(Staff Anesthesiologist, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland), and Jos-Manuel Garcia (Technical Coordinator, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals) for their contribution in the video of the simulated scenario. OVERVIEW Laryngospasm is potentially life-threatening closure of the true vocal chords resulting in partial or complete airway obstruction unresponsive to airway positioning maneuvers. Children are more prone to laryngospasm than adults, with laryngospasm being reported more commonly in children (17.4/1,000) than in the general population (8.7/1,000).2,5,,7In fact, the incidence of laryngospasm has been found to range from 1/1,000 up to 20/100 in high-risk surgery (i.e. It is frequently observed in fetuses and newborns, whereas later on, laryngeal closure reflex and cough become predominant.21This developmental pattern may be implicated in sudden infant death. [Laryngospasm]. 1. 3, 5, 7 In both partial and complete laryngospasm, signs of varying degrees of airway obstruction, such as suprasternal retraction, supraclavicular retractions, tracheal tug, Shortness of breath. An example of such a simulation-training scenario of a laryngospasm, including a description of the session and the debriefing, can be found in the appendix. Accessed Nov. 5, 2021. PDF Case Scenario: Perianesthetic Management of Laryngospasm in Children Learning breathing techniques can help you remain calm during an episode. Target Audience: tracheal tug, indrawing), vomiting or desaturation. have demonstrated an increased risk for laryngospasm only when cold symptoms are present the day of surgery or less than 2 weeks before (table 2).5Therefore, for children who present for elective procedures with a temperature higher than 38C, mucopurulent airway secretions, or lower respiratory tract signs such as wheezing and moist cough, surgery is usually postponed. 2012 Aug;117(2):441-2. doi: 10.1097/ALN.0b013e31825f02b4. Anesthesiology. A 10-month-old boy (8.5 kg body weight) was taken to the operating room (at 11:00 PM), without premedication, for emergency surgery of an abscess of the second fingertip on the right hand. In the largest study published in the literature (n = 136,929 adults and children), the incidence of laryngospasm was 1.7% in 09 yr-old children and only 0.9% in older children and adults.7The highest incidence (more than 2%) was found in preschool age groups. Copyright 2012, the American Society of Anesthesiologists, Inc. Perianesthetic Management of Laryngospasm in Children, A Tool to Screen Patients for Obstructive Sleep Apnea, ACE (Anesthesiology Continuing Education), https://doi.org/10.1097/ALN.0b013e318242aae9, 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting DurationA Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting, 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade, 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway, Perianesthetic Dental Injuries : Frequency, Outcomes, and Risk Factors, Understanding the Mechanics of Laryngospasm Is Crucial for Proper Treatment, Fentanyl Does Not Reduce the Incidence of Laryngospasm in Children Anesthetized with Sevoflurane. The anesthesiologist assesses that the head/neck could be placed in a more ideal position . Qual Saf Health Care. Pulm Pharmacol Ther 2004; 17:37781, Suskind DL, Thompson DM, Gulati M, Huddleston P, Liu DC, Baroody FM: Improved infant swallowing after gastroesophageal reflux disease treatment: A function of improved laryngeal sensation? You also have the option to opt-out of these cookies. , partial or complete) and of the bradycardia as well as the existence of contraindication to succinylcholine. Laryngospasm is usually defined as partial or complete airway obstruction associated with increasing abdominal and chest wall efforts to breathe against a closed glottis. Laryngospasm usually isnt life-threatening, but it can be a terrifying experience. the unsubscribe link in the e-mail. Paediatr Anaesth 2002; 12:6258, Batra YK, Ivanova M, Ali SS, Shamsah M, Al Qattan AR, Belani KG: The efficacy of a subhypnotic dose of propofol in preventing laryngospasm following tonsillectomy and adenoidectomy in children. }, #FOAMed Medical Education Resources byLITFLis licensed under aCreative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. In contrast, results from studies in children with recent URIs have shown that LMA was associated with an increased occurrence of laryngospasm.28,32In a recent, large, prospective study, the incidence of laryngospasm was increased after direct stimulation of the upper airway by both LMA and ETT in comparison with a facemask.5Therefore, LMA may be considered more stimulating than the facemask but certainly less than the ETT. padding-bottom: 0px; Furthermore, the efficacy of propofol to break complete laryngospasm when bradycardia is present has been questioned.4In our case, two bolus