2. LaryngospasmLaryngospasm
A protective reflexive glottic closure toA protective reflexive glottic closure to
prevent aspirationprevent aspiration
•• Its exaggeration impedes respirationIts exaggeration impedes respiration
•• Self-limited mostly: prolonged hypoxia andSelf-limited mostly: prolonged hypoxia and
hypercapnia abolish the reflexhypercapnia abolish the reflex
•• If sustained, in high risk groups--morbidityIf sustained, in high risk groups--morbidity
(e.g.Bradicardia, cardiac arrest, pulmonary(e.g.Bradicardia, cardiac arrest, pulmonary
edema…etc.) and mortality ensueedema…etc.) and mortality ensue
3. IncidenceIncidence
Rare but Mostly seen during anesthesiaRare but Mostly seen during anesthesia
Emergence 48%, induction 28%,Emergence 48%, induction 28%,
maintenance 24%maintenance 24%
1. An overall incidence: 8.7/10001. An overall incidence: 8.7/1000
patientspatients
children (0-9 y/o): 17.4/1000children (0-9 y/o): 17.4/1000
infants (birth to 3 m/o): 28.2/1000infants (birth to 3 m/o): 28.2/1000
4. 2. adolescence: male > female2. adolescence: male > female
male: 12.1/1000; female: 7.2/1000male: 12.1/1000; female: 7.2/1000
Children with an upper respiratory infection orChildren with an upper respiratory infection 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:
5. 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
6. Surgery relatedSurgery related
–– Throat and/or Airway surgeryThroat and/or Airway surgery
–– Laryngeal SurgeryLaryngeal Surgery
–– Thyroid surgeryThyroid surgery
--Tonsils surgery--Tonsils surgery
•• SLN injurySLN injury
•• HypoparathyroidismHypoparathyroidism
–– Esophageal procedureEsophageal procedure
–– Reflex stimulation: anal surgeryReflex stimulation: anal surgery
,cervical stimulation,cervical stimulation
7. Anaesthesia relatedAnaesthesia related
–– Insufficient depth ofInsufficient depth of
anesthesia during induction or surgical stimulusanesthesia during induction or surgical stimulus
–– i.v. induction agentsi.v. induction agents
•• BarbiturateBarbiturate
•• Ketamine, salivaKetamine, saliva
–– LMA > ETT > face maskLMA > ETT > face mask
–– Airway irritationAirway irritation
Irritant Volatile anesthetics: isofluraneIrritant Volatile anesthetics: isoflurane
Airway handlingAirway handling
Mucus or blood after extubationMucus or blood after extubation
Residual paralysis: common causeResidual paralysis: common cause
vomiting or regurgitationvomiting or regurgitation
10. Sensory nerve innervation: C.N. X (vagusSensory nerve innervation: C.N. X (vagus
nerve)nerve)
Internal branch of the superiorInternal branch of the superior
laryngeal nerve (SLN) :laryngeal nerve (SLN) : the area abovethe area above
the true cordthe true cord
Recurrent laryngeal nerveRecurrent laryngeal nerve: below the: below the
true vocal cord to upper part of thetrue vocal cord to upper part of the
tracheatrachea
11. Motor nerve innervation: C.N. X (vagusMotor nerve innervation: C.N. X (vagus
nerve)nerve)
External branch of superior laryngealExternal branch of superior laryngeal
nervenerve: inferior pharyngeal constrictors: inferior pharyngeal constrictors
and cricothyroid muscleand cricothyroid muscle
Recurrent laryngeal nerve: otherRecurrent laryngeal nerve: other
intrinsic laryngeal muscleintrinsic laryngeal muscle
12. Intrinsic laryngeal musclesIntrinsic laryngeal muscles
Posterior cricoarytenoid : the onlyPosterior cricoarytenoid : the only
abductorabductor
Lateral cricoarytenoid m.:.....adductorLateral cricoarytenoid m.:.....adductor
Thyroarytenoid m.:..............shorteningThyroarytenoid m.:..............shortening
Cricothyroid m.:.............lengtheningCricothyroid m.:.............lengthening
Interarytenoid m.:.........adductionInterarytenoid m.:.........adduction
13. Laryngeal reflex: (glottis closure reflex; quickLaryngeal reflex: (glottis closure reflex; quick
protective response)protective response)
laryngeal closure (vocal cord adduction, protectlaryngeal closure (vocal cord adduction, protect
lungs from aspiration of foreign materiallungs from aspiration of foreign material
Laryngospasm: a prolonged form of vocalLaryngospasm: a prolonged form of vocal
cord of adduction (closure of the true vocalcord of adduction (closure of the true vocal
cords alone or the true and false vocal cords)cords alone or the true and false vocal cords)
14. PhysiologyPhysiology
A multitude of mechanoreceptors,A multitude of mechanoreceptors,
chemoreceptors and thermoreceptors arechemoreceptors and thermoreceptors are
throughout the larynxthroughout the larynx
•• The density is greatest around the laryngealThe density is greatest around the laryngeal
openingopening
•• The posterior aspect of the true vocal folds hasThe posterior aspect of the true vocal folds has
greater density than the anteriorgreater density than the anterior
•• Stimulation of these receptors induce short-livedStimulation of these receptors induce short-lived
glottic adduction to protect from aspirationglottic adduction to protect from aspiration
15. Fink, 1956, AnesthesiologyFink, 1956, Anesthesiology
Laryngospasm: three levelsLaryngospasm: three levels
1.1.
