Lidocaine lubricants for intubation-related complications: a systematic review and meta-analysis

Effects of continuous and slow tracheal tube cuff deflation on cough reflex during extubation in noncardiac surgery patients: a randomised clinical trial

BACKGROUND

The incidence of cough reflex during extubation is 76%. Cough reflex causes severe hemodynamic fluctuations and airway complications. This prospective trial investigated the potential effects of tracheal tube cuff deflation on cough reflex during extubation.

METHODS

One hundred and twenty-six patients scheduled for operations within 3 h under general anaesthesia with orotracheal intubation were randomly assigned to one of three groups: control (C), experimental (E) or syringe (S) groups. Patients in group C underwent tracheal tube cuff deflation using a 10-ml syringe in 1 s, patients in group E underwent tracheal tube cuff deflation continuously and slowly in 5 s using a cuff pressure gauge until the pressure was zero and patients in group S underwent tracheal tube cuff deflation using a 10-ml syringe at a speed of 1 ml s^-1. The incidence and severity of cough reflexs during extubation and the incidence of postoperative airway complications within 48 h were assessed.

RESULTS

Compared with group C (60.0%), the incidence of cough reflex in group E was 9.8% (p < 0.001) and in group S was 12.5% (p < 0.001). The severity of cough reflex was graded as 2 (1-2) in group C, 1 (1-1) in group E and 1 (1-1) in group S (p < 0.001 for group comparisons). The incidence of hoarseness in group C was 0.0%, in group E was 19.5% and in group S was 5.0% (p < 0.05 for all groups, p = 0.009 between group C and E).

CONCLUSIONS

Compared with deflating a trachal tube cuff with a 10-ml syringe in 1 s, the use of a 10-ml syringe at a speed of 1 ml s^-1 or a cuff pressure guage within 5 s can both reduce the incidence of cough reflex, but deflating with a cuff pressure guage can increase the incidence of postoperative hoarseness.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, identifier: ChiCTR2100054089, Date: 08/12/2021.

Pharmacologic methods to minimise coughing during extubation in the era of COVID-19

BACKGROUND/AIM

Given the current severe acute respiratory syndrome coronavirus 2 pandemic, coughing at the time of extubation is at risk of creating aerosolisation. This may place health care workers at risk of nosocomial infection during the perioperative period. This study aims to summarise the current pharmacologic methods to minimise cough at the time of extubation, and to determine whether some strategies could be more beneficial than others.

METHODS

This is a summary of systematic reviews. A comprehensive search through MEDLINE was performed. Thirty-three publications were screened for eligibility. Only the manuscripts discussing pharmacologic methods to minimise coughing on extubation were included in this review.

FINDINGS

Many pharmacological agents have been proposed to decrease the incidence of cough at the time of extubation. Of these, intravenous administration of dexmedetomidine (relative risk 0.4; 95% CI: 0.4-0.5) or remifentanil (RR 0.4; 95% CI: 0.4-0.5) seems to have the largest effect to reduce cough on extubation.

CONCLUSION

The available data in the current literature is sparse. Yet, dexmedetomidine and remifentanil seem to be the most efficient agents to decrease the incidence of emergence coughing.

Internal branch of superior laryngeal nerve block by dexamethasone alleviates sore throat after thyroidectomy: a randomized controlled trial

PURPOSE

Postoperative sore throat (POST) is a common complaint following thyroidectomy. Dexamethasone was reported to alleviate POST when administered via different routes. This study aimed to compare the effects of local spray and perineural injection surrounding the internal branch of superior laryngeal nerve (iSLN) in preventing POST and alleviating postoperative impaired voice function.

METHODS

A randomized, double-blinded, controlled trial was performed to test the efficacy of the iSLN block in inhibiting of POST. A total of 161 patients who underwent elective thyroidectomy were randomly allocated to two groups. Group Spray: 4 mg dexamethasone was sprayed on to the vocal cord; Group iSLN: bilateral perineural injection with 4 mg dexamethasone around the iSLN. The incidence and severity of POST, swallowing pain, and its side effects were evaluated. Postoperative acoustic analysis, including jitter and shimmer, was also performed.

RESULTS

Group iSLN exhibited a significantly less incidence and intensity of POST at 6 h and 24 h (P < 0.001). The patients experienced less swallowing pain at 6 h (P < 0.001) after the surgery, compared with Group Spray. When compared with Group Spray, Group iSLN improved postoperative voice function, which was characterized by lower jitter and lower shimmer value at 6 h and 24 h (P < 0.001) after the surgery. The severity of postoperative cough is higher in Group Spray (P < 0.001).

CONCLUSIONS

Among patients undergoing elective thyroidectomy, those who received perineural injection surrounding iSLN with dexamethasone had improved voice function and presented with more excellence in the inhibition of POST and cough, in comparison with the local spray.

REGISTER INFORMATION

This trial was registered in the Chinese Clinical Trial Registry on 4th Jan, 2021 (ChiCTR2100042145). The trial is registered at http://www.chictr.org.cn/showproj.aspx?proj=120142 .

Comparative Efficacy of 6 Topical Pharmacological Agents for Preventive Interventions of Postoperative Sore Throat After Tracheal Intubation: A Systematic Review and Network Meta-analysis

BACKGROUND

Topical pharmacological agents typically used to treat postoperative sore throat (POST) after tracheal intubation include nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, lidocaine, Glycyrrhiza (licorice), and N-methyl-d-aspartate (NMDA) receptor antagonists (including ketamine and magnesium). However, the optimal prophylactic drug remains elusive.

