TY - JOUR
AU - Badawy, Manar M
AB - Abstract Smoke inhalation results in bronchospasm of the trachea, increasing secretion of mucus, casts formation, and improvement of blood flow of the airway. High frequency chest wall oscillation is a common modality used for clearing mucus secretion in patients suffering from hypersecretion of thick mucus and used also to help cough clearance. This study aimed to detect the effect of high frequency chest wall oscillation in improving pulmonary function in burn patients suffering from smoke inhalation. Sixty smoke inhalation injury patients were randomly distributed into two groups of equal size. Group A: received high frequency chest wall oscillation and conventional chest physical therapy (breathing exercises, early ambulation, and cough training) thrice per week for 8 weeks. Group B: received traditional chest physical therapy (breathing exercises, early ambulation, and cough training) thrice per week for 8 weeks. Pulmonary function test (forced vital capacity, forced expiratory volume in the first second and peak expiratory flow rate) was measured at enrollment and after 8 weeks by using spirometer. Pulmonary function increased significantly posttreatment when compared with that pretreatment in groups A and B (P > .001). Also, they increased significantly in group A compared with that of group B posttreatment (P > .05). High-frequency chest wall oscillation have an impact on improving pulmonary function and should be handled to be a part of the pulmonary rehabilitation plan for smoke inhalation injury patients. Inhalation injury is associated with increasing rates of morbidity and mortality. This form of injury causes patients’ prolonged pulmonary dysfunction.1 Inhalation of smoke raises the occurrence of breathing problems including pneumonia or acute respiratory distress syndrome.2 Smoke inhalation causes thermal injury of the supraglottis, respiratory tract chemical irritation, systemic toxicity as a result of chemical agents as cyanide, carbon monoxide, or mixture of both insults. This results in production of the inflammatory process which can lead to higher volumes of fluid resuscitation and increased dependency of the ventilator.3,4 Due to more even spread and deep transmission through the lung tissue, chemical damage is considered a widespread insult to lung tissue. Usually, thermal damage does not expand past the larynx because of the low real air pressure, the upper airway’s excellent pressure exchanger, and the glottis’ defensive reflex closure. In unconscious patients, this latter becomes ineffective. Steam has 4000 times higher heat power than air and can reach the lower airway.5 Smoke-related toxins produced by the incomplete burning of certain products cause damage to the lower airways.6 The smoke composition is determined by the fire materials and the inflammatory reactions’s intensity. These cause the lung parenchyma to give a violent response. After inhalation, the subglottic pathophysiological changes are hyperemia of the airway mucosa, bronchospasm, sloughing of the mucosa, formation of exudation cast into the airways, and inspired mucus.3 The bronchospasm etiology following inhalation injury is uncertain, but it may result from the release of neuropeptides from airway sub-mucosa. The compounds within the inhaled smoke and the individual sensitivity of the airways to the chemical toxins and irritants determines the spasm degree.7,8 Some factors detect delayed improvement in inhalation injury management. Skin grafts to burnt cutaneous tissue can be helpful; however, management of damaged respiratory tract requires preventive procedures to eliminate secondary damages such as ventilator induced lung injury to allow repairing of the damaged tissue.9 Extra lung mucus secretions, injured mucosa, contaminants, and aspirated substances should be handled in their early stages. In the case of fibrinous material transudates, compromised mucociliary secretions and mucosal slough must be cleared. There are different methods to assist the clearance of secretions as bronchoscopy, ventilator, mucolytics, suction, and chest physiotherapy.10 Pulmonary rehabilitation protocols consists of percussion, cough techniques, and early mobilization are essential to assist expectoration of secretions. Also, postural drainage is essential, and it is highly recommended whenever possible.11 Percussion and vibration applied to the thoracic