Laryngospasm question

[bkell101]

Hello everybody. MS4 with questions about Laryngospasm.

1. First has to do with basic recognition and differential diagnosis of stridor following extubation. A review article I was reading states "Both supraglottic obstruction and partial laryngospasm are associated with inspiratory stridor and intercostal retractions with rapidly deteriorating oxygenation." What are the causes of supraglottic obstruction that I should be aware of for differential purposes. Supraglottic obstruction just sounds vague to me and I'm not sure what exactly causes it. What else should be on my differential that may mimic partial or complete laryngospasm?

2. The same review article discusses the use of propofol before resorting to sux in a linear algorithm after jaw thrust, CPAP, pulling of mandible, and pressure in a special notch fail. Is this commonly practiced? (it cites 75% percent of the time propofol will releive the spasm). It would make me nervous in a desaturating patient wait for some period of time to see if this is going to be that one out of four cases where propofol isn't going to help. Does your choice depend on the O2 sat? I also saw a two armed algorithm based on complete vs. partial obstruction. Would anybody be willing to share pearls on how they practice or organize the treatment algorithms in their mind?

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[bkell101]

I truly appreciate the teaching and input by attendings/residents found in various forum on this site. I've learned a great deal just by browsing aimlessly for hours. So thank you very much in advance for any input.

 

[epidural man]

For laryngospasm, sux works 100% of the time - and quickly too.

 

[Idiopathic]

two types of laryngospasm for all practical purposes. in one variety, thecords clamp shut, you may occasionally hear a stridorous breath, or not. in the other variety, the supraglottic/pharyngeal muscles spasm, the cords may or may not close. i think that form responds better to positive pressure, both respond to sux.

other forms of supraglottic obstruction that you should be aware of are simple obstructive sleep apnea/excessive pharyngeal soft tissue, tumor, edema, abscess...usually has to deal with soft tissue pathology.

ive jaw thrusted/bag masked, and if this doesnt work, ive used sux. most people around here would tell you the same thing. most of these people are out of it, somewhat, which is why they spasm. ive never considering giving propofol unless it was in conjunction with sux...you just dont typically have a lot of time

 

[RxBoy]

pressure in a special notch fail

Ahhh... The Larson maneuver. Very few anesthesiologists I work with know about it or even use it. Its referenced nicely in big miller. Its actually very effective... I think it works because its so painful that it takes patients from a grade 2 anesthesia to a grade 1. http://en.wikipedia.org/wiki/Laryngospasm_notch

Think of a larngospasm as the feeling you get when you swallow water down wrong pipe except in light anesthesia the glottis locks. Theres only 4 ways to truly break the reflex:
1) Going from stage 2 to stage 3 anesthesia (getting someone deeper with propofol)
2) Going from stage 2 to stage 1 anesthesia (painful stimuli or waiting game)
3) Forcing it open (CPAP to manually open it or sux to paralyze it)
4) Letting the hypoxia become so significant, the glottic muscles fatigue themselves and can no longer stay contracted, that is of course if death doesn't come first.

Like others said, sux will works every-time, propofol might not. If it happens at the beginning of a case I might use propofol otherwise I'll always use sux. I have a very low threshold for using sux (although they are very infrequent now that I do awake LMA extubations). Basically if the pt desats in the 80s I push it.

Another resident I work tried the whole CPAP/100% routine until the patient was in the 60s. Attending broke it with sux, but the patient ended up with negative pressure pulmonary edema.

 

[imfrankie]

For laryngospasm, sux works 100% of the time - and quickly too.

And it's important to know that a wee little bit of sux works too. We used to use sux drips (back when dinosaurs roamed the earth).

 

[btbam]

And it's important to know that a wee little bit of sux works too. We used to use sux drips (back when dinosaurs roamed the earth).

yes 20mg is all you need

 

[MTGas2B]

And it's important to know that a wee little bit of sux works too. We used to use sux drips (back when dinosaurs roamed the earth).

I used one once in residency, when working with one of said dinosaurs.