|Year : 2016 | Volume
| Issue : 1 | Page : 104-107
Does nebulized dexamethasone decrease the incidence of postextubation sore throat?: a randomized controlled study
Atef K Salama MD , Ahmed M El-badawy
Department of Anesthesiology, Faculty of Medicine, Cairo University, Cairo, Egypt
|Date of Submission||04-Oct-2015|
|Date of Acceptance||22-Dec-2015|
|Date of Web Publication||17-Mar-2016|
Atef K Salama
Lecturer of Anesthesia, Anesthesia Department, Faculty of Medicine, Cairo University, Kasr Al Ainy Street, 11562 Cairo
Source of Support: None, Conflict of Interest: None
Objective and aim of study
Postoperative sore throat (POST) is a common complaint in about 21-65% of patients undergoing general anesthesia with endotracheal intubation. The aim of this randomized controlled study was to evaluate the efficacy of preoperative nebulized dexamethasone in decreasing the incidence of postextubation sore throat.
Patients and methods
A total of 120 American Society of Anesthesiologists (ASA) physical status I-II patients of both sexes aged 25-60 years sexes were included in this study. Patients were randomly assigned into one of the two groups of 60 patients each: group D received dexamethasone 8 mg in 5 ml nebulization and group S (the control group) received normal saline in 5 ml nebulization 15 min before general anesthesia and endotracheal intubation. The intensity of sore throat and hemodynamic variables were monitored before nebulization, on arrival to the postanesthesia care unit (0 h), and at 2, 4, 8, 12, and 24 h postoperatively.
The incidence and severity of POST were significantly reduced in the dexamethasone group than in the saline group at the following time intervals: 2 h after extubation (P = 0.009), 4 h after extubation (P = 0.000), 8 h after extubation (P = 0.000), and 12 h after extubation (P = 0.002). There was no complication associated with dexamethasone nebulization.
Preoperative nebulization with dexamethasone 8 mg reduces the incidence and severity of POST in patients receiving general anesthesia with endotracheal intubation.
Keywords: dexamethasone, general anesthesia, intubation, sore throat
|How to cite this article:|
Salama AK, El-badawy AM. Does nebulized dexamethasone decrease the incidence of postextubation sore throat?: a randomized controlled study
. Ain-Shams J Anaesthesiol 2016;9:104-7
|How to cite this URL:|
Salama AK, El-badawy AM. Does nebulized dexamethasone decrease the incidence of postextubation sore throat?: a randomized controlled study
. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2019 Jun 25];9:104-7. Available from: http://www.asja.eg.net/text.asp?2016/9/1/104/178888
| Introduction|| |
Postoperative sore throat (POST) is considered a minor postoperative complication that occurs in 21-65% of patients receiving general anesthesia with endotracheal intubation  . It may be very distressing to the patient and may cause significant postoperative morbidity  . Many modalities of treatment have been tried to abolish this complication, both pharmacological and nonpharmacological  . Factors contributing to the development of POST include trauma to pharyngolaryngeal mucosa from laryngoscopy, placement of a nasogastric tube, or oral suctioning  . In addition, the cuff design and pressure may affect tracheal mucosal capillary perfusion  , and the contact of the tracheal tube with the vocal cords and posterior pharyngeal wall result in edema or mucosal lesions  . The common prophylactic measures used to decrease the incidence of POST include the use of smaller-sized endotracheal tubes with a low intracuff pressure  , use of topical lidocaine  , steroid-coated endotracheal tubes  , and inhalation of steroids  .
Steroids have anti-inflammatory functions and are widely used in common practice. The inhaled corticosteroids deliver the drug to the site of action where it is used in patients with airway diseases without systemic effects. Dexamethasone is a potent synthetic glucocorticoid with anti-inflammatory effects. It has been reported that dexamethasone is effective in the treatment of sore throat  . Therefore, inhaling dexamethasone may be used as an agent to reduce POST following general anesthesia. The current trial discussed the effect of dexamethasone inhalation in decreasing the severity and incidence of POST and hoarseness of voice.
| Patients and methods|| |
After approval of the local ethical and scientific committee and obtaining informed written consent from all patients, 120 patients of both sexes with ASA physical status I-II aged 25-60 years who were scheduled for surgical procedures in the supine position under general anesthesia with endotracheal intubation at Kasr Al Ainy Hospital during the period between May 2014 and January 2015 were included in this study. Patients with a history of recent respiratory tract infection or sore throat, those using steroids or NSAIDs, those with inserted nasogastric tube, those with Mallampati grade more than 2, those who had undergone head and neck surgeries, patients with more than one attempt of tracheal intubation, obese individuals, pregnant women, and diabetic patients were excluded from the study. In the preparation room under local anesthesia, an intravenous cannula was inserted, and midazolam 2 mg and ranitidine 50 mg were given to all patients. At 15 min before induction, patients were randomly allocated using computer-generated random numbers in sealed opaque envelops into one of two groups: group D received dexamethasone 8 mg (2 ml) with 3 ml normal saline nebulization and group S received 5 ml of normal saline nebulization. The patient was then transferred to the operating room, and standard monitors were applied (noninvasive blood pressure, pulse oximetry, and ECG besides capnography after induction of anesthesia).
