Design

Single-center, randomized, controlled trial

N= 127 

Objective

Study Groups

Nebulized lidocaine (n= 62)

Nebulized terbutaline (n= 65)

Inclusion Criteria

Exclusion Criteria

Methods

Patients were randomized 1:1 to either nebulized lidocaine or terbutaline inhalation administered over 15-25 min. In lidocaine patients, solution was prepared by diluting 1 mg/kg cardiac lidocaine with saline for a total volume of 4 mL. Alternatively, 2 mL terbutaline was mixed with 2 mL saline solution to result in 4 mL total volume. No other antitussives were administered in ED prior to completion of questionnaire, and patients were asked not to eat or drink for one hour after inhalation. A questionnaire was completed to measure cough severity, assessed on a 10-point scale (1 point = no cough, 10 points = most severe cough). Patients were monitored for at least 2 hours after administration of treatment.

Duration

Enrollment occurred over a 6-month period in 2003

Treatment was administered over 15-25 minutes

Outcome Measures

Baseline Characteristics

Nebulized lidocaine (n= 62)

Nebulized terbutaline (n= 65)

Age, years

Female

Results

Nebulized lidocaine (n= 62)

Nebulized terbutaline (n= 65)

p-Value between groups

Cough severity score

Before treatment (IQR)

After treatment (IQR)

p-Value before vs. after treatment

8 (7 to 8)

3 (2 to 5)

< 0.01

0.21

0.44

Adverse events

Tremor

Palpitation

Oropharyngeal numbness

Bitter taste

Dyspnea

Nausea/vomiting

Dizziness

3 (4.8%)

5 (8.1%)

38 (61.3%)

34 (54.8%)

5 (8.1%)

4 (6.5%)

2 (3.2%)

60 (92.3%)

59 (90.8%)

3 (4.6%)

4 (6.2%)

4 (6.2%)

3 (4.6%)

4 (6.2%)

< 0.01

< 0.01

< 0.01

< 0.01

0.67

0.65

0.44

Adverse Events

Study Author Conclusions

InpharmD Researcher Critique

The severity of cough is subjective so ratings between patients may be inconsistent. This study also only looked at short term outcomes in this study and did not evaluate lidocaine levels for toxicity. All included patients had a documented history of COPD. 

Effect of 4% Nebulized Lignocaine versus 2% Nebulized Lignocaine for Awake Fibroscopic Nasotracheal Intubation in Maxillofacial Surgeries

Design

Randomized control trial

N= 60

Objective

To compare the effectiveness of two different concentrations, 2% lignocaine and 4% lignocaine, in nebulized form for airway anesthesia during awake fiber-optic nasotracheal intubation in terms of patient's comfort and optimal intubating conditions, hemodynamic changes, and intubation time

Study Groups

Group A: 4% lignocaine (n= 30)

Group B: 2% lignocaine (n= 30)

Inclusion Criteria

Patients aged 18-55 years belonging to American Society of Anesthesiologists Class I-II, with anticipated difficult airway planned for elective surgery

Exclusion Criteria

Nasal mass bleeding disorder; known allergy to study medication; uncontrolled hypertension; pregnancy; ischemic heart disease; hepatic or renal disorders; history of recent nasopharyngeal surgery 

Methods

Patients were randomly assigned to receive either 4% lignocaine (Group A) or 2% lignocaine (Group B). Patients were kept nil per oral for 8 hours prior to surgery; 15 minutes prior to the procedure patients were premedicated with intravenous (IV) glycopyrrolate 0.2 mg, dexamethasone IV 4 mg, and two drops of 0.1% xylometazoline through each nostril for nasal decongestion. Both strengths of nebulized lidocaine were administered as 10 mL in prefilled syringes through ultrasonic nebulizer for about 10 minutes, followed by IV midazolam 0.05 mg/kg and IV fentanyl 1 mg/kg prior to the procedure. Superior laryngeal nerve block was administered bilaterally with 2 mL of 2% lignocaine; patient was lying in 30° propped-up position and the fiber-optic bronchoscope was introduced through the more patent nostril, with the other nostril used for oxygen insufflation (3-4 L/min). After passage of the tube through vocal cords and identification of carina, the tube was secured and cuff inflated; propofol 1 mg/kg IV and IV vecuronium bromide 0.08 mg/kg were used for general anesthesia and mechanical ventilation. 

