Widespread Application of Topical Steroids to Decrease Sore Throat, Hoarseness, and Cough After Tracheal Intubation

Tracheal intubation for general anesthesia often leads to trauma of the airway mucosa, resulting in postoperative sore throat (ST), cough (C), and hoarseness (H), with reported incidences of 21%-65% [1,2]. Although typically not incapacitating, these sequelae can be very uncomfortable and may be especially annoying to patients returning home after ambulatory procedures. The aforementioned effects are likely the consequences of local irritation and inflammation and hence may be amenable to locally administered steroids. However, relatively little research has been performed in this area. Topical application of 1% hydrocortisone near the endotracheal tube cuff was not beneficial [3], whereas one puff of a beclomethasone inhaler (50 [micro sign]g) effectively reduced the incidence of ST from 55% to 10% [4]. Neither of these studies evaluated the effect of the steroid on H and C. In light of the cost associated with pretreatment with inhalers, we sought to determine whether we could obtain a reduction of C and H as well as ST with a wider distribution of topical gel. We hypothesized that coating the endotracheal tube from the cuff to the 15-cm mark with betamethasone, a water-soluble steroid that has been used topically for the treatment of inflammatory lesions of the oral mucosa, would reduce these sequelae. Methods With institutional review board approval, written, informed consent was obtained from 87 ASA physical status I-III patients scheduled for elective surgery under general endotracheal anesthesia with propofol and a nondepolarizing relaxant. Subjects were informed that we would be inquiring about ST, C, and H. Exclusion criteria included operations involving the head and neck, anticipated rapid-sequence induction or airway difficulty, and patients who were <16 yr old or who were using steroids preoperatively. Patients were randomly assigned so that before intubation, the endotracheal tube was lubricated uniformly by an unblind investigator from the cuff to the 15-cm mark with 3 mL of a water-soluble gel containing chlorhexidine gluconate alone or with the addition of betamethasone 0.05% (equivalent to 3 mg of prednisone). After preoxygenation for 2-5 min, anesthesia was induced with propofol and a nondepolarizing relaxant. Tracheal intubation then was performed by residents in their second year of clinical training who were blinded to the nature of the gel. Male and female patients received 7.5- and 7.0-mm inner diameter tubes, respectively. Immediately after intubation, tracheal tube cuffs were filled with the minimal volume of room air required to prevent an audible leak. An orogastric tube was placed and remained in place until just before tracheal extubation. Anesthetic management consisted of positive pressure ventilation and was otherwise at the discretion of the anesthesia care team. All patients received oxygen via a face mask postoperatively. A blind member of the research team assessed the patients 1 and 24 h postoperatively, using the questionnaire shown in Table 1 [by providing direct questions, as suggested by Harding and McVey [5]]. Differences in severity between groups were compared using the Mann-Whitney U-test; differences in incidence were compared by using chi squared analysis. A P value <0.05 was considered statistically significant. We calculated that 40 patients were required in each group to detect a difference with a power >or=to0.90 and [alpha] = 0.05. A patient was eliminated from the study if more than two attempts at passage of the endotracheal tube were required.Table 1: Scoring System for Sore Throat, Cough, and HoarsenessResults The duration of anesthesia was 118 +/- 56 min in the placebo group and 110 +/- 50 min in the steroid group (P = not significant). As noted in Table 2 and Table 3, pretreatment with the steroid gel markedly reduced incidence and severity of ST, H, and C. The scores for ST and H were significantly lower in the steroid group at 1 h and 24 h (P < 0.05). C tended to be less severe in the treated group, but the intergroup difference was not significantly different. The number of patients with neither ST nor H after steroid treatment was 18 and 28 at 1 and 24 h, respectively. In contrast, only 4 and 13 patients reported neither ST nor H at 1 and 24 h after lubrication with the placebo gel (P < 0.05). The benefit of steroid application was also evident when the incidence of patients with a score of 3 (on the 0-3 scale) for either ST, H, or C was compared at 1 h (31 in the placebo group versus 8 in the betamethasone group; P < 0.05) and at 24 h (14 in the placebo group versus 3 in the steroid group; P < 0.05).Table 2: Summary StatisticsTable 3: Relative Incidence of Different Severity ScoresDiscussion This study confirms the relatively high incidence of pharyngolaryngotracheal sequelae after general anesthesia with laryngoscopy and tracheal intubation. Application of betamethasone to the portions of the endotracheal tube that contact the posterior pharyngeal wall, vocal cords, and trachea markedly reduced ST, H, and C. This may be attributable to decreased inflammation and edema as a result of local steroid application. The widespread application of gel in the present study may account for the greater benefit compared with those achieved by Stride [3] when he applied topical hydrocortisone from the distal tip to 5 cm above the cuff. It does not seem that the total dose of steroid was responsible, because the doses used in our study and in Stride's [3] were equivalent to 3 mg and 5.2-7.7 mg of prednisone, respectively. The beneficial effect of steroids is consistent with the fact that endotracheal tubes [6] and their cuffs [7] may cause local irritation with pharyngeal, laryngeal, and/or tracheal discomfort. It also has been shown that virtually all tracheal intubations are associated with laryngeal changes that affect the voice-frequency histogram [8,9] even if they do not cause blatant H. Not surprisingly, the use of topical steroids in the present study was more effective than topical or aerosolized lidocaine [10,11] in the prevention of symptoms indicative of local irritation. We conclude that, in patients in whom the development of ST, H, or C is considered undesirable, the likelihood and severity of such sequelae can be markedly decreased by applying betamethasone as a topical steroid cream so that it covers the major points of contact with the pharynx, larynx, and trachea.