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Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
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ORIGINAL ARTICLE
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 65-72
 

Controlled comparison between betamethasone gel and lidocaine jelly applied over endotracheal tube in reducing postoperative sore throat, cough, and hoarseness of voice


Department of Anesthesiology and Critical Care, Jaipur Golden Hospital, New Delhi, India

Date of Submission07-Jul-2018
Date of Acceptance23-Sep-2018
Date of Web Publication15-Nov-2018

Correspondence Address:
Dr. Nitish Upadhyay
B-5/334-335, First Floor, Sector 3, Rohini, New Delhi - 110 085
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_30_18

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  Abstract 


Background and Aims: Postoperative sore throat (POST), cough (C), and hoarseness of voice (H) are common, uncomfortable, and frequently ignored sequel after endotracheal intubation. They are likely to be the consequences of local irritation and inflammation so may be amenable to locally administered steroids. Systemic corticosteroids have been shown to prevent the postextubation upper airway obstruction after long-term intubation. Various reports about the efficacy of pharmacological and nonpharmacological measures on complications of intubation have been published.
Materials and Methods: A prospective, randomized, hospital-based experimental study including 180 patients (American Society of Anesthesiologists physical status I and II; age group 18–45 years; and scheduled for elective surgery requiring general endotracheal anesthesia were randomly allocated into three groups – Group I, II, and C). Incidence and severity of POST, C, and H were compared using betamethasone gel, lignocaine jelly, or when nothing was applied. Incidence of coughing or bucking and hemodynamic variability was also compared between groups. Quantitative variables in various groups were expressed as mean ± standard deviation and compared using ANOVA and/or unpaired t-test between the groups and paired t-test within each group. Qualitative variables were expressed as frequencies/percentages and compared using Chi-square test.
Results: Incidence and severity of POST, C, H, and coughing/bucking was maximum in Group C, followed by Group II and least in Group I (P < 0.05).
Conclusion: Betamethasone gel applied over tracheal tube effectively reduces the incidence and severity of POST, C, and H as compared to lignocaine jelly or when nothing was applied.


Keywords: Betamethasone, cough, hoarseness of voice, lignocaine, postoperative, sore throat


How to cite this article:
Upadhyay N, Gupta R, Prakash S, Bhalla S. Controlled comparison between betamethasone gel and lidocaine jelly applied over endotracheal tube in reducing postoperative sore throat, cough, and hoarseness of voice. Indian Anaesth Forum 2018;19:65-72

How to cite this URL:
Upadhyay N, Gupta R, Prakash S, Bhalla S. Controlled comparison between betamethasone gel and lidocaine jelly applied over endotracheal tube in reducing postoperative sore throat, cough, and hoarseness of voice. Indian Anaesth Forum [serial online] 2018 [cited 2022 Oct 3];19:65-72. Available from: http://www.theiaforum.org/text.asp?2018/19/2/65/245540





  Introduction Top


Postoperative sore throat (POST), cough (C), and hoarseness of voice (H) are common, uncomfortable, and distressing sequelae after endotracheal intubation.[1],[2] The incidence of POST is reported to be 6.6% to 90%.[1],[2] Although typically not incapacitating, these sequelae can be very uncomfortable and may be especially annoying to patients returning home.

Many factors including the diameter of the tracheal tube, cuff design and pressure, intubation procedure, movement of the tracheal tube during the surgery, bucking and coughing on the tube, and excessive pharyngeal suctioning during extubation have been described to influence the incidence of these symptoms.[1],[3],[4] Numerous nonpharmacological and pharmacological measures have been used for attenuating POST, C, and H with variable success. Among the nonpharmacological methods, small-sized endotracheal tubes, lubricating the endotracheal tube with water-soluble jelly, careful airway instrumentation, intubation after full relaxation, gentle oropharyngeal suctioning, minimizing intracuff pressure, and extubation when the tracheal tube cuff is fully deflated have been reported to decrease the incidence of earlier mentioned complications.[5]

Pharmacological measures, including beclomethasone inhalation and gargling with azulene sulfonate have been reported to decrease the incidence of POST, C, and H.[6],[7] Tenoxicam (hydrophilic nonsteroidal anti-inflammatory drug [NSAID]) from an impregnated gauze pack have been shown to be effective in reducing moderate or severe POST.[8] Since the aforementioned symptoms are likely to be the consequences of local irritation and inflammation, they may be amenable to locally administered steroids. However, little research has been performed in this area.

