Crisis management during anaesthesia: laryngospasm

Abstract

Background: Laryngospasm is usually easily detected and managed, but may present atypically and/or be precipitated by factors which are not immediately recognised. If poorly managed, it has the potential to cause morbidity and mortality such as severe hypoxaemia, pulmonary aspiration, and post-obstructive pulmonary oedema. Objectives: To examine the role of a previously described core algorithm ''COVER ABCD-A SWIFT CHECK'', supplemented by a specific sub-algorithm for laryngospasm, in the management of laryngospasm occurring in association with anaesthesia. Methods: The potential performance of this structured approach for the relevant incidents amongst the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. Results: There were 189 reports of laryngospasm among the first 4000 incidents reported to AIMS. These were extracted and analysed. In 77% of cases laryngospasm was clinically obvious, but 14% presented as airway obstruction, 5% as regurgitation or vomiting, and 4% as desaturation. Most were precipitated by direct airway stimulation (airway manipulation, regurgitation, vomiting, or blood or secretions in the pharynx), but patient movement, surgical stimulus, irritant volatile agents, and failure to deliver the anaesthetic were also precipitating factors. Desaturation occurred in over 60% of cases, bradycardia in 6% (23% in patients aged ,1 year), pulmonary oedema in 4%, and pulmonary aspiration in 3%. It was considered that, correctly applied, the combined core algorithm and sub-algorithm recommended for the diagnosis and management of laryngospasm would have led to earlier recognition of the problem and/or better management in 16% of cases. Conclusion: Laryngospasm may present atypically and, if not promptly managed effectively, may lead to morbidity and mortality. Although usually promptly recognised and appropriately managed, the use of a structured approach is recommended. If such an approach had been used in the 189 reported incidents, earlier recognition and/or better management may have occurred in 16% of cases.

Recurrent negative pressure pulmonary oedema after tracheal extubation

“…2,4e6 The development of non-cardiogenic pulmonary oedema has been observed after different types of obstruction of the upper airways and it is more frequent in the presence of laryngeal spasm (50% of reported cases), which has an incidence of 0.05%e5% of anaesthetic procedures. 7 The frequency depends mainly on the type of surgery, with greater incidence in ENT procedures. 7 Approximately 11% of patients who develop laryngeal spasm go on to develop NPPO.…”

“…7 The frequency depends mainly on the type of surgery, with greater incidence in ENT procedures. 7 Approximately 11% of patients who develop laryngeal spasm go on to develop NPPO. 7 During the episodes of upper airway obstruction, inspiratory efforts against a closed glottis (modified Mueller manoeuvre) may result in markedly negative pleural pressures (>À100 cm H 2 O).…”

“…7 Approximately 11% of patients who develop laryngeal spasm go on to develop NPPO. 7 During the episodes of upper airway obstruction, inspiratory efforts against a closed glottis (modified Mueller manoeuvre) may result in markedly negative pleural pressures (>À100 cm H 2 O). 8 The speed of onset, the appearance of pink frothy secretions after relief of obstruction and the relatively fast recovery are characteristics of NPPO.…”

Postoperative Apnea Induced by Fentanyl and Other Multiple Respiratory-Modulating Factors

“…A use of anxiolytics in addition to analgesics might be an appropriate choice at the emergence from anesthesia since the patient could be expected to be susceptible to postoperative agitation, considering her fragile mentality [24]. Fourth, an insufflation of sevoflurane in an attempt to relieve ventilation difficulty might be inappropriate [25]. However, we were unable to immediately prepare intravenous glottis dilators such as a muscle relaxant and propofol when we faced with the ventilation difficulty.…”

Bloqueo de la vía aérea tras la extubación. Revisión bibliográfica

“…Otras causas de BVA tras la extubación son el laringoespasmo, la parálisis laríngea bilateral (por lesión bilateral del nervio laríngeo recurrente generalmente secundario a tiroidectomía), el edema de vía aérea superior (por posición en Trendelenburg, exceso de fluidoterapia, anafilaxia), traumatismos sobre la vía aérea (en la intubación, debido a cirugía en la vía aérea), hematoma sofocante o cuerpos extraños en la vía aérea [8][9][10][11][12][13][14][15][16][17]. La incidencia global de BVA tras la extubación es baja, en torno al 0,17% [18] por lo que el mejor método de investigación es la revisión bibliográfica sistemática.…”