Breathing them down

[Arch Guillotti]

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Unfortunately I see kids in varying degrees of laryngospasm and obstruction post-extubation all the time. The nurses I work with cannot differentiate between the two, nor can they adequately determine the appropriate time to extubate.

Here is what it says in Cote:

Anterior and upward displacement of the jaw ("jaw thrust") longitudinally separates the base of the tongue, the epiglottis, and the aryepiglottic folds from the vocal folds, thereby helping to relieve laryngospasm.

Do you disagree?

So you think that a problem, caused by stimulating underanesthetized cords, should be treated with more stimulation? Or do you think that laryngospasm is caused by something else?

How does jaw thrust and oral airway treat laryngospasm? I would agree with both if what you are treating is in fact upper airway obstruction (90% of what is called laryngospasm is probably only upper airway obstruction anyway IMHO), but how will either help with true laryngospasm?

If their glottis is closed, where is your "gentle positive pressure" going to go, and how does this stimulation of the cords break the laryngospasm if it is indeed a stimulation induced phenomenon?

If you aren't convinced that this is the root cause, then you can make a logical argument for your interventions... except "gentle positive pressure." Filling the stomach with air is never a positive thing.

- pod

 

[jetproppilot]

Unfortunately I see kids in varying degrees of laryngospasm and obstruction post-extubation all the time.

If this is true Arch,

SOMEONE IS DOING SOMETHING WRONG.

Like previously referenced, I've worked at a busy surgery center full of

KID ENT

and laryngospasm/obstruction was uncommon.

 

[Arch Guillotti]

If this is true Arch,

SOMEONE IS DOING SOMETHING WRONG.

Yes they are unfortunately.

 

[michigangirl]

Large proportion of my practice is outpatient ENT and peds dental with a scattering of <6 mo's peds and/or neonates.

1) Last 4 yrs probably one instance of oral versed and one instance of IM ketamine for older adult-sized developmental delay patients

2) No dexmed avail for outpt, much less up the nose

3) All kids breathe themselves down on N20 and Sevo FiO2 30-100%

4) When the kids can tolerate eventual jaw thrust and exhibit regular spontaneous ventilation without squirming or tension, then they're deep enough (past stage II) for an IV

5) IV in, additional fentanyl and touch o' prop, intubate

6) kids remain spontaneously ventilating or resume prior to desat

7) our surgeons all turn bed 90 degrees for tonsils

To OP - you're not waiting till they're deep enough and out of stage II if they're laryngospasming on the regular. Note this also applies on emergence - just cause they're squirming doesn't mean they're out of stage II and ready for extubation.

👍👍👍 Ditto

Knock on wood, I've never had to give succ or propofol to break laryngospasm-- and its the real deal, sats plummet, zero end-tidal-- patience and CPAP with a closed or semi-closed popoff applied correctly will break 99.9 % of these cases. Many of my colleagues will jump to drug much quicker, it's a personal preference/comfort level thing, I guess.

 

[IlDestriero]

I let my residents extubate when they feel its time and work through the struggles of stage 2 laryngospasm when they choose incorrectly and do it too early in response to the "squirms".

There's no way in hell I would do this.
They can f around on their own malpractice insurance with their own patients.
I tend to not let my residents do things that I know are wrong to my patients. That's what I'm paid to do. Please don't use me or my kids to generate your "teachable moments".

 

[michigangirl]

Point taken, was explained poorly. When I'm in the room for extubation, they are definitely waiting until the tube is ready to come out, that is the "teachable moment"-- on rare occasions, despite best intentions, the tube will be taken out before I make it to the room, sometimes prematurely. That is the situation to which I was referring to.

 

[Planktonmd]

Here is a little advice for what it's worth:
1- Always give PO Midazolam if possible
2- Always take a aprent with you to the OR if you can
3- Always do a mask induction with a previously primed circuit running N2O 70% in Oxygen + Sevo all the way up
4- don't listen to all the other stupid crap