This study provides, for the first time, an overall view of the national distribution, organization, and structure of physiotherapy departments following pediatric patients affected by PCD and NCFB.
Previous surveys on physiotherapy have mainly focused on techniques and clinical management of patients (15) (10), and more specific data on the Italian physiotherapy units is lacking.
The importance of services provided by hospital-based physiotherapy departments is increasingly recognized, particularly in the multidisciplinary treatment of respiratory diseases. This need is even greater for rare conditions as PCD and NCFB, which, as has been reported in the literature over the last decade (16) (10) require the establishment of daily airway clearance treatment and individualized exercise programs to reduce the decline of lung function over time. For this reason, it seemed appropriate to study the distribution of physiotherapy units on the Italian territory that follow pediatric PCD and NCFB patients, and then try to identify the organization and services offered by each center.
In our survey we achieved an excellent response rate of 97.5%, confirming the positive attitude and increasing interest of Italian physiotherapists to be engaged in research projects. Unfortunately, we are missing data from three regions (Valle D’Aosta, Molise, Basilicata) in our survey. As hypothesized in our previous national research project (14), this can be related to the absence of specialized centers in those regions or to our difficulties in reaching all the territorial centers. Moreover, the three centers lacking a physiotherapy unit for respiratory care, declared to refer patients to facilities outside the region or to medical/nurse care. Our data reveals the challenge in finding professional physiotherapists trained in respiratory care. We all agree that a well-planned chest therapy program is essential, and the competencies that physiotherapists are acquiring over time are of paramount importance, as suggested by the literature (17) (3). These data, highlighting the potential absence of professional respiratory therapists in some Italian regions should be seriously taken into account.
Analyzing the distribution and features of the centers, the primary distinction lies is in terms of territorial distribution, particularly between the northern (13 centers) versus center/southern Italian area (8 centers/8 centers). The heterogeneity of units is evident, and this diversity extends to the organization of logistic teams. Respiratory therapy predominantly takes place in outpatient and regular ward settings as observed in 100% and 96,5% of centers respectively. In contrast, intensive and semi-intensive care units play a partial role in the work of physiotherapists, with interventions being conducted in only 17 out of 29 centers. Furthermore, concerning team composition, among the 29 centers, 19 (65%) have a dedicated respiratory team. Nevertheless, therapists still spend ≥ 50% of their time on respiratory care in 6 out of 10 units. This leads us to hypothesize that the need for respiratory physiotherapy is definitively growing due to a progressively greater number of diagnosed rare respiratory diseases or an increasing importance given to respiratory physiotherapy treatments.
In our survey we retrieved a decreasing average number of respiratory therapists per center, going from the north to the south region of our country. We could hypotize that the northern centers have a greater availability of respiratory therapists. However, we cannot show if this data is related to a major workload of patients treated from the unit.
Considering the interventions made by respiratory therapists, our survey showed that professionals not only play an irreplaceable role in developing an airway clearance program. In fact, assessment of patient condition through tests and pulmonary function tests, educational training for caregivers, titration of oxygen definition of NIV requirements, and workout programs are usual care activities in which Italian respiratory therapists are involved. This highlights the crucial role of respiratory therapists on multidisciplinary teams dealing with PCD and NCFB (18). Moreover, we appreciate how physiotherapists are expanding their expertise in respiratory care, and the growing competence of these professionals is aligning with the increasing knowledge and consideration of these rare diseases.
Additionally, our survey revealed heterogeneity between healthcare providers in the interventions provided by physiotherapists, possibly due to the unique needs and specificities of each center. In the majority of centers, therapists perform walking tests and spirometry. However, it is important to note that in almost 20% of centers, tests such as bronchial provocation and dilation tests and Multi-Breath Washout tests, are also conducted by physiotherapy units. Definitively fewer centers perform more specialized procedures such as DLCO, FOT and IOS. These results show that according to the specific needs of centers, physiotherapists are professional figures that can cover various respiratory tests and functional evaluations.
Related to the professional perception of the offered service, our study emphasized that although airway clearance is a core element of the treatment of PCD and non NCFB, there is still a varying perception of the confidence of the different airway clearance techniques. In many cases, therapists do not feel fully confident when using more complex techniques, such as airway clearance using instrumentation (as IPV, cough machine, EFA and HFCWO) and with NIV. Moreover, the adequacy of devices available was considered inadequate in 17% of units. This result strongly highlights the importance of addressing the training needs of professionals involved in the respiratory field and further implementing the devices needed in all centers. This could ensure professionals and patients to have the same clinical possibilities for high quality treatment.
Finally, our results raise new questions about the evolution of respiratory therapists’ skills. These include telemedicine, chest ultrasounds and collaboration with physicians in the titration and training process for NIV and oxygen therapy. This evolution could be explained by the need for a more specialized approach to patient care. Forming a network of professionals throughout the national territory is crucial to address the new challenge that the future presents, namely the increase in complex cases and, consequently, in healthcare needs.