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Laryngospasm: Review of Different Prevention and Treatment Modalities

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Laryngospasm: Review of Different Prevention and Treatment Modalities Pediatric Anesthesia 2008 18: 281–288 doi:10.1111/j.1460-9592.2008.02448.x Review article Laryngospasm: review of different prevention and treatment modalities ACHIR A. ALALAMI MD, CHAKIB M. AYOUB AND ANIS S. BARAKA MD Department of Anaesthesia, American University of Beirut Medical Center, Beirut, Lebanon Summary Laryngospasm is a common complication in pediatric anesthesia. In the majority of cases, laryngospasm is self-limiting. However, some- times laryngospasm persists and if not appropriately treated, it may result in serious complications that may be life-threatening. The present review discusses laryngospasm with the emphasis on the different prevention and treatment modalities. Keywords: laryngospasm; review; anesthesia; treatment; prevention; modalities Introduction Epidemiology Laryngospasm is mainly seen in children. It is a The overall incidence of laryngospasm is 0.87%. The reflex closure of the upper airway as a result of incidence in children in the first 9 years of age is the glottic musculature spasm. It is essentially a 1.74% with a higher incidence of 2.82% in infants protective reflex that acts to prevent foreign between 1 and 3 months (4). material entering the tracheobronchial tree. The The incidence of morbidity resulting from laryn- exaggeration of this reflex may result in complete gospasm can vary as follows: cardiac arrest 0.5%, glottic closure and consequently impeding respira- postobstructive negative pressure pulmonary edema tion (1). This leads to hypoxia and hypercapnea. In 4%, pulmonary aspiration 3%, bradycardia 6% and the majority of patients, the prolonged hypoxia oxygen desaturation 61% (4,6–8). and hypercapnea abolishes the spastic reflex and the problem is self-limited (2–4). However, in Mechanism certain cases, the spasm is sustained as long as the stimulus continues and morbidity such as Most laryngeal reflexes are elicited by stimulation of cardiac arrest, arrhythmia, pulmonary edema, the afferent fibers contained in the internal branch of bronchospasm or gastric aspiration may occur the superior laryngeal nerve. These reflexes control (4–6). the laryngeal muscle contractions which protect the The present review discusses the general aspects airway during swallowing. Laryngospasm may of laryngospasm with the emphasis on the different occur secondary to loss of inhibition of the laryngeal prevention and treatment modalities. closure reflex as a result of abnormal excitation (3). Correspondence to: Achir A. Alalami MD, Chief resident of Clinical manifestation Anaesthesiology, Department of Anaesthsiology, American Uni- versity Hospital, Riad El Solh, 1107-2020, Beirut, Lebanon (email: Laryngospasm can be partial, when there is [email protected]). some degree of air entry and it is recognized by Ó 2008 The Authors Journal compilation Ó 2008 Blackwell Publishing Ltd 281 282 A.A. ALALAMI ET AL. inspiratory stridor (6). Laryngospasm can be com- Anesthesia-related factors plete, with no air movement and absence of breath sounds. It is early recognized by feeling with the Insufficient depth of anesthesia during both induc- hand or placing the ear over the mouth (9,10). In tion and emergence predisposes to laryngospasm. both partial and complete laryngospasm, signs of During anesthesia including tracheal intubation, airway obstruction such as tracheal tug, paradoxical laryngospasm tends to occur after extubation, while movement of the chest and abdomen are noticed anesthesia by spontaneous breathing using a face or (6,11,12). Late signs such as oxyhemoglobin desatu- laryngeal mask may result in laryngospasm during ration, bradycardia and central cyanosis may ensue induction or maintenance (8,11,17). (8). In addition, airway irritation with volatile anes- thetics, mucus or blood and airway manipulation Differential diagnosis with suction catheter or laryngoscope blade may also induce laryngospasm (11,17). Laryngospasm should be differentiated from other Among the intravenous (i.v.) induction agents, causes of airway obstruction such as bronchospasm barbiturates such as thiopentone have been shown to or supraglottic obstruction (8). Both supraglottic increase the incidence of laryngospasm (4,6,18–22). obstruction and partial laryngospasm are associated Ketamine is rarely associated with laryngospasm with inspiratory stridor and intercostal retractions (0.4%) (5,23). However, Ketamine may cause hyper- with rapidly deteriorating oxygenation. These two salivation which can precipitate laryngospasm by complications can be differentiated by directly visua- irritating the vocal cords (23). Also, anesthesia lizing the vocal cords while the patient is making induction with propofol is less associated