Efficacy of endotracheal lidocaine administration with continuous infusion of remifentanil for attenuating tube-induced coughing during emergence from total intravenous anesthesia

Superior laryngeal nerve block with in-line lignocaine nebulization for awake extubation response

Background and Aims:

Tracheal extubation is associated with various undesirable hemodynamic and airway responses. Various drugs are used effectively to curb these responses. But these drugs have limitations and produce side effects. Hence, the study was planned to assess the effects of superior laryngeal nerve block with inline lignocaine nebulization on awake extubation responses to suggest an alternative. The aim of this study was to assess the effect of bilateral superior laryngeal nerve block with inline lignocaine nebulization on awake extubation responses.

Material and Methods:

A study was conducted in 35 patients aged 18-60 years, posted for surgery less than 3 h under general anesthesia. The hemodynamic responses like heart rate, arterial blood pressure, and mean arterial pressure were recorded preoperatively and at 1, 5, and 10 min postextubation. Undesirable respiratory responses like bucking, severity of sore throat, and cough response were also assessed. Repeated measures analysis of variance followed by the Tukey HSD test was used to find the significance of hemodynamic parameters. Qualitative data were expressed as percentages.

Results:

Decrease in Systolic Blood Pressure, Diastolic Blood Pressure and Mean Arterial Pressure was statistically significant at 5 mins (T2) and 10 mins (T3) postextubation as compared to baseline (T0). No cough was observed postextubation in 80% patients while 20% had mild Grade 1 cough.

Conclusion:

Superior laryngeal nerve block with in-line lignocaine nebulization for awake extubation is effective in curbing the haemodynamic and respiratory responses of extubation.

Impact of topical airway anesthesia on immediate postoperative cough/bucking: a systematic review and meta-analysis

BACKGROUND

Postoperative cough may occur after tracheal intubation, but it is indistinct which drug is best at diminishing these events. Additionally, airway reflexes are commonly accompanied by severe hemodynamics responses during emergence.

OBJECTIVES

To evaluate the role of topical airway anesthesia on immediate post-extubation cough/bucking and extubation time.

METHODS

Randomized clinical trials from MEDLINE, EMBASE, CENTRAL, and LILACS published until December 23, 2020 were included. Our primary outcome was postoperative cough/bucking incidence which was compared between local anesthetics and controls. Extubation times were likewise considered. Predisposition appraisal and subgroup, affectability investigations were likewise performed.

RESULTS

The pooled analysis found a 45% reduction in cough incidence after treatment with topical airway local anesthetic (RR.á=.á0.55; 95% CI: 0.42 to 0.72; p.á<.á0.001). The number needed to treat (NNT) was 4.61. The intervention showed no differences in reduction of the extubation time (mean difference = -0.07; 95% CI: -0.14 to 0.28; p.á=.á0.49).

CONCLUSION

Topical airway anesthesia demonstrated better than placebo or no medication in reducing immediate post-extubation cough/bucking. Further studies could have this objective to combine the different ways to perform better outcomes for patients.

Effect of Pharmacological Agents Administered for Attenuating the Extubation Response on the Quality of Extubation: A Systematic Review

Background

Several drugs have been tried to obtund the hemodynamic extubation response but all have variable side effects that may affect the quality of short-term recovery.

Objective

Our primary objective was to evaluate the effect of pharmacological agents, such as dexmedetomidine, local anesthetics, and so on, administered for attenuating the extubation response on the quality of extubation, as judged by the presence or absence of cough, sedation, and laryngospasm/bronchospasm in adult patients who had undergone general anesthesia. A secondary objective was to evaluate the effect of these drugs on other immediate post-extubation complications such as respiratory depression, desaturation, bradycardia, hypotension, and nausea and vomiting (PONV).

Methods

This is a systematic review of (randomized controlled trials) RCTs with meta-analysis. The Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for RCTs on the effect of pharmacological agents on both the hemodynamic extubation response as well as the quality of extubation.

Results

Fourteen out of 24 included studies were subjected to a meta-analysis. The risk of cough was less likely in the intervention group as compared to control groups (OR 0.26, 95% CI 0.15 to 0.46, p<0.00001, I²=35%). Sedation, hypotension (OR= 10.47; 95% CI: 1.86, 58.80, p=0.008, I²=0%), and bradycardia (OR= 6.57; 95% CI: 2.09, 20.64, p=0.001, I²=0%) were reported with dexmedetomidine. Only one study reported laryngospasm with dexmedetomidine and two studies with opioids.

Conclusion

Dexmedetomidine 0.4 to 0.5 ug/kg was associated with smooth extubation, minimal coughing, no laryngospasm/ bronchospasm, and with stable hemodynamics, without causing respiratory depression, PONV, and desaturation. However, in higher doses (more than 0.5 ug/kg), it caused bradycardia, hypotension, and sedation. Other pharmacological agents, such as local anesthetics, calcium channel blockers, and opioids, did not attenuate cough associated with extubation.

