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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

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.
slide3

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
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.
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
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
summary
Summary
  • Definition
  • Incidence
  • Factors
  • Pathophysiology
  • Signs
  • Prevention
  • Treatment
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