Intensive and Critical Care Nursing (2014) 30, 318—324
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ORIGINAL ARTICLE
Sore throat in women after intubation with 6.5 or 7.0 mm endotracheal tube: A quantitative study Linda Gustavsson a, Irene Vikman b, Cecilia Nyström c, Åsa Engström d,∗ a
Department of Anaesthesia, Central Operation Ward, Sunderby Hospital, Luleå, Sweden Division of Health and Rehabilitation, Department of Health Science, Luleå University of Technology, Luleå, Sweden c Intensive Care Unit 57, Sunderby Hospital, Luleå, Sweden d Division of Nursing, Department of Health Science, Luleå University of Technology, Luleå, Sweden b
Accepted 9 July 2014
KEYWORDS Endotracheal intubation; Nursing; Quantitative; Sore throat; Women; Postanaesthesia care unit
Summary Background: Women experience more sore throats than men after endotracheal intubation. Aim: The aim of this study was to investigate the incidence of self-rated sore throat immediately, and 2—4 hours postoperatively, in women after elective gynaecological surgery under general anaesthesia using an endotracheal tube (ETT) size 6.5 or 7.0 mm in inner diameter. Method: Eighty-two female participants who had undergone elective gynaecological surgery participated, 44 and 38 were intubated with size 6.5 mm ETT and 7.0 mm ETT respectively. They estimated the occurrence of sore throat preoperatively and postoperatively, according to a 4-point Likert scale. Statistical data were analysed using the Package for Social Science (SPSS) 19. Results: Sore throat was present in 29.5% of participants who were intubated with size 6.5 mm ETT immediately postoperatively and in 39.5% of those who were intubated with size 7.0 mm ETT. Conclusion: Nurses specialising in the supervision of daily care specific to the intubated patient should note and alleviate sore throat as part of their nursing care. © 2014 Elsevier Ltd. All rights reserved.
∗ Corresponding author at: Department of Health Science, Luleå University of Technology, SE-971 87 Luleå, Sweden. Tel.: +46 920 49 38 75; fax: +46 920 49 38 50. E-mail address: [email protected] (Å. Engström).
http://dx.doi.org/10.1016/j.iccn.2014.07.003 0964-3397/© 2014 Elsevier Ltd. All rights reserved.
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Implications for Clinical Practice • Women who were intubated with a size 6.5 mm endotracheal tube (ETT) estimated they had fewer and milder symptoms of sore throat postoperatively. • Nurses specialising in anaesthesia and intensive care should note and alleviate sore throat after ETT intubation as part of their nursing care. • Sore throat after ETT intubation should be acknowledged and documented in the patient’s record.
Introduction Waking up with an endotracheal tube (ETT) in the throat is a choking and stressful experience for the patient; expressed as feelings of being unable to breathe or communicate properly (Grap et al., 2002). In addition to this psychological complication, sore throat is commonly reported (Jaensson et al., 2010) as a contributory factor to unpleasant feelings and dissatisfaction (Johnson and Sexton, 1990). Therefore, reducing and minimising a sore throat is an important intervention. Sore throat has been studied extensively over the last few decades and the incidence is reported to vary between 21 and 74 percent (%) (Al-Qahtani and Messahel, 2005; Bunker Fuller, 1992; Hamdan et al., 2007; Jaensson et al., 2010; Porter et al., 1999). This considerable variation is possibly due to differences in measurements used, as well as the types of surgery and populations studied. The incidence is reported as higher among females (Ahmed et al., 2007; Biro et al., 2005; Chen et al., 2004; Higgins et al., 2002; Jaensson et al., 2010; McHardy and Chung, 1999; Myles et al., 1997; Stoelting and Miller, 1994; Stout et al., 1987), which may be because because women have a thinner mucosa covering their vocal cords. In endotracheal intubation, the tube is placed below the vocal cords and may cause irritation of the mucosa (Stoelting and Miller, 1994). More extensive surgery related to the throat, such as thyroid surgery, is also a contributory factor to increased incidence of sore throat (Kadri et al., 2009). If sore throat is present, it occurs immediately after extubation, and then subsides over 24—72 hours postoperatively (Biro et al., 2005; Hamdan et al., 2007; Jaensson et al., 2010; Stoelting and Miller, 1994). Risk factors mentioned as associated with sore throat are, amongst others, the use of muscle relaxants, the design of the laryngoscope blade, the humidity of inhaled gases (Bunker Fuller, 1992) and, the size of the endotracheal cuff. The size of the ETT has also been shown to impact on the incidence rate of sore throat in females. In a recently published review, ETTs with a small inner diameter were significantly associated with a reduction in the incidence of sore throat in the post-anaesthesia care unit and 24 hours after surgery (Hu et al., 2013). Moreover, ETTs with a smaller inner diameter have been shown to reduce the risk of airway trauma and to ease extubation (Koh et al., 1998), but there is a lack of studies describing the incidence of sore throat among women using ETTs with the size 6.5 respectively 7.0 mm. Therefore, the aim of this study was to investigate the incidence of self-rated sore throat immediately and 2—4 hours postoperatively among women after elective gynaecological surgery under general anaesthesia using an ETT with size 6.5 or 7.0 mm inner diameter.
Method Setting and participants Participants in this non-randomised study were recruited from April 2011 through January 2012 from the surgical ICU at a county hospital located in the northern part of Sweden. One hundred women undergoing elective gynaecological surgery were consecutively enrolled in the study (Fig. 1). Inclusion criteria were: • • • •
Female, aged more than or equal to 18 years. Undergoing elective gynaecological surgery. No sore throat. American Society of Anesthesiologists’ physiological status classification (ASA) I—II (ASA I = healthy, ASA II = mild systemic disease, no functional limitation, Wolters et al., 1996). The exclusion criteria were:
• • • •
Not undergoing elective gynaecological surgery. Female under 18 years old. Male. ASA’s physiological status classification of more than II, and has functional limitation (Wolters et al., 1996). • Surgery involving the cervical region. • More than two intubation attempts. • Rapid Sequence Induction (RSI).
During the data collection period the participants were intubated with size 6.5 mm ETTs or 7.0 mm ETTs depending on which day their surgery took place, i.e. all patients fulfilling the inclusion criteria undergoing surgery on Mondays for instance were intubated with size 6.5 mm ETTs and all patients on Thursdays were intubated with size 7.0 mm ETTs. All participants were given similar general anaesthesia, administrated by experienced anaesthetists and anaesthesia nurses, following standard procedure used in the hospital. Pre-intubation pain relief was generally administered in the form of fentanyl. However, for two patients, this was replaced by remifentanil. Propofol was used to induce sleep. However, three participants were allergic to the drug, and were injected with thiopenthal intravenously instead. Before intubation, all participants received muscle relaxants. Most participants were given rocurium bromide, but some participants received succinylcholine (suxamethonium) or mivakuriumchloride. The ETT cuff was filled with air after intubation and the cuff pressure was measured.
320
L. Gustavsson et al.
100 females
Excluded before anesthesia; because of sore throat n= 7
Size 6.5 mm ETT
Size 7.0 mm ETT
n=48
n= 45
Excluded postoperatively; lack of data concerning sore throat
Excluded postoperatively; lack of data concerning sore throat
n= 4
n= 7 Size 6.5 mm ETT
Size 7.0 mm ETT
n= 44
n= 38
Figure 1
Distribution of participants through the study.
Most of the ETTs, 96% of size 6.5 mm ETT and 100% size 7.0 mm ETT, were lubricated with Xylocaine gel before insertion into the trachea. Anaesthesia was maintained with a mixture of Sevoflurane, oxygen and air. Electrocardiography (ECG), noninvasive blood pressure, pulse oximetry (SPO2 ) and end-tidal carbon dioxide (EtCO2 ) were continuously monitored. The participants were ventilated and EtCO2 values were between 4.5 and 6.5 kPa (Edmark et al., 2003).
