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Newsletter June 2021: Clinical corner - The quest for a smooth extubation!

Marcelo Sperandio Ramos
marcelosperandioramos@yahoo.com

Clinical corner – The quest for smooth extubation! – I banned air from the ETT cuff for good…

It is known for a fact that tracheal extubation is associated with a significant risk of complications, – The Difficult Airway Society (DAS) developed a guideline for the management of tracheal extubation in 2012. While the DAS guideline provides an excellent starting point in developing strategies for achieving successful extubation, it does not provide a distinction between successful extubation and smooth extubation. The concept of smooth emergence was mentioned in the DAS guideline as desirable for the success of certain surgical procedures, but it did not specify which procedures. Despite much of the discussion regarding extubation techniques in the literature, there is no precise definition of “smooth extubation”. Coughing during emergence from general anaesthesia affects 40 to76% of intubated patients. Among the physiological sequelae of peri-extubation coughing, we can cite complications as neck haematoma after thyroidectomy or carotid endarterectomy, wound dehiscence after laparotomy, and intracerebral haemorrhage after intracranial surgery. As such, the ”quest for a smooth extubation” has been pursued in the literature, as I do so in my practice. Multiple medications have been shown to reduce emergence coughing in isolation, such as lidocaine (I.V., intracuff, topical, and tracheal routes), dexmedetomidine, fentanyl, and remifentanil. Beyond the humanitarian aspect the ”smooth extubation” should be a goal to be pursued even in ordinary anaesthesia, because it is a potentially avoidable source of complications for any patient. It is uncertain; however, which combination of measures and/or medication is the most effective for reducing this adverse event. Studies are limited by small sample sizes and heterogenous medication dosages. These limitations are also reflected in the published systematic reviews and meta-analyses. , . Importantly, studies are sparse with a meaningful head-to-head comparison of medications. As such, the comparative effects of these medications to reduce perioperative cough are unknown.

It should be noted that the COVID-19 pandemic has heightened the importance of developing our knowledge of effective techniques to achieve smooth emergence. In an effort to reduce the transmission of COVID-19 to healthcare workers, smooth extubation may contribute to primary prevention by reducing coughing, bucking, and aerosolisation.

Among methods used to apply a local anaesthetic to the mucosa, intracuff lidocaine, in addition to the local anaesthetic effect and suppressing complications during extubation, prevents diffusion of nitrous oxide into the ETT cuff without delaying awakening. Coughing during emergence from general anaesthesia is a common clinical problem. Inflation of the endotracheal tube cuff with lidocaine would create a reservoir of local anaesthetic, which might diffuse across the cuff membrane to anaesthetize the mucosa and attenuate tracheal stimulation. Lidocaine efficacy has long been known since was evaluated in a Cochrane review in 2009. Lidocaine administered as a cuff inflation medium reduces sensitive input from the tracheal mucosa through its continuous topical anaesthetic effect. Alkalinised lidocaine could have a potential advantage over its non-alkalinised variety, with a quicker onset, duration, and quality of the block, despite the possibility of completely losing its anaesthetic action due to precipitation if a minimal error in the addition of bicarbonate occurs.

By filling the cuff with lidocaine, diffusion of the uncharged base form of the drug occurred across the hydrophobic PVC walls of the ETT cuff. Lidocaine binds avidly to the respiratory mucosa, where it exerts its action blocking the sensitive input from the tracheal mucosa. The absorption characteristics of the mucosa, epithelial thickness, number of membrane pores and tissue pH also serve to delay absorption. Thus, the tracheal mucosa in direct contact with the ETT cuff wall can be anaesthetised locally with a longer than expected effect of lidocaine and with intact supraglottic reflexes, preventing aspiration in these patients even though buffered lidocaine could achieve better results – even plain 2% lidocaine injected into the ETT cuff, not only reducing the incidence of a sore throat but also enables improved ETT tolerance and helps in producing smooth extubation in patients with hyperactive airways.

Based on all the mentioned literature and my observation during my clinical practice, I switched room air for lidocaine into the cuff since 2000, and since then I have been employing lidocaine for filling the cuffs for good.

