Comparative study between betamethasone gel and lignocaine jelly applied over the tracheal tube to reduce postoperative airway complications

Guriqbal Singh; Priti Jadeja; R Yashwanth Patnaik; Sugadev Ravinbothayan; Vijaylaxmi Singh; Raghav Dhawan

doi:10.4103/BJOA.BJOA_159_20

ORIGINAL ARTICLE

Year : 2021 | Volume : 5 | Issue : 1 | Page : 11-14

Comparative study between betamethasone gel and lignocaine jelly applied over the tracheal tube to reduce postoperative airway complications

Guriqbal Singh¹, Priti Jadeja², R Yashwanth Patnaik³, Sugadev Ravinbothayan⁴, Vijaylaxmi Singh², Raghav Dhawan⁵
¹ Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College), Ahmedabad, Gujarat, India
² Department of Anesthesia, M.P. Shah Medical College, Jamnagar, Gujarat, India
³ Department of Anesthesia, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
⁴ Department of Critical Care Medicine, Hinduja Hospital, Mumbai, Maharashtra, India
⁵ Government Medical College, Amritsar, Punjab, India

Date of Submission	30-Jul-2020
Date of Decision	13-Sep-2020
Date of Acceptance	22-Sep-2020
Date of Web Publication	8-Feb-2021

Correspondence Address:
Dr. Priti Jadeja
Department of Anesthesiology, M. P. Shah Medical College, Jamnagar, Gujarat - 361 008
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/BJOA.BJOA_159_20

Abstract

Background: Postoperative sore throat (POST), postextubation cough (PEC), and hoarseness of voice (HOV) are some of the common postoperative morbidities due to airway instrumentation. This study is aimed to compare the efficacy of 0.05% betamethasone gel to 2% lignocaine gel applied over the oro-endotracheal tube to reduce the incidence of POST, PEC, and HOV. Patients and Methods: This was a prospective, randomized, double-blinded clinical study in patients scheduled for elective surgeries under general anesthesia. They were randomized into two groups of 30. In Group B (betamethasone), the endotracheal tube was lubricated from the distal end of the cuff using 2.5 ml of betamethasone gel, and in Group L, the endotracheal tube was lubricated with lignocaine jelly in the same way. Patients were examined for POST, PEC, and HOV at intervals of 1, 3, 8, and 24 h after extubation. Results: Significant differences were found at 8 and 24 h postextubation. The incidence of PEC were 30% versus 6.7 % (P=0.02) and 26.7% versus 3.3% (P=0.01) in favour to group B. The incidence of POST were 30% vs 3.3% (P=0.005) and 23.3% vs 0% (P=0.004) in group L vs group B, respectively. Similarly, the incidence of HOV were 20% vs 3.3% (P=0.04) and 13.3% vs 0% (P=0.03) in group B's favour. Conclusion: Patients who underwent general anesthesia using betamethasone gel 0.05% applied to endotracheal tube reported a lower incidence of POST, PEC, and HOV in comparison to those with the application of lignocaine 2% on the endotracheal tube.

Keywords: Coughing, hoarseness, intubation, sore throat

How to cite this article:
Singh G, Jadeja P, Patnaik R Y, Ravinbothayan S, Singh V, Dhawan R. Comparative study between betamethasone gel and lignocaine jelly applied over the tracheal tube to reduce postoperative airway complications. Bali J Anaesthesiol 2021;5:11-4

How to cite this URL:
Singh G, Jadeja P, Patnaik R Y, Ravinbothayan S, Singh V, Dhawan R. Comparative study between betamethasone gel and lignocaine jelly applied over the tracheal tube to reduce postoperative airway complications. Bali J Anaesthesiol [serial online] 2021 [cited 2023 Mar 23];5:11-4. Available from: https://www.bjoaonline.com/text.asp?2021/5/1/11/308882

Introduction

Postoperative sore throat (POST), postextubation cough (PEC), and hoarseness of voice (HOV) are common. They are uncomfortable and distressing sequelae after tracheal intubation. It has been postulated that these effects are due to mucosal injury with resulting inflammation caused by the process of airway instrumentation.

