Laryngospasm
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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 . Laryngospasm. Definition . A protective reflexive glottic closure which prevents aspiration

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Laryngospasm

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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

Laryngospasm


Definition

Definition

  • A protective reflexive glottic closure which prevents aspiration

  • if exaggerated impedes respiration to produce morbidity and occasionally mortality.


Laryngospasm

  • Self-limited mostly:

  • prolonged hypoxia and hypercapnia abolish the reflex.


Incidence

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

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

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

Ball valve


Certain factors patient

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

Surgical factors

  • Oral endoscopy

  • Tonsillectomy

  • Adenoidectomy

  • Appendicectomy

  • Hypospadias

  • Skin graft in children

  • Thyroid surgeries


Anaesthetic factors

Anaesthetic factors

  • Rarely as transfusion reactions

  • LMA > ETT

  • Insufficient depth

  • Ketamine – secretion

  • Mucus and blood

  • Desflurane


Clinical manifestations

Clinical manifestations

  • Partial – stridor

  • Complete – laryngospasm – no air movement – tracheal tug, paradoxical breathing

  • Oxygen desaturation 61%

  • – Bradycardia 6%

  • – Cardiac arrest 0.5%

  • – Pulmonary aspiration 3%

  • – Postobstructive negative pressure PE 4%

Complications


Differential diagnosis

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

Treatment

Prevention


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


Prevention1

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

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.


Laryngospasm

Treatment


Treatment1

Treatment

  • Seek help

  • Laryngoscopy

  • Remove secretions, mucus, blood

  • 100 % oxygen – CPAP

  • LARSON maneuver

  • Subhypnoticpropofol -0.2 mg/kg

  • Scoline – 0.1 – 1 mg / kg

  • Atropine


Jaw thrust

Jaw thrust


Larson maneuver laryngospasm notch

Larson Maneuver-- Laryngospasm notch


Three problems with scoline

Three problems with scoline

  • Scoline apnea

  • Previous non depolarizers

  • Hyperkalemia

  • No IV access –

  • Scoline 4 mg / kg IM

  • Intra osseous route – described


Chest compression

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

Other options

  • Doxapram – 1.5 mg / Kg for 15 seconds

  • IV nitroglycerin 4 mcg /kg

  • Superior laryngeal nerve block


Superior laryngeal nerve block

Superior laryngeal nerve block


Laryngospasm

Algorithms


Summary

Summary

  • Definition

  • Incidence

  • Factors

  • Pathophysiology

  • Signs

  • Prevention

  • Treatment


Laryngospasm

  • Thank you all


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