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* From the Departments of Dentistry and Oral Surgery and
Anesthesiology, University of Hirosaki School of Medicine, Hirosaki 036-8562, Japan, and
University Department of Anaesthesia and Pain Management, Leicester Royal Infirmary, Leicester LE1 5WW, UK.
Address correspondence to: Dr. K. Hirota, Department of Anesthesiology, University of Hirosaki School of Medicine, Hirosaki 036-8562, Japan. Phone: +81-172-39-5111; Fax: +81-172-39-5112; E-mail: masuika{at}cc.hirosaki-u.ac.jp
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Abstract |
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Methods: Two tracheostomy tube cuffs were inflated with 5 ml lidocaine 4% solution and air at 20 cmH2O, and then placed in 20 ml distilled water at 37°C. After vigorous stirring, 100 µl of this water was then sampled immediately then 1, 2, 4, 8, 24 hr later to measure lidocaine concentration by high-performance liquid chromatography. Sixteen patients undergoing tracheostomy following oral cancer resection were randomly assigned to two groups: lidocaine (n=8) and placebo (n=8). A tracheostomy tube cuff was inflated with 5 ml lidocaine 4% or saline 0.9% and air to a cuff pressure of 20 cmH2O, in the lidocaine and placebo groups respectively. Tube discomfort was evaluated using a visual analogue scale at 0, 0.5, 1, 2 and 4 hr after lidocaine or saline administration. Neither analgesics nor sedatives was given during the evaluation period.
Results: Lidocaine time-dependently diffused across the tracheostomy tube cuff. Thirty and 60 min after cuff inflation lidocaine concentrations in the water bath reached approximately 8 and 17 µg•ml–1 representing 160 and 340 µg in 20 ml of water, respectively. The VAS decreased from 53.5 ± 10.6 to 25.1 ± 9.8 mm (P < 0.01) 0.5 hr following lidocaine administration which continued until the end of evaluation period. In the placebo group, VAS did not change.
Conclusion: Lidocaine diffusion across the tracheostomy tube cuff reduces tube discomfort.
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Introduction |
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Sconzo et al. reported that lidocaine diffuses across the cuff of an endotracheal tube.1 This is because the cuff is manufactured from polyvinyl chloride and acts as a semipermeable membrane. In addition, Huang and colleagues have also reported considerable lidocaine diffusion across endotracheal tube cuffs.2 In a study by Navarro and Baughman lidocaine from an endotracheal tube cuff was sufficient to produce some local anesthetic action as it was reported that there was a reduction of postoperative sore throat.3
In this study, we examined whether lidocaine diffuses across the tracheostomy tube cuff that is routinely used in our hospital, and whether placing lidocaine in the tracheostomy cuff reduced tube discomfort.
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Methods |
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In vitro study
Two tracheostomy tubes (
con GBII tracheostomy tube, ID 8.0 mm, Fuji Systems, Tokyo) were used in this study. The tube cuff was inflated with 5 ml lidocaine 4% solution and air at 20 cmH2O, and then placed in 20 ml distilled water at 37°C. Following vigorous stirring 100 µl of this water was sampled immediately and at 1, 2, 4, 8, 24 hr later. The concentration of lidocaine in the samples was measured by high-performance liquid chromatography. The lower detection limits were 0.2 µg•ml–1 and the intra-assay coefficient of variation was 5.2%.
Clinical study
Sixteen adult patients undergoing tracheostomy following oral cancer resection were randomly assigned to two groups: lidocaine group (n=8, 59.9 ± 4.5 [SE] yr, male/female=5/3) and placebo group (n=8, 57.3 ± 2.7 yr, male/female=6/2). The following protocol was performed on the 2nd postoperative day when patients did not require large dose of analgesics and sedatives.
All patients were blinded to study drugs. The tracheostomy tube cuff was inflated with 5 ml lidocaine 4% or saline 0.9%. The cuff was further inflated with air until cuff pressure reached 20 cmH2O. Tube discomfort was evaluated by visual analogue scale (VAS: 0 mm = no discomfort; 100 mm = worst possible discomfort) before and at 0.5, 1, 2 and 4 hr after cuff inflation with lidocaine or saline.
