Pediatric Anesthesia ISSN 1155-5645

REVIEW ARTICLE

Lignocaine topicalization of the pediatric airway

Mari H. Roberts & Christopher D. Gildersleve
Department of Anaesthesia, University Hospital of Wales, Cardiff, UK

Keywords
local anesthesia; lidocaine; child; airway
management; review
Correspondence
Mari H. Roberts, Department of
Anaesthesia, Intensive Care and Pain
Medicine, University Hospital of Wales,
Heath Park, Cardiff CF14 4XN, UK
Email: mari_h_roberts@yahoo.co.uk
Section Editor: Brian Anderson
Accepted 28 January 2016
doi:10.1111/pan.12868
Summary
The application of topical laryngeal lignocaine is a technique used frequently
in pediatric anesthesia. It is often used to facilitate open airway procedures,
tracheal intubation, or to reduce the incidence of perioperative adverse respi-
ratory events such as coughing and laryngospasm. A number of studies have
shown that applying topical lignocaine to the larynx reduces perioperative
respiratory adverse events, while others have shown an increased incidence of
respiratory complications with lignocaine administration. There is a lack of
evidence on the effect of topical lignocaine on the sensitivity of upper airway
reflexes and swallowing, the duration of time that airway reflexes are
obtunded, and the optimum and safe maximum dose of lignocaine when used
by this route. We review the current literature relating to the use of lignocaine
to topicalize the pediatric airway. This review concentrates on the indications
for use, the maximum safe dose, the effect on swallowing, and risk of aspira-
tion and the complications of the technique.

prevent perioperative respiratory adverse events, some

Introduction
Topical laryngeal lignocaine (topicalization) is frequently
used in pediatric anesthesia; to facilitate open airway pro-
cedures, aid intubation, or to prevent coughing or other
adverse respiratory events (1,2). There is a lack of evi-
dence on the effect of lignocaine on the sensitivity of
upper airway reflexes and swallowing, the duration of
time that airway reflexes are obtunded, the time before
oral intake can be recommenced, and the safe maximum
dose of lignocaine when used by this route.
It is common practice among UK pediatric anes-
thetists to withhold oral intake following topicalization,
to minimize the risk of aspiration. It is unclear whether
this is necessary and if so, for how long. Studies have
demonstrated a risk of aspiration immediately following
topicalization in adults (35). No studies were identified
that looked at the duration of action of topical ligno-
caine on swallowing and risk of aspiration.
The British National Formulary for children (BNFC)
recommends the same maximum lignocaine dose of
3 mg
kg 1 for surface anesthesia, as for infiltration (6).
Many anesthetists routinely use doses in excess of
3 mg
kg 1 for pediatric laryngeal topicalization, but the
extent and safety of this practice is unclear. In addition,
while some anesthetists use lignocaine topicalization to
studies suggest its use may increase the incidence of air-
way and respiratory complications (1,2), casting doubt
on the appropriateness of using the technique for the
prevention of coughing and laryngospasm.
This review focuses on the indications for use, the
maximum safe dose, the effect on swallowing and risk of
aspiration, and the complications associated with ligno-
caine topicalization of the pediatric airway. In addition,
we conducted a survey of current practice of members of
the Association of Paediatric Anaesthetists of Great Bri-
tain and Ireland (APAGBI) on the use of lignocaine
topicalization in their pediatric practice.
Methods
Search strategy
We carried out a PubMed and Cochrane Central Regis-
ter of Controlled Trials search using the keywords lido-
caine, local anesthesia, topical, topicalization, airway
anesthesia, spray, laryngeal, endotracheal, children,
pediatrics, swallowing, laryngospasm, and aspiration.
Papers retrieved using these search items were reviewed.
In addition, references to these papers were examined
and papers of relevance were also reviewed.

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Pediatric airway topicalization
Survey
All UK members of the APAGBI were invited to com-
plete the electronic survey (www.surveymonkey.com),
which was accessible between 29th July 2013 and 30th
September 2013. One reminder was sent out following
the original invitation. Two hundred and ninety-seven
anesthetists responded to the survey (response rate
29%). Personalized correspondence instead of a generic
e-mail to all UK members or a second reminder e-mail
may have improved compliance. Results of this survey
are presented in the relevant sections of this review.
Indications
Lignocaine topicalization is commonly used to provide
airway anesthesia to facilitate open airway procedures.
Other uses include: tracheal intubation in the absence of
neuromuscular blockade (7), reduction of the incidence
of coughing and laryngospasm on induction or emer-
gence from general anesthesia (813), attenuation of the
haemodynamic changes to laryngoscopy (14), attenua-
tion of bronchial hyper-reactivity (15,16), and reduction
in the incidence of postoperative sore throat (17).
