Impact of topical airway anesthesia on immediate postoperative cough/bucking: a systematic review and meta-analysis

Abstract Background Postoperative cough may occur after tracheal intubation, but it is indistinct which drug is best at diminishing these events. Additionally, airway reflexes are commonly accompanied by severe hemodynamics responses during emergence. Objectives To evaluate the role of topical airway anesthesia on immediate post-extubation cough/bucking and extubation time. Methods Randomized clinical trials from MEDLINE, EMBASE, CENTRAL, and LILACS published until December 23, 2020 were included. Our primary outcome was postoperative cough/bucking incidence which was compared between local anesthetics and controls. Extubation times were likewise considered. Predisposition appraisal and subgroup, affectability investigations were likewise performed. Results The pooled analysis found a 45% reduction in cough incidence after treatment with topical airway local anesthetic (RR = 0.55; 95% CI: 0.42 to 0.72; p< 0.001). The number needed to treat (NNT) was 4.61. The intervention showed no differences in reduction of the extubation time (mean difference = -0.07; 95% CI: -0.14 to 0.28; p= 0.49). Conclusion Topical airway anesthesia demonstrated better than placebo or no medication in reducing immediate post-extubation cough/bucking. Further studies could have this objective to combine the different ways to perform better outcomes for patients.

Abordaje respiratorio del paciente con enfermedad neuromuscular en la unidad de cuidado intensivo pediátrica / Respiratory approach to the patient with neuromuscular disease in the pediatric intensive care unit

En algunas ocasiones, los pacientes con enfermedades neuromusculares infantojuveniles, pueden requerir internación en unidades de cuidados intensivos pediátricos. La principal causa de ingreso hospitalario es la insuficiencia respiratoria aguda, desencadenada por atelectasias y neumonías que, en la mayoría de los casos, tienen su inicio en infecciones del tracto respiratorio superior. Independientemente de su forma de presentación, las enfermedades neuromusculares en periodo infantojuvenil, pueden comprometer en grados distintos a los 3 grupos musculares vinculados a la ventilación pulmonar y protección glótica. Es posible dar asistencia a los músculos inspiratorios y espiratorios con soporte ventilatorio no invasivo y asistencia mecánica de la tos respectivamente. Esta estrategia combinada permite el manejo no invasivo de este tipo de pacientes, logrando extubar o decanular a aquellos considerados potencialmente no destetables con las estrategias clásicas utilizadas en unidades de cuidados intensivos en pediatría. El objetivo de esta revisión es sugerir recomendaciones en cuidados respiratorios no invasivos para pacientes con enfermedades neuromusculares ingresados en unidades de paciente crítico pediátrico. Se presentan 2 casos clínicos ilustrativos, en los cuales estas estrategias fueron utilizadas en forma exitosa.

On some occasions, patients with childhood and adolescent neuromuscular diseases may require hospitalization in pediatric intensive care units. The main cause of hospital admission is acute respiratory failure triggered by atelectasis and pneumonia, which, in most cases, start with upper respiratory tract infections. Regardless of their form of presentation, neuromuscular diseases in children and adolescents can damage the 3 muscle groups linked to pulmonary ventilation and glottic protection to different degrees. Inspiratory and expiratory muscles can be assisted with noninvasive ventilatory support and mechanical cough assist, respectively. This combined strategy allows the non-invasive management of this type of patients, managing to extubate or decannulate those considered potentially unweanable with the classic strategies used in pediatric intensive care units. The aim of this review is present noninvasive respiratory care recommendations for patients with neuromuscular diseases admitted to pediatric intensive critical care unit and illustrated with clinical reports of two patients treated with these strategies successfully.

Broncodilatadores en pacientes con bronquiolitis / Bronchodilators for bronchiolitis

La bronquiolitis es una infección respiratoria aguda baja de causa viral, de aparición invernal, que es común en bebés de 0a 12 meses de edad. Conduce a que las vías respiratorias pequeñas se inflamen y se llenen de desechos, obstruyéndose.El bebé tiene una tos fuerte, secreción nasal, generalmente fiebre y puede presentar sibilancias dificultad respiratoria ydesaturación de oxígeno. Tras la presentación de un caso en la guardia se generó una controversia científica sobre lautilidad de los broncodilatadores en pacientes con bronquiolitis. Luego de realizar una búsqueda bibliográfica y seleccionarla evidencia más reciente y de mejor calidad, se concluye que la evidencia no apoya el uso de broncodilatadores enpacientes con bronquiolitis.(AU)

