Bali Journal of Anesthesiology

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 6  |  Issue : 2  |  Page : 75--79

Intratracheal Lidocaine Reduces Incidence of Cough During Extubation and Sore Throat After Tonsillectomy Surgery: A Randomized, Single-blind Clinical Trial


I Made Artawan1, Sidarta Sagita2, Maria Agnes Etty Dedi1,  
1 Department of Anesthesia and Intensive Care, Faculty of Medicine and Veterinary Medicine, Universitas Nusa Cendana, Kupang, East Nusa Tenggara 85001, Indonesia
2 Department of Public Health and Community Medicine, Faculty of Medicine and Veterinary Medicine, Universitas Nusa Cendana, Kupang, East Nusa Tenggara 85001, Indonesia

Correspondence Address:
I Made Artawan
Department of Anesthesia and Intensive Care, Faculty of Medicine and Veterinary Medicine, Universitas Nusa Cendana, Adisucipto Street, Penfui, Kupang, East Nusa Tenggara 85001
Indonesia

Abstract

Background: The incidence of cough during extubation occurs in 40–76% of patients. One effort to reduce this incidence is the use of lidocaine. This study aims to further investigate the benefits of intratracheal lidocaine in reducing the incidence of cough during extubation and sore throat after tonsillectomy surgery. Materials and Methods: This study is a single-blind clinical trial. The research subjects were taken by consecutive sampling. A total of 51 subjects who met inclusion and exclusion criteria will be divided into three groups: lidocaine intubation group (Group LI); lidocaine extubation group (Group LE), and control group. Comparison of cough scores during extubation and sore throat scores on the 1st and 6th hours after tonsillectomy surgery in the three groups was analyzed. Results: In this study, the results showed the cough scores and sore throat scores on the 1st and 6th hours postoperatively between the LI and LE groups when compared with the control group were significantly lower (P < 0.001). The cough scores between the LI group and the LE group were not significantly different (P = 0.234). Likewise, comparison of sore throat scores on the 1st and 6th hours postoperatively between the LI group and the LE group was not significantly different (P = 0.728 and P = 0.537, respectively). Conclusion: Lidocaine intratracheal given just before intubation or just before extubation significantly reduced the incidence of cough during extubation and sore throat on the 1st and 6th hours postoperatively when compared with placebo in the post-tonsillectomy surgery.



How to cite this article:
Artawan I M, Sagita S, Dedi MA. Intratracheal Lidocaine Reduces Incidence of Cough During Extubation and Sore Throat After Tonsillectomy Surgery: A Randomized, Single-blind Clinical Trial.Bali J Anaesthesiol 2022;6:75-79


How to cite this URL:
Artawan I M, Sagita S, Dedi MA. Intratracheal Lidocaine Reduces Incidence of Cough During Extubation and Sore Throat After Tonsillectomy Surgery: A Randomized, Single-blind Clinical Trial. Bali J Anaesthesiol [serial online] 2022 [cited 2022 Jun 26 ];6:75-79
Available from: https://www.bjoaonline.com/text.asp?2022/6/2/75/344887


Full Text



 Background



The incidence of postoperative sore throat is one of the most undesirable morbidities that occur in more than 50% of patients undergoing surgery under general anesthesia intubation. During recovery from general anesthesia, coughing can occur, the patient’s condition is agitated and restless which can increase intracranial, intrathoracic, intra-abdominal pressure, bronchospasm, open surgical wounds, and bleeding. Other complications that can occur are hoarseness, dysphonia, or postoperative dysphagia.[1]

Incidence of cough on recovery from general anesthesia intubation occurs in 40–76% of patients. Physiological sequelae due to the incidence of peri-extubation cough can cause significant complications, for example, neck hematoma after thyroidectomy or carotid endartectomy, impaired wound healing after laparotomy, or intracerebral hemorrhage after intracranial surgery. For this reason, it is recommended to use the smooth emergence technique to minimize coughing and avoid complications that can occur after the surgery.[2]

