Laryngospasm

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

13. 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.

14. Treatment Prevention

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

16. 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

17. 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.

18. Treatment

19. 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

20. Jaw thrust

21. Larson Maneuver-- Laryngospasm notch

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

23. 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

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

25. Superior laryngeal nerve block

26. Algorithms

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

30. Thank you all