Laryngospasm

[RxBoy]

Question...

What technique is preferred for laryngospasm? I have had attendings crank up the 02 and apply positive pressure via bag and I have had other attendings crank up the 02, set the pop off valve to 20ish (essentially CPAP), and just apply a tight seal with jaw thrust to the face. Is there a preferred method?

Lastly, what is the actual mechanism for laryngospam relaxation? One attending told me that ultimately hypoxia causes a reflexive relaxation of the laryngospasm. If this is true why even apply I high FiO2?

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[2ndyear]

Positive pressure, whether given by hand or circuit is the same thing, and first line treatment for laryngospasm.

Deepening the anesthetic, usually by a short acting IV agent is another treatment, as is muscle relaxation typically in the form of succinylcholine.

Hypoxia does relax vocal cords, but so does death and once you get to this point one leads to another relatively quickly so we try to avoid it.

 

[Idiopathic]

Question...

What technique is preferred for laryngospasm? I have had attendings crank up the 02 and apply positive pressure via bag and I have had other attendings crank up the 02, set the pop off valve to 20ish (essentially CPAP), and just apply a tight seal with jaw thrust to the face. Is there a preferred method?

Lastly, what is the actual mechanism for laryngospam relaxation? One attending told me that ultimately hypoxia causes a reflexive relaxation of the laryngospasm. If this is true why even apply I high FiO2?

well i would suggest that if you dont have expiration against a closed pop off valve then you might not get your pressure up. i mean if you apply a mask to a wall even with 15L/min you may not build up enough pressure to break laryngospasm, so I would always bag gently at pressures 20-30 (or whatever it took).

you dont need to apply high FiO2 - room air would do the trick, but you certainly dont want to rely on hypoxia to break your spasm either, especially in children

 

[Intensivist]

What are your experiences with roc? I know sux is the drug of choice thought i books, but I guess roc would do the same thing. Whcih one would you prefer in IM route?

 

[rsgillmd]

What are your experiences with roc? I know sux is the drug of choice thought i books, but I guess roc would do the same thing. Whcih one would you prefer in IM route?

Roc would take too long to work, unless you gave a RSI dose -- in that case you may as well bring the patient out on a vent.

Never given IM Roc.

The couple of laryngospasms I've handled have resolved with positive pressure and IV agents. Only the one I had a couple of weeks ago I had to resort to Sux. I think it was starting to resolve because I saw some end-tidal CO2 a little before the resident pushed the Sux, but the patient was desatting by that time (obese and smoker).

 

[Patron]

If you were extubating the patient awake and you had mimimal inhalational agents in his circulation those positive pressure ventilation and jaw thrust works most of the times sometime I give lidocaine IV. but if the patient is deep I would give succ, in very small doses...

 

[Fastrach]

If you were extubating the patient awake and you had mimimal inhalational agents in his circulation those positive pressure ventilation and jaw thrust works most of the times sometime I give lidocaine IV. but if the patient is deep I would give succ, in very small doses...

Um, if he's deep, why would he be in laryngospasm in the first place? Unless he wasn't actually deep, but you thought he was at that Des level of 3.0...

Sorry, that's just one of my biggest pet peeves with CA1's & CRNA's.. I tell them "Let's extubate this guy deep", and almost none of them think that means 1 MAC or greater, I don't know why. Well, I kinda know why, but I digress...

 

[Patron]

Um, if he's deep, why would he be in laryngospasm in the first place? Unless he wasn't actually deep, but you thought he was at that Des level of 3.0...

Sorry, that's just one of my biggest pet peeves with CA1's & CRNA's.. I tell them "Let's extubate this guy deep", and almost none of them think that means 1 MAC or greater, I don't know why. Well, I kinda know why, but I digress...[/Q

I meant even when you extubate deep sometimes the patient is not deep enough (even though he is > 1.5 MAC) he might have larygospams while taking out the tube it happens rarely but can happen... once i took over a case from an AA the patient had a spinal and he was running 150 mcg propafol for 2 hours? so upon emegence the patient had larygospasm that I couldnt break until
I gave him sux.

 

[jwk]

Um, if he's deep, why would he be in laryngospasm in the first place? Unless he wasn't actually deep, but you thought he was at that Des level of 3.0...

Sorry, that's just one of my biggest pet peeves with CA1's & CRNA's.. I tell them "Let's extubate this guy deep", and almost none of them think that means 1 MAC or greater, I don't know why. Well, I kinda know why, but I digress...

Patients can be extubated deep, but can still spasm as they awaken. Most of the time it clears with positive pressure, but sometimes it doesn't. I still use lots of lidocaine, but I personally have a short trigger for using sux - and I mean only about 10mg. It will break the spasm, and they keep right on breathing. I've never had a case of NPPE, and had never even seen a case until 15 years into my career.

 

[Idiopathic]

yeah when srna/crnas tell me they want to extubate deep what they really mean is some ethereal plane between awake and asleep or as i like to call it "spasm-land"

 

[dhb]

yeah when srna/crnas tell me they want to extubate deep what they really mean is some ethereal plane between awake and asleep or as i like to call it "spasm-land"

Laryngospasm happens in stage 2 you're not in stage 2 all the way from etDES 5.9 to 0.1
Semi-deep is fine provided the patient isn't in stage 2

 

[michigangirl]

1. Laryngospasm happens in Stage 2
2. You do CPAP with 100% O2 because- a.) by the time you figure out they are in laryngospasm or the sats drop, you are already 10 seconds behind and need to catch up with the Os b.) CPAP just helps you stent open the cords until the patient goes into stage I
3. Only give propofol/inhalational if the CPAP doesn't break it and then be ready for another possible stage 2 fiasco

 

[IlDestriero]

1. Laryngospasm happens in Stage 2
2. You do CPAP with 100% O2 because- a.) by the time you figure out they are in laryngospasm or the sats drop, you are already 10 seconds behind and need to catch up with the Os b.) CPAP just helps you stent open the cords until the patient goes into stage I
3. Only give propofol/inhalational if the CPAP doesn't break it and then be ready for another possible stage 2 fiasco

If CPAP doesn't break laryngospasm, inhalational agents aren't going to help because they're not going to get to the lungs to be absorbed. 8% sevo may help with severe bronchospasm. If you have actual laryngospasm that doesn't break with 100% O2 and significant positive pressure along with a painful jaw lift, it's time to think about IV meds. I usually don't screw around with prop boluses and just give sux. It works quickly every time.
BTW, it is true that laryngospasm will break eventually in everyone without any intervention at all, but they will probably have ischemia, arrhythmia, bradycardia, anoxic brain injury, death, etc. first. I wouldn't count on time to solve the problem. Unless the "problem" is your continued employment as a physician.

 

[kazuma]

I've only seen 2 cases of laryngospasm. The first one resolved with PPV and a propopfol bolus, however the second case didn't go so smoothly and the patient (teenager) ended up with NPPE.

Obviously there are multiple variables involved, but is there a rough estimate of how much time you have to break the spasm before the pt develops NPPE? It seems like it would happen rather quickly if the patient has decent diaphragm strength.

 

[IlDestriero]

I've only seen 2 cases of laryngospasm. The first one resolved with PPV and a propopfol bolus, however the second case didn't go so smoothly and the patient (teenager) ended up with NPPE.

Obviously there are multiple variables involved, but is there a rough estimate of how much time you have to break the spasm before the pt develops NPPE? It seems like it would happen rather quickly if the patient has decent diaphragm strength.

You could get NPPE with one obstructed breath.