Perioperative respiratory adverse events
While there is some evidence that lignocaine topicaliza-
tion reduces perioperative respiratory adverse events
such as coughing and laryngospasm (811), other work
shows an increased incidence of respiratory complica-
tions with lignocaine administration (1,2,18). A large
cohort study of children undergoing general anesthesia
over a 1-year period reported an increased incidence of
perioperative laryngospasm and bronchospasm with
laryngeal lignocaine application before tracheal intuba-
tion (2). In addition, an observational audit of children
undergoing general anesthesia with tracheal intubation
without a neuromuscular blocking agent, showed an
increased incidence of desaturations (from induction to
discharge from recovery) when topical lignocaine was
used (1). Inadequate depth of anesthesia during ligno-
caine application may have contributed to the increased
incidence of complications in these observational studies
(1,2,18). It would seem that lignocaine topicalization
increases the overall incidence of perioperative respira-
tory adverse events (from induction to recovery), when
applied across the population of children having general
anesthesia.
Studies reporting a reduction in perioperative respira-
tory complications with lignocaine have largely been
controlled studies of complications at extubation or
postoperatively and do not report on complications at
338
M. H. Roberts and C. D. Gildersleve
induction (810,12,13). A recent systematic review
demonstrated a reduction in the incidence of laryn-
gospasm in children with both topical and intravenous
lignocaine administration (11). This review covers stud-
ies of laryngospasm at both induction and following
extubation, but does not differentiate between these two
different clinical scenarios. Five randomized controlled
studies using topical lignocaine (spray, aerosol, or ligno-
caine gel to laryngeal mask airway) were included. Of
these, only two demonstrated a reduction in laryn-
gospasm with topical lignocaine (9,10). Both these stud-
ies looked exclusively at the incidence of postextubation
laryngospasm in patients undergoing tonsillectomy and
adenoidectomy, a cohort of patients who are likely to be
at increased risk of laryngospasm. The other three stud-
ies (1921) found no difference in the incidence of laryn-
gospasm following topicalization. As laryngospasm is a
relatively rare occurrence in the general pediatric popu-
lation, these studies may have been underpowered to
detect a difference. Indeed the review is not confined to
the pediatric population as one of these five studies
included patients ranging from 1 to 71 years of age (9).
Coughing postextubation is reduced if topicalization
immediately precedes or is within 2 h of extubation in
adults (8,12,13). In children, lignocaine gel applied to a
laryngeal mask has been shown to decrease postopera-
tive coughing but only in patients with recent or ongoing
upper respiratory tract infections (21).
In summary, lignocaine topicalization may be of ben-
efit in reducing perioperative respiratory events such as
laryngospasm and coughing in selected cases, e.g., some
ENT surgery and laryngotracheal procedures or in chil-
dren with recent or current upper respiratory tract infec-
tion. Current evidence cannot support its routine use in
all children.
Attenuation of bronchial hyper-reactivity
Both topical and intravenous lignocaine have been used
to prevent reflex-induced bronchoconstriction in
patients with bronchial hyper-reactivity (15,16,22). Lig-
nocaine has an interesting effect on airway tone in these
patients. Inhaled lignocaine causes an initial dose-depen-
dent reduction in FEV1. This is not seen with intra-
venous lignocaine and thought to be due to direct
airway irritation. Attenuation of bronchoconstriction
then follows with both topical and intravenous ligno-
caine (15,16). This reduction in airway tone has only
been demonstrated when bronchoconstriction is
induced, e.g., by histamine. Intravenous lignocaine has
been shown to increase baseline airway tone in asth-
matic patients (22), suggesting that lignocaine only
attenuates the induced increase in tone, above baseline,
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Pediatric Anesthesia 26 (2016) 337344
M. H. Roberts and C. D. Gildersleve
caused by drugs that cause bronchoconstriction, such as
histamine.
Postoperative sore throat
Sore throat is a common minor complaint following
general anesthesia (23). We could find no evidence of the
impact of lignocaine on postoperative sore throat in
children. A systematic review of the effect of lignocaine
on postoperative sore throat in adults concluded that
both topical and intravenous lignocaine reduced the
incidence and severity of sore throat after anesthesia
with a tracheal tube (17). Only five of the 15 studies
reviewed showed a reduction in sore throat and three of
the studies demonstrated an increase in sore throat. Lig-
nocaine spray, which contains additives including men-
thol and ethanol, has been shown to increase the
incidence of sore throat compared with lignocaine with-
out additives (24).
