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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 1  |  Page : 43-48

Intracuff lidocaine 2% for prevention of postoperative cough and sore throat


Lecturer of Anesthesiology and Intensive Care, Al-Azhar University Hospital, Cairo; Department of Anesthesia, Fakhry Hospital, Al Khobar, Egypt

Date of Submission24-Nov-2017
Date of Acceptance26-Jul-2018
Date of Web Publication20-Nov-2018

Correspondence Address:
Mokhtar Mahmoud Younes
Lecturer of Anesthesiology and Intensive Care, Al-Azhar University Hospital, Cairo (Egypt); Department of Anesthesia, Fakhry Hospital, AL Khobar, 31952 Alkhobar
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_64_17

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  Abstract 


Background Tracheal intubation results in an alteration of the laryngeal mucosa. Coughing during emergence from general anesthesia is a common clinical problem. Inflation of the endotracheal tube cuff with lidocaine would create a reservoir of local anesthetic, which might diffuse across the cuff membrane to anesthetize the mucosa and attenuate stimulation during tracheal extubation.
Aim To evaluate the efficacy of intracuff lidocaine 2% for the prevention of postoperative cough and sore throat.
Patients and methods This prospective, randomized, controlled, double-blind study included 80 healthy patients scheduled for elective surgery of less than 2 h under general anesthesia with orotracheal intubation. These 80 patients were randomized through a computer-generated and sealed opaque envelope method into four equal groups, with 20 patients each. After induction of general anesthesia and tracheal intubation, the tracheal tube cuff was filled with 2 ml of 2% lidocaine solution (40 mg) or 0.9% saline. Twenty minutes before extubation, the participants received 1.5 mg/kg intravenous lignocaine or saline. In this way, four groups were formed: lidocaine cuff–lidocaine group (lidocaine in cuff and lidocaine intravenous), lidocaine cuff–saline group (lidocaine in the cuff and saline intravenous); saline cuff–lidocaine group (saline in cuff and lidocaine intravenous), and saline cuff–saline group (saline in cuff and saline intravenous). The primary outcome was the incidence of coughing at extubation. The secondary outcomes were sore throat scores and hemodynamic change. The incidence and severity of sore throat was recorded at 15, 60 min, and 24 h after extubation. Hemodynamic change was assessed at before induction (baseline), 5-min interval after induction, at intubation, 10 min after intubation, 10 min before extubation, at extubation, and 10 min after extubation.
Result There was a statistically significant reduction of postoperative cough and sore throat in lidocaine cuff groups in comparison to saline cuff groups. Intravenous lidocaine was not effective to reduce either cough or sore throat severity. However, there was no significant difference among all groups regarding hemodynamic change.
Conclusion Intracuff lidocaine 2% reduces incidence of cough and the severity of postoperative sore throat in surgery of less than 120 min. Intravenous lidocaine was not effective to reduce either cough or sore throat severity. There was no significant difference among all groups regarding hemodynamic change.

Keywords: hemodynamic change, intracuff lidocaine, intravenous lidocaine, postoperative cough, sore throat


How to cite this article:
Younes MM. Intracuff lidocaine 2% for prevention of postoperative cough and sore throat. Al-Azhar Assiut Med J 2018;16:43-8

How to cite this URL:
Younes MM. Intracuff lidocaine 2% for prevention of postoperative cough and sore throat. Al-Azhar Assiut Med J [serial online] 2018 [cited 2018 Dec 18];16:43-8. Available from: http://www.azmj.eg.net/text.asp?2018/16/1/43/244153




  Introduction Top


Tracheal intubation may contribute to respiratory complications. Endotracheal tube (ETT) is a source of discomfort and pain. Irritation by tube cuff increases airway secretions and exacerbates cough and produces more discomfort. To keep the patient in a comfortable state, a significant amount of sedatives and analgesics is needed [1].

Emergence from general anesthesia is often complicated by the ETT-induced emergence phenomena (EP), which include coughing, sympathetic stimulation, sore throat, increased bleeding from the surgical site, and increased intracranial and intraocular pressures [2].

