|Year : 2015 | Volume
| Issue : 2 | Page : 105-110
A comparison of betamethasone gel and lidocaine jelly as prophylaxis against intubation-associated throat complications
Adamu Muhammad Sarki, Alhassan Datti Mohammed
Department of Anaesthesiology and Intensive Care, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||10-Nov-2015|
Adamu Muhammad Sarki
Department of Anaesthesiology and Intensive Care, Bayero University and Aminu Kano Teaching Hospital, Kano
Source of Support: None, Conflict of Interest: None
Background: Sore throat, cough and hoarseness of voice are common postoperative throat complications that follow general anaesthesia with tracheal intubation. Objective: This prospective study was designed to compare the efficacies of lidocaine jelly and betamethasone gel in the prevention of postoperative sore throat, cough and hoarseness after general anaesthesia with tracheal intubation. Materials andn Methods: Ninety ASA I and II consenting patients aged 18–65 years were recruited and randomly allocated into three groups of 30 each. The outer surface of the tracheal tube used in intubating patient was lubricated with one of three agents (2% lidocaine jelly, 0.05% betamethasone gel or KY jelly) from the distal tip of the tube to the 15 cm mark. The incidence and severity of sore throat, cough and hoarseness were then assessed by a blinded interviewer at the 6th, 24th and 48th h postoperative. Results: The highest incidence of throat complaints was recorded during the first evaluation at the 6th h postoperative. The incidence of sore throat was 36.7%, 66.7% and 80%; cough was 13.3%, 26.7% and 43.3%; and hoarseness was 23.3%, 30% and 46.7%, for the betamethasone, lidocaine and KY jelly groups, respectively. Betamethasone gel demonstrated significant superiority over lidocaine and KY jellies in the prevention of sore throat (P = 0.002), cough (P = 0.03) and hoarseness (P = 0.03) throughout the study. Duration of tracheal intubation longer than 2 h was associated with significant increase in the incidence of throat complaints (P < 0.001). Conclusion: Application of betamethasone gel on endotracheal tube effectively reduces incidence of postoperative sore throat, cough and hoarseness after tracheal intubation compared to lidocaine jelly.
Keywords: Betamethasone gel, general anaesthesia, lidocaine jelly, sore throat, tracheal intubation
|How to cite this article:|
Sarki AM, Mohammed AD. A comparison of betamethasone gel and lidocaine jelly as prophylaxis against intubation-associated throat complications. Niger J Basic Clin Sci 2015;12:105-10
|How to cite this URL:|
Sarki AM, Mohammed AD. A comparison of betamethasone gel and lidocaine jelly as prophylaxis against intubation-associated throat complications. Niger J Basic Clin Sci [serial online] 2015 [cited 2021 Jun 23];12:105-10. Available from: https://www.njbcs.net/text.asp?2015/12/2/105/169294
| Introduction|| |
Tracheal intubation is often required during general anaesthesia to secure the airway and facilitate ventilation. The process of laryngoscopy and placement of tracheal tube is associated with postoperative throat complications such as sore throat, cough and hoarseness of voice. The incidence of these throat complications vary between 15% and 94%. Although not typically incapacitating, these sequelae can be very discomforting and often a major source of patients' dissatisfaction postoperatively.
postoperative throat complications following tracheal intubation are thought to result from a number of events. One mechanism is trauma to the pharyngotracheal mucosa following laryngoscopy and placement of endotracheal tube (ETT). Prolonged contact of the ETT with the vocal cords and posterior pharyngeal wall may also result in pathological changes such as epithelial loss, glottic haematoma and/or oedema, submucosal tear and contact granuloma. These, in addition to neuropraxia of the recurrent laryngeal nerve due to compression from excessive intracuff pressure have been implicated in the pathogenesis of postoperative hoarseness.
Measures used in the prevention of postoperative throat complications include use of a small sized tracheal tube, use of low-pressure cuff tube, use of topical or intravenous lidocaine,,, topical application of corticosteroids as spray or gel ,,, and ketamine gargle.
