ORIGINAL ARTICLES
The Effect of Cold Vapor Applied for Sore
Throat in the Early Postoperative Period
H€ulya Bulut, PhD, RN, Sevilay Erden, PhD, RN, Sevil G€uler Demir, PhD, RN,
Bilge C
¸ akar, RN, Z€uhal Erdogan, MSN, RN, Nevra Demir, RN, Ali Ay, MSN, RN,
Emine Aydın, MSN, RN
Purpose:This study was conducted for the purpose of determining the ef-fect of cold vapor applied for sore throat in the early postoperative stage.
Design:A quasi-experimental design was used.
Methods:The study sample consisted of 60 patients who underwent lum-bar disc herniation surgery in the Neurosurgery Clinic of Gazi University Health Research and Practice Center in Ankara, Turkey. The study involved two intervention groups and one control group. The study data were collected through questionnaire and observation forms.
Findings:65% (n5 39) of patients experienced sore throat. There were no statistical differences between the groups in terms of sore throat and hoarseness (P. .05); however, a significant difference was determined in the group to whom oxygen together with cold vapor was applied for dry throat (4th and 8th hours) and swallowing difficulties(8th and 12th hours) (P, .05).
Conclusions:Cold vapor did not have an effect on sore throat on its own; however, it decreased hoarseness and swallowing difficulties when applied together with oxygen.
Keywords: cold vapor, postoperative care, sore throat, research. Ó 2016 by American Society of PeriAnesthesia Nurses TODAY, TOGETHER WITH TECHNOLOGICAL
developments in surgery, advances in preoperative and postoperative patient care have led to the wide-spread implementation of surgical interventions.1
Despite surgical interventions being an important treatment option in the solution of health prob-lems, postoperative throat complaints related to intubation-based larynx and pharynx traumas
H€ulya Bulut, PhD, RN, is an Associate Professor, Department of Nursing, Faculty of Health Sciences, Gazi University, An-kara, Turkey; Sevilay Erden, PhD, RN, is an Assistant Professor, Department of Nursing, Faculty of Health Sciences, C¸ ukurova University, Adana, Turkey; Sevil G€uler Demir, PhD, RN, is an Instructor, Department of Nursing, Faculty of Health Sciences, Gazi University, Ankara, Turkey; Bilge C¸ akar, RN, is a staff nurse, Gazi University Health Research and Practice Center Neurosurgery Clinic, Ankara, Turkey; Z€uhal Erdogan, MSN, RN, is a Research Assistant, Department of Nursing, Faculty of Health Sciences, Gazi University, Ankara, Turkey; Nevra Demir, RN, is a Research Assistant, Department of Nursing, Faculty of Health Sciences, Gazi University, Ankara, Turkey; Ali Ay, MSN, RN, is a Research Assistant, Department of Nursing, Faculty of Health Sciences, Gazi University, Ankara, Turkey; and Emine Aydın, MSN, RN, is a Research Assistant, Department of Nursing, School of Health, Erzincan Univer-sity, Ankara, Turkey.
Sources of support: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest: None to report.
Authors’ Contributions: All authors were responsible for the study conception and design. HB, SE, and ZE were responsible for analysis and interpretation of data. HB, SE, and SGD were responsible for drafting of the manuscript and final approval of the version to be published.
Address correspondence to Sevil G€uler Demir, Department of Nursing, Faculty of Health Sciences, Gazi University, Besev-ler, Ankara 06500, Turkey; e-mail address:sevilgulerdemir@ yahoo.com.
Ó 2016 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00
http://dx.doi.org/10.1016/j.jopan.2014.10.005
such as sore throat, dry throat, hoarseness, and swallowing difficulties are frequently observed, especially in patients who have undergone general anaesthesia.2 In the literature, it is reported that sore throat is frequently observed after endotra-cheal intubation (14.4% to 100%) and is one of the complications most feared by patients.3-5 In another study investigating the prevalence of sore throat in the first 24 postoperative hours, sore throat was found in 26% of patients.6
As sore throat can lead to swallowing and breath-ing difficulties in the postoperative period, this in-fluences the nutrition and fluid intake of the patient and may extend the recovery period.2 Sore throat creates a physical source of stress, in-creases postoperative morbidity, and dein-creases pa-tient satisfaction.4,7Because of all these adversities observed in the patient care process, sore throat should be evaluated and treated carefully.
