Abstract
Background
Chest physiotherapy for hospitalized patients with COVID-19 has been poorly reported. Although recommendations were published to guide physiotherapists, practice might have differed depending on education and training.
Objective
To analyze the differences in chest physiotherapy applied for hospitalized patients with COVID-19 between certified specialists and non-certified specialists.
Methods
An online questionnaire survey was developed for physiotherapists involved in the management of hospitalized patients with COVID-19. The questionnaire inquired about professional information and characteristics of physiotherapy practice.
Results
There were 485 respondents, yielding a completion rate of 76%. Of these, 61 were certified specialists and 424 non-certified specialists. The certified specialists were older, had more years of professional experience, were more qualified, and had better job conditions. For mechanically ventilated patients, the certified specialists used the ventilator hyperinflation maneuver more frequently (50.4% vs 35.1%, p=0.005), and the hard/brief expiratory rib cage compression (ERCC) (26.9% vs 48.3%, p=0.016), soft/long ERCC (25.2% vs 39.1%, p=0.047), and manual chest compression-decompression (MCCD) maneuver (22.4% vs 35.6%, p=0.001) less often. For spontaneously breathing patients, the certified specialists used the active cycle of breathing technique (30.8% vs 67.1%, p<0.001), autogenic drainage (7.7% vs 20.7%, p=0.017), and MCCD maneuver (23.1% vs 41.4%, p=0.018) less frequently.
Conclusions
Certified specialists with higher levels of expertise seem to prefer the use of chest physiotherapy techniques that are applied with the mechanical ventilator over manual techniques. Furthermore, they use techniques that could potentially increase the work of breathing less frequently, mitigating the risk of exacerbating respiratory conditions in patients with COVID-19.
Keywords: Survey, COVID-19, Physiotherapy, Hospitalization, Critical illness, Respiratory therapy
Introduction
Physiotherapy practice for hospitalized patients has been poorly reported worldwide. Moreover, physiotherapists’ tasks differ among countries, hospital types, personal availability, and training, which hampers comparison and best practice assessment.1
The main tasks often assigned to physiotherapists working in hospitals are to promote airway clearance and pulmonary re-expansion (usually called chest physiotherapy), avoid deconditioning and reduction of functional capacity, and manage invasive and noninvasive mechanical ventilation.2 Among these four clinical tasks, chest physiotherapy appears to be the most contentious, requiring a more substantial body of evidence at present. Although it is widely agreed that chest physiotherapy should only be applied when there is a clear indication, such as heavy sputum, secretion retention, or reduced pulmonary volume, there is a lack of evidence on which techniques to use.1,3
Recently, we published the results of our study that provided an overview of physiotherapy practice for hospitalized patients with COVID-19 in Brazil.4 We found great variability in chest physiotherapy techniques when compared with mobilization therapies. Also, it was clear that chest physiotherapy techniques considered effective were underutilized. Since we now have a better understanding of COVID-19, we decided to revise our study data and found that physiotherapy practice differed when the respondents were grouped according to qualification into certified specialists versus non-certified specialists. In Brazil, there are postgraduate specialization courses (Lato Sensu) designed to prepare physiotherapists to work in intensive and hospital care. These courses last at least 360h, their theoretical and practical training programs may vary across institutions and are all regulated by the Brazilian Education Ministry. However, to become a certified specialist, Brazilian physiotherapists must be approved in a rigorous exam, which consists of a theoretical test and an evaluation of titles, performed by the Associação Brasileira de Fisioterapia Cardiorrespiratória e Fisioterapia em Terapia Intensiva (ASSOBRAFIR, Brazilian Association of Cardiorespiratory Physiotherapy and Intensive Care Physiotherapy) and accredited by the Conselho Federal de Fisioterapia e Terapia Ocupacional (COFFITO, Federal Council of Physiotherapy and Occupational Therapy).
We hypothesized that having a specialist title is relevant in influencing physiotherapy practice. Therefore, this study aimed to explore the differences in chest physiotherapy interventions applied for hospitalized patients with COVID-19 between certified specialists and non-certified specialists.
Methods
This was a cross-sectional, online, questionnaire survey and was approved by the Research Ethics Committee of Federal University of Sao Paulo (number 44,771,021.2.0000.5505).4 The study methods were reported in detail elsewhere. Briefly, physiotherapists who treated hospitalized patients with COVID-19 in Brazil for at least two months were eligible to complete the survey. Recruitment occurred between June 2021 and October 2021. The respondent to be considered a certified specialist had to have a specialist title recognized by the ASSOBRAFIR and certified by the COFFITO. The specialist title could pertain to any of the three areas associated with physiotherapy care to adult patients, namely, respiratory, intensive care, and cardiovascular.