Bronchiolitis is a low acute respiratory lower respiratory tract infection of viral origin, winter appearance, which is commonin babies from 0 to 12 months of age. It causes the small airways in the lungs to become inflamed and fill with debris. Theinfant has a harsh cough, runny nose, usually fever and may have wheezing, respiratory distress and oxygen desaturation.After the presentation of a case in the emergency department, a scientific controversy was generated about the usefulnessof bronchodilators in patients with bronchiolitis. After conducting a literature search and selecting the most recent and bestquality evidence, it is concluded that evidence does not support the use of bronchodilators in patients with bronchioliTIS.(AU)

Predicted EC50 and EC95 of Remifentanil for Smooth Removal of a Laryngeal Mask Airway Under Propofol Anesthesia

PURPOSE: The purpose of this study was to determine the effect-site concentration (Ce) of remifentanil in 50% of patients (EC50) and 95% of patients (EC95) for smooth laryngeal mask airway (LMA) removal in adults under propofol and remifentanil anesthesia. MATERIALS AND METHODS: Twenty-five patients of ASA physical status I-II and ages 18-60 years who were to undergo minor gynecological or orthopedic surgery were assessed in this study. Anesthesia was induced and maintained with propofol and remifentanil target-controlled infusion (TCI). Remifentanil was maintained at a predetermined Ce during the emergence period. The modified Dixon's up-and-down method was used to determine the remifentanil concentration, starting from 1.0 ng/mL (step size of 0.2 ng/mL). Successful removal of the LMA was regarded as absence of coughing/gagging, clenched teeth, gross purposeful movements, breath holding, laryngospasm, or desaturation to SpO2<90%. RESULTS: The mean+/-SD Ce of remifentanil for smooth LMA removal after propofol anesthesia was 0.83+/-0.16 ng/mL. Using isotonic regression with a bootstrapping approach, the estimated EC50 and EC95 of remifentanil Ce were 0.91 ng/mL [95% confidence interval (CI), 0.77-1.07 ng/mL] and 1.35 ng/mL (95% CI, 1.16-1.38 ng/mL), respectively. CONCLUSION: Our results showed that remifentanil TCI at an established Ce is a reliable technique for achieving safe and smooth emergence without coughing, laryngospasm, or other airway reflexes.

Optimal Effect-Site Concentration of Remifentanil for Inhibiting Response to Laryngeal Mask Airway Removal during Emergence

PURPOSE: This randomized, controlled, double-blind study was designed to determine the optimal dose of remifentanil for preventing complications associated with the removal of a laryngeal mask airway (LMA) without delaying emergence. MATERIALS AND METHODS: This study randomly assigned 128 patients to remifentanil effect-site concentrations (Ce) of 0 ng/mL (group R0), 0.5 ng/mL (group R0.5), 1.0 ng/mL (group R1.0), and 1.5 ng/mL (group R1.5) during emergence. The emergence and recovery profiles were recorded. Adverse events such as coughing, airway obstruction, breath-holding, agitation, desaturation, nausea, and vomiting were also evaluated. RESULTS: The number of patients with respiratory complications such as coughing and breath-holding was significantly lower in the R1.0 and R1.5 groups than in the R0 group (p<0.05). Emergence agitation also decreased in the R1.0 and R1.5 groups (p<0.0083). The time to LMA removal was significantly longer in the R1.5 group than in the other groups (p<0.05). CONCLUSION: Maintaining a remifentanil Ce of 1.0 ng/mL during emergence may suppress adverse events such as coughing, breath-holding, and agitation following the removal of LMA without delayed awakening.

Optimal Effect-Site Concentration of Remifentanil for Inhibiting Response to Laryngeal Mask Airway Removal during Emergence

PURPOSE: This randomized, controlled, double-blind study was designed to determine the optimal dose of remifentanil for preventing complications associated with the removal of a laryngeal mask airway (LMA) without delaying emergence. MATERIALS AND METHODS: This study randomly assigned 128 patients to remifentanil effect-site concentrations (Ce) of 0 ng/mL (group R0), 0.5 ng/mL (group R0.5), 1.0 ng/mL (group R1.0), and 1.5 ng/mL (group R1.5) during emergence. The emergence and recovery profiles were recorded. Adverse events such as coughing, airway obstruction, breath-holding, agitation, desaturation, nausea, and vomiting were also evaluated. RESULTS: The number of patients with respiratory complications such as coughing and breath-holding was significantly lower in the R1.0 and R1.5 groups than in the R0 group (p<0.05). Emergence agitation also decreased in the R1.0 and R1.5 groups (p<0.0083). The time to LMA removal was significantly longer in the R1.5 group than in the other groups (p<0.05). CONCLUSION: Maintaining a remifentanil Ce of 1.0 ng/mL during emergence may suppress adverse events such as coughing, breath-holding, and agitation following the removal of LMA without delayed awakening.