Duration

Outcome assessed during nasotracheal intubation

Outcome Measures

Primary: patient's comfort and tolerance to fiberscope by Puchner comfort scale (no reaction: 1; slight grimacing: 2; heavy grimacing: 3; verbal objection: 4; defensive movements of head and hands: 5)

Secondary: optimal intubating conditions; hemodynamic changes

Baseline Characteristics

4% lignocaine (n= 30)

2% lignocaine (n= 30)

Age, years

Male

Results

Endpoint

4% lignocaine (n= 30)

p-Value

Puchner scale score

Procedural time, min

Number of intubation attempts

Additional sedation required

Pre and post nebulization heart rate and mean arterial blood pressure were similar in both groups. 

Adverse Events

N/A

Study Author Conclusions

Four percent nebulized lidocaine provided adequate airway anesthesia and optimal intubating conditions along with stable hemodynamics for awake fiber-optic intubation as compared to 2% nebulized lidocaine. 

InpharmD Researcher Critique

The study is limited by its small sample size and subjective nature of the primary outcome. 

Nebulization versus standard application for topical anaesthesia during flexible bronchoscopy under moderate sedation - a randomized controlled trial

Design

Randomized, controlled, parallel study

N= 60

Objective

To compare the tolerability and safety of nebulized lidocaine with conventional lidocaine administration via syringe in patients undergoing bronchoscopy with moderate sedation

Study Groups

Lidocaine syringe (n= 30)

Lidocaine nebulizer (n= 30)

Inclusion Criteria

Patients aged ≥ 18 years requiring diagnostic bronchoscopy

Exclusion Criteria

Patients requiring cryobiopsy, endobronchial ultrasound, epilepsy, severe neurological or psychiatric disorder, hemodynamic instability requiring catecholamine treatment, decompensated heart failure, severe respiratory failure (pH < 7.35, arterial oxygen pressure [PaO₂] < 55 mmHg despite supplemental oxygen), history of upper airway surgery or radiation, allergy to lidocaine, propofol or midazolam, or any bleeding disorder.

Methods

Patients received midazolam IV bolus before start of bronchoscopy, with no additional doses given during procedure. Propofol boluses were administered at investigator's discretion until sufficient tolerance for procedure achieved. Fentanyl bolus doses also permitted. Lidocaine (20 mg/mL) 20 mg to 40 mg was administered during bronchoscopy by nebulizer or syringe; target zones in both groups were vocal cords, trachea, main carina, and main bronchi. Approximately 10 sec waiting period was allotted between lidocaine administration at different sites. Additional injections were administered at the discretion of bronchoscopist, e.g. for excessive cough.

Patient tolerance was assessed using Global Tolerance Score, based on visual analogue scale (VAS; 0 [non-existent] to 100 [unbearable]) to rate nausea, asphyxia, cough, and pain. ALDRETE (global assessment of post-aesthetic condition) score was used to assess recovery after bronchoscopy procedure. 