The questionnaire was designed within a secure, web-based software platform - REDCap - hosted at the Universidade Federal do Ceará.
The survey consisted of 50 questions regarding professional information, characteristics of the respondent's hospital of employment, reasons for indications for physiotherapy, and respiratory/mobilization interventions. When answering questions regarding technique application, participants were instructed to assume that the patients had favorable clinical conditions for their use. This precaution was intended to prevent patient clinical status from impacting the selection of the technique.
The questions regarding indications for physiotherapy and the interventions used were closed-ended and scored on a five-point Likert scale; response options were “very frequently”, “frequently”, “occasionally”, “rarely”, or “never.” Questions about using a specific instrument, such as incentive spirometer, also had a “not available” option. Responses marked as “rarely” or “never” opened another question asking why that specific instrument or technique was “rarely” or “never” used.
In this manuscript, only the answers regarding chest physiotherapy interventions are presented.
Statistical analysis
Data are reported as median (IQR) for numerical data or absolute and relative frequencies for categorical data. The Mann-Whitney test or the Chi-Square test, as appropriate, was used to analyze qualitative variables. The Mann-Whitney test was performed to compare ordinal variables between the two groups, certified vs non-certified specialists.
To confirm our hypothesis that physiotherapy practice could be predicted by the qualification of being a certified specialist, two dependent variables - manual-techniques and ventilator-techniques - were created. The Likert scale was simplified on a three-point score; response options “very frequently” and “frequently” were grouped as well as “rarely” and “never”, and “occasionally” was kept unchanged. Then, the Likert scale data were transformed into numerical values. Manual-techniques variable was calculated as the mean score for the questions that inquired about the following techniques: chest vibration, percussion, hard/brief expiratory rib cage compression (ERCC), soft/long ERCC, and compression-decompression maneuver. Ventilator-techniques variable was calculated as the mean score for the questions about alveolar recruitment maneuver and ventilator hyperinflation.
The strength of the relationships between manual-techniques and ventilator-techniques scores and other variables was evaluated with univariate regression analysis. Variables with a p-value <0.1 were included in two ordinal logistic regression analyses, with manual-techniques and ventilator-techniques scores as the dependent variables. The independent variables tested were being a certified specialist, having a specialization degree (lato sensu postgraduate course), age, working experience, Brazilian regions, hospital type, and hospital connection to the university. The significance level of p<0.05 was considered. The software used was SPSS version 22.
Results
Sample characteristics
The number of physiotherapists who consented to participate and initiated the questionnaire was 643, of whom 488 completed the survey, yielding a completion rate of 76%. However, 3 respondents were excluded because they completed the survey in less than 10min. Of the 488 respondents, 61 were certified specialists and 427 non-certified specialists, their characteristics and of their institutions are presented in Table 1.
Table 1.
Characteristics of the respondents and of their primary hospital of employment.
| Non-certified Specialist (n=424) | Certified Specialist (n=61) | p | |
|---|---|---|---|
| Age (years) | 32 [27–39] | 38 [35–44] | <0.001 |
| Gender, n (%) | 0.962 | ||
| Male | 110 (25) | 16 (26) | |
| Female | 314 (74) | 45 (73) | |
| Time since graduation (years) | 8 [4–14] | 14 [10–21] | <0.001 |
| Region of Brazil, n (%) | 0.519 | ||
| Southeast | 268 (63) | 30 (49) | |
| Northeast | 89 (21) | 13 (21) | |
