired brain injury ( ABI ) . Design and setting Two-part , prospect i ve , r and omised controlled trial . Patients A total of 144 subjects with ABI admitted with a Glasgow Coma Scale ≤9 , requiring intracranial pressure monitoring , and invasive mechanical ventilation ( MV ) for > 24 h ; 33 subjects were subsequently diagnosed with VAP.InterventionRespiratory  physiotherapy comprised six treatments ( positioning , manual hyperinflation and suctioning ) in each 24-h period whilst on MV . The Control Group received st and ard medical/nursing care but no respiratory physiotherapy . Measurements and results There were no significant differences between groups for incidence of VAP , duration of MV , length of ICU stay or clinical variables such as requirement for re-ventilation . Conclusions In adults with ABI , regular respiratory physiotherapy in addition to routine medical/nursing care does not appear to prevent VAP , reduce length of MV or ICU stay . Due to small numbers , it is not possible to draw any conclusions as to whether or not respiratory physiotherapy hastens recovery from VAP Abstract Objective . Pneumonia is an important complication in patients who are intubated and mechanically ventilated , when it is commonly referred to as ventilator-associated pneumonia ( VAP )  . Since VAP may be contributed to by impaired sputum clearance , we studied whether chest physiotherapy design ed to enhance sputum clearance decreases the occurrence of VAP . Design . Prospect i ve controlled systematic allocation trial . Setting . Tertiary teaching hospital ICU . Patients and participants . Sixty adult patients intubated and mechanically ventilated for at least 48 h. Interventions . Chest physiotherapy ( intervention group ) or sham physiotherapy ( control group ) . Measurements and results . Control and intervention groups were well matched for age , sex , and admission PaO2/FiO2 ratio , APACHE II score , and Glasgow Coma Score . There were no differences in the duration of mechanical ventilation , length of stay in ICU or mortality . VAP was assessed daily by combined clinical assessment and the clinical pulmonary infection score ( CPIS ) . VAP occurred in 39 % ( 14/36 ) of the control group and 8 % ( 2/24 ) of the intervention group ( OR=0.14 , 95 % CI 0.03 to 0.56 , P=0.02 ) . After adjustment was made by logistic regression for other important variables 
    Output:
    
MAIN RESULTS Six RCTs ( 434 participants ) appraised four types of chest physiotherapy ( conventional chest physiotherapy ; osteopathic manipulative treatment ( which includes paraspinal inhibition , rib raising and myofascial release ) ; active cycle of breathing techniques ( which include active breathing control , thoracic expansion exercises and forced expiration techniques ) ; and positive expiratory pressure).None of the physiotherapies ( versus no physiotherapy or placebo ) improved mortality rates of adults with pneumonia .
Conventional chest physiotherapy ( versus no physiotherapy ) , active cycle of breathing techniques ( versus no physiotherapy ) and osteopathic manipulative treatment ( versus placebo ) did not increase the cure rate or chest X-ray improvement rate .
Based on current limited evidence , chest physiotherapy might not be recommended as routine additional treatment for pneumonia in adults