This study compares the efficacies of two agents; lidocaine jelly against betamethasone gel applied over tracheal tube in the prevention of postoperative throat complications following general anaesthesia with tracheal intubation.
| Materials and Methods|| |
This was a randomised controlled double-blind study conducted in a teaching hospital in North-Western Nigeria. Ethical clearance was obtained from the Institutional Ethics and Research Committee, and informed consent was signed by all eligible patients before recruitment. Ninety voluntarily consenting patients with American Society of Anesthesiologists' physical status class I or II, of either sex aged 18–65 years who were scheduled to undergo elective surgical procedures that required general anaesthesia with orotracheal intubation were recruited into the study. Procedures likely to last more than 180 min, those in the head and neck regions and those that require nasotracheal or nasogastric intubation were excluded. In addition, cigarette smokers, patients with existing symptoms of sore throat or on steroid therapy and those with anticipated difficult airway were also excluded.
Patients were randomly allocated through blind balloting into three groups of 30 patients each.
- Lidocaine group: Lidocaine 2% water miscible jelly
- Betamethasone group: Betamethasone 0.05% water miscible gel
- Control group: KY jelly (an inert water-soluble lubricant).
Routine pre-anaesthesia evaluation was carried out in all patients a day prior to the scheduled procedure. All patients received 5 mg of oral diazepam with sips of water 2 h before induction of anaesthesia as premedication. Baseline values for pulse rate, Blood pressure and arterial oxygen saturation were measured and recorded. Standard monitored parametres that included electrocardiography, non-invasive blood pressure, end tidal capnography and pulse oximetry were recorded at 5 min interval throughout the procedure.
Single-use high-volume low-pressure cuffed polyvinyl chloride tracheal tubes were used for all patients. Appropriately sized ETTs in the range of 7.5–8.0 mm and 7.0–7.5 mm for male and female patients respectively were used. The study drug was prepared by an assistant not blinded to patient's group allocation. A 2 ml unlabelled syringe was used to withdraw the choice agent and handed over to the assistant that did patients' randomisation, who then lubricated the ETT from the distal end to the 15 cm mark. Both assistants took no further part in the study.
Antisialogogue premedication was provided with intravenous glycopyrrolate 4 mcg/kg just before induction of anaesthesia. All patients had 3–5 min of pre-oxygenation with 100% O2. Induction was achieved with 100 mcg of intravenous fentanyl and sleeping dose of propofol.
Either of two non-depolarising muscle relaxant (atracurium - 0.5 mg/kg or pancuronium - 0.1 mg/kg), was used to facilitate tracheal intubation after 3 min of assisted ventilation. All intubations were performed by an anaesthetist with at least 2 years of training. In each case, the anaesthetist that performed the intubation remained blinded to the nature of gel used in lubricating the ETT. The tracheal tube cuffs were inflated with just enough room air to prevent audible leak. All patients had appropriately sized Guedel oropharyngeal airway inserted before securing the ETT.
Anaesthesia was maintained in all cases with 1–1.5% isoflurane in 100% oxygen at 1–2 L/min flow via circle absorber system. Muscle relaxation was maintained with intermittent boluses of the chosen muscle relaxant as required, while ventilation was controlled by intermittent positive pressure ventilation. Additional analgesia was provided with pentazocine or pethidine as required.
At the end of the procedure, residual neuromuscular block was reversed with intravenous atropine 0.02 mg/kg and neostigmine 0.05 mg/kg. All patients had blind oral suctioning just before extubation. The name of the lubricating agent used was not recorded in the anaesthesia chart.
Assessment of patients for sore throat, cough and hoarseness of voice was done by the investigator who remained blinded to patients' group allocation. Sore throat was assessed using verbal rating score on a four point scale with zero representing no sore throat and three representing severest form of sore throat ever experienced. Cough and hoarseness of voice were assessed through direct questioning technique as suggested by Harding and McVey  at 6th, 24th and 48th h after surgery. Severity of symptoms was graded on a four-point scale as indicated in [Table 1]. Patients with mild sore throat were reassured while those with moderate to severe sore throat were treated with lozenges (Strepsil®).
