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Lignocaine as a pretreatment to rapid sequence intubation in patients with status asthmaticus
  1. John Butler, Consultant,
  2. Rupert Jackson, Consultant
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jonesman.ac.uk

    Abstract

    A shortcut review was carried out to establish whether pretreatment with intravenous lignocaine is of benefit in asthmatic patients undergoing rapid sequence intubation (RSI). Altogether 157 papers were found using the reported search, of which one presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated (table 3). It is concluded that there is no good evidence to support the use of lignocaine in this circumstance.

    • asthmaticus
    • asthma
    • lignocaine
    • rapid sequence intubation
    • tachycardia

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    Clinical scenario

    A patient attends the emergency department in status asthmaticus. On examination they have a sinus tachycardia at a rate of 150/min, an oxygen saturation of 92% on high flow oxygen, and a pCO2 of 7.0 kPa. Despite maximal medical treatment they are becoming exhausted. You decide that the patient needs a RSI and continuous mandatory ventilation. You wonder whether the pretreatment with lignocaine will attenuate the respiratory response (bronchospasm) to airway manipulation.

    Three part question

    In [asthmatic patients who need RSI and ventilation] does [pre-treatment with intravenous lignocaine prior to RSI] reduce the incidence of [adverse airway responses]?

    Search strategy

    Medline OVID 1966 to week 4 June 2005. [exp Asthma OR exp Asthma, exercise induced OR asthma$.mp OR exp Bronchial spasm OR bronchospasm.mp] AND [exp Lidocaine OR lidocaine$ OR lignocaine$ OR lignocaine.mp]. LIMIT to human, English language, and publication year 2000–2005.

    Embase OVID 1980 to week 27 2005. [exp Asthma OR exp Asthma, exercise induced OR asthma$.mp OR exp bronchospasm OR bronchospasm.mp] AND [exp Lidocaine OR lidocaine$ OR lignocaine$ OR lignocaine.mp]. LIMIT to human, English language, and publication year 2000–2005.

    The Cochrane Library Issue 2 2005. [{Asthma MeSH }] AND [{bronchial spasm MeSH}] AND [{lidocaine MeSH OR lignocaine ALL FIELDS}].

    Search outcome

    Altogether 157 papers were found in 2000–2005, of which 143 were unique, of which one was relevant to the question.

    Comments

    Tracheal intubation in asthmatics is linked to the risk of life threatening bronchospasm. This reflex is in part neurally mediated through the vagus nerve. Local anaesthetics have been used as a pretreatment to airway stimulation in susceptible patients in the hope of attenuating the reflex induced bronchoconstriction. The National Emergency Airway Course recommends a pretreatment dose of intravenous lignocaine (3 mg/kg) given 3 minutes prior to intubation in this patient group. There is no evidence from the above trial that this will be of value. Interestingly pretreatment with albuterol did attenuate the response.

    CLINICAL BOTTOM LINE

    There is no evidence for the use of lignocaine as a pretreatment agent in asthmatic patients needing an RSI.

    Table 3

    References

    View Abstract

    Footnotes

    • Report by John Butler, ConsultantSearch checked by Rupert Jackson, Consultant

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