Use of lidocaine to prevent postoperative coughing after partial laryngectomy: comparison of three delivery methods

Objective: To compare the effectiveness of lidocaine administration (intravenous injection, dripping via the tracheostomy tube, and spraying into the tracheostomy incision) on postoperative coughing after partial laryngectomy.

Patients and methods: A total of 115 male patients with laryngeal carcinoma scheduled for partial laryngectomy under general anesthesia were randomized into three groups. In group I (n=35), 2% lidocaine hydrochloride (1.5 mg/kg) was slowly infused intravenously. In group II (n=40), 2% lidocaine hydrochloride (1.5 mg/kg) was dripped into the tracheostomy tube upon completion of surgery. In group III (n=40), 7% lidocaine aerosol (5 sprays, 22.5mg) was sprayed into the tracheostomy incision before tracheostomy tube placement. We recorded incidences of coughing, incisional bleeding, and hemodynamic changes when leaving the postanesthesia care unit (T₁), and 6 hrs (T₂) and 24 hrs (T₃) after surgery.

Results: The coughing scores and incisional bleeding scores were significantly lower in group II and III than that in group I at T₁, T₂, and T₃. Group II and III had significantly lower heart rate than group I at T₁ and T₂. Compared with group I, mean arterial pressure decreased significantly in group II (T₁ and T₂) and group III (T₁ and T₃).

Conclusion: In patients undergoing partial laryngectomy, spraying 7% lidocaine aerosol into the tracheostomy incision before placing the tracheostomy tube or instilling 2% lidocaine hydrochloride into the tracheostomy tube upon completion of surgery effectively prevented postoperative coughing, which reduced the risk of bleeding from the incision and thus facilitates postoperative rehabilitation.

Replacing a double-lumen tube with a single-lumen tube or a laryngeal mask airway device to reduce coughing at emergence after thoracic surgery: a randomized controlled single-blind trial

BACKGROUND

Coughing episodes occur frequently at extubation after thoracic surgery, and this may be due in part to the double-lumen tube (DLT). In this study, the DLT was replaced with either a single-lumen endotracheal tube (ETT) or a laryngeal mask airway (LMA) device or left in place, and the incidence of coughing at emergence was compared between the three groups.

METHODS

Fifty-eight adults scheduled for thoracic surgery with a DLT were included. Exclusion criteria were an anticipated difficult airway, obesity, and contraindication to the use of an LMA ProSeal™ (LMA-P). After surgery but before emergence, patients were randomized to having the DLT (1) removed and replaced by an LMA-P (LMA-P Group), (2) removed and replaced by an ETT (ETT Group), or (3) left in place (DLT Group). The primary outcome was the number of coughing episodes at extubation.

RESULTS

Among 184 patients screened, 124 did not meet inclusion criteria, and two patients, both in the ETT Group, were excluded after randomization, leaving 20, 18, and 20 patients in the LMA-P, ETT, and DLT Groups, respectively. There were fewer coughing episodes (median [quartiles]) in the LMA-P Group than in the DLT Group (0[0-1] vs 2[1-3], respectively; P = 0.01). In the DLT Group, 90% of patients coughed at least once. This incidence was not significantly different in the ETT Group (83%; P = 0.222) but was significantly reduced in the LMA-P Group (35%; P < 0.001). No patient had oxygen desaturation during airway exchange or at extubation. The incidence and severity of hoarseness and sore throat were similar in all groups.

CONCLUSION

Coughing at extubation after thoracic surgery can be reduced if the DLT is replaced by an LMA-P before emergence. The number of patients in this trial was too small to evaluate the risks associated with exchanging the airway device. This trial was registered at ClinicalTrials.gov: NCT00925613.

The efficacy of lidocaine to prevent laryngospasm in children: a systematic review and meta-analysis

The purpose of this meta-analysis was to determine the efficacy of lidocaine in preventing laryngospasm during general anaesthesia in children. An electronic search of six databases was conducted. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were adhered to. We included randomised controlled trials reporting the effects of intravenous and/or topical lidocaine on the incidence of laryngospasm during general anaesthesia. Nine studies including 787 patients were analysed. The combined results demonstrated that lidocaine is effective in preventing laryngospasm (risk ratio (RR) 0.39, 95% CI 0.24-0.66; I(2)  = 0). Subgroup analysis revealed that both intravenous lidocaine (RR 0.34, 95% CI 0.14-0.82) and topical lidocaine (RR 0.42, 95% CI 0.22-0.80) lidocaine are effective in preventing laryngospasm. The results were not affected by studies with a high risk of bias. We conclude that, both topical and intravenous lidocaine are effective for preventing laryngospasm in children.