It is not surprising that local anesthetic agents, such as lignocaine gel or spray, were found to be ineffective in preventing sore throat after endotracheal intubation.[9],[10],[11] Although these agents limit injury to the tracheal mucosa and prevent C they are found to be ineffective in preventing sore throat probably because they do not have any anti-inflammatory effects.[9] Systemic corticosteroids have recently been shown to prevent postextubation upper airway obstruction after long-term intubation in the intensive care unit.[12]

Topical application of 1% hydrocortisone near the endotracheal tube cuff was not found to be beneficial[9] whereas one puff of NSAID from an impregnated gauze pack have been shown to be effective in reducing moderate-to-severe POST.[8] Hamelberg first described the beneficial effects of lignocaine ointment (containing 1% hydrocortisone) in prevention of POST.[9] On the other hand, Stride et al. reported that topical hydrocortisone could increase the frequency of POST.[9] In other studies, variable reports about the efficacy of these agents on different complications of intubation have been made too.[13],[14] In view of uncertainty about the effects of topical steroids on POST, C, and H, the aim of the present study was to evaluate and compare the efficiency of 0.05% betamethasone gel in reducing the incidence of the commonly occurring complications following endotracheal intubation and to compare its use with lignocaine jelly and control group.


  Materials and Methods Top


On the basis of results of a prior study, we calculated that 176 patients were required for the study to detect a difference with confidence level 99.95%, (α = 0.05) by Statistical Package for the Social Sciences (SPSS) SPSS for windows, version 16.0, (Chicago, SPSS Inc., United States of America). Hence, rounding 176–180 allowed us to make three groups, each of 60 patients. Time period of the study was January 2016–October 2016.

The patients within age group 18–45 years posted for elective surgery requiring general endotracheal anesthesia were randomly divided into Group I (0.5% betamethasone jelly group), Group II (2% lignocaine jelly group), and Group C (control group). The patients in all the three groups were comparable with respect to demographic parameters. Patients were randomized into the following three groups by using the numbers generated by the computer.

The observer and the patient both were kept blinded of group allocation till the end of observation period. To achieve this, a nursing staff, especially trained and instructed for this purpose, was handed over the sealed envelope containing group name of the patient and accordingly applied jelly or nothing. The assigned nursing staff did not take part in the subsequent anesthetic management and postoperative observations which were entirely done by an anesthesiologist unaware of group allocation of the patient. All patients were visited a day before the day of surgery for preanesthetic evaluation. Those patients who met the criteria were informed and explained in details about the anesthetic procedure and the study, and consent was obtained for their inclusion in the study as well as for the anesthesia. All patients were informed preoperatively that we would be inquiring about ST, C, and H in the postoperative period as per the questionnaire by Harding and McVey[14] [Figure 1] All patients received anesthesia in the supine position. The appropriate endotracheal tube was selected (single-use PVC tracheal tube [Portex® Profile Tracheal Tube] low pressure–high volume cuff, 7/8 mm internal diameter for female and male patients, respectively).
Figure 1: Harding and McVey questionnaire

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All patients were premedicated with midazolam 0.05 mg/kg intravenous (IV) 20 min before the induction of anesthesia. At induction of anesthesia, betamethasone gel/lidocaine jelly/nothing was applied on the external surface of the tracheal tube. The endotracheal tube was lubricated from the distal end of cuff to a distance of 15 cm from the tip using 2.5 ml of betamethasone gel or lignocaine jelly, spread uniformly with sterile precautions by an operating theater technician as per group allocation of the patient. The patient and the observer who provided postoperative scoring were blinded to group allocation of the patient.