Pharmacological and nonpharmacological methods are applied in the elimination of sore throat. As pharmacological methods, the use of ste-roids and local anesthetics in the form of mouth-washes and sprays are recommended.8,9 As nonpharmacological methods, the selection of a smaller endotracheal tube number, lubrication of the endotracheal tube with water-soluble gel, correct performance of oropharyngeal aspira-tion, careful intubaaspira-tion, resting after intubaaspira-tion, and reduction of endotracheal tube cuff pressure are recommended.3,10 In addition to these methods, ways of reducing larynx damage such as preventing throat dryness and swallowing difficulties are also considered to reduce sore throat. Thus, in the conclusion of a study conducted by Jung et al11on patients undergoing thyroidectomy, humidification of the throat with vapor was recommended as it was found to reduce sore throat and coughing. Furthermore, literature also supports that cold vapor is effective in reducing fever, airway inflammation, and the viscosity of secretion and could be applied in the control of larynx damage-related complaints (hoarseness, coughing, throat dryness, etc.).12,13
Our observations have indicated that postoperative sore throat is frequently encountered in surgical clinics; cold vapor is applied in the early postoper-ative period for prophylactic purposes, and pa-tients have been relieved after this practice.
However, no study was encountered in our country on cold vapor application for the purpose of relieving sore throat in surgical clinics. It is consid-ered that cold vapor applied to patients in postop-erative care will reduce pain and relieve the patient in the postoperative period.
Aim
This study was conducted for the purpose of deter-mining the effect of cold vapor applied in the early postoperative stage on patients’ sore throat.
Ethical Considerations
A written consent form was obtained from the Head Doctor’s Office of the Gazi University Health Research and Practice Center and the Gazi University Clinic Studies Ethics Board (date: 28.6.2012; number: B.30.2.G € UN.0.20-4271) so that the study could be conducted. Furthermore, information was provided to pa-tients participating in the study, and informed consent was obtained.
Methods
Study Design
This study was conducted between January and June in 2013 using a quasi-experimental design.
Setting and Participants
The study was conducted at the Neurosurgery Clinic of Gazi University Health Research and Prac-tice Center in Ankara, Turkey. This clinic has a ca-pacity of 28 beds and provides service to pediatric and adult patients. Medical and surgical treatments of all diseases involving the nervous system, such as intracranial, spinal, and peripheral nervous sys-tem tumors, vein diseases, such as aneurysms, arte-riovenous malformation, nervous system diseases specific to childhood, congenital anomalies, spinal diseases, epilepsy, and diseases associated with head and spinal traumas are performed at the clinic. A total of 10 nurses work at the clinic on a shift system between the hours of 08.00 to 16.00 and 16.00 to 08.00.
Cold vapor is not provided to all patients as part of standard postoperative care at the clinic where the
study was conducted. Administration of cold va-por varies depending on nurses working at the clinic. Some nurses administer this application, whereas others do not.
Study Sample
Patients undergoing lumbar disc herniation surgery at the Neurosurgery Clinic of Gazi University Health Research and Practice Center constitute the study sample. Included patients voluntarily accepted participation in the study, were older than 18 years, and could establish communication. Patients with difficult intubation, intubated after more than one attempt, received steroid drug therapy, had cooper-ation difficulties, or had psychiatric problems were not included in the study. Additionally, patients with a history of asthma and other restrictive airway diseases were not included. Furthermore, patients who underwent intracranial were not included in the scope of the study.
There were a total of three groups in the study, of which two were intervention groups and one was a control group. Cold vapor was applied to the first intervention group and cold vapor with oxygen to the second; nothing was applied to patients in the control group.
Sore throat incidence was determined as the main parameter in the study. However, as no study was encountered in the literature on the effect of cold vapor on sore throats, no power analysis was performed while calculating sample size. The sample of the study was determined based on previous studies as 60 patients with 20 in each experimental group and 20 in the control group.14,15In our study,a 5 0.05, and its power was determined to be 0.67.
