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Laryngospasm

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  1. 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

  2. Definition • A protective reflexive glottic closure which prevents aspiration • if exaggerated impedes respiration to produce morbidity and occasionally mortality.

  3. Self-limited mostly: • prolonged hypoxia and hypercapnia abolish the reflex.

  4. Incidence • 0.87 % - overall • Children 0 -9 years – 1.74 % • Infants – 2.82 % • Most occurs during anesthesia • – Emergence 48%, induction 28%, maintenance 24%

  5. Two reasons • Laryngospasm occurs during anesthesia for : • a lack of inhibition of glottic reflexes because of inadequate central nervous system depression • secondly increased stimuli

  6. 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

  7. Ball valve

  8. 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

  9. Surgical factors • Oral endoscopy • Tonsillectomy • Adenoidectomy • Appendicectomy • Hypospadias • Skin graft in children • Thyroid surgeries

  10. Anaesthetic factors • Rarely as transfusion reactions • LMA > ETT • Insufficient depth • Ketamine – secretion • Mucus and blood • Desflurane

  11. 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

  12. 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.

  13. Treatment Prevention

  14. Prevention • Identify patients at risk for laryngospasm (described already) • Sevoflurane • Deep extubation – no touch technique • Positive pressure inflation of the lungs before tracheal extubation

  15. 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

  16. 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.

  17. Treatment

  18. 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

  19. Jaw thrust

  20. Larson Maneuver-- Laryngospasm notch

  21. Three problems with scoline • Scoline apnea • Previous non depolarizers • Hyperkalemia • No IV access – • Scoline 4 mg / kg IM • Intra osseous route – described

  22. 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

  23. Other options • Doxapram – 1.5 mg / Kg for 15 seconds • IV nitroglycerin 4 mcg /kg • Superior laryngeal nerve block

  24. Superior laryngeal nerve block

  25. Algorithms

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

  27. Thank you all