Data collection We gained access to participants after contacting and informing the two heads of an operating theatre ward in the northern part of Sweden about the aim of the study. They gave their written permission for the study to be performed. The data were collected by registered anaesthesia nurses. To measure the sore throat problems, participants were asked to rate the intensity of their throat pain using a single question with a four-point rating scale with 0, no sore throat; 1, mild sore throat (less severe than a cold); 2,
moderate sore throat (similar to that noted with a cold) and 3, severe sore throat (more severe than with a cold) (Stout et al., 1987). The question was asked immediately and 2—4 hours postoperatively in the postanaesthesia care unit (PACU). The single question has been used in previous studies (e.g. Hisham et al., 2001; Jaensson et al., 2010; Stout et al., 1987). Data including age; weight; height; smoking habits; type of surgery; anaesthesia duration; endotracheal tube size; number of intubation attempts; cuff pressure; airway pressure; minute ventilation; EtCO2 , respiration rate; anaesthetic drugs; and insertion of nasogastric tube were collected from the participants’ medical records (Table 1).
Ethical consideration Participants were informed verbally by an anaesthesia nurse about the study before premedication, and those who agreed to participate gave their permission verbally which they then signed in the study protocol with the help of the anaesthesia nurse, following the Nuremberg Code and
Sore throat in women: A quantitative study
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Age in years, m (SD) Height in cm, m (SD) Weight in kg, m (SD) BMI, m (SD) Smoker, n (%) Cuff pressure in cm H2 O, m (SD) Airway pressure in cm H2 O, m (SD) Minute volume, m (SD) EtCO2 in kPa, m (SD) Duration of intubation minutes, m (SD) Xylocaine gel on tube, n (%) One intubation attempt, n (%) Two intubation attempts, n (%) Stomach tube inserted, n (%)
Size 6.5 ETT n = 44 49.8 (15.5) 162.4 (6.4)
Size 7.0 ETT n = 38 46.1 (14.0) 164.3 (5.2)
66.0 (11.7)
71.8 (14.2)
25.3 (4.2) 7 (16.7) 25.0 (4.3)
26.4(4.6) 4 (10.5) 25.1 (5.0)
16.3 (3.5)
15.2 (3.5)
Immediately postoperavely n=31
70
n=23
60 50 ETT 6,5
40 30
n=10
n=3 n=3
10 0
4.4 (0.3)
5.7 (0.7) 4.5 (0.3)
No pain
Mild pain
102.1 (33.3)
43 (97.7)
38 (100.0)
36 (81.8)
26 (68.4)
8 (18.2)
12 (31.6)
20 (45.5)
18 (47.4)
Helsinki Declaration. Assurances were given that all data would remain confidential, that participation was voluntary and that participants had the right to withdraw at any time without prejudice. Approval for the study was obtained from the Ethics Committee, Luleå University of Technology.
Data analysis The statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) version 19. Data were analysed descriptively and presented as frequencies, mean and standard deviations. To analyse the differences between groups, for non-parametric variables (self-rated sore throat, smoker, Xylocain gel on tube, one/two intubation attempts, stomach tube inserted), the Chi-square and Mann—Whitney U tests were used. For parametric variables (age, height, weight, BMI, cuff pressure, airway pressure, minute volym) the independent Students’ t-test was used (Polit and Beck, 2012). The significance level was set at p < 0.05 (5%).
Result The results showed no differences between the groups with respect to participants’ characteristics, except for weight which was higher (p < 0.05) in the size 7.0 mm ETT group (Table 1). Of the variables related to the anaesthesia, there
Moderate pain Severe pain
Figure 2 Relative frequencies of self-rated sore throat immediately postoperatively. 80
2 to 4 hours postoperavely n=32 n=24
60 50 40 n=12n=11
30
ETT 6,5 ETT 7,0
20 n=3
10
106.0 (41.6)
n=2 0
70
5.3 (0.8)
ETT 7,0
n=10
20
Precent of parcipants
Background data
80 Precent of parcipants
Table 1 Participant characteristics and measurements during anaesthesia in the two groups.
0
0
No pain
0
0
Mild pain Moderate Severe pain pain
Figure 3 Relative frequencies of self-rated sore throat 2—4 hours postoperatively.
was a significant difference (p < 0.05) between the groups only concerning minute volume (Table 1). The overall incidence of sore throat postoperatively was 34%. In the group intubated with size 6.5 mm ETT, 29.5% rated some degree of sore throat compared to 39.5% in the group with size 7.0 mm ETT. The difference between the groups was not statistically significant (p = 0.286) (Table 2). The corresponding figures for sore throat 2—4 hours postoperatively were 27% for the ETT 6.5 mm and 37% for the ETT 7.0 mm respectively. The distributions of sore throat from no pain, mild, moderate, to severe pain, immediately and 2—4 hours postoperatively are presented in Figs. 1 and 2. A summary of the participants’ self-rated sore throat shows that 29.5% of the participants who were intubated with size 6.5 mm ETT reported a sore throat (mild, moderate or severe) immediately postoperatively. For the group of participants who were intubated with size 7.0 mm ETT the figure was 39.5%. Of those who were intubated with size 6.5 mm ETT, 27. 3% still had a sore throat 2—4 hours postoperatively. For the size 7.0 mm ETT group this figure was 36.8% (Table 2). Figs. 2 and 3 describe the distribution of participants regarding the 4-point scale for sore throat. The results of this study showed no statistically significant difference between the tube size and self-rated sore throat. This may be because the study had too few participants; a larger sample might change the results. As the difference in diameter between size 6.5 mm and size 7.0 mm ETT is so small it may be more difficult to achieve statistical significance than if the difference in the tubes is greater. Descriptive statistics reveal a trend for participants who were intubated using size 6.5 mm ETT to have fewer and less severe symptoms of sore throat postoperatively. To measure sore throat, a single question with a 4-point rating scale
322 Table 2
L. Gustavsson et al. Self-rated sore throat immediately and 2—4 hours postoperatively.
Sore throat
No pain, n (%) Mild pain, n (%) Moderate pain, n (%) Severe pain, n (%)
Sore throat postop
Sore throat postop
Size 6.5 ETT n = 44 31 (70.5) 10 (22.7) 3 (6.8) 0 (0.0)
Size 7.0 ETT n = 38
Sore throat 2—4 hours postop Size 6.5 ETT n = 44
Sore throat 2—4 hours postop Size 7.0 ETT n = 38
23 (60.5) 10 (26.3) 3 (7.9) 2 (5.3)
32 (72.7) 12 (27.3) 0 (0.0) 0 (0.0)
24 (63.2) 11 (28.9) 3 (7.9) 0 (0.0)
was used. A method used in several studies (Hisham et al., 2001; Jaensson et al., 2010; Stout et al., 1987). As the scale is established, it is possible to compare this study’s results with those of other studies; it is replicable, but it is not reliability tested; therefore inter-rater reliability could not be determined. Seven per cent of participants were excluded because of sore throat before anaesthesia. Four participants in the group size 6.5 mm ETT and seven in group size 7.0 mm ETT respectively were excluded postoperatively because of lack of data concerning sore throat. The loss was almost twice as large in the latter group. As participants intubated with size 7.0 mm ETT rated their pain as more severe on the scale, perhaps a smaller loss in this group would have contributed to a greater difference between the groups and, thus, changed the results of the study. All the participants in this study underwent gynaecological surgery and belonged to ASA I to II, thus, forming a homogeneous group, which can be seen as a strength. This is in contrast with other studies (Al-Qahtani and Messahel, 2005; Canbay et al., 2008; Jaensson et al., 2010; Mandøe et al., 1992) where participants underwent a variety of surgical procedures, including ear, nose and throat surgery and gynaecological surgery. This variation complicates the assessment of whether sore throat is due to pain after surgery or the ETT. In some of the studies (Al-Qahtani and Messahel, 2005; Canbay et al., 2008), participants had surgery in the cervical region to prevent blood and secretions from flowing into the ventricle, and had been given a nose or throat pack. These studies are likely to be less reliable due to uncertainty about whether the sore throats were caused by the throat pack, rather than the size of the ETT.
