Brazilian Journal of Anesthesiology
Brazilian Journal of Anesthesiology
Systematic Review

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

Thiago Mamoru Sakae, Renato Lucas Passos de Souza, Julio Cezar Mendes Brandão

Downloads: 1
Views: 17


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.

To evaluate the role of topical airway anesthesia on immediate post-extubation cough/bucking and extubation time.

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.

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).

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.


Airway management;  Topical anesthesia;  Intubation, intratracheal;  Cough;  Anesthesia recovery period;  Airway extubation


1 N.P. Singh, J.K. Makkar, R.B. Cappellani, et al. Efficacy of topical agents for prevention of postoperative sore throat after single lumen tracheal intubation: a Bayesian network meta-analysis Can J Anaesth., 67 (2020), pp. 1624-1642

2 T. Mihara, K. Uchimoto, S. Morita, et al. The efficacy of lidocaine to prevent laryngospasm in children: A systematic review and meta-analysis Anaesthesia., 69 (2014), pp. 1388-1396

3 L.W. Li, L. He, Y. Ai, et al. Site-directed topical lidocaine spray attenuates perioperative respiratory adverse events in children undergoing elective surgery J Surg Res., 203 (2016), pp. 206-210

4 P. Fang, Z. Zong, Y. Lu, et al. Effect of topical ropivacaine on the response to endotracheal tube during emergence from general anesthesia: A prospective randomized double-blind controlled study BMC Anesthesiol., 18 (2018), pp. 1-6

5 A.H.W. Liao, S.R. Yeoh, Y.C. Lin, et al. Lidocaine lubricants for intubation-related complications: a systematic review and meta-analysis Can J Anesth., 66 (2019), pp. 1221-1239

6 P.A. Sumathi, T. Shenoy, M. Ambareesha, et al. Controlled comparison between betamethasone gel and lidocaine jelly applied over tracheal tube to reduce postoperative sore throat, cough, and hoarseness of voice Br J Anaesth., 100 (2008), pp. 215-218

7 T. Shabnum, Z. Ali, I. Naqash, et al. Effects of lignocaine administered intravenously or intratracheally on airway and hemodynamic responses during emergence and extubation in patients undergoing elective craniotomies in supine position Anesth Essays Res., 11 (2017), pp. 216-222

8 M.H. Roberts, C.D. Gildersleve Lignocaine topicalization of the pediatric airway Paediatr Anaesth., 26 (2016), pp. 337-344

9 S. Clivio, A. Putzu, M.R. Tramèr Intravenous Lidocaine for the Prevention of Cough: Systematic Review and Meta-analysis of Randomized Controlled Trials Anesth Analg., 129 (2019), pp. 1249-1255

10 A. Tung, N.A. Fergusson, N. Ng, et al. Medications to reduce emergence coughing after general anaesthesia with tracheal intubation: a systematic review and network meta-analysis Br J Anaesth., 124 (2020), pp. 480-495

11 S.S. Yang, N.N. Wang, T. Postonogova, et al. Intravenous lidocaine to prevent postoperative airway complications in adults: a systematic review and meta-analysis Br J Anaesth., 124 (2020), pp. 314-323

12 L.M. Kulkarni, R. Holyachi, M.S. Kurdi Vegetable gum based gel lubrication of endotracheal tube cuffs improves efficacy of alkalinized intracuff lignocaine in preventing postoperative sore throat: a randomized controlled study Anaesth, Pain Intensive Care., 20 (2016), pp. 422-428

13 F. Lam, Y. Lin, H. Tsai, et al. Effect of intracuff lidocaine on postoperative sore throat and the emergence phenomenon: a systematic review and meta-analysis of randomized controlled trials PLoS One., 10 (2015), Article e0136184

14 F. D’Aragon, N. Beaudet, V. Gagnon, et al. The effects of lidocaine spray and intracuff alkalinized lidocaine on the occurrence of cough at extubation: A double-blind randomized controlled trial Can J Anesth., 60 (2013), pp. 370-376

15 R. Bousselmi, M.A. Lebbi, A. Bargaoui, et al. Bousselmi 2014 Article medicale General anaesthesia Tunis Med., 92 (2014), pp. 29-33

