Laryngospasm Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi medical college and research institute , puducherry, India Definition • A protective reflexive glottic closure which prevents aspiration • if exaggerated produce mortality. impedes respiration to morbidity and occasionally • Self-limited mostly: • prolonged hypoxia and hypercapnia abolish the reflex. Incidence • 0.87 % - overall • Children 0 -9 years – 1.74 % • Infants – 2.82 % • Most occurs during anesthesia • – Emergence 48%, induction 28%, maintenance 24% Two reasons • Laryngospasm occurs during anesthesia for : • a lack of inhibition of glottic reflexes because of inadequate central nervous system depression • secondly increased stimuli Pathophysiology • • • • • Three levels Vocal cords – shutter Inspiratory pressure gradient increases Thyrohyoid shortens – (extrinsic) Supra glottic tissue ,False vocal cords loosen to become a redundant tissue – ball • Falls on the opening Ball valve Certain factors ??? – patient • • • • • • H/O URI 10 times – 6 weeks Wheezing Presence of Ryle s tube Smoking – passive - Smokers – 10 days GERD Down , parkinson , hypocalcemia, hypomagnesemia Surgical factors • • • • • • • Oral endoscopy Tonsillectomy Adenoidectomy Appendicectomy Hypospadias Skin graft in children Thyroid surgeries Anaesthetic factors • • • • • • Rarely as transfusion reactions LMA > ETT Insufficient depth Ketamine – secretion Mucus and blood Desflurane Clinical manifestations • Partial – stridor • Complete – laryngospasm – no air movement – tracheal tug, paradoxical breathing • Oxygen desaturation 61% • – Bradycardia 6% Complications • – Cardiac arrest 0.5% • – Pulmonary aspiration 3% • – Postobstructive negative pressure PE 4% Differential diagnosis: • Bronchospasm • Supraglottic obstruction • Vocal cord palsy. Bilateral incomplete palsy is more dangerous than complete palsy. • Tracheomalacia • Psychogenic • Laryngomalacia • Airway edema • Hematoma, soft tissue obstruction, • foreign material such as throat packs. Treatment Prevention Prevention • Identify patients at risk for laryngospasm (described already) • Sevoflurane • Deep extubation – no touch technique • Positive pressure inflation of the lungs before tracheal extubation Prevention • • • • • Anticholinergics Benzodiazepines IV lignocaine IV magsulf Use 5% carbon dioxide (CO2)( for 5 min prior to tracheal extubation) • Extubate deep / no touch technique • Partially inflated LMA the “no touch” technique • blood and secretions are carefully suctioned from the pharynx, - extubate • patient is then turned to the lateral (recovery) position • the volatile anesthetics are discontinued, and no further stimulation is allowed until patients spontaneously wake up. Treatment Treatment • • • • • • • • Seek help Laryngoscopy Remove secretions, mucus, blood 100 % oxygen – CPAP LARSON maneuver Subhypnotic propofol -0.2 mg/kg Scoline – 0.1 – 1 mg / kg Atropine Jaw thrust Larson Maneuver -- Laryngospasm notch Three problems with scoline • Scoline apnea • Previous non depolarizers • Hyperkalemia • No IV access – • Scoline 4 mg / kg IM • Intra osseous route – described Chest compression • Half the force of CPR • 20 -25 / min. • extended palm of the free hand placed on the middle of the chest, with the fingers directed caudally. • Partial ok • Complete – it can convert to partial Other options • Doxapram – 1.5 mg / Kg for 15 seconds • IV nitroglycerin 4 mcg /kg • Superior laryngeal nerve block Superior laryngeal nerve block Algorithms Summary • • • • • • • Definition Incidence Factors Pathophysiology Signs Prevention Treatment • Thank you all