| South | 42 (9) | 12 (19) | |
| Midwest | 16 (3) | 5 (8) | |
| North | 9 (2) | 1 (1) | |
| Qualifications, n (%) | |||
| Postgraduate specialization course related to in-hospital physiotherapy of at least 360 h | 335 (79) | 55 (90) | 0.040 |
| Stricto sensu degree including master, PhD, and post-doctoral titles | 66 (15) | 30 (49) | <0.001 |
| Hospital experience, n (%) | <0.001 | ||
| Between 2 and 11 months | 61 (13) | 2 (3) | |
| Between 1 and 5 years | 166 (39) | 3 (4) | |
| > 5 years | 197 (46) | 56 (91) | |
| Workplace setting, n (%) | 0.641 | ||
| Ward | 45 (10) | 2 (3) | |
| ICU | 178 (42) | 35 (57) | |
| Both | 201 (47) | 24 (39) | |
| Type of hospital, n (%) | 0.248 | ||
| Public | 275 (64) | 45 (73) | |
| Private | 114 (26) | 10 (16) | |
| Others | 35 (8) | 6 (9) | |
| Hospital connection to university, n (%) | 0.039 | ||
| Yes | 157 (37) | 31 (50) | |
| No | 267 (63) | 30 (49) | |
| Employment contract, n (%) | <0.001 | ||
| Public servant | 45 (10) | 22 (36) | |
| Public servant with CLT | 41 (9) | 10 (16) | |
| CLT | 203 (47) | 23 (37) | |
| Outsourced | 92 (21) | 3 (4) | |
| Others | 43 (10) | 3 (4) | |
| Number of patients seen in ICU per 6h-shift | 10 [7–10] | 8 [6–10] | 0.019 |
| Number of patients seen in ward per 6h-shift | 10 [8–12] | 8 [7–10] | 0.016 |
| Training in COVID-19, n (%) | 367 (86) | 58 (95) | 0.059 |
| Type of training in COVID-19, n (%) | |||
| Virtual classes | 325 (76) | 55 (90) | 0.017 |
| Virtual classes of at least 10h | 193 (45) | 31 (50) | 0.438 |
| Reading articles | 335 (79) | 56 (91) | 0.018 |
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Ordinary data are expressed as median [IQR]. CLT: employment contract according to the Consolidated Labor Laws-Brazil; ICU: intensive care unit.
The certified specialists were older (38vs 32 years, p<0.001) and had more years of professional experience (14vs 8 years, p<0.001) compared to the non-certified specialists. In terms of postgraduate qualifications, the certified specialists reported having more postgraduate specialization (90% vs 79%, p=0.040) and stricto sensu degree (49% vs 15%, p<0.001) compared to non-certified specialists.
Regarding the length of hospital working experience, in both groups, most of the respondents had more than 5 years of experience, but with a higher percentage for certified specialists (91%) compared to non-certified specialists (46%) (p<0.001).
Although most of the respondents of both groups worked in public hospitals (73% vs 64%), the institutions where the non-certified specialists worked were less connected to universities (37% vs 50%) (p=0.039).
Most of the non and certified specialists had employment contracts according to the Consolidated Labor Laws of Brazil, 47% and 37% respectively, but certified specialists had more public employees and fewer outsourced contracts (p<0.001). In a 6-hour shift, the median of patients seen by the certified specialists, both in the ICU and in the ward, was 8, and for non-certified specialists, 10 patients (p<0.02).
Predictors of manual-technique and ventilator-technique variables
Univariate analysis identified three potential predictors for ventilator-techniques variable: being a certified specialist (p=0.046), Brazilian regions (p=0.001), and hospital type (p=0.010); for manual-techniques, three variables were identified: being a certified specialist (p=0.018), Brazilian regions (p=0.001), and hospital connection to university (p=0.045) (Table 2). In the multivariate ordinal regression model with ventilator-techniques as the dependent variable, Brazilian regions and type of hospital were significant, and being a certified specialist was marginally significant (p=0.060). In the multivariate ordinal regression model with manual-techniques as the dependent variable, all included variables were significant (Table 2). The analysis showed that the non-certified specialists used more frequently manual techniques than the specialists (OR=2.03 [1.14- 3.59]).
Table 2.
Ordinal logistic model of the dependent variables: manual-techniques and ventilator-techniques.