 

References

  1. M. Hartley and R. S. Vaughan,” British Journal of Anaesthesia, vol. 71, no. 4, pp. 561–568, 1993
  2. M. Popat, V. Mitchell, R. Dravid, A. Patel, C. Swampillai, and A. Higgs, “Anaesthesia, vol. 67, no. 3,pp. 318–340, 2012
  3. Estebe J-P, Gentili M, Le Corre P, Gi Dollo, Chevanne F, Ecoffey C.. Anesth Analg 2005; 101: 1536e41
  4. Peng F, Wang M, Yang H, Yang X, Long M.. Journal of International Medical Research. February 2020. doi:10.1177/0300060520901872
  5. Salim B, Rashid S, Ali M, et al. (December 20, 2019). Cureus 11(12): e6427. DOI 10.7759/cureus.6427
  6. Jubb A, Ford P. Update Anaesth 2009; 25: 30e6
  7. Tung A, Fergusson NA, Ng N, Hu V, Dormuth C, Griesdale DGE. Syst Rev 2019; 8: 1e7
  8. R. Aminnejad, A. Salimi, and M. Saeidi, “Canadian Journal of Anesthesia/Journal Canadien D’anesth´esie, vol. 67, no. 6, p. 759, 2020
  9. Dollo G, Estebe JP, Le Corre P, et al. Eur J Pharm Sci 2001; 13: 319–323
  10. Navarro RM and Baughman VL. J Clin Anesth 1997; 9: 394–397.

 

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12 replies

Dr CHASSAING François
Local lidocaine , by spray road or trans cuff of the ITT , is an efficient technique for depress coughing , and also lidocaine IV ( during 30 sec after the bolus ...). Animal data are 40 years old ! Problem : reflexes stay depressed during some hours , and in the post operating room these hours are the golden hours , reflexes are protective from inhalation
2 months ago
Marcelo Sperandio RAmos
To Desiré. Absorption occurs at a small rate that does not affect cuff pressure. With lasers, I do fill a special cuff (tube with 2 cuffs the cranial with lido tainted with blue dye to warn the surgeon in case of accidental rupture)
3 months ago
Marcelo Sperandio RAmos
to Rafael Bello Puentes. Manometers are not used with lidocaine for two reasons: They're designed to work with gas. Although they operate perfectly with liquid, this may result in inaccurate measuring, but it is primarily to prevent people from discussing the possibility of cross infection. This is how I do fill the cuff: I fill it with lidocaine until there is no leaking at top inspiratory pressure, then I gradually take a little bit of lido from the cuff up to the point a very small leak appears... This way, I am sure I got the necessary pressure to allow me to ventilate the patient with the least pressure over the tracheal wall (mucosa).
3 months ago
Peter Odnoga
What is the usual volume of lidocaine used? Do you measure cuff pressure? Is there a risk of tracheal trauma, since the fluid is incompressible?
4 months ago
NATALYA
Спасибо за статью!Обязательно буду использовать этот метод, надеюсь что лидокаин поможет гладко экстубировать больного.
4 months ago
Marisa Baeta
Do you think that pulmonary aspiration migth be increased with your technique?
4 months ago
Marcelo Sperandio
I read about, but because my routine is to administer local anesthetics both as instillation over the glottis and subglottis (atomized or liquid) before intubation AND filling the cuff with local anesthetics, I really do not need IV lidocaineto achieve a smooth extubation.
4 months ago
michael olusegun Ayeko
iv lidocaine 1mg/kg just before extubation combined with ivi remifentanil at <= 0.05 mcg/kg/min seem to be just as good.
4 months ago
Dr. Jigisha Pujara
How much volume of lidocaine you use to fill the cuff? Do you have any experience of cuff rupture due to lidocaine?
4 months ago
Désirée
Interesting. Do you have to add additional Lidocain after a certain time because of the uptake? And do you use it as well in ENT Laser Surgery?
4 months ago
Rafael Bello Puentes
If you use lidocaine, how do you measure the cuff inflation pressure? Can you use standard nanometers?
4 months ago
Varvaridi Ioanna
What about your experience with IV lidocaine pre-extubation? Do you use it? Does any of its limitations specifically concern you?
4 months ago

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