Abstract: 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. Osteopathic manipulative treatment (versus placebo) and positive expiratory pressure (versus no physiotherapy) reduced the mean duration of hospital stay by 2.0 days (mean difference (MD) -2.0 days, 95% CI -3.5 to -0.6) and 1.4 days (MD -1.4 days, 95% CI -2.8 to -0.0), respectively. Conventional chest physiotherapy and active cycle of breathing techniques did not. Positive expiratory pressure (versus no physiotherapy) reduced fever duration (MD -0.7 day, 95% CI -1.4 to -0.0). Osteopathic manipulative treatment did not. Osteopathic manipulative treatment (versus placebo) reduced the duration of intravenous (MD -2.1 days, 95% CI -3.4 to -0.9) and total antibiotic treatment (MD -1.9 days, 95% CI -3.1 to -0.7). Limitations of this review are that the studies addressing osteopathic manipulative treatment were small, and that six published studies which appear to meet the inclusion criteria are awaiting classification. Based on current limited evidence, chest physiotherapy might not be recommended as routine additional treatment for pneumonia in adults.

Plain-language summary: Six randomised controlled trials assessing 434 participants were included. The studies appraised four types of chest physiotherapy, namely conventional chest physiotherapy, osteopathic manipulative treatment (including paraspinal inhibition, rib raising, and diaphragmatic or soft myofascial release), active cycle of breathing techniques (including active breathing control, thoracic expansion exercises and forced expiration technique) and positive expiratory pressure. None of these techniques (versus no physiotherapy or placebo therapy) reduce mortality. Among three of the techniques (conventional chest physiotherapy, active cycle of breathing techniques and osteopathic manipulative treatment) there is no evidence to support a better cure rate in comparison with no physiotherapy or placebo therapy. Limited evidence indicates that positive expiratory pressure (versus no physiotherapy) and osteopathic manipulative treatment (versus placebo therapy) can slightly reduce the duration of hospital stay (by 2.02 and 1.4 days, respectively). In addition, positive expiratory pressure (versus no physiotherapy) can slightly reduce the duration of fever by 0.7 day, and osteopathic manipulative treatment (versus placebo therapy) might reduce the duration of antibiotic use by 1.93 days. No severe adverse events were found. In summary, chest physiotherapy should not be recommended as routine additional treatment for pneumonia in adults. The limitation of our review is that six published studies which appear to meet the inclusion criteria are awaiting classification (five of which are published in Russian).