| Variables | Manual-techniques | Ventilator-techniques | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Univariate model | Multivariate model | Univariate model | Multivariate model | ||||||||||
| OR | IC 95% | p-value | OR | IC 95% | p-value | OR | IC 95% | p-value | OR | IC 95% | p-value | ||
| Certified Specialist | No | 1.95 | 1.12–3.38 | 0.018* | 2.03 | 1.14–3.59 | 0.016* | 0.58 | 0.34–0.99 | 0.046* | 0.60 | 0.35–1.02 | 0.060 |
| Yes | 1 | – | – | 1 | – | – | 1 | – | – | 1 | – | – | |
| Age (years) | 0.990 | 0.97- 1.01 | 0.359 | 1.01 | 0.99–1.03 | 0.341 | |||||||
| Specialization | No | 1.24 | 0.78–1.97 | 0.369 | 0.97 | 0.61–1.56 | 0.911 | ||||||
| Yes | 1 | – | – | 1 | – | – | |||||||
| Working experience | Less than 1 y | 1.50 | 0.85–2.64 | 0.163 | 1.07 | 061–1.85 | 0.824 | ||||||
| Between 1 and 5ys | 1.18 | 0.80–1.73 | 0.403 | 1.15 | 0.79–1.67 | 0.477 | |||||||
| More than 5 ys | 1 | – | – | 1 | – | – | |||||||
| Brazilian regions | North & Northeast | 0.56 | 0.30–1.05 | 0.070 | 0.55 | 0.29–1.04 | 0.066 | 2.93 | 1.53–5.60 | 0.001* | 3.13 | 1.62–6.03 | 0.001* |
| Central west | 0.14 | 0.04–0.53 | 0.004* | 0.14 | 0.04–0.53 | 0.004* | 1.47 | 0.56–3.87 | 0.438 | 1.38 | 0.52–3.70 | 0.519 | |
| Southeast | 1.05 | 0.61–1.81 | 0.857 | 0.97 | 0.56–1.70 | 0.902 | 1.25 | 0.72–2.17 | 0.432 | 1.45 | 0.82–2.55 | 0.201 | |
| South | 1 | – | – | 1 | – | – | 1 | – | – | 1 | – | – | |
| Type of hospital | Public | 1 | – | – | 1.13 | 0.60–2.13 | 0.714 | 1.16 | 0.61–2.22 | 0.645 | |||
| Private | 1.04 | 0.68–1.57 | 0.869 | 0.55 | 0.37–0.83 | 0.004* | 0.60 | 0.39–0.90 | 0.014* | ||||
| Others | 0.76 | 0.40–1.46 | 0.410 | 1 | – | – | 1 | – | – | ||||
| Hospital connection to university | No | 0.69 | 0.48–0.99 | 0.045* | 0.69 | 0.47–1.00 | 0.050* | 0.77 | 0.54–1.11 | 0.165 | |||
| Yes | 1 | – | – | 1 | – | – | 1 | – | – | ||||
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* p<0.05.
Frequency of used chest physiotherapy techniques for mechanically ventilated patients in the ICU
The airway clearance technique most frequently used for mechanically ventilated patients by both groups was positioning (certified specialists, 78.3% vs non-certified specialists, 81.8%) and the least used was chest percussion (certified specialists, 0% vs non-certified specialists, 0.5%) (Fig. 1). Certified specialists used the ventilator hyperinflation maneuver more frequently (50.4% vs 35.1%, p=0.015), and the hard/brief ERCC (26.9% vs 48.3%, p=0.016) and soft/long ERCC (25.2% vs 39.1%, p=0.047) less often compared to non-certified specialists. No significant difference was found for the other techniques.
Fig. 1.
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The most cited lung re-expansion techniques by certified and non-certified specialists, respectively, were positioning (94.9% vs 88.1%) and alveolar recruitment maneuvers (66.1% vs 74.4%). Certified specialists used the manual compression-decompression maneuver less frequently than non-certified specialists, with “never” using being cited by 35.6% of certified specialists and 22.4% of non-certified specialists (p=0.001). No significant difference was found for the other techniques.
Frequency of used chest physiotherapy techniques for spontaneously breathing patients in the ward
The three most frequently used airway clearance techniques for spontaneously breathing patients by the two groups (certified and non-certified specialists, respectively) were positioning (73.1% vs 78.0%), assisted coughing (61.5% vs 76.0%), and forced expiration technique (57.7% vs 59.0%) (Fig. 2). The least used techniques by the two groups were chest percussion (0% and 0.8%) and slow and complete expiration in the lateral posture with opened glottis (ELTGOL) (0% and 11.3%).
Fig. 2.
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Certified specialists used the active cycle of breathing technique (ACBT) (30.8% vs 67.1%, p<0.001) and autogenic drainage (7.7% vs 20.7%, p=0.017) less frequently than non-certified specialists. No significant difference was found for the other techniques.
The lung re-expansion techniques most often used as “very frequently” and “frequently” for certified and non-certified specialists, respectively were active prone position (76.9% vs 90.6%), breathing exercises (73.1% vs 89.8%), and continuous positive airway pressure (CPAP) (84.6% vs 75.6%). The manual chest compression-decompression maneuver was less used by certified specialists (23.1% vs 41.4%, p=0.018). No significant difference was found for the other techniques. The incentive spirometer was “never” used by 61.5% of certified specialists and 44.3% of non-certified specialists (p=0.138).
