title: Incidence of ventilator associated pneumonia in burn patients with inhalation injury treated with high frequency percussive ventilation versus volume control ventilation: A systematic review.
abstract: BACKGROUND
  Pneumonia increases mortality in burn patients with inhalation injuries. We evaluated whether the use of High Frequency Percussive Ventilation (HFPV) in burn patients with inhalation injuries can decrease rates of Ventilator Associated Pneumonia (VAP) compared to Volume Control Ventilation (VCV).
  
  
  METHODS
  Data were gathered from PubMed, EMBASE, Web of Science, reference lists, and hand search. For unpublished data we searched ClinicalTrials.gov and RePORTER. We included observational and Randomized Controlled Trials (RCTs) that compared rates of VAP with the use of HFPV and VCV in adult burn patients with inhalation injury. Two reviewers independently extracted data from the retrieved studies and assessed them for eligibility, methodology, and quality.
  
  
  RESULTS
  281 abstracts were reviewed, of which 4 studies (540 patients) were included. Two were observational and two were RCTs. All studies had moderate risk of bias. One study had low external validity while others had moderate external validity. The two observational studies found non-concordant results. One study found a 24% statistically significant reduction in the rates of VAP while the other found no difference. The two RCTs had small sample sizes. There was no significant difference in VAP rates between HFPV and VCV. The VCV arms of the four studies were heterogeneous. Only one study used low tidal volumes, whereas the rest used high tidal volumes in the VCV arm.
  
  
  CONCLUSIONS
  Evidence about decreased incidence of VAP in burn patients with inhalation injuries who are on HFPV compared to those on VCV is inconclusive. Although enhanced airway clearance by HFPV was thought to play a role in decreasing VAP in this population, high tidal volume in the VCV arms could be a confounding factor that should be eliminated in future studies before a firm conclusion can be reached. More RCTs comparing HFPV to low tidal volume VCV are needed.
authors.affiliation: Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA. Electronic address: alaashry@musc.edu.
authors.forename: Haitham S
authors.initials: HS
authors.lastname: Al Ashry
authors.affiliation: Division of Hospital Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO 63108, USA.
authors.forename: George
authors.initials: G
authors.lastname: Mansour
authors.affiliation: Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA.
authors.forename: Andre C
authors.initials: AC
authors.lastname: Kalil
authors.affiliation: Division of Clinical Research and Evaluative Sciences, Department of Medicine, Creighton University Medical Center, Omaha, NE 68131, USA.
authors.forename: Ryan W
authors.initials: RW
authors.lastname: Walters
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Creighton University Medical Center, Omaha, NE 68131, USA.
authors.forename: Renuga
authors.initials: R
authors.lastname: Vivekanandan
mesh_terms: D002056:Burns / Q000628:therapy*; D006612:High-Frequency Ventilation / Q000379:methods*; D006801:Humans; D015994:Incidence; D053717:Pneumonia, Ventilator-Associated / Q000453:epidemiology*; D012121:Respiration, Artificial / Q000379:methods; D012307:Risk Factors; D015208:Smoke Inhalation Injury / Q000628:therapy*; D013990:Tidal Volume
keywords: Burns; High frequency percussive ventilation; Inhalation injury; Ventilator associated pneumonia