The vocal cordsThe vocal cords
2.2.
The false cordsThe false cords
3.3.
The Arytenoids-Epiglottis foldsThe Arytenoids-Epiglottis folds
16. A ball-valve effect: FinkA ball-valve effect: Fink
After reflex the true and false vocal cordAfter reflex the true and false vocal cord
closes translaryngeal inspiratory pressurecloses translaryngeal inspiratory pressure
gradient increases and supraglottic softgradient increases and supraglottic soft
tissue become rounded and redundant andtissue become rounded and redundant and
drawn into the laryngeal inlet......causingdrawn into the laryngeal inlet......causing
obstruction during inspiration.obstruction during inspiration.
17. A ball-valve effect: FinkA ball-valve effect: Fink
Ball: Supra glotic tissue - preepiglottic body (fromBall: Supra glotic tissue - preepiglottic body (from
hyoid to notchhyoid 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 gradientTranslaryngeal inspiratory pressure gradient
increasedincreased
18. DignosisDignosis
Harsh breathing inspiratory sound (stridor)Harsh breathing inspiratory sound (stridor)
exclude oexclude other causes of airway obstruction, e.g.ther causes of airway obstruction, e.g.
tongue drop, blood clot impaction,tongue drop, blood clot impaction,
bronchospasm,bronchospasm,
–– fall in spo2(usually late)fall in spo2(usually late)
Partial laryngospasmPartial laryngospasm
•• Signs of inspiratory airway obstructionSigns of inspiratory airway obstruction
–– Suprasternal retractionSuprasternal retraction
–– Use of accessory musclesUse of accessory muscles
–– Paradoxical movement of chest and abdomenParadoxical movement of chest and abdomen
19. 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 grouppt. with IHD and H.T.-- high risk group
20. TreatmentTreatment
•• Partial laryngospasmPartial laryngospasm
–– Identify and remove the stimulusIdentify and remove the stimulus
–– Apply jaw thrust maneuverApply jaw thrust maneuver
–– Insert oral or nasal airwayInsert oral or nasal airway
–– Positive pressure ventilation with 100% O2Positive pressure ventilation with 100% O2
–– Anxiolysis( assurance and sedation)Anxiolysis( assurance and sedation)
–– Inj. Xylocard 1 mg/kgInj. Xylocard 1 mg/kg
–– Inj.Propofol 0.25-1 mg /kgInj.Propofol 0.25-1 mg /kg
–– Steroids -Inj. Hydrocort, DexamethasoneSteroids -Inj. Hydrocort, Dexamethasone
21. –– Magnesium sulphate in a dose of 15Magnesium sulphate in a dose of 15
mg/kg diluted in 30 ml of 0.9% normalmg/kg diluted in 30 ml of 0.9% normal
saline and given over 20 minutessaline and given over 20 minutes
–– NTG 4 mcg/kgNTG 4 mcg/kg
Other drugs : Doxapram, DiazepamOther drugs : Doxapram, Diazepam
22. Complete laryngospasmComplete laryngospasm
–– Call for helpCall for help
–– Deepen the anesthesia levelDeepen the anesthesia level
•• If laryngospasm occurs without i.v. lineIf laryngospasm occurs without i.v. line
intraosseous route offer a faster centralintraosseous route offer a faster central
circulation than peripheralcirculation than peripheral
•• LidocaineLidocaine
–– SLN blockSLN block
–– 5 mL of 2% lidocaine + 5 mL NS nebulized by5 mL of 2% lidocaine + 5 mL NS nebulized by
100% O2100% O2
–– Transtracheal injection of 1~2 mL 4% lidocaineTranstracheal injection of 1~2 mL 4% lidocaine
23. Airway maneuverAirway maneuver
Airway maneuver: Jaw thrustAirway maneuver: Jaw thrust
forcing the chin forward with strongforcing the chin forward with strong
pressure from behind thepressure from behind the
ascending rami of the jawascending rami of the jaw
→→ dislocate TMJ anteriorlydislocate TMJ anteriorly
→→ lengthen thyrohyoid musclelengthen thyrohyoid muscle
→→ unfold the soft supraglottic tissueunfold the soft supraglottic tissue
24.