Discussion The results showed an increased incidence of sore throat with increased size of ETTs, but the differences between the two groups were not statistically significant. Immediately postoperatively 29.5% of the participants intubated with size 6.5 mm ETT and in 39.5% of those who were intubated with size 7.0 mm ETT rated sore throat to some degree. Stout et al. (1987) found an incidence of sore throat in 22% of women who were intubated with size 6.5 mm, and the incidence increased to 53% among those intubated with size 8.5 mm ETT. Jaensson et al. (2010) found among women intubated with size 6.0 mm ETT a 27.1% incidence which is in line with our figure, 29, 5% for women intubated with size
p-Value
0.286
p-Value
0.262
6.5 mm ETT. However, when comparing endotracheal tubes with a larger inner diameter, Jaensson et al. (2010) found an incidence of 51.1% in women intubated with size 7.0 mm ETT compared to 39.5% in the present study. One explanation for this difference could be that in our study 97.7% of those intubated with size 6.5 mm ETT and 100% of those intubated with size 7.0 mm ETT had local anaesthetic gel (lidocaine) applied to their ETTs compared with 0% of the patients in the study by Jaensson et al. (2010). Older and other contemporary researches, however, showed that the uses of lidocaine gel has no or even the opposite effect in reducing sore throat (Basaranoglu et al., 2004; McHardy and Chung, 1999; Maruyama et al., 2004; Soltani and Aghadavoudi, 2002). Sumathi et al. (2008) found that the incidence of sore throat, cough, and hoarseness of voice was significantly less when bethamesasone was widely applied over the ETT compared to lidocaine gel or nothing applied. Lidocaine gel reduced the incidence of sore throat significantly compared with no application to the ETT (Sumathi et al., 2008). Xu et al. (2012) demonstrated that the use of ETTs of smaller diameter combined with intravenous lidocaine reduces the incidence and severity of postoperative sore throat in women undergoing thyroid surgery. According to Tanaka et al. (2013), it is common clinical practice to use lidocaine for the prevention of postoperative sore throat, and they confirmed the effectiveness of topical and systematic lidocaine for the prevention of postoperative sore throat in their systematic review. The effectiveness of lidocaine would appear to be influenced by its concentration, route of administration and the outcomes measured (Tanaka et al., 2013). The results of this study, like those in the past (Hamdan et al., 2007; Jaensson et al., 2010; Stoelting and Miller, 1994) showed a reduction in the incidence of sore throat over time. More participants felt the sore throat immediately postoperatively than after a few hours or up to one day later. In previous studies, the incidence of postoperative sore throat varied between 21 and 74% of the total sample (Bennett et al., 2000; Canbay et al., 2008; Christensen et al., 1994; Ebneshahidi and Mohseni, 2010; Higgins et al., 2002; Loeser et al., 1980; Maruyama et al., 2004; Park et al., 2008). Most previous studies (Ebneshahidi and Mohseni, 2010; Liu et al., 2010; Loeser et al., 1980; Mandøe et al., 1992) noted that the female participants were intubated using ETT sizes from 7.0 to 8.0. Jaensson et al. (2012a) found that of 292 women intubated tracheally with size 6.0 mm ETT (n = 263) or 7.0 mm ETT (n = 29), 169 (64%) intubated with size 6.0 mm had no postoperative sore
Sore throat in women: A quantitative study throat compared to 14 (48%) who were intubated with size 7.0 mm ETT. They also showed that the main factors in developing sore throat in women were the use of size 7.0 mm ETT instead of size 6.0 mm ETT, and multiple laryngoscopies during intubation. Mitchell and Jones (2005) stated that the advantages of small ETTs outweigh the disadvantages for anaesthesia in adults. Comparison of the occurrence of sore throat among the two groups in the current study shows the following: of the participants intubated with size 6.5 mm ETT 70.5% had no sore throat immediately postoperatively. In the group intubated with size 7.0 mm ETT, 60.5% had no pain; participants intubated with a narrower diameter ETT less pain; 2—4 hours postoperatively compared to those who were intubated with a larger diameter ETT. Similarly, Jaensson et al. (2012b) found three variables that were significant risk factors for postoperative sore throat: age greater than 60 years (p = 0.01), the use of a throat pack (p = 0.04) and size 7.0 mm ETT (size 7 mm; p = 0.02) compared with size 6.0 mm ETT. According to Jaensson et al. (2012a), age above 40 years increases the incidence of postoperative sore throat in women (p = 0.028). The results showed that the mean of the measured airway pressure was 16.3 and 15.2 cm H2 O for size 6.5 mm and size 7.0 mm ETTs respectively. This minimal difference is consistent with Stenqvist et al. (1979) results. A conscious decision was taken to exclude nitrous oxide as this gas expands in air-filled cavities (Combes et al., 2001). The results showed that the average cuff pressure was 25.0 and 25.1 cm H2 O for size 6.5 mm and size 7.0 mm ETTs respectively. According to Liu et al. (2010), the purpose of inflating the endotracheal cuff is to prevent air leakage; thereby ensuring the ventilation effect and reducing the risk of leakage of anaesthetic drugs. Very high pressure in the cuff increases the risk of severe and even fatal injuries when blood flow to the mucosa of the trachea is reduced and may even cause ischaemic damage (Stewart et al., 2003). High cuff pressure and postoperative sore throat are directly linked. Liu et al. (2010) showed further that ETT cuff pressure estimated by palpation only is often much higher than when measured or than what may be optimal; proper control using a manometer helps to reduce ETT-related postprocedural respiratory complications such as sore throat even in procedures of such short duration as 1—3 hours. The importance of closely monitoring the ETT cuff pressure is supported by Sengupta et al. (2004). Of the participants in this study who were intubated with a size 6.5 mm ETT, 81.8% required only one intubation attempt compared with 68.4% of those intubated with size 7.0 mm ETT. This is consistent with the results of Koh et al. (1998) showing that using a smaller ETT reduces the number of intubation attempts. Studies have proposed other treatments to further improve patient care and reduce the symptoms of sore throat postoperatively. Tazeh-Kand et al. (2010) showed that participants who inhaled steroid drugs preoperatively experienced significantly less discomfort from sore throats. The benefit of inhaled steroids is that the medication is delivered in smaller doses and for a shorter time. Liu et al. (2010) studied the effect of Benzydamine Hydrocloride, a non-steroidal drug (Zyx® ) available over the counter (OTC) in Sweden. If given preoperatively, according to Liu et al. (2010), before endotracheal intubation, it can reduce mild to moderate sore throat postoperatively. Ebneshahidi and
323 Mohseni (2010) showed that the use of Strepsilis® preoperatively reduces sore throat postoperatively. They evaluated the experience of sore throat immediately postoperatively and 24 hours after the procedure. The pain was rated on a 4-point scale (0—3), like the one used in this study, but in our study the participants did not receive steroids or Strepsils.
Conclusion Women who were intubated with size 6.5 mm ETT rated less severe sore throat, compared to those intubated with size 7.0 mm ETT. Nevertheless, the results were not statistically significant. Application of lidocaine gel on the ETT may have a reducing effect on sore throat, especially among participants who were intubated with a size 7.0 mm ETT. It is important that the cuff pressure and the mucosa are closely monitored to help reduce the risk of the risk of postoperative sore throat. Nurses specialising in the supervision of daily care specific to the intubated patients should look for and alleviate sore throat as part of their nursing care. Further research in this area is needed, as a sore throat after ETT intubation is a common problem. One suggestion is to perform a study similar to this one but with more participants and to also ask about hoarseness. It would also be of interest to study how the age of participants influences the experience of sore throat and what further interventions can be implemented to decrease the experience of sore throat after oral intubation.
Acknowledgements We would like to thank the patients who participated and the nurses who completed the questionnaires. Thanks to Pat Shrimton for revising the English language. The research was funded by grants from the County Council of Norrbotten, Sweden.