doses of 5 mg IV propofol (each representing a dose of 0.6 mg/kg) were administered but did not relieve airway obstruction. The afferent nerves include the trigeminal nerve for the nasopharynx, the glossopharyngeal nerve for the oropharynx and hypopharynx, the superior and recurrent laryngeal nerves, and both branches of the vagus nerve, for the larynx and trachea. Laryngospasm: Causes, Symptoms, and Treatments - WebMD Performance cookies are used to understand and analyze the key performance indexes of the website which helps in delivering a better user experience for the visitors. can occur spontaneously, most commonly associated with extubation or ENT procedures, extubation especially children with URTI symptoms, intubation and airway manipulation (especially if insufficiently sedated), drugs e.g. It occurs during general or local anesthesia, natural sleep (rapid eye movement phase of sleep), hypercapnia, and hypoxia, as well as various muscular, neuromuscular junction, or peripheral nerves disorders affecting the efferent neural pathway and effector organs of upper airway reflexes.19, This condition arises as a result of an exaggerated and prolonged laryngeal closure reflex that can be triggered by mechanical (manipulation of pharynx or larynx) or chemical stimuli (e.g. #mc-embedded-subscribe-form input[type=checkbox] { Therefore, giving IV atropine before IV injection of suxamethonium to treat laryngospasm is mandatory.66. According to Phil Larson: This notch is behind the lobule of the pinna of each ear. PDF Postanesthesia Care Unit Simulation - WordPress.com It should be suspected whenever airway obstruction occurs, particularly in the absence of an obvious supraglottic cause. The treatment includes opening and clearing the oropharynx, applying CPAP with 100% oxygen, followed by deepening of anaesthesia usually with an i.v . If the diagnosis is laryngospasm or other vocal cord dysfunction, your doctor may refer you to a speech-language pathologist to help you learn breathing exercises. Finally, third-level studies evaluate the effect of education on patient outcomes. #mergeRow-gdpr { The child was placed over a forced air warmer (Bear Hugger, Augustine Medical, Inc., Eden Prairie, MN). In addition, in complete laryngospasm, there is no air movement, no breath sounds, absence of movement of the reservoir bag, and flat capnogram.3Finally, late clinical signs occur if the obstruction is not relieved including oxygen desaturation, bradycardia, and cyanosis.3. J Appl Physiol 1998; 84:202035, Menon AP, Schefft GL, Thach BT: Apnea associated with regurgitation in infants. Whether or not this is relevant to perioperative risk of laryngospasm has been questioned many times in the literature.9,11Von Ungern-Sternberg et al. A new episode of laryngospasm was immediately suspected. In a more recent series, the overall incidence of laryngospasm was lower8but the predominance of such incidents at a young age was still clear: 50 to 68% of cases occurred in children younger than 5 yr. A competence-based training that includes a structured curriculum and regular workplace-based assessment may help mitigate the effects of caseload reduction. , the overall incidence of respiratory adverse events seems to be higher in children who were awake when their LMA was removed and lower in those who were awake when their endotracheal tube was removed.5In summary, evidence seems to favor deep LMA and awake ETT removal. Int J Pediatr Otorhinolaryngol 2010; 74:4868, Al-alami AA, Zestos MM, Baraka AS: Pediatric laryngospasm: Prevention and treatment. Anesth Analg 1991; 73:26670, Rachel Homer J, Elwood T, Peterson D, Rampersad S: Risk factors for adverse events in children with colds emerging from anesthesia: A logistic regression. Other pharmacologic agents have been proposed for the prevention and/or treatment of laryngospasm, including magnesium,17doxapram,67diazepam,68and nitroglycerine.69However, because of the small number of patients included in these series no firm conclusions can be drawn. Epiglottitis - EMCrit Project (https://pubmed.ncbi.nlm.nih.gov/31587728/), (https://academic.oup.com/bjaed/article/14/2/47/271333). The goal is to slow your breathing and allow your vocal cords to relax. Complete airway obstruction is characterized by: Where is the laryngospasm notch? A laryngospasm is a muscle spasm in the vocal cords that can lead to problems with speaking and breathing. Adapted from Hampson-Evans D, Morgan P, Farrar M: Pediatric laryngospasm. But opting out of some of these cookies may have an effect on your browsing experience. Attempt airway maneuvers such as jaw thrust and nasal airway. Advertising revenue supports our not-for-profit mission. These risk factors can be Laryngospasm is a frightening condition that happens when your vocal cords suddenly seize up, making breathing more difficult. APPENDIX. PDF Appendix 3: Protocols For