POST was recently ranked as the second-most common minor problem of current clinical anesthesiology and during anesthesia recovery, with a reported incidence varies from 15% to 90%.^[1],[2] Hence, the prophylactic management of POST is recommended to improve the quality of postanesthesia care and improve patient satisfaction. The etiology of POST is multifactorial, including patient-related factors such as age, sex, smoking; and intubation factors including technique, duration, tube size, intracuff pressure, cuff design, trauma to pharyngolaryngeal mucosa, contact of the tracheal tube with vocal cords, pressure-induced tracheal mucosal capillary hypoperfusion, use of nitrous oxide, intra-operative tube movement and suctioning.^[3],[4]

Local anesthetic jelly, along with its lubricating properties, limits the potential damage to the tracheal mucosa by suppressing bucking on the tracheal tube. Its role in the prevention of POST is inconclusive, as it does not possess any intrinsic anti-inflammatory action.^[5] Steroids are known to be anti-inflammatory. In this study, we have used a water-soluble long-acting betamethasone steroid gel, an anti-inflammatory agent that is applied topically to study the reduction in POST, PEC, and HOV.

This prospective, randomized, double-blinded clinical study was undertaken to compare the effects between betamethasone gel and lignocaine jelly applied extensively over the endotracheal tube in reducing the complications during the first 24 postoperative hours after elective surgical procedures in patients under general anesthesia with endotracheal intubation.

Patients and Methods

In this prospective, randomized, double-blinded clinical study, individuals belonging to the age group of 18–60 years falling into the American Society of Anaesthesiologist (ASA) Grade I–III and undergoing an elective surgery lasting between 30 and 240 min were considered to be eligible for the study. Surgeries of oral cavity or pharynx, anticipated difficult airway, those who required more than two attempts for intubation, surgeries that need a nasogastric tube or throat packs, acute upper respiratory tract infection, steroid therapy, pregnancy, cardiovascular disease, respiratory disease, diabetes mellitus, central nervous system pathologies, and history of adverse drug reactions especially to local anesthetics were excluded from the study.

The study was conducted following the principles of the Declaration of Helsinki. Institutional ethical clearance was obtained on January 02, 2018, with registry number IEC/Certi/12/2018. After obtaining informed and written consent from the patients, 66 patients were enrolled in the study. Six patients did not meet the inclusion criteria and were excluded from the study. Sixty patients who qualified for the above criteria were then randomized into two groups of 30 by block randomization method. Patients in Group B (Betamethasone) would be intubated by endotracheal tube with the application of betamethasone gel 0.05% as a lubricant, while patients in Group L (Lignocaine) received the application of lignocaine 2% jelly as the tube's lubricant [Figure 1].

Figure 1: Consort flow diagram

Click here to view

Thorough clinical history taking was carried out the day before the surgery to exclude those with any of the exclusion criteria. All patients had routine preoperative investigations and preparations as per institutional standards. In the operating theater, we used standard ASA monitoring. All patients received glycopyrrolate (4 μg/kg), ondansetron (80 μg/kg), and midazolam (20 μg/kg) as premedication.

During the administration of the premedication, the tracheal tube (Portex Profile) was lubricated from the distal end of the cuff to a distance of 15 cm from the tip using 2.5 ml of betamethasone gel or lidocaine jelly under strict aseptic conditions, sparing the tip of the endotracheal tube. Single-use polyvinyl chloride (PVC) tracheal tubes with low-pressure, high-volume cuffs of appropriate size were used for male (ID 8.0) and female (7.0) patients, respectively.

We used propofol 2 mg/kg for induction and succinylcholine 1.5 mg/kg as a muscle relaxant. Using direct laryngoscopy, the prepared endotracheal tube was inserted by a trained anesthesiologist (at least 10 years of experience). Immediately, after intubation, the tracheal tube was inflated and maintained at 20–25 mmHg. The cuff pressure was monitored at 15 min interval. Further analgesic and relaxation were achieved by giving intermittent dexmedetomidine 1 μg/kg and atracurium 0.5 mg/kg, respectively. Each patient received O2:N2O mixture to achieve 40% of inspired oxygen fraction. The inspired concentration of the inhalational sevoflurane was kept to maintain a minimal alveolar concentration value of 1.5.