Mode of delivery
The most frequently described method of anesthetizing
the pediatric airway is to spray lignocaine onto the
laryngeal and tracheal mucosa under direct vision. Two
different types of device are available; one which delivers
a jet of solution and one that produces a fine atomized
spray. Devices that deliver a jet of local anesthesia
include the Xylocaine 10 mg spray (AstraZeneca UK,
Luton, Bedfordshire, UK), the Laryngojet (Amphastar
Pharmaceuticals, Rancho Cucamonga, CA, USA)
(Figure 1) and the Cass needle (Victor-G & Co, Kanpur,
India). The Xylocaine spray is a metered spray device
that delivers a 10 mg dose of lignocaine with each spray
via a single use spray nozzle. Wider coverage may be
obtained with the Laryngojet or the Cass needle. The
Laryngojet consists of a prefilled vial of 4% lignocaine
attached to a cannula, which has holes along its length
allowing a 360 spray coverage. Similarly, the Cass nee-
dle has a 360 dispersion pattern due to its four-side
holes and one distal opening. The alternative device
produces a fine atomized spray, e.g. MAD Mucosal
Atomization Device (Wolfe Tory Medical Inc., South
Salt Lake City, UT, USA) (Figure 1). The MAD
Mucosal Atomization Device is a malleable stylet, which
can be attached to a syringe. The spray delivered has a
typical particle size of 30100 lm. This fine mist is likely
to be less irritant to the airway compared to a jet of
liquid and may cover a wider area for the same volume.
The smaller droplets are also more likely to reach the
peripheral airways.
The delivery of a spray under direct vision allows tar-
geted coverage of key laryngeal structures, as well as
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Pediatric Anesthesia 26 (2016) 337344
Pediatric airway topicalization
subglottic application. The disadvantage of this
technique is the need for laryngoscopy. Described meth-
ods of topicalization that do not require laryngoscopy
for application include the blind instillation of ligno-
caine to the back of the mouth (25), and nebulization
(15,26,27). Lignocaine instilled blindly into the back of
the mouth has been shown to deliver solution to key
laryngeal structures (25), but it is likely to be less reliable
than application under direct vision and unlikely to
anesthetize the subglottic region. Nebulization is likely
to be less irritant to the airway than application with a
spray and may be of benefit in procedures requiring a
wide distribution of local anesthesia such as flexible
bronchoscopy (26) and fibreoptic intubation (27), as
nebulization enhances the spread of much smaller dro-
plets to the peripheral airways. The disadvantages of
nebulization are that the solution cannot be targeted to
a particular area, it may take time to administer and the
total dose delivered is unknown as nebulized solution
will escape around the mask. Other methods of topical-
ization include administration directly down the tracheal
tube (13) and application on the airway device, e.g., lig-
nocaine gel applied to a laryngeal mask airway (21).
Dose
The maximum dose of lignocaine that can be safely
administered to children for topical airway anesthesia is
unknown. The median maximum dose used among pedi-
atric anesthetists in the UK who responded to our sur-
vey is 4 mg
kg 1 (110 [35]) (range) [IQR]). The most
commonly used maximum dose was 3 mg
kg 1, consis-
tent with the BNFC recommended maximum (6). Many
respondents used higher doses, up to 10 mg
kg 1.
Figure 1 Topicalization spray devices: The Laryngojet (top) and
The MAD Mucosal Atomization Device (bottom).
339
Pediatric airway topicalization
The use of such high doses may be influenced by adult
practice. Historically a much higher maximum dose
(8.2 mg
kg 1) was used for adult bronchoscopy (28). This
recommendation is based on a lack of evidence of toxicity
at this dose in adults (29,30). The rationale is that during
bronchoscopy a variable amount of the local anesthetic is
swallowed or removed through the bronchoscope suc-
tion. During topicalization of the pediatric airway small
volumes may indeed be removed by suction, some will
be swallowed, or pass passively into the esophagus so
peak plasma concentration may be influenced by this.
Doses in excess of 3 mg
kg 1 have been used safely for
airway topicalization in a number of pediatric studies (31
33). In the largest of these studies 4 mg
kg 1 of lignocaine
was applied to the larynx of 96 children (32). Although
peak plasma lignocaine concentrations were within the
accepted safe limit (<5 lg
ml 1) in the majority of patients,
concentrations of over 8 lg
ml 1 (and up to 10 lg
ml 1)
were reported. These unpredictable high concentrations
appeared in all age groups. Despite high plasma concentra-
tions no clinical evidence of lignocaine toxicity was seen
and it was concluded that a dose of 4 mg
kg 1 via tracheal
spray is safe in anesthetized children.
Occasional high plasma concentrations have been
demonstrated in a number of other pediatric and adult
studies (30,32,34,35). These results are likely to reflect
individual differences in lignocaine absorption and
metabolism. A number of factors may affect peak
plasma concentration of lignocaine after topical admin-
istration. Peak plasma concentration is dependent on
the rate of absorption from the mucous membrane.
More rapid absorption occurs in the alveoli and periph-
eral airways compared with the upper airways (14,35).