Duration

October 2014 - November 2017

Outcome Measures

Primary outcome: Dosages of administered propofol and lidocaine

Secondary outcome: Dosages of midazolam and fentanyl, post procedural blood gas values, duration of the bronchoscopy, occurrence of complications, time span until an ALDRETE score of at least 9 was recorded after the procedure

Baseline Characteristics

Lidocaine syringe (n= 30)

Lidocaine nebulizer (n= 30)

Age, years

Male

Weight, kg

FEV₁, % predicted

PaO₂, mmHg

PaCO₂, mmHg

Indications for bronchoscopy

Lung cancer

Interstitial lung disease

Unexplained pulmonary opacities

Hemoptysis

Other

23.3%

40%

20%

6.7%

10%

40%

16.6%

13.3%

10%

20%

FEV₁, forced expiratory volume in 1 s; PaCO₂, arterial partial pressure of carbon dioxide; PaO₂, arterial partial pressure of oxygen

Results

Endpoint

Endobronchial lidocaine, mg

Medication dosage administered, mg

Propofol bolus

Intrabronchial lidocaine

Midazolam bolus

Fentanyl bolus

63 ± 40.36

250.4 ± 42.38

1.7 ± 0.25

0.0283 ± 0.0429

62.33 ± 33.6

164.7 ± 20.8

1.78 ± 0.36

0.0217 ± 0.0387

0.5806

< 0.0001

0.5356

0.6127

Duration of bronchoscopy, min

12.17 ± 4.6

0.0594

Arterial blood gas post-procedure, mmHg

PaCO₂^*

PaO₂**

42.75 ± 8.18

70.4 ± 17.5

41.67 ± 4.57

74.2 ± 11.2

0.5291

0.3271

Complications

≥ 1 reported

Rate per procedure

Episodes of SpO₂ < 90%

14 (46.67%)

1.17 ± 1.62

1.03 ± 1.33

6 (20%)

0.3 ± 0.79

0.27 ± 0.78

0.0539

0.0121

0.0070

Time to reach ALDRETE score ≥ 9, min

4 ± 3.6

4.7 ± 4.1

No differences in the dosage of sedative drugs were observed between the two groups (all p> 0.05). No significant differences in VAS scores for global tolerance, nausea, asphyxia, cough, and pain were reported between groups. 

*Compared with pre-procedural values, post-procedural PaCO₂ was significantly higher in both groups (both p< 0.0001).

**A significant increase between pre- and post-interventional PaO₂ was seen in the nebulizer group (difference 7.6 ± 12.1 mmHg; 95% CI 3.1 to 12.1; p= 0.0018) but not in the syringe group (difference 1.1 ± 16.8 mmHg; 95% CI -5.2 to 7.4; p= 0.7188)

Adverse Events

See 'complications' in Results section above. 

Study Author Conclusions

In summary, administration of topical lidocaine via nebulizer during flexible bronchoscopy under moderate sedation is associated with reduced consumption of lidocaine compared with standard administration via syringe. Furthermore, nebulizing lidocaine during bronchoscopy was associated with improved oxygenation during the procedure and fewer peri-interventional complications. Therefore, nebulizers can be recommended for usage during diagnostic bronchoscopy, especially for patients suffering from respiratory failure.

InpharmD Researcher Critique

There was a slight imbalance in groups as diagnostic bronchoscopies without sampling were more common in nebulizer group, however not statistically significant.

Role of Lignocaine Nebulization as an Adjunct to Airway Blocks for Awake Fiber-Optic Intubation: A Comparative Study

Design

Double-blinded randomized prospective study

N= 60

Objective

To evaluate the effectiveness of using lignocaine nebulization in addition to specific airway blocks for awake fiber-optic intubation (AFOI) 

Study Groups

Nebulization with lignocaine (LB group; n= 30)

Nebulization with normal saline (NB group; n= 30)

Inclusion Criteria

Age 20–60 years, weighing 40–80 kg, and American Society of Anesthesiologists (ASA) physical status Classes I and II having LEMON score of >2 with written informed consent for surgery and emergency tracheostomy

Exclusion Criteria

Nasal problems (fractures and trauma), fracture base of the skull, hypersensitivity (asthma and bronchitis), allergy to drugs used in the procedure (lignocaine), epileptics, bleeding tendency, obesity, and other comorbid diseases

Methods

Patients were randomized to one of two treatment groups. Patients in group LB received nebulization of 2% lignocaine 4 mL while those in group NB received 0.9% normal saline 4 mL. Both groups received airway blocks as bilateral superior laryngeal (2% lignocaine 1–2 mL each) and transtracheal (2% lignocaine 4 mL) block, as well as two puffs of 10% lignocaine to nose and postnasal space on each side.  