cage such as high-frequency chest wall oscillation (HFCWO) help to get ride of expectorations.12 HFCWO consists of a vest that applies pressure to pass oscillations with high frequency into the chest. Aimed to mobilize lung secretions which are then cleared by chest mobility techniques by either cough or suction in patients with intubation.13 Usually, the technique produces chest compression by an inflatable vest linked to a generator with an air pump that provides an intermittent flow to the jacket. The vest applies pressure rapidly and unlocks the thoracic wall at various frequencies.14 METHODS This study was conducted in agreement with the principles of Declaration of Helsinki for experiments on humans and was approved by The Ethical Committee of Faculty of Physical Therapy, Cairo University, Giza, Egypt (No: P.T.REC/012/002610). A randomized controlled study design was used to evaluate the impact of HFCWO on pulmonary function in burn patients suffering from inhalation injury. Sixty participants were randomly chosen from the department of burn, Kasr El Aini Hospital, Cairo University, Egypt. All participants were asked to assign an informed consent before participation in the study after they informed about the aim of the study. Randomization was carried out by using closed envelopes which held a card with either (HFCWO group) or (control group). Each patient was instructed to pick a closed envelope indicating whether the patient was assigned to either the HFCWO group (n = 30) who received HFCWO and conventional chest physical therapy (breathing exercises, early ambulation, and cough training) thrice per week for 8 weeks, or the control group (n = 30) who received conventional chest physical therapy (breathing exercises, early ambulation, and cough training) thrice per week for 8 weeks. The inclusion criteria were: Patients in both sexes and their age ranged from 20 to 50 years, patients with deep partial thickness burn suffering from smoke inhalation injury diagnosed by fiberoptic bronchoscopy, 1 month after injury (after complete closure of burn wound), patients suffering from retained secretions which were unresponsive to medical treatment, all patients were clinically and medically stable, and patients had the same medical treatment. The exclusion criteria were: patients with previous pulmonary disorders; patients with instability of the haemodynamics; patients with open wounds in order not to interfere with application of HFCWO; patients with chest wall abnormalities or any musculoskeletal disorders as rib fracture or osteomyelitis of the ribs; patients with recent skin graft in the chest, history of osteoporosis or gastro-oseophageal reflux, pregnant women, presence of hiatus hernia, recent acute cardiac disease, or cardiac failure; patients with infection, active inflammation or sepsis; and patients with any contra-indications for spirometry (eg, instability of the cardiovascular status, active hemoptysis, pneumothorax, and cerebral or abdominal aneurysms). Procedures Assessment Methods A portable spirometer device (2120; Vitalograph Ltd, UK) was used to assess FVC, FEV1, and PEFR at enrollment and after 8 weeks. Spirotrac IV software version 4.30 was used for analysis of data. The treatment protocol was explained to each patient carefully and simply, to actively motivate them to do their maximal effort. The estimated parameters of volume and flow were established with the peak performance and the peak expiratory volume. The procedure carried out as follows: breathe was taken in maximally (with the lungs maximally full with air), the mouth was clenched around the mouthpiece, then the air shot out as rapid as possible until the lungs were totally empty. The assessment procedure was repeated for three successive times.15 Treatment Protocol High-frequency chest wall oscillation was administered by using the airway vest clearance device (Hill-Rom, Batesville, IN) Model 205 with 13 to 15 Hz oscillating frequency, according to the patient tolerance, and at 2 to 5 cm H2O pressure to ensure a comfortable and tight fit.16,17 The duration of the HFCWO session was 20 minutes and was applied 3 sessions per week for 8 weeks. Patients were kept in an upright sitting position. No sessions immediately after a meal. For comfort, a single layer of clothing was worn, and the circumferential inflatable vest applied to the patient’s chest wall. After the HFCWO, patients were