Alkalinized Lidocaine Preloaded Endotracheal Tube Cuffs Reduce Emergence Cough After Brief Surgery: A Prospective Randomized Trial

The Influence of Piriform Recess Instillation with Lidocaine Before Bronchoscopy on Post-General Anesthesia Cough: A Randomized Controlled Trial

Background and Importance

Postoperative cough is a common complication of general anesthesia after bronchoscopy. The aim of the present study was to determine the safety profile and efficacy of piriform recess instillation with lidocaine in reducing the incidence of coughing.

Objective

To what extent could piriform recess instillation with lidocaine decrease the incidence of cough at 10min after extubation?

Outcome Measures and Analysis

Eighty-eight consecutive patients were equally randomized to a lidocaine group receiving piriform recess instillation with 2mL 2% lidocaine, and a normal saline group receiving piriform recess instillation with 2mL saline. The primary outcome was the incidence of cough after extubation, and the secondary outcomes were throat score at 10 min and 6 h after extubation assessed by the numerical rating scale, cough severity at 10 min and 6 h after extubation assessed by the Visual Analog Scale (VAS), 24 h 40-item Quality of Recovery Score (QoR-40), and subject-rated satisfaction score on a VAS.

Main Results

Compared with saline group, the incidence of cough in lidocaine group was significantly lower (63.6% vs 86.4%, P=0.014). The sore throat score at 10 min after extubation was significantly lower (0[0,0] vs 1[0,2], P<0.001). The subject-rated overall anesthesia satisfaction score was significantly higher (84.8[±6.2] vs 76.6[±8.6], P<0.001). The severity of cough at 10 min after extubation was significantly lower (Mild: 36.4% vs 11.4%, P=0.006; Severe: 9.1% vs 43.2%, P<0.001). There was no significant difference in the sore throat score at 6 h after extubation, severity of cough at 6 h after extubation, or QoR-40 at 24 h after extubation between the two groups.

Conclusion

Piriform recess instillation with lidocaine before bronchoscopy is a simple and effective method for reducing early cough intensity and alleviating early sore throat. At 6 hours, there were no differences observed between the groups.

Clinical Trial Registration

Chinese Clinical Trial Registry (identifier: ChiCTR2200067087).

Intracuff Lidocaine and Postoperative Throat Mucosal Injuries: An Evidence-based Review

PURPOSE

Examine the effectiveness of using intracuff lidocaine to minimize postoperative complications.

DESIGN

Systematic review.

METHODS

This review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines. PubMed, CINAHL, Cochrane, Google Scholar, and gray literature databases were searched to obtain eligible studies and minimize selection bias. The Johns Hopkins Nursing Evidence-Based Practice Model was used to appraise the level of evidence for the varying studies. Only randomized controlled trials (RCT) and systematic reviews with meta-analyses of RCTs were included in the review.

FINDINGS

Three RCTs and three systematic reviews with meta-analyses incorporating a total of 2,337 patients were included in this review. Intracuff lidocaine (alkalinized and nonalkalinized) had the lowest incidence of postoperative sore throat in the early and late postoperative periods compared to intracuff air or intracuff saline. Furthermore, the evidence suggested that the use of intracuff lidocaine reduced postextubation cough and the incidence of hoarseness but had little or no effect on dysphagia. All studies were Level 1 and Grade A, indicating clinically solid evidence in analyzing intracuff lidocaine's effect on all outcomes measured.

CONCLUSIONS

The current literature suggests the feasibility of using intracuff lidocaine as an effective method to reduce the incidence of postoperative sore throat, postextubation cough, and hoarseness. The implications to practice include improving the norm of postoperative throat mucosal injuries by implementing an evidence-based practice intervention of intracuff lidocaine.

Effects of lidocaine administration via the perforated outer cuff of a dual-cuff endotracheal tube and remifentanil administration on recovery from general anaesthesia for female patients undergoing thyroidectomy: a single centre, double-blind, randomised study

Background

Cough caused by endotracheal tube (ETT) placement is ubiquitous and correlates with adverse outcomes. Remifentanil administration via target-controlled infusion (TCI) is one of the cough prevention measures used during recovery. In a pilot study, lidocaine administered via the perforated outer cuff of a dual-cuff endotracheal tube was also found to prevent cough due to ETT placement. We therefore compared these two cough prevention approaches during recovery after thyroidectomy in a single-centre, double-blind, randomised study conducted in China during the period from 09/10/2020 to 30/04/2021.