References Ahmed A, Abbasi S, Ghafoor AH, Ishaq M. Postoperative sore throat after elective surgical procedures. J Ayub Med Coll Abbottabad 2007;19:12—4. Al-Qahtani AS, Messahel FM. Quality improvement in anesthetic practice — incident of sore throat after using small tracheal tube. Middle East J Anesthesiol 2005;18:179—83. Basaranoglu G, Erden V, Delatioglu H. Postoperative sore throat: effect of lidocaine jelly and pomade on endotracheal intubation. J Clin Anesth 2004;16:79—80. Bennett MH, Isert PR, Cumming RG. Postoperative sore throat and hoarseness following tracheal intubation using air or saline to inflate the cuff — a randomized controlled trial. Anaesth Intensive Care 2000;28:408—13. Biro P, Seifert B, Pasch T. Complaints of sore throat after tracheal intubation: a prospective evaluation. Eur J Anaesthesiol 2005;22:307—11. Bunker Fuller P. The relationship between preintubation lidocaine and postanesthesia sore throat. J Am Assoc Nurse Anesth 1992;60:374—8. Canbay O, Celebi N, Sahin A, Celiker V, Ozgen S, Aypar U. Ketamine gargle for attenuating postoperative sore throat. Br J Anaest 2008;100:490—3.
324 Chen KT, Tzeng JL, Liu KS, Hsu CS, Wang JJ. Risk factors associated with sore throat after tracheal intubation: an evaluation in the postanesthetic recovery room. Acta Anaesthesiol Taiwan 2004;42:3—8. Christensen AM, Willemoes-Larsen H, Lundby L, Jakobsen KB. Postoperative throat complaints after tracheal intubation. Br J Anaesth 1994;73:786—7. Combes X, Schauvliege F, Peyrouset O, Motamed C, Kirov K, Dhonneur G, Duvaldestin P. Intracuff pressure and tracheal morbidity: influence of filling cuff with saline during nitrous oxide anesthesia. Aneshesiology 2001;95:1120—4. Ebneshahidi A, Mohseni M. Strepsils® tablets reduce sore throat and hoarseness after tracheal intubation. Anesth Analg 2010;111:892—4. Edmark L, Kostova-Aherdan K, Enlund M, Hedenstierna G. Optimal oxygen concentration during induction of general anesthesia. Anesthesiology 2003;98:28—33. Grap MJ, Blecha T, Munro C. A description of patients’ report of endotracheal tube discomfort. Intensive Crit Care Nurs 2002;18:244—9. Hamdan A-L, Sibai A, Rameh C, Kanazeh G. Short-term effects of endotracheal intubation on voice. J Voice 2007;21:762—8. Higgins PP, Chung F, Mezei G. Postoperative sore throat after ambulatory surgery. Br J Anaesth 2002;88:582—4. Hisham AN, Roshilla H, Amri N, Aina EN. Post-thyroidectomy sore throat following endotracheal intubation. ANZ J Surg 2001;71:669—71. Hu B, Bao R, Wang X, Liu S, Tao T, Xie Q, et al. The size of endotracheal tube and sore throat after surgery: a systematic review and meta-analysis. PLOS ONE 2013;8:e74467, http://dx.doi.org/10.1371/journal.pone.0074467. Jaensson M, Olowsson LL, Nilsson U. Endotracheal tube size and sore throat following surgery: a randomized controlled study. Acta Anaesthesiol Scand 2010;54:147—53. Jaensson M, Gupta A, Nilsson U. Gender differences in risk factors for airway symptoms following tracheal intubation. Acta Anaesthesiol Scand 2012a;56:1306—13. Jaensson M, Gupta A, Nilsson U. Risk factors for development of postoperative sore throat and hoarseness after endotracheal intubation in women: a secondary analysis. AANA J 2012b;80:67—72. Johnson MM, Sexton DL. Distress during mechanical ventilation: patients’ perceptions. Crit Care Nurse 1990;10: 48—57. Kadri IA, Khanzada TW, Samad A, Memon W. Post-thyroidectomy sore throat: a common problem. Pak J Med Sci 2009;25: 408—12. Koh KF, Hare JD, Calder I. Small tube revisited. Anaesthesia 1998;53:46—50. Liu J, Zhang X, Gong W, Li S, Wang F, Fu S, et al. Correlations between controlled endotracheal tube cuff pressure and postprocedural complications: a multicenter study. Anesth Analg 2010;111:1133—7. Loeser EA, Bennett GM, Orr DL, Stanley TH. Reduction of postoperative sore throat with new endotracheal tube cuffs. Anesthesiology 1980;52:257—9. Mandøe H, Nikolajsen L, Lintrup U, Jepsen D, Mølgaard J. Sore throat after endotracheal intubation. Anesth Analg 1992;74:897—900.
L. Gustavsson et al. Maruyama K, Sakai H, Miyazawa H, Toda N, Iinuma Y, Mochizuki N, et al. Sore throat and hoarseness after total intravenous anaesthesia. Br J Anaesth 2004;92:541—3. McHardy FE, Chung F. Postoperative sore throat: cause, prevention and treatment. Anaesthesia 1999;54:444—53. Mitchell V, Jones H. Gas, tubes and flow. Anaesth Intensive Care Med 2005;6:240—2. Myles PS, Hunt JO, Moloney JT. Postoperative minor complications. Comparison between men and women. Anaesthesia 1997;52:300—6. Park S-H, Han S-H, Do S-H, Kim J-W, Rhee K-Y, Kim JH. Prophylactic dexamethasone decreases the incidence of sore throat and hoarseness after tracheal extubation with a double-lumen endobronchial tube. Anesth Analg 2008;107: 1814—8. Polit DF, Beck CT. Nursing research: principles and methods. Philadelphia: Lippincott Williams & Wilkins; 2012. Porter NE, Sidou V, Husson J. Postoperative sore throat: incidence and severity after the use of lidocaine, saline or air to inflate the endotracheal tube cuff. J Am Assoc Nurse Anesth 1999;67:49—52. Sengupta P, Sessler D, Maglinger P, Wells S, Vogt A, Durrani J, et al. Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure. BMC Anesthesiol 2004;4:1—6. Soltani HA, Aghadavoudi O. The effect of different lidocaine application methods on postoperative cough and sore throat. J Clin Anesth 2002;14:15—8. Stenqvist O, Sonander H, Nilsson K. Small endotracheal tubes: ventilator and intratracheal pressures during controlled ventilation. Br J Anasth 1979;51:375—81. Stewart SL, Seacrest JA, Norwood BR, Zachary R. A comparison of endotracheal tube cuff pressures using estimation techniques and direct intracuff measurement. AANA J 2003;71: 443—7. Stoelting RK, Miller RD. Basics of anesthesia. New York: Churchill Livingstone; 1994. Stout DM, Bishop MJ, Dwersteg JF, Cullen BF. Correlation of endotracheal tube size with sore throat and hoarseness following general anesthesia. Anesthesiology 1987;67:419—21. Sumathi PA, Shenoy T, Ambareesha M, Krishna HM. Controlled comparison between betamethasone gel and lidocain jelly applied over tracheal tube to reduce postoperative sore throat, cough, and hoarseness of voice. Br J Anaesth 2008;100:215—8. Tanaka Y, Nakayma T, Nishimori M, Sato Y, Furuya H. Lidocaine for preventing postoperative sore throat. Cochrane Libr 2013;5:1—34. Tazeh-Kand NF, Eslami B, Mohammadian K. Inhaled fluticasone propionate reduces postoperative sore throat, cough, and hoarseness. Anesth Analg 2010;111:895—8. Wolters U, Wolf T, Stutzer H, Schröder T. ASA classification and perioperative variables as predictors of postoperative outcomes. Br J Anaesth 1996;77:217—22. Xu YJ, Wang SL, Ren Y, Zhu Y, Tan ZM. A smaller endotracheal tube combined with intravenous lidocaine decreases post-operative sore throat — a randomized controlled trial. Acta Anaesthesiol Scand 2012;56:1314—20.