Duration

Trial: 30 months

Outcome Measures

Patient comfort and satisfaction

Baseline Characteristics

NB (n= 30)

LB (n= 30)

Age, years

Female

Weight

ASA

Class I

Class II

24

6 

22

8

Bronchoscopy time, seconds

Results

Endpoint

NB (n= 30)

LB (n= 30)

p-Value

Patient comfort

No reaction

Slight grimacing

Heavy grimacing

Verbal objection

Defensive movements

6

16

6

2

0

8

20

2

0

0

Patient satisfaction (excellent/good experience)

Adverse Events

Study Author Conclusions

Upper airway blocks (bilateral superior laryngeal and transtracheal nerve block) provide adequate anesthesia for performance of awake FOB. Furthermore, when 4 mL of 2% lignocaine through nebulization is added with airway blocks, it improves the quality of anesthesia by increasing overall comfort and satisfaction of patients, thus providing more acceptable condition for awake FOB.

InpharmD Researcher Critique

Serum lignocaine levels were not measured. Additionally, this study appears to have been conducted outside of the United States, where standard of care may vary. 

A Randomized Controlled Trial to Assess the Effect of Lidocaine Administered via Throat Spray and Nebulization in Patients with Refractory Chronic Cough

Design

Randomized, double-blind, double-dummy, placebo-controlled, three-way crossover study

N= 26

Objective

To investigate the efficacy of nebulized lidocaine and lidocaine throat spray versus matched placebos in refractory chronic cough (RCC)

Study Groups

Nebulizer-spray-placebo (n= 4)

Nebulizer-placebo-spray (n= 5)

Placebo-nebulizer-spray (n= 4)

Placebo-spray-nebulizer (n= 4)

Spray-nebulizer-placebo (n= 4)

Spray-placebo-nebulizer (n= 4)

Inclusion Criteria

Adult patients with RCC, resistant to treatment of possible underlying causes

Exclusion Criteria

Upper respiratory tract infection in last 4 weeks; current or ex-smokers of < 6 months abstinence; > 20 pack year cigarette smoking history; diabetes; pregnancy; clinically significant comorbidities (i.e., ischemic heart disease, heart failure, sinoatrial disease, bradycardia, and all types of heart block); any medications likely to affect cough reflex sensitivity (i.e., ACE inhibitors, codeine, low dose morphine, gabapentin, pregabalin, baclofen)

Methods

Study treatments were administered in random order with at least 2-day minimum and 3-day maximum washout period between treatments. Study medications were dispensed as lidocaine 10% w/v and placebo (0.9% normal saline) in matching glass bottles; one was labelled for nebulization and the other for use as throat spray.

On study days, the nebulized treatment was administered first followed by the throat spray (10 actuations); patients were randomly assigned to receive the following interventions: nebulized lidocaine 600 mg followed by placebo throat spray; nebulized placebo followed by placebo throat spray; or nebulized placebo followed by lidocaine throat spray 100 mg. Study treatments were delivered by continuous nebulization by a Porta-neb VentStream®; the nebulized lidocaine dose of 600mg was anticipated to deliver approximately 100 mg in the throat; as such the lidocaine throat spray was dosed to match this. A 24-hour ambulatory cough recording device was provided to the patient and initiated recording immediately prior to the study drug administration. Patients reported urge-to-cough (UtC) intensity and severity of cough on 100 mm visual analogue scales (VAS) prior to treatment, every 15 minutes for 2 hours, then hourly for 8 hours at home. Patients were nil by mouth after drug administration, with clear liquids allowed 2 hours after and food 4 hours after; patients were observed in the research ward for 4 hours after treatment then discharged with cough monitor and diary for 24 hours after treatment. 

