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Momen M. Wahidi, MD, MBA, FCCP; Pyng Lee, MD, FCCP
Author and Funding Information

From the Department of Medicine (Dr Wahidi) Duke University Medical Center; and the National University Hospital (Dr Lee).

Correspondence to: Momen M. Wahidi, MD, MBA, FCCP, Department of Internal Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Box 3683, Durham, NC 27710; e-mail: momen.wahidi@duke.edu


Financial/nonfinancial disclosures: Dr Wahidi was an investigator on the multicenter trial of Fospropofol. Dr Lamb has been an Educational Board Consultant for the following: Boston Scientific 2007 to current, Cardinal Health 2007 and 2008, and Super Dimension 2007. Dr Lee 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):1641. doi:10.1378/chest.12-0754
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To the Editor:

We appreciate the comments from Dr Davis about our recent consensus statement in CHEST1 and his concerns regarding our association of tetracaine with methemoglobinemia. Methemoglobinemia is a serious adverse event that has been reported to occur with multiple topical anesthetics including benzocaine, prilocaine, lidocaine, and tetracaine.2 Benzocaine is by far the most commonly reported agent with respect to association with methemoglobinemia, which could occur in a dose-independent fashion, even after a single benzocaine spray.2 The US Food and Drug Administration has issued multiple Public Health Advisory warnings about methemoglobinemia with the use of benzocaine sprays during medical procedures.3

Although the literature suggests a lower association of methemoglobinemia with tetracaine, the risk still exists and its nature is further confounded by the popularity of a particular pharmaceutical preparation, Cetacaine, containing benzocaine 14%, butyl aminobenzoate 2%, and tetracaine 2%, making it difficult to separate the action of the two drugs. Numerous reports have reported on the association of Cetacaine and methemoglobinemia and have discouraged its use in medical procedures.4-6

We agree with Dr Davis that all the topical anesthetic agents used during flexible bronchoscopy have the potential for toxicity. Our goal was to alert the chest physician to the risk of methemoglobinemia but we could have better delineated the attributed risk to different topical anesthetic agents. However, the data surrounding this differential risk with various agents are scant, and our panel felt the need to increase the general alertness to a potentially very serious condition.

A consensus statement is not designed to provide evidence-based practice guidelines, but rather, suggestions for good clinical practice and a forum for debate.7 This is exactly what this letter to the editor and response are embodying.

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]
 
Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg. 2009;1083:837-845. [CrossRef] [PubMed]
 
US Department of Health and Human Services FDA’s information for healthcare professionals. US Food and Drug Administration website.http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM274557.pdf. Accessed March 21, 2012.
 
Byrne MF, Mitchell RM, Gerke H, et al. The need for caution with topical anesthesia during endoscopic procedures, as liberal use may result in methemoglobinemia. J Clin Gastroenterol. 2004;383:225-229. [CrossRef] [PubMed]
 
Gregory PJ, Matsuda K. Cetacaine spray-induced methemoglobinemia after transesophageal echocardiography. Ann Pharmacother. 2000;349:1077. [CrossRef] [PubMed]
 
Khan NA, Kruse JA. Methemoglobinemia induced by topical anesthesia: a case report and review. Am J Med Sci. 1999;3186:415-418. [CrossRef] [PubMed]
 
Baumann MH, Gutterman DD. American College of Chest Physicians evidence-based guidelines—the next generation: considering resource use and evolution to a single grading system. Chest. 2006;1291:10-12. [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]
 
Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg. 2009;1083:837-845. [CrossRef] [PubMed]
 
US Department of Health and Human Services FDA’s information for healthcare professionals. US Food and Drug Administration website.http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM274557.pdf. Accessed March 21, 2012.
 
Byrne MF, Mitchell RM, Gerke H, et al. The need for caution with topical anesthesia during endoscopic procedures, as liberal use may result in methemoglobinemia. J Clin Gastroenterol. 2004;383:225-229. [CrossRef] [PubMed]
 
Gregory PJ, Matsuda K. Cetacaine spray-induced methemoglobinemia after transesophageal echocardiography. Ann Pharmacother. 2000;349:1077. [CrossRef] [PubMed]
 
Khan NA, Kruse JA. Methemoglobinemia induced by topical anesthesia: a case report and review. Am J Med Sci. 1999;3186:415-418. [CrossRef] [PubMed]
 
Baumann MH, Gutterman DD. American College of Chest Physicians evidence-based guidelines—the next generation: considering resource use and evolution to a single grading system. Chest. 2006;1291:10-12. [CrossRef] [PubMed]
 
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