Full text of DOI:10.1007/BF03018969

412
REPORTS OF INVESTIGATION
Lidocaine added to a
tracheostomy tube cuff
Waka Hirota DDS PhD,* Wataru Kobayashi DDS PhD,*
Keiichi Igarashi DDS PhD,* Yasuko Yagihashi DDS PhD,*
Hiroto Kimura DDS PhD,* James Strupish BSc,†
reduces tube discomfort Kazuyoshi Hirota MD‡
Purpose: To examine whether lidocaine diffusion across an endotracheal tube cuff affects tracheostomy tube dis-
comfort.
Methods: Two tracheostomy tube cuffs were inflated with 5 ml lidocaine 4% solution and air at 20 cmH2O, and
then placed in 20 ml distilled water at 37°C. After vigorous stirring, 100 µl of this water was then sampled imme-
diately then 1, 2, 4, 8, 24 hr later to measure lidocaine concentration by high-performance liquid chromatogra-
phy. Sixteen patients undergoing tracheostomy following oral cancer resection were randomly assigned to two
groups: lidocaine (n=8) and placebo (n=8). A tracheostomy tube cuff was inflated with 5 ml lidocaine 4% or
saline 0.9% and air to a cuff pressure of 20 cmH2O, in the lidocaine and placebo groups respectively. Tube dis-
comfort was evaluated using a visual analogue scale at 0, 0.5, 1, 2 and 4 hr after lidocaine or saline administra-
tion. Neither analgesics nor sedatives was given during the evaluation period.
Results: Lidocaine time-dependently diffused across the tracheostomy tube cuff. Thirty and 60 min after cuff infla-
tion lidocaine concentrations in the water bath reached approximately 8 and 17 µg·ml–1 representing 160 and
340 µg in 20 ml of water, respectively. The VAS decreased from 53.5 ± 10.6 to 25.1 ± 9.8 mm (P < 0.01) 0.5
hr following lidocaine administration which continued until the end of evaluation period. In the placebo group,
VAS did not change.
Conclusion: Lidocaine diffusion across the tracheostomy tube cuff reduces tube discomfort.
Objectif : Vérifier si la diffusion de lidocaïne au travers du ballonnet du tube endotrachéal a un effet sur l’incon-
fort lié à la canule de trachéotomie.
Méthode : Deux ballonnets de canules de trachéotomie ont été gonflés avec une solution contenant 5 ml de
o
lidocaïne à 4 % et de l’air dans 20 cmH2O, et placées ensuite dans 20 ml d’eau distillée à 37 C. Après avoir
vigoureusement agité le mélange, on a immédiatement prélevé 100 µl de cette eau, puis 1, 2, 4, 8, 24 h plus
tard, pour mesurer la concentration de lidocaïne par chromatographie à haute performance. Seize patients devant
subir une trachéotomie à la suite de la résection d’un cancer oral ont été répartis au hasard en deux groupes :
lidocaïne (n=8) et placebo (n=8). Une canule de trachéotomie à ballonnet a été gonflée avec 5 ml de lidocaïne
à 4 % ou une solution salée à 0,9 % et de l’air jusqu’à une pression 20 cmH2O, chez les patients des groupes
lidocaïne et placebo, respectivement. L’inconfort du tube a été évalué à l’aide de l’échelle visuelle analogique à 0;
0,5; 1; 2 et 4 h après l’administration de lidocaïne ou de solution salée. Aucun analgésique ou sédatif n’a été
administré pendant la période d’évaluation.
Résultats : La diffusion de la lidocaïne au travers du ballonnet de la canule de trachéotomie était fonction du
temps. Trente et 60 min après le gonflement du ballonnet, les concentrations de lidocaïne avaient atteint environ
8 et 17 µg·ml–1, ce qui représentait 160 et 340 µg dans 20 ml d’eau, respectivement. Les valeurs de l’EVA ont
diminué de 53,5 ± 10,6 à 25,1 ± 9,8 mm (P< 0,01) 0,5 h après l’administration de lidocaïne, laquelle a été
poursuivie jusqu’à la fin de la période d’évaluation. Dans le groupe placebo, l’EVA n’a pas montré de modification.
Conclusion : La diffusion de la lidocaïne au travers du ballonnet de la canule de trachéotomie a réduit l’incon-
fort lié au tube.
From the Departments of Dentistry and Oral Surgery* and Anesthesiology,‡ University of Hirosaki School of Medicine, Hirosaki 036-
8562, Japan, and University Department of Anaesthesia and Pain Management,† Leicester Royal Infirmary, Leicester LE1 5WW, UK.
Address correspondence to: Dr. K. Hirota, Department of Anesthesiology, University of Hirosaki School of Medicine, Hirosaki 036-
8562, Japan. Phone: +81-172-39-5111; Fax: +81-172-39-5112; E-mail: masuika@cc.hirosaki-u.ac.jp
Accepted for publication February 2, 2000.
CAN J ANESTH 2000 / 47: 5 / pp 412–414

