|Year : 2019 | Volume
| Issue : 1 | Page : 9-15
Effects of intracuff alkalinized lignocaine, dexamethasone, or normal saline on endotracheal tube-induced emergence phenomena: A randomized double-blinded study
Teena Desai, Rohini V Bhat Pai, Deependra Kambli, Eufemia Sellia Dias, Shaila S Kamat
Department of Anaesthesiology, Goa Medical College, Bambolim, Goa, India
|Date of Submission||02-Dec-2018|
|Date of Acceptance||28-Jan-2019|
|Date of Web Publication||6-May-2019|
Dr. Rohini V Bhat Pai
Department of Anaesthesiology, Goa Medical College, Bambolim, Goa
Source of Support: None, Conflict of Interest: None
Context: During endotracheal intubation, as we aim for smooth induction, smooth extubation is also mandatory. During extubation, coughing, sore throat, hoarseness, and laryngospasm are not desired and have to be prevented.
Aims: The aim of the study is to study the effects of inflating the endotracheal tube (ETT) cuff with alkalinized lignocaine (Group L) or dexamethasone (Group D) or saline (Group S) on the emergence phenomena of endotracheal extubation.
Settings and Design: Tertiary hospital, randomized double-blinded prospective study.
Subjects and Methods: A total of 90 patients undergoing surgery under general anesthesia were randomly allotted into three groups, 30 in each group. After endotracheal intubation, the tube cuff was inflated with alkalinized lignocaine (Group L) or dexamethasone (Group D) or saline (Group S) as per the randomization sequence. At emergence and 1 h after surgery for hemodynamic indices and incidence of postextubation, sore throat, cough, hoarseness, and laryngospasm were assessed.
Results: With respect to cough and sore throat, Group L and Group D were significantly better than Group S but the hoarseness was the worst in Group D.
Conclusions: Inflating the ETT cuff with alkalinized lignocaine or dexamethasone helped in preventing sore throat and cough to a better extent than saline, the hoarseness, however, being the worst in dexamethasone group.
Keywords: Endotracheal tube, emergence phenomena, intracuff alkalinized-lignocaine dexamethason, saline
|How to cite this article:|
Desai T, Bhat Pai RV, Kambli D, Dias ES, Kamat SS. Effects of intracuff alkalinized lignocaine, dexamethasone, or normal saline on endotracheal tube-induced emergence phenomena: A randomized double-blinded study. Indian Anaesth Forum 2019;20:9-15
|How to cite this URL:|
Desai T, Bhat Pai RV, Kambli D, Dias ES, Kamat SS. Effects of intracuff alkalinized lignocaine, dexamethasone, or normal saline on endotracheal tube-induced emergence phenomena: A randomized double-blinded study. Indian Anaesth Forum [serial online] 2019 [cited 2019 Aug 22];20:9-15. Available from: http://www.theiaforum.org/text.asp?2019/20/1/9/257685
| Introduction|| |
Endotracheal intubation with cuffed endotracheal tubes (ETTs) is a standard practice in general anesthesia. The tracheal tube cuff pressure is responsible for complications such as loss of mucosal cilia and ulceration and some serious complications such as hemorrhage, tracheal stenosis, and tracheoesophageal fistula.
Up to 90% of intubated patients complaint of postoperative sore throat, referred to as tracheal tube-induced emergence phenomenon and is considered the most common complaint after tracheal intubation, other complications being laryngeal edema and ischemia.
Besides sore throat and hoarseness, coughing induced by an ETT can adversely affect emergence from general anesthesia, thus resulting in potentially dangerous hyperdynamic responses in the postoperative period such as hypertension, tachycardia, bronchospasm, dysrhythmia, increased intraocular pressure, increased intracranial pressure, and wound dehiscence.
Various methods have been tried to attain a smooth emergence and prevent the complications of endotracheal intubation such as replacing the air in the ETT cuff with saline, lignocaine, dexamethasone, and lubrication of the ETT cuff with water-soluble gel.
We aimed to study the effects of inflating the ETT cuff with alkalinized lignocaine (Group L) or dexamethasone (Group D) or saline (Group S) on the emergence phenomena of endotracheal extubation. The incidence and severity of (1) sore throat, (2) cough, (3) hoarseness, and (4) laryngospasm following the instillation of saline or alkalinized lignocaine or dexamethasone in the cuff of the ETT were also compared.
| Methods|| |
This randomized prospective study was conducted in a tertiary care center after taking approval from the Institutional Ethics Committee, and written informed consent was obtained from all the participants.