Oxygen was only administered to the cold vapor with oxygen group in the study. Patients in the other groups (control group and cold vapor group) did not have an oxygen need in the early postoper-ative period. Therefore, there were no patients removed from the study.
Data Collection
Data were collected with a questionnaire and an evaluation form. The data collection instruments were prepared through review of the literature
and observations. The questionnaire contained 12 questions on the sociodemographic characteristics, operation details, and postoperative information of patients. The evaluation form consisted of five ques-tions on the treatment and methods implemented for sore throat, the frequency of sore throat, and complaints in the first 12 postoperative hours. Sore throat and other complaints were determined through patient self-report.
Procedure
The study was conducted between January 2013 and June 2013. Patients conforming to the study criteria were included in the study as (1) vapor, (2) vapor and oxygen, and (3) control groups. No randomization was implemented in the selection of the patients. All patients admitted to the clinic and voluntarily consented to participate were included in the sample. After reaching 20 patients who were required for the first group, the applica-tion was continued in the other groups. The ques-tionnaire and evaluation form on the postoperative period were filled out through one-on-one inter-views with patients and using the patient files. The data in the evaluation form were collected by one nurse on each shift. Nurses were provided information before the commencement of the study, and application guidelines were prepared.
The cold vapor group received cold vapor for 15 minutes in the first hour after the admission of the patient to the postoperative unit. The cold vapor with oxygen group received cold vapor for 15 minutes and 2 L of nasal oxygen per minute in the first hour after the admission of the patient to the postoperative unit. No intervention was made for the control group.
The patient’s sore throat and complaints (hoarse-ness, throat dry(hoarse-ness, etc.) development status was evaluated by the nurse in the first postopera-tive hour before the intervention and the 2nd, 4th, 8th, and 12th hours after the intervention. It was planned to monitor patients for 24 hours; however, as patients were discharged after the 12th hour, data were only collected for 12 hours.
Statistical Analyses
Statistical evaluation was performed using the Sta-tistical Package for Social Science, version 17.0
(SPSS Inc., Chicago, IL). The descriptive data of the study were specified with mean, standard devia-tion, and percentage. Evaluation was performed with chi-square test in cross tables, one-way anal-ysis of variance in parametric tests of variables determined with the measurement of groups of three, and the Kruskal-Wallis test in nonparametric tests. Pain and throat complaints at five different times for each group were compared with the Friedman test, and if there was a significant differ-ence, the duo causing the difference was evaluated with post hoc multiple comparisons test (Bonfer-roni). In all tests, P, .05 was accepted as statisti-cally significant.
Results
Patients who participated in the study were ho-mogenous in terms of age, gender, and smoking status (Table 1). Half of the patients were females, 31.7% were smokers, smoking patients had smoked on average for 20 6 10.4 years, and mean age was 46.536 11.2 years (Table 1). No sta-tistically significant difference was determined in terms of the mean age, gender, and period of smok-ing of patients (P..05).
Orotracheal intubation was used in all patients. No statistically significant difference was found be-tween the endotracheal tube number distribution of patients and intubation period (P . .05) (Table 2).
Table 3consists of the postoperative throat com-plaints observed in patients. Before any applica-tion, the status of sore throat observation in the control, cold vapor, and cold vapor with oxygen groups was 60%, 65%, and 70%, respectively; it was determined as 10%, 30%, and 15% in the 12th hour. Although there was no statistical differ-ence between groups (P . .05), the highest decrease in sore throat was in the group that received cold vapor together with oxygen. There was no statistically significant difference between the groups in terms of hoarseness (P..05). A sig-nificant difference was determined in favor of the group who received cold vapor together with oxy-gen in terms of throat dryness (4th and 8th hours) and swallowing difficulties (8th and 12th hours) (P , .05). Although not indicated in the table, the saturation values of the group administered oxygen together with vapor (in the 4th and
8th hours) were higher (P, .05). In comparison with post hoc (Bonferroni correction), a signifi-cant difference was found in favor of cold vapor together with oxygen (P, .017).