Various strategies have been employed to attenuate this response, including extubation in a deep plane of anesthesia, administration of intravenous agents like short-acting narcotics, intravenous lidocaine, topical lidocaine, and intracuff application of lidocaine. Each of these methods has its limitations [3].

Topical lidocaine has been used for many years for blunting emergence adverse effect after general anesthesia. Delivery of lidocaine to the mucosa in contact with the tracheal tube cuff has been used to decrease tracheal stimuli. As lidocaine is injected into the ETT cuff, it spreads through the semipermeable membrane wall and produces anesthetic action in the trachea and increases tolerance to tracheal tubes and its cuff, resulting in significant decrease in the incidence of cough at tracheal extubation [4].

The aim of this study is to ascertain if intracuff lidocaine 2% can suppress tracheal tube-associated adverse effects during emergence from general anesthesia.


  Patients and methods Top


This prospective, randomized, controlled, double-blind study included 80 healthy patients admitted to Fakhry Hospital, Al Khobar, Saudi Arabia, from May 2016 to November 2016. Following the local ethics committee approval, a written informed consent was taken. All patients were older than 21 years, of both sexes, with ASA physical status I or II, and their Mallampati classification was equal to 1 [5]. The patients with symptomatic gastric reflux, history of difficult airway, an upper respiratory tract infection in the last month or asthma, history of pulmonary disease, and lidocaine hypersensitivity were excluded from the study. Patients were scheduled to elective surgery of less than 2 h under general anesthesia with orotracheal intubation. After induction of general anesthesia and tracheal intubation, the tracheal tube cuff was filled with 2 ml of 2% lidocaine solution (40 mg) or 0.9% saline. Twenty minutes before extubation, they received 1.5 mg/kg intravenous lignocaine or saline. All patients were randomized through a computer-generated and sealed opaque envelope method into four equal groups, with 20 patients each, labeled as L1L2, L1S2, S1L2, and S1S2 groups, where 1 indicated cuff syringe and 2 for intravenous syringe.
  • L1L2 (lidocaine cuff–lidocaine group): lidocaine in cuff and lidocaine intravenous.
  • L1S2 (lidocaine cuff–saline group): lidocaine in cuff and saline intravenous.
  • S1L2 (saline cuff–lidocaine group): saline in cuff and lidocaine intravenous.
  • S1S2 (saline cuff–saline group): saline in the cuff and saline intravenous.


The lignocaine used for the study was manufactured by Astra Zeneca Pharma (Bangalore, Karnataka, India). An anesthetist who gave anesthesia and a nurse who collected data postoperatively were blinded about the study drug regimens. The patients were informed about the visual analogue scale (VAS) preoperatively and were explained how to rate their severity of pain of postoperative sore throat on the scale (VAS 1–3, mild; 4–6, moderate; and 7–10, severe pain) [6]. Patients were premedicated with oral diazepam 0.15 mg/kg with a sip of water an hour before the surgery and received ondansetron 4 mg, intravenous. General anesthesia was given to all patients. Propofol 2 mg/kg, atracurium besylate 0.5 mg/kg, and fentanyl 1.5 μg/kg, intravenous, were given at induction. They were ventilated with 40% oxygen in nitrous oxide (N2O) with sevoflurane 2–3%, using circle system with a flow of 3 l. Patients were intubated using 7.5 mm internal diameter (ID) ETT with large-volume low-pressure cuff. The ETT cuff was filled with 2% lidocaine in L1L2 and L1S2 groups or 0.9% saline with a syringe having 2 ml volume to obtain a seal in S1L2 and S1S2 groups. Anesthesia was maintained using 40% oxygen in N2O and sevoflurane 2–3%. Muscle relaxation was maintained using injection atracurium besylate 10 mg on the appearance of one twitch on train of four. Moreover, 20 min before the end of the surgery, patients in L1L2 and S1L2 groups received intravenous lidocaine, and those in L1S2 and S1S2 groups received intravenous saline. The anesthesia provider was blinded about lidocaine or saline administration, as all solutions were colorless, with a volume of 20 ml. A staff nurse, not otherwise involved in the study, prepared the solutions. The application of local anesthetic by any other means was prohibited. Residual muscle paralysis was reversed using neostigmine (0.05 mg/kg) and glycopyrrolate (0.02 mg/kg) after the return of two twitches on train of four. Pharyngeal secretions were gently aspirated before the sevoflurane vaporizer was turned off. Tracheal extubation was performed when the patients were responsive to verbal commands and occurrence of cough was noted at and immediately after extubation. For postoperative analgesia, patients received pethidine 1.0 mg/kg, intravenous.