Neither analgesics nor sedatives were given during the evaluation. If patients required analgesics or sedatives during the evaluation, they were excluded from the study.
Statistical analysis was by Repeated Measures ANOVA followed by Fisher PLSD for intra-group comparisons and by unpaired t test for between-group comparisons. A P < 0.05 was considered significant. All data are expressed as mean ± SEM.
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) indicating that lidocaine diffused across the tracheostomy tube cuff.
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Discussion |
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The amount of lidocaine that diffused through the cuff after 30 min was only 170 µg in total. Lidocaine concentrations of 140 µM (i.e., equivalent to about 650 µg in our 20 ml bath) are required to produce a 50% reduction in Na+ channel activity.4 It should be noted that this in vitro data is for homogenous solutions and, in the present study, the concentration of lidocaine where the cuff touches the tracheal surface would have been considerably higher. This small amount of lidocaine is sufficient to produce a demonstrable local anesthetic action, i.e. reduced irritation in the area contacted by the cuff.
In the present study lidocaine produced approximately 50% reduction in tube discomfort VAS (from 53.5 ± 10.6 (SEM) to 25.1 ± 9.8 mm). These data are in good agreement with those of Navarro and Baughman who found that 5.5 ± 1.4 (SD) ml lidocaine 4% in the cuff reduced postanesthetic sore throat by about 50% (severity score: from 18.7 ± 27 (SD) to 7.9 ± 18.1 and 25.6 ± 27.5 to 14.5 ± 24.8 one and 24 hr following anesthesia).2
It is possible that increasing the lidocaine concentration in the cuff may reduce discomfort severity by more than 50%. However, as the concentration of lidocaine in the cuff increases, accidental cuff rupture becomes a problem that may result in local anesthetic toxicity. We do not recommend use of higher concentrations.
Whilst tube discomfort is primarily caused by cuff irritation, coughing produced by the irritation increases airway secretions, which exacerbates coughing and, hence, produces more discomfort. Intravenous and topical lidocaine are well known to reduce the cough reflex.5–7 Therefore, even though lidocaine diffusion does not completely block the direct cuff irritation, it may reduce the cough reflex, secretion and hence further discomfort. In addition, as Mallick and colleagues reported, lidocaine instillation also reduces total propofol and alfentanil requirements for endotracheal tube use in the intensive care unit.8 Lidocaine in the tracheal tube cuff might also reduce the need for sedatives and analgesics although this was not assessed in the present study.
In conclusion, the present data suggest that lidocaine diffuses through its cuff of an endotracheal tube and is sufficient to significantly reduce tube discomfort.
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Acknowledgments |
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Accepted for publication February 2, 2000.
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2
Huang C-J, Tsai M-C, Chen C-T, Cheng C-R, Wu K-H, Wei T-T. In vitro diffusion of lidocaine across endotracheal tube cuffs. Can J Anesth 1999; 46: 82–6.
3 Navarro RM, Baughman VL. Lidocaine in the endotracheal tube cuff reduces postoperative sore throat. J Clin Anesth 1997; 9: 394–7.[Medline]
4 Willow M, Gonoi T, Postma SW, Caterall WA. Inhibition of voltage-sensitive sodium channels by local anesthetics and anticonvulsants. In: Roth SH, Miller KW (Eds.). Molecular and Cellular Mechanisms of Anesthetics. New York: Plenum Press, 1986: 243–58.
5
Yukioka H, Yoshimoto N, Nishimura K, Fujimori M. Intravenous lidocaine as a suppressant of coughing during tracheal intubation. Anesth Analg 1985; 64: 1189–92.
6
Nishino T, Hiraga K, Sugimori K. Effects of iv lignocaine on airway reflexes elicited by irritation of the tracheal mucosa in humans anaesthetized with enflurane. Br J Anaesth 1990; 64: 682–7.
7
Gonzalez RM, Bjerke RJ, Drobycki T, et al. Prevention of endotracheal tube-induced coughing during emergence from general anesthesia. Anesth Analg 1994; 79: 792–5.
8
Mallick A, Smith SN, Bodenham AR. Local anaesthesia to the airway reduces sedation requirements in patients undergoing artificial ventilation. Br J Anaesth 1996; 77: 731–4.
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