To calculate the sample size, it was estimated by a pilot study that the use of intracuff alkalinized lignocaine would decrease the rate of postoperative sore throat by 30%–40%. Based on this estimation and at a significance level of 0.05 with a power of 80%, 25 participants were needed in each group. We recruited a total of 90 patients of the American Society of Anesthesiologists I and II and scheduled for elective surgeries under general anesthesia with 30 patients per group to compensate any loss of patients during the study.
Patients having impaired kidney or liver functions, a history of bronchial asthma and chronic obstructive pulmonary disease, a history of smoking, respiratory tract infection during the past 6 weeks, hypertensives taking angiotensin-converting enzyme inhibitors, surgery time of less than 1 or more than 4 h, and patients with difficult intubation were excluded from the study.
Randomization of the patients into the three groups was done using a table of random numbers. The syringes were prefilled with one of the three study drugs by an anesthesiologist who did not participate in any other part of the study. The anesthesiologist recording the findings and the patients were blinded to the drug.
The patients were divided into three groups, Group L, where in the ETT cuffs were filled with 2% lignocaine (40 mg) and 1 cc sodium bicarbonate (NaHCO3) 8.4%; Group D, with dexamethasone (8 mg), and Group S, with saline consort chart [Figure 1]. Since the initial volume of the drug in Group L was 3 cc, the dexamethasone in the D group was diluted to 3 cc, and in the S group, 3 cc saline was used for cuff inflation at the outset. To provide an adequate seal, the cuffs in all three groups were injected with additional saline until there was no audible leak. ETT cuff pressure was monitored using cuff pressure manometer, and the pressure was maintained between 20 and 30 cm H2O.
After initiating standard monitoring which included electrocardiography, noninvasive blood pressure, and pulse oximetry, general anesthesia was induced using intravenous fentanyl 2 μg/kg, intravenous propofol 2 mg/kg, and intravenous atracurium 0.5 mg/kg. The patients were intubated with Portex (polyvinyl chloride) ETT (7.0 mm ID in female patients and 8.0 mm ID in male patients). For maintenance of anesthesia O2+ N2O with sevoflurane, intravenous morphine 0.1 mg/kg and intravenous atracurium were used.
The extubation protocol was the same in all groups. Therefore, when the extubation criteria, i.e., full reversal of neuromuscular block, spontaneous ventilation, ability to follow verbal commands, eye opening, or handgrip, were met, tracheal extubation was performed immediately after suctioning at the discretion of the anesthesiologist in charge of the patient. Time to extubation (time from the beginning of reversal until the end of extubation) was recorded.
The vitals were monitored at regular intervals intraoperatively and postoperatively. An anesthesiologist (blinded) assessed the patient during emergence and 1 h after surgery for hemodynamic indices, including heart rate and blood pressure and incidence of postextubation sore throat, cough, hoarseness, and laryngospasm.
| Results|| |
A total number of 88 patients completed the study. There was no statistically significant difference between the three groups regarding the demographic variables [Table 1].
ANOVA and post hoc Tukey's tests were used to compare the heart rates [Figure 1] and blood pressure [Figure 2] between the three groups. The difference in the heart rates between the three groups was not significant throughout the intraoperative period.
However, at 5 min and 15 min postextubation, heart rate between Group L and Group S showed a mean difference of − 9.581 and − 7.924 which was statistically significant with P = 0.002 and 0.008, respectively [Figure 2].
No significant differences were recorded in arterial blood pressure between the groups at any point in the study [Figure 3].
The parameters of emergence phenomena – cough, sore throat, hoarseness, and laryngospasm – were compared using Chi-square test. There was no statistical difference between the three groups in terms of cough at extubation; however, thereafter, the difference in cough between the three groups was statistically significant with P < 0.001 [Table 2]. The patients in the saline group had four patients with severe cough up to 30 min postextubation.
|Table 2: Comparison of cough at and after extubation between the three groups|
Click here to view
The difference in the sore throat between the three groups immediately after extubation and until 45 min postextubation was statistically significant [Table 3]. The severity of sore throat was maximum in the saline group as compared to the other two groups.