Preoxygenation was done for 3 min. Induction was done with IV fentanyl 2 μg/kg and thiopentone 5 mg/kg. Vecuronium bromide 0.1 mg/kg IV facilitated tracheal intubation after 3 min following induction and assisted ventilation. All intubations were performed by anesthesiologist having at least 5 years of experience and blinded to the nature of the gel applied. With a peak airway pressure at 20 cmH2O, the tracheal tube cuff was inflated with room air and the cuff pressure was maintained at 18–22 cmH2O which was measured using handheld pressure gauge in which the transducer was connected to the pilot balloon of the endotracheal tube to provide continuous digital display of the intracuff pressure on the screen of the monitor.

Patient requiring more than two attempts for intubation were eliminated from the study. Anesthesia was maintained with oxygen 33% and nitrous oxide 66% and supplemented with isoflurane and bolus doses of vecuronium bromide guided by train-of-four (TOF) monitoring maintaining one to two twitches. At the end of the surgery, oxygen 100% was administered and residual neuromuscular block was antagonized by a combination of neostigmine 0.05 mg/kg and atropine 0.02 mg/kg IV. Oral suctioning by a 12 F suction catheter was done gently just before extubation under only direct vision to avoid trauma to the tissues and to confirm that the clearance of secretions was complete. The trachea was extubated after deflating the cuff when the TOF was at least 70% and patient fully awake. All patients received oxygen by facemask postoperatively.

All patients were assessed and graded for the incidence and severity of POST, C Cand H, and any other side effects, immediately after extubation, and in the postanesthesia care unit at 15 min, 1, 6, 12, and 24 h by the anesthetist in charge of postoperative care unit blinded to the group allocation, using the questionnaire shown in the table (by providing direct questions as suggested by Harding and McVey).[14] The quantitative variables in various groups were expressed as mean ± standard deviation and compared using ANOVA and/or unpaired t-test between the groups and paired t-test within each group at various follow-up. The qualitative variables were expressed as frequencies/percentages and compared using Chi-square test. P < 0.05 was considered statistically significant. SPSS version 16.0 was used for statistical analysis.


  Results Top


Our study conducted on 180 patients, divided into betamethasone gel group (Group I), lignocaine jelly group (Group II), and control group (Group C) with 1:1:1 distribution, was completed in a prospective-randomized way and results were analyzed and tested by appropriate statistical methods. The groups were comparable in terms of age distribution, sex distribution, weight distribution, and American Society of Anesthesiologists (ASA) distribution (P > 0.05) [Table 1] and [Chart 1]. The SpO2(on room air) values, duration of laryngoscopy, duration of surgery, intracuff pressure values, and attempt of intubation in all the three groups were comparable and no statistical difference was observed (P > 0.05) [Table 2] and [Chart 2]. The incidence of POST recorded at different time intervals (15 min, 1 h, 6 h, 12 h, and 24 h) in three groups were C (38, 55, 52, 60, 60), I (3, 31, 36, 35, 12) and II (16, 31, 36, 35, 47), respectively. The incidence of C recorded at different time intervals (15 min, 1 h, 6 h, 12 h, and 24 h) in three groups were C (47, 53, 54, 58, 56), I (9, 10, 10, 11, 17), and II (18, 23, 29, 37, 38), respectively. The incidence of H recorded at different time intervals (15 min, 1 h, 6 h, 12 h, and 24 h) in three groups were C (38, 40, 42, 44, 46), I (14, 14, 14, 15, 15), and II (19, 24, 25, 27, 28), respectively. On analysis, these differences were found statistically significant (P < 0.05) [Table 3] and [Chart 3]. The severity of the POST, C, and H recorded by interview based on Harding and McVey Questionnaire [Figure 1] was analyzed, and it was found that the difference between the recordings were statistically significant (P < 0.05) [Table 3] and [Chart 3].
Table 1: Demographics

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Table 2: Secondary parameters

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Table 3: Primary parameters

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The incidence of coughing or bucking was more in control group, lesser in Group II and minimum in Group I. The difference between these values were statistically significant as P < 0.05.