All patients were monitored for ECG, pulse oximetry, noninvasive blood pressure, end-tidal capnography, and neuromuscular function monitor (nerve stimulator). The intracuff pressure and volume of the inflation solution and air withdrawn from the ETT cuff were recorded.

Data to be collected

Intraoperative

Heart rate and mean arterial blood pressure before induction, after induction, at intubation, 5 and 10 min after intubation, 10 and 5 min before extubation, at extubation, 5 and 10 min after extubation were recorded.

Postoperative

Cough at tracheal extubation was determined during the time interval from the moment of tracheal extubation until appropriate spontaneous ventilation was established. The anesthetist blinded about groups’ assignment noted ‘yes’ or ‘no’ on the evaluation Performa regarding presence or absence of cough. For the secondary outcomes, patients were assessed regarding occurrence and severity of sore throat using a VAS 0–10 at 15 min, 1 h, and 24 h after extubation. The nurse blinded about the treatment groups collecting this information.

The tolerance to ETT at this time was noted by the number of coughs and smoothness of extubation, and was graded as follows, as suggested by Venkatesan and Korula [7]:
  • Grade 1: no cough or mild cough only during removal of ETT.
  • Grade 2: coughing while breathing regularly.
  • Grade 3: coughing before regular breathing is established.


Statistical analysis

Data were coded and entered using the statistical package for the social sciences, version 22. Data were summarized using mean, SD, and frequencies (number of cases) and relative frequencies (percentages) for categorical variables. Comparisons between groups was done using analysis of variance followed by post-hoc test if there is significance in normally distributed quantitative variables. χ2 test is used to compare frequency and percentage. P value less than 0.05 is considered significant.

Result

All patients completed the study. There were 20 patients in each group. Thus, data from 80 patients were included and analyzed.

There was no significant difference among the four groups regarding patients’ demographics data. The mean age of patients was 38±6, 37±5, 41±8, and 40±7 years for lidocaine cuff–lidocaine, lidocaine cuff–saline, saline cuff–lidocaine, and saline cuff–saline groups, respectively. The mean weights of four groups were 72±8, 69±7, 70±9, and 73±7 kg, respectively ([Table 1]).
Table 1 Patients’ demographic data

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Regarding cough at extubation, there was a statistically significant reduction of postoperative cough in L1L2 and L1S2 groups in comparison to S1L2 and S1S2 groups. The incidence of cough was 15, 20, 75, and 80% in L1L2, L1S2, S1L2, and S1S2 groups, respectively, with P value of less than 0.001, which was highly significant ([Table 2]).
Table 2 Cough at extubation (primary outcome)

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Regarding postoperative sore throat, there was a statistically significant reduction of postoperative sore throat in L1L2 and L1S2 groups in comparison with S1L2 and S1S2 groups, as there is no postoperative sore throat in 80% and 75% and incidence of mild postoperative sore throat was 20% and 25% in L1L2 and L1S2 groups, respectively, with P value of less than 0.001, which was highly significant, whereas no postoperative sore throat was seen in 25 and 10%, incidence of mild postoperative sore throat was 40 and 20%, and the incidence of moderate postoperative sore throat was 35 and 70% in S1L2 and S1S2 groups, respectively ([Table 3]).
Table 3 Sore throat severity (secondary outcome)

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Regarding heart rate, there was no significant difference between groups regarding heart rate change at baseline up to 10 min after extubation ([Table 4]).
Table 4 Heart rate changes in different studied groups

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Regarding mean arterial blood pressure, there was no significant difference between groups regarding mean arterial blood pressure change at baseline up to 10 min after extubation ([Table 5]).
Table 5 Mean arterial blood pressure (mmHg) changes in different studied groups

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  Discussion Top


Postextubation-induced EP are a cluster of airway complications after general anesthesia. Various symptoms result from mucosal injury or inflammation caused by airway instrumentation or the irritating effects of ETT [8].

