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

• if exaggerated impedes respiration to

produce morbidity and occasionally

mortality.

• Self-limited mostly:

• prolonged hypoxia and hypercapnia abolish the reflex.

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

• Laryngospasm occurs during anesthesia for :

• a lack of inhibition of glottic reflexes because of inadequate central nervous system depression

• secondly increased stimuli

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

Ball valve

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

• Oral endoscopy • Tonsillectomy • Adenoidectomy • Appendicectomy • Hypospadias • Skin graft in children• Thyroid surgeries

Anaesthetic factors

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

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:• 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

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

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

• 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.

Treatment

Treatment

• Seek help • Laryngoscopy • Remove secretions, mucus, blood • 100 % oxygen – CPAP • LARSON maneuver • Subhypnotic propofol -0.2 mg/kg • Scoline – 0.1 – 1 mg / kg • Atropine

Jaw thrust

Larson Maneuver -- Laryngospasm notch

Three problems with scoline

• Scoline apnea • Previous non depolarizers• Hyperkalemia

• No IV access – • Scoline 4 mg / kg IM • Intra osseous route – described

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

• Doxapram – 1.5 mg / Kg for 15 seconds

• IV nitroglycerin 4 mcg /kg

• Superior laryngeal nerve block

Superior laryngeal nerve block

Algorithms

Summary

• Definition • Incidence • Factors • Pathophysiology • Signs • Prevention • Treatment

• Thank you all