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Raj care laryngospasm ppt


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Raj care laryngospasm ppt

  1. 1. LARYNGOSPASMLARYNGOSPASM ....can be....can be a nightmarea nightmare forfor AnaesthesiologistAnaesthesiologist Dr RajkumarrDr Rajkumarr Care hospitalCare hospital nagpurnagpur
  2. 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. 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. 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. 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. 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. 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
  8. 8. AnatomyAnatomy
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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)
  13. 13. 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
  14. 14. 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
  15. 15. 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.
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. –– 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
  21. 21. 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
  22. 22. 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
  23. 23. 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)
  24. 24. Superior laryngeal nerve BlockSuperior laryngeal nerve Block
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. •• 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)
  29. 29. 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
  30. 30. 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
  31. 31. Thank you allThank you all