Comparative Efficacy of 6 Topical Pharmacological Agents for Preventive Interventions of Postoperative Sore Throat After Tracheal Intubation: A Systematic Review and Network Meta-analysis

Abstract

BACKGROUND: Topical pharmacological agents typically used to treat postoperative sore throat (POST) after tracheal intubation include nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, lidocaine, Glycyrrhiza (licorice), and N-methyl-d-aspartate (NMDA) receptor antagonists (including ketamine and magnesium). However, the optimal prophylactic drug remains elusive. METHODS: The literature published before September 8, 2019 was searched on the PubMed, the Embase, the Web of Science, and the Cochrane Library. Randomized controlled trials (RCTs) covering topical prophylactic medications for patients with POST were included. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assess the quality of evidence. The primary outcome is the risk of POST. Combining both direct and indirect evidence, a network meta-analysis was performed to assess odds ratios (ORs) between the topical pharmacological agents and surface under the cumulative ranking (SUCRA) curve for the treatment-based outcomes. This study is registered with PROSPERO, number CRD42020158985. RESULTS: Sixty-two RCTs (at least 73% of which were double blinded) that included a total of 6708 subjects and compared 6 categories of drugs and/or placebos were ultimately enrolled. All preventive interventions except lidocaine were more effective than placebo at the 4 time intervals. Lidocaine (OR: 0.35, 95% credible interval [CrI], 0.16-0.79) has a greater POST preventative intervention effect than the placebo at a time interval of only 2 to 3 hours after surgery. Relative to lidocaine, the risk of POST except 2 to 3 hours was lower for the following treatments: corticosteroids, ketamine, magnesium, NSAIDs, and Glycyrrhiza. The NMDA receptor antagonists studied here included ketamine and magnesium. Magnesium generally demonstrated greater benefit than ketamine at 24 hours postsurgery/extubation (OR: 0.41, 95% CrI, 0.18-0.92). Compared with ketamine, corticosteroids were associated with a reduced risk of POST during the 4 to 6 hours (OR: 0.40, 95% CrI, 0.19-0.83) and 24 hours (OR: 0.34, 95% CrI, 0.16-0.72) time intervals. During the 2 to 3 hours time interval, Glycyrrhiza (OR: 0.38, 95% CrI, 0.15-0.97) was more efficacious than magnesium. CONCLUSIONS: Our analysis shows that, among the 6 topical medications studied, lidocaine is not optimal for topical use to prevent POST. Glycyrrhizin, corticosteroids, NSAIDs, and NMDA receptor antagonists (ketamine and magnesium) are associated with a reduced postoperative pharyngeal pain across the 4 postsurgical time intervals studied, all of which can be chosen according to the clinical experience of the anesthesiologists and the patient preferences and are recommended for the reduction of postoperative throat pain.

Postoperative Sore Throat

“…Lidocaine spray has proved NOT to decrease the intensity or presence of POST and can even be linked to worse outcomes [13]. The lidocaine's vehicle creates a film over the mucosa and prevents normal secretion.…”

“…Magnesium has been shown to be more effective than ketamine to reduce the incidence and severity of POST [13,17] but has little clinical use due to the difficulty for preoperative nebulization as well as the added costs in both public and private settings since the equipment for nebulization is not generally necessary in a healthy patient undergoing surgery.…”

The role of local inflammation in complications associated with intubation in pediatric patients: A narrative review

“…There are also many other ETT coatings that can be used to possibly decrease inflammation related symptoms such as sore throat or tracheitis. A systematic review done by Wang et al found that glycyrrhizin, corticosteroids, nonsteroidal anti‐inflammatory drugs (NSAIDs), and N ‐methyl‐d‐aspartate (NMDA) receptor antagonists (ketamine and magnesium) were associated with reduced postoperative pharyngeal pain 48 …”

“…A systematic review done by Wang et al found that glycyrrhizin, corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and N-methyl-d-aspartate (NMDA) receptor antagonists (ketamine and magnesium) were associated with reduced postoperative pharyngeal pain. 48 In a comparative study, it was established that the benzydamine hydrochloride gel on the ETT cuff is a simple and effective method that can significantly decrease the severity of postoperative sore throat compared with 10% lidocaine, 5% lidocaine, and normal saline. 49 However, in a subsequent study done by Yhim et al, it was concluded that application of prophylactic benzydamine hydrochloride spray to the vocal cords and upper trachea did not show a reduction in postoperative sore throat in the pediatric population.…”

Identifying the Risk Factors for Postoperative Sore Throat After Endotracheal Intubation for Oral and Maxillofacial Surgery

“…Postoperative sore throat (POST) is a common consequence of general anesthesia after endotracheal intubation with an incidence varying from 15% to 64%. 7 , 8 The symptoms of POST include pain and discomfort, cough, hoarseness, and laryngitis, which may be the result of inflammation caused by mucosal damage during airway fixation. 9 , 10 Its etiology is believed to involve mucosal dehydration, trauma from tracheal intubation, and mucosal erosion caused by tracheal tube cuff pressure.…”