Postoperative sore throat is one of the most annoying morbidities that occur in 50% or more of surgical patients during emergence from general anesthesia [9].

Different strategies have been used to attenuate this response. The results of this study reveal that the use of intracuff lidocaine 2% significantly reduced the incidence of postoperative cough and sore throat, whereas intravenous lidocaine was not effective at reducing either coughing or sore throat severity.

In agreement with the current result, a study conducted by Fagan et al. [3] concluded that inflation of the cuff of the ETT with lidocaine rather than saline or air can reduce the incidence of coughing in the initial postextubation period; however, Fagan and colleagues used lidocaine 4% in this study, whereas we used lidocaine 2%.

Other studies done by Navarro and colleagues and Estebe and colleagues support this study. They reported that ETT cuffs filled with alkalinized lidocaine prevented the occurrence of high cuff pressures during N2O anesthesia and reduced ETT discomfort and postoperative sore throat incidence [10],[11]. In this study, we used nonalkalinized lidocaine; however, Lam et al. [12] proved that both alkalinized and nonalkalinized intracuff lidocaine may prevent and alleviate postoperative sore throat and postintubation-related EP.

George and colleagues compared the effect of lignocaine instilled through the ETT and intravenous lignocaine on the extubation response in patients undergoing craniotomy with skull pins, and they concluded that lignocaine instillation of 1 mg/kg into the ETT will not attenuate the airway and hemodynamic response during emergence from anesthesia, and an intravenous administration using the same dose is unlikely to prevent cough if given 10 min before extubation, which support the results of this study [13].

On the contrary, there are studies proving that the use of 2% intracuff lidocaine and intravenous lidocaine significantly reduce the incidence of cough and postoperative sore throat [7].

One study conducted by Venkatesan and Korula in patients undergoing elective craniotomies in supine position showed that 4% ETT cuff lignocaine was not superior to 1.5 mg/kg intravenous lignocaine in attenuating coughing. This study is in contrary to the results of the current study [7]. However, in craniotomies, there are other factors, such as the patients are almost hyperventilated and extubated in deep plane of anesthesia.

However, a study done by Khan and colleagues using lidocaine spray onto the larynx showed a significant decrease in the incidence of cough at tracheal extubation in patients undergoing total abdominal hysterectomy. However, the use of lidocaine into ETT cuffs had no effect on the incidence of cough or sore throat. This study is against the results of the current study [14]. However, in their study, the tracheal tube cuff was filled with 4 ml of 2% lidocaine, and this large volume may lead to a high-pressure cuff.

Bousselmi and colleagues investigated the efficacy of instilled lidocaine onto the glottis before intubation. Lidocaine reduced both the incidence of coughing and the severity of postoperative sore throat in surgery of less than 120 min. Intracuff lidocaine 2% was not effective to reduce either coughing or sore throat severity, but the volume used to inflate the cuff was not mentioned. Maybe, they used large volume, leading to a high-pressure cuff [15].

The result of this study reveals that hemodynamic change was comparable in the entire group, which is almost similar to those reported by Fagan et al. [3] or Venkatesan and Korula [7].

In contrary with this result, Estebe and colleagues evaluated the effect of filling an ETT cuff with 40 mg lidocaine alone or alkalinized lidocaine in comparison with air on adverse EP, and they conclude that the increase of arterial blood pressure and cardiac frequencies during the extubation period was less in the liquid groups than in the control group [11], but there was a difference, as air was used in the cuffs in the control group instead of liquid.


