JMSCR Vol 05 Issue 07 Page July 2017

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1 Imact Factor 5.84 Index Coernicus Value: ISSN (e) x ISSN () DOI: htts://dx.doi.org/ /jmscr/v5i7.107 A Comarative Study on the Incidence and Severity of Post Oerative Sore Throat with and without Controlling Endotracheal Tube Cuff Pressure Authors Sruthi.A 1, Sheela.P 2, R.Muraleedharan 3 1 Senior Resident, Deartment of Anaesthesiology, Government Medical College Kollam 2 Professor, Deartment of Anaesthesiology, Government Medical College Thiruvananthauram 3 Assistant Professor, Deartment of Anaesthesiology, Government Medical College Thiruvananthauram Corresonding Author Dr Sruthi.A T.C 14/1691, Deviriya, FORA C7, Vazhuthacaud, Thiruvananthauram, Kerala, India PIN Phone: , sruthianair@gmail.com Abstract Background: Endotracheal intubation during general anaesthesia often leads to ost rocedural comlications like ost oerative sore throat, cough and hoarseness of voice. In this study we tried to determine the effects of controlled ETT cuff ressure in these comlications. Methods: After obtaining aroval from Research committee and institutional ethical committee, a total of 170 atients who satisfied the inclusion and exclusion criteria constituted the study oulation. During the first eoch of 3 months of study eriod the ETT cuff was inflated till there was no audible leak and during the second eoch of 3 months the cuff ressure was measured and adjusted within the range of 18-25mms of Hg/25-34cms of H2O with the hel of a manometer. Patients were questioned for ost oerative sore throat( POST) at 0,12 and 24 hr after the extubation. Results: In the resent study the 2 grous were comarable with resect to age, gender, weight, height, BMI and duration of surgery. The incidence of POST at 12 and 24 hr in the grou with controlled ETT cuff ressure was significantly lower than the grou with uncontrolled ETT cuff ressure. There was no significant difference in the incidence of POST at 0 hr between the 2 grous. Conclusion: Proer control of ETT cuff ressure during general anaesthesia with the hel of a manometer significantly reduces the incidence and severity of POST. Keywords: Post oerative sore throat, ETT cuff ressure, intubation. Introduction Sore throat is a common ost oerative comlaint. 1 Endotracheal intubation is mandatory during general anaesthesia for control over resiration and to rotect airway. Literature shows that the incidence of sore throat varies from 14.4% to 50% after tracheal intubation. 2,3,4,5 Post oerative sore throat will lead to dissatisfaction and discomfort after surgery. This may rolong hosital stay. Though a minor comlication, it still remains unresolved in atients undergoing general anaesthesia with endotracheal intubation. 6 The ETT cuff ressure has been imlicated as one of the risk factors for sore throat after general Sruthi.A et al JMSCR Volume 05 Issue 07 July 2017 Page 24953

2 anaesthesia. 7 The urose of the cuff system is to rovide a seal between the tube and the tracheal wall to revent assage of haryngeal contents into the trachea and ensure that no gas leaks ast the cuff during ositive ressure ventilation. It is desirable that the cuff seal the airway without exerting so much ressure on the trachea. So minimum air is used to inflate the cuff. Severe over inflation of the ETT cuff affects blood flow to the tracheal mucosa, resulting in tracheal mucosal ischaemia, necrosis, ulceration, trachea oesohageal fistula 8,9 or tracheal ruture. 10,11 The usual ractice is to use minimal air just enough to revent audible leak. But as anaesthesia roceeds the cuff ressure increases as a result of absortion of N2O into it. So there is a theoretical ossibility of reducing the incidence of sore throat if we are able to control the cuff ressure as the surgery and anaesthesia roceeds longer. 12,13 Objective To comare the incidence and severity of ost oerative sore throat in subjects undergoing general anaesthesia with endotracheal tube lacement with and without controlling the cuff ressure. Materials and Methods This study was a rosective observational study conducted in the deartment of Anaesthesiology at a tertiary care centre after obtaining aroval of the Research Committee and Institutional Ethical Committee. Duration of the study was 6 months (May October 2014) 170 atients who underwent general anaesthesia with endotracheal tube lacement during the study eriod who satisfied the inclusion and exclusion criteria constituted the study oulation. Inclusion criteria ASA I and ASA II atients above 18 years who had to undergo general anaesthesia with endotracheal tube lacement. Exclusion criteria 1. Patients undergoing thyroid surgeries, oral and laryngoharyngeal surgeries 2. atients with cough and sore throat within 6 weeks before surgery 3. use of nasogastric tube or throat ack during surgery 4. atients with anticiated difficult intubation like micrognathia, ost burn contracture of neck, obvious facial anomalies. Samle size calculation N= [Zα+Z(1-β)]2[P1(1-P1)+P2(1-P2)]/(P1-P2)2 Where [Zα+Z(1-β)]2=7.19 P1=50% P2=30% By substituting we will get N= 82.5 So we included 85 in each grou Written informed consent to take art in this study was obtained from those atients. General anaesthesia was given to these atients according to the institutional rotocol. In the first eoch of 3 months of the study eriod the cuff of endotracheal tube was inflated after intubation till there was no audible leak. No ressure adjustment thereafter during the entire eriod of anaesthesia. This comrises the uncontrolled grou. In the second eoch of 3 months cuff ressure was measured and adjusted within the range of mms of Hg/25-34cms of H2O14 every 15 minutes with the hel of a cuff ressure manometer. This comrises the controlled grou. After the surgery all study atients were questioned for Post oerative sore throat at 0 hr, 12 hr and 24 hr after the extubation. The severity of sore throat was assessed by the following scoring system. SCORE GRADE 0 No comlaints ertaining to sore throat 1 Minimal (comlains of sore throat only on asking) 2 Moderate (comlains of sore throat on his/her own) 3 Severe (sore throat associated with hoarseness, cough) Statistical Analysis Data analysed by SPSS version 16. The rimary outcome variable is exressed as number (roortion) and chi square test was done to Sruthi.A et al JMSCR Volume 05 Issue 07 July 2017 Page 24954