Reported reasons for not using chest physiotherapy techniques
Fig. 3A and B show the relative frequencies of the reasons selected to explain why the respondents “never” or “rarely” used certain techniques for mechanically ventilated and spontaneously breathing patients, respectively. For the techniques applied to mechanically ventilated patients, the certified specialists selected “not knowing the technique” and “the technique was not part of their institution's protocol” less frequently, and “the clinical condition of most patients With COVID-19 is quite critical” more frequently compared to non-certified specialists (p<0.001).
Fig. 3.
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For the techniques applied to spontaneously breathing patients, the certified specialists selected “the technique could bring more harm than benefit to the patient” more frequently, and “the technique was not part of their institution's protocol” less frequently compared to non-certified specialists (p<0.001).
Discussion
The main findings of this study revealed that certified specialists, i.e., better-qualified professionals, utilized manual chest physiotherapy interventions and energy-demanding techniques, such as ACBT, less frequently than non-certified specialists.
The multivariate ordinal regression analyses showed that the Brazilian regions and being certified specialists influenced chest physiotherapy practice. As the distribution of respondents across Brazilian regions was uneven, with inadequate representation from three out of the five regions (North, Central-West, and South), the examination of physiotherapy practice based on certification status was a sensible approach. Of note, Brazil is the fifth-largest country in the world by land area and its five regions have unique cultural, economic, educational, and climatic attributes. This led us to consider that physiotherapy practice may vary across these regions. Nonetheless, the absence of a worldwide consensus on the most effective chest physiotherapy approach for mechanically ventilated patients, including non-COVID-19 cases, is a crucial factor that supports our view that these practices may vary across them.
Importantly, the multivariate ordinal regression analyses also showed that age, working experience, and postgraduate specialization courses were not independently associated with chest physiotherapy practice. However, it is noteworthy that our multivariate regression analysis revealed a positive correlation between the use of manual chest techniques and affiliation with a university. This indicates that a hospital's association with a university, in the absence of appropriate training, may not necessarily lead to improved practices. However, we caution against overemphasizing this finding.
The certified specialists clearly had different characteristics than the non-certified specialists. They were more qualified, had more working experience, and mainly worked in ICU- a setting that requires more training. They also had better working conditions illustrated by better job contracts and fewer patients seen per 6h-shift. Moreover, their institutions were more connected to universities which incentives the recycling of knowledge. Finally, the certified specialists seldom cited unfamiliarity with specific techniques as a justification for refraining from their application. These discrepancies likely suggest that the attainment of the certified specialist title did not solely render physiotherapists more qualified professionals. Rather, it is more reasonable that the result of their pursuit of better training and qualifications enabled them to earn the title and thereby, acquire better working conditions.
The inclination of certified specialists to apply mechanical ventilation-assisted techniques rather than manual techniques can be considered a scientifically optimal choice. The utilization of a mechanical ventilator during chest physiotherapy presents the distinct advantage of enabling the monitoring of respiratory mechanics, thereby providing real-time feedback on the efficacy of the technique.5 A recent systematic review has established that chest physiotherapy interventions that augment tidal volume may facilitate the removal of secretions and enhance lung compliance in adult patients with pneumonia receiving invasive ventilation.6 Furthermore, "in vitro" and animal studies have demonstrated that increasing the expiratory flow bias, mainly via a reduction of inspiratory flow, can effectively enhance secretion clearance.7,8 In light of these findings, the use of a mechanical ventilator during chest physiotherapy is likely the most effective and secure method for ensuring that tidal volume increment and expiratory flow bias are achieved.
Moreover, until now, there is no high-quality evidence that supports the use of manual techniques like percussion and vibration in hospitalized patients. One of the methodological limitations of studies about manual techniques is that their delivery is hard to standardize. It is known that their performance may be influenced by age, clinical experience, and hand grip, not to mention that they are physically laboring.9,10
Curiously, percussion and vibration are still frequently used for mechanically ventilated patients and even recommended by experts.11 Recent studies reported the use of percussion and chest wall vibrations varying from 20% to 100% during physiotherapy treatments for ICU patients without COVID-19.1,12, 13, 14, 15 Also, an international survey about physiotherapy practice for patients with COVID-19 showed that percussion and vibration were used for mechanically ventilated patients by 74% of the respondents.16 Yet, the comprehension of vibration use requires caution because the technique is rarely well described and may be applied as a fine oscillatory or coarse movement to the thorax, combined or not to ERCC.