Discussion
Larynx and pharynx traumas because of endotra-cheal intubation and cold and dry gases used in general anesthesia lead to postoperative sore throat and hoarseness. Sore throat is a widespread complaint of anesthesia, affecting the comfort of the patient in the postoperative period and delay-ing the patient’s return to routine activities.2,16,17
Nurses assume a key role in ensuring the comfort and convenience of patients after their operation. In our study investigating the effect of cold vapor applied by nurses to sore throat in the early operative stage, 60% to 70% of patients had post-operative sore throat. The frequencies of observing sore throat in the control, cold vapor, and cold vapor with oxygen groups before any application were, respectively, determined to be 60%, 65%, and 70% (Table 3). The findings of our study are similar to the study results of Chris-tensen et al,18where researchers determined the frequency of observing sore throat after gynecol-ogy, orthopaedics, and general surgery opera-tions to be 61.8%. In a study conducted by Jung et al11with 61 patients, it was determined that before applying vapor, sore throat was deter-mined in 75% of the intervention group and 90% of the control group. These rates indicate that sore throat is widely observed in the early postoperative period.
In our study, it was determined that after applying cold vapor for 15 minutes, the frequencies of observing sore throat in the 12th hour for the con-trol group, the group that received cold vapor, and the group that received cold vapor together with oxygen, were, respectively, determined to decrease to 10%, 30%, and 15% (Table 3). Although there is no statistical difference between the groups (P . .05), the highest decrease in sore throat was in the group that received cold vapor together with oxygen. In the study by Jung et al,11 in the 24th hour after vapor application, the frequency of sore throat in the intervention group decreased from 73% to 37%, and it decreased from 90% to 65% in the control group.
A significant difference was detected in favor of the vapor group (P, .05).
When other throat complaints encountered in pa-tients were observed in our study, it was deter-mined that there was no statistical difference between the groups in terms of hoarseness (P. .05), whereas there was a statistically significant difference among the groups in favor of the group that received cold vapor together with oxygen (P, .05) in terms of throat dryness (4th and 8th hours) and swallowing difficulties (8th and 12th hours). The throat dryness observed in patients cause swallowing difficulties and discomfort in pa-tients. It is considered that the relief of this symp-tom expressed to be discomfort by patients is an important result of the study. Marley12 reported that cold vapor is effective in decreasing fever, airway inflammation, and viscosity of secretion;
and Komorn et al13 reported that it can be used in the control of larynx damage-related complaints (hoarseness, coughing, throat dryness, etc). In further studies, cold vapor application to patients especially after operations such as tonsillectomies and thyroidectomies was recommended.11
Study Limitations
This study has several limitations. First, this study was a pilot study and represents a small group. A study conducted on a larger sample size and on patient groups that have undergone different surgi-cal interventions will assist in determining the ef-fect of cold vapor. Another limitation of the study is the lack of measurement of tracheal cuff pres-sure. As high cuff pressure will lead to mucosal ischemia-related sore throat, measurement of this pressure will ensure that the study is conducted Table 1. Patients’ Sociodemographic Characteristics
Sociodemographic Characteristics
Control Group (N5 20)
Cold Vapor Group (N5 20)
Cold Vapor and Oxygen Group (N5 20)
Statistical Analysis
Number % Number % Number %
Gender Female 9 30.0 10 33.3 11 36.7 X25 0.400* Male 11 36.7 10 33.3 9 30.0 P5 .819 Smokingy 21.66 10.7 (5-35) 16.76 12.9 (5-35) 21.56 8.9 (2-30) X25 0.421z P5 .663 Agey 44.76 12.8 (24-66) 49.26 10.6 (25-68) 45.76 10.2 (30-62) F5 0.893x P5 .415 *Chi-square test was used.
yMean and standard deviation (minimum-maximum) values were given. zKruskal-Wallis test was used.
xOne-way analysis of variance test was used.