Methods

Ninety-eight female patients aged 18–65 years with American Society of Anaesthesiologists Physical Status scores of I and II were scheduled to undergo thyroidectomy. The ETT contained an internal cuff covered by a perforated outer cuff to allow for lidocaine delivery. Patients were randomised to receive either 4 ml of saline solution (Group R, n = 49) or 4 ml of 2% lidocaine in the outer cuff (Group L, n = 49) at the beginning of skin suturing. Remifentanil (2 ng/ml) was maintained in Group R until extubation, while remifentanil was maintained in Group L until the end of skin suturing. The primary outcome was cough during patient transfer, at 1 min before extubation, and at extubation. The secondary outcomes were haemodynamics and other recovery parameters.

Results

Primary outcomes were compared between remifentanil vs. lidocaine application, namely, the incidence of cough during patient transfer (0% in Group R vs. 0% in Group L), at 1 min before extubation (22.45% in Group R vs. 4.08% in Group L; P = 0.015), and at extubation (61.22% in Group R vs. 20.41% in Group L; P < 0.001). Compared with remifentanil, lidocaine more effectively decreased heart rate elevation and hypoxemia at 5 min after extubation, the spontaneous respiration recovery time, the extubation time, the duration of post-anaesthesia care unit (PACU) stay, Richmond Agitation-Sedation Scale scores in the agitated range and Critical-Care Pain Observation Tool scores.

Conclusion

Lidocaine administered via the perforated outer cuff of the ETT significantly improved recovery from general anaesthesia compared to remifentanil in female patients after thyroidectomy.

Trial registration

Chinese Clinical Trial Registry (No. ChiCTR2000038653), registered on 27/09/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01734-1.

Comparison of the effects of intravenous propofol and propofol with low-dose ketamine on preventing postextubation cough and laryngospasm among patients awakening from general anaesthesia: A prospective randomised clinical trial

BACKGROUND

Coughing and laryngospasm are undesirable consequences occurring when patients awaken from general anaesthesia. The objective of the study aimed to compare the effects of intravenous propofol and propofol with low-dose ketamine on preventing postextubation cough and laryngospasm.

METHODS

In all, 120 patients scheduled surgery under general anaesthesia were randomly assigned into three groups. Patients in the control group (C-group) received intravenous 0.9% NaCl, while patients in the propofol group (P-group) received intravenous 0.25mg/kg propofol and patients in the propofol combined with ketamine group (PK-group) received intravenous 0.25mg/kg of propofol plus 0.15mg/kg of ketamine. Drugs were administered before extubation. Incidence and severity of coughing and laryngospasm were recorded by a blinded anaesthesiologist.

RESULTS

Subjects of the PK-group (25%) experienced significantly reduced incidence of postoperative cough than that in the P-group (55%) and C-group (72.5%) (all P < 0.05). The severity of cough in the PK-group was significantly less than that in the P-group and C-group (P = 0.039 and P < 0.001, respectively). No significant difference was found in the incidence and severity of laryngospasm between comparison groups.

CONCLUSION

Intravenous combination of propofol and low-dose ketamine significantly reduced the incidence and severity among patients awakening from general anaesthesia.

Intracuff alkalinized lidocaine to prevent postoperative airway complications: A meta-analysis

BACKGROUND

Post-extubation cough is a common phenomenon in surgical patients undergoing general anesthesia, which can lead to potentially dangerous complications. In this meta-analysis, we evaluated the efficacy and safety of intracuff alkalinized lidocaine in patients with tracheal intubation to prevent cough and other airway complications during the perioperative period.

AIM

To perform a systematic review and meta-analysis of intracuff alkalinized lidocaine for the prevention of postoperative airway complications.

METHODS

PubMed, Embase, Cochrane, and Web of Science were searched for randomized controlled trials (RCTs) that compared intracuff alkalinized lidocaine to placebo. We used risk-of-bias assessment to assess the RCTs, and the quality of evidence was assessed using the grading of recommendations, assessment, development, and evaluations.