In tonsillectomy surgery, extubation must be done smoothly and the patient should be in a condition that he/she can obey orders so as to ensure that the airway protection reflex is functioning properly to avoid unwanted postoperative complications. The occurrence of coughing and bucking during extubation can cause bleeding complications after the tonsillectomy surgery.[3]

Various methods are used to reduce the incidence of postoperative cough and sore throat. The deep extubation technique can be performed on patients who meet the requirements for deep extubation. This technique can reduce cardiovascular stimulation and reduce the incidence of coughing during extubation.[4] In addition, many medicines have shown effectiveness to reduce or prevent coughing during extubation, for example, lidocaine (intravenous, intracuff, intratracheal), dexmedetomidine, fentanyl, and remifentanil. However, research on these drugs is still limited with heterogeneous doses.[2]

A study showed that administration of 2% lidocaine by instillation through an endotracheal tube at a dose of 1.25 mg/kg just before extubation could significantly reduce the incidence of coughing during extubation in patients undergoing surgery under general anesthesia intubation.[5] Another study found that the incidence of cough during extubation was lower in subjects who received 4 mL of 2% lidocaine intratracheally via glottic instillation at the time of intubation. Likewise, the incidence of postoperative sore throat was significantly lower in the group receiving intratracheal lidocaine and intracuff lidocaine.[6]

Research on the benefits of intratracheal lidocaine to reduce coughing during extubation and reduce the incidence of postoperative sore throat that have been carried out is generally still limited to non-head-neck surgery. This study aimed to further investigate the benefits of intratracheal lidocaine in reducing the incidence of cough during extubation and sore throat after tonsillectomy surgery.

 Materials and Methods



This study is a randomized, single-blind clinical trial. The research was carried out after obtaining research ethics approval from the Institutional Review Board (registry number 45/UN15.16/KEPK/2021 dated June 3, 2021). This research was carried out in the operating room of the Wirasakti Army Hospital, Kupang, Indonesia.

Inclusion criteria included patients aged 16–40 years with ASA (American Society of Anesthesiologists) physical status 1 or ASA 2 who underwent tonsillectomy surgery under general anesthesia by endotracheal intubation. Exclusion criteria included patients with known allergy to local anesthetic drugs, refused to participate in the study, patients with coexisting acute or chronic respiratory disease, patients with abnormalities of airway anatomy, patients with a history of smoking, and patients with a Mallampati score of 3 or 4. Patients with a Cormack score of 3 or 4 and those whose surgery lasted for more than 2 h were dropped out from the study. Group allocation was carried out by randomization by random allocation of blocks available on https://www.randomizer.org/, with varying blocks performed by third parties [Figure 1].{Figure 1}

We administered dexamethasone 10 mg, metamizole 1 g, ondansetron 4 mg, midazolam 2 mg, and sulfas atropine 0.5 mg intravenously as premedications. We started induction with propofol 2 mg/kg, fentanyl 2 mcg/kg as analgesic, and muscle relaxation with atracurium 0.5 mg/kg intravenously. After achieving the onset of atracurium, we performed laryngoscopy intubation. The treatment to the subjects of this study was divided into 3 groups of 17: treatment group 1 (Group LI) was given 4 mL of 2% lidocaine intratracheally through glottic instillation just before intubation and 4 mL of intratracheal saline via endotracheal tube instillation just before extubation; treatment group 2 (Group LE) was given 4 mL of intratracheal saline via glottic instillation just before intubation and 4 mL of lidocaine 2% intratracheal via endotracheal tube instillation just before extubation; and the control group (Group C) was given 4 mL of intratracheal saline via glottic instillation just before and 4 mL of intratracheal saline via endotracheal tube instillation just before extubation (17 subjects).

Extubation was performed while the patient was conscious and able to follow orders. The incidence of cough was assessed with a score of 0–3. Score 0 if there is no cough within the first 5 min of extubation; score 1 if cough occurs once in the first 5 min of extubation; score 2 if coughing occurs two to five times in the first 5 min of extubation; score 3 if coughing occurs more than five times in the first 5 min of extubation. The incidence of sore throat in the first and sixth hours after tonsillectomy surgery was assessed by a Numerical Rating Scale with a scale of 0–10.