At the beginning of the skin closure, sevoflurane was discontinued. After completion of surgery and adequate suctioning of the oropharynx, the reversal of neuromuscular blockade was given by neostigmine 50 μg/kg and glycopyrrolate 8 μg/kg. Once the patient established an adequate spontaneous breathing pattern and was responsive to command, we performed the extubation. Sodium diclofenac 1.5 mg/kg was given as an analgesic after completion of surgery. In the postanesthesia care unit, anesthesiologists blinded to group allocation interviewed all patients for the presence and severity of PEC, POST, and HOV at 1, 3, 8, and 24 h after extubation.

Statistical analysis was performed using SPSS software, version 11.5 (SPSS Inc., Chicago, IL, USA). Patients' characteristics were analyzed using unpaired t-test to compare variables between each group wherever appropriate. Chi-square test was applied for comparison of two proportions for cough, sore throat, and hoarseness. A value of P < 0.05 was considered statistically significant.

Results

Sixty patients were randomized into two groups for this study [Table 1]. No patient experienced failed intubation during the study [Table 2].

Table 1: Demographic profile of the patients

Click here to view

Table 2: The incidence of postextubation cough, postoperative sore throat, and hoarseness of voice in the two groups

Click here to view

Number of patients who coughed at the time of extubation were 4 in group B compared to 16 patients in group L [Figure 2].

Figure 2: Graphical representation of percentage of patients having bucking/coughing on tube at the time of extubation in two groups

Click here to view

The incidence of coughing at 1 and 3 h after extubation were 11 versus 14 (P = 0.43) and 7 versus 12 (P = 0.17), respectively. The incidence of POST at 8 and 24 hours post-extubation were 1 vs. 9 (P=0.005) and 0 vs. 7 (P=0.004), respectively. The incidence of HOV at 1 and 3 hours after extubation were 14 vs. 16 (P=0.6) and 8 vs. 11 (P=0.4), respectively. The incidence of HOV at 8 and 24 hours post-extubation were 1 vs. 6 (P=0.04) and 0 vs. 4 (P=0.03), respectively.

Discussion

Coughing during emergence from anesthesia can cause serious problems during neurosurgical, ophthalmological, and vascular procedures. A method that allows smooth extubation of patients emerging from anesthesia, providing airway protection, preventing problems like raised intraocular pressure and intracranial pressure is required. Furthermore, these patients complain of sore throat, cough, and hoarseness postoperatively, causing postoperative morbidity.

Lubricants applied over endotracheal tubes are helpful in reducing these complications. The basis of the present study was that the local anesthetic jelly, along with its lubricating properties, limits the damage to the tracheal mucosa by suppressing bucking on the tracheal tube; however, its role in the prevention of POST is inconclusive as it does not possess any intrinsic anti-inflammatory action while aerosolized lignocaine is associated with a higher incidence of POST, cough, and HOV.^{[5],[6],[7],[8],[9]} Steroids are known for their anti-inflammatory action. Betamethasone gel applied to the tracheal tube might reduce the incidence of POST, cough, and HOV.^[10],[11]

Our study found that the incidence of PEC, POST, and HOV are less in the betamethasone group. However, the difference of the incidence of those complications was statistically significant only at 8 and 24 h after extubation. This might be because of the prolonged anti-inflammatory action of betamethasone gel. There have also been studies that postoperative administration of the potent corticosteroid like dexamethasone intravenously has been confirmed to offer analgesic and anti-inflammatory effects.^[12]

A study concluded that 1% hydrocortisone water-soluble cream was ineffective in reducing the incidence of POST.^[13] The drawback being that topical hydrocortisone was applied only from the distal tip to 5 cm above the cuff. The beneficial effect of steroid gel application was observed in subsequent studies when it was applied to all portions of the tube that came in contact with the pharyngeal wall, vocal cords, and trachea and not just confined to the tip and cuff.