Table 2. Patients’ Characteristics Regarding Intubation
Characteristics
Control Group (N5 20)
Cold Vapor Group (N5 20)
Cold Vapor and Oxygen Group (N5 20)
Statistics
Number % Number % Number %
Endotracheal tube number
7.0-7.5 13 36.1 12 33.3 11 30.6 X25 0.417*
8.0-8.5 7 29.2 8 33.3 9 37.5 P5 .812
Intubation time (h)y 2.66 0.6 (2-4) 2.46 0.8 (1.5-3.5) 2.56 0.8 (1.5-5) X25 1.727* P5 .422 *Chi-square test was used.
more accurately. Third, in our study, the com-plaints (sore throat, throat dryness, hoarseness, and swallowing difficulty) had been evaluated as present or absent. The investigators aimed to eval-uate the sore throat intensity using the visual analog scale (VAS) within the scope of the study. Within this context, the sore throat intensity was asked to all patients in a manner they could under-stand during the implementation of the study. However, despite all explanations provided to them, they only responded to throat soreness as present or absent. In the study conducted in our country by Sayin and Akyolcu19 it was reported that the VAS was considered to be very simple and meaningless, not reliable, and not clearly
comprehensible by patients. Sayin and Akyolcu19 determined that the use of VAS was not very suit-able in Turkish society and emphasized that it was important to use brief, simple, visual, verbal, or numeric clues in the evaluation of the pain of surgical patients.
Conclusion
Although the investigators were expecting cold vapor to decrease throat soreness, there was no statistical difference between groups (P . .05); the highest decrease in sore throat was in the group that received cold vapor together with ox-ygen. This result was surprising for the Table 3. Postoperative Throat Complications
Complications
Postoperative Period Before
Application 2 h 4 h 8 h 12 h
Number % Number % Number % Number % Number %
Sore throat
Control group (N5 20) 12 60.0 11 55.0 8 40.0 4 20.0 2 10.0
Cold vapor group (N5 20) 13 65.0 15 75.0 14 70.0 11 55.0 6 30.0
Cold vapor and oxygen group (N5 20) 14 70.0 13 65.0 8 40.0 6 30.0 3 15.0 Statistics* X25 0.440 P5 .803 X25 1.758 P5 .415 X25 4.800 P5 .091 X25 5.714 P5 .057 X25 2.894 P5 .235 Throat dryness Control group (N5 20) 16 80.0 16 80.0 17 85.0 9 45.0 2 10.0
Cold vapor group (N5 20) 14 70.0 15 75.0 15 75.0 9 45.0 1 5.0
Cold vapor and oxygen group (N5 20) 16 80.0 13 65.0 10 50.0 2 10.0 - -Statistics* X25 0.745 P5 .689 X25 1.193 P5 .551 X25 6.190 P5 .045** X25 7.350 P5 .025** X25 2.105 P5 .349 Hoarseness Control group (N5 20) 8 40.0 6 30.0 5 25.0 2 10.0 1 5.0
Cold vapor group (N5 20) 9 45.0 7 35.0 6 30.0 4 20.0 -
-Cold vapor and oxygen group (N5 20) 7 35.0 4 20.0 5 25.0 1 5.0 1 5.0 Statistics* X25 0.417 P5 .812 X25 1.149 P5 .563 X25 0.170 P5 .918 X25 2.264 P5 .322 X25 1.034 P5 .596 Swallowing difficulty Control group (N5 20) 10 50.0 12 60.0 11 55.0 6 30.0 1 5.0
Cold vapor group (N5 20) 13 65.0 9 45.0 10 50.0 10 50.0 7 35.0
Cold vapor and oxygen group (N5 20) 9 45.0 8 40.0 8 40.0 - - - -Statistics* X25 1.741 P5 .419 X25 1.735 P5 .420 X25 0.934 P5 .627 X25 12.955 P5 .002** X25 12.404 P5 .002** *Chi-square test was used.
investigators. In conclusion, in the study, it was determined that cold vapor does not have an ef-fect on sore throat on its own; however, it can decrease hoarseness and swallowing difficulties when applied with oxygen. Based on findings ob-tained in our study, the effectiveness of cold vapor
on throat soreness should be repeated on more extensive groups.
Acknowledgments
The authors thank the nurses of the Neurosurgery Clinic.
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