16 D.H. Lee, S.J. Park Effects of 10% lidocaine spray on arterial pressure increase due to suspension laryngoscopy and cough during extubation Korean J Anesthesiol., 60 (2011), pp. 422-427

17 A. Kuriyama, M. Aga, H. Maeda Topical benzydamine hydrochloride for prevention of postoperative sore throat in adults undergoing tracheal intubation for elective surgery: a systematic review and meta-analysis Anaesthesia., 73 (2018), pp. 889-900

18 S.C. Minogue, J. Ralph Laryngotracheal topicalization with lidocaine before intubation decreases the incidence of coughing on emergence from general anesthesia Anesth Analg., 99 (2004), pp. 1253-1257

19 Y. Tanaka, T. Nakayama, M. Nishimori, et al. Lidocaine for preventing postoperative sore throat Cochrane Database Syst Rev., 14 (2015), Article CD004081

20 V. Ahuja, S. Mitra, R. Sarna Nebulized ketamine decreases incidence and severity of post-operative sore throat Indian J Anaesth., 59 (2015), pp. 37-42

21 W. Gu, M. Xu, H. Lu, et al. Nebulized dexmedetomidine-lidocaine inhalation as a premedication for flexible bronchoscopy: a randomized trial J Thorac Dis., 11 (2019), pp. 4663-4670

22 A. Kuriyama, H. Maeda, R. Sun Topical application of magnesium to prevent intubation-related sore throat in adult surgical patients: a systematic review and meta-analysis Can J Anesth., 66 (2019), pp. 1082-1094

23 M.J. Malcharek, M. Bartz, B. Rogos, et al. Comparison of Enk Fibreoptic Atomizer with translaryngeal injection for topical anaesthesia for awake fibreoptic intubation in patients at risk of secondary cervical injury: A randomised controlled trial Eur J Anaesthesiol., 32 (2015), pp. 615-623

24 Y. Takaenoki, K. Masui, Y. Oda, et al. The Pharmacokinetics of Atomized Lidocaine Administered via the Trachea: A Randomized Trial Anesth Analg., 123 (2016), pp. 74-81

25 B.S. von Ungern-Sternberg, K. Boda, N.A. Chambers, et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study Lancet., 376 (2010), pp. 773-783

26 N.D. Hamilton, M. Hegarty, A. Calder, et al. Does topical lidocaine before tracheal intubation attenuate airway responses in children? An observational audit Paediatr Anaesth., 22 (2012), pp. 345-350

27 J.P.T. Higgins, J. Thomas, J. Chandler, et al. Cochrane Handbook for Systematic Reviews of Interventions Version 6.0 (Updated July 2019) Available from (2019)

28 H. Yamasaki, K. Takahashi, S. Yamamoto, et al. Yamasaki 2013 Efficacy of endotracheal lidocaine administration with J Anesth., 27 (2013), pp. 822-826

29 J. Zamora-Lozano, J.A. Cruz-Villaseñor, J. Rodríguez-Reyes, et al. Comparison of topical, intravenous, and intracuff lidocaine for reducing coughing after extubation during emergence from general anesthesia Rev Esp Anestesiol Reanim., 54 (2007), pp. 596-601

30 C.A.B. Diachun, B.P. Tunink, J.G. Brock-Utne Suppression of cough during emergence from general anesthesia: Laryngotracheal lidocaine through a modified endotracheal tube J Clin Anesth., 13 (2001), pp. 447-451

31 D. Dutta, M. Godara, S. Purohit, et al. Comparison of the effect of intravenous dexmedetomidine and lignocaine spray instilled into the endotracheal tube on extubation response in patients undergoing spine surgery J Neuroanaesth Crit Care., 3 (2016), pp. 239-244

32 D. Jee, S.Y. Park Lidocaine sprayed down the endotracheal tube attenuates the airway-circulatory reflexes by local anesthesia during emergence and extubation Anesth Analg., 96 (2003), pp. 293-297