Sex Differences in Remifentanil Requirements for Preventing Cough during Anesthetic Emergence

PURPOSE: Target-controlled infusion (TCI) of remifentanil can suppress coughing during emergence from general anesthesia; nevertheless, previous studies under different clinical conditions recommend significantly different effective effect-site concentrations (effective Ce) of remifentanil for 50% of patients (EC50). The differences among these studies include type of surgery and patient sex. In recent years, study of sex differences in regards to anesthetic pharmacology has drawn greater interest. Accordingly, we attempted to determine the effective Ce of remifentanil for preventing cough for each sex under the same clinical conditions. MATERIALS AND METHODS: Twenty female and 25 male ASA physical status I-II grade patients between the ages of 20 and 46 years who were undergoing thyroidectomy were enrolled in this study. The effective Ce of remifentanil for preventing cough was determined for each sex using the isotonic regression method with a bootstrapping approach, following Dixon's up-and-down method. RESULTS: Isotonic regression with a bootstrapping approach revealed that the estimated EC50 of remifentanil for preventing coughing during emergence was significantly lower in females {1.30 ng/mL [83% confidence interval (CI), 1.20-1.47 ng/mL]} than in males [2.57 ng/mL (83% CI, 2.45-2.70 ng/mL)]. Mean EC50 in females was also significantly lower than in males (1.23+/-0.21 ng/mL vs. 2.43+/-0.21 ng/mL, p<0.001). Mean arterial pressure, heart rate, and respiratory rate over time were not significantly different between the sexes. CONCLUSION: When using remifentanil TCI for cough prevention during anesthetic emergence, patient sex should be a considered for appropriate dosing.

Comparison of the effects of inhalational salbutamol, inhalational beclomethasone and intravenous lidocaine in prevention of fentanyl-induced coughing before induction of anesthesia

Fentanyl, a synthetic opioid is a popular choice amongst anesthesiologists in the operating room, Preinduction IV fentanyl bolus is associated with coughing in 28-45% of patients. Coughing due to fentanyl is not always benign and at times maybe explosive requiring immediate intervention. The goal of this study was to compare the role of inhalation of salbutamol beclomethasone and IV lidocaine in preventing fentanyl induced coughing. This clinical trial study was performed in Ghaem Hospital in 2006. 320 patients aged 20-60 years, undergoing elective orthopedics surgery were randomized into four groups of 80. Group I served as control, while groups II, III, IV received an inhalation of salbutamol, beclomethasone or IV lidocaine before induction of anesthesia. Following IV fentanyl [2 micro g/kg] the incidence of cough was recorded and graded as mild [1-2], moderate [3-4] and severe [>/= 5] depending on the number of coughs observed. Patients' characteristics and coughs, and the results of using different drugs were recorded in a questionnaire and analyzed by descriptive statistical methods. A p value of =/< 0.05 was considered significant. The incidence of cough was 40% in the control group, 6.25%, 1.25% and 11.25% in the salbutamol, beclomethasone and lidocaine groups, respectively. Occurrence of cough was significantly low in the treatment groups; however the difference among the groups was not significant. The use of inhalation salbutamol, beclomethasone or IV lidocaine prior to IV fentanyl administration minimizes fentanyl induced coughing, and in conditions like corneal rupture or increased intracranial pressure, which coughing is highly dangerous, they are beneficial

[ comparison of beclomethasone inhaler and intravenous lidocaine in prevention of postoperative airway and throat complaints]

Tracheal intubation can result in trauma and nerve damage which may also account for postoperative throat symptoms such as hoarseness and dysphagia. The effects of beclomethasone inhaler and intravenous lidocaine in prevention of the above symptoms were documented in previous studies. The aim of the present study is comparison of the effects of beclomethasone inhaler with various clinically used dosages of intravenous lidocaine prior to endotracheal intubation on the incidence and severity of postoperative sore throat, cough, sputum, hoarseness, and dysphagia. A total of 120 patients undergoing elective operations were enrolled in this randomized double-blind clinical trial. Patients were assigned to one of four treatment modalities: lidocaine 1mg/kg [group L[1]], lidocaine 1.5 mg/kg [group L[2]], a dose of 50 micrograms beclomethasone inhaler [Group B], and normal saline [Group C]. Incidence and severity of sore throat, cough, sputum, hoarseness, and dysphagia were compared between the groups before leaving the operating room, 1 hr later, at the time of the first postoperative drink or meal [for assessment of dysphagia], and in the morning after the surgery. In all time intervals of evaluating postoperative symptoms, the incidence and severity of sore throat were significantly lower in groups L2 and B than in group C [P <0.05]. One and twenty hours after emergence of anesthesia, the incidence and severity of cough were significantly lower in groups L[2] and B than in group C [P <0.05]. The incidence and severity of sore throat or cough was not significantly different between groups L2 and B. Throughout the study, the incidence and severity of sputum were significantly lower in group B than in group C [P <0.05]. Beclomehtasone in comparison with intravenous lidocaine prior to intubation decreases the postoperative sore throat and cough. In addition, beclomethasone inhaler decreases the incidence and severity of postoperative sputum

