Sore Throat After Endotracheal Intubation

Hans Mandoe, MD, Lone Nikolajsen, MD, Uffe Lintrup, Dorte Jepsen, and Jerrgen Merlgaard, MD
Department of Anesthesia, Central Hospital, Herning, Denmark

Nitrous oxide can diffuse into the cuff of an endotracheal tube during tracheal intubation, and the cuff pressure against the tracheal Wall may Cause mucosal tube has been damage. An endotracheal (Brandt Anesthesia Tube) that effectively limits nitrous oxide-related intracuff pressure increases. We determined whether the incidence of postoperative throat could be reduced by using this tube. Forv-eight female patients, 1g-50 yr of age, were included in the study. Endotracheal intubation was performed with either a Brandt Anesthesia Tube or a

Mallinckrodt endotracheal tube. All patients were interviewed postoperatively after 20-30 h by individuals who did not know which tube was used. In the Mallinckrodt group, 12 of 20 patients had a sore throat and patients had inhacuff pressures greater than 25 mm Hg. Only of 2o patients in the Brandt group had a sore throat. We found that the incidence of sore throats after intubation could be significantly reduced by using the Ehndt Anesthesia Tube ( p < 0.005).
(Anesth Analg 1992;74:897-900)

itrous oxide will diffuse through the cuff wall of an endotracheal tube during anesthesia, causing an increase of cuff volume and intracuff pressure (1-3). The pressure of the cuff against the tracheal wall depends on the compliance of the cuff and the trachea. A new cuff system (Brandt, Rediffusion System, Mallinckrodt Medical (UK) Ltd, Northampton, U.K.) has been developed that limits increases in nitrous oxide-induced pressure (4).The purpose of this study was to investigate whether the incidence of sore throat after short-term endotracheal intubation could be reduced by using the Brandt Anesthesia Tube.

Methods
After gaining approval from the County Ethical Committee, 48 female patients (all between 18 and 50 yr of age) were studied. All were to undergo operation for which endotracheal intubation was expected to last for at least 1 h. The operations were 27 gynecologic laparotomies, 5 cholecystectomies, 7 mastectomies, and 9 orthopedic arthroscopies. Patients who smoked more than 10 cigarettes a day or who had symptoms of upper airway irritation were excluded from the study. Endotracheal intubation was performed with either a Mallinckrodt endotracheal tube or a Brandt Anesthesia Tube. The tubes were identical in both size
Accepted for publication January 17, 1992. Address correspondence to Dr. Mandee, Department of Anesthesia, Central Hospital, DK 7400 Herning, Denmark.
01992 by the International Anesthesia Research Society 0003-29W/92/$5.00

(7.5 mm) and composition (polyvinyl chloride), and each had a large-diameter low-pressure cuff (Figure 1). The Brandt tube had a specially designed pilot rediffusion balloon outside the patient. Because the cuff and the pilot balloon communicated through the inflation line, an increase in the nitrous oxide concentration in the cuff would have the consequence of producing the same increase in the nitrous oxide concentration in the pilot balloon. The balloon had a higher compliance and larger volume than the cuff, and therefore, the cuff pressure increase was limited to safe levels (5). All 48 patients consented to participate in the study and were randomized to tracheal intubation with either tube. Anesthesia was intravenously induced with fentanyl and thiopental. Atracurium was used for muscle relaxation; its magnitude was monitored by a train-of-four stimulation. The endotracheal tube was moistened with water, and the intubation was performed by one of the investigators. A pressure gauge was connected to the ventilation bag, and the cuff was inflated until stethoscopic control over the trachea showed no sign of leaking air with an intra-airway pressure of 20 cm H,O. In every case, intracuff pressures were measured every 10 min by a Mallinckrodt hand pressure gauge. As intracuff pressures never exceeded 25 mm Hg in the Brandt group, pressures were registered only in the Mallinckrodt group. A gauze roll was inserted between the teeth instead of an oropharyngeal airway. Anesthesia was maintained by a mixture of 67% nitrous oxide and 33% oxygen and with intravenous atracurium, thiopental,
Anesth Analg 1992;74:897-900

