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Tetracaine’s Bad Reputation Is Not Well DeservedTetracaine's Bad Reputation Is Not Well Deserved FREE TO VIEW

Konrad L. Davis, MD, FCCP
Author and Funding Information

From the Department of Medicine, Tripler Army Medical Center.

Correspondence to: Konrad L. Davis, MD, FCCP, Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Rd, Tripler AMC, Honolulu, HI 96859; e-mail: konrad_davis@yahoo.com


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


© 2012 American College of Chest Physicians


Chest. 2012;141(6):1640-1641. doi:10.1378/chest.12-0153
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To the Editor:

Lidocaine and tetracaine are among the oldest topical anesthetics used during flexible bronchoscopy. Some authors have suggested that tetracaine has a narrow therapeutic window and, accordingly, a higher incidence of adverse reactions. The American College of Chest Physicians consensus statement by Wahidi et al1 in a recent issue of CHEST (November 2011) states that “tetracaine should be used with extreme caution because of the risk of induced methemoglobinemia.” Data to support this statement are lacking.

In 1974, Credle et al2 published survey data including > 24,000 procedures and identified only one death attributable to tetracaine toxicity. The amount of tetracaine administered was not identified in the article nor was their mention of which topical anesthetic (presumably lidocaine) was given to the two other patients who died. Suratt et al3 also conducted a questionnaire, the results of which indicated adverse reactions during bronchoscopy. Their survey covered 48,000 procedures and identified just two patients who experienced tetracaine toxicity. One of these patients had an “unsuspected 2-day old myocardial infarction,” whereas the other complication was described as “mass in right lung; COPD; dyspneic at rest; sinus tachycardia.”3 Based on the review by Suratt et al,3 the textbook by Feinsilver and Fein4 on bronchoscopy states, “Tetracaine’s low margin of safety has resulted in cardiac arrests and deaths. Topical tetracaine is no longer recommended for airway anesthesia.”

Both reviews by Credle et al2 and Suratt et al3 hardly justify Feinsilver and Fein’s4 conclusion. Quite the contrary; tetracaine was associated with an exceedingly low incidence of adverse reactions in a large number of procedures. More recent reviews have also demonstrated a side-effect profile of tetracaine that is comparable to that of lidocaine.5,6 Methemoglobinemia was also reported in just one patient in the review by Credle et al.2 A more recent summary of 242 episodes of local-anesthetic-related methemoglobinemia identified 12 cases attributable to lidocaine, compared with just one case attributable to tetracaine.7

Consensus statements and guidelines should be based on a rigorous review of the evidence. When rigorous evidence is lacking, caution should be used in making strong recommendations regarding a clinical practice. All of the topical anesthetic agents used during flexible bronchoscopy have the potential for toxicity. However, the only published data available demonstrates that tetracaine has a safety profile that is noninferior to that of lidocaine.

Wahidi MM, Jain P, Jantz M, et al. American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adult patients. Chest. 2011;1405:1342-1350. [CrossRef] [PubMed]
 
Credle WF Jr, Smiddy JF, Elliott RC. Complications of fiberoptic bronchoscopy. Am Rev Respir Dis. 1974;1091:67-72. [PubMed]
 
Suratt PM, Smiddy JF, Gruber B. Deaths and complications associated with fiberoptic bronchoscopy. Chest. 1976;696:747-751. [CrossRef] [PubMed]
 
Feinsilver SH, Fein AM. Textbook of Bronchoscopy. 1995; Baltimore, MD Wilkins and Williams
 
Colt HG, Matsuo T. Hospital charges attributable to bronchoscopy-related complications in outpatients. Respiration. 2001;681:67-72. [CrossRef] [PubMed]
 
Davis KL, Channick CL. Safety of topical tetracaine in patients undergoing flexible bronchoscopy. J Bronch Intervent Pulmonol. 2009;162:95-98. [CrossRef]
 
Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg. 2009;1083:837-845. [CrossRef] [PubMed]
 

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References

Wahidi MM, Jain P, Jantz M, et al. American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adult patients. Chest. 2011;1405:1342-1350. [CrossRef] [PubMed]
 
Credle WF Jr, Smiddy JF, Elliott RC. Complications of fiberoptic bronchoscopy. Am Rev Respir Dis. 1974;1091:67-72. [PubMed]
 
Suratt PM, Smiddy JF, Gruber B. Deaths and complications associated with fiberoptic bronchoscopy. Chest. 1976;696:747-751. [CrossRef] [PubMed]
 
Feinsilver SH, Fein AM. Textbook of Bronchoscopy. 1995; Baltimore, MD Wilkins and Williams
 
Colt HG, Matsuo T. Hospital charges attributable to bronchoscopy-related complications in outpatients. Respiration. 2001;681:67-72. [CrossRef] [PubMed]
 
Davis KL, Channick CL. Safety of topical tetracaine in patients undergoing flexible bronchoscopy. J Bronch Intervent Pulmonol. 2009;162:95-98. [CrossRef]
 
Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg. 2009;1083:837-845. [CrossRef] [PubMed]
 
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