Physiotherapy guidelines and protocols in paediatric intensive care: a document analysis
Issue Name: Phys Resp Care Volume 1 (1)
Issue Date: 30 July 2026
Article Location: p30-40
Emma Shkurka Harriet Shannon Jo Wray
DOI: https://doi.org/10.56792/HTQG5125
Lead Author: Emma Shkurka emma.shkurka@gosh.nhs.uk
Introduction
Respiratory physiotherapy is a frequently used treatment within UK paediatric intensive care units (PICUs).1 Treatment aims to facilitate airway clearance, improve ventilation and minimise complications associated with a PICU admission.2,3 Physiotherapists use a range of airway clearance techniques, including manual/ventilator hyperinflations, positioning and mechanical adjuncts.1,4 Variations in practice have been described and attributed to limited evidence, individual preferences of those training staff and local policies.1 How physiotherapists make treatment decisions is particularly important in this context due to the complex nature of the PICU environment, together with the necessity for quick decisions and timely treatments.
Clinical decision-making has been described as the core competency of professional practice, defined as taking the best judged action in a specific context.5 Several authors have studied physiotherapists’ decision-making in the adult respiratory setting, where it was identified as a dynamic and multidimensional process, with physiotherapists utilising multiple sources of information.6–8 More recently, physiotherapists’ decision-making on PICU has been described as complex, iterative and collaborative, with experience and expertise important factors.9
Within healthcare, documents such as protocols and guidelines are reportedly used to improve the quality of care, standardise practice and ensure evidence-based practice.10,11 Given the variations in physiotherapy practice, the need to adhere to organisational protocols/guidelines may influence decision-making and treatment delivery. Therefore, this study aimed to determine the availability of local organisational documents related to respiratory physiotherapy and explore these documents in relation to decision-making support.
Methods
Study design
This was a qualitative study involving document analysis. ‘Documents’ were defined as ‘textual content not generated by the researcher’ and the focus was organisational documents.12 Document analysis can examine the production, content, and engagement with the documents, with the aim of understanding the document within its social and textual context.13,14 This study focussed on the function and content of the documents. Data collection took place between April 2021-March 2022.
Sample and recruitment
The lead physiotherapist at each of the 27 UK NHS PICUs was contacted via email and invited to participate.15 Requests were made for organisational documents that related to respiratory physiotherapy assessment or treatment of children on PICU.
Ethical considerations
The study was part of a project approved by the Health Research Authority (278215). Ethical approval was not required as this study only involved documents.
Data collection
Document copies were sent directly to the researcher via email. Demographics including geographical region and size of PICU unit (based on number of admissions <16 years in 2019: small <500, medium 500 -799, large ≥80015) were recorded for responding units.
Data analysis
Framework analysis, involving five interconnected stages, was used for data analysis.16 See Supplementary material I for details. Following initial familiarisation, frameworks were created based on document subject. This was a variation to classic framework analysis; however, allowed easier comparison between cases and is still considered a valid approach.17 Themes were developed deductively from the aims of the study. Indexing of the documents was completed by hand and charting completed in NVivo. During the interpretation and mapping phase framework summaries for the themes were created. Analysis was completed by the lead researcher (ES) and final frameworks verified by the research team.
The lead researcher was a PhD student and physiotherapist working in a UK PICU. Her clinical background enabled understanding of the clinical context and documents. By adopting a researcher role and engaging in reflexivity, the influence of personal opinions and experiences was acknowledged and minimised. Additionally, using Framework analysis ensured the results were data driven.17
Data security
Each document was assigned a unique document number and identifiable data were removed. PICU name and document number were stored separately and securely.
Results
Responses were received from 70% (19/27) of UK NHS PICUs. Table I displays the number of responding sites from each geographical region. Of the PICUs who responded, six were classified as large sites, eight medium and five small.