Duration

February 2011 to May 2011

24 hours after study treatment 

Outcome Measures

Primary: cough frequency over 10 hours following treatment

Secondary: change in VAS score for UtC and cough severity; adverse events 

Baseline Characteristics

Total cohort (N= 26)

Age, years

Female

Never-smokers

Median cough duration (IQR), years

FEV1% predicted, L

FVC% predicted, L

105.2 ± 16.8

112.4 ± 18

FEV1: forced expiratory volume in 1 second; FVC: forced vital capacity; IQR: interquartile range

Results

Endpoint

Total cohort (N= 26)

p-Value

Cough frequency over 10 hours, mean, cough/hour (95% CI)

Placebo spray

Lidocaine throat spray

Nebulized lidocaine spray

n= 25

27.6 (18.6 to 41.3)

22.2 (14.5 to 33.8)

26.9 (18.5 to 39.2)

0.04*

Cough severity VAS score, mean difference compared to placebo, mm

Lidocaine throat spray

Nebulized lidocaine

-6.2

-7

0.029

0.022

UtC VAS score, mean difference compared to placebo, mm

Lidocaine throat spray

Nebulized lidocaine

-6.1

-8.62

-.014

0.005

CI: confidence interval

*Lidocaine throat spray compared to placebo

Reduction in cough frequency compared to placebo: lidocaine spray (20%; 95% CI -52% to 22%; p= 0.017); nebulized lidocaine (p= 0.84)

Exploratory analysis of treatment effect by hour suggested a significant effect of intervention on hourly cough frequency in 5 hours after treatment administration (p= 0.004); lidocaine spray resulted in greatest effect (compared to placebo) in first hour with little difference by hours 4 and 5. 

Coughs during nebulization (median [IQR]): placebo: 2 [0], [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]; lidocaine throat spray: 1 [0-15.5]; nebulized lidocaine: 14 [0], [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35]; p= 0.018

Adverse Events

Common Adverse Events: swallowing difficulty (nebulized lidocaine, n= 1); sore throat (nebulized lidocaine, n=1; placebo, n= 2); heartburn (nebulized lidocaine, n= 1); breathlessness (nebulized lidocaine, n= 1); headache (nebulized lidocaine, n= 1; lidocaine throat spray, n= 1; placebo, n= 1); panic attack (lidocaine throat spray, n= 1); itching (lidocaine throat spray, n=1; placebo, n= 1); palpitation (lidocaine throat spray, n= 1); skin bruise (lidocaine throat spray, n= 1); painful hand (lidocaine throat spray, n= 1)

Serious Adverse Events: none

Percentage that Discontinued due to Adverse Events: N/A

Study Author Conclusions

InpharmD Researcher Critique

Effect of Lidocaine Nebuliser Compared with NSS Nebuliser in Reducing Cough Symptom and Pain in Early Tracheostomy Care

Design

Prospective, randomized, single-blind, cross over study

N= 32

Objective

To compare the effectiveness of pain and cough reduction in the early postoperative period following tracheostomy between a lidocaine-NSS and a NSS nebulizer

Study Groups

AB, lidocaine-NSS nebulizer then NSS nebulizer (n= 16)

BA, NSS nebulizer then lidocaine-NSS nebulizer (n= 16)

Inclusion Criteria

Age ≥ 18 years with tracheostomy

Exclusion Criteria

Pregnancy; chronic lung disease; lung infection; skin infection at the neck; lidocaine or amide allergy; cancer with metastasis to the neck skin; had to receive another operation other than tracheostomy; use of ventilator after operation; chronic liver or kidney disease

Methods

Patients were randomized to two groups: the AB group received lidocaine-NSS nebulizer at 10 AM and 8 hours later received NSS nebulizer at 6 PM; the BA group received NSS nebulizer at 10 AM, then the lidocaine-NSS nebulizer 8 hours later at 6 PM. Treatment was administered on postoperative day 2 after deflation of tracheostomy cuff and after adequate time for the intraoperative analgesic drug which was administered to wear off. Pain and cough were scored by patients using a visual analog scale (VAS; 0= no symptom, 10= severe symptom) before and 60-90 minutes after each nebulization. Those with severe pain were capable of requesting an analgesic (i.e., acetaminophen, tramadol, or morphine) for pain relief; those who requested painkillers between 6 AM and 6 PM were excluded in the pain score analysis.