The comparison of cough scores during extubation after tonsillectomy surgery in the three groups was analyzed using the analysis of variance (ANOVA) test with the alternative of the Kruskal–Wallis test, if the ANOVA test did not meet the requirements. The comparison for the incidence of sore throat in the 1st and 6th hours postoperatively was carried out using the Mann–Whitney test. The difference is significant if the P-value was less than 0.05. All data analysis from this study will be carried out with the SPSS version 24 (IBM Corp. Released 2016 IBM SPSS Statistics for Windows, Version 24.0, IBM Corp., Armonk, NY, USA).

 Results



The characteristics of the research subjects in the three groups can be seen in [Table 1]. In this study, we found that the cough scores during extubation in the three groups of subjects were significantly different (P < 0.001) [Table 2]. The comparison of cough scores between the LI and LE groups compared with the control group was significantly lower (P < 0.001), whereas the comparison of cough scores between the LI group and the LE group was not significantly different (P = 0.234), as seen in [Table 3].{Table 1} {Table 2} {Table 3}

The comparison of sore throat scores on the 1st and 6th hours postoperatively in the three groups of subjects was significantly different with P < 0.001 [Table 4]. The comparison of sore throat scores on the 1st and 6th hours postoperatively between the LI and LE groups when compared with the control group was significantly lower (P < 0.001) [Table 5], whereas that between the LI group and the LE group was not significantly different (P = 0.728 and P = 0.537, respectively).{Table 4} {Table 5}

 Discussion



In this study, it was found that there was a significant difference between cough scores between the treatment and control groups; the group given intratracheal lidocaine just before intubation or intratracheal lidocaine administration just before extubation has significantly reduced the incidence of post-extubation cough. This is in line with the results of a study by Suryaningrat et al.[5] in 2014, where administration of lidocaine 2% 1.25 mg/kg intratracheal 5 min before extubation could significantly reduce the incidence of post-extubation cough when compared with the control group. In the study by Hong et al.,[7] it was also found that the use of 1% lidocaine 0.5 mg/kg intratracheal just before extubation significantly reduced the degree of post-extubation cough. This is also consistent with the results of a systematic review and meta-analysis study conducted by Tung et al.[2] in 2019, in which it was stated that intratracheal lidocaine administration was one of the effective ways to reduce the incidence of post-extubation cough by 59.2%, compared with placebo. Lidocaine has several beneficial effects such as analgesia, antihyperalgesic, and anti-inflammatory. In addition, lidocaine can suppress spike activity, amplitude, and conduction time in both myelinated and unmyelinated A nerve fibers. Several studies have shown that lidocaine can reduce the incidence and severity of cough during the onset of anesthesia by various methods, including intracuff, tube lubrication, intratracheal, or slow intravenous bolus prior to induction.[8] In the study of Shabnum et al.[9] in 2017, it was found that the incidence of cough during extubation was lower in the intravenous lidocaine group and the intratracheal lidocaine group when compared with the control group.

Postoperative sore throat is an important factor for patient dissatisfaction and delay in returning to normal activities. The mechanism of postoperative sore throat is probably mediated by mucosal trauma, erosion, and inflammation caused by irritation of the endotracheal tube.[10] Many interventions are suggested to reduce the incidence of airway complications after surgery such as extubation under deep general anesthesia, intravenous opioids, intravenous dexmedetomidine, administration of intravenous lidocaine, intracuff or topical, and topical methylprednisolone.[10],[11] In this study, it was found that there was a significant difference between the throat pain scores 1 and 6 h postoperatively between the treatment group and the control group, whereas in the group given intratracheal lidocaine before intubation or intratracheal lidocaine administration shortly before extubation, there was significantly reduced throat pain scores in 1 and 6 h postoperatively. This is in line with the research of Hong et al.[7] in 2018, in which administration of 1% lidocaine 0.5 mg/kg intratracheally before extubation significantly reduced the score for post-extubation throat pain. Likewise, in the research of Bousselmi et al.[6] in 2014, it was found that the incidence of postoperative sore throat was significantly lower in the group receiving intratracheal lidocaine + intracuff lidocaine and intratracheal lidocaine + intracuff saline when compared with placebo.