Fifteen (79%) of the 19 PICUs reported having organisational documents related to respiratory physiotherapy, with four reporting no documents. In total, the 15 units reported 39 documents, with copies of 29 of these shared with the researcher. Nine PICUs shared all their documents, three provided copies of certain documents but not all, and the remaining three PICUs did not share any. The decision to provide copies was at the discretion of the lead physiotherapist. Table II outlines the subjects of all documents reported (n=39) and summarises details of the documents received (n=29). The subject of the documents encompassed three areas: disease, physiotherapy techniques and mucoactive agents. The majority, 86% (25/29), were related to physiotherapy techniques.
All 29 documents received were included in the analysis. In total 11 frameworks were created linked to the different subjects, with each including two themes. The framework subjects and themes are listed below:
Frameworks
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Bronchiolitis
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Directed saline lavage
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High frequency chest wall oscillation (HFCWO)
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Manual assisted cough
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Manual techniques
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Metaneb
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Manual hyperinflations (MHI)
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Manual insufflation/exsufflation (MI-E)
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Non-bronchoscopic broncheoalveolar lavage (NBBAL)
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Ventilator hyperinflations (VHI)
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Mucoactive agents
Themes
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Purpose
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Content
The individual frameworks, including case summaries, are displayed in Supplementary material II. The results are presented as a narrative including document extracts in Table IV identified by document number (D).
Document purpose
Table III displays framework summaries for the theme of document purpose. Nine documents were relevant to all paediatric patients within the hospital, 19 exclusively to intubated and ventilated patients, and one to both invasively and non-invasively ventilated children. Several of the documents aimed to facilitate a standardised and consistent approach to treatment. This was linked to ensuring safety and effectiveness (Table IV, extracts 1 & 2). Ensuring evidence-based practice was also frequently included within the purpose of the documents, illustrated in extracts 3 and 4 (Table IV). Several of the documents were designed to support training and ensure competency in the use of treatments (Table IV, extracts 5 & 6). Eight of the documents did not explicitly outline their purpose.
Document content
Framework summaries related to the content of the documents are displayed in Table III. There was a clear difference in the content of the documents depending on document type. The standard operating procedures (SOPs) were procedural and practical, and focussed on description and providing a ‘how to’ guide for completing the technique. Although potential complications and risks were stated, there was no guidance for management of these or support for decision-making. Three of the SOPs, all from the same unit, explicitly stated that physiotherapists must use their own clinical reasoning (Table IV, extract 7).
The content and detail of the clinical guidelines varied. All documents provided indications and included a step-by-step procedural guide. Several of the documents used photographs to depict equipment and/or how to complete the technique. Contra-indications, complications and risks were included in most of the guidelines. However, the depth of detail provided varied, as demonstrated in extracts 8 and 9 (Table IV). Five of the documents provided additional information on how to manage or avoid unwanted effects, offering the reader practical support for decision-making. The more comprehensive documents also included guidance on how to adapt the treatment to improve its effectiveness (Table IV, extracts 10 & 11).
Ten documents were well referenced and evidence based. A further four included a comprehensive reference list, although these were not integrated into the body of the document. Documents from multiple PICUs were received for six of the framework subjects, Figure 1 summarises the comparison of techniques described within these documents. Similarities included indications for use, contraindications and safety considerations. Several differences were apparent related to personnel involved and the procedure itself, including pressure settings and length of treatment.
Discussion
Most centres in this study had access to documents relevant to respiratory physiotherapy on PICU. Documents analysed related to specific physiotherapy techniques or treatment adjuncts. Excluding NBBAL, they are all recognised treatment options within the profession.1,18 Most documents were related to NBBAL, MHI, VHI, and MI-E, which may be related to the complexity and/or risk of the interventions, or frequency of use.
