Accepted Manuscript Editorial comment to the case report awake extubation: Superior laryngeal nerve block with lignocaine nebulization Daniela Godoroja PII:
S2210-8440(18)30054-6
DOI:
10.1016/j.tacc.2018.04.012
Reference:
TACC 418
To appear in:
Trends in Anaesthesia and Critical Care
Received Date: 1 April 2018 Accepted Date: 16 April 2018
Please cite this article as: Godoroja D, Editorial comment to the case report awake extubation: Superior laryngeal nerve block with lignocaine nebulization, Trends in Anaesthesia and Critical Care (2018), doi: 10.1016/j.tacc.2018.04.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Corresponding Author: Daniela Godoroja, MD, As. Prof. Department of Anaesthesia, Ponderas Academic Hospital, Regina Maria University of Medicine and Pharmacy “Carol Davila” Bucharest Romania
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Address: 85 A, Nicolae Caramfil Street, 85 A, 014412, Bucharest, Romania Phone number: 0040756026125
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Email:
[email protected]
Editorial comment to the case report AWAKE EXTUBATION: SUPERIOR
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LARYNGEAL NERVE BLOCK WITH LIGNOCAINE NEBULIZATION Daniela Godoroja
Department of Anaesthesia and Intensive Care, Ponderas Academic Hospital Regina Maria, 85 A, Nicolae Caramfil Street, 85 A, 014412, Bucharest, Romania, University of Medicine
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and Pharmacy “Carol Davila” Bucharest Romania.
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Correspondence to Daniela Godoroja, MD, As. Prof. (
[email protected])
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ACCEPTED MANUSCRIPT In the current issue of TACC, ultrasound guided bilateral superior laryngeal nerve blocks plus lignocaine nebulization were employed for an awake tracheal extubation of a patient with coronary disease and unstable angina. I would like to thank the authors for sharing this case with us.
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Problems associated with tracheal extubation are common, and many aspects of emergence from anaesthesia remain controversial. There are fewer guidelines or protocols available for extubation than for tracheal intubation [1]. Both the American Society of Anesthesiologists[2] and Difficult Airway Society[3] algorithms and guidelines do consider some key points for
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extubation. For example, the patient should be awake and follow simple commands before extubation. Exceptions include paediatric patients, patients with neurologic disease or who cannot understand verbal commands. Vital signs should be stable (blood pressure, pulse rate,
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oxygen saturation) and the respiratory rate < 30 /min. Protective reflexes should be present (gag, swallow and cough) to protect against aspiration. Reversal of neuromuscular block should be adequate to allow good respiratory mechanics[4].
The Hagberg algorithm [2,4] lists three grades of sedation during tracheal extubation; (a)
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“deep extubation” recommended only in patients with severe asthma, (b) “sedated extubation” where airway reflexes have returned (anaesthesiologist observes swallow and cough) and (c) “secure” or “awake extubation”. The latter two sedation levels are those generally considered
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for elective surgical patients.
The overall rate of complications [5] associated with extubation may be greater than problems during intubation. Complications are usually respiratory (severe coughing,
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laryngospasm, desaturation, vomiting, reflux and aspiration) and cardiac (hypertension, arrhythmias and myocardial ischemia). Patients at high risk for these complications associated with extubation require specific pre-formulated strategies[1].
Tracheal extubation is associated with a 10–30% increase in arterial pressure and heart rate lasting 5-15 minutes. Patients with coronary artery disease experience a 40-50% decrease in myocardial ejection fraction. “Deep extubation” decreases cardiovascular stimulation and reduces the incidence of coughing and straining on the endotracheal tube. However, the incidence of respiratory complications, especially aspiration, is greater after extubation under deep anaesthesia regardless of the type of operation. 2
ACCEPTED MANUSCRIPT As a general rule, most patients should be extubated awake. The sympathetic responses during extubation may be attenuated by pharmacological interventions including esmolol, glyceryl trinitrate, magnesium, propofol infusion, remifentanil/alfentanil infusions, i.v. lidocaine and perioperative oral nimodipine with labetalol. Alternatively, the endotracheal
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tube can be exchanged for a laryngeal mask airway (LMA) prior to extubation [6]. The LMA is substituted for a tracheal tube while the patient is still anaesthetized and paralysed, and is removed only after spontaneous breathing resumes and commands are obeyed. This technique avoids coughing and a pressor response to extubation with less need for airway manipulation
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compared with deep tracheal extubation, which usually requires insertion of Guedel airway. Another approach is to fill the tracheal tube’s cuff with liquid7 rather than air. This avoids
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subsequent overinflation from an increase in temperature or intraoperative N2O diffusion. Lignocaine (2%) with NaHCO3 (1.4% or 8.4%) is cuff safe and is less irritant if the cuff ruptures. This solution diffuses from the PVC cuff to the tracheal mucosa. With this technique there is less coughing, bucking and hoarseness during emergence, without suppressing the swallowing reflex and should be considered for patients with cardiovascular
period. [1]
