LARYNGOSPASMLARYNGOSPASM

....can be ....can be a a nightmarenightmare for for

AnaesthesiologistAnaesthesiologist

Dr RajkumarrDr RajkumarrCare hospital Care hospital

nagpurnagpur

LaryngospasmLaryngospasm

A protective reflexive glottic closure A protective reflexive glottic closure toto

prevent aspirationprevent aspiration

• • Its exaggeration impedes Its exaggeration impedes respirationrespiration

• • Self-limited mostly: prolonged Self-limited mostly: prolonged hypoxia andhypoxia and

hypercapnia abolish the reflexhypercapnia abolish the reflex• • If sustained, in high risk groups--If sustained, in high risk groups--

morbidity (e.g.Bradicardia, cardiac morbidity (e.g.Bradicardia, cardiac arrest, pulmonary edema…etc.) and arrest, pulmonary edema…etc.) and mortality ensuemortality ensue

IncidenceIncidence

Rare but Mostly seen during Rare but Mostly seen during anesthesiaanesthesia

Emergence 48%, induction Emergence 48%, induction 28%, maintenance 24%28%, maintenance 24%

1. An overall incidence: 1. An overall incidence: 8.7/1000 patients8.7/1000 patients

children (0-9 y/o): 17.4/1000children (0-9 y/o): 17.4/1000infants (birth to 3 m/o): infants (birth to 3 m/o):

28.2/100028.2/1000

2. adolescence: male > female2. adolescence: male > femalemale: 12.1/1000; female: 7.2/1000male: 12.1/1000; female: 7.2/1000

Children with an upper respiratory Children with an upper respiratory infection orinfection or

bronchial asthma: 95.8/1000bronchial asthma: 95.8/1000

3.Insertion of NG tube3.Insertion of NG tube

4.Oral endoscopy and esophagoscopy:4.Oral endoscopy and esophagoscopy:

Risk factorsRisk factors Unknown ....(43%) Patient-related– Young age– Anxiety– GERD– URI or active asthma 2~10 folds the risk– Chronic smoker, voice abuse– Airway anomaly ,sleep apnea synd.– Unsupervised patients in recovery of

anaesthesia specially children's

Surgery relatedSurgery related

– – Throat and/or Airway Throat and/or Airway surgerysurgery

– – Laryngeal SurgeryLaryngeal Surgery– – Thyroid surgeryThyroid surgery--Tonsils surgery--Tonsils surgery• • SLN injurySLN injury• • HypoparathyroidismHypoparathyroidism– – Esophageal procedureEsophageal procedure– – Reflex stimulation: anal Reflex stimulation: anal

surgery ,cervical stimulationsurgery ,cervical stimulation

Anaesthesia relatedAnaesthesia related– – Insufficient depth ofInsufficient depth ofanesthesia during induction or surgical anesthesia during induction or surgical

stimulusstimulus– – i.v. induction agentsi.v. induction agents• • BarbiturateBarbiturate• • Ketamine, saliva Ketamine, saliva – – LMA > ETT > face maskLMA > ETT > face mask– – Airway irritationAirway irritationIrritant Volatile anesthetics: isofluraneIrritant Volatile anesthetics: isofluraneAirway handlingAirway handlingMucus or blood after extubationMucus or blood after extubationResidual paralysis: common causeResidual paralysis: common causevomiting or regurgitation vomiting or regurgitation

AnatomyAnatomy

Sensory nerve innervation: C.N. X Sensory nerve innervation: C.N. X (vagus(vagus

nerve)nerve)Internal branch of the superiorInternal branch of the superiorlaryngeal nerve (SLN) :laryngeal nerve (SLN) : the area above the area abovethe true cordthe true cord

Recurrent laryngeal nerveRecurrent laryngeal nerve: below the: below thetrue vocal cord to upper part of thetrue vocal cord to upper part of thetracheatrachea

Motor nerve innervation: C.N. X Motor nerve innervation: C.N. X (vagus(vagus

nerve)nerve)External branch of superior External branch of superior

laryngeallaryngealnervenerve: inferior pharyngeal : inferior pharyngeal

constrictorsconstrictorsand cricothyroid muscleand cricothyroid muscle

Recurrent laryngeal nerve: otherRecurrent laryngeal nerve: otherintrinsic laryngeal muscleintrinsic laryngeal muscle

Intrinsic laryngeal Intrinsic laryngeal musclesmuscles

Posterior cricoarytenoid : the onlyPosterior cricoarytenoid : the onlyabductorabductorLateral cricoarytenoid Lateral cricoarytenoid

m.:.....adductorm.:.....adductorThyroarytenoid Thyroarytenoid

m.:..............shorteningm.:..............shorteningCricothyroid Cricothyroid

m.:.............lengtheningm.:.............lengtheningInterarytenoid m.:.........adductionInterarytenoid m.:.........adduction