Factors which may increase delivery of the drug to the
peripheral airways include direct application to the tra-
chea and peripheral airways (34), positive pressure venti-
lation (36), increased depth of respiration if breathing
spontaneously and use of devices that optimize droplet
size (37). Droplets of 40 lm are distributed only in the
upper airways while 2 lm droplets may reach the
peripheral airways (37). The presence of bronchial
mucus will decrease lignocaine delivery to the peripheral
airways (35). The rate of absorption may also be depen-
dent on the dryness of the mucosa, especially in children
under 2 years of age (31). Therefore, use of an antisiala-
gogue may result in significantly higher plasma concen-
trations in this age group.
Studies reporting the effect of age on the peak plasma
concentration have demonstrated earlier (31,32) and
higher (31) peak serum lignocaine concentrations in
younger children compared with older patients, which
may be due to greater vascularity of the respiratory tract
mucous membrane. In these studies, patients received
340
M. H. Roberts and C. D. Gildersleve
either hyoscine or atropine premedication and positive
pressure ventilation. When a mucosal drying agent is
not used and spontaneous respiration maintained
throughout, a later peak plasma concentration is seen in
infants <6 months of age compared with older children
(38). This suggests that the use of an antisialagogue
and/or positive pressure ventilation may have a greater
influence on lignocaine absorption in young infants
compared to older children. Neonates and infants up to
6 months of age have lower plasma concentrations of
albumin and a1 -acid glycoprotein, which results in a
higher fraction of unbound local anesthetic and hence
an increased risk of toxicity (39).
Another consideration is the duration over which the
lignocaine is administered. Lignocaine topicalization
administered as a spray is effectively a bolus. When
administered via nebulization (26) or as repeated smaller
boluses during bronchoscopy (40), it is given over a
longer period of time and is more likely to produce a
maintained plateau, rather than a sharp peak in concen-
tration. Doses of up to 8.5 mg
kg 1 have been used
safely in children, when administered as multiple small
boluses during bronchoscopy up to 45 min in duration
(40). Such high total dosage in small increments should
be administered with caution. Following a bolus the
time to maximum lignocaine concentration (Tmax) is
12.6 min (SD 8.9) (38). Therefore, repeated boluses given
within this time frame may result in accumulation. This
is important to consider when using topical laryngeal
lignocaine in addition to a regional technique with an
amide local anesthetic agent.
Lignocaine is extensively metabolized by the liver and
its clearance is dependent on hepatic blood flow. Chil-
dren with cardiac failure may have reduced lignocaine
clearance due to decreased blood flow to the liver
(39,41). Clearance can be compromised when hepatic
parenchymal disease is severe. Renal impairment may
also cause an increase in peak plasma concentration due
to the enhanced absorption caused by the hyperdynamic
circulation seen in uremic patients (39).
A number of publications have shown occasional
peak serum lignocaine concentrations of over 5 lg
ml 1
without any clinical signs of toxicity in anesthetized
patients (30,32,34,35). The lack of signs of toxicity may
be due to a protective effect of general anesthesia. In
anesthetized adults, the potentially toxic plasma ligno-
caine concentrations may be much higher than
5 lg
ml 1 and may be in the region of 10 lg
ml 1 (35).
We found no similar toxic plasma lignocaine concentra-
tions published for pediatric populations.
Current evidence supports a maximum bolus dose of
4 mg
kg 1 in the majority of anesthetized children. It
would be wise to avoid using higher doses in neonates
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Pediatric Anesthesia 26 (2016) 337344
M. H. Roberts and C. D. Gildersleve
and young infants and when there are factors present
that may increase lignocaine absorption. A lower dose
should be considered in patients with renal, cardiac, and
severe hepatic failure. Although higher doses may be
safe, even at a dose of 4 mg
kg 1 occasional unpre-
dictable high lignocaine concentrations have been
demonstrated (32). Use of a higher total dose cannot be
guaranteed to avoid lignocaine toxicity in all children
and cannot be recommended.
Onset and duration of action
Lignocaine has a fast onset of action when injected into
tissue at normal physiological pH (42). When applied
topically to the tongue or lower lip mucous membrane,
it has an onset of action of 12 min, with maximum
analgesic effect achieved at 45 min (43,44).
Lignocaine has a duration of action of 12 h when
used for various regional anesthesia techniques (42).
When applied to the oral mucosa and airway, the dura-
tion of action may be much shorter (15,43,44). The
hypoalgesic effect of topical lignocaine when applied to
the lower lip has been shown to last <15 min (44). Simi-
larly, topical 2% and 4% lignocaine applied to the ton-
gue lasts 12 and 15 min, respectively (43). In the cat,
laryngeal responses are lost after a mean duration of
1.8 min following topical application. The mean dura-
tion of action (until the first recovery of laryngeal
response) was found to be similar when 10 mg of ligno-
caine was administered as 2% (13 min) and 5% solution
(19 min). When the same dose was applied as 10% lig-
nocaine, this duration was significantly longer (35 min).
In addition, the return to baseline laryngeal response
was significantly shorter with 2% lignocaine (63 min)
than 5% (103 min) and 10% lignocaine (117 min) (45).