with inspiratory efforts (9). However, in the clinical laryngospasm than sevoflurane induction (24). situation, inserting a laryngoscope to visualize the Volatile anesthetics have been associated with vocal cords in such situation may worsen laryngo- laryngospasm in pediatric anesthesia (2.3%) (5,6). spasm. Jaw thrust or head tilt maneuver with or Among all the volatile agents, the highest incidence without insertion of oral or nasal airway while of laryngospasm is associated with desflurane applying gentle positive pressure would relieve both (50%). Isoflurane is more associated with laryngo- supraglottic obstruction and partial laryngospasm. If spasm than enflurane, halothane and sevoflurane these fail to treat the obstruction, complete laryngo- (6,7,25,26). There is no difference in the incidence of spasm should be suspected and appropriate treat- laryngospasm between sevoflurane and halothane ment should be initiated (10). In this issue if the (27). journal, Anghelescu and Burgoyne (13) discuss the Finally, laryngospasm is more likely to occur in incidence and treatment of laryngospasm at the St children which are supervised by less experienced Jude Children’s Research Hospital in Memphis. Anes- anesthesiologists (28). thesiologists must also differentiate laryngospasm from breath-holding by the presence of rocking-type Patient-related factors movement of the chest wall and abdomen (14). Laryngospasm can be psychogenic which is most The incidence of laryngospasm following general often seen in anxious adolescents and young adults. anesthesia is inversely correlated with age (29). It presents with sudden paroxysms of stridor or Children with upper respiratory tract infection or wheezing in response to exercise or emotional stress active asthma have irritable airway and are appro- and is treated with reassurance and midazolam ximately 10-fold more prone to develop laryngo- sedation (15,16). spasm. Airway hyperactivity lasts for up to 6 weeks after Risk factors respiratory infection, thus elective surgery can be delayed for 6 weeks (4,5,18,30–32). Risk factors can be classified into three categories: Chronic smokers have increased airway reflex anesthesia-related factors, patient-related factors and sensitivity and are more prone to develop laryn- surgery-related factors: gospasm. A period of abstinence from smoking of at Ó 2008 The Authors Journal compilation Ó 2008 Blackwell Publishing Ltd, Pediatric Anesthesia, 18, 281–288 REVIEW OF DIFFERENT PREVENTION AND TREATMENT MODALITIES 283 least 48 h and possibly up to 10 days may be The advantage of deep tracheal extubation over required to reduce the risk of airway problems awake extubation in children undergoing tonsillec- (33). There is a 10-fold increase in the incidence of tomy is that patients are less likely to cough and laryngospasm in children who are exposed to strain which can cause bleeding from the tonsilar tobacco smoke. Therefore, preoperative visit should bed and consequently increasing the risk of laryn- include questioning about ‘passive smoking’ (20, gospasm. On the other hand, awake tracheal extu- History of gastroesophageal reflux is also a risk bation offers the advantage of protecting the airway factor for developing laryngospasm. (34,35). Finally, against aspiration during this vulnerable period. patients with elongated uvula and those with history Patel et al. (48) undertook a study comparing of choking during sleep may also develop laryn- awake vs anesthetized tracheal extubation of gospasm under general anesthesia (11,36,37). patients after tonsillectomy and adenoidectomy. They used the criteria of awake extubation when Surgery-related factors patients demonstrated facial grimace, had adequate tidal volumes and respiratory rate, coughed with There is a close association between laryngospasm open mouths or opened their eyes. They concluded and the type of surgery (4,8). Tonsillectomy and that there is no difference in laryngospasm incidence adenoidectomy have the highest incidence of lar- between the two techniques. On the other hand, yngospasm (21–26%) (1,19,38–43). Other types of Pounder et al. (49) studied the incidence of respira- surgery such as appendicectomy, cervical dilation, tory complications in children undergoing minor hypospadias surgery and skin transplant in chil- surgery and found greater oxyhemoglobin desatu- dren are highly associated with laryngospasm (4). ration in the awake extubation group than in the Thyroid surgery has been associated with laryn- deep extubation group (P < 0.05). They also found gospasm secondary to superior laryngeal nerve 16% incidence of laryngospasm in the awake group injury or to (44) iatrogenic removal of parathyroid vs 4% incidence in the anesthetized group glands causing hypocalcemia that predisposes to (P > 0.05). The ‘No Touch’ technique was initially laryngospasm (45). Esophageal procedures
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