25. Intractable laryngospasm – muscle relaxantsIntractable laryngospasm – muscle relaxants
Intravenous:Intravenous: atropine and succinylcholineatropine and succinylcholine
Intramuscular :Intramuscular : succinylcholine (4mg/kg)succinylcholine (4mg/kg)
vocal cords relax within one minute; lastvocal cords relax within one minute; last
several minutes ….IPPV---Intubationseveral minutes ….IPPV---Intubation
Intralingual: atropine and succinylcholineIntralingual: atropine and succinylcholine
(not recommended for children with(not recommended for children with
halothane/nitrous oxide/O2; ventricularhalothane/nitrous oxide/O2; ventricular
arrhythmia)arrhythmia)
28. Fallow up – very importantFallow up – very important
Patient can be kept in recoveryPatient can be kept in recovery
position with oxygen supplementposition with oxygen supplement
Assess for the possibility ofAssess for the possibility of
developingdeveloping
–– Pulmonary aspirationPulmonary aspiration
–– Postobstructive negative pressurePostobstructive negative pressure
pulmonary edemapulmonary edema
29. Paroxysmal LaryngospasmParoxysmal Laryngospasm
•• Extremely rare and is diagnosed by history:Extremely rare and is diagnosed by history:
spontaneous sudden onset of stridulousspontaneous sudden onset of stridulous
dyspnea, resolve within minutesdyspnea, resolve within minutes
•• Frequently have a positional component, mayFrequently have a positional component, may
wake the patientwake the patient
•• Extremely distressing, impending doomExtremely distressing, impending doom
•• mucosal hypersensitivity..mucosal hypersensitivity..
maladapted reflex arcmaladapted reflex arc
30. PreventionPrevention
•• Identify patients at risk is the most importantIdentify patients at risk is the most important
•• 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 positiveExtubate while the lungs are inflated by positive
pressurepressure
– ⇓– ⇓ Adductor response of laryngeal muscleAdductor response of laryngeal muscle
–– Artificial coughArtificial cough
•• 5% CO2 inhalation for 5 min before extubaion5% CO2 inhalation for 5 min before extubaion
CO2 exhalation drive > the laryngospasm reflexCO2 exhalation drive > the laryngospasm reflex
31. •• DrugsDrugs
–– Premedication with oral BZDPremedication with oral BZD
–– Anticholinergics secretion⇓Anticholinergics secretion⇓
–– LignocaineLignocaine
•• Spray to larynx at 4 mg/kg (1 mL 10% lidocaineSpray to larynx at 4 mg/kg (1 mL 10% lidocaine
for a 25 kg pt)for a 25 kg pt)
32. Intravenous xylocard (lignocaine)Intravenous xylocard (lignocaine)
•• Controversial in preventing laryngospasmControversial in preventing laryngospasm
•• Some said i.v. at 1 mg/kg 5 min beforeSome said i.v. at 1 mg/kg 5 min before
extubation fairly effective as topical useextubation fairly effective as topical use
33. Deep versus Awake ExtubationDeep versus Awake Extubation
•• ControversialControversial
•• Awake extubationAwake extubation
–– Protect the airway from aspirationProtect the airway from aspiration
–– 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 secretionwhich can cause collection of secretion
---throat irritation---throat irritation
