Post intubation Pharyngolaryngeal Pain in Otorhinolaryngology Surgery: Efficiency of Intra cuff and Extra cuff Lidocaine

Hafiane Reda, MD, PhD

Physician, Department of Anesthesiology and Intensive Care Unit, 20 August Hospital, Casablanca, Morocco; E-mail: hafiane.reda89@gmail.com

INTRODUCTION

Post intubation pharyngolaryngeal pain is a real concern for anesthesiologists. In fact, it represents one of the most reported complains in post-operative care unit (POCU). Many factors were discussed: duration of intubation and intratracheal cuff’s pressure. Therefore many studies have tried using lidocaine associated or not with other medications (like betamethasone or alkalinized solutions) in order to reduce this pain. In our study we wanted to assess the efficiency of liquid lidocaine 2% used to inflate the cuff and as a gel on the cuff’s external surface on post-operative sore throat (POST).

MATERIALS AND METHODS

It’s a prospective study realized during three months in the otorhinolaryngology operative rooms in the 20 August hospital in Casablanca, Morocco.

After a full explanation of the procedure to the patients and obtaining their consent, we randomized them in three groups: control group with no lidocaine (Group 1), use of liquid lidocaine in the cuff (Group 2), use of both lidocaine gel around the cuff and liquid in the cuff (Group 3).

Inclusion criteria were: every orotracheal or nasotracheal intubation realized in our operative rooms.

Exclusion criteria were: non cooperative patient, surgery concerning upper airways or tonsillectomy and sore throat before surgery. Patients with an age less than 18-years-old were excluded.

Cuff’s pressure was standardized for all patients to prevent air leak during ventilation.

Collected data concerned: demographics, type of surgery with the duration of intubation, number of attempts in intubation with the use or not of other airway device for difficult intubation, coughing after extubation with reintubation. Pain was assessed with visual analog scale (VAS) at H1, H6, H24 and before patient’s discharge from the hospital. A physician applied the protocol during anesthesia and the VAS assessment was determined with a help of another anesthesiologist without knowing which protocol was used.

Extracted data was analyzed using SPSS software (IBM New York, United States), Chi-square test was used to assess the relation between sore throat and the protocol. A significance threshold of 0.05 was adopted for all statistical analyses.

The protocol of anesthesia was standardized for all patients.

Induction was performed using: Fentanyl 2,5 µg/Kg, propofol 3 mg/Kg and rocuronium at 0,6 mg/Kg to facilitate intubation after a proper ventilation and preoxygenation. Intubation was performed using a single use cuffed PVC tracheal tube. Cuff’s pressure was adjusted to 25 cm H₂O. In Group1: the cuff was inflated with air, in the second group with liquid Lidocaine 2%; for the third group, the cuff was inflated with liquid lidocaine 2% and lidocaine 2% gel was applied on the external surface of the cuff.

RESULTS

During the period of the study we included 99 patients. They were randomized into 3 groups:

Group 1: 30 patients,

Group 2: 34 and

Group 3: 35 patients.

3 cases of difficult intubation were noted.

DISCUSSION 

This POST can represent a discomfort and even a painful experience. It is represented by a syndrome called: Post Extubation Syndrome (PES).¹

The present study revealed that lidocaine used as liquid in the cuff and as jelly on the external surface reduced the incidence and the intensity of the POST. Although this finding, emergence coughing and the incidence of PONV did not decrease.

The specificity of our study is to relate the PES in short surgeries and in day hospital interventions conducted under general anesthesia. Therefore, intensity of POST can be more important than the post-operative pain.

The incidence of POST is influenced by many factors such as intubation procedure, endotracheal tube (ETT) cuff’s pressure, ETT mobilization during procedure, coughing and aspirations before extubation.^2,3,4 After mucosae irritation with the ETT, lidocaine, with its analgesic and anti-inflammatory effects seems to be the first choice for POST topic therapy. Therefore, therapies using lidocaine were applied in order to lower its incidence and severity.⁵

Protocols using lidocaine associated with alkalinized solution or with betamethasone were also evaluated.^6,7 They found that the use of betamethasone and lidocaine did not decrease the incidence of hoarseness, but it increased sore throats incidence. We can hypothesize that the anesthetic effect can decrease the incidence of sore throat but associated lidocaine jelly with its spray increased its side effects.

Post extubation cough can increase the incidence of several complications: bleeding, bronchospasm, higher intra ocular, intra cranial pressure, and wound dehiscence. Therefore, IV lidocaine was efficient in extubation and previous investigation demonstrated that lidocaine jelly applied on the ETT with barrel-shaped cuff prevents cough at immediate post-operative period.⁶ Whereas, our study did not find a significant difference in emerging cough.

We found multiple limitations. The first one concerned the subjectivity of the POST. The second one concerned the small number of included patients. The third one is that we included a young population with a maximum mean age at 43-years-old; therefore, results cannot be generalized to elderly people.

It would have been interesting to study smokers’ population. With underlying airway irritability, lidocaine can be evaluated in reducing the PES.

CONCLUSION

The present study demonstrated that lidocaine applied on both sides of the cuff reduced efficiently the incidence and the intensity of POST without reducing coughing or PONV. There is a need in conducting larger studies to support this result.

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest.

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