We found in our study that chest percussion was seldom used for mechanically ventilated and spontaneously breathing patients even by non-certified specialists. However, chest vibration was frequently applied by 27.3% and 35.9% of certified specialists and non-certified specialists, respectively. Nevertheless, we believe the reported percentages of vibration usage would be substantially reduced, similar to percussion, had the survey question not allowed for the inclusion of its application in conjunction with ERCC. Importantly, the most frequent reasons chosen to explain why the techniques were rarely and never used were the belief that they have no scientific evidence supporting their efficacy and that others are more effective, but not the risk of creating COVID-19 airborne transmission. These findings support that Brazilian physiotherapists are likely not applying chest percussion even to patients with other diseases than COVID-19.
Concerning the ERCC technique, the use of soft/long ERCC has already been shown to reduce residual functional capacity in mechanically ventilated pigs, worsening lung mechanics, gas exchange, and cardiac output, and therefore it should not be recommended to critical patients.17 On the other hand, the hard/brief ERCC has some evidence that supports its use to improve airway clearance.17,18 Moreover, the effectiveness of hard/brief ERCC can be checked at the bedside in mechanically ventilated patients. If its application in synchronization with the beginning of the end-expiratory phase does not increase the peak expiratory flow, the maneuver is probably of no benefit to that patient.
Alveolar recruitment maneuvers were one of the most cited lung re-expansion techniques as frequently used by both certified and non-certified specialists. Although their efficacy is controversial, the Brazilian Health Ministry's guideline for managing mechanically ventilated patients with COVID-19 recommended prone positioning or applying an alveolar recruitment maneuver followed by PEEP titration if the patient had a PaO2/FiO2 < 150mmHg or was being ventilated with PEEP>14 cmH2O and FIO2> 70%.19,20,21 The interdisciplinary team typically discussed which strategy to apply, always requiring the physician's participation in the process. The maneuver was also recommended as rescue therapy in cases of refractory hypoxemia. Physiotherapists usually performed the alveolar recruitment maneuver and PEEP titration, but a physician and/or a nurse were present in the room to provide assistance as needed. Due to COVID-19′s lung heterogeneity, the alveolar recruitment maneuver was brief and respected a maximum inspiratory pressure of 40 cmH2O or 45 cmH2O for patients with a body mass index > 30kg/m2.
Regarding chest physiotherapy for spontaneously breathing patients, the use of breathing exercises and ACBT for hospitalized patients with COVID-19, although recommended by guidelines and experts is controversial.22, 23, 24 COVID-19 is characterized by severe lung inflammation, reduced lung reserve, hypoxia, and high risk of respiratory failure.25 Strategies that increase the inspiratory effort may provide high transpulmonary pressure swings and aggravate lung damage through patient-self-inflicted lung injury (P-SILI).26 In this sense, a better strategy for lung re-expansion in spontaneously ventilated patients may be the use of CPAP with careful monitoring of respiratory work and tidal volume. The knowledge of P-SILI risk might explain the less use of ACBT and autogenic drainage by the certified specialists.
This study has some limitations. Since it was not probabilistic, our sample probably does not accurately represent the overall physiotherapy practice in Brazil. In the pandemic context, it is likely that the most qualified subjects were selected to work at the COVID-19 reference hospitals, which explains a higher percentage of professionals with lato sensu postgraduation in our sample. Moreover, only a few physiotherapists were certified specialists, what may have underpowered the multivariate analysis and intergroup comparisons. Even though, this study included professionals from every Brazilian region and a meaningful sample of 488 physiotherapists. Therefore, we believe that this work highlights the importance of the regulatory and professional associations in promoting the specialist title certification and brought an opportunity to discuss the rationale of manual chest physiotherapy techniques.
Conclusions
Certified specialist physiotherapists with greater expertise are less likely to employ techniques that may increase the work of breathing which is not recommended for patients with COVID-19. In addition, the certified specialists tend to favor chest physiotherapy techniques that are administered with mechanical ventilators instead of manual techniques. This preference is supported by scientific evidence and should be considered during the standardization of chest physiotherapy treatment for mechanically ventilated patients, as well as in future research.
Declaration of Competing Interest
The authors declare no conflicts of interests.
Acknowledgments
Funding sources
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Acknowledgments
The authors would like to thank the physiotherapists who completed the survey, as well as the ASSOBRAFIR, CREFITO-1, CREFITO-3, CREFITO-4, CREFITO-12, and CREFITO-18 for sharing the questionnaire.
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