Laryngeal reflex: (glottis closure reflex; quickLaryngeal reflex: (glottis closure reflex; quickprotective response)protective response)laryngeal closure (vocal cord adduction, laryngeal closure (vocal cord adduction,

protect lungs from aspiration of foreign protect lungs from aspiration of foreign materialmaterial

Laryngospasm: a prolonged form of vocalLaryngospasm: a prolonged form of vocalcord of adduction (closure of the true cord of adduction (closure of the true

vocalvocalcords alone or the true and false vocal cords alone or the true and false vocal

cords)cords)

PhysiologyPhysiologyA multitude of mechanoreceptors,A multitude of mechanoreceptors,chemoreceptors and thermoreceptors arechemoreceptors and thermoreceptors arethroughout the larynxthroughout the larynx• • The density is greatest around the The density is greatest around the

laryngeallaryngealopeningopening• • The posterior aspect of the true vocal The posterior aspect of the true vocal

folds hasfolds hasgreater density than the anteriorgreater density than the anterior• • Stimulation of these receptors induce Stimulation of these receptors induce

short-livedshort-livedglottic adduction to protect from glottic adduction to protect from

aspirationaspiration

Fink, 1956, AnesthesiologyFink, 1956, Anesthesiology

Laryngospasm: three levelsLaryngospasm: three levels1.1. The vocal cordsThe vocal cords2.2. The false cordsThe false cords3.3. The Arytenoids-Epiglottis The Arytenoids-Epiglottis

foldsfolds

A ball-valve effect: FinkA ball-valve effect: Fink

After reflex the true and false After reflex the true and false vocal cord closes translaryngeal vocal cord closes translaryngeal inspiratory pressure gradient inspiratory pressure gradient increases and supraglottic soft increases and supraglottic soft tissue become rounded and tissue become rounded and redundant and drawn into the redundant and drawn into the laryngeal inlet......causing laryngeal inlet......causing obstruction during inspiration.obstruction during inspiration.

A ball-valve effect: FinkA ball-valve effect: Fink

Ball: Supra glotic tissue - preepiglottic Ball: Supra glotic tissue - preepiglottic body (from hyoid to notchbody (from hyoid to notch

of the thyroid cartilage) of the thyroid cartilage)

Valve: upper surface of the false cordsValve: upper surface of the false cords

Translaryngeal inspiratory pressure Translaryngeal inspiratory pressure gradientgradient

increasedincreased

DignosisDignosis

Harsh breathing inspiratory sound Harsh breathing inspiratory sound (stridor)(stridor)

exclude oexclude other causes of airway ther causes of airway obstruction, e.g. tongue drop, blood obstruction, e.g. tongue drop, blood clot impaction, bronchospasm, clot impaction, bronchospasm,

– – fall in spo2(usually late)fall in spo2(usually late)

Partial laryngospasmPartial laryngospasm• • Signs of inspiratory airway Signs of inspiratory airway

obstructionobstruction– – Suprasternal retractionSuprasternal retraction– – Use of accessory musclesUse of accessory muscles– – Paradoxical movement of chest and Paradoxical movement of chest and

abdomenabdomen

Auscultation : Inspiratory ObstructionAuscultation : Inspiratory Obstruction

Complete laryngospasmComplete laryngospasm : : absence of breath soundsabsence of breath sounds• • Late changeLate change– – BradycardiaBradycardia– – CyanosisCyanosis– – pt. with IHD and H.T.-- high risk pt. with IHD and H.T.-- high risk

groupgroup

TreatmentTreatment• • Partial laryngospasmPartial laryngospasm– – Identify and remove the Identify and remove the

stimulusstimulus– – Apply jaw thrust maneuverApply jaw thrust maneuver– – Insert oral or nasal airwayInsert oral or nasal airway– – Positive pressure ventilation Positive pressure ventilation

with 100% O2with 100% O2– – Anxiolysis( assurance and Anxiolysis( assurance and

sedation)sedation)– – Inj. Xylocard 1 mg/kg Inj. Xylocard 1 mg/kg – – Inj.Propofol 0.25-1 mg /kgInj.Propofol 0.25-1 mg /kg– – Steroids -Inj. Hydrocort, Steroids -Inj. Hydrocort,

DexamethasoneDexamethasone

– – Magnesium sulphate in a dose Magnesium sulphate in a dose of 15 mg/kg diluted in 30 ml of of 15 mg/kg diluted in 30 ml of 0.9% normal saline and given 0.9% normal saline and given over 20 minutesover 20 minutes

– – NTG 4 mcg/kg NTG 4 mcg/kg Other drugs : Doxapram, DiazepamOther drugs : Doxapram, Diazepam