Our study results are comparable to the study conducted by Sumathi et al.^[14] They reported that in the first 24 h after surgery, the incidence of the PEC was 6%, 40%, and 28%, POST was 40%, 100%, and 100% and postoperative HOV was 4.1%, 32.9%, and 50% for the betamethasone, lidocaine and control groups, respectively. The incidence of PEC, POST, and HOV was significantly lower in the betamethasone group compared with the other two groups (P < 0.05). However, they did not standardize the cuff pressure, and no monitoring for cuff pressure was done. Ayoub et al.^[10] reported a lower incidence of sore throat and HOV in the betamethasone group compared to the control group but was ineffective in reducing cough.^[10]

Our study is also comparable to a study conducted by Selvaraj and Dhanpal,^[11] who compared steroid gel with lidocaine jelly and control group to study the incidence of POST, PEC, and HOV. They reported that the incidence of cough was 23.3% in the steroid group, 63.3% in the lidocaine group, and 50% in the control group at extubation, which is comparable to our result. We monitored cuff pressure of the tube and maintained it around 20–25 mm Hg using cuff pressure manometer. However, nitrous oxide was used during our study, which is known to increase the cuff volume and pressure. However, we monitored cuff pressure at 15 min interval and maintained it at 20–25 mm Hg. There are no reports of cuff damage of endotracheal tubes by lignocaine jelly or betamethasone gel in literature, which was not observed in our study too.

Limitation of our study was that the effect of betamethasone gel and lignocaine jelly for prolonged intubations were not studied since this study only included patients undergoing surgeries of duration up to 240 min.

Conclusion

Patients who underwent general anesthesia using betamethasone gel 0.05% applied to endotracheal tube reported a lower incidence of POST, PEC, and HOV in comparison to those with the application of lignocaine 2% on the endotracheal tube.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Bilotta F, Branca G, Lam A, Cuzzone V, Doronzio A, Rosa G. Endotracheal lidocaine in preventing endotracheal suctioning-induced changes in cerebral hemodynamics in patients with severe head trauma. Neurocrit Care 2008;8:241-6.
2.	Kloub R. Sore throat following tracheal intubation. Middle East J Anaesthesiol 2001;16:29-40.
3.	Stone DJ, Gal TJ. Airway management. In: Miller RD, editor. Anesthesia. 5^th ed. Philadelphia: Churchill Livingstone Co; 2000. p.1414-51.
4.	Henderson J. Airway management in the adult: In: Ronald D, Miller RD, editors. Anesthesia. 7^th ed., Vol. II. Philadelphia: Churchill Livingstone Co; Elsevier; 2010. p. 1573-611.
5.	Christensen AM, Willemoes-Larsen H, Lundby L, Jakobsen KB. Postoperative throat complaints after tracheal intubation. Br J Anaesth 1994;73:786-7.
6.	McHardy FE, Chung F. Postoperative sore throat: Cause, prevention and treatment. Anaesthesia 1999;54:444-53.
7.	Klemola UM, Saarnivaara L, Yrjölä H. Post-operative sore throat: Effect of lignocaine jelly and spray with endotracheal intubation. Eur J Anaesthesiol 1988;5:391-9.
8.	Herlevsen P, Bredahl C, Hindsholm K, Kruhøffer PK. Prophylactic laryngo-tracheal aerosolized lidocaine against postoperative sore throat. Acta Anaesthesiol Scand 1992;36:505-7.
9.	Maruyama K, Sakai H, Miyazawa H, Toda N, Iinuma Y, Mochizuki N, et al. Sore throat and hoarseness after total intravenous anaesthesia. Br J Anaesth 2004;92:541-3.
10.	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.
11.	Selvaraj T, Dhanpal R. Evaluation of the application of topical steroids on the endotracheal tube in decreasing postoperative sore throat. J Anaesthesiol Clin Pharmacol 2002;18:167-70.
12.	Elhakim M, Ali NM, Rashed I, Riad MK, Refat M. Dexamethasone reduces postoperative vomiting and pain after pediatric tonsillectomy. Can J Anaesth 2003;50:392-7.
13.	Stride PC. Postoperative sore throat: Topical hydrocortisone. Anaesthesia 1990;45:968-71.
14.	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.