dr. s. parthasarathy md., da., dnb, md (acu), dip. diab. dca, dip. software statistics phd (physio)...
TRANSCRIPT
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Dr. S. Parthasarathy MD., DA., DNB, MD (Acu),
Dip. Diab. DCA, Dip. Software statistics
PhD (physio)Mahatma Gandhi medical
college and research institute , puducherry, India
Laryngospasm
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Definition
• A protective reflexive glottic closure which
prevents aspiration
• if exaggerated impedes respiration to
produce morbidity and occasionally
mortality.
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• Self-limited mostly:
• prolonged hypoxia and hypercapnia abolish the reflex.
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Incidence
• 0.87 % - overall
• Children 0 -9 years – 1.74 %
• Infants – 2.82 % • Most occurs during anesthesia• – Emergence 48%, induction 28%,
maintenance 24%
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Two reasons
• Laryngospasm occurs during anesthesia for :
• a lack of inhibition of glottic reflexes because of inadequate central nervous system depression
• secondly increased stimuli
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Pathophysiology
• Three levels • Vocal cords – shutter • Inspiratory pressure gradient increases • Thyrohyoid shortens – (extrinsic)• Supra glottic tissue ,False vocal cords loosen to
become a redundant tissue – ball • Falls on the opening
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Ball valve
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Certain factors ??? – patient
• H/O URI 10 times – 6 weeks • Wheezing• Presence of Ryle s tube • Smoking – passive - Smokers – 10 days • GERD • Down , parkinson , hypocalcemia,
hypomagnesemia
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Surgical factors
• Oral endoscopy • Tonsillectomy • Adenoidectomy • Appendicectomy • Hypospadias • Skin graft in children• Thyroid surgeries
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Anaesthetic factors
• Rarely as transfusion reactions • LMA > ETT• Insufficient depth • Ketamine – secretion • Mucus and blood • Desflurane
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Clinical manifestations
• Partial – stridor • Complete – laryngospasm – no air movement
– tracheal tug, paradoxical breathing • Oxygen desaturation 61%• – Bradycardia 6%• – Cardiac arrest 0.5%• – Pulmonary aspiration 3%• – Postobstructive negative pressure PE 4%
Complications
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Differential diagnosis:• Bronchospasm• Supraglottic obstruction• Vocal cord palsy. Bilateral incomplete palsy is more
dangerous than complete palsy.• Tracheomalacia• Psychogenic• Laryngomalacia • Airway edema • Hematoma, soft tissue obstruction, • foreign material such as throat packs.
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Treatment
Prevention
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Prevention
• Identify patients at risk for laryngospasm (described already)
• Sevoflurane • Deep extubation – no touch technique• Positive pressure inflation of the lungs before
tracheal extubation
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Prevention• Anticholinergics • Benzodiazepines • IV lignocaine • IV magsulf • Use 5% carbon dioxide (CO2)( for 5 min prior
to tracheal extubation) • Extubate deep / no touch technique • Partially inflated LMA
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the “no touch” technique
• blood and secretions are carefully suctioned from the pharynx, - extubate
• patient is then turned to the lateral (recovery) position
• the volatile anesthetics are discontinued, and no further stimulation is allowed until patients spontaneously wake up.
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Treatment
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Treatment
• Seek help • Laryngoscopy • Remove secretions, mucus, blood • 100 % oxygen – CPAP • LARSON maneuver • Subhypnotic propofol -0.2 mg/kg • Scoline – 0.1 – 1 mg / kg • Atropine
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Jaw thrust
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Larson Maneuver -- Laryngospasm notch
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Three problems with scoline
• Scoline apnea • Previous non depolarizers• Hyperkalemia
• No IV access – • Scoline 4 mg / kg IM • Intra osseous route – described
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Chest compression
• Half the force of CPR • 20 -25 / min.• extended palm of the free hand placed on the
middle of the chest, with the fingers directed caudally.
• Partial ok • Complete – it can convert to partial
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Other options
• Doxapram – 1.5 mg / Kg for 15 seconds
• IV nitroglycerin 4 mcg /kg
• Superior laryngeal nerve block
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Superior laryngeal nerve block
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Algorithms
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Summary
• Definition • Incidence • Factors • Pathophysiology • Signs • Prevention • Treatment
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• Thank you all