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ORIGINAL ARTICLE
Sore throat in women after intubation with 6.5 or 7.0 mm endotracheal tube: A quantitative study Linda Gustavsson a, Irene Vikman b, Cecilia Nyström c, Åsa Engström d,∗ a
Department of Anaesthesia, Central Operation Ward, Sunderby Hospital, Luleå, Sweden Division of Health and Rehabilitation, Department of Health Science, Luleå University of Technology, Luleå, Sweden c Intensive Care Unit 57, Sunderby Hospital, Luleå, Sweden d Division of Nursing, Department of Health Science, Luleå University of Technology, Luleå, Sweden b
Accepted 9 July 2014
KEYWORDS Endotracheal intubation; Nursing; Quantitative; Sore throat; Women; Postanaesthesia care unit
Summary Background: Women experience more sore throats than men after endotracheal intubation. Aim: The aim of this study was to investigate the incidence of self-rated sore throat immediately, and 2—4 hours postoperatively, in women after elective gynaecological surgery under general anaesthesia using an endotracheal tube (ETT) size 6.5 or 7.0 mm in inner diameter. Method: Eighty-two female participants who had undergone elective gynaecological surgery participated, 44 and 38 were intubated with size 6.5 mm ETT and 7.0 mm ETT respectively. They estimated the occurrence of sore throat preoperatively and postoperatively, according to a 4-point Likert scale. Statistical data were analysed using the Package for Social Science (SPSS) 19. Results: Sore throat was present in 29.5% of participants who were intubated with size 6.5 mm ETT immediately postoperatively and in 39.5% of those who were intubated with size 7.0 mm ETT. Conclusion: Nurses specialising in the supervision of daily care specific to the intubated patient should note and alleviate sore throat as part of their nursing care. © 2014 Elsevier Ltd. All rights reserved.
∗ Corresponding author at: Department of Health Science, Luleå University of Technology, SE-971 87 Luleå, Sweden. Tel.: +46 920 49 38 75; fax: +46 920 49 38 50. E-mail address: [email protected] (Å. Engström).
http://dx.doi.org/10.1016/j.iccn.2014.07.003 0964-3397/© 2014 Elsevier Ltd. All rights reserved.
Sore throat in women: A quantitative study
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Implications for Clinical Practice • Women who were intubated with a size 6.5 mm endotracheal tube (ETT) estimated they had fewer and milder symptoms of sore throat postoperatively. • Nurses specialising in anaesthesia and intensive care should note and alleviate sore throat after ETT intubation as part of their nursing care. • Sore throat after ETT intubation should be acknowledged and documented in the patient’s record.
Introduction Waking up with an endotracheal tube (ETT) in the throat is a choking and stressful experience for the patient; expressed as feelings of being unable to breathe or communicate properly (Grap et al., 2002). In addition to this psychological complication, sore throat is commonly reported (Jaensson et al., 2010) as a contributory factor to unpleasant feelings and dissatisfaction (Johnson and Sexton, 1990). Therefore, reducing and minimising a sore throat is an important intervention. Sore throat has been studied extensively over the last few decades and the incidence is reported to vary between 21 and 74 percent (%) (Al-Qahtani and Messahel, 2005; Bunker Fuller, 1992; Hamdan et al., 2007; Jaensson et al., 2010; Porter et al., 1999). This considerable variation is possibly due to differences in measurements used, as well as the types of surgery and populations studied. The incidence is reported as higher among females (Ahmed et al., 2007; Biro et al., 2005; Chen et al., 2004; Higgins et al., 2002; Jaensson et al., 2010; McHardy and Chung, 1999; Myles et al., 1997; Stoelting and Miller, 1994; Stout et al., 1987), which may be because because women have a thinner mucosa covering their vocal cords. In endotracheal intubation, the tube is placed below the vocal cords and may cause irritation of the mucosa (Stoelting and Miller, 1994). More extensive surgery related to the throat, such as thyroid surgery, is also a contributory factor to increased incidence of sore throat (Kadri et al., 2009). If sore throat is present, it occurs immediately after extubation, and then subsides over 24—72 hours postoperatively (Biro et al., 2005; Hamdan et al., 2007; Jaensson et al., 2010; Stoelting and Miller, 1994). Risk factors mentioned as associated with sore throat are, amongst others, the use of muscle relaxants, the design of the laryngoscope blade, the humidity of inhaled gases (Bunker Fuller, 1992) and, the size of the endotracheal cuff. The size of the ETT has also been shown to impact on the incidence rate of sore throat in females. In a recently published review, ETTs with a small inner diameter were significantly associated with a reduction in the incidence of sore throat in the post-anaesthesia care unit and 24 hours after surgery (Hu et al., 2013). Moreover, ETTs with a smaller inner diameter have been shown to reduce the risk of airway trauma and to ease extubation (Koh et al., 1998), but there is a lack of studies describing the incidence of sore throat among women using ETTs with the size 6.5 respectively 7.0 mm. Therefore, the aim of this study was to investigate the incidence of self-rated sore throat immediately and 2—4 hours postoperatively among women after elective gynaecological surgery under general anaesthesia using an ETT with size 6.5 or 7.0 mm inner diameter.
Method Setting and participants Participants in this non-randomised study were recruited from April 2011 through January 2012 from the surgical ICU at a county hospital located in the northern part of Sweden. One hundred women undergoing elective gynaecological surgery were consecutively enrolled in the study (Fig. 1). Inclusion criteria were: • • • •
Female, aged more than or equal to 18 years. Undergoing elective gynaecological surgery. No sore throat. American Society of Anesthesiologists’ physiological status classification (ASA) I—II (ASA I = healthy, ASA II = mild systemic disease, no functional limitation, Wolters et al., 1996). The exclusion criteria were:
• • • •
Not undergoing elective gynaecological surgery. Female under 18 years old. Male. ASA’s physiological status classification of more than II, and has functional limitation (Wolters et al., 1996). • Surgery involving the cervical region. • More than two intubation attempts. • Rapid Sequence Induction (RSI).
During the data collection period the participants were intubated with size 6.5 mm ETTs or 7.0 mm ETTs depending on which day their surgery took place, i.e. all patients fulfilling the inclusion criteria undergoing surgery on Mondays for instance were intubated with size 6.5 mm ETTs and all patients on Thursdays were intubated with size 7.0 mm ETTs. All participants were given similar general anaesthesia, administrated by experienced anaesthetists and anaesthesia nurses, following standard procedure used in the hospital. Pre-intubation pain relief was generally administered in the form of fentanyl. However, for two patients, this was replaced by remifentanil. Propofol was used to induce sleep. However, three participants were allergic to the drug, and were injected with thiopenthal intravenously instead. Before intubation, all participants received muscle relaxants. Most participants were given rocurium bromide, but some participants received succinylcholine (suxamethonium) or mivakuriumchloride. The ETT cuff was filled with air after intubation and the cuff pressure was measured.
320
L. Gustavsson et al.
100 females
Excluded before anesthesia; because of sore throat n= 7
Size 6.5 mm ETT
Size 7.0 mm ETT
n=48
n= 45
Excluded postoperatively; lack of data concerning sore throat
Excluded postoperatively; lack of data concerning sore throat
n= 4
n= 7 Size 6.5 mm ETT
Size 7.0 mm ETT
n= 44
n= 38
Figure 1
Distribution of participants through the study.
Most of the ETTs, 96% of size 6.5 mm ETT and 100% size 7.0 mm ETT, were lubricated with Xylocaine gel before insertion into the trachea. Anaesthesia was maintained with a mixture of Sevoflurane, oxygen and air. Electrocardiography (ECG), noninvasive blood pressure, pulse oximetry (SPO2 ) and end-tidal carbon dioxide (EtCO2 ) were continuously monitored. The participants were ventilated and EtCO2 values were between 4.5 and 6.5 kPa (Edmark et al., 2003).