Acknowledging the difficulty in applying animal labo-
ratory work to the clinical setting, two points bear con-
sideration. Firstly, the duration of action of topical
laryngeal lignocaine may be dependent on the concentra-
tion used. In this study, the 2% and 5% solutions were
produced by diluting the 10% solution with saline,
resulting in a larger spray volume (45), which spreads
more extensively along the respiratory tract. It seems log-
ical that the smaller volume of the 10% spray concen-
trated the 10 mg dose around the larynx, accounting for
the longer duration of action. If this is the case, then the
duration of action is likely to be dependent on the dose
applied per unit area. In contrast, no significant increase
in duration of hypoalgesia was demonstrated when a
dose of 60 mg was applied to the lower lip mucous mem-
brane compared to 30 mg on the same surface area (44).
It may be that increasing the dose will have an effect on
the duration of action, until a threshold is reached.
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Pediatric Anesthesia 26 (2016) 337344
Pediatric airway topicalization
Secondly, the duration of time until the laryngeal reflexes
recovered to baseline was considerably longer than the
time to recover the first response (45).
In summary, airway instrumentation and intubation
can be achieved 1.52 min after lignocaine topicalization
(4345). Stimulating procedures should be performed
during the period of maximum hypoalgesia and before
the recovery of any laryngeal response, which is within
approximately 15 min. A varying and declining hypoal-
gesic effect will remain thereafter, the duration of which
is likely to be partially dependent on the dose applied.
When used to facilitate prolonged open airway surgery,
repeated application after 1015 min could be consid-
ered, but within a 4 mg
kg 1 total dose.
Swallowing and the effect of topical anesthesia
Swallowing is initiated by the presence of a bolus of fluid
or solid within the oropharynx which activates sensory
receptors (46). It is a complex progression of muscle
actions which includes pulling the larynx upwards and
forwards to close the airway. Impairment of the swal-
lowing reflex after local anesthesia application is consid-
ered to be largely due to the blocking of sensory
receptors (46). Antagonizing these receptors may pre-
vent the initiation of the reflex and/or impair informa-
tion describing the bolus (e.g., volume and viscosity),
leading to an inadequate swallow (5). Topical anesthesia
may also interfere with the peripheral feedback mecha-
nism, thus impairing swallowing (46).
Concern regarding the risk of aspiration has led many
anesthetists to adopt a practice of withholding oral
intake for a period of time following topicalization of
the pediatric airway. Ninety percent of respondents to
our survey withhold oral intake following topicalization.
The median reported nil by mouth duration was
120 min (20240 [60120]) ((range) [IQR]). Although it
seems intuitive that a child following topical airway
anesthesia will be at greater risk of aspiration due to
impaired swallowing function and diminished protective
reflexes, to date there have been no reported cases of
aspiration in children following topicalization.
Adult studies have demonstrated an increased risk of
aspiration immediately following lignocaine administra-
tion (35). Swallowing was assessed in 13 volunteers
pre- and postlignocaine application to the oropharynx,
larynx, and subglottic region. Nine of the volunteers
demonstrated some degree of abnormal swallowing in
the anesthetized state, with significant aspiration
demonstrated in one volunteer. All incidences of aspira-
tion occurred within the first two swallows and within
20 min (3). Dysphagia to swallowing fluid has been
demonstrated following application of 10% xylocaine to
341
Pediatric airway topicalization
the posterior tonsillar pillars, soft palate, and posterior
pharyngeal wall (5). Five of 12 volunteers also demon-
strated signs of aspiration on swallowing during the first
few minutes following local anesthesia application. Nor-
mal swallowing function returned in all volunteers
within 6 min of lignocaine administration. These studies
suggest that aspiration is a risk immediately following
airway topicalization, and that the effect of lignocaine
on swallowing is either short-lived (<20 min), or that a
safe swallow in the anesthetized state can be learnt by
adults. As local anesthesia primarily affects swallowing
due to its effect on sensory receptors, it is of no surprise
that this duration of <20 min is similar to the 15 min of
hypoalgesia previously described (43,44).
We could find only one study that directly examined
the degree and duration of effect of lignocaine on upper
airway reflexes in humans. Lignocaine was administered
to the nose and larynx of seven adult volunteers. Upper
airway reflex sensitivity was measured using an increas-
ing concentration of ammonia, which produced glottic
closure when a threshold concentration was reached.
Following lignocaine administration, upper airway
reflex sensitivity to ammonia was reduced for up to
100 min (47). It is unclear how closely the effect of lig-
nocaine on laryngeal chemoreceptors relates to the risk
of aspiration post topicalization. In addition, the degree
of laryngeal reflex recovery required to facilitate a safe
swallow and full protection of the airway is unknown. It
is unlikely that full recovery to baseline responses is
needed before oral intake can be recommenced, but it
would be wise to assume that aspiration is still a risk for
a period of time after the return of the first response.
