ANESTH ANALG 1189
1985;M: 1189-92
Intravenous Lidocaine as a Suppressant of Coughing during
Tracheal Intubation
Hidekazu Yukioka, MD, Noritada Yoshimoto,
Mitsugu Fujimori, MD
YUKIOKA H, YOSHIMOTO N, NISHIMURA K,
FUJlMORl M. Intravenous lidocaine as a suppressant of
coughing during tracheal intubation. Anesth Analg
1985;64:1189-92.
Effects of intravenously administered lidocaine on cough
suppression during tracheal intubation under general anes-
thesia were evaluated in two studies. In study 1, 100 pa-
tients received either a placebo or 0.5, l .O, l .5, or 2.0 mglkg
lidocaine intravenously 1 niin before tracheal intubation.
All visible coughs were classified as coughing. The incidence
of coughing decreased as the dose of lidocaine increased. A
dose of 1 mglkg or more of intravenous lidocaine suppressed
the cough reflex significantly ( P < 0.01). Coughing was
suppressed completely by 2 mglkg of intravenous lidocaine.
It is well known that small intravenous doses of lido-
caine suppress the cough reflex without serious side
effects (1-4) during endotracheal intubation, extu-
bation, bronchography, bronchoscopy, and laryngos-
copy (1,2,5-7). The dose of lidocaine needed to sup-
press coughing during tracheal intubation under
general anesthesia and the time it should be given
have not, however, been defined. This study was
designed to determine the optimal dose and the ef-
fective time of intravenous lidocaine for suppression
of coughing during tracheal intubation under gen-
eral anesthesia induced by a face mask with
N20-halothane-02.
Methods
The study included 208 ASA physical status I patients
scheduled for orthopedic, urologic, gynecologic, and
general surgery, whose ages ranged from 15-55 yr
with a mean age of 38 yr and a mean weight of 53
~~
Received from the Department of Anesthesiology, Osaka City
University Medical School, Osaka, Japan. Accepted for publication
June 10, 1985.
Address correspondence to Dr. Yukioka, Department of Anes-
thesiology, Osaka City University, Medical School, 7-5-1, Asahi-
machi, Abeno-ku, Osaka, 545, Japan.
0 1985 by the International Anesthesia Research Society
MD, Kiyoji Nishimura, MD, and
In study 2 , 108 patients received 2 mglkg lidocaine intra-
venously or a placebo 1 , 3 , 5, 7 , 10, or 15 inin before
intubation. The same criteria for determining whether a
patient did or did not cough during tracheal intubation were
used as in study 1 . The incidence of coughing decreased
significantly ( P < 0.01) when 2 mglkg of lidocaine was
injected intravenously between 1 and 5 min before our at-
tempting intubation. Cough reflex was suppressed com-
pletely by plasma concentrations of lidocaine in excess of
3 pglml.
Key Words: INTUBATION, TRACHEAL-intraVenOUS
lidocaine. ANESTHETICS, LOCAL-intraVenOuS lido-
caine.
kg. There were 46 men and 162 women. Informed
consent was obtained from each patient, and the pro-
tocol was approved by the Institutional Human Stud-
ies Committee. Preanesthetic medications consisted
of intramuscular atropine (0.5 mg) and either seco-
barbital (100 mg) or diazepam (10 mg) given intra-
muscularly 60-90 min before induction of anesthesia.
Study 2
One hundred patients were assigned at random to
one of five groups with 20 patients in each category.
Anesthesia was induced by a face mask with 67%
nitrous oxide and halothane in oxygen. Halothane
concentration was increased gradually by 0.5% with
each successive respiration and reached 3% within 30
sec. Respirations were spontaneous throughout the
study. Lidocaine (0.5, 1.0, 1.5, or 2.0 mg/kg) or pla-
cebo (saline) was administered intravenously using a
double blind technique. The staff anesthesiologist based
observations that satisfactory surgical anesthesia had
been reached on criteria including changes in respi-
ratory pattern, the size of the pupils, and fixation of
the eyeball in the central position. After the injection
of lidocaine or placebo, respiration was assisted for 1
min, and the trachea then was intubated without
1190 ANESTH ANALG
1985;64:1189-92
Table 1. InductionTimesand IntubationTimesinStudy la
Induction time
(rnin)
~~
Placebo 10.4 ? 1.5”
Lidocaine (intravenous)
0.5 rng/kg 10.2 ? 0.6
1.0 mglkg 10.6 f 1.1
1.5 mg/kg 10.6 -C 0.9
2.0 mg/kg 10.5 f 1.1
= 20 in each group.