instructed to take deep breathing then huff or cough for removal of loosened secretions. The patients were monitored throughout the sessions for vital signs, changes in the respiratory pattern, work of breathing, and skin color. RESULTS Seventy-five participants were assessed for eligibility. Ten participants were excluded (seven participants did not meet the inclusion criteria and three participants declined to participate). Sixty-five participants randomly enrolled into HFCWO group or control group. Five participants withdrew before data collection at the eighth week as they did not complete the treatment sessions. Figure 1 illustrates the flow diagram of the randomization process throughout the study. Figure 1. Open in new tabDownload slide CONSORT flow chart. Figure 1. Open in new tabDownload slide CONSORT flow chart. Unpaired t test was carried out for comparison of subject characteristics between both groups. Chi-squared test was conducted to compare sex distributions between both groups. Shapiro–Wilk test was carried out to evaluate the normal distribution of results. To test the homogeneity between groups, Levene’s test for homogeneity of variances was carried out. Within and between groups effects on FVC, FEV1 and PEFR were analyzed by Mixed MANOVA. Multiple comparisons were carried out with the bonferroni correction by using posthoc tests. The level of significance was (P < .05) for all tests. The SPSS version 25 for windows (SPSS, IBM SPSS, Chicago, IL) was used for all statistical analysis. Subject Characteristics The subject characteristics of the groups A and B are shown in Table 1. No significant difference was recorded between both groups in the mean age, height, weight, BMI, TBSA, and sex distribution (P > .05). Table 1. Comparison of subject characteristics between groups A and B . x¯ ± SD . . MD . t-value . P . . Group A . Group B . . . . Age (y) 35.5 ± 8.58 36.16 ± 6.47 −0.66 −0.34 .73 Weight (kg) 72.53 ± 5.03 73.36 ± 6.86 −0.83 −0.53 .59 Height (cm) 167.8 ± 7.4 168.16 ± 7.88 −0.36 −0.18 .85 BMI (kg/m2) 25.73 ± 2.15 25.93 ± 1.75 −0.2 −0.39 .69 TBSA 33.07 ± 3.38 33.33 ± 2.48 −0.26 −0.34 .73 Sex  Females 11 (37%) 13 (43%) (χ 2 = 0.27) .59  Males 19 (63%) 17 (57%) . x¯ ± SD . . MD . t-value . P . . Group A . Group B . . . . Age (y) 35.5 ± 8.58 36.16 ± 6.47 −0.66 −0.34 .73 Weight (kg) 72.53 ± 5.03 73.36 ± 6.86 −0.83 −0.53 .59 Height (cm) 167.8 ± 7.4 168.16 ± 7.88 −0.36 −0.18 .85 BMI (kg/m2) 25.73 ± 2.15 25.93 ± 1.75 −0.2 −0.39 .69 TBSA 33.07 ± 3.38 33.33 ± 2.48 −0.26 −0.34 .73 Sex  Females 11 (37%) 13 (43%) (χ 2 = 0.27) .59  Males 19 (63%) 17 (57%) x¯ ⁠, mean; SD, standard deviation; MD, mean difference; χ 2, chi-squared value; P, probability value. Open in new tab Table 1. Comparison of subject characteristics between groups A and B . x¯ ± SD . . MD . t-value . P . . Group A . Group B . . . . Age (y) 35.5 ± 8.58 36.16 ± 6.47 −0.66 −0.34 .73 Weight (kg) 72.53 ± 5.03 73.36 ± 6.86 −0.83 −0.53 .59 Height (cm) 167.8 ± 7.4 168.16 ± 7.88 −0.36 −0.18 .85 BMI (kg/m2) 25.73 ± 2.15 25.93 ± 1.75 −0.2 −0.39 .69 TBSA 33.07 ± 3.38 33.33 ± 2.48 −0.26 −0.34 .73 Sex  Females 11 (37%) 13 (43%) (χ 2 = 0.27) .59  Males 19 (63%) 17 (57%) . x¯ ± SD . . MD . t-value . P . . Group A . Group B . . . . Age (y) 35.5 ± 8.58 36.16 ± 6.47 −0.66 −0.34 .73 Weight (kg) 72.53 ± 5.03 73.36 ± 6.86 −0.83 −0.53 .59 Height (cm) 167.8 ± 7.4 168.16 ± 7.88 −0.36 −0.18 .85 BMI (kg/m2) 25.73 ± 2.15 25.93 ± 1.75 −0.2 −0.39 .69 TBSA 33.07 ± 3.38 33.33 ± 2.48 −0.26 −0.34 .73 Sex  Females 11 (37%) 13 (43%) (χ 2 = 0.27) .59  Males 19 (63%) 17 (57%) x¯ ⁠, mean; SD, standard deviation; MD, mean difference; χ 2, chi-squared value; P, probability value. Open in new tab Effect of Treatment on FVC, FEV1, and PEFR Mixed Model MANOVA reported a significant interaction of treatment and time [F (3,56) = 10.89, P > .001]. The significant time main effect was [F (3,56) = 205.06, P > .001]. The significant treatment main effect was [F (3,56) = 4.96, P > .01]. Within-Group Comparison The values of FVC, FEV1, and PEFR increased significantly in posttreatment compared with that pretreatment in groups A and B (P > .001). The percent of the increase in FVC, FEV1, and PEFR in group A was 74.02%, 67.54%, and 75%, respectively, whereas that in group B was 50.71%, 43.1%, and 43.84% for FEV1, FVC, and PEFR, respectively (Table 2; Figure 2). Table 2. Mean FVC, FEV1, and PEFR pre- and posttreatment of the groups A and B . Group A . Group B . P . . x¯ ± SD . x¯ ± SD . . FVC (L)  Pretreatment 1.54 ± 0.54 1.4 ± 0.53 .27  Posttreatment 2.68 ± 0.65 2.11 ± 0.54 .001**  % of change 74.02 50.71 P = .001** P = .001** FEV1 (L)  Pretreatment 1.14 ± 0.44 1.16 ± 0.34 .85  Posttreatment 1.91 ± 0.4 1.66 ± 0.5 .02**  % of change 67.54 43.1 P = .001** P = .001** PEFR (L/S)  Pretreatment 1.32 ± 0.34 1.3 ± 0.3 .71  Posttreatment 2.31 ± 0.5 1.87 ± 0.46 .001**  % of change 75 43.84 P = .001** P = .001** . Group A . Group B . P . . x¯ ± SD . x¯ ± SD . . FVC (L)  Pretreatment 1.54 ± 0.54 1.4 ± 0.53 .27  Posttreatment 2.68 ± 0.65 2.11 ± 0.54 .001**  % of change 74.02 50.71 P = .001** P = .001** FEV1 (L)  Pretreatment 1.14 ± 0.44 1.16 ± 0.34 .85  Posttreatment 1.91 ± 0.4 1.66 ± 0.5 .02**  % of change 67.54 43.1 P = .001** P = .001** PEFR (L/S)  Pretreatment 1.32 ± 0.34 1.3 ± 0.3 .71  Posttreatment 2.31 ± 0.5 1.87 ± 0.46 .001**  % of change 75 43.84 P = .001** P = .001** x¯ ⁠, mean; SD, standard deviation; P, probability value. **Significant. Open in new tab Table 2. Mean FVC, FEV1, and PEFR pre- and posttreatment of the groups A and B . Group A . Group B . P . . x¯ ± SD . x¯ ± SD . . FVC (L)  Pretreatment 1.54 ± 0.54 1.4 ± 0.53 .27  Posttreatment 2.68 ± 0.65 2.11 ± 0.54 .001**  % of change 74.02 50.71 P = .001** P = .001** FEV1 (L)  Pretreatment 1.14 ± 0.44 1.16 ± 0.34 .85  Posttreatment 1.91 ± 0.4 1.66 ± 0.5 .02**  % of change 67.54 43.1 P = .001** P = .001** PEFR (L/S)  Pretreatment 1.32 ± 0.34 1.3 ± 0.3 .71  Posttreatment 2.31 ± 0.5 1.87 ± 0.46 .001**  % of change 75 43.84 P = .001** P = .001** . Group A . Group B . P . . x¯ ± SD . x¯ ± SD . . FVC (L)  Pretreatment 1.54 ± 0.54 1.4 ± 0.53 .27  Posttreatment 2.68 ± 0.65 2.11 ± 0.54 .001**  % of change 74.02 50.71 P = .001** P = .001** FEV1 (L)  Pretreatment 1.14 ± 0.44 1.16 ± 0.34 .85  Posttreatment 1.91 ± 0.4 1.66 ± 0.5 .02**  % of change 67.54 43.1 P = .001** P = .001** PEFR (L/S)  Pretreatment 1.32 ± 0.34 1.3 ± 0.3 .71  Posttreatment 2.31 ± 0.5 1.87 ± 0.46 .001**  % of change 75 43.84 P = .001** P = .001** x¯ ⁠, mean; SD, standard deviation; P, probability value. **Significant. Open in new tab Figure 2. Open in new tabDownload slide Mean FVC, FEV1, and PEFR pre- and posttreatment of the groups A and B. Figure 2. Open in new tabDownload slide Mean FVC, FEV1, and PEFR pre- and posttreatment of the groups A and B. Between-Groups Compariso: No significant difference was reported in the values of FVC, FEV1, and PEFR between both groups pretreatment (P > .05). There was a significant increase in FVC, FEV1, and PEFR in group A compared with that of group B (P > .05) after comparison between both groups posttreatment (Table 2). DISCUSSION Inhalation injury is a combination of several insults such as thermal damage of the supraglottic, subglottic airway, poisoning of the alveoli, and chronic toxicity of ingested toxins from small molecules. These toxic insults have an impact on all pulmonary functions and directly affect systemic physiology.18 Many toxic particles pass through the alveoli and decrease the pulmonary surfactant which results in atrophy and collapse of the alveoli.19 Deposited materials that include fibers, epithelial cells in the bronchi, neutrophils, and mucus can also block the airways. Smoke inhalation recruits, sheds, or secretes those materials.20 Other smoke products including halogen acids, unsaturated aldehydes (eg, acrolein), and formaldehyde work as irritants to the respiratory system. Damage of the respiratory mucosa occurs due to exposure to chemicals, resulting in airway sloughing and produces an inflammatory reaction. Also, chemical damage activates neutropenic endings of the vasomotor and sensory nerves.21 The findings of this study showed a marked improvement in pulmonary function including FVC, FEV1, and PEFR posttreatment relative to that pretreatment in both groups (P > .001). A significant increase was noted in FVC, FEV1, and PEFR in HFCWO group compared with that of control group. Also, patients in HFCWO group noted that there was a great improvement in their breathing pattern and their abilities to get rid of secretions after the end of 8 weeks. HFCWO improves clearance of mucus centrally and peripherally and reduces the viscoelastic and cohesive properties of mucus.12,22 There are several underlying mechanisms to reduce viscoelasticity including increase in the interaction between airflow and mucus, the production of an expiratory airflow