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MANDOE ET AL. BRANDT ANESTHESIA VS MALLINCKRODT

ANESTH ANALG
1992;74:897-900

Table 1. Mean Score and Distributions of Scores

n
~~~

Mean score
0.2

No. of patients

Score 0
17

Score 1 2
7

Score 2
1
4

Score 3
0

Brandt ( n = 20) Mallinckrodt (n = 20)

0.9

Scoring scale: 0 = no complaints at all, 1 = minimal sore throat, 2 = moderate sore throat and/or a slight hoarseness, 3 = severe sore throat andlor a severe hoarseness.

2 01

Figure 1. A Brandt tube (bottom) and a Mallinckrodt tube (top).

E
2 c

12 10

and fentanyl as needed. Every 60 min, cuff pressure was decreased to the value that just permitted the trachea to be sealed using the same procedure as described earlier. All patients were interviewed 20-30 h postoperatively by one of the investigators who used a set protocol but who had no knowledge of which of the two endotracheal tubes was used. Patients were asked whether they had experienced a sore or scratchy throat from the time of extubation to the interview. The replies were divided as follows: (a) no complaints at all (0 points), (b) minimal sore throat (1 point), (c) moderate sore throat andor a slight hoarseness (2 points), and (d) a severe sore throat and/or a severe hoarseness (3 points). As a sore throat could also be caused by acid gastric contents, patients were also asked about nausea and vomiting to eliminate this effect. Patients were excluded from the study if they needed a gastric tube, sustained a difficult endotracheal intubation (i,e., more than one attempt at passage of the tube), or coughed during intubation. The Mann-Whitney test was used to identify age differences, durations of tracheal intubation, and sore throat scores between the two groups. The incidence of nausea was evaluated with Fishers exact test. Spearmans test was used to test the correlation between the sore throat scores and cuff pressure and the duration of tracheal intubation. P < 0.05 was accepted as statistically significant.

d 6 8
4 2

0
0
1 2

Score
Figure 2. The distribution of scoring in the Brandt (open burs) and Mallinckrodt group (cross-hatched burs).

Results
Eight patients were excluded from the study because of difficult intubation (four), because of coughing during intubation (two), and because of having a gastric tube (two). There was no statistical significance in age difference and nausea incidence between the two groups (Fishers exact test, P = 0.75). The

duration of endotracheal intubation ranged from 60 to 180 min and did not differ in the two groups. Also, there was no correlation between the duration of endotracheal intubation and sore throat scores (Brandt group: p = 0.383, correlation for ties; Mallinckrodt group: p = 0.157, correlation for ties). There was a high statistical difference of sore throat scoring in the two groups ( P < 0.01). The mean score and distribution of sore throats scoring are shown in Table 1. In the Mallinckrodt group, 12 of 20 patients complained of a sore throat postoperatively; in the Brandt group, only 3 of 20 patients complained of a sore throat. The number of patients and their scores are shown in Figure 2. In the Mallinckrodt group, 10 intracuff pressures higher than 25 mm Hg were measured; and there was a statistically significant correlation between intracuff pressure and sore throat score ( p = 0.464, P = 0.049). Table 2 shows data for age, duration of endotracheal intubation, nausea, score (and for the Mallinckrodt group, intracuff pressure). The number of patients and the distribution of intracuff pressure in each score group is shown in Figure 3.

Discussion
The incidence of postanestheticsore throat ranged from 24% to 90% (6) and was affected by endotracheal cuff

MANDQE ET AL. BRANDT ANESTHESIA VS MALLINCKRODT

899

Table 2. Patient Data

Brandt Anesthesia Tube Age Duration of intubation (min) 120 155 100 120 65 105 90 60 90 100 90 60 90 115 90 75 90 120 60 120 Age (Yr) 39 35 45 33 45 48 28 28 30 46 39 23 45 49 29 33 50 46 41 45
=

Mallinckrodt tube Duration of intubation (min) 105 90 70 65 180 60 70 90 105 90 60 135 60 120 130 120 115 80 120 60 Maximum

(Yd
39 48 42 46 25

Nausea

Score
0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 1 0 0 1 0

Nausea

Score 2 0 2 1 1 0 0 0 0 1 0 2 3 1 0 1 0 2 1 1
=

cuff pressure (mm Hg)

-

+ + + +
-

+
-

+ +
+
-

44 44
44 48 49 26 45 28 39 31 32 45 45 43 45

+ + +
-

+
-

+ + + + +
-

+ + +
-

7 42 31 24 23 14 19 14 41 28 37 46 19 26 42 44 15 22 32

Scoring scale: 0 = no complaints at all, 1 = ininimal sore throat. 2 hoarseness.

moderate sore throat and/or a slight hoarseness, 3

severe sore throat and/or a severe

'
c
v)

*40

mm Hg
mm Hg

30-39

.-

H 2 o - 2 9 mmHg 10-19. mrn Hg

Q)

c 0

a 0-9
Score

mm Hg

Figure 3. The number of patients and the distribution of intracuff pressure in each score group.

