Abstract
Dear Editor,
We read with great interest the study by Hong et al 1 examining the role of nasal herbal steam therapy (NHST) in managing post-extubation respiratory symptoms (PERS) after thyroidectomy. The pragmatic design and integration of traditional Korean medicine into a controlled trial reflect an important attempt to expand supportive care options for patients undergoing endotracheal intubation.
While the trial is notable for exploring a non-invasive adjunct, several methodological choices limit the strength of its clinical inference. The reliance on patient-reported Wisconsin Upper Respiratory Symptom Survey scores as the primary endpoint introduces subjectivity without parallel objective markers, such as laryngeal edema grading or pulmonary function parameters. This reliance complicates interpretation, as improvement in survey scores does not necessarily translate into better airway patency or reduced complications that influence recovery trajectories. 2
The small sample size of 66 patients, coupled with the short 5-day intervention window, raises concerns regarding statistical power and durability of effect. More importantly, from a clinical standpoint, PERS often extends beyond the immediate postoperative period, and transient improvement may not alter downstream outcomes such as unplanned readmission, prolonged analgesic use, or delayed oral intake. 3 The absence of longer-term follow-up therefore curtails the clinical applicability of the reported findings.
Another limitation is the lack of blinding. Because NHST involves a ritualized, sensory intervention, knowledge of treatment allocation could influence subjective outcome reporting, amplifying placebo effects. Without strategies such as sham steam therapy, it remains unclear whether observed improvements are attributable to the pharmacologic action of herbal constituents or to expectation bias. This distinction is clinically meaningful, as the adoption of NHST into recovery protocols would require evidence that extends beyond nonspecific symptomatic reassurance. 4
Finally, the safety profile is incompletely addressed. Steam inhalation carries risks of thermal injury, bronchospasm, and infection if preparation standards are inconsistent. Although the study reports no adverse events, the small sample size and short observation period may underestimate the true risk profile, which is particularly relevant if NHST is to be integrated into routine perioperative pathways.
In conclusion, the study introduces an innovative approach to addressing PERS, yet the lack of objective outcome validation, limited follow-up, and potential expectancy bias restrict its immediate impact on clinical decision-making. Future investigations with blinded, adequately powered designs, and longer observation windows are essential before NHST can be recommended as a reliable adjunct in postoperative airway management. The present work, however, contributes to ongoing dialogue on integrating traditional practices into modern recovery strategies.
Footnotes
Author Contributions
K.P contributed to Correspondence, Validation, Supervision, and Writing – Review & Editing. H.M was responsible for Writing – Original Draft and Writing – Review & Editing. M.K contributed to Conceptualization, Methodology, Writing – Original Draft, and Writing – Review & Editing.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Generative AI Use Statement
Generative AI tools, including Paperpal and ChatGPT-4o, were utilized solely for language refinement, grammar enhancement, and stylistic refinement. These tools had no role in the conceptualization, data analysis, interpretation of results, or substantive content development of this manuscript. All intellectual contributions, data analysis, and scientific interpretations remain the sole work of the authors. The final content was critically reviewed and edited to ensure accuracy and originality. The authors take full responsibility for the accuracy, originality, and integrity of the work presented.