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Management of Laryngospasm.

Last post 18 Mar 2012, 11:49 AM by robert walker. 0 replies.
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  •  18 Mar 2012, 11:49 AM 1096

    Management of Laryngospasm.

    We congratulate the authors on producing excellent well thought out guidelines on tracheal extubation. However, we would like to comment on the appendix concerning the prevention and treatment of Laryngospasm [1].

     Laryngospasm as they correctly point out is a serious complication and must be promptly managed to avoid serious physiological disturbance. In the recent analysis of the first 189 reports of laryngospasm to the Australian incident monitoring study, one in three patients suffered significant physiological disturbance. Indeed, in one in five patients the cause was blood, secretions, regurgitation or vomiting and the recommendation of checking the pharynx in this situation is very important [2], something that does not appear in the management guidelines. The authors of this paper also point out that one in four of the reports the diagnosis of laryngospasm was not initially clinically obvious and may present with desaturation, or regurgitation, making it more important not to waste time in the management of this situation when it  becomes clear that laryngospasm is the cause of airway obstruction.

     

    In terms of the treatment of laryngospasm, the overriding principles of oxygenation and prompt management could be clearer in table A1. The principle of CPAP with 100% oxygen is accepted but the addition of Larson’s Manoeuvre is surprising. This technique is published in letter form only and although the author claims great success with its use, there are no case reports, case series or trials using it as a form of management [3]. We understand that it is a simple and easily applied technique but reliance on it may delay definitive management of the problem with either intravenous propofol or suxamethonium.

     

    The dose of suxamethonium needs some clarification in the situation where either intravenous access is lost or has not been achieved as yet, for example during a gaseous induction in paediatric practice.  A dose range is not always helpful in these stressful circumstances, as quoted in table A1. The accepted dose for intramuscular administration of suxamethonium is 4mg/kg. Lower doses will provide variable levels of relaxation often as low as 20-30% of maximal twitch depression after 3-4minutes [4]. Intramuscular suxamethonium requires 3-4 minutes to provide full relaxation, however, the observations of Beldavs from 1959 that the administration of intramuscular suxamethonium to conscious children caused them to loose their voice within 30-45seconds before there was weakening of the extremities, suggests that the laryngeal muscles are affected first.[5,6] This observation has been supported by some work by Donati, showing that the laryngeal muscles are more sensitive to the effects of muscle relaxants [7]. This suggests that IM suxamethonium will have an effect within the required time of one minute in the laryngospasm scenario. The dose of intralingual suxamethonium is accepted as 2mg/kg following work in the 1960s [8]. Relaxation was complete within 75seconds, but interestingly in the original paper there was a high incidence of arrhythmias associated with the intralingual route and not the intramuscular or intravenous route. This observation was not explaned. The submental route has been studied for intralingual administration of suxamethonium in a dose of 3mg/kg [9]. The effect is more variable and the onset of complete relaxation just over 2 minutes, but it remains an option.

     

    The choice of route for administration of suxamethonium is a personal one, but intramuscular is the simplest and most accessible and should this not solve the situation within 30-45 seconds, an intraosseous canula can be placed for further management. Intralingual suxamethonium is potentially messy and loss of CPAP is a disadvantage.

     

    The management of laryngospasm is often straight forward but in some circumstances can be challenging to say the least, and in those cases time is of the essence and the emphasis should be on oxygenation and prompt relaxation by whatever means.

     

    G. Gavel

    R. Walker

    Royal Manchester Children’s Hospital

    Manchester, U.K.

    Email: birobwalker@aol.com

    No external funding and no competing interests declared.

    References. 

    1. Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society guidelines for the management of tracheal extubation. Anaesthesia 2012; 67:318-340.
    2. Visvanathan T, Kluger MT, Webb RK, Westhorpe RN. Crisis management during anaesthesia:laryngospasm. Quality and Safety in Health Care 2005;14:3-8.
    3. Larson P. Laryngospasm – the best treatment. Anesthesiology 1998; 89(5): 1293-4.
    4. Liu LMP, DeCook TH, Goudsouzian NG, Ryan JF. Dose response to succinylcholine in children. Anesthesiology 1981;55: 599-602.          
    5. Beldavs J. Intramuscular succinylcholine for endotracheal intubation in infants and children. Canadian Anaesthetists’ Society Journal 1959; 6: 141-7.
    6. Walker RWM, Sutton R. Which port in a storm? Use of suxamethonium without intravenous access for severe laryngospasm. Anaesthesia 2007; 62: 757-9.                    
    7. Donati F, Plaud B, Meistelman C. A method to measure elicited contraction of laryngeal adductor muscles during anesthesia. Anesthesiology 1991; 74: 827-832.
    8. Mazze RI, Dunbar RW. Intralingual succinylcholine in children. An alternative to intravenous and intramuscular routes? Anesthesia and Analgesia 1968; 47: 605-615.
    9. Redden RJ, Miller M, Campbell RL. Submental administration of succinylcholine in children. Anesthesiology Progress 1990;37:296-300.
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