General anesthesia was induced with propofol 2 mg/kg and fentanyl 2 µg/kg. Endotracheal intubation was facilitated with atracurium 0.5 mg/kg. Laryngoscopy was performed by the same anesthesiologist for all patients using a standard 3 or 4 Macintosh metal blades. An endotracheal tube with an internal diameter of 8 or 8.5 mm for male patients and 7 or 7.5 mm for female patients was used. The cuff was inflated to just obtain a seal. Mechanical ventilation was adjusted to maintain end tidal carbon dioxide between 30 and 35 mmHg, and anesthesia was maintained using isoflurane 1.2% in oxygen 100% and top up doses of atracurium 0.15 mg/kg every 20 min. At the end of surgery, inhalational anesthetic was turned off, muscle relaxant was reversed, and the trachea was extubated when the patient was fully conscious.
The intensity of sore throat was recorded before nebulization (baseline), and at recovery 0, 2, 4, 8, 12, and 24 h postoperatively. Sore throat was scaled on a four-point scale (0-3)  : 0 = no sore throat; 1 = mild sore throat (complains of sore throat only on asking); 2 = moderate sore throat (complains of sore throat on his/her own); and 3 = severe sore throat (change in voice or hoarseness, associated with throat pain). Protocol for pain management was advocated as follows: pethidine 50 mg intravenous and 1 g paracetamol every 6 h.
Statistical analysis and sample size: The sample size was calculated on the basis of a previous study  . If the incidence of POST was considered to be 65%, to achieve a 50% decrease in incidence at α-error 0.05 and power of 90% the sample size was 50 in each arm and so 60 patients were included to account for dropouts.
Data were statistically described in terms of mean ± SD, median and range, or frequencies (number of cases) and percentages, when appropriate. Comparison of numerical variables between the study groups was made using Student's t-test for independent samples. For comparing categorical data, the χ2 -test was performed. An exact test was used instead when the expected frequency was less than 5. P values less than 0.05 were considered statistically significant. All statistical calculations were performed using computer program SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago, Illinois, USA) release 15 for Microsoft Windows (2006).
| Results|| |
A total of 121 ASA I-II patients were enrolled in this study; one patient was excluded from the analysis because of a Cormack and Lehane score of 4 during laryngoscopy [Figure 1]. Demographic data are shown in [Table 1]. There were no significant differences among the two groups with respect to age, sex, weight, duration of anesthesia, and ASA classification. In addition, the approach to postoperative pain relief and the total dose of analgesic drugs were comparable among the two groups.
The incidence and severity of POST were graded using a four-point scale (0-3) and was significantly lower in group D than in group S at the following time intervals: 0 h (immediately after extubation) (P = 0.024); 2 h after extubation (P = 0.009); 4 h after extubation (P = 0.000); 8 h after extubation (P = 0.000); and 12 h after extubation (P = 0.002). However, there was no significant difference at 24 h after extubation (P = 0.513) [Figure 2] and [Table 2].
|Figure 2: The mean sore throat using a four-point scale (0-3) between the study groups over time|
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|Table 2 The mean sore throat using a four-point scale (0-3) between the study groups over the study period|
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Patients of the two groups remained hemodynamically stable with no adverse effects during the entire study period.
| Discussion|| |
The major result of this trial is that nebulization with dexamethasone 8 mg 15 min before intubation is effective in reducing the incidence and severity of POST. Postoperative symptoms are believed to be due to mucosal injury-induced inflammatory process. With normal mucosal lining the inflammatory process to the mucosa is considered as a response to airway instrumentation or irritation by foreign objects such as laryngoscope, endotracheal tube, and suctioning catheter  .
The use of inhaled and topical corticosteroids was described as an anti-inflammatory agent  to treat airway diseases such as asthma  and pharyngitis  with reduced systemic side effects compared with other corticosteroid therapies.
Chen et al.  concluded that the use of prophylactic inhaled budesonide suspension significantly decreases the incidence and severity of sore throat and hoarseness after tracheal intubation in patients scheduled for thyroid surgery with general anesthesia. These results showed a higher incidence of sore throat in the control group compared with the current study. It may be due to the type of surgery in which there is manipulation and hyperextension of the neck.
Tabari et al.  studied the effectiveness of betamethasone gel applied to the tracheal tube and intravenous dexamethasone on POST on 225 ASA I and II patients undergoing elective abdominal surgery with tracheal intubation who were randomly allocated into three groups: the betamethasone gel group, the intravenous dexamethasone group, and the control group. In the postanesthesia care unit, a blinded investigator interviewed all patients as regards POST at 1, 6, and 24 h after surgery and concluded that the widespread application of betamethasone gel over tracheal tubes effectively decreased POST, compared with intravenous dexamethasone application. These findings are consistent with the topical application of steroid on the upper airway before endotracheal intubation , .
Stride  used a standardized anesthesia technique with application of hydrocortisone ointment to the endotracheal tube before intubation, and concluded that hydrocortisone ointment was ineffective in the prevention of POST; the cause may be the presence of additive materials that may irritate the tracheal mucosa.
Another study demonstrated that both betamethasone gel applied over the endotracheal tube and ketamine gargle were effective in attenuating POST after elective surgical procedures. However, betamethasone application was better, with marked reduction in the incidence of postoperative cough and hoarseness of voice  .
Limitations to this study are that we cannot conclude that the effects of dexamethasone in reducing the incidence and severity of POST were due to topical or systemic effects; moreover, the scale used to assess POST was a subjective scale and this may be associated with bias.
| Conclusion|| |
A prophylactic single dose of nebulized 8 mg dexamethasone decreases the incidence and intensity of sore throat following general anesthesia with endotracheal intubation, with no apparent adverse effects.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]