Complete laryngospasmComplete laryngospasm– – Call for helpCall for help– – Deepen the anesthesia levelDeepen the anesthesia level• • If laryngospasm occurs without i.v. If laryngospasm occurs without i.v.

line intraosseous route offer a faster line intraosseous route offer a faster central circulation than peripheralcentral circulation than peripheral

• • LidocaineLidocaine– – SLN blockSLN block– – 5 mL of 2% lidocaine + 5 mL NS 5 mL of 2% lidocaine + 5 mL NS

nebulized by 100% O2nebulized by 100% O2– – Transtracheal injection of 1~2 mL Transtracheal injection of 1~2 mL

4% lidocaine4% lidocaine

Airway maneuverAirway maneuver

Airway maneuver: Jaw thrustAirway maneuver: Jaw thrustforcing the chin forward with forcing the chin forward with strong pressure from behind strong pressure from behind the ascending rami of the the ascending rami of the jawjaw

→ → dislocate TMJ anteriorlydislocate TMJ anteriorly→ → lengthen thyrohyoid musclelengthen thyrohyoid muscle→ → unfold the soft supraglottic unfold the soft supraglottic tissuetissue

Intractable laryngospasm – muscle Intractable laryngospasm – muscle relaxantsrelaxants

Intravenous:Intravenous: atropine and atropine and succinylcholinesuccinylcholine

Intramuscular :Intramuscular : succinylcholine succinylcholine (4mg/kg)(4mg/kg)

vocal cords relax within one minute; vocal cords relax within one minute; lastlast

several minutes ….IPPV---Intubationseveral minutes ….IPPV---Intubation

Intralingual: atropine and Intralingual: atropine and succinylcholinesuccinylcholine

(not recommended for children with(not recommended for children withhalothane/nitrous oxide/O2; ventricularhalothane/nitrous oxide/O2; ventriculararrhythmia)arrhythmia)

Superior laryngeal nerve Superior laryngeal nerve BlockBlock

Fallow up – very Fallow up – very importantimportant

Patient can be kept in Patient can be kept in recovery position with recovery position with oxygen supplementoxygen supplement

Assess for the possibility of Assess for the possibility of developingdeveloping

– – Pulmonary aspirationPulmonary aspiration– – Postobstructive negative Postobstructive negative pressure pulmonary edemapressure pulmonary edema

Paroxysmal Paroxysmal LaryngospasmLaryngospasm

• • Extremely rare and is diagnosed by Extremely rare and is diagnosed by history:history:

spontaneous sudden onset of stridulousspontaneous sudden onset of stridulousdyspnea, resolve within minutesdyspnea, resolve within minutes• • Frequently have a positional Frequently have a positional

component, maycomponent, maywake the patientwake the patient• • Extremely distressing, impending Extremely distressing, impending

doomdoom• • mucosal hypersensitivity..mucosal hypersensitivity..� � maladapted reflex arcmaladapted reflex arc

PreventionPrevention• • Identify patients at risk is the most Identify patients at risk is the most

importantimportant• • Nonirritant inhalational anesthetic, e.g.Nonirritant inhalational anesthetic, e.g.sevofluranesevoflurane• • Deep anesthesia before intubationDeep anesthesia before intubation• • Extubate while the lungs are inflated by Extubate while the lungs are inflated by

positivepositivepressurepressure– ⇓ – ⇓ Adductor response of laryngeal muscleAdductor response of laryngeal muscle– – Artificial coughArtificial cough• • 5% CO2 inhalation for 5 min before 5% CO2 inhalation for 5 min before

extubaionextubaionCO2 exhalation drive > the laryngospasm CO2 exhalation drive > the laryngospasm

reflexreflex

• • DrugsDrugs

– – Premedication with oral BZD Premedication with oral BZD

– – Anticholinergics ⇓ secretionAnticholinergics ⇓ secretion

– – LignocaineLignocaine

• • Spray to larynx at 4 mg/kg (1 mL Spray to larynx at 4 mg/kg (1 mL 10% lidocaine for a 25 kg pt)10% lidocaine for a 25 kg pt)

Intravenous xylocard Intravenous xylocard (lignocaine)(lignocaine)

• • Controversial in preventing Controversial in preventing laryngospasmlaryngospasm

• • Some said i.v. at 1 mg/kg 5 min Some said i.v. at 1 mg/kg 5 min beforebefore

extubation fairly effective as extubation fairly effective as topical usetopical use

Deep versus Awake ExtubationDeep versus Awake Extubation

• • ControversialControversial• • Awake extubationAwake extubation– – Protect the airway from Protect the airway from

aspirationaspiration– – Increases anxiety in patientsIncreases anxiety in patients• • Deep extubationDeep extubation– – Less likely to cough and strainLess likely to cough and strain which can cause collection of which can cause collection of

secretion ---throat irritation secretion ---throat irritation

Thank you Thank you all all