tube design, intracuff pressure, use of cleaning agents, endotracheal tube lubricants, and several other factors. It has been proposed that the incidence and severity of sore throat after intubation is highly correlated to endotracheal tube cuff design (7-9). The effects of cuff design seem to be related to the cuff-trachea contact area. Although the eroded area of a high-volume, low-pressure cuff is much larger than a low-volume, high-pressure one, it produces less depth of tracheal mucosa erosion. Also, some high-volume, lowpressure cuffs wrinkle even though they are properly inflated, resulting in deep mucosal grooves (10). We

concluded that the incidence of postanesthetic sore throat could be significantly decreased by using endotracheal tubes with a short tracheal cuff contact length 173). Some data suggest that cuff lubrication may be a causative factor in producing sore throat and that some lubricants should be avoided (9). Endotracheal tube cuffs may contain toxic or irritating materials from fabrication or washing procedures (6). In 1974, in vitro studies showed that nitrous oxide diffused into the cuffs of endotracheal tubes and increased their volume and pressure (1).Several in vivo studies have confirmed these findings, and it has been concluded that cuff overexpansion during anesthesia might be an important cause of sore throat after intubation (1-3). Investigations in animals have shown that the tracheal mucosa will be ischemic at a cuff-trachea pressure of more than 30 mm Hg. The investigators recommended that the intracuff pressures be monitored and kept below 20 mm Hg (11). To avoid intracuff pressure increases during anesthesia, the endotracheal cuff may be inflated either with an anesthetic gas mixture or saline (12,13). In 1983, the Brandt Anesthesia Tube was developed, which limited nitrous oxide-related intracuff pressure increases. Even during long-term anesthesia, the intracuff pressure never exceeded 25 mm Hg (4,5,14). We have demonstrated that the incidence and
~ . I

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ANESTH ANALG 1992;74:897-900

severity of postoperative sore throat after intubation is significantly reduced with the use of the Brandt Anesthesia Tube. This tube has one disadvantage, namely, its large sealing volume. However, this is outweighed by several advantages. Monitoring intracuff pressure and deflating the cuff to barely above seal pressure is not needed when using this tube. Thus, the risk of aspirating saliva and mucus to the airways is reduced. Once the cuff is inflated and sealed, no further adjustment is necessary, and the anesthesiologist is allowed to concentrate on other monitoring procedures. Cuff herniation is theoretically impossible with the Brandt Anesthesia Tube. Postanesthetic sore throat cannot be totally avoided using the Brandt Anesthesia Tube as 3 of 20 patients complained of slight hoarseness after intubation. This indicates the presence of other causative factors such as laryngeal trauma when performing intubation. In conclusion, this study confirms the importance of limiting intracuff pressure increases during anesthesia. Deflating the cuff every hour does not keep the intracuff pressure below a safe level. Perhaps intracuff pressure should be monitored continuously during endotracheal intubation. Alternatively, the Brandt Anesthesia Tube can be used.

References
1. Stanley TH, Kawamura R, Graves C. Effects of nitrous oxide on

volume and pressure of endotracheal tube cuffs. Anesthesiology 1974;41:256-61.

2. Stanley TH. Nitrous oxide and pressures and volumes of high- and low-pressure endotracheal-tube cuffs in intubated patients. Anesthesiology 1975;42:63741. 3. Brandt L, Pokar H, Renz D, Schutte H. Cuffdruckanderungen durch Lachgasdiffusion. Anesthesist 1982;31:345-48. 4. Brandt L, Pokar H. Das Rediffusionssystem. Anesthesist 1983; 32:459-64. 5. Brandt L, Muller-Spath R, Moussa RG. Reduction of nitrous oxide-induced endotracheal tube-cuff pressure rise during anesthesia with the Rediffusion System. Mallinckrodt Scientific Edition Booklet, 2nd ed. Hennef, Germany: Mallinckrodt GmbH MAP Division, 1990. 6. Christiansen CL, Koch J, Halkier P. Throat complaints following brief intubation. Ugeskr Lager 1986;148:1143-6. 7. Loeser EA, Orr DL, Bennett GM, Stanley TH. Endotracheal tube cuff design and postoperative sore throat. Anesthesiology 1976;45:68&7. 8. Loeser EA, Bennett GM, Orr DL, Stanley TH. Reduction of postoperative sore throat with new endotracheal tube cuffs. Anesthesiology 1980;52:257-9. 9. Loeser EA, Kaminsky A, Diaz A, Stanley TH, Pace NL. The influence of endotracheal tube cuff design and cuff lubrication on postoperative sore throat. Anesthesiology 1983;58: 376-9. 10. Loeser EA, Hodges M, Gliedman J, et al. Tracheal pathology following short term intubation with low- and highpressure endotracheal tube cuffs. Anesth Analg (Cleve) 1978; 57:578-9. 11. Nordin U, Lindholm CE, Wolgast M. Blood flow in the rabbit tracheal mucosa under normal conditions and under the influence of tracheal intubation. Acta Anaesthesiol Scand 1977;21: 81-93. 12. Raeder JC, Borchgrevink PC, Sellevold S. Tracheal tube cuff pressures. Anesthesia 1985;40:44&7. 13. Patel Rl, Oh TH, Chandra R, Epstein BS. Tracheal tube cuff pressure. Anesthesia 1984;39:8624. 14. Brandt L. Prevention of nitrous oxide-induced increases in endotracheal tube cuff pressure. Anesth Analg 1991;72:262-70.