“Mean 2 su.
muscle relaxant, topical anesthetic, or stylet. Anes-
thesia was maintained with 67% nitrous oxide and
1%halothane in oxygen by manual ventilation for 2
min after tracheal intubation. Patients with difficult
or esophageal intubation were eliminated from the
study. Induction time of anesthesia (time from the
application to removal of the face mask) and tracheal
intubation time (time from removal of the face mask
to the first manual ventilation after tracheal intuba-
tion) were measured. All visible coughs were classi-
fied as coughing. No attempt was made to evaluate
the degree of severity of coughing. Data were ana-
lyzed using multiple comparisons as described by
Goodman (8) and modified by Miller (9). This is an
adaptation of Scheffe’s F-projection to nominal data.
Study 2
Anesthesia was induced by a face mask with nitrous
oxide-halothane-oxygen as described in study 1. In
study 2, induction time was, as determined in study
1, consistently 10.5 min. One hundred and eight pa-
tients received 2 mg/kg intravenous lidocaine or a
placebo in a double-blind manner 1, 3, 5, 7, 10, or 15
min before removal of the face mask. The 108 patients
were divided at random into six groups according to
the administration time of 2 mg/kg intravenous lido-
caine or the placebo, with 18 patients in each group.
Each group of 18 patients consisted of 15 patients
given 2 mg/kg intravenous lidocaine and 3 patients
given the placebo. Respiration was assisted for 1 min
before the removal of the face mask. The trachea was
then intubated and anesthesia maintained with
N20-02-halothane, as described in study 1. Patients
with difficult or esophageal intubation were elimi-
nated from the study. Intubation time was measured,
and the same criteria as in study 1 were used for
determining whether a patient did or did not cough
during tracheal intubation.
From each group, four or five patients were se-
lected at random for arterial blood sampling. Samples
YUKlOKA ET AL.
Table 2. Incidence of Coughing in Study 1
Intubation time Incidence of coughing (%)
(see) Placebo 70
43.8 ? 15.1 Lidocaine (intravenous)
0.5 mg/kg 65
42.4 ? 11.1 1.0 mg/kg 30
44.7 t 12.5 1.5 mg/kg 20
39.6 ? 11.3 2.0 mg/kg 0
46.0 -C 17.0
were withdrawn within 10 sec at intubation for mea-
surement of plasma lidocaine concentrations by gas
chromatographic analysis. The concentrations in the
two groups of patients, those who coughed and those
who did not, were compared using the ”two-sample”
t-test in the Minitab statistical package. Other data
were analyzed using multiple comparisons, as de-
scribed in study 1.
Results
Study 1
There were no sigruficant differences among the groups
in sex, age, weight or height. Induction time (average
time, 10.5 min), intubation time (average time, 43.3
sec), and the incidence of coughing is shown in Tables
1 and 2. The incidence of coughing decreased as the
dose of intravenous lidocaine increased. A dose of 1
mg/kg or more of intravenous lidocaine suppressed
the cough reflex significantly (P < 0.01). Intravenous
lidocaine in doses of 2 mg/kg suppressed the cough
reflex completely.
Study 2
There were no sigruficant differences among the groups
in sex, age, weight, or height. Intubation time, about
43 sec, was similar in all groups. The incidence of
coughing and plasma concentrations of lidocaine are
shown in Tables 3 and 4. Coughing was suppressed
completely 1 min after injection of 2 mg/kg of lidocaine
intravenously. At 3 and 5 min after injection, there
was significant depression of the cough reflex ( P <
0.01). At 7 min and thereafter, however, suppression
of the cough reflex was no longer significant. The
mean plasma concentration of lidocaine (mean 2 SD)
was significantly greater in those patients who did
not cough (3.95 2 1.76 pg/ml) than in those who did
cough (2.30 & 0.56 pg/ml) (P < 0.01). Coughing was
completely suppressed by plasma lidocaine concen-
trations in excess of 3 pg/ml (Fig. 1). Serious side
effects of intravenous lidocaine did not occur in either
study 1 or 2.