Data collection We gained access to participants after contacting and informing the two heads of an operating theatre ward in the northern part of Sweden about the aim of the study. They gave their written permission for the study to be performed. The data were collected by registered anaesthesia nurses. To measure the sore throat problems, participants were asked to rate the intensity of their throat pain using a single question with a four-point rating scale with 0, no sore throat; 1, mild sore throat (less severe than a cold); 2,
moderate sore throat (similar to that noted with a cold) and 3, severe sore throat (more severe than with a cold) (Stout et al., 1987). The question was asked immediately and 2—4 hours postoperatively in the postanaesthesia care unit (PACU). The single question has been used in previous studies (e.g. Hisham et al., 2001; Jaensson et al., 2010; Stout et al., 1987). Data including age; weight; height; smoking habits; type of surgery; anaesthesia duration; endotracheal tube size; number of intubation attempts; cuff pressure; airway pressure; minute ventilation; EtCO2 , respiration rate; anaesthetic drugs; and insertion of nasogastric tube were collected from the participants’ medical records (Table 1).
Ethical consideration Participants were informed verbally by an anaesthesia nurse about the study before premedication, and those who agreed to participate gave their permission verbally which they then signed in the study protocol with the help of the anaesthesia nurse, following the Nuremberg Code and
Sore throat in women: A quantitative study
321
Age in years, m (SD) Height in cm, m (SD) Weight in kg, m (SD) BMI, m (SD) Smoker, n (%) Cuff pressure in cm H2 O, m (SD) Airway pressure in cm H2 O, m (SD) Minute volume, m (SD) EtCO2 in kPa, m (SD) Duration of intubation minutes, m (SD) Xylocaine gel on tube, n (%) One intubation attempt, n (%) Two intubation attempts, n (%) Stomach tube inserted, n (%)
Size 6.5 ETT n = 44 49.8 (15.5) 162.4 (6.4)
Size 7.0 ETT n = 38 46.1 (14.0) 164.3 (5.2)
66.0 (11.7)
71.8 (14.2)
25.3 (4.2) 7 (16.7) 25.0 (4.3)
26.4(4.6) 4 (10.5) 25.1 (5.0)
16.3 (3.5)
15.2 (3.5)
Immediately postoperavely n=31
70
n=23
60 50 ETT 6,5
40 30
n=10
n=3 n=3
10 0
4.4 (0.3)
5.7 (0.7) 4.5 (0.3)
No pain
Mild pain
102.1 (33.3)
43 (97.7)
38 (100.0)
36 (81.8)
26 (68.4)
8 (18.2)
12 (31.6)
20 (45.5)
18 (47.4)
Helsinki Declaration. Assurances were given that all data would remain confidential, that participation was voluntary and that participants had the right to withdraw at any time without prejudice. Approval for the study was obtained from the Ethics Committee, Luleå University of Technology.
Data analysis The statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) version 19. Data were analysed descriptively and presented as frequencies, mean and standard deviations. To analyse the differences between groups, for non-parametric variables (self-rated sore throat, smoker, Xylocain gel on tube, one/two intubation attempts, stomach tube inserted), the Chi-square and Mann—Whitney U tests were used. For parametric variables (age, height, weight, BMI, cuff pressure, airway pressure, minute volym) the independent Students’ t-test was used (Polit and Beck, 2012). The significance level was set at p < 0.05 (5%).
Result The results showed no differences between the groups with respect to participants’ characteristics, except for weight which was higher (p < 0.05) in the size 7.0 mm ETT group (Table 1). Of the variables related to the anaesthesia, there
Moderate pain Severe pain
Figure 2 Relative frequencies of self-rated sore throat immediately postoperatively. 80
2 to 4 hours postoperavely n=32 n=24
60 50 40 n=12n=11
30
ETT 6,5 ETT 7,0
20 n=3
10
106.0 (41.6)
n=2 0
70
5.3 (0.8)
ETT 7,0
n=10
20
Precent of parcipants
Background data
80 Precent of parcipants
Table 1 Participant characteristics and measurements during anaesthesia in the two groups.
0
0
No pain
0
0
Mild pain Moderate Severe pain pain
Figure 3 Relative frequencies of self-rated sore throat 2—4 hours postoperatively.
was a significant difference (p < 0.05) between the groups only concerning minute volume (Table 1). The overall incidence of sore throat postoperatively was 34%. In the group intubated with size 6.5 mm ETT, 29.5% rated some degree of sore throat compared to 39.5% in the group with size 7.0 mm ETT. The difference between the groups was not statistically significant (p = 0.286) (Table 2). The corresponding figures for sore throat 2—4 hours postoperatively were 27% for the ETT 6.5 mm and 37% for the ETT 7.0 mm respectively. The distributions of sore throat from no pain, mild, moderate, to severe pain, immediately and 2—4 hours postoperatively are presented in Figs. 1 and 2. A summary of the participants’ self-rated sore throat shows that 29.5% of the participants who were intubated with size 6.5 mm ETT reported a sore throat (mild, moderate or severe) immediately postoperatively. For the group of participants who were intubated with size 7.0 mm ETT the figure was 39.5%. Of those who were intubated with size 6.5 mm ETT, 27. 3% still had a sore throat 2—4 hours postoperatively. For the size 7.0 mm ETT group this figure was 36.8% (Table 2). Figs. 2 and 3 describe the distribution of participants regarding the 4-point scale for sore throat. The results of this study showed no statistically significant difference between the tube size and self-rated sore throat. This may be because the study had too few participants; a larger sample might change the results. As the difference in diameter between size 6.5 mm and size 7.0 mm ETT is so small it may be more difficult to achieve statistical significance than if the difference in the tubes is greater. Descriptive statistics reveal a trend for participants who were intubated using size 6.5 mm ETT to have fewer and less severe symptoms of sore throat postoperatively. To measure sore throat, a single question with a 4-point rating scale
322 Table 2
L. Gustavsson et al. Self-rated sore throat immediately and 2—4 hours postoperatively.
Sore throat
No pain, n (%) Mild pain, n (%) Moderate pain, n (%) Severe pain, n (%)
Sore throat postop
Sore throat postop
Size 6.5 ETT n = 44 31 (70.5) 10 (22.7) 3 (6.8) 0 (0.0)
Size 7.0 ETT n = 38
Sore throat 2—4 hours postop Size 6.5 ETT n = 44
Sore throat 2—4 hours postop Size 7.0 ETT n = 38
23 (60.5) 10 (26.3) 3 (7.9) 2 (5.3)
32 (72.7) 12 (27.3) 0 (0.0) 0 (0.0)
24 (63.2) 11 (28.9) 3 (7.9) 0 (0.0)
was used. A method used in several studies (Hisham et al., 2001; Jaensson et al., 2010; Stout et al., 1987). As the scale is established, it is possible to compare this study’s results with those of other studies; it is replicable, but it is not reliability tested; therefore inter-rater reliability could not be determined. Seven per cent of participants were excluded because of sore throat before anaesthesia. Four participants in the group size 6.5 mm ETT and seven in group size 7.0 mm ETT respectively were excluded postoperatively because of lack of data concerning sore throat. The loss was almost twice as large in the latter group. As participants intubated with size 7.0 mm ETT rated their pain as more severe on the scale, perhaps a smaller loss in this group would have contributed to a greater difference between the groups and, thus, changed the results of the study. All the participants in this study underwent gynaecological surgery and belonged to ASA I to II, thus, forming a homogeneous group, which can be seen as a strength. This is in contrast with other studies (Al-Qahtani and Messahel, 2005; Canbay et al., 2008; Jaensson et al., 2010; Mandøe et al., 1992) where participants underwent a variety of surgical procedures, including ear, nose and throat surgery and gynaecological surgery. This variation complicates the assessment of whether sore throat is due to pain after surgery or the ETT. In some of the studies (Al-Qahtani and Messahel, 2005; Canbay et al., 2008), participants had surgery in the cervical region to prevent blood and secretions from flowing into the ventricle, and had been given a nose or throat pack. These studies are likely to be less reliable due to uncertainty about whether the sore throats were caused by the throat pack, rather than the size of the ETT.