Emergencies - American Association of Oral Only sevoflurane or halothane should be used for inhalational induction. Treatment of laryngospasm. Elsevier; 2021. https://www.clinicalkey.com. Singapore Med J 1998; 39:32830, Warner DO: Intramuscular succinylcholine and laryngospasm. Breathe in and out through the straw without pausing between the inhale and the exhale. Common triggers of reflex laryngeal response during anesthesia are secretions, blood, insertion of an oropharyngeal airway suction catheter, and laryngoscopy. Laryngospasm (luh-RING-go-spaz-um) is a transient and reversible spasm of the vocal cords that temporarily makes it difficult to speak or breathe. Bronchospasm: Symptoms, Causes, Diagnosis, Treatment - Verywell Health They are most likely located in the medullary neuronal network rather than in the brainstem.2223The higher center seems to regulate upper airway reflexes. In the study by von Ungern-Sternberg et al. The team must initiate usual anaphylaxis treatment including salbutamol for bronchospasm. laryngospasm - EM Sim Cases Taking an antacid or acid inhibitor for a few weeks may help diagnose the problem by the process of elimination. These are usually rare events and recurrence is uncommon, but if it happens, try to relax. ANESTHESIOLOGY 1996; 85:47580, Nishino T: Physiological and pathophysiological implications of upper airway reflexes in humans. Laryngospasm scenario. If youve had recurring laryngospasms, you should see your healthcare provider to find out whats causing them. You may opt-out of email communications at any time by clicking on Cleveland Clinic is a non-profit academic medical center. A simulation scenario is an artificial representation of a real-world event to achieve educational goals through experiential learning. Definition. Discover the causes, such as anesthesia and gastroesophageal reflux disease (GERD). If positive-pressure ventilation is to be performed, then moderate intermittent pressure should be applied. } Case Scenario Perianesthetic Management of Laryngospasm In; Hazard Identification and Risk Assessment; Permit to Work Ensuring a Safe Work Environment Introduction Industrial Workers Face Many Hazards in Their Daily Routines; Health Surveillance Employer's Pack; Incidence and Associated Factors of Laryngospasm Among Pediatric Paediatr Anaesth 2003; 13:437, Schreiner MS, O'Hara I, Markakis DA, Politis GD: Do children who experience laryngospasm have an increased risk of upper respiratory tract infection? Experimentally, Oberer et al. The next step in management depends on whether laryngospasm is partial or complete and if it can be relieved or not. Recently, a new technique with gentle chest compression has been proposed as an alternative to standard practice for relief of laryngospasm.47In this before-after study, extubation laryngospasm was managed with standard practice (CPAP and gentle positive pressure ventilation via a tight-fitting facemask with 100% O2via facemask) during the first 2 yr of the study, whereas in the following 2 yr, laryngospasm was managed with 100% O2and concurrent gentle chest compression. Although third-level studies may prove very difficult or subject to bias, first- and second-level studies are feasible but have yet to be performed for laryngospasm and pediatric airway training. #mc_embed_signup { These cookies track visitors across websites and collect information to provide customized ads. and bronchomotor reflexes, indicating that not only skeletal but also smooth muscles are involved in upper airway reflexes.19. The use of desflurane during maintenance of anesthesia appeared to be associated with a significant increase in perioperative respiratory adverse events, including laryngospasm, compared with sevoflurane and isoflurane.5Isoflurane appeared to produce laryngeal effects similar to sevoflurane.5. Evidence on this subject is scarce, but the study by von Ungern-Sternberg et al. The cause of vocal cord spasms is often unknown, and it is usually in response to a trigger such as anxiety or acid reflux. In most cases, a laryngospasm lasts for up to one minute, but it may feel much longer. Pulmonary complications. ANESTHESIOLOGY 1981; 55:599602, Walker RW, Sutton RS: Which port in a storm? Laryngospasm Administer 100% oxygen via nasal mask Suction the oropharynx, hypopharynx, and nasopharynx with a tonsil suction tip Suction/remove all blood, saliva, and foreign material from the oral cavity Pack the surgical site to prevent bleeding into the hypopharynx Draw the tongue and/or mandible forward A single copy of these materials may be reprinted for noncommercial personal use only. Laryngospasm (luh-RING-o-spaz-um) is a condition in which your vocal cords suddenly spasm (involuntarily contract or seize). Acta Anaesthesiol Scand 1999; 43:10813, Visvanathan T, Kluger MT, Webb RK, Westhorpe RN: Crisis management during anaesthesia: Laryngospasm.