3 comare the result. Other study variables were exressed as mean or median and t test or Mannwhitney U test were used as statistical tests. P value <0.05 was considered statistically significant. Results Of the total 170 atients who satisfied the inclusion and exclusion criteria 85 belongs to controlled grou and 85 belongs to uncontrolled grou. Table1: Distribution of age, weight, height, BMI, duration of surgery among the two grous Controlled (N=85) Uncontrolled (N=85) Mean SD Mean SD Age (yr) Weight(Kg) Height(cm) BMI(Kg/m2) Duration(mts) Here 2 grous are comarable with resect to age, weight, height, BMI, duration of surgery. Table 2: Comarison of two grous based on the at 0 hour Post oerative Grou sore throat - at 0 hour Controlled Uncontrolled No comlaints Minimal 0 0 Moderate 1 0 Severe 0 0 χ Table 3: Comarison of two grous based on the at 12 hour Post oerative Grou sore throat - at 12 hour Controlled Uncontrolled No comlaints Minimal 11 6 Moderate Severe 2 12 χ2 t Table 4: Comarison of two grous based on the at 24 hour Post oerative sore throat - at 24 hour Controlled Grou Uncontrolled No comlaints Minimal 8 6 Moderate Severe 2 13 Table 5: Comarison of incidence of ost oerative sore throat among the two grous Time since Controlled Uncontrolled extubation (%) (%) 0 hour hour hour Discussion Post oerative sore throat (POST) though a minor comlication, still remains unresolved in atients undergoing endotracheal intubation. The urose of endotracheal intubation is to control resiration and to rotect airway. After tracheal intubation the incidence of sore throat varies from 14.4% to 50%. 2,3,4,5 The method used for airway management has the strongest influence on the incidence of POST but several atient and oerative factors may be involved. By knowing these factors, awareness of the roblem will increase and this will hel the anaesthesiologists in avoiding combinations of the redictive factors, thus decreasing the incidence of POST and imroving atient satisfaction. A multimodal aroach which consists of harmacological and non harmacological interventions has been advocated to decrease the incidence of ost oerative sore throat. The endotracheal tube cuff ressure has been imlicated as a risk factor for sore throat after general anaesthesia. The urose of cuff inflation after endotracheal intubation is to revent air leakage, thus ensuring the effect of ventilation and reducing the leakage of inhalation anaesthetics. The resent study was undertaken to determine the χ Sruthi.A et al JMSCR Volume 05 Issue 07 July 2017 Page 24955