Discussion The results showed an increased incidence of sore throat with increased size of ETTs, but the differences between the two groups were not statistically significant. Immediately postoperatively 29.5% of the participants intubated with size 6.5 mm ETT and in 39.5% of those who were intubated with size 7.0 mm ETT rated sore throat to some degree. Stout et al. (1987) found an incidence of sore throat in 22% of women who were intubated with size 6.5 mm, and the incidence increased to 53% among those intubated with size 8.5 mm ETT. Jaensson et al. (2010) found among women intubated with size 6.0 mm ETT a 27.1% incidence which is in line with our figure, 29, 5% for women intubated with size
p-Value
0.286
p-Value
0.262
6.5 mm ETT. However, when comparing endotracheal tubes with a larger inner diameter, Jaensson et al. (2010) found an incidence of 51.1% in women intubated with size 7.0 mm ETT compared to 39.5% in the present study. One explanation for this difference could be that in our study 97.7% of those intubated with size 6.5 mm ETT and 100% of those intubated with size 7.0 mm ETT had local anaesthetic gel (lidocaine) applied to their ETTs compared with 0% of the patients in the study by Jaensson et al. (2010). Older and other contemporary researches, however, showed that the uses of lidocaine gel has no or even the opposite effect in reducing sore throat (Basaranoglu et al., 2004; McHardy and Chung, 1999; Maruyama et al., 2004; Soltani and Aghadavoudi, 2002). Sumathi et al. (2008) found that the incidence of sore throat, cough, and hoarseness of voice was significantly less when bethamesasone was widely applied over the ETT compared to lidocaine gel or nothing applied. Lidocaine gel reduced the incidence of sore throat significantly compared with no application to the ETT (Sumathi et al., 2008). Xu et al. (2012) demonstrated that the use of ETTs of smaller diameter combined with intravenous lidocaine reduces the incidence and severity of postoperative sore throat in women undergoing thyroid surgery. According to Tanaka et al. (2013), it is common clinical practice to use lidocaine for the prevention of postoperative sore throat, and they confirmed the effectiveness of topical and systematic lidocaine for the prevention of postoperative sore throat in their systematic review. The effectiveness of lidocaine would appear to be influenced by its concentration, route of administration and the outcomes measured (Tanaka et al., 2013). The results of this study, like those in the past (Hamdan et al., 2007; Jaensson et al., 2010; Stoelting and Miller, 1994) showed a reduction in the incidence of sore throat over time. More participants felt the sore throat immediately postoperatively than after a few hours or up to one day later. In previous studies, the incidence of postoperative sore throat varied between 21 and 74% of the total sample (Bennett et al., 2000; Canbay et al., 2008; Christensen et al., 1994; Ebneshahidi and Mohseni, 2010; Higgins et al., 2002; Loeser et al., 1980; Maruyama et al., 2004; Park et al., 2008). Most previous studies (Ebneshahidi and Mohseni, 2010; Liu et al., 2010; Loeser et al., 1980; Mandøe et al., 1992) noted that the female participants were intubated using ETT sizes from 7.0 to 8.0. Jaensson et al. (2012a) found that of 292 women intubated tracheally with size 6.0 mm ETT (n = 263) or 7.0 mm ETT (n = 29), 169 (64%) intubated with size 6.0 mm had no postoperative sore
Sore throat in women: A quantitative study throat compared to 14 (48%) who were intubated with size 7.0 mm ETT. They also showed that the main factors in developing sore throat in women were the use of size 7.0 mm ETT instead of size 6.0 mm ETT, and multiple laryngoscopies during intubation. Mitchell and Jones (2005) stated that the advantages of small ETTs outweigh the disadvantages for anaesthesia in adults. Comparison of the occurrence of sore throat among the two groups in the current study shows the following: of the participants intubated with size 6.5 mm ETT 70.5% had no sore throat immediately postoperatively. In the group intubated with size 7.0 mm ETT, 60.5% had no pain; participants intubated with a narrower diameter ETT less pain; 2—4 hours postoperatively compared to those who were intubated with a larger diameter ETT. Similarly, Jaensson et al. (2012b) found three variables that were significant risk factors for postoperative sore throat: age greater than 60 years (p = 0.01), the use of a throat pack (p = 0.04) and size 7.0 mm ETT (size 7 mm; p = 0.02) compared with size 6.0 mm ETT. According to Jaensson et al. (2012a), age above 40 years increases the incidence of postoperative sore throat in women (p = 0.028). The results showed that the mean of the measured airway pressure was 16.3 and 15.2 cm H2 O for size 6.5 mm and size 7.0 mm ETTs respectively. This minimal difference is consistent with Stenqvist et al. (1979) results. A conscious decision was taken to exclude nitrous oxide as this gas expands in air-filled cavities (Combes et al., 2001). The results showed that the average cuff pressure was 25.0 and 25.1 cm H2 O for size 6.5 mm and size 7.0 mm ETTs respectively. According to Liu et al. (2010), the purpose of inflating the endotracheal cuff is to prevent air leakage; thereby ensuring the ventilation effect and reducing the risk of leakage of anaesthetic drugs. Very high pressure in the cuff increases the risk of severe and even fatal injuries when blood flow to the mucosa of the trachea is reduced and may even cause ischaemic damage (Stewart et al., 2003). High cuff pressure and postoperative sore throat are directly linked. Liu et al. (2010) showed further that ETT cuff pressure estimated by palpation only is often much higher than when measured or than what may be optimal; proper control using a manometer helps to reduce ETT-related postprocedural respiratory complications such as sore throat even in procedures of such short duration as 1—3 hours. The importance of closely monitoring the ETT cuff pressure is supported by Sengupta et al. (2004). Of the participants in this study who were intubated with a size 6.5 mm ETT, 81.8% required only one intubation attempt compared with 68.4% of those intubated with size 7.0 mm ETT. This is consistent with the results of Koh et al. (1998) showing that using a smaller ETT reduces the number of intubation attempts. Studies have proposed other treatments to further improve patient care and reduce the symptoms of sore throat postoperatively. Tazeh-Kand et al. (2010) showed that participants who inhaled steroid drugs preoperatively experienced significantly less discomfort from sore throats. The benefit of inhaled steroids is that the medication is delivered in smaller doses and for a shorter time. Liu et al. (2010) studied the effect of Benzydamine Hydrocloride, a non-steroidal drug (Zyx® ) available over the counter (OTC) in Sweden. If given preoperatively, according to Liu et al. (2010), before endotracheal intubation, it can reduce mild to moderate sore throat postoperatively. Ebneshahidi and
323 Mohseni (2010) showed that the use of Strepsilis® preoperatively reduces sore throat postoperatively. They evaluated the experience of sore throat immediately postoperatively and 24 hours after the procedure. The pain was rated on a 4-point scale (0—3), like the one used in this study, but in our study the participants did not receive steroids or Strepsils.
Conclusion Women who were intubated with size 6.5 mm ETT rated less severe sore throat, compared to those intubated with size 7.0 mm ETT. Nevertheless, the results were not statistically significant. Application of lidocaine gel on the ETT may have a reducing effect on sore throat, especially among participants who were intubated with a size 7.0 mm ETT. It is important that the cuff pressure and the mucosa are closely monitored to help reduce the risk of the risk of postoperative sore throat. Nurses specialising in the supervision of daily care specific to the intubated patients should look for and alleviate sore throat as part of their nursing care. Further research in this area is needed, as a sore throat after ETT intubation is a common problem. One suggestion is to perform a study similar to this one but with more participants and to also ask about hoarseness. It would also be of interest to study how the age of participants influences the experience of sore throat and what further interventions can be implemented to decrease the experience of sore throat after oral intubation.
Acknowledgements We would like to thank the patients who participated and the nurses who completed the questionnaires. Thanks to Pat Shrimton for revising the English language. The research was funded by grants from the County Council of Norrbotten, Sweden.
