Laryngospasm in Children, Dr. Chang

Helen A. Chang, DO

Article:
Case Scenario: Perianesthetic Management of Laryngospasm in Children

Orliaguet, Gilles A., et al. Anesthesiology, February 2012. Vol 116, No 2, pgs 458-468.

Summary:

This article presented a case about a 10-year old male taken for an emergent incision and drainage for a fingertip abscess. Only remarkable history included a recent URI 4 weeks prior, but clear of symptoms at the time of surgery. The primary anesthetic utilized manual ventilation with 2% expired sevoflurane with a mixture of oxygen and nitrous oxide (50/50%). After a peripheral IV was established, sufentanil (1mcg) was administered for analgesia. Mask ventilation became difficult and respiratory stridor was noted. With rapidly developing hypoxia and bradycardia, jaw thrust maneuver, positive pressure ventilation with 100% oxygen, and two boluses of propofol (total 10mg) did not break the suspected laryngospasm. Atropine IV and succinylcholine (16mg) followed by tracheal intubation followed, which improved oxygenation.

Children are more prone to laryngospasm than adults (17.4/1000). Risk factors for perioperative laryngospasm include:

-        Sex: male > female

-        URI present at time of surgery, or within past 2 weeks

-        Wheezing during exercise, or > 3 events within past year

-        Nocturnal dry cough

-        Eczema present, or within past year

-        Family hx: at least 2 family members with asthma, atopy, eczema, or smoking

Possible ways to prevent and manage laryngospasm:

-        Delay elective surgery 2-3 weeks s/p URI

-        Although various studies do not provide a “gold standard” per se, generalized increased risk of laryngospasm (increasing rank) are: Mask > LMA > ETT

-        Sufficient depth of anesthesia important when placing or removing an airway device, regardless route of induction (i.e. intravenous versus inhalation)

-        Caution with negative pressure pulmonary edema

-        At emergence, provide adequate suctioning, check for residual paralysis (if muscle relaxant administered), limit stimulus in operating room setting until patient spontaneously opens eyes, and consider using “artificial cough technique”

-        If you suspect laryngospasm, be cognizant, act fast, and aggressive!