Download Size: 2 MB - laryngospasm mgmc

Laryngospasm
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
Definition
• A protective reflexive glottic closure which
prevents aspiration
• if
exaggerated
produce
mortality.
impedes respiration to
morbidity
and
occasionally
• 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%
Complications
• – Cardiac arrest 0.5%
• – Pulmonary aspiration 3%
• – Postobstructive negative pressure PE 4%
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