  Discussion Top


POST, C, and H can be very uncomfortable and has a high incidence (6.6%–90%)[1],[2] which could be due to the factors such as the diameter of the tracheal tube, cuff design and pressure, intubation procedure, movement of the tracheal tube during the surgery, bucking/coughing on the tube, and excessive pharyngeal suctioning during extubation.[1],[3],[4] Recognizing the potential role of inflammation in these postoperative airway sequelae, the use of inhaled and topical steroids was described. Stride in their study concluded that 1% hydrocortisone water-soluble cream was ineffective in reducing the incidence of POST, but it was realized that they had applied topical hydrocortisone only from the distal tip to 5 cm above the cuff. The beneficial effect of steroid gel application was observed in subsequent studies because of widespread application of steroid gel to all portions of the tube that came in contact with the posterior pharyngeal wall, vocal cords, and trachea and not just confined to the tip and cuff of the tracheal tube.[9]

Our study confirms the study by Sumathi et al., Ayoub et al., and Selvaraj and Dhanpal proving that the widespread application of betamethasone gel significantly reduces the incidence of POST, C, and H.[15],[16],[17] However, Ayoub et al. compared only the betamethasone gel group versus the control group. We, like Sumathi et al., included a lidocaine jelly group in addition to the control group because lidocaine jelly is widely used in clinical practice to lubricate the tracheal tube.[15] However, the sample size in our study was high (n = 180), leading to the confidence level of 99.95% (α = 0.05). While aerosolized lidocaine has been associated with a higher incidence of POST, C, and H, the role of lidocaine jelly is not clear. Contrary to our findings, Selvaraj and Dhanpal found the incidence of postoperative C and hoarseness to be higher in the lidocaine jelly group than in the control group. However, they had not standardized the extubation protocol in the groups studied, which could have affected the incidence of POST, C, and hoarseness.[17]

Our study confirms the study by Sumathi et al. that the incidence of POST, C, and H was significantly less when betamethasone gel was widely applied over the tracheal tube compared with lidocaine jelly or when nothing applied over the tube. But in contrast to their finding, that lidocaine jelly only reduced the incidence of POST but not C or H compared with the control group, we found that lidocaine also reduces the incidence of C and H significantly as compared to control group. They did not standardize the cuff pressure and no measurement was done for the same which can be the reason of the higher incidence of C and H in their study. In our study, we standardized the cuff pressure values for all patients and continuous monitoring was done. In addition to this, the incidence of coughing or bucking was also recorded in our study in various groups and betamethasone and lignocaine jelly significantly decreases the incidence of coughing or bucking as compared to the control group (P < 0.05).[17] The severity of the POST, C, and H was recorded at different time intervals after extubation (15 min, 1 h, 6 h, 12 h, and 24 h) on the basis of Harding and McVey Questionnaire.[14] The difference among the three groups was statistically significant. Group I (betamethasone gel) was most effective in not only reducing the incidence of the complications but also in reducing the severity in cases where these are present. Group II (lignocaine jelly) was less effective than Group I but more effective than the control group in reducing the incidence and severity of the complications.

Hemodynamic parameters were also recorded and analyzed, but no statistically significant difference was observed (P > 0.05). The benefit of betamethasone gel or lidocaine jelly application during prolonged intubation needs to be evaluated.

There are certain limitations in our study. First, the results of our study are applicable only to patients of ASA I and II and of age group 18-45 years posted for surgeries of duration <240 min. Furthermore, the results of our study are prone to change if the intubation is not done by an expert anesthesiologist. Finally, the standard extubation protocol is to be followed and regular intracuff pressure monitoring is to be done to produce the similar results.


  Conclusion Top


Betamethasone gel applied widely over tracheal tube effectively reduces the incidence of POST, C, and H as compared to lignocaine jelly or when nothing was applied over the tube.

