Bronchiolitis: why respiratory physiotherapy is no longer recommended in some cases

Respiratory physiotherapy on children under one year of age is no longer recommended since 2019 in cases of bronchiolitis, some methods are even contraindicated. But in practice, this practice is not prohibited.

Considered a key treatment for bronchiolitis for years, respiratory physiotherapy is no longer recommended in certain cases by the French National Authority for Health (HAS) since 2019. “Respiratory physiotherapy for bronchial clearance is no longer recommended today. in the event of a 1st episode “for babies under 12 months, wrote the HAS in its notice dated November 2019.

“We have no level of proof of this method. In hospitalized children with the most severe forms, respiratory physiotherapy is not only useless but surely counterproductive. It will worsen the condition of the child, which is already tired and has trouble breathing “, then estimated Professor Pierre-Louis Druais, general practitioner and vice-chairman of the HAS recommendations commission.

What does respiratory physiotherapy consist of?

Bronchiolitis manifests itself indeed in babies under two years of age with a cold, then coughing fits which may be accompanied by wheezing. The child may be embarrassed to breathe as well as to eat and drink. In some cases, which remain rare, hospitalization is necessary.

Respiratory physiotherapy, which can take different forms, then aims to “move the mucus from the bronchi to the throat by pressure from the hands on the ribs and belly, the physiotherapist will release the air from the lungs to make move the mucus up to the throat “, explains a page from the Bordeaux University Hospital, devoted to this technique. It is stressed that “these physiotherapy techniques can be impressive but are neither painful nor dangerous”.

With respiratory physiotherapy, “we treat the symptoms of the disease, it is not a treatment to cure it”, explains to Antoine Rousseaux, physiotherapist. He underlines moreover that “the physiotherapist is paramedical, one never sees the children without medical recommendation, without the approval of the attending physician, who first auscultates the sick baby.

After practicing this gesture, “the baby breathes and sleeps better,” Sébastien Guérard, president of the FFMKR (French Federation of Physiotherapists Rehabilitation Masseurs), explains to, because his ways are no longer blocked.

Recommendations are aimed at children under 12 months of age

It should now be emphasized that the HAS recommendations concern a very specific part of patients: “management of the first episode of acute bronchiolitis in infants under 12 months”. But bronchiolitis affects babies up to about two years old, and they can develop the disease several times.

For HAS, “respiratory physiotherapy techniques by postural drainage, vibration, clapping are contraindicated in acute bronchiolitis”, and those “by increased expiratory flow (AFE) is not recommended in hospitalized infants”, ie a baby with severe bronchiolitis, otherwise worrying symptoms. Respiratory physiotherapy can however be discussed when the child has comorbidities, but it is “not recommended” on an outpatient basis, due to a lack of data on it.

For “the light forms, those which one does not hospitalize, they are forms which do not require the physiotherapy because there is, obviously, no utility, and no evidence that we bring something “to the baby, also explains Pierre-Louis Druais.

In any case, respiratory physiotherapy is not systematically practiced as soon as a child is sick, underlines Antoine Rousseaux. After the doctor’s recommendation, “we look at the context, the age of the baby, if he is too young or too tired, we do not necessarily practice it”. He further emphasizes that the techniques cited in the report have evolved, “the clapping is over”.

A lack of data on this practice

“French physiotherapists have not practiced these techniques for several decades”, assure l’Ordremk (Order of physiotherapists), citing vibrations, clapping and postural drainage. “We now practice mainly very slow practices, adapted to the child, so that the latter is not too embarrassed by our maneuvers”, declared in February 2020 on BFM Lyon Philippe Joud, respiratory physiotherapist.

In short, the HAS recommendations are therefore only intended for a portion of patients with bronchiolitis, and respiratory physiotherapy is currently not really prohibited. “The recommendations of the HAS are non-normative”, reminds Sébastien Guérard.

In their opinion there is, moreover, no concept of danger, it is especially underlined that there is a lack of data on the effectiveness of respiratory physiotherapy. “There is a lack of studies to prove that this has an interest, that is the problem”, declares Philippe Joud.

“Clear the baby’s nose and show how to do it”

The publication of these recommendations has, for the physiotherapists interviewed by, harmed the profession, and could have kept parents away from their practices, while their role is not limited to the practice of respiratory physiotherapy facing bronchiolitis.

In the context of this disease, consultations with physiotherapists make it possible “to see the patient every day, to watch his progress, and only if the situation worsens to send him to the hospital”, explains Sébastien Guérard. Their intervention makes it possible, for example, to avoid the systematic passage to pediatric emergencies as soon as the child has difficulty breathing. The practitioner must indeed “monitor” the state of the baby, agrees the Bordeaux University Hospital, “he will tell you if necessary if you must return to see the attending physician or if your baby must be hospitalized”.

There is also an educational and pedagogical side, because the physiotherapist must also intervene “to clear the baby’s nose and show the parents how to do it”, explains the Bordeaux University Hospital.

In addition to respiratory physiotherapy, in mild or moderate cases of the disease, it is in fact possible to limit the symptoms of the baby thanks to “techniques for clearing the upper airways, without nasopharyngeal aspirations”, writes the HAS. “The management is based above all on a regular nose wash and monitoring for signs of worsening of the infant’s condition”, she assures.

A still relevant practice

The HAS recommendations were followed by a year when, due to barrier actions and confinements linked to Covid-19, the bronchiolitis epidemic was very low. It is therefore difficult for physiotherapists to assess the impact of these recommendations on patients. “There are some doctors who will no longer prescribe respiratory physiotherapy, but others will continue,” says Sébastien Guerard.

However, the first observations on this subject have started in recent days, as a new epidemic of bronchiolitis is currently spreading, and promises to be stronger than the previous ones. And “yes we see the parents coming for a respiratory physiotherapist”, declares the president of the FFMKR. “Last weekend alone, the permanence of respiratory physiotherapists in Gironde was called 140 times”, also writes LCI.

Hospitalizations for bronchiolitis in children under 2 years of age compared to the previous 2 years
Hospitalizations for bronchiolitis in children under 2 years of age compared to the previous 2 years © Santé Publique France

“I see a patient today for that”, declares for his part Antoine Rousseaux, explaining that this is not his first. However this year, “it is certain that one walks a little more on eggshells with the parents, that one must explain the process to them more”.

Today there is no direct treatment for bronchiolitis, the existing methods are only used to calm the symptoms of the disease. To prevent the infant from catching it, it is necessary to respect the barrier gestures, to wear a mask in the event of cough and to avoid the very frequented places. In France, 30% of children under 2 are affected by bronchiolitis each year, or nearly 500,000 individuals.

Salome Vincendon

Salome Vincendon BFMTV reporter

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