bias enhancing the mucus movement in the cephalad, and the stimulation of mucus.13,23 HFCWO therapy is an effective, safe, and comfortable modality in patients with thoracic trauma and further studies are recommended to detect whether HFCWO’s airway clearance efficiency related to care for thoracic trauma.24 HFCWO is comfortable and well-tolerated in patients with chronic obstructive pulmonary disease (COPD) or acute asthma when it is applied as adjunctive therapy to standard medical treatment and has a great beneficial effect on patients with dyspnea.25 HFCWO improves gas mixing and homogenizes alveolar ventilation in chronic obstructive pulmonary diseases for ventilated patients.26,27 HFCWO device also causes the symptom scores and quality of life to improve. Pulmonary function was not significantly improved and the quantities of wet mucus were variable between patients. HFCWO has an effective impact on improving clearance of secretions in COPD patients with hypersecretion of mucus.28,29 HFCWO has provided an improvement in many parameters of the lung function (FVC, FEV1) relative to conventional chest physiotherapy in bronchiectasis patients.16 The Vest HFCWO program can decrease the number of respiratory problems related to hospitalization in patients with neuromuscular disease and cerebral palsy leading to saving of costs for the National Health Service (NHS).30 The HFCWO vest airway clearance is fairly costly, but it does have a lot of benefits, ie, high enforcement levels due to the ease of use and does not require special positioning or breathing techniques. This is theoretically independent and conducted without the support of qualified healthcare workers, so caregiver factors do not impede its effectiveness. It can also be applied in patients with acute illness (ie, ICU patients and children) who cannot use Flutter device properly.31 HFCWO is also successful in acute pneumonic failure patients in ICU. During oscillation, HFCWO did not affect ventilator settings but significantly changed respiratory patterns and increased mean airway pressure, and diastolic blood pressure and modestly decreased spO2 with subsequent sputum suction. HFCWO tended to significantly lower heart rate compared with conventional sputum suction and chest physical therapy.32 In patients suffering from cystic fibrosis who reported an acute exacerbation of their pulmonary disease, the application of HFCWO was correlated with enhancement of ventilation, mixing of gases, and slight reduction in spO2.33 The limitations of this study include the following: the recruitment of participants was from a single hospital, the study did not measure other pulmonary function test parameters, and the follow-up period was after 8 weeks only. The authors suggest further research to assess the impact of HFCWO on patients with smoke inhalation injury after a long treatment period on a broad sample scale. Other pulmonary functions such as FEV1/FVC level, total lung capacity, and residual volume are also recommended. CONCLUSION The present study revealed that HFCWO is an effective, comfortable, and safe modality for improving pulmonary function for smoke inhalation injury patients and should be a part of the pulmonary rehabilitation program. Conflict of interest statement. The authors have no conflict of interest. ACKNOWLEDGMENTS The authors appreciate the cooperation and patience of the medical staff and participating patients. REFERENCES 1. Park GY , Park JW, Jeong DH, Jeong SH. Prolonged airway and systemic inflammatory reactions after smoke inhalation . Chest 2003 ; 123 : 475 – 80 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Shirani KZ , Pruitt BA Jr, Mason AD Jr. The influence of inhalation injury and pneumonia on burn mortality . Ann Surg 1987 ; 205 : 82 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 3. Dries DJ , Endorf FW. Inhalation injury: epidemiology, pathology, treatment strategies . Scand J Trauma Resusc Emerg Med 2013 ; 21 : 31 . 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TI - Does High-Frequency Chest Wall Oscillation Have an Impact on Improving Pulmonary Function in Patients With Smoke Inhalation Injury?
JO - Journal of Burn Care & Research
DO - 10.1093/jbcr/iraa147
DA - 2021-03-04
UR - https://www.deepdyve.com/lp/oxford-university-press/does-high-frequency-chest-wall-oscillation-have-an-impact-on-improving-FA3MyovF0Y
SP - 300
EP - 304
VL - 42
IS - 2
DP - DeepDyve
ER -