4 after controlling the endotracheal tube cuff ressure within the range of 18-25mms of Hg/25-34cms of H2O throughout anaesthesia and to comare it with that of uncontrolled cuff ressure where the cuff is inflated soon after intubation until there is no audible leak. No ressure adjustment thereafter. A multi centre study by Liu J,Zhang X, Gong W, LiS, Wang F,et al in 2010 in 509 atients from four tertiary care university hositals in Shanghai, China scheduled for elective surgery under general anesthesia were assigned to a control grou without measuring ETT cuff ressure, and a study grou with ETT cuff ressure measured and adjusted. Their study showed that the incidence of ostrocedural sore throat, hoarseness, and bloodstreaked exectoration in the control grou was significantly higher than in the study grou 13. When the duration of endotracheal intubation increased, the incidence of sore throat and blood-streaked exectoration in the control grou increased. The incidence of sore throat in the study grou also increased with increasing duration of endotracheal intubation. Fiberotic bronchoscoy in the 20 atients showed that the tracheal mucosa was injured in varying degrees in both grous, but the injury was more severe in the control grou than in the study grou. But in our study there was no association of POST with duration of Surgery. ETT cuff ressure estimated by alation with ersonal exerience is often much higher than measured or what may be otimal. Proer control of ETTc ressure by a manometer heled reduce ETTrelated ost rocedural resiratory comlications such as cough, sore throat, hoarseness, and bloodstreaked exectoration even in rocedures of short duration (1 3 hours). Severe over inflation of the endotracheal tube cuff (ETTc) imarts risk for serious or even fatal injury and affects blood flow suly to the tracheal mucosa, resulting in tracheal mucosal ischemia, ulceration, necrosis, tracheoesohageal fistula 8,9, or tracheal ruture 10,11. This has been shown rimarily for atients with rolonged (days) endotracheal intubation. For brief rocedures lasting only a few hours, most clinicians give little attention to inflation ressure of the ETTc, and simly determine the ressure by ilot balloon alation according to their exerience. Studies by faculty anesthesiologists, anesthesia residents and critical care unit staff 15,16, have demonstrated a revalent inability of these clinicians to accurately determine ETTc ressure by ilot balloon alation. A study by Suzuki N, Kooguchi et al in 1999, studied about Postoerative hoarseness and sore throat after tracheal intubation: effect of a low intra cuff ressure of endotracheal tube and the usefulness of cuff ressure indicator12. In this study, one hundred and ninety atients of ASA classes I or II were allocated randomly to two grous, low cuff ressure grou (< 15 mmhg) or high cuff ressure grou (15-25 mmhg), using continuous monitoring with a cuff ressure gauge. The incidence of ostoerative hoarseness and sore throat at 24 hours after intubation and on the seventh ostoerative day was measured. The incidence of ostoerative hoarseness and sore throat was significantly decreased in the low ressure grou at 24 hours after intubation as comared with the high ressure grou, but there was no significant difference between the two grous on the seventh ostoerative day. These results suggest that keeing the cuff ressure under 15 mmhg can revent ostoerative hoarseness or sore throat at 24 hours after intubation, and that a cuff ressure gauge is thought to be one of the indisensable monitors during anesthesia. In a cross sectional study by Hamed-Basir Ghafouri, Hossein Saeeidiet al 17 in 2012, the cuff ressure of 100 atients in emergency deartment and intensive care units of 2 university hositals was evaluated by using a sensitive and accurate analogue standard manometer after insertion of the ETT and checking the ilot balloon by the rovider. In their study they concluded that the estimation of cuff ressure using alation techniques is not accurate and in order to revent adverse effects of cuff over inflation, it is better to recheck the ressure using a manometer, regardless of lace, time and the inserter of the endotracheal tube. Previous studies have shown that cuff alation is not sufficient to detect high cuff Sruthi.A et al JMSCR Volume 05 Issue 07 July 2017 Page 24956