  Conclusion Top


Results of this study indicate that the use of 2% intracuff lidocaine significantly reduces the incidence of cough and postoperative sore throat. Intravenous lidocaine was not effective at reducing either cough or sore throat severity. However, there was no significant difference among all groups regarding hemodynamic change.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schwilk B, Bothner U, Schraag S, Goergieff M. Preoperative respiratory events in smokers and nonsmokers undergoing general anesthesia. Acta Anaesthesiol Scand 1997; 41:348–355.  Back to cited text no. 1
    
2.
Kori K, Muratani T, Tatsumi S, Minami T. Influence of endotracheal tube cuff lubrication on postoperative sore throat and hoarseness. Masui 2009; 58:342–345.  Back to cited text no. 2
    
3.
Fagan C, Frizelle HP, Laffey J, Hannon V, Carey M. The effects of intracuff lidocaine on endotracheal-tube-induced emergence phenomena after general anesthesia. Anesth Analg 2000; 91:201–205.  Back to cited text no. 3
    
4.
Tanaka Y, Nishimori M, Sato Y, Furuya H. Lidocaine for preventing postoperative sore throat. Cochrane Database Syst Rev 2009; 8:CD004081.  Back to cited text no. 4
    
5.
Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, Liu PL. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anesth Soc J 1985; 32:429–434.  Back to cited text no. 5
    
6.
Dixon JS, Bird HA. Reproducibility along a 10 cm vertical visual analogue scale. Ann Rheum Dis 1981; 40:87–89.  Back to cited text no. 6
    
7.
Venkatesan T, Korula G. A comparative study between the effects of 4% endotracheal tube cuff lignocaine and 1.5 mg/kg intravenous lignocaine on coughing and hemodynamic during extubation in neurosurgical patients. A randomized controlled double-blind trial. J Neurosurg Anesthesiol 2006; 18:230–234.  Back to cited text no. 7
    
8.
McHardy FE, Chung F. Postoperative sore throat: cause, prevention and treatment. Anesthesia 1999; 54:444–453.  Back to cited text no. 8
    
9.
Biro P, Seifert B, Pasch T. Complaints of sore throat after tracheal intubation: a prospective evaluation. Eur J Anesthesiol 2005; 22:307–311.  Back to cited text no. 9
    
10.
Navarro LH, Braz JR, Nakamura G, Lima RM, Silva Fde P, Módolo NS. Effectiveness and safety of endotracheal tube cuffs filled with air versus filled with alkalinized lidocaine, a randomized clinical trial. Sao Paulo Med J 2007; 125:322–328.  Back to cited text no. 10
    
11.
Estebe JP, Dollo G, Le Corre P, Le Naoures A, Chevanne F, Le Verge R, Ecoffey C. Alkalinization of intracuff lidocaine improves endotracheal tube-induced emergence phenomena. Anesth Analg 2002; 94:227–230.  Back to cited text no. 11
    
12.
Lam F, Lin YC, Tsai HC, Chen TL, Tam KW, Chen CY. Effect of intracuff lidocaine on postoperative sore throat and the emergence phenomenon. A systematic review and meta-analysis of randomized controlled trials. PLoS One 2015; 10:e0136184  Back to cited text no. 12
    
13.
George SE, Singh G, Mathew BS, Fleming D, Korula G. Comparison of the effect of lignocaine instilled through the endotracheal tube and intravenous lignocaine on the extubation response in patients undergoing craniotomy with skull pins. A randomized double blind clinical trial. J Anesthesiol Clin Pharmacol 2013; 29:168–172.  Back to cited text no. 13
    
14.
Khan MA, Siddiqi KJ, Aqeel M. Lidocaine 4% spray is better than intracuff lidocaine 2% for reducing the incidence of post-extubation cough in patients undergoing total abdominal hysterectomy. Anesth Pain Intensive Care 2014; 18:162–166.  Back to cited text no. 14
    
15.
Bousselmi R, Lebbi MA, Bargaoui A, Ben Romdhane M, Messaoudi A, Ben Gabsia A, Ferjani M. Lidocaine reduces endotracheal tube associated side effects when instilled over the glottis but not when used to inflate the cuff. A double blind, placebo-controlled, randomized trial. Tunis Med 2014; 92:29–33.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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