Emergence cough mitigation in endonasal surgery: The multimodal approach

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Created On: 10/05/2024

The aim of this randomized double-blind trial was to determine the safety and effectiveness of a multimodal intervention in alleviating emergence cough in those undergoing nasal surgery.

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Key take away

In adult endonasal surgery patients, a multimodal intervention involving Ropivacaine, Dexmedetomidine, and Remifentanil markedly decreases emergence cough without delaying anesthesia recovery or raising adverse events.

Background

The aim of this randomized double-blind trial was to determine the safety and effectiveness of a multimodal intervention in alleviating emergence cough in those undergoing nasal surgery.

Method

Overall, 150 adults (aged 18 to 65 years) scheduled for nasal endoscopic surgery were segregated into three groups. The control group (n = 50) was given standard anesthesia without any additional intervention. The double intervention group (n = 50) was given endotracheal spraying of 3 mL normal saline prior to intubation. This was followed by a 10-minute infusion of Dexmedetomidine at 0.4 μg/kg post-intubation.

At an effect-site concentration of 1.5 ng/mL, maintenance of the target-monitored Remifentanil infusion was done prior to extubation. The multimodal intervention arm (n = 50) was given 3 mL of 0.5% Ropivacaine endotracheally prior to intubation, along with Dexmedetomidine and Remifentanil administration as in the double intervention arm. The occurrence of emergence cough, defined as a single cough or more from the end of surgery to five minutes post-extubation was the key outcome ascertained.

Result

The multimodal intervention group exhibited a remarkably lower incidence of emergence cough in comparison with both the double intervention (relative risk 0.78; 95% CI 0.63 to 0.95; p = 0.012) and control (relative risk 0.71; 95% CI 0.59 to 0.86; p < 0.001) groups, as shown in Table 1:

However, the difference in incidence between the double intervention and control arms was not profound (relative risk 0.92; 95% CI 0.83 to 1.02; p = 0.20). Furthermore, the intensity of sore throat was substantially reduced in the multimodal intervention arm when compared to the control arm (median difference -1; 95% CI −2 to 0; p = 0.016). No notable differences were witnessed in adverse events among the study groups.

Conclusion

In adult patients undergoing endonasal surgery, a multimodal intervention comprising Ropivacaine topical anesthesia prior to intubation, Dexmedetomidine use post-intubation, and Remifentanil infusion pre-extubation considerably decreased emergence cough incidence and proved to be safe.