5 ressures. 18,19 Even after manual control of the cuff ressure by feeling the ilot balloon, over inflation of the endotracheal cuff is commonly reorted in ICU atients. Over inflation of the ETT cuff is an avoidable risk factor for tracheal ischemia and subsequent comlications. In our study the incidence of ost oerative sore throat at 12 hour in the grou with controlled ETT cuff ressure was 35.3% which was significantly lower ( value 0.003) than 54.1% in the grou with uncontrolled ETT cuff ressure. Only 2 atients in the controlled grou had severe ost oerative sore throat when comared to 12 atients in the uncontrolled grou. The incidence of ost oerative sore throat at 24 hour in the grou with controlled ETT cuff ressure was 25.9% which was significantly lower( value 0.001) than 49.5% in the grou with uncontrolled ETT cuff ressure. Only 2 atients in the controlled grou had severe ost oerative sore throat when comared to 13 atients in the uncontrolled grou. In our study there was no significant difference in the incidence of POST at 0 hour between the 2 grous. Limitation in our study is fibreotic bronchoscoy is not done to confirm the severity of injury. The incidence of coughing or bucking on the endotracheal tube at the time of extubation was not recorded in both grous. The correlation between coughing or bucking at the time of extubation and the incidence of sore throat, cough and hoarseness could not be evaluated in this study. No large rosective study assessing short term benefits of measuring ETT cuff ressure has been reorted. The resent study confirms the findings of studies by the above mentioned authors roving that roer control of ETT cuff ressure with the hel of a manometer significantly reduces the incidence of POST, cough and hoarseness of voice. The major findings of this study are: The incidence of ost oerative sore throat at 12 hr and 24 hr in the grou with controlled ETT cuff ressure was 35.3% and 25.9% resectively. This was significantly lower than 54.1% and 49.5% resectively of the grou with uncontrolled ETT cuff ressure. There was no significant difference in the incidence of ost oerative sore throat at 0 hour between the 2 grous. Conclusion During general anaesthesia, control of endotracheal tube cuff ressure within mms of Hg/25-34cms of H2O with the hel of a manometer can significantly reduce the incidence and severity of ost oerative sore throat. Sources of suort: Nil References 1. McHardy F & Chung F (1999) Postoerative sore throat: cause, revention and treatment. Anaesthesia; 54: Christensen AM, Willemoes-Larsen H, Lundby L, Jakobsen KB. Postoerative Throat comlaints after tracheal intubation. British Journal of Anaesthesia 1994;73: Harding CJ,McVeyFK.Interview method affects incidence ofpostoerative sore throat.anaesthesia 1987;42: Obiaya MO, Okechukwu C, Dakaraju P et al. The incidence of ost anaesthetic comlications-a follow-u rogramme. West Afr J Med 1984;3: Higgins PP, Chung F, Mezei G. Postoerative sore throat after ambulatory surgery. Br J Anaesth 2002; 88: Ogata J, Minami K, Horishita T, Shiraishi M, Okamoto T, Terada T, et al.gargling with sodium azulenesulfonate reducer the ost oerative sore throat after intubation of the trachea. Anesth Analog.2005 Jul;101(1); Combes X, Schauviliege F, Peyrouset O, Motamed C, Kirov K, Dhonneur G, Duvaldestin P. Intracuff ressure and tracheal morbidity: Influence of filling cuff with saline during nitrous oxide anesthesia. Anesthesiology 2001;95: Sruthi.A et al JMSCR Volume 05 Issue 07 July 2017 Page 24957

6 8. Deslee G, Brichet A, Lebuffe G, Coin MC, Ramon P, Marquette CH.Obstructive fibrinous tracheal seudomembrane:a otentially fatal Comlication of tracheal intubation.am J ResirCrit Care Med2000;162: Fan CM, Ko PC, Tsai K, Chiang W, Chang Y, Chen W, Yuan A.Tracheal ruture comlicating emergency endotracheal intubation. Am J Emerg Med 2004;22: Harris R,JosehA.Acute tracheal ruture related to endotracheal Intubation: case reort. J Emerg Med 2000;18: Hofmann HS, Rettig G, Radke J, Neef H, Silber RE. Iatrogenic ruture Of the tracheobronchial tree.eur J Cardiothorac Surg2002;21: Suzuki N, Kooguchi K, MizobeT, Hirose M, TakanoY. Postoerative hoarseness and sore throat after tracheal intubation: effect of a low intracuff ressure of Endotracheal tube and the usefulness of cuff ressure indicator[in Jaanese]. Masui.1999;48 (10): Liu J,ZhangX, GongW,LiS, WangF, et al.(2010)correlations between Controlled endotracheal tube cuff ressure and ost rocedural Comlications: a multicentre study. Anesth Analg 111: Jerry A. Dorsch and Susan E.Dorsch, Understanding Anaesthesia equiment, 5th edition, NewDelhi, Wolters Kluwer, Fernandez R, Blanch L, Mancebo J, Bonsoms N, Artigas A. Endotrachealtube Cuff ressure assessment: itfalls of finger estimation and need for objective Measurement. Crit care Med 1990;18: Ganner C. The accurate measurement of endotracheal tube cuff ressures.br J Nurs 2001;10: Nseir S, Brisson H, Marquette CH, Chaud P, Di Pomeo C, Diarra M, Durocher A. Variations in endotracheal cuff ressure in intubated critically ill atients: Prevalence and risk factors.eur J Anaesthesiol 2009;26: Winkel E, Knudsen J. Effects on the incidence of ostoerative sore throat Of 1 ercent cinchocaine jelly for endotracheal intubation. Anesthesia and Analgesia 1971;50: Granja C,Faraldo S, Laguna P, Gois L. Control of the endotracheal cuff balloon Pressure as a method of reventing laryngotracheal lesions in critically ill Intubated atients. Rev Es Anestesiol Reanim 2002;49: Sruthi.A et al JMSCR Volume 05 Issue 07 July 2017 Page 24958

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