Although clinical studies in adults suggest a duration
of 20 min might be safe (3,5), no equivalent pediatric
evidence can be quoted and the effect of lignocaine on
laryngeal reflexes may last significantly longer than this
(45,47). There is currently insufficient evidence to make
formal recommendations on withholding oral intake fol-
lowing topicalization. In the child who cannot reliably
confirm the presence or absence of sensation, our prac-
tice is to withhold oral intake for 1 h post topicalization.
Our rationale is that 1 h will allow adequate time for the
safe recovery of laryngeal reflexes and cause minimal
distress to the child. Withholding oral intake for longer
than 1 h is unnecessary. It is likely that an older child
can reliably confirm when normal sensation has
returned, and it would be reasonable to allow such a
child oral intake once this has occurred.
Complications
Laryngeal topicalization is a widely practiced and
predominantly safe procedure despite an increased
342
M. H. Roberts and C. D. Gildersleve
incidence of laryngospasm, bronchospasm, and coughing
being demonstrated (1,2,18). A number of anesthetists who
responded to our survey also reported laryngospasm (28%
of respondents) and/or severe coughing (14% of respon-
dents) associated with topicalization. The most likely cause
of these complications is application before an adequate
depth of anesthesia has been reached. The method of
application may also alter the risk of airway complica-
tions. Unilateral bronchospasm has been described in an
adult patient following lignocaine administration with a
Laryngojet spray (48). In this case, a jet of solution is
thought to have preferentially streamed unilaterally,
stimulating airway receptors in the left main bronchus,
causing severe unilateral bronchospasm.
Lignocaine toxicity is a rarely reported complication
of airway topicalization. Cases in the adult literature
have either been associated with doses in excess of the
maximum recommended (49,50) or in patients with
known risk factors of congestive heart failure and liver
disease (51). We found no cases reported in the pediatric
literature. Additional reported complications include
increased frequency of obstructive respiratory events
(52) and worsening visual appearance of laryngomalacia
at laryngobronchoscopy (53). The latter should be con-
sidered when using topicalization to facilitate diagnostic
laryngobronchoscopy when laryngomalacia is suspected
and may warrant discussion with the surgeon.
Although concern exists among anesthetists regarding
the risk of aspiration following lignocaine topicalization,
we failed to find a single reported case in the adult or
pediatric literature of this complication. It is noteworthy
that 10% of respondents to our survey allow oral intake
immediately after emergence from anesthesia.
Conclusion
Lignocaine topicalization is a commonly used technique in
pediatric anesthesia. Current evidence supports using a
maximum dose of 4 mg
kg 1 in the majority of anes-
thetized children. Airway procedures should ideally be per-
formed within 15 min of application and repeated
application should be considered for extended procedures,
within a 4 mg
kg 1 maximum dose. There is currently
insufficient evidence to make formal recommendations on
withholding oral intake following topicalization.
Funding
The research was carried out without funding.
Conflict of interest
No conflicts of interest declared.
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Pediatric Anesthesia 26 (2016) 337344
M. H. Roberts and C. D. Gildersleve
Acknowledgments
We thank the APAGBI and its members for the distri-
bution and completion of our survey. The survey was
References
1 Hamilton ND, Hegarty M, Calder A et al.
Does topical lidocaine before tracheal intu-
bation attenuate airway responses in chil- 13
dren? An observational audit Pediatr Anesth
2012; 22: 345350.
2 von Ungern-Sternberg BS, Boda K, Cham-
bers NA et al. Risk assessment for respira-
tory complications in paediatric anaesthesia: 14
a prospective cohort study. Lancet 2010;
376: 773783.
3 Bastian RW, Riggs LC. Role of sensation in
swallowing function. Laryngoscope 1999; 15
109: 19741977.
4 Lester S, Langmore SE, Lintzenich CR et al.
The effects of topical anesthetic on swallow-
ing during nasendoscopy. Laryngoscope
2013; 123: 17041708.
5 Ertekin C, Kiylioglu N, Tarlaci S et al. 16
Effect of mucosal anaesthesia on oropharyn-
geal swallowing. Neurogastroenetrology
2000; 12: 567572.
6 BNF for children. The authority on the
selection and use of medicines in children. 17
July 2013July 2014. BMJ Group, Pharma-
ceutical Press and RCPCH Publications Ltd
2013. Page 652.
7 Bulow K, Nielsen TG, Lund J. The effect of 18
topical lignocaine on intubating conditions
after propofol-alfentanil induction. Acta
Anaesthesiol Scand 1996; 40: 752756.
8 Minogue SC, Ralph J, Lampa MJ. Laryngo- 19
tracheal topicalization with lidocaine before
intubation decreases the incidence of cough-
ing on emergence from general anesthesia.
Anesth Analg 2004; 99: 12531257.