Duration

June 2016 to June 2017

Outcomes assessed 60-90 minutes after each nebulization

Outcome Measures

Cough, pain

Baseline Characteristics

All patients (N= 32)

Age, years

Female

Anesthesia

General

Local

56.3%

43.8%

Indication

Bilateral vocal cord paralysis

CA larynx

CA esophagus

CA oropharynx

CA hypopharynx

CA oral cavity

9.4%

43.8%

3.1%

25%

6.3%

21.9%

Painkiller requested

31.3%

CA: cancer

Results

Endpoint

AB (n= 16)

BA (n= 16)

Delta (95% CI); p-value

Cough

Lidocaine-NSS

Pre-treatment

Post-treatment

Delta

NSS

Pre-treatment

Post-treatment

Delta

6.06 ± 1.81

3.63 ± 2.73

2.44 ± 2.48

4.44 ± 2.31

3.75 ± 2.79

0.69 ± 2.21

5.44 ± 1.79

3.69 ± 2.24

1.75 ± 1.77

5.13 ± 2.03

4.06 ± 2.54

1.06 ± 1.73

0.63 (-0.67 to 1.92); 0.333

-0.06 (-1.87 to 1.74); 0.944

0.69 (-0.87 to 2.24); 0.373

-0.69 (-2.26 to 0.88); 0.378

-0.31 (-2.24 to 1.62); 0.743

-0.38 (-1.81 to 1.06); 0.597

Pain

Lidocaine-NSS

Pre-treatment

Post-treatment

Delta

NSS

Pre-treatment

Post-treatment

Delta

3.88 ± 2.39

2.69 ± 2.63

1.19 ± 1.17

3.31 ± 3.16

2.81 ± 2.64

0.5 ± 1.55

3.88 ± 2.16

2.56 ± 1.59

1.31 ± 1.74

4.06 ± 2.29

3 ± 2.45

1.06 ± 1.73

0 (-1.64 to 1.64); 1.0

0.13 (-1.44 to 1.69); 0.872

-0.13 (-1.19 to 0.94); 0.813

-0.75 (-2.74 to 1.24); 0.448

-0.19 (-2.03 to 1.65); 0.836

-0.56 (-1.75 to 0.62); 0.34

CI: confidence interval 

Pre-treatment and post-treatment analysis:

Cough

-lidocaine-NSS: delta 2.09; 95% CI 1.32 to 2.87; p< 0.001

-NSS: dellta 0.88; 95% CI 0.17 to 1.58; p= 0.017

Pain

-lidocaine-NSS: delta 1.25; 95% CI 0.72 to 1.78; p< 0.001

-NSS: delta 0.78; 95% CI 0.19 to 1.37; p= 0.011

Adverse Events

None observed 

Study Author Conclusions

A 1% lidocaine mixed 4:1 (v/v) with NSS and administered via a nebulizer caused a significant reduction in cough and pain symptoms in early postoperative tracheostomy patients, particularly for the cough symptom compared with using only a NSS nebulizer. 

InpharmD Researcher Critique

The study is limited by its small sample size and short duration of the intervention and follow-up period. Additionally, outcomes were assessed in a subjective manner which may lead to interpatient variability. 

