Lidocaine topicalization of the Trachea
Myron Yaster MD, Francis Veyckemans MD, and Lynne G. Maxwell MD
Today’s PAAD by Iliff et al.[1] is a consensus statement of a group of experts on the use of topical lidocaine to anesthetize the pediatric airway prior to instrumentation. We previously discussed this topic in the PAAD (Feb 08, 2025), in which we reviewed a survey study conducted by many of the same authors as in today’s article.[2] To be honest, we weren’t sure if we should post this review because as the authors of today’s article repeatedly point out: “In the absence of evidence, our aim was to establish a safe and pragmatic framework to support clinical practice.”[1] Surprisingly, there is very little evidence to support their recommendations making this an area of potential future research. Nevertheless, because topicalization of the airway is an everyday occurrence in almost everyone’s practice, I thought reviewing their key recommendations would be of value. But take these recommendations with a grain of salt. Myron Yaster MD
Original article
Iliff HA, Parnell J, Baker PA, Baxter A, Chapman R, Coulson J, Dotherty C, Endlich Y, Frykholm P, Harkin J, Jagannathan N, Kubba H, Kwizera Ndekezi J, McGuire B, Mesbah A, Mehanna R, Miskovic A, Newton R, Orban N, Perry S, Peyton J, Rivett K, Roberts M, Temo K. Consensus recommendations for paediatric airway topicalisation using lidocaine. Anaesthesia. 2025 Jul 27. doi: 10.1111/anae.16705. Epub ahead of print. PMID: 40717423.
Pediatric anesthesiologists provide sedation or anesthesia to children undergoing procedures in which airway topicalization is employed (e.g. laryngoscopy, microlaryngoscopy/bronchoscopy, bronchoscopy +/- dilation, supraglottoplasty). Though the individual administering the local anesthetic can vary (anesthesiologists, surgeons, pulmonologists being the most common) anesthesiologists are the gatekeepers who determine, advise and monitor the safe administration of local anesthetic for airway topicalization. And because topicalization of the airway with lidocaine is routinely used in many pediatric practices prior to tracheal intubation, [2, 3] how to administer it is not simply an academic exercise.
To us, the shocking feature of today’s article is that there is very little evidence to guide the recommendations made by the expert consensus panel in today’s article. Only a few papers are available.[4-7]
What did Iliff et al.[1] recommend?
1. The age and weight of the child, the concentration of solution and the volume required should be taken into account when considering dosing of topical lidocaine for airway procedures (Grade B, strong recommendation).
2. Pre-operative discussion between anaesthetists and surgeons is recommended at the team brief where both parties plan to use lidocaine. The maximum dose should be identified and divided appropriately according to need (Grade D, strong recommendation).
3. A maximum dose of 5 mg.kg-1 (ideal body weight) is recommended as a safe dose for procedures up to 2 h; however, lesser doses are often deemed to be clinically effective, and a conservative approach is advised (Grade C, strong recommendation).
4. Ideal body weight should be used for dosing calculations (Grade B, strong recommendation).
5. Lidocaine solutions > 4% should not be used in children (Grade D, strong recommendation).
6. Patients should be routinely fasted for at least 1 h after airway topicalization with lidocaine. If the child is deemed to be at significant risk of aspiration, this time may need to be extended (Grade C, strong recommendation).
7. Timing of all topicalization and total dose of lidocaine used should therefore be documented clearly (Grade D, strong recommendation).
8. 20% intravenous lipid emulsion should be immediately available in departments where lidocaine topicalisation takes place (Grade C, strong recommendation).
These recommendations are intuitive and consistent with most practice. Finally, although not stated in the article, early signs and symptoms of local anesthetic systemic toxicity (LAST) are unlikely to be observed in the anesthetized patient and systemic toxicity because the patients are under general anesthesia. If LAST does occur (elevated T waves on ECG, cardiovascular collapse) having 20% intralipid emulsion will only help if you know/remember the dose and how it should be administered and where it is stored in your facility. DO NOT RELY ON YOUR MEMORY! Opening the Society for Pediatric Anesthesia’s PediCrisis app v 2 should be one of the first things you do in managing the crisis.