9 Staffel JG, Weissler MC, Tyler EP et al. The 20
prevention of postoperative stridor and
laryngospasm with topical lidocaine. Arch
Otolaryngol Head Neck Surg 1991; 117:
11231128.
10 Koc C, Kocaman F, Aygenc E et al. The use 21
of preoperative lidocaine to prevent stridor
and laryngospasm after tonsillectomy and
adenoidectomy. Otolaryngol Head Neck Surg
1998; 118: 880882.
11 Mihara T, Uchimoto K, Morita S et al. 22
The efficacy of lidocaine to prevent laryn-
gospasm in children: a systematic review
and meta-analysis. Anaesthesia 2014; 69:
13881396. 23
12 DAragon F, Beaudet N, Gagnon V et al.
The effects of lidocaine spray and intracuff
alkalinized lidocaine on the occurrence of 24
cough at extubation: a double-blind
2016 John Wiley & Sons Ltd
Pediatric Anesthesia 26 (2016) 337344
presented as a poster presentation at the APAGBI
Annual Scientific Meeting in Leeds, 2014. The abstract
(number 52) can be found at: http://www.apagbi.or-
g.uk/sites/default/files/images/Final_web_abstracts.pdf
randomized controlled trial. Can J Anesth
2013; 60: 370376.
Jee D, Park SY. Lidocaine sprayed down the
endotracheal tube attenuates the airway-cir-
culatory reflexes by local anesthesia during
emergence and extubation. Anesth Analg
2003; 96: 293297.
Hamaya Y, Dohi S. Differences in cardiovas-
cular response to airway stimulation at dif-
ferent sites and blockade of the responses by
lidocaine. Anesthesiology 2000; 93: 95103.
Groeben H, Grobwendt T, Silvanus MT
et al. Lidocaine inhalation for local anaesthe-
sia and attenuation of bronchial hyper-reac-
tivity with least airway irritation. Effect of
three different dose regimens. Eur J Anaes-
thesiol 2000; 17: 672679.
Groeben H, Silvanus MT, Beste M et al.
Both Intravenous and inhaled lidocaine
attenuate reflex bronchoconstriction but at
different plasma concentrations. Am J Respir
Crit Care Med 1999; 159: 530535.
Tanaka Y, Nakayama T, Nishimori M et al.
Lidocaine for preventing postoperative sore
throat. Cochrane Database Syst Rev 2009; 8:
CD004081.
Bordet F, Allaouchiche B, Lansiaux S et al.
Risk factors for airway complications during
general anaesthesia in paediatric patients.
Pediatr Anesth 2002; 12: 762769.
ONeill B, Templeton JJ, Caramico L et al.
The laryngeal mask airway in pediatric
patients: factors affecting ease of use during
insertion and emergence. Anesth Analg 1994;
78: 659662.
Penaloza IV, Diaz MVP, Jimenez TD. Use of
beclametazone dipropionate for prevention
of post-intubation laryngospasm in pedi-
atrics vs topical lidocaine. Anestesia en Mex-
ico 1999; 11: 162166.
Schebesta K, Guloglu E, Chiari A et al.
Topical lidocaine reduces the risk of periop-
erative airway complications in children with
upper respiratory tract infections. Can J
Anesth 2010; 57: 745750.
Chang H-YS, Togias A, Brown RH. The
effects of systemic lidocaine on airway tone
and pulmonary function in asthmatic sub-
jects. Anesth Analg 2007; 104: 11091115.
McHardy FE, Chung F. Postoperative sore
throat: cause prevention and treatment.
Anaesthesia 1999; 54: 444453.
Hara K, Maruyama K. Effect of additives in
lidocaine spray on postoperative sore throat,
Pediatric airway topicalization
hoarsness and dysphagia after total intra-
venous anaesthesia. Acta Anaesthesiol Scand
2005; 49: 463467.
25 Beringer R, Skeahan N, Sheppard S et al.
Study to assess the laryngeal and pharyngeal
spread of topical local anesthetic adminis-
tered orally during general anesthesia in chil-
dren. Pediatr Anesth 2010; 20: 757762.
26 Gjonaj ST, Lowenthal DB, Dozar AJ. Nebu-
lized lidocaine administration to infants and
children undergoing flexible bronchoscopy.
Chest 1997; 112: 16651669.
27 Tsui BCH, Cunningham K. Fibreoptic endo-
tracheal intubation after topicalization with
in-circuit nebulized lidocaine in a child with a
difficult airway. Anesth Analg 2004; 98:
12861288.
28 Honeybourne D, Babb J, Bowie P et al. Bri-
tish Thoracic Society guidelines on diagnostic
flexible bronchoscopy. Thorax 2001; 56
(Suppl I): i1i21.
29 Langmack EL, Martin RJ, Pak J et al.
Serum lidocaine concentrations in asthmatics
undergoing research bronchoscopy. Chest
2000; 117: 10551060.