COUGH SUPPRESSION BY LIDOCAINE 1V ANESTH ANALG 1191
1%5;&1:1 189-92

Table 3. Incidence of Coughing in Study 2

Incidence of coughing (%)
s
1 min” ( 1 1 = 15) 0
3 min ( n = 15) 13
5 min ( 1 1 = 15) 13 a
0
7 min ( n = 15) 33
10 min ( 1 1 = 15) 53
7 0
15 min ( n = 15) 53
Placebo ( n = 18) 67
6
DTimebetween administration of lidocaine, 2 mgikg, and removal of the 0
face mask.
5
Table 4. Arterial Plasma Concentrations of Lidocaine i n 00
Study 2 0

Time“ (min) Lidocaine concentration” (pg/ml)
1 ( n = 4) 6.24 -t 1.51‘
3 (n = 4) 3.65 -t 1.12
5 ( n = 5) 3.11 t 0.52
7 ( n = 4) 2.99 ? 0.49
10 ( n = 4) 2.18 ? 0.78
15 ( n = 4) 1.81 t 0.63
“Time, time from administration of lidocaine, 2 mg/kg intravenously, to
removal of the face mask.
“Lidocaine concentration, plasma concentration of lidocaine at the time
of intubation.
‘Mean ? SD.
Discussion
There are many reports on the cough-suppressant
effect of intravenous lidocaine. Steinhaus et al. (lo),
for example, reported that intravenous lidocaine sup-
presses the cough reflex produced by moving the en-
dotracheal tube. Smith et al. (2) reported that a test
dose of 2% lidocaine, 40 mg, followed by an additional
150-200 mg injected in less than 60 sec suppressed
the cough reflex successfully for 8-9 min during bron-
chography after tracheal intubation with thiopental
and succinylcholine. Although other investigators also
reported successful cough suppression by intrave-
nous lidocaine during tracheal intubation, extubation,
bronchoscopy, and laryngoscopy (1,5-7) under gen-
eral anesthesia, dose-dependent responses of intra-
venous lidocaine and the correlation of plasma con-
centration of lidocaine with cough suppression have
not been examined in previous studies.
In the present study, the effect of intravenous lido-
caine on cough suppression was increased in a dose-
dependent manner and correlated well with plasma
levels of lidocaine. Administration of 2 mg/kg intra-
venous lidocaine was effective in blocking the cough
reflex during tracheal intubation with the patient un-
der general anesthesia induced by a face mask with
N20-halothane-02. Coughing was effectively elimi-
nated by plasma concentrations of lidocaine in excess
of 3 pg/ml.
..
4
0
0
3 00000
0
0 0
0
2 m
0
0
1 0
0
COUGH (+) COUGH(-)
Figure 1. ‘lasma concentrations of lidocaine at the time of intu-
bation in atients who did ( + ) and did not ( - ) cough.
Plasma concentrations of lidocaine after 2 mg/kg of
intravenous lidocaine may be high enough to be as-
sociated with possible systemic toxicity. The lack of
side effects in this study may be related to the fact
that the patients were under general anesthesia.
It is concluded that the optimal dose of lidocaine
is 2 mg/kg intravenously for the suppression of cough-
ing stimulated by tracheal intubation after induction
of anesthesia with nitrous oxide and halothane. The
data also indicate that intravenous lidocaine sup-
presses the cough reflex effectively without serious
side effects if patients are well anesthetized.
References
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as cough depressant during general anesthesia for bronchog-
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3. Poulton TJ, James FM. Cough suppression by lidocaine. Anes-
thesiology 1979;50:470-2.
4. Christensen V, Ledegaard-Pedersen HI, Skovsted P. Intrave-
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5. Blancato LS, Peng ATC, Alonsabe D. Intravenous lidocaine as
an adjunct to general anesthesia for endoscopy. Anesth Analg
1969;48:224-7.
1192 ANESTH ANALG YUKIOKA ET AL.
1985;64:1189-92

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~ ~ lido- ~
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