NBBAL was the most common focus of the documents. This diagnostic procedure obtains samples from the lower respiratory tract to determine causative pathogenic organisms.19 Reported complications of NBBAL include desaturation, bradycardia and pulmonary haemorrhage.19,20 NBBAL is often completed on critically ill children which, coupled with the potential hazards described above, make this a high-risk procedure. Manual and ventilator hyperinflations were also common subjects of the documents analysed. This may be due to the techniques’ popularity within PICU.1,4 MHI with chest wall vibrations was the most commonly used treatment in a study based in a Canadian PICU.21 The VHI documents received in this study were all created after 2020, indicative of a response to the COVID19 pandemic. Published guidance advised against ventilator disconnection, recommending VHI as a first line treatment for COVID19 patients.22,23
Variation in physiotherapy techniques was apparent in this study. Variation in physiotherapy practice is well documented in the adult intensive care setting.6,24,25 Although MI-E is well established in the paediatric neuromuscular population the settings used vary.26,27 There is limited evidence for optimal titration and studies are limited to paediatric lung models.28 Variation in NBBAL procedures is apparent within both adult and paediatric literature. Differences include the use of fixed volumes of saline versus weight-based volumes, the number of samples collected (1 to 4) and the use of MHI or remaining on the ventilator.19,20,29,30 This lack of consensus proliferates variation and individual unit-based practices.
Most of the organisational documents analysed were classified as SOPs or clinical guidelines. SOPs are defined as written means to instruct employees on how a particular procedure should be carried out, aiming to achieve uniformity.31 This definition aligns with the purpose and content of the SOPs analysed in this study. Clinical guidelines are rigorously developed using evidence-based medicine and consist of two components: the evidence summary and detailed instructions for the application to patient care.31,32 The inclusion of relevant evidence varied in the guidelines analysed in this study. This may be due to the lack of robust trials to support respiratory physiotherapy in PICU, with documents based on local expert opinion and consensus instead.4
It is important to emphasise the use of clinical expertise in conjunction with guidelines. This has been highlighted as of particular significance in critical care.10 In this setting patients’ clinical conditions and needs vary significantly and patients may require care that involves several overlapping and potentially conflicting guidelines. The practical, real-time support provided by organisational documents have been questioned in this study. The documents analysed provided minimal support regarding choice of treatments and were not designed for use at the bed side in an evolving clinical situation.
Limitations related to the use of guidelines include unrealistic expectations, inflexibility, and naive use.33 However, there are several examples of the positive impact of PICU guidelines. The implementation of guideline-directed sedation and analgesia management in Australian PICUs demonstrated a reduced risk of remaining ventilated.34 The use of a multidisciplinary PICU bundle including delirium, sedation, and early mobilisation, was effective for improving delirium screening, detection, and treatment, and also associated with decreased delirium prevalence.35 A recent systematic review investigated the strategies used to implement clinical practice guidelines.36 Educational intervention, reminders, audit, and feedback were reported as the most effective strategies to promote guideline implementation.
Limitations
Main limitations are the completeness and representativeness of the documents. The study failed to recruit eight of the UK PICUs and three of the responding sites who reported documents did not make these available. However, the sites who provided documents were representative of all geographical regions and accounted for a range of size of units. It is also important to acknowledge that the implementation of guidelines into practice is challenging and there is a gap between guidelines and what happens in practice.37 This study analysed the intended purpose and content of the organisational documents, but did not explore how frequently they were accessed, the content implemented, and by whom.
Conclusion
This study has generated novel data related to organisational physiotherapy documents. Most responding centres had access to documents relevant to respiratory physiotherapy in PICU. Documents most frequently focused on treatment techniques. The documents analysed appeared to provide minimal support regarding choice of treatment and were not designed for use at the bedside in an evolving clinical situation. Ethnographic research exploring document use in practice would be beneficial.
Declaration of interest
HS is current Chair of the ACPRC.
Funding
This study was funded by the National Institute for Health Research (NIHR) [ICA-CDRF-2018-ST2–018] and was supported by the National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
Acknowledgments
The authors would like to thank the UK PICU physiotherapists who took part in the study.