33 C. Paltura, A. Güvenç, ÖN. Develioğlu, et al. Original Research: Aerosolized Lidocaine: Effective for Safer Arousal After Suspension Laryngoscopy J Voice., 34 (2020), pp. 130-133

34 I.B. Arslan, I. Kose, E. Ciger, et al. Does Topical Anesthesia Using Aerosolized Lidocaine Inhibit the Superior Laryngeal Nerve Reflex? Laryngol Neurolaryngology., 149 (2013), pp. 466-472

35 H.A. Soltani, O. Aghadavoudi The effect of different lidocaine application methods on postoperative cough and sore throat J Clin Anesth., 14 (2002), pp. 15-18

36 S. Gupta, B. Heames, M. Lampa The effect of laryngotracheal lidocaine on coughing after general anesthesia for carotid endarterectomy Eur J Anaesthesiol., 23 (2006), p. 258

37 R. Rajendram, A. Joseph, S.K. Ramachandran Pharmacological interventions to prevent cough at extubation: a meta-analysis Eur J Anaesthesiol., 33 (2016), p. 84

38 A. Thierbach Franz Kuhn, his contribution to anaesthesia and emergency medicine Resuscitation., 48 (2001), pp. 193-197

39 S. Dhooria, S. Chaudhary, B. Ram, et al. A Randomized Trial of Nebulized Lignocaine, Lignocaine Spray, or Their Combination for Topical Anesthesia During Diagnostic Flexible Bronchoscopy Chest., 157 (2020), pp. 198-204

40 M. Struys, A. Absalom, S.L. Shafer “Intravenous Drug Delivery Systems” in Miller’s Anesthesia (8th ed.), Elsevier (2014)

41 C. Woodruff, P.M. Wieczorek, T. Schricker, et al. Atomised lidocaine for airway topical anaesthesia in the morbidly obese: 1% Compared with 2% Anaesthesia., 65 (2010), pp. 12-17

42 M.B. Khezri, H. Kayalha The effect of combined ephedrine and lidocaine pretreatment on pain and hemodynamic changes due to propofol injection Acta Anaesthesiol Taiwan., 49 (2011), pp. 54-58

43 W. Chen, P. Sun, L. Yang, et al. Improving endotracheal tube tolerance with intracufflidocaine: a meta-analysis of randomized controlled trials J Med Coll PLA., 28 (2013), pp. 302-312

44 H.L. Sun, T.J. Wu, C.C. Ng, et al. Efficacy of oropharyngeal lidocaine instillation on hemodynamic responses to orotracheal intubation J Clin Anesth., 21 (2009), pp. 103-107

45 Y.F. Meng, G.X. Cui, W. Gao, et al. Local airway anesthesia attenuates hemodynamic responses to intubation and extubation in hypertensive surgical patients Med Sci Monit., 20 (2014), pp. 1518-1524

46 M.C. Grant, P.M. Sommer, C. He, et al. Preserved analgesia with reduction in opioids through the use of an acute pain protocol in enhanced recovery after surgery for open hepatectomy Reg Anesth Pain Med., 42 (2017), pp. 451-457

47 E.J. Koepke, E.L. Manning, T.E. Miller, et al. The rising tide of opioid use and abuse: the role of the anesthesiologist Perioper Med., 7 (2018), p. 16

48 J.B. Stevens, P.A. Vories, S.C. Walker Nebulized tetracaine attenuates the hemodynamic response to tracheal intubation Acta Anaesthesiol Scand., 40 (1996), pp. 757-759

49 P.M. Wieczorek, T. Schricker, B. Vinet, et al. Airway topicalisation in morbidly obese patients using atomised lidocaine: 2% compared with 4% Anaesthesia., 62 (2007), pp. 984-988

50 E.N. Brown, K.J. Pavone, M. Naranjo Multimodal General Anesthesia: Theory and Practice Anesth Analg., 127 (2018), pp. 1246-1258

51 H.D. de Boer, R.V. Carlos, J.P. Mulier Is the Balance in Anesthesia Right? Multitarget Approach and Alteration of Systemic Inflammation Anesth Analg., 128 (2019), p. e130

6098305fa953956cc65f7de5 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections