LARYNGOSPASAM

LARYNGOSPASM
....can be a nightmare for

Anesthesiologists
LARYNGOSPASM
 A protective reflexive glottis closure to
prevent aspiration
 Its exaggeration impedes respiration Self-

limited mostly: prolonged hypoxia and
hypercapnia
2
LARYNGOSPASM
 Closure of the upper airway caused by glottic
muscle spasm.
Presentation
 • Difficult or impossible face mask
ventilation
 • Difficult or impossible ventilation with a
supraglottic airway
 • “Crowing” sound on inspiration
3
INCIDENCE
 Rare but Mostly seen during anesthesia
Emergence 48%,
induction 28%,
maintenance 24%
 An overall incidence: 8.7/1000 patients
 Children (0-9 y/o): 17.4/1000
 Infants (birth to 3 m/o): 28.2/1000
4
INCIDENCE
 Adolescence: male > female
 Male: 12.1/1000; Female: 7.2/1000
 Children with an upper respiratory infection
or bronchial asthma: 95.8/1000
 Insertion of NG tube
 Oral endoscopy and esophagoscopy
5
PATHOPHYSIOLOGY
 Laryngospasm is especially common in
children and is associated with light planes
of anesthesia and irritation of the vocal cords
by foreign matter (e.g., blood or secretions).
6
DIFFERENTIAL DIAGNOSIS
 Bronchospasm
 Stridor
 Foreign body in the airway
 Airway obstruction from edema, infection,
tumor,
 hematoma, etc.
7
RISK FACTORS
  Unknown ....(43%)
 Patient-related
 – Young age
 – Anxiety
 – GERD
 – URI or active asthma (2~10 folds the risk)
 – Chronic smoker
 – Airway anomaly ,sleep apnea synd.
 – Unsupervised patients in recovery of
anaesthesia (specially children's)
8
SURGERY RELATED
 – Throat and/or Airway surgery
 – Laryngeal Surgery
 – Thyroid surgery
 Tonsil's surgery
 SLN injury
 Hypoparathyroidism
 – Esophageal procedure
 – Reflex stimulation: anal surgery Cervical
surgery (Brewer–Luckhardt reflex).
9
ANAESTHESIA RELATED
 – Insufficient depth of anesthesia during induction
or surgical stimulus
 – i.v. induction agents
 • Barbiturate
 • Ketamine, saliva
 – LMA > ETT > face mask
 – Airway irritation
 Irritant Volatile anesthetics: isoflurane
 Airway handling
 Mucus or blood after extubation
 Residual paralysis: common cause vomiting or
regurgitation
10
DIAGNOSIS
 Harsh breathing inspiratory sound (stridor)
 exclude other causes of airway obstruction,
e.g.
 tongue drop, blood clot impaction,
bronchospasm,
 – fall in spo2(usually fast)
 Partial laryngospasm
 • Signs of inspiratory airway obstruction
 – Use of accessory muscles
 – Paradoxical movement of chest and
abdomen
11
 Auscultation : Inspiratory Obstruction
 Complete laryngospasm :
 absence of breath sounds
 Late change
 – Bradycardia
 – Cyanosis
12
PREVENTION
 • Identify patients at risk is the most
important
 • Nonirritant inhalational anesthetic, e.g.
 sevoflurane
 • Deep anesthesia before intubation
 No surgical stimulation in light plan of
anesthesia
 • Extubate while the lungs are inflated by
positive pressure
 – ⇓ Adductor response of laryngeal muscle
 – Artificial cough
13
PREVENTION
 Drugs
 – Premedication with oral BZD
 – Anticholinergics ⇓ secretion
 – Lignocaine Spray to larynx at 4 mg/kg (1 mL
10% lidocaine for a 25 kg pt)
14
INTRAVENOUS (LIGNOCAINE)
 • Controversial in preventing laryngospasm
 Some said i.v. at 1 mg/kg 5 min before

extubation fairly effective as topical use
15
MANAGEMENT (TREATMENT)
 – Identify and remove the stimulus

 – Apply jaw thrust maneuver
 – Insert oral or nasal airway
 – Positive pressure ventilation with 100% O2
 – Anxiolysis( assurance and sedation)
 – Inj. Xylocaine 1 mg/kg
 – Inj. Propofol 0.25-1 mg /kg
 – Steroids -Inj. Hydrocortisone ,
Dexamethasone
16
COMPLETE LARYNGOSPASM
 – Call for help
 – Deepen the anesthesia level
 • If laryngospasm occurs without i.v. line
 intraosseous route offer a faster central
 circulation than peripheral
 • Lidocaine
 – SLN block
 – 5 mL of 2% lidocaine + 5 mL NS nebulized by
100% O2
 – Transtracheal injection of 1~2 mL 4%
lidocaine
17
 Intravenous: atropine and succinylcholine
 Intramuscular : succinylcholine (4mg/kg)
 vocal cords relax within one minute; last
several minutes ….IPPV---Intubation
18
19
SPECIAL CONSIDERATIONS
 • Untreated laryngospasm can rapidly lead to
hypoxemia and hypercarbia.
 • Patients who generate high negative
inspiratory pressures while attempting to
breathe against the obstruction may develop
negative-pressure pulmonary edema.
20
TH
AN
K
YO
U
21

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LARYNGOSPASAM

Uploaded by

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Available Formats

LARYNGOSPASM

....can be a nightmare for

 Its exaggeration impedes respiration Self-

 Oral endoscopy and esophagoscopy

 Some said i.v. at 1 mg/kg 5 min before

 – Identify and remove the stimulus

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