From a practical point of view, topicalization can be done with a spray or a disposable atomization device such as MADgic® (Wolfe Tory Medical) connected to a syringe. As you all know, the systemic absorption of local anesthetic through the airway mucosae is rapid : in adults, the peak is observed about 7 minutes after the administration of 3 mg/kg and reaches a mean of 1.9 mcg/mL (1.4 - 3.2) with an atomizer and 1.1 mcg/mL (0.6 -2) with a spray.[6] Moreover, the child’s age and mucosal moistness are important to consider. In a study of 25 children receiving 4 mg/kg of lidocaine by spray under halothane anesthesia, those under 2 years of age had higher mean plasma levels than the older ones. In addition, all children had received atropine IM as premedication: the mean peak lidocaine levels were higher in the children whose mucosae were the most dry as subjectively evaluated at the time of laryngoscopy. The authors hypothesized that saliva and upper airway secretions act as a barrier between lidocaine and the airway mucosa, and that a decreased amount of secretions increases the systemic absorption of lidocaine.[4]
The use of topical lidocaine has been a topic of controversy when laryngoscopy is performed to diagnose and evaluate laryngomalacia. In 104 children less than 2 years-old sedated with midazolam and nalbuphine, spraying the larynx and vocal cords with 1 mL 2% lidocaine resulted in most cases in an increase in the malacia score which could cause an overestimation of its severity.[8] This was not confirmed in a study of 13 infants using 3 mg/kg lidocaine administered through the suction channel of the bronchoscope under propofol anesthesia.[9] The authors of the latter study speculate that the lighter sedation level in the former study could interfere with the effect of topical lidocaine. It has indeed be shown in awake adults that topical lidocaine decreases upper airway muscles contractions during inspiration and increases respiratory resistance: the increased blunting of airway reflexes under propofol anesthesia may mitigate this effect.[10]
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Iliff HA, Parnell J, Baker PA, Baxter A, Chapman R, Coulson J, Dotherty C, Endlich Y, Frykholm P, Harkin J et al: Consensus recommendations for paediatric airway topicalisation using lidocaine. Anaesthesia 2025.
2. Iliff HA, Baxter A, Chakladar A, Endlich Y, McGuire B, Peyton J: Airway topicalization in pediatric anesthesia: An international cross-sectional study. Paediatric anaesthesia 2024, 34(2):145–152.
3. Hamilton ND, Hegarty M, Calder A, Erb TO, von Ungern-Sternberg BS: Does topical lidocaine before tracheal intubation attenuate airway responses in children? An observational audit. Paediatric anaesthesia 2012, 22(4):345–350.
4. Whittet HB, Hayward AW, Battersby E: Plasma lignocaine levels during paediatric endoscopy of the upper respiratory tract. Relationship with mucosal moistness. Anaesthesia 1988, 43(6):439–442.
5. Sitbon P, Laffon M, Lesage V, Furet P, Autret E, Mercier C: Lidocaine plasma concentrations in pediatric patients after providing airway topical anesthesia from a calibrated device. Anesthesia and analgesia 1996, 82(5):1003–1006.
6. Takaenoki Y, Masui K, Oda Y, Kazama T: The Pharmacokinetics of Atomized Lidocaine Administered via the Trachea: A Randomized Trial. Anesthesia and analgesia 2016, 123(1):74–81.
7. Roberts MH, Gildersleve CD: Lignocaine topicalization of the pediatric airway. Paediatric anaesthesia 2016, 26(4):337–344.
8. Nielson DW, Ku PL, Egger M: Topical lidocaine exaggerates laryngomalacia during flexible bronchoscopy. Am J Respir Crit Care Med 2000, 161(1):147–151.
9. von Ungern-Sternberg BS, Trachsel D, Zhang G, Erb TO, Hammer J: Topical Lidocaine Does Not Exaggerate Laryngomalacia in Infants During Flexible Bronchoscopy Under Propofol Anesthesia. J Bronchology Interv Pulmonol 2016, 23(3):215–219.
10. Ho AM, Chung DC, Karmakar MK, Gomersall CD, Peng Z, Tay BA: Dynamic airflow limitation after topical anaesthesia of the upper airway. Anaesthesia and intensive care 2006, 34(2):211–215.