30 Milman N, Laub M, Munch E et al. Serum
concentrations of lignocaine and its metabo-
lite monoethylglycinexylidide during fibreop-
tic bronchoscopy in local anaesthesia. Resp
Med 1998; 92: 4043.
31 Whittet HB, Hayward AW, Battersby E.
Plasma lignocaine levels during paediatric
endoscopy of the upper respiratory tract.
Relationship with mucosal moistness. Anaes-
thesia 1988 Jun; 43: 439442.
32 Eyres RL, Bishop W, Oppenheim RC.
Plasma lidocaine concentrations following
topical laryngeal application. Anesth Inten-
sive Care 1983; 11: 2326.
33 Eyres RL, Kidd J, Oppenheim R. Local
anaesthetic plasma levels in children. Anesth
Intensive Care 1978; 6: 243247.
34 Curran J, Hamilton C, Taylor T. Topical
analgesia before tracheal intubations. Anaes-
thesia 1975; 30: 765768.
35 Bromage PR, Robson JG. Concentration of
lignocaine in the blood after intravenous,
intramuscular, epidural and endotracheal
administration. Anaesthesia 1961; 16: 461
478.
36 Scott DB, Littlewood DG, Covino BG et al.
Plasma lignocaine concentration following
endotracheal spraying with an aerosol. Br J
Anaesth 1976; 48: 899901.
343
Pediatric airway topicalization
37 Chu SS, Rah KH, Brannan MD et al.
Plasma concentration of lidocaine after
endotracheal spray. Anesth Analg 1975; 54:
438441.
38 Sitbon P, Laffon M, Lesage V et al. Lido-
caine plasma concentrations in pediatric
patients after providing airway topical anes-
thesia from a calibrated device. Anesth Analg
1996; 92: 10031006.
39 Rosenberg PH, Veering BT, Urmey WF.
Maximum recommended doses of local anes-
thetics: a multifactorial concept. Reg Anesth
Pain Med 2004; 29: 564575.
40 Amitai Y, Zylber-Katz E, Avital A et al.
Serum lidocaine concentrations in children
during bronchoscopy with topical anesthesia.
Chest 1990; 98: 13701373.
41 Thompson PD, Melmon KL, Richardson JH
et al. Lidocaine pharmacokinetics in
advanced heart failure, liver disease and renal
failure in humans. Ann Intern Med 1973; 78:
499506.
42 Covino BG. Pharmacology of local anaesthetic
agents. Br J Anaesth 1986; 58: 701716.
344
43 Adriani J, Zepernick R, Arens J et al. The
comparative potency and effectiveness of
topical anesthetics in man. Clin Pharmacol
Ther 1964; 5: 4962.
44 Schonemann NK, van der Burght M,
Arendt-Nielsen L et al. Onset and duration
of hypoalgesia of lidocaine spray applied to
oral mucosa a dose response study. Acta
Anaesthesiol Scand 1992; 36: 733735.
45 Robinson EP, Rex MAE, Brown TCK. A
comparison of different concentrations of
lidocaine hydrochloride used for topical
anaesthesia of the larynx of the cat. Anaesth
Intensive Care 1985; 13: 137144.
46 Nishino T. Swallowing as a protective reflex
for the upper respiratory tract. Anesthesiol-
ogy 1993; 79: 588601.
47 Raphael JH, Stanley GD, Langton JA.
Effects of topical benzocaine and lignocaine
on upper airway reflex sensitivity. Anaesthe-
sia 1996; 51: 114118.
48 Farmery AD. Severe unilateral bron-
chospasm mimicking inadvertent endo-
bronchial intubation: a complication of the
M. H. Roberts and C. D. Gildersleve
use of a topical lidocaine Laryngojet injector.
Br J Anaesth 2000; 85: 917919.
49 Mehra P, Caiazzo A, Maloney P. Lidocaine
toxicity. Anesth Prog 1998; 45: 3841.
50 Day RO, Chalmers DR, Williams KM et al.
The death of a healthy volunteer in a human
research project: implications for Australian
clinical research. Med J Aust 1998; 168: 449
451.
51 Wu FL, Razzaghi A, Souney PF. Seizure
after lidocaine for bronchoscopy: case report
and review of the use of lidocaine in airway
anesthesia. Pharmacotherapy 1993; 13: 72
78.
52 Chadwick GA, Crowley P, Fitzgerald MX
et al. Obstructive sleep apnea following topi-
cal oropharyngeal anesthesia in loud snorers.
Am Rev Respir Dis 1991; 143: 810813.
53 Nielson DW, Ku PL, Egger M. Topical lido-
caine exaggerates laryngomalacia during flex-
ible bronchoscopy. Am J Respir Crit Care
Med 2000; 161: 147151.
2016 John Wiley & Sons Ltd
Pediatric Anesthesia 26 (2016) 337344