Data generated was analysed using IBM SPSS version 18 statistical software. Quantitative variables were summarised as mean ± standard deviation or median, while qualitative variables were presented as frequencies and percentages. One-way analysis of variance was used to compare means for patients' characteristics across treatment groups. Test for statistical significance for association between categorical variables was done using Chi-squire test and Fisher's exact test as appropriate. P < 0.05 was considered statistically significant.
| Results|| |
A total of 90 patients (30 in each group) completed the study. The study groups were comparable with respect to age, sex, weight and baseline clinical characteristics as shown in [Table 2] (P > 0.05). The mean durations of laryngoscopy in the three groups were 8.83 ± 0.99 s, 8.86 ± 0.56 s and 8.81 ± 0.64 s for the lidocaine, betamethasone and control groups respectively (P = 0.958). Similarly, the duration of tracheal intubation; defined as the period from the time the tracheal tube was placed in the trachea to the time patient was extubated, was comparable in the three study groups (P = 0.96). The baseline PR and mean arterial pressure were also not significantly different across the three study groups (P = 0.87 and 0.93, respectively).
[Table 3] displays the summary of the incidence and severity of sore throat, cough, and hoarseness of voice at various times post-operatively, while [Figure 1],[Figure 2],[Figure 3] are pictorial representations of the same. During the first evaluation at 6 h [Figure 1], the overall incidences of sore throat in the study groups (lidocaine, betamethasone and control) were 66.7%, 36.7 and 80% respectively. Similarly, the incidences of cough and hoarseness of voice at 6 h were 26.7%, 14.3%, 43.3% and 30%, 23.3%, 46.7% for the lidocaine, betamethasone and control groups, respectively.
At 24 h evaluation time [Figure 2], there were lower incidences of sore throat, cough and hoarseness of voice in the betamethasone group compared to the lidocaine and control groups. No patient reported severe sore throat, cough or hoarseness in the betamethasone group. By the 48th h evaluation time, none of the patients in the betamethasone group had moderate to severe sore throat, cough or hoarseness of voice [Figure 3].
[Table 4] compares the incidence of airway complications in the three study groups at various times. At 6 h, significantly fewer patients had sore throat in the betamethasone group when compared to lidocaine and control groups (χ2 = 12.44, P = 0.002). This trend was maintained at the 24 h (χ2 = 16.80, P < 0.001) and 48 h (χ2 = 15.45, P < 0.001) evaluation time. Meanwhile, the difference in the incidence of sore throat between lidocaine and control groups remained statistically insignificant (P > 0.05). There was a significantly lower incidence of cough in the betamethasone group compared to lidocaine and control groups at both 6th and 24th h period (χ2 = 6.76, P = 0.034 and χ2 = 6.24, P = 0.044 respectively).
Fewer patients had hoarseness of voice in the betamethasone group when compared to the other two study groups during all evaluations. At the 6th h evaluation, a comparison of betamethasone with control group just failed to reach statistical significance (P = 0.058). However, the difference reached statistical significance during the 24 h period (χ2 = 7.13, P = 0.028). At the 48 h period, a comparison of the difference in incidence of hoarseness in the betamethasone group (3.3%) and control group (20%) was found to be statistically significant (χ2 = 4.04, P = 0.04). On the other hand, the incidence of hoarseness in the lidocaine group is not significantly different from that seen in the control group at the various times (P > 0.05).
An analysis of the duration of tracheal tube in situ on the development of throat complications [Table 5] revealed that those patients whose tracheal intubation lasted more than 2 h were at a significantly higher risk of developing throat complications (P < 0.001).
|Table 5: Influence of duration of tracheal intubation on the incidence of airway symptoms|
Click here to view
| Discussion|| |
Tracheal intubation is one of the various means of securing the airway for patients under anaesthesia. It is often regarded as the gold standard for ensuring airway security during general anaesthesia. Due to the inherent nature of the procedures that entail intubation, it is not without associated complications that present as throat symptoms postoperatively. These complications are often manifestations of breach in the mucosal integrity of the airway and/or the inflammation that follows prolonged contact and pressure due to the presence of ETT in situ.