Beclomethasone inhaler versus intravenous lidocaine in the prevention of postoperative airway and throat complaints: a randomized, controlled trial

Previous reports indicate that inhaled corticosteroids attenuate airway inflammation. Beclomethasone inhaler was highly effective in the prevention of postoperative airway symptoms. Intravenous lidocaine prior to endotracheal intubation has also been shown to decrease the incidence of postoperative sore throat and cough. The aim of the present study was to compare the effect of beclomethasone inhaler with various clinically used dosages of intravenous lidocaine prior to endotracheal intubation on the incidence and severity of postoperative sore throat, cough, sputum, hoarseness, and dysphagia. One hundred twenty patients undergoing elective operations were assigned to one of four treatments: intravenous lidocaine 1mg/kg [Group L1, n=30], intravenous lidocaine 1.5 mg/kg [Group L2, n=30], beclomethasone inhaler 50 micro g [Group B, n=30] or intravenous normal saline [Group C, n=30]. The incidence and severity of sore throat, cough, sputum, hoarseness, and dysphagia were compared between the beclomethasone inhaler and intravenous lidocaine groups before they left the operating room, 1 hour later, at time of the first postoperative drink or meal [for assessment of dysphagia], and on the morning after surgery. In the evaluation of postoperative symptoms, the incidence and severity of sore throat were significantly lower in Group L2 and B than Group C [P<.05] at all time intervals. One and 20 hours after emergence from anesthesia, the incidence and severity of cough were significantly lower in Group L2 and B than Group C [P<.05]. The incidence and severity of sore throat or cough was not significantly different between Groups L2 and B. Throughout the study, the incidence and severity of sputum were significantly lower in Group B than group C [P<.05]. Beclomethasone inhaler is comparable with intravenous lidocaine prior to intubation in decreasing postoperative sore throat and cough. In addition, beclomethasone inhaler decreases the incidence and severity of postoperative sputum

effect of betamethasone gel in reducing sore throat, cough, and hoarseness after laryngo-tracheal intubation

Tracheal intubation for general anesthesia often leads to traumatization of the airway mucosa resulting in postoperative sore throat, hoarseness and cough. This study was undertaken to determine the effects of betamethasone gel in reducing these complications. One hundred patients [ASA I-II] to undergo endotracheal intubation, were randomly divided equally into two groups; 50 Case [Group A]. 50 Control [Group B]. The tracheal tubes for Case Group A were lubricated with 0.05% betamethasone gel and for the Control Group B with KY gel. Patients were interviewed at end of procedures and 1 and 24 hour after extubation. The incidence and severity of sore throat, hoarseness and cough, 1 and 24 hours postoperatively was reduced significantly in Case Group A. Betamethasone gel, when was used for lubrication of endotracheal tubes pre-operatively, was shown to be effective in decreasing postoperative sore throat, hoarseness, and cough

Tos persistente / Presistent cough in children

La tos es un síntoma molesto, quizás más para los circunstantes que para quien la padece, es un reflejo protector del paciente y una voz de alerta para el médico, es el síntoma más frecuente en pediatría. El centro de la tos está situado en la parte superior del tallo cerebral y protuberancia, muy cerca del centro del vómito, lo que explica que con frecuencia la tos produzca éste

Tracheal extubation under intravenous xylocaine.

The quality of extubation and circulatory changes during extubation of the trachea with or without prior xylocaine (1 mg/kg iv) were observed in 30 patients having CAD or 2 or more cardiac risk factors. 73.33 per cent of the patients receiving xylocaine had smooth extubation (grade I) in contrast to only 46.66 per cent in the control group. Also, in patients in the xylocaine group, the circulatory changes were statistically insignificant as compared to highly significant rise in rate pressure product in the control group.