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disease. It also significantly reduces the incidence of sore throat in the 24 hour postoperative
The case report proposal for bilateral superior laryngeal nerve blocks for safe tracheal
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extubation to reduce coughing and bucking needs to be discussed. The internal branch of the superior laryngeal nerve (a branch of the vagus nerve) provides sensory innervation to the base of the tongue, posterior surface of the epiglottis, aryepiglottic
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fold, and the arytenoids. The internal branch originates from the superior laryngeal nerve lateral to the greater cornu of the hyoid bone. In most patients, the nerve passes approximately 2-4 mm inferior to the greater cornu of the hyoid bone. From here, it pierces the thyrohyoid membrane and travels under the mucosa in the pyriform recess. Blockade of the sensory input to this branch can often be accomplished non-invasively by mucosal saturation with local anaesthetic by either inhalational or direct topical application techniques. Less invasive blockade can be accomplished by placing anaesthetic-soaked cotton pledgets into the pyriform fossae bilaterally. In some patients, however, this may not provide timely adequate anaesthesia and a direct regional blockade of the superior laryngeal nerve is necessary. A rare complication of this block is intravascular injection into the 3
ACCEPTED MANUSCRIPT superior laryngeal artery or vein since both lie in proximity to the nerve on the thyrohyoid membrane. [8] An ultrasound approach [9] can be useful when landmarks are difficult to locate. Two techniques have been described for echo-guided superior laryngeal nerve block. The
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longitudinal [10] (para-sagittal) and transverse [11]approach both identify the ultrasound anatomy of the surrounding structures in superior laryngeal nerve’s extralaryngeal course including thyrohyoid muscle, the hyoid bone with the greater cornu, the thyrohyoid
membrane and the thyroid cartilage. The superior laryngeal nerve was not identified generally
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and the superior laryngeal artery was rarely seen.
Since the recurrent laryngeal nerve provides sensory innervation to the vocal folds and the
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trachea and the blockade of this nerve is necessary to provide comfort and prevent coughing while an endotracheal tube is being passed between the vocal cords, superior laryngeal nerve block alone may be not sufficient to prevent bucking and coughing at extubation.
Blocking the hypopharynx, pharynx, and trachea is a technique especially for awake intubation where the protective reflexes of the airway are lost. Complete anaesthesia requires
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blockade of the superior laryngeal nerve as well as the recurrent laryngeal nerve and poses the danger of a blocked airway, temporary hoarseness or weakness of voice or coughing and increases the risk of aspiration. Thus this technique is dangerous if routinely applied at
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extubation when it is necessary to maintain the protective airway reflexes. Again I want to thank the authors to remind us of this technique in a challenging extubation
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case. They remind us that expertise with regional anaesthesia of the airway, including the use of ultrasound to identify airway anatomy is important. This is especially true for awake patients with suspected difficult intubation, upper airway trauma, or cervical spine fractures. It is essential that every anaesthesiologist be skilled in the administration of general anaesthesia, with both intubation but also extubation remembering Confucius and later Albert Einstein ` quote: ”Keep things simple and focus on what matters !!”
Acknowledgements The author gratefully acknowledge the support of Prof. Jay Brodsky (Stanford USA) who kindly provided revision and thoughtful comments on drafts of this editorial comment. 4
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Presentation of a New Algorithm. (2012). In Benumof and Hagberg's Airway Management: Third Edition Elsevier Inc.. DOI: 10.1016/B978-1-4377-2764-7.00010-5
3. DAS Extubation guidelines. https://www.das.uk.com/content/das-extubation-guidelines 4.Roth R, Chowdhury F, Frost E.A.M. Extubation: Making The Unpredictible Safer.
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Anesthesiology News 2012,69-74
5.Asai T, Koga K, Vaughan RS. Respiratory complications associated with tracheal intubation and extubation. Br J Anaesthesia 1998; 80: 767–75
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6. Cooper RM. Tracheal Extubation of the difficult airway. Internet J Airway Manage 2005; Jan 2004–Dec 2005.
7. Estebe J.P., Genhill M, Corre P.L., Dollo G, Chevanne F, Ecoffey C. Alkalinization of intracuff lidocaine: efficacy and safety. Anesth Analg 2005; 101: 1536–41 8. Regional and Topical Anesthesia for Awake Endotracheal Intubation
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Based on Hadzic’s Textbook of RAPM 2nd Ed 2017
https://www.nysora.com/regional-and-topical-anesthesia-for-awake-endotracheal-intubation 9. Kristensen M.S., Teoh W.S., Graumann O, Laursen CB. Ultrasonography for clinical decision-making and intervention in airway management: from the mouth to the lungs and
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10. Barberet G, Henry Y, Tatu L, Berthier F, Besch G, Pili-Floury S, Samain E. Ultrasound description of a superior laryngeal nerve space as an anatomical basis for echoguided regional anaesthesia BJA: British Journal of Anaesthesia, (2012) Volume 109, Issue 1, 1 (2012,) Pages 126–128, https://doi.org/10.1093/bja/aes203 11. Kumar A, Sinha C, Kumar A, Kumar Bhadani U. Transverse approach for ultrasoundguided superior laryngeal nerve block for awake fiberoptic intubation . Saudi Journal of Anesthesia (2017) Volume: 11 (3 ): 373-374
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