Similarly, the difference in the hoarseness between the three groups immediately after extubation and until 1 h postextubation was statistically significant. The severity of hoarseness was found to be maximum in the dexamethasone group with 10% of the patients having hoarseness which was obvious to the observer at 1 h [Table 4]. There was no incidence of severe laryngospasm in any of the three groups. One patient in Group D had partial laryngospasm which was resolved with 100% O2 and positive pressure ventilation [Table 5].
| Discussion|| |
Sore throat is a frequent side effect of general anesthesia and is reported to be between 30% and 70% of patients after tracheal intubation. It is thought to be due to mucosal erosion caused by the cuff of the ETT, trauma from intubation and mucosal dehydration. Mucosal erosion may be caused by the patient bucking, coughing, or friction between the tracheal mucosa and ETT during general anesthesia.
A smooth extubation without coughing and bucking is the aim of all anesthesiologists. Several methods are utilized to attenuate the emergence phenomenon such as the use of narcotics, extubation in a deeper plane of anesthesia, and use of lignocaine. Lignocaine in the cuff of the ETT has proven to be effective in reducing sore throat. The strong stimulation caused by laryngoscopy or moving the tube may excite airway sensory C fibers and produce secondary neuroplasticity, associated with postoperative sore throat and cough. Lignocaine prevents this excitement of sensory C fibers. Lignocaine also reduces injury to the tracheal mucosa during extubation.
The mechanism of intracuff dexamethasone is presumably based on its anti-inflammatory activity, which includes inhibition of leukocyte migration, maintenance of cell membrane integrity, attenuation of lysosome release, and reduction of fibroblast proliferation.
Rafiei et al. compared the effects of intracuff dexamethasone, lignocaine, and normal saline in reducing postextubation reactions. Estebe et al. showed the benefits of alkalinized lignocaine filled in ETT cuff in combination with water-soluble gel lubrication in preventing postintubation sore throat. In a meta-analysis by Lam et al., it was shown that both alkalinized and nonalkalinized lignocaine reduced the postintubation-related emergence phenomena.
In our study, we compared intracuff alkalinized lignocaine with intracuff dexamethasone and intracuff saline with respect to emergence phenomena related to extubation.
The comparison of the heart rates and the mean arterial pressures showed that the difference between the three groups is not significant, throughout the surgery. This is in agreement with the results of the study by Rafiei et al.
At 5 min and 15 min postextubation, the heart rate in the L group was significantly lower than the S group, but this finding was not consistent thereafter.
In our study, the cough at extubation was not statistically significantly different in the three groups, but thereafter, the difference was statistically significant between the three groups until 1 h postextubation (P < 0.05). Group L and Group D showed no cough at 5 min postextubation and thereafter. However, in the saline group, four patients had severe cough till 30-min postextubation and twenty patients still had mild cough 1 h later. In the study by Rafiei et al., the incidence of cough was less in Group L but the severity was lesser in Group D.
In contrast with Rafiei et al., wherein there was no statistical difference in the frequency of sore throat between the three groups; in our study, the difference in sore throat was statistically significant between the three groups immediately after extubation and until 45 min later. Group L and Group D had 6 (20%) and 4 (13.30%) patients, respectively, with mild sore throat, and Group D had one patient with moderate sore throat at 1 h postextubation. However, in Group S, the incidence and severity of sore throat were more than the other two groups.
Difference in the incidence of hoarseness was found to be statistically different in the three groups (P < 0.05). The Group D had the highest incidence and severity of hoarseness between the three groups. This is in contrast with the study by Rafiei et al. which showed that all three drugs affected hoarseness similarly. In a study by Kep Kee and Nadia, it was proven that intracuff dexamethasone significantly reduced the incidence of hoarseness compared to intracuff air and both intracuff dexamethasone and alkalinized lignocaine reduced the incidence of emergence significantly although the restlessness was better controlled in the alkalinized lignocaine group.
The reason why intracuff dexamethasone should have a higher incidence and severity of hoarseness cannot be explained. In the study by Kep Kee and Nadia, one of the study groups was intracuff air. The incidence of hoarseness in intracuff air was found to be greater than intracuff dexamethasone. In our study, we used intracuff saline in lieu of air. Although the other two groups proved to be better than saline in other aspects, with respect to hoarseness, the intracuff saline proved to be better than intracuff dexamethasone.
One patient in the Group D had partial laryngospasm which was easily relieved with 100% oxygen and Continuous positive airway pressure (CPAP). This was not statistically significant which concurs with the result of the study by Rafiei et al.
Rafiei et al. compared lignocaine with dexamethasone but did not alkalinize the lignocaine.
It has been reported that lignocaine alone has a low diffusion rate across an ETT cuff (1% released during a 6-h period). Only high doses of lignocaine (200 ± 500 mg) were supposed to produce a clinical effect when used to inflate the cuff, but they had no advantage over saline, and if the ETT cuff ruptured, it would be very dangerous, with a relatively high dose of lignocaine delivered into the trachea and bronchium leading to toxicity. However, lignocaine-induced cuff rupture has never been reported either in vivo or in vitro.
Bicarbonate, too, can lead to tracheal wall damage if a cuff rupture occurs. The small dose used in the present study (1 mL of 8.4% bicarbonate) was enough to increase the pH of the lignocaine solution, and facilitate its diffusion, but is unlikely to produce damage on the trachea if any cuff damage occurs.
Estebe et al. also demonstrated that the amount of lignocaine diffusing across the ETT cuff in the presence of NaHCO3 is proportional to the dose of lignocaine used between 20 and 40 mg. The use of alkalinized local anesthetic in the ETT cuff offered the advantages of minimal stress response to extubation and cough-free emergence.
Navarro et al. demonstrated that intracuff alkalinized 2% lignocaine was better than saline in decreasing the incidence of emergence coughing and sore throat during the postoperative period in smokers.
Kori et al. concluded that ETT lubrication increased the severity of sore throat. Lignocaine, when used as a spray or a jelly, increased ETT-induced emergence phenomena from anesthesia. We did not lubricate the ETT. However, we ensured adequate relaxation and intubation by the same two experienced anesthesiologists.
| Conclusion|| |
The study showed that intracuff alkalinized lignocaine and dexamethasone were better than saline in preventing cough and sore throat at extubation and immediately thereafter. Intracuff dexamethasone group had a higher incidence of hoarseness than the other two groups. Therefore, alkalinized lignocaine was the best option to inflate the cuff of ETT.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rafiei MR, Arianpour N, Rezvani M, Ebrahimi A. Effects of intracuff dexamethasone on post-extubation reactions. J Res Med Sci 2012;17:338-43.
Estebe JP, Delahaye S, Le Corre P, Dollo G, Le Naoures A, Chevanne F, et al.
Alkalinization of intra-cuff lidocaine and use of gel lubrication protect against tracheal tube-induced emergence phenomena. Br J Anaesth 2004;92:361-6.
Combes X, Schauvliege F, Peyrouset O, Motamed C, Kirov K, Dhonneur G, et al.
Intracuff pressure and tracheal morbidity: Influence of filling with saline during nitrous oxide anesthesia. Anesthesiology 2001;95:1120-4.
Navarro RM, Baughman VL. Lidocaine in the endotracheal tube cuff reduces postoperative sore throat. J Clin Anesth 1997;9:394-7.
Navarro LH, Lima RM, Aguiar AS, Braz JR, Carness JM, Módolo NS, et al.
The effect of intracuff alkalinized 2% lidocaine on emergence coughing, sore throat, and hoarseness in smokers. Rev Assoc Med Bras (1992) 2012;58:248-53.
Chang AB. Cough, cough receptors, and asthma in children. Pediatr Pulmonol 1999;28:59-70.
Park SH, Han SH, Do SH, Kim JW, Rhee KY, Kim JH, et al.
Prophylactic dexamethasone decreases the incidence of sore throat and hoarseness after tracheal extubation with a double-lumen endobronchial tube. Anesth Analg 2008;107:1814-8.
Lam F, Lin YC, Tsai HC, Chen TL, Tam KW, Chen CY, et al.
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.
Kep Kee W, Nadia MN. Post-intubation airway related adverse effects: A comparison between intra-cuff dexamethasone and intra-cuff alkalinized lignocaine original articles. J Surg Acad 2013;3:26-31.
Estebe JP, Dollo G, Le Corre P, Le Naoures A, Chevanne F, Le Verge R, et al.
Alkalinization of intracuff lidocaine improves endotracheal tube-induced emergence phenomena. Anesth Analg 2002;94:227-30.
Kori K, Muratani T, Tatsumi S, Minami T. [Influence of endotracheal tube cuff lubrication on postoperative sore throat and hoarseness]. Masui 2009;58:342-5.
Soltani HA, Aghadavoudi O. The effect of different lidocaine application methods on postoperative cough and sore throat. J Clin Anesth 2002;14:15-8.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]