LARYNGOSPASM

LOOK FOR (1, 2)

Inspiratory stridor/airway obstruction
Increased inspiratory efforts/tracheal tug
Paradoxical chest/abdominal movements
Desaturation, bradycardia, central cyanosis
 

Airway irritation and/or obstruction
Blood/secretions in the airway
Regurgitation and aspiration
Excessive stimulation/"light" anaesthesia
Failure of anaesthesia delivery system.
 

Cease stimulation/surgery (2)
100% Oxygen (3)
Try gentle chin lift/jaw thrust (4)
Request immediate assistance
Deepen anaesthesia with an IV agent (5)
Visualise and clear the pharynx/airway
     If you suspect aspiration then go to Regurgitation (6)
     If you suspect airway obstruction go to Airway Obstruction (7)
Try mask CPAP/IPPV, if this is unsuccessful
     Give suxamethonium unless contraindicated (8)
     Give atropine unless contraindicated (9)
Again, try mask CPAP/IPPV (10)
Intubate and ventilate (11)
 

Careful postoperative review of the patient to:
     confirm a clear airway
     exclude pulmonary aspiration (6)
     exclude post obstructive pulmonary oedema (8)
     explain what happened to the patient.
There is a risk of awareness
     go and see the patient in the ward
     explain again, and reassure the patient.
See After the Crisis

It was judged that correct use of this algorithms would have led to earlier recognition of the problem and/or better management in 16% of 189 relevant incidents reported to AIMS.
(1) 77% of cases were clinically obvious, 14% presented as airway obstruction, 5% as regurgitation, 4% as desaturation.
(2) Airway manipulation - 44%; blood/secretions in the airway - 12%; regurgitation/vomiting - 9%; surgical stimulation - 5%; moving the patient - 4%; irritant volatile anaesthetics - 2%; failure of anaesthesia delivery system - 2%.
(3) 61% of reports documented desaturation.
(4) The cricothyroid muscle is the only tensor of the vocal cords. Gentle stretching of this muscle may overcome moderate laryngospasm. In applying jaw thrust, gentle pressure should be exerted on the angle of the mandible, and not on soft tissues.
(5) Try 20% of the induction dose; this may be all that is needed (5% of cases were managed in this way); for more details, and for advice about children see (12) below.
(6) 3% of cases were associated with aspiration.
(7) 23% of cases initially presented clinically as airway obstruction.
(8) Suxamethonium: Delay in relieving severe laryngospasm was associated with post-obstructive pulmonary oedema in 4% of cases; 15% of cases were managed with suxamethonium:
  Without intubation:
          0.5 mg/kg IV to relieve laryngospasm (maximum 50 mg IV adult dose)
   For intubation:
          1.0 - 1.5 mg/kg IV (100 mg adult dose)
          OR 4 mg/kg intramuscularly for intubation, if no IV access (up to 400mg adult dose).
(9) Atropine: 0.01 mg/kg. Bradycardia occurred in 6% of all cases and in 23% of patients less than 1 year of age.
(10) 28% of cases were managed by face mask CPAP/IPPV
(11) 43% of cases were intubated

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