METHODS

The literature published before September 8, 2019 was searched on the PubMed, the Embase, the Web of Science, and the Cochrane Library. Randomized controlled trials (RCTs) covering topical prophylactic medications for patients with POST were included. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assess the quality of evidence. The primary outcome is the risk of POST. Combining both direct and indirect evidence, a network meta-analysis was performed to assess odds ratios (ORs) between the topical pharmacological agents and surface under the cumulative ranking (SUCRA) curve for the treatment-based outcomes. This study is registered with PROSPERO, number CRD42020158985.

RESULTS

Sixty-two RCTs (at least 73% of which were double blinded) that included a total of 6708 subjects and compared 6 categories of drugs and/or placebos were ultimately enrolled. All preventive interventions except lidocaine were more effective than placebo at the 4 time intervals. Lidocaine (OR: 0.35, 95% credible interval [CrI], 0.16-0.79) has a greater POST preventative intervention effect than the placebo at a time interval of only 2 to 3 hours after surgery. Relative to lidocaine, the risk of POST except 2 to 3 hours was lower for the following treatments: corticosteroids, ketamine, magnesium, NSAIDs, and Glycyrrhiza. The NMDA receptor antagonists studied here included ketamine and magnesium. Magnesium generally demonstrated greater benefit than ketamine at 24 hours postsurgery/extubation (OR: 0.41, 95% CrI, 0.18-0.92). Compared with ketamine, corticosteroids were associated with a reduced risk of POST during the 4 to 6 hours (OR: 0.40, 95% CrI, 0.19-0.83) and 24 hours (OR: 0.34, 95% CrI, 0.16-0.72) time intervals. During the 2 to 3 hours time interval, Glycyrrhiza (OR: 0.38, 95% CrI, 0.15-0.97) was more efficacious than magnesium.

CONCLUSIONS

Our analysis shows that, among the 6 topical medications studied, lidocaine is not optimal for topical use to prevent POST. Glycyrrhizin, corticosteroids, NSAIDs, and NMDA receptor antagonists (ketamine and magnesium) are associated with a reduced postoperative pharyngeal pain across the 4 postsurgical time intervals studied, all of which can be chosen according to the clinical experience of the anesthesiologists and the patient preferences and are recommended for the reduction of postoperative throat pain.

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.

Effects of thermal softening of endotracheal tubes on postoperative sore throat: A randomized double-blinded trial

BACKGROUND

Postoperative throat complications after intubation are undesirable but frequent outcomes. A randomized, double-blinded study was performed to determine whether thermal softening of endotracheal tubes reduced throat complications after intubation.

METHODS

Patients (n = 196) undergoing nasal surgery were randomly allocated into the control group and thermal softening groups. Sore throat and hoarseness were evaluated 1 and 24 hours after extubation. The severity of sore throat was evaluated using the numeric rating scale (NRS). The primary outcome was the incidence of sore throat 1 hour after extubation and sore throat was defined as a painful or scratchy feeling in the throat. The secondary outcomes were the incidence of hoarseness 1 hour after extubation, the incidence of sore throat and hoarseness 24 hours after extubation, severity of sore throat, and vocal cord injuries.

RESULTS

The incidence of sore throat 1 hour after extubation was lower in the thermal softening group than in the control group (35.1% vs 52.7%, P = .02). Moreover, thermal softening decreased the mean NRS score for sore throat in the thermal softening group by 10% an hour after extubation (thermal softening group, 1.29 [95% CI, 0.88-1.70] vs control group, 2.33 [95% CI, 1.77-2.89]; P < .01). At 24 hours after extubation, the incidence of sore throat (38.3% vs 40.7%, P = .77) and hoarseness (34.0% vs 35.2%, 0.95 [0.52-1.74], P = .74) were comparable between the two groups.

CONCLUSIONS

Intubation using endotracheal tubes with thermal softening significantly decreased the incidence of sore throat 1 hour after extubation when compared with endotracheal tubes without thermal softening.

Nebulized pharmacological agents for preventing postoperative sore throat: A systematic review and network meta-analysis

Postoperative sore throat is one of the most common complications following endotracheal intubation. Nebulization therapy, a preferable and safety method of drug delivery, has been shown to be effective in postoperative sore throat prevention in many studies. However, the relative efficacy of various nebulized agents remains unknown. In this review, we aimed to quantify and rank order the efficacy of available nebulized agents for various postoperative sore throat-related outcomes. A comprehensive literature search of PubMed, EMBASE, CENTRAL and Google Scholar was conducted to identify eligible studies from inception to 25 May 2020. Incidence of postoperative sore throat 1hour and 24hours postoperatively and severity of postoperative sore throat 24 hours postoperatively were the primary outcomes. We conducted a Bayesian network meta-analysis to combine direct and indirect evidence to estimate the relative effects between treatments as well as the probabilities of ranking for treatments based on their protective effects. We identified 32 trials assessing 6 interventions. Overall inconsistency and heterogeneity were acceptable. Nebulized corticosteroids, magnesium, and ketamine differed from non-analgesic methods on the three primary outcomes. Based on the surface under the cumulative ranking curve, nebulized corticosteroids ranked first in almost all outcomes among the nebulized drugs. Considering only high-quality and 2-arm design studies, nebulized corticosteroids still seemed best. In conclusion, prophylactic use of nebulized corticosteroids, magnesium, and ketamine can effectively prevent postoperative sore throat, and nebulized corticosteroids appears to be the overall best approach.