 Conclusion



Administration of 4 mL of 2% lidocaine intratracheally just before intubation or just before extubation significantly reduced the incidence of cough during extubation and sore throat on the 1st and 6th hours postoperatively compared with placebo in the post-tonsillectomy surgery.

Acknowledgments

The authors would like to express their gratitude to the Head of the Army Hospital Tk.III Wirasakti, Kupang and Dr. I. Gusti N.G. Harrypana, Sp. THT-KL who has allowed this research to be carried out in the operating room of the Army Hospital Tk.II Wirasakti, Kupang.

Financial support and sponsorship

This research was financed from PNBP funds from the University of Nusa Cendana with Activity Code 4471.QEI.011.052 Account 525119 for Fiscal Year 2021.

Conflicts of interest

There are no conflicts of interest.

References

1Lam F, Lin YC, Tsai HC, Chen TL, Tam KW, Chen CY. 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.
2Tung A, Ferguson NA, Ng N, Hu V, Dormuth C, Griesdale DEG. Medications to reduce emergence coughing after general anaesthesia with tracheal intubation: A systematic review and network meta-analysis. Br J Anaesth 2020;124:480-95. https://doi.org/10.1016/j.bja.2019.12.041
3Jaffe RA, Samuels SI, Schmiesing, Clifford A, Golianu B. Otolaryngology—Head and Neck Surgery: Anesthesiologist’s Manual of Surgical Procedures. 4th ed. Philadhelpia, PA: Lippincott, Williams & Wilkins; 2009. p. 203-8.
4Karmarkar S, Varshney S. Tracheal extubation. Contin Educ Anaesth Crit Care Pain 2008;8:214-20. https://doi.org/10.1093/bjaceaccp/mkn036.
5Suryaningrat IGB, Bisri T, Oktaliansah E. The effect of 2% lidocaine endotracheal before extubation on cough incidence decline during extubation process. Anesth Critical Care2014;32:171-7.
6Bousselmi R, Lebbi MA, Bargaoui A, Ben Romdhane M, Messaoudi A, Ben Gabsia A, et al. Lidocaine reduces endotracheal tube associated side effects when instilled over the glottis but not when used to inflate the cuff: A double blind, placebo-controlled, randomized trial. Tunis Med 2014;92:29-33.
7Hong SM, Ji SM, Lee JG, Kwon MA, Park JH, Kim S, et al. The effect of endotracheal 1% lidocaine administration to reduce emergence phenomenon after general anesthesia. Anesth Pain Med 2019;14:152-7. https://doi.org/10.17085/apm.2019.14.2.152.
8Hu S, Li Y, Wang S, Xu S, Ju X, Ma L. Effects of intravenous infusion of lidocaine and dexmedetomidine on inhibiting cough during the tracheal extubation period after thyroid surgery. BMC Anesthesiol 2019;19:66. https://doi.org/10.1186/s12871-019-0739-1.
9Shabnum T, Ali Z, Naqash IA, Mir AH, Azhar K, Zahoor SA, et al. Effects of lignocaine administered intravenously or intratracheally on airway and hemodynamic responses during emergence and extubation in patients undergoing elective craniotomies in supine position. Anesth Essays Res 2017;11:216-22.
10Yang SS, Wang NN, Postonogova T, Yang GJ, McGillion M, Beique F, et al. Intravenous lidocaine to prevent postoperative airway complications in adults: A systematic review and meta-analysis. Br J Anaesth 2020;124:314-23.
11Wong TH, Weber G, Abramowicz AE. Smooth extubation and smooth emergence techniques: A narrative review. Anesthesiol Res Pract 2021;2021:8883257.