Chest physiotherapy (CPT) use in infants has been reported in the literature to varying degrees over the years, with inconsistent techniques and for broadly differing indications. CPT has been reported to be associated with deleterious changes in heart rate, respiratory rate, and oxygenation in some case series, (1)(2)(3) but improved oxygenation and secretion clearance in others. (4)(5) Significant complications of the technique also have been reported, including rib fractures (6) and periosteal reactions. (7) Even more concerning were reports indicating a possible link with the development of grade III/IV intraventricular hemorrhage or porencephaly in neonates treated with CPT. (8)(9) However, later reports dispute these findings, including a follow-up report from one of the groups that originally reported the association. (10)(11)The difficulty in evaluating existing evidence lies in the widely disparate CPT techniques and protocols, indications, and patient populations that have been studied. Study endpoints and objectives are similarly inconsistent. Most of the reports are case series that include small numbers of patients; there are few randomized, controlled trials. In addition, many of the studies were performed in the late 1970s and early 1980s, during the presurfactant, preantenatal steroid era. Thus, the clinical condition of the patient populations in studies and case reports may be substantially different from that encountered currently. Many early studies also were limited by continuous positive airway pressure (CPAP) not being available to support infants after extubation, further differentiating routine therapeutic approaches from those of the present.Given these considerations, clear guidelines cannot be formulated for all postulated CPT indications in neonates. Furthermore, safety issues have not been addressed sufficiently by existing studies. One recent retrospective report indicated that CPT prescribed for bronchiolitis or pneumonia was associated with lateral and posterior rib fractures in five young children, two of whom were 1 month of age or younger. (12) Thus, caution is warranted when considering this therapeutic maneuver for any indication. However, some conclusions can be drawn regarding specific outcomes associated with narrowly defined CPT use in the postextubation period.A Cochrane review (13) attempted to ascertain the effect of “active” CPT (vibration or percussion with or without devices) used in the postextubation period on primary outcomes that included lobar collapse, reintubation within 24 hours, hypoxemia or bradycardia, duration of oxygen therapy, intracranial lesions, and death before discharge. Some secondary outcomes also were evaluated. The meta-analysis also attempted to differentiate outcomes of all infants from those younger than 32 weeks’ estimated gestational age, although this subanalysis was less powerful.Four randomized trials (14)(15)(16)(17) were included that compared CPT with no intervention or “nonactive” techniques such as positioning (Table 1). The four trials differed in several aspects: 1) mean gestational age ranged from 29 to 35 weeks; 2) only two trials included infants being extubated from a first course of intubation and mechanical ventilation; 3) only Finer and associates (17) included patients who had bacterial pneumonia and meconium aspiration; and 4) although all studies evaluated lobar collapse and need for reintubation within 24 hours, they differed with respect to reporting other “primary” outcomes targeted by the Cochrane review. The Cochrane analysis authors indicated that data were insufficient to assess any targeted outcomes adequately other than lobar collapse and reintubation within 24 hours (Table 2).The only significant finding of the Cochrane analysis was that reintubation was less likely in the treatment group. However, this finding was influenced heavily by results of the oldest studies (Finer 1979, Vivian-Beresford 1987); neither of the more recent studies, if reviewed individually (and with cumulatively greater numbers of patients), showed any decrease in risk for reintubation with CPT. This suggests that changes in routine therapies such as surfactant treatment and CPAP may have improved postextubation outcomes without the need for CPT.