We found in this study, the incidence of sore throat, cough and hoarseness after general endotracheal anaesthesia without prophylaxis to be 80%, 43.3% and 46.7%, respectively. This result is similar to the incidence Selvaraj and Dhanpal  reported in their study where they found an incidence of 73.3% for sore throat and 50% each for cough and hoarseness. The incidence is however, lower than what Sumathi et al. reported in a similar study. All the patients without prophylaxis in that study developed sore throat, while 50% and 28% developed hoarseness and cough, respectively. This observed increase in the incidence of sore throat and hoarseness in the latter study was presumably due to the use of nitrous oxide during maintenance of anaesthesia. Nitrous oxide is known to diffuse into air-filled cavities including ETT cuff. We hypothesised that nitrous oxide use in the study was associated with increase in intracuff volume and pressure. This may have led to ischaemia and sloughing of tracheal mucosa from capillary perfusion compromise thus accounting for the rise in the incidence of throat symptoms.
The incidence of sore throat, cough and hoarseness of voice after prophylaxis with betamethasone gel, was also significantly lower than the corresponding incidence when lidocaine or KY jelly was used for prophylaxis. This result supports the report by Sumathi et al. in their work that compared betamethasone gel against lidocaine jelly; proving that betamethasone gel is superior to lidocaine jelly in the prevention of post, cough and hoarseness. Ayoub et al. however compared only betamethasone against placebo gel in their study, and the incidence of sore throat was significantly lower (27.2%) in the betamethasone group compared to 55.8% in the placebo group. Similarly, the incidence of cough and hoarseness were respectively reduced to 20.5% and 18.2% from 37.2% and 46.5% in the placebo group.
The effectiveness of steroids in the alleviation of post-operative throat symptoms further supports the inflammation theory in the pathogenesis of postoperative airway complications. Although an earlier study on 1% hydrocortisone cream by Stride  failed to demonstrate its efficacy; further studies by various authors demonstrated the beneficial effects of steroids in the alleviation of postoperative airway symptoms.,,,, It is also interesting to note that in the study by Stride, the cream was only applied to the distal 5 cm of the ETT, thus limiting the contact area of the cream to the distal larynx and laryngopharynx. Subsequent studies including ours, employed a more generous application of the cream or gel, allowing for sufficient drug application to major points of contact between the ETT and the airway mucosa.,, Steroids in the form of aerosols used in the treatment of bronchial asthma have also been investigated by many workers with resounding success., However, considering the relatively higher cost of inhaled steroids, the efficacy recorded by betamethasone gel (a cheaper and readily available steroid) in this study, will afford anaesthetists practising in low-resource settings opportunity of preventing these distressing postoperative airway complications at affordable cost.
Duration of tracheal intubation longer than 120 min was found to be significantly associated with higher incidence of postoperative airway complications. One mechanism suggested for the development of postoperative throat symptoms is the pressure-induced ischaemic injuries caused by the ETT or its cuff. The degree of the injury is dependent on both pressure and the duration it is applied. Thus, it is plausible that an ETT that is in place for a longer duration will result in both higher incidence and severity of airway complications. In a study by Edomwonyi et al., duration of intubation longer than 60 min was significantly associated with higher incidence of throat complications. On the other hand, Kolawole and Ishaq  found no significant association between duration of tracheal intubation and incidence of airway complaints. However, the mean duration of surgery in that study was 72.48 ± 30.62 min; as only obstetrics and gynaecological procedures that tend to have shorter duration were included.
| Conclusion|| |
We conclude that generous application of betamethasone gel on the ETT effectively decrease the incidence of postoperative sore throat, cough and hoarseness of voice after tracheal intubation compared to lidocaine jelly.
One limitation in this study is that postoperative administration of nonsteroidal anti-inflammatory drugs and other analgesics could not be standardised due to the different needs of patients for analgesia. This could mask the perception of symptoms such as sore throat and therefore lead to underestimation. Furthermore, the blind suctioning employed in this study, and the insertion of oropharyngeal airway in all patients may have resulted in increased incidence of throat symptoms. Similarly, the volume of air used in inflating the ETT cuff was not measured; and individual variation in the assessment of what is 'enough to prevent audible leak' might have affected the findings in this study.
Financial support and sponsorship
Aminu Kano Teaching Hospital.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]