Peritonsillar abscess: a cohort study of an unusual imaging and needle guidance approach

Design

Prospective, single-center, nonrandomized study

N= 91

Objective

To establish a noninvasive, safe, and reliable sonographic technique for evaluating peritonsillar abscess and subsequent drainage

Study Groups

Full cohort (N= 91)

Inclusion Criteria

Patients treated in emergency medicine department with suspected peritonsillar abscess (PTA)

Exclusion Criteria

Patients not admitted from the emergency department

Methods

Patient data were compiled via retrospective chart review. All patients were initially evaluated using imaging without needle guide attachment to confirm abscess. Most patients were imaged transorally with endocavity probe. Various anesthesia techniques were utilized. During initial phase, physicians preferred to infiltrate varying amounts of 1% lidocaine to posterior pharynx.

In one technique, patients received topical anesthesia with nebulized 2% lidocaine and or 2% viscous lidocaine-soaked gauze wrapped around a curved clamp. Light sedation with opiate or benzodiazepine was used, followed by submucosal injection of lidocaine for additional anesthesia.

Another technique included a topical anesthetic spray of 14% benzocaine, 2% butamben, and 2% tetracaine to the posterior pharynx.

Once anesthesia was achieved, needle-guided drainage was performed with static sagittal sonogram assistance.

Duration

Patients admitted between March 2010 to November 2022

Outcome Measures

Baseline Characteristics

Full cohort (N= 91)

Age, years (range)

Female

Number of abscesses found

Bilateral peritonsillar abscess

87

5

Abscess drainage with ultrasound guidance

Results

All abscesses were successfully drained without complications. There were no breakdowns of the number of patients receiving each anesthetic technique.

Adverse Events

Study Author Conclusions

This level of evidence demonstrates a possible method is safer, which may be more effective than a nonimaging approach for needle aspiration. This technique is easily applied by both physician and sonographer with minimal training.

InpharmD Researcher Critique

Awake tracheostomy in a child with respiratory distress due to retropharyngeal abscess

Design

Case presentation

A 10-year-old male patient weighing 35 kg arrived at a tertiary hospital's emergency room complaining of respiratory distress and audible stridor. Three days prior, the patient reported ingesting a plastic toy that was removed painlessly while under general anesthesia (GA). The patient experienced audible stridor, orthopnea, dysphagia, and a gradually growing visible swelling in the neck over the next few days. An urgent computed tomography scan and neck X-ray showed an hourglass-shaped retropharyngeal abscess compressing the trachea. The sizeable retropharyngeal abscess filled the laryngopharynx, oropharynx, and infraglottic region of the trachea.

The child needed emergency abscess drainage due to a heart rate of 120 beats per minute, respiratory rate of 30 beats per minute, inability to lie down, and SpO2 of 98% on FIO2 of 0.6. Supportive care was administered in the interim, including nebulization with ipratropium bromide and salbutamol every 6 hours, as well as intravenous (IV) ceftriaxone 1 g every 12 hours.

A local infiltration was administered using 2% lidocaine and 1:200,000 adrenaline. A 6.0 mm tracheostomy tube was inserted during the 3.5-minute awake tracheostomy procedure, which was carried out after sufficient skin analgesia was established. Following the proper placement of the tracheostomy tube using capnography, fentanyl 70 µg and propofol 60 mg were injected IV, along with 20 mg of atracurium for neuromuscular blockade. This resulted in the establishment of general anesthesia. Sevoflurane 1-2% and oxygen in the air were used to maintain general anesthesia. The retropharyngeal abscess was incised and drained by an otolaryngologist.

After the procedure, a nasogastric tube was placed for feeding, and intravenous neostigmine and glycopyrrolate were used to reverse the neuromuscular blockade. The patient was then kept in the ward on oxygen delivered 8 liters per minute at first using a T-piece, and then switched to room air. During the postoperative period, patients received psychological support and 500 mg of acetaminophen intravenously every six hours. After seven days, the patient had his cannula removed, and he could then breathe and swallow without complications.

Study Author Conclusions