RESULTS

Twelve randomized trials (1175 patients) were analyzed. Meta-analysis showed that intracuff alkalinized lidocaine was associated with less cough compared to that produced by placebo [risk ratio (RR): 0.38; 95% confidence interval (CI): 0.23-0.63]. Similarly, intracuff alkalinized lidocaine was more effective than the control in reducing postoperative sore throat at 24 h (RR: 0.19; 95%CI: 0.09-0.41) and postoperative hoarseness (RR: 0.38; 95%CI: 0.21-0.69).

CONCLUSION

Intracuff alkalinized lidocaine is an effective adjuvant that can decrease airway complications, such as coughing, hoarseness, and sore throat.

Supine versus semi-Fowler's positions for tracheal extubation in abdominal surgery-a randomized clinical trial

BACKGROUND

Tracheal extubation is commonly performed in the supine position. However, in patients undergoing abdominal surgery, the supine position increases abdominal wall tension, especially during coughing and deep breathing, which may aggravate pain and lead to abdominal wound dehiscence. The semi-Fowler's position may reduce abdominal wall tension, but its safety and comfort in tracheal extubation have not been reported. We aimed to evaluate the safety and comfort of different extubation positions in patients undergoing abdominal surgery.

METHODS

We enrolled 141 patients with an American Society of Anesthesiologists grade of I-III who underwent abdominal surgery. All patients were anesthetized with propofol, fentanyl, cisatracurium, and sevoflurane. After surgery, all patients were transferred to the post-anesthesia care unit (PACU). Patients were then randomly put into the semi-Fowler's (n = 70) or supine (n = 71) position while 100% oxygen was administered. The endotracheal tube was removed after the patients opened their eyes and regained consciousness. Vital signs, coughing, and pain and comfort scores before and/or after extubation were recorded until the patients left the PACU.

RESULTS

In comparison with the supine position, the semi-Fowler's position significantly decreased the wound pain scores at all intervals after extubation (3.51 ± 2.50 vs. 4.58 ± 2.26, 2.23 ± 1.68 vs. 3.11 ± 2.00, 1.81 ± 1.32 vs. 2.59 ± 1.88, P = 0.009, 0.005 and 0.005, respectively), reduced severe coughing (8[11.43%] vs. 21[29.58%], P = 0.008) and bucking after extubation (3[4.29%] vs. 18[25.35%], P < 0.001), and improved the comfort scores 5 min after extubation (6.11 ± 2.30 vs. 5.17 ± 1.78, P = 0.007) and when leaving from post-anesthesia care unit (7.17 ± 2.27 vs. 6.44 ± 1.79, P = 0.034). The incidences of vomiting, emergence agitation, and respiratory complications were of no significant difference.

CONCLUSION

Tracheal extubation in the semi-Fowler's position is associated with less coughing, sputum suction, and pain, and more comfort, without specific adverse effects when compared to the conventional supine position.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR1900025566 . Registered on 1st September 2019.

Trans-Cricothyroid Membrane Injection of Local Anesthesia Attenuates Cough Response and Postoperative Sore Throat to the Nasotracheal Tube

Objective

This study aims to investigate the effects of trans-cricothyroid membrane injection of local anesthesia on cough response and postoperative sore throat to the nasotracheal tube.

Methods

Patients who require general anesthesia with nasotracheal tube for oral and maxillofacial surgery were randomised divided into groups L and C. The patients in group L received trans-cricothyroid membrane injection of 2% lidocaine (3 mL) before anesthesia. Meanwhile, the same volume of 0.9% saline was administered to group C. The incidences of cough response, mean arterial pressure (MAP) and heart rate (HR) were recorded during emergency from general anesthesia. Postoperative sore throat (POST) was assessed at 1, 6, 12 and 24 h after surgery.

Results

The data of 60 patients in group L and 61 in group C were included in this study. The incidence of cough was lower in group L than in group C, ie, 41.7% vs 67.2% upon extubation (P=0.006) and 20.0% vs 41.0% at five minutes after extubation (P=0.018). MAP and HR in group L were significantly lower than in group C during emergency from general anesthesia (P<0.05). POST incidence was significantly reduced in group L at 1 and 6 h after surgery, ie, 35.0% vs 55.7% at 1 h after surgery (P=0.029) and 20.0% vs 37.7% at 6 h after surgery (P=0.044).