Hirota et al.: TRACHEOSTOMY TUBE DISCOMFORT
413
OLLOWINGoral cancer resection with rad-
ical neck dissection, most patients undergo
tracheostomy to avoid postoperative upper
comfort was evaluated by visual analogue scale (VAS:
0 mm = no discomfort; 100 mm = worst possible dis-
comfort) before and at 0.5, 1, 2 and 4 hr after cuff
inflation with lidocaine or saline.
Neither analgesics nor sedatives were given during
the evaluation. If patients required analgesics or seda-
tives during the evaluation, they were excluded from
the study.
Statistical analysis was by Repeated Measures
ANOVA followed by Fisher PLSD for intra-group
comparisons and by unpaired t test for between-group
comparisons. A P < 0.05 was considered significant.
All data are expressed as mean SEM.
F
airway obstruction from laryngeal edema.
These patients suffer from considerable tube discom-
fort, and sedatives and analgesics are titrated until the
tube is tolerated. However, there is a risk of respirato-
ry depression following opioid or minor tranquilizer
administration.
Sconzo et al. reported that lidocaine diffuses across
the cuff of an endotracheal tube.1 This is because the
cuff is manufactured from polyvinyl chloride and acts
as a semipermeable membrane. In addition, Huang
and colleagues have also reported considerable lido-
caine diffusion across endotracheal tube cuffs.2 In a
study by Navarro and Baughman lidocaine from an
endotracheal tube cuff was sufficient to produce some
local anesthetic action as it was reported that there was
a reduction of postoperative sore throat.3
Results
There was a time dependent increase in the concen-
tration of lidocaine recovered from the incubation
medium (Figure 1) indicating that lidocaine diffused
across the tracheostomy tube cuff.
In this study, we examined whether lidocaine diffus-
es across the tracheostomy tube cuff that is routinely
used in our hospital, and whether placing lidocaine in
the tracheostomy cuff reduced tube discomfort.
In patients who received a tracheostomy tube with a
lidocaine containing cuff the VAS decreased from 53.5
10.6 to 25.1 9.8 mm (P < 0.01) 0.5 hr after lido-
caine administration and the effect was maintained until
the end of the evaluation period. In the placebo (saline)
group there was no reduction in VAS (Figure 2).
Methods
The protocol was approved by our University Ethics
Committee.
Discussion
The present study suggests that considerable amounts
of lidocaine diffused across the tracheostomy tube cuff
and was sufficient to reduce tracheal tube discomfort.
The maximum reduction in discomfort was observed
at 30 min although diffusion continued to increase in
a time dependent manner. Thirty and 60 min after
cuff inflation, lidocaine concentrations in the water
bath reached approximately 8 and 17 µg·ml–1 repre-
In vitro study
Two tracheostomy tubes (ncon GBII tracheostomy
tube, ID 8.0 mm, Fuji Systems, Tokyo) were used in
this study. The tube cuff was inflated with 5 ml lido-
caine 4% solution and air at 20 cmH2O, and then
placed in 20 ml distilled water at 37°C. Following vig-
orous stirring 100 µl of this water was sampled imme-
diately and at 1, 2, 4, 8, 24 hr later. The concentration
of lidocaine in the samples was measured by high-per-
formance liquid chromatography. The lower detection
limits were 0.2 µg·ml– 1 and the intra-assay coefficient
of variation was 5.2%.
Clinical study
Sixteen adult patients undergoing tracheostomy follow-
ing oral cancer resection were randomly assigned to two
groups: lidocaine group (n=8, 59.9
4.5 [SE] yr,
male/female=5/3) and placebo group (n=8, 57.3 2.7
yr, male/female=6/2). The following protocol was per-
formed on the 2nd postoperative day when patients did
not require large dose of analgesics and sedatives.
All patients were blinded to study drugs. The tra-
cheostomy tube cuff was inflated with 5 ml lidocaine
4% or saline 0.9%. The cuff was further inflated with
air until cuff pressure reached 20 cmH2O. Tube dis-
FIGURE 1 Lidocaine diffuses across the tracheostomy tube cuff
in a time dependent manner. Data are mean of two experiments.

414
CANADIAN JOURNAL OF ANESTHESIA
es airway secretions, which exacerbates coughing and,
hence, produces more discomfort. Intravenous and
topical lidocaine are well known to reduce the cough
reflex.5–7 Therefore, even though lidocaine diffusion
does not completely block the direct cuff irritation, it
may reduce the cough reflex, secretion and hence fur-
ther discomfort. In addition, as Mallick and colleagues
reported, lidocaine instillation also reduces total
propofol and alfentanil requirements for endotracheal
tube use in the intensive care unit.8 Lidocaine in the
tracheal tube cuff might also reduce the need for seda-
tives and analgesics although this was not assessed in
the present study.
In conclusion, the present data suggest that lidocaine
diffuses through its cuff of an endotracheal tube and is
sufficient to significantly reduce tube discomfort.
FIGURE 2 Lidocaine from the tracheostomy tube cuff reduces
tube discomfort. All data are Mean SEM. *P < 0.01.
Acknowledgment
We thank Dr. D.G. Lambert (University Department
of Anaesthesia and Pain Management, Leicester Royal
Infirmary, UK) for his valuable comments.
senting 160 and 340 µg in 20 ml of water, respective-
ly. These data are in good agreement with those of
Sconzo and colleagues of 46 and 360 µg.1
References
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noted that this in vitro data is for homogenous solu-
tions and, in the present study, the concentration of
lidocaine where the cuff touches the tracheal surface
would have been considerably higher. This small
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Whilst tube discomfort is primarily caused by cuff
irritation, coughing produced by the irritation increas-