References Ahmed A, Abbasi S, Ghafoor AH, Ishaq M. Postoperative sore throat after elective surgical procedures. J Ayub Med Coll Abbottabad 2007;19:12—4. Al-Qahtani AS, Messahel FM. Quality improvement in anesthetic practice — incident of sore throat after using small tracheal tube. Middle East J Anesthesiol 2005;18:179—83. Basaranoglu G, Erden V, Delatioglu H. Postoperative sore throat: effect of lidocaine jelly and pomade on endotracheal intubation. J Clin Anesth 2004;16:79—80. Bennett MH, Isert PR, Cumming RG. Postoperative sore throat and hoarseness following tracheal intubation using air or saline to inflate the cuff — a randomized controlled trial. Anaesth Intensive Care 2000;28:408—13. Biro P, Seifert B, Pasch T. Complaints of sore throat after tracheal intubation: a prospective evaluation. Eur J Anaesthesiol 2005;22:307—11. Bunker Fuller P. The relationship between preintubation lidocaine and postanesthesia sore throat. J Am Assoc Nurse Anesth 1992;60:374—8. Canbay O, Celebi N, Sahin A, Celiker V, Ozgen S, Aypar U. Ketamine gargle for attenuating postoperative sore throat. Br J Anaest 2008;100:490—3.
324 Chen KT, Tzeng JL, Liu KS, Hsu CS, Wang JJ. Risk factors associated with sore throat after tracheal intubation: an evaluation in the postanesthetic recovery room. Acta Anaesthesiol Taiwan 2004;42:3—8. Christensen AM, Willemoes-Larsen H, Lundby L, Jakobsen KB. Postoperative throat complaints after tracheal intubation. Br J Anaesth 1994;73:786—7. Combes X, Schauvliege F, Peyrouset O, Motamed C, Kirov K, Dhonneur G, Duvaldestin P. Intracuff pressure and tracheal morbidity: influence of filling cuff with saline during nitrous oxide anesthesia. Aneshesiology 2001;95:1120—4. Ebneshahidi A, Mohseni M. Strepsils® tablets reduce sore throat and hoarseness after tracheal intubation. Anesth Analg 2010;111:892—4. Edmark L, Kostova-Aherdan K, Enlund M, Hedenstierna G. Optimal oxygen concentration during induction of general anesthesia. Anesthesiology 2003;98:28—33. Grap MJ, Blecha T, Munro C. A description of patients’ report of endotracheal tube discomfort. Intensive Crit Care Nurs 2002;18:244—9. Hamdan A-L, Sibai A, Rameh C, Kanazeh G. Short-term effects of endotracheal intubation on voice. J Voice 2007;21:762—8. Higgins PP, Chung F, Mezei G. Postoperative sore throat after ambulatory surgery. Br J Anaesth 2002;88:582—4. Hisham AN, Roshilla H, Amri N, Aina EN. Post-thyroidectomy sore throat following endotracheal intubation. ANZ J Surg 2001;71:669—71. Hu B, Bao R, Wang X, Liu S, Tao T, Xie Q, et al. The size of endotracheal tube and sore throat after surgery: a systematic review and meta-analysis. PLOS ONE 2013;8:e74467, http://dx.doi.org/10.1371/journal.pone.0074467. Jaensson M, Olowsson LL, Nilsson U. Endotracheal tube size and sore throat following surgery: a randomized controlled study. Acta Anaesthesiol Scand 2010;54:147—53. Jaensson M, Gupta A, Nilsson U. Gender differences in risk factors for airway symptoms following tracheal intubation. Acta Anaesthesiol Scand 2012a;56:1306—13. Jaensson M, Gupta A, Nilsson U. Risk factors for development of postoperative sore throat and hoarseness after endotracheal intubation in women: a secondary analysis. AANA J 2012b;80:67—72. Johnson MM, Sexton DL. Distress during mechanical ventilation: patients’ perceptions. Crit Care Nurse 1990;10: 48—57. Kadri IA, Khanzada TW, Samad A, Memon W. Post-thyroidectomy sore throat: a common problem. Pak J Med Sci 2009;25: 408—12. Koh KF, Hare JD, Calder I. Small tube revisited. Anaesthesia 1998;53:46—50. Liu J, Zhang X, Gong W, Li S, Wang F, Fu S, et al. Correlations between controlled endotracheal tube cuff pressure and postprocedural complications: a multicenter study. Anesth Analg 2010;111:1133—7. Loeser EA, Bennett GM, Orr DL, Stanley TH. Reduction of postoperative sore throat with new endotracheal tube cuffs. Anesthesiology 1980;52:257—9. Mandøe H, Nikolajsen L, Lintrup U, Jepsen D, Mølgaard J. Sore throat after endotracheal intubation. Anesth Analg 1992;74:897—900.
L. Gustavsson et al. Maruyama K, Sakai H, Miyazawa H, Toda N, Iinuma Y, Mochizuki N, et al. Sore throat and hoarseness after total intravenous anaesthesia. Br J Anaesth 2004;92:541—3. McHardy FE, Chung F. Postoperative sore throat: cause, prevention and treatment. Anaesthesia 1999;54:444—53. Mitchell V, Jones H. Gas, tubes and flow. Anaesth Intensive Care Med 2005;6:240—2. Myles PS, Hunt JO, Moloney JT. Postoperative minor complications. Comparison between men and women. Anaesthesia 1997;52:300—6. Park S-H, Han S-H, Do S-H, Kim J-W, Rhee K-Y, Kim JH. Prophylactic dexamethasone decreases the incidence of sore throat and hoarseness after tracheal extubation with a double-lumen endobronchial tube. Anesth Analg 2008;107: 1814—8. Polit DF, Beck CT. Nursing research: principles and methods. Philadelphia: Lippincott Williams & Wilkins; 2012. Porter NE, Sidou V, Husson J. Postoperative sore throat: incidence and severity after the use of lidocaine, saline or air to inflate the endotracheal tube cuff. J Am Assoc Nurse Anesth 1999;67:49—52. Sengupta P, Sessler D, Maglinger P, Wells S, Vogt A, Durrani J, et al. Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure. BMC Anesthesiol 2004;4:1—6. Soltani HA, Aghadavoudi O. The effect of different lidocaine application methods on postoperative cough and sore throat. J Clin Anesth 2002;14:15—8. Stenqvist O, Sonander H, Nilsson K. Small endotracheal tubes: ventilator and intratracheal pressures during controlled ventilation. Br J Anasth 1979;51:375—81. Stewart SL, Seacrest JA, Norwood BR, Zachary R. A comparison of endotracheal tube cuff pressures using estimation techniques and direct intracuff measurement. AANA J 2003;71: 443—7. Stoelting RK, Miller RD. Basics of anesthesia. New York: Churchill Livingstone; 1994. Stout DM, Bishop MJ, Dwersteg JF, Cullen BF. Correlation of endotracheal tube size with sore throat and hoarseness following general anesthesia. Anesthesiology 1987;67:419—21. Sumathi PA, Shenoy T, Ambareesha M, Krishna HM. Controlled comparison between betamethasone gel and lidocain jelly applied over tracheal tube to reduce postoperative sore throat, cough, and hoarseness of voice. Br J Anaesth 2008;100:215—8. Tanaka Y, Nakayma T, Nishimori M, Sato Y, Furuya H. Lidocaine for preventing postoperative sore throat. Cochrane Libr 2013;5:1—34. Tazeh-Kand NF, Eslami B, Mohammadian K. Inhaled fluticasone propionate reduces postoperative sore throat, cough, and hoarseness. Anesth Analg 2010;111:895—8. Wolters U, Wolf T, Stutzer H, Schröder T. ASA classification and perioperative variables as predictors of postoperative outcomes. Br J Anaesth 1996;77:217—22. Xu YJ, Wang SL, Ren Y, Zhu Y, Tan ZM. A smaller endotracheal tube combined with intravenous lidocaine decreases post-operative sore throat — a randomized controlled trial. Acta Anaesthesiol Scand 2012;56:1314—20.
