Medications to reduce emergence coughing after general anaesthesia with tracheal intubation: a systematic review and network meta-analysis

Abstract

Background: Emergence coughing can harm the patient following completion of surgery, but it is unclear which medication is most effective at reducing this event. We conducted a systematic review and network meta-analysis of RCTs to determine the medications' relative efficacies on decreasing moderate to severe emergence coughing after general anaesthesia. Medications studied were lidocaine (i.v., intracuff, topical, or tracheal application), dexmedetomidine, remifentanil, and fentanyl. Methods: We searched eight different medical literature databases, conference abstracts, and article references. After screening, included citations were evaluated for bias and had their data extracted. Pooled odds ratios and 95% confidence intervals for each treatment comparison were calculated. A surface under the cumulative ranking curve analysis (SUCRA) determined the relative rank of each intervention to decrease moderate to severe emergence coughing. Subgroup analyses included severe coughing only, extubation times, type of maintenance anaesthetic, and dosages. Results: The network meta-analysis included 70 studies and 5286 patients. All study medications had favourable odds in reducing moderate and severe peri-extubation coughing compared with either no medication or placebo. No single medication was favoured over another. Dexmedetomidine had the highest SUCRA rank, followed in order by remifentanil, fentanyl, and lidocaine via intracuff, tracheal/topical, and i.v. routes. Remifentanil was ranked highest for decreasing severe coughing only. Intracuff lidocaine had higher odds of prolonging extubation times compared with placebo, dexmedetomidine, fentanyl, and remifentanil. Conclusion: All study medications were better than placebo or no medication in reducing moderate to severe emergence cough, with dexmedetomidine ranked the most effective. Systematic review registration: PROSPERO registration number: CRD42018102870. Editor's key pointsThe authors examined the literature to establish the effectiveness of various drugs in reducing coughing around the time of tracheal extubation.Dexmedetomidine, remifentanil, fentanyl, and lidocaine all reduced the incidence of moderate to severe emergence coughing. Dexmedetomidine appeared to be the most effective medication for decreasing the frequency of moderate to severe emergence cough.

Consensus guidelines for managing the airway in patients with COVID‐19

“…d During anaesthesia, drugs to minimise coughing at emergence include dexmedetomidine, lidocaine and opioids [32]. The value of these is unproven in critical care and needs to be balanced against adverse impact on respiratory drive, neuromuscular function and blood pressure.…”

Enclosure with augmented airflow to decrease risk of exposure to aerosolized pathogens including coronavirus during endotracheal intubation. Can the reduction in aerosolized particles be quantified?

“…However, it may decrease the number of aerosolized particles that anesthesia providers and other operating room staff are exposed to during endotracheal intubation and extubation. Furthermore, the plastic drape will provide additional protection during coughing and forceful expulsion of particles but care must be taken to decrease coughing and forceful breathing upon extubation 11 . This study did not evaluatethe efficacy of this device in transmission of aerosolized pathogens or changes in clinical safety for healthcare workers.…”

Soins de fin de vie pour les patients atteints d’un virus respiratoire extrêmement transmissible : implications pour la COVID-19

“…Local protocols that include palliation without extubation, or extubation with protection to manage AGMP (PPE, use of negative airflow rooms, physical barriers, antitussives) have been published. [42][43][44][45] The opportunity for organ and tissue donation is part of quality end-of-life care in Canada. 28 Currently, patients with COVID19 are being deemed medically unsuitable as potential donors.…”