Acknowledgment

I would like to express my deepest appreciation to all those who provided me the possibility to complete this report. Furthermore, I would also like to acknowledge with much appreciation the crucial role of the staff of Department of Anesthesiology, Jaipur Golden Hospital, New Delhi, who gave the permission to use all required equipment and the necessary materials to complete the task.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Christensen AM, Willemoes-Larsen H, Lundby L, Jakobsen KB. Postoperative throat complaints after tracheal intubation. Br J Anaesth 1994;73:786-7.  Back to cited text no. 1
    
2.
Mandøe H, Nikolajsen L, Lintrup U, Jepsen D, Mølgaard J. Sore throat after endotracheal intubation. Anesth Analg 1992;74:897-900.  Back to cited text no. 2
    
3.
McHardy FE, Chung F. Postoperative sore throat: Cause, prevention and treatment. Anaesthesia 1999;54:444-53.  Back to cited text no. 3
    
4.
Soltani HA, Aghadavoudi O. The effect of different lidocaine application methods on postoperative cough and sore throat. J Clin Anesth 2002;14:15-8.  Back to cited text no. 4
    
5.
Al-Qahtani AS, Messahel FM. Quality improvement in anesthetic practice-incidence of sore throat after using small tracheal tube. Middle East J Anaesthesiol 2005;18:179-83.  Back to cited text no. 5
    
6.
el Hakim M. Beclomethasone prevents postoperative sore throat. Acta Anaesthesiol Scand 1993;37:250-2.  Back to cited text no. 6
    
7.
Macario A, Weinger M, Carney S, Kim A. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesth Analg 1999;89:652-8.  Back to cited text no. 7
    
8.
Ogata J, Minami K, Horishita T, Shiraishi M, Okamoto T, Terada T, et al. Gargling with sodium azulene sulfonate reduces the postoperative sore throat after intubation of the trachea. Anesth Analg 2005;101:290-3, table of contents.  Back to cited text no. 8
    
9.
Stride PC. Postoperative sore throat: Topical hydrocortisone. Anaesthesia 1990;45:968-71.  Back to cited text no. 9
    
10.
Elhakim M, Siam A, Rashed I, Hamdy MH. Topical tenoxicam from pharyngeal pack reduces postoperative sore throat. Acta Anaesthesiol Scand 2000;44:733-6.  Back to cited text no. 10
    
11.
Stock MC, Downs JB. Lubrication of tracheal tubes to prevent sore throat from intubation. Anesthesiology 1982;57:418-20.  Back to cited text no. 11
    
12.
Epstein SK. Corticosteroids to prevent postextubation upper airway obstruction: The evidence mounts. Crit Care 2007;11:156.  Back to cited text no. 12
    
13.
Herlevsen P, Bredahl C, Hindsholm K, Kruhøffer PK. Prophylactic laryngo-tracheal aerosolized lidocaine against postoperative sore throat. Acta Anaesthesiol Scand 1992;36:505-7.  Back to cited text no. 13
    
14.
Harding CJ, McVey FK. Interview method affects incidence of postoperative sore throat. Anaesthesia 1987;42:1104-7.  Back to cited text no. 14
    
15.
Ayoub CM, Ghobashy A, Koch ME, McGrimley L, Pascale V, Qadir S, et al. Widespread application of topical steroids to decrease sore throat, hoarseness, and cough after tracheal intubation. Anesth Analg 1998;87:714-6.  Back to cited text no. 15
    
16.
Sumathi PA, Shenoy T, Ambareesha M, Krishna HM. Controlled comparison between betamethasone gel and lidocaine jelly applied over tracheal tube to reduce postoperative sore throat, cough, and hoarseness of voice. Br J Anaesth 2008;100:215-8.  Back to cited text no. 16
    
17.
Selvaraj T, Dhanpal R. Evaluation of the application of topical steroids on the endotracheal tube in decreasing postoperative sore throat. J Anesthesiol Clin Pharmacol 2002;18:167-70.  Back to cited text no. 17
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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