Abstract: We included three new RCTs for this update, for a total of six included RCTs involving 559 children aged from 29 days to 12 years with pneumonia who were treated as inpatients. Pneumonia severity was described as moderate in one trial, severe in two trials, and was not stated in three trials. The studies assessed five different interventions: effects of conventional chest physiotherapy (3 studies, 211 children), positive expiratory pressure (1 study, 72 children), continuous positive airway pressure (CPAP) (1 study, 94 children), bubble CPAP (bCPAP) (1 study, 225 children), and assisted autogenic drainage (1 studies, 29 children). The included studies were conducted in Bangladesh, Brazil, China, Egypt, and South Africa. The studies were overall at low risk of bias. Blinding of participants was not possible in most studies, but we considered that the outcomes were unlikely to be influenced by the lack of blinding. One study of bCPAP reported that three deaths occurred in children in the physiotherapy group (N = 79), and 20 deaths in the control group (N = 146) (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.08 to 0.90; 225 children; low-quality evidence). One study of assisted autogenic drainage (N = 29), and one study of conventional chest physiotherapy (N = 72) reported no deaths occurred. It is uncertain whether chest physiotherapy techniques (bCPAP, assisted autogenic drainage, and conventional chest physiotherapy) reduced hospital stay duration (days) (mean difference (MD) 0.10, 95% CI -0.56 to 0.76; 4 studies; low-quality evidence). There was variation among clinical parameters used to define clinical resolution. Two small studies found no difference in resolution of fever between children in the physiotherapy (conventional chest physiotherapy and assisted autogenic drainage) and control groups. Of five studies that considered peripheral oxygen saturation levels, only two reported that use of chest physiotherapy (CPAP and conventional chest physiotherapy) showed a greater improvement in peripheral oxygen saturation levels. However, it was unclear whether respiratory rate (breaths/min) improved after conventional chest physiotherapy (MD -2.25, 95% CI -5.17 to 0.68; 2 studies, 122 children; low-quality evidence). Two studies assessed adverse events (number of events), but only one study reported any events (RR 1.28, 95% CI 0.98 to 1.67; 2 studies, 254 children; low-quality evidence). We could draw no reliable conclusions concerning the use of chest physiotherapy for children with pneumonia due to the small number of included trials with differing study characteristics and statistical presentation of data. Future studies should consider the following key points: appropriate sample size with adequate power to detect expected differences, standardisation of chest physiotherapy techniques, appropriate outcomes (such as duration of leukocytosis, and airway clearance), and adverse effects.

Plain-language summary: We included six studies involving 559 children with pneumonia aged from 29 days to 12 years. This is an update of a review published in 2013 and includes three new studies. Studies were conducted in hospitals in Bangladesh, Brazil, China, Egypt, and South Africa. Pneumonia was described as moderate to severe in three studies, but severity was not described in three studies. All studies included children who received physiotherapy and others who did not. All children also received standard medical treatment for pneumonia. The studies assessed deaths, length of hospital stay, time taken to attain normal test results (no signs of pneumonia), and adverse events. Four studies reported sources of funding (a child health agency, university, government research grants), and two did not report study funding sources. One study reported fewer deaths in children who received bubble continuous positive airway pressure (bCPAP). Physiotherapy techniques (bCPAP, assisted autogenic drainage, and conventional chest physiotherapy) were not associated with shorter hospital stays. Two studies reported improvements in blood oxygen levels after chest physiotherapy (CPAP and conventional chest physiotherapy). No clear improvement in respiratory rate was observed after conventional chest physiotherapy. Based on the available evidence, we could not confirm if chest physiotherapy is beneficial or not for children with pneumonia. We assessed the overall quality of the evidence as low due to inadequate study methods and design, differing results among studies, and few data.