Conclusion

Trans-cricothyroid membrane injection of local anesthesia is a simple and effective method to attenuate the incidence of cough response during emergency from general anesthesia. This technique can reduce the incidence of POST after surgery.

Effects of intravenous infusion of lidocaine and dexmedetomidine on inhibiting cough during the tracheal extubation period after thyroid surgery

Background

Intravenous lidocaine and dexmedetomidine treatments have been proposed as methods for inhibiting cough. We compared the efficacy of intravenous lidocaine and dexmedetomidine treatments on inhibiting cough during the tracheal extubation period after thyroid surgery.

Methods

One hundred eighty patients undergoing thyroid surgeries were randomly allocated to the LIDO group (received lidocaine 1.5 mg/kg loading, 1.5 mg/kg/h infusion), the DEX group (received dexmedetomidine 0.5 μg/kg loading, 0.4 μg/kg/h infusion) and the CON group (received saline), with 60 cases in each group. The primary outcomes of cough were recorded. Secondary outcomes included hemodynamic variables, awareness time, volume of drainage, the postoperative visual analogue scale and adverse effects were recorded.

Results

The incidence of cough were significantly lower in the LIDO group (28.3%) and the DEX group (31.7%) than that in the CON group (66.7%) (P = 0.000). Additionally, both moderate and severe cough were significantly lower in the LIDO group (13.3%) and the DEX group (13.4%) than these in the CON group (43.4%) (P < 0.05). Compared with the two treatment groups, both mean arterial blood pressure and heart rate were significantly increased in the CON group during tracheal extubation (P < 0.05). Compared with the CON group, the volume of drainage was significantly reduced in the two treatment groups within 48 h after surgery (P < 0.05). compared with the CON group, the postoperative visual analogue scale was significantly lower in groups LIDO and DEX after surgery(P < 0.05). Compared with the LIDO group and the CON group, the time to awareness was longer in the DEX group (P < 0.05). In the DEX group, bradycardia was noted in 35 patients, while no bradycardia was noted in LIDO group and CON group.

Conclusion

Compared with intravenous infusions of normal saline, both lidocaine and dexmedetomidine had equal effectiveness in attenuating cough and hemodynamic changes during the tracheal extubation period after thyroid surgery, and both of these treatments were able to reduce the volume of postoperative bleeding and provide better analgesic effect after surgery. But intravenous infusions of dexmedetomidine resulted in bradycardia and delayed the time to awareness when compared with lidocaine and normal saline.

Trial registration

ChiCTR1800017482. (Prospective registered). Initial registration date was 01/08/2018.

Effect of topical ropivacaine on the response to endotracheal tube during emergence from general anesthesia: a prospective randomized double-blind controlled study

Background

The airway reflex such as cough is common accompanied with severe fluctuations of hemodynamics during emergence. This prospective double-blind randomized controlled trial tested the hypothesis that topical ropivacaine may reduce extubation response and postoperative sore throat.

Methods

Fifty-four patients undergoing thyroidectomy were randomly assigned to two groups. The patients in Group R were received 0.75% ropivacaine, which was sprayed on the tracheal mucosa, epiglottis, tongue base, and glottis to achieve uniform surface anesthesia. As control, patients in Group C were received the same volume saline. The primiary outcome was the incidence and grade of cough during peri-extubation.

Results

The incidence (34.62% vs. 76.92%, P = 0.002) of cough during extubation were lower in Group R compared to Group C. Meanwhile, the sore throat visual acuity score at 12 h after surgery was lower in Group R than that in Group C (2.00 vs. 3.50, P = 0.040).

Conclusion

Topical anesthesia with 0.75% ropivacaine before intubation can significantly reduce the incidence of cough during peri-extubation. Meanwhile, it reduced hemodynamic fluctuations and postoperative throat pain without influence patients recovery.

Trial registration

Chinese Clinical Trial Registry, ChiCTR1800014412 (date of registration January 2018).