5/8/2013
Laryngospasm and Bronchospasm in Pediatric Anesthesia
Danai Udomtecha, MD
Clinical Assistant Professor
Divisions Of Pediatric and Cardiothoracic Anesthesia
Department Of Anesthesia
University of Iowa Hospitals and Clinics
Disclosure
I have no financial relationships to disclose
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5/8/2013
 A 3‐year‐old, 15‐kg boy scheduled for adenotonsillectomy
 Upon emergence, patient breathing spontaneously
 Endotracheal tube was removed
 Patient develops paradoxical movement of chest and abdomen, then becomes hypoxemic
 What is the diagnosis?
Endoscopic View of Larynx
False vocal cords
Intralaryngeal part of epiglottis
True vocal cords
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Laryngospasm
 Glottic spasm: adducted true vocal cords
 A minimal opening at the posterior commissure (arrow) permits some air movement
False vocal cords
True vocal cords
Laryngospasm
 (True) laryngospasm:
 False and true vocal cords adducted  Intralaryngeal part of epiglottis moves posteriorly
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Why Does This Occur
 Reflex occurs due to increased stimuli  Direct airway stimulation  Indirect stimulation
 With lack of inhibition of glottis reflexes due to inadequate CNS depression
Hampson‐Evans D, et al. Pediatric Anesthesia 2008; 18: 303‐7
Signs
 Patient’s breathing effort  Suprasternal, intercostals, subcostal retraction  Paradoxical movement of chest and abdomen  Small amount or no anesthesia bag movement  Small amount or no ventilation  + Stridor
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Complications
 Hypoxemia
 Leading cause of respiratory related periop cardiac arrest in children
 Negative pressure pulmonary edema, although not common in infants, probably due to pliable rib cage
Multifactorial Risk Factors
 Patient‐related
 Anesthesia‐related
 Surgery‐related
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Patient‐Related Risk Factors
 Age
 URI
 increases risk of laryngospasm (2.3‐5.6 times)  Risk continues even after resolution
 Passive smoking  risk of laryngospasm
risk of laryngospasm x10
x10
Orliaguet GA, et al. Anesthesiology 2012; 116: 458‐71
Von Ungern‐Sternberg BS, et al. Lancet 2010; 376: 773‐83
Anesthesia‐Related Risk Factors
 Inadequate depth of anesthesia
 Vocal cord irritation
 Supervision by less experienced and non‐
pediatric anesthesiologists
 Anesthetic agents
 Choice of airway devices in patients with current or recent URI
Alalami AA, Ayoub CM, Baraka AS. Pediatric Anesthesia 2008; 18: 281‐8
Alalami AA, Zestos MM, Baraka AS. Current Opin Anesthesiol 2009; 22: 388‐95
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Surgery‐Related Risk Factors
 Up to 21‐26% in adenotonsillectomy
 Airway procedure, bronchoscopy
 Urgent vs elective procedures
 Appendectomy, hypospadius repair
Prevention
 Preop
 Identify risk factors
 Postpone surgery after a URI if surgery is not urgent, especially with presence of other risk factors
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Prevention
 Induction
 Experienced anesthesiologist
 Not using N2O?
 IV placement or airway manipulation only when anesthesia is deep enough
 Anticholinergic reduces secretion
 Use muscle relaxant when plan to intubate
Alalami AA, Ayoub CM, Baraka AS. Pediatric Anesthesia 2008; 18: 281‐8
Prevention
 Maintenance
 If not intubated
 adequate depth of anesthesia
 not using desflurane
 Emergence
 Laryngospasm occurs most often during emergence
 Timing of airway removal in URI patients
 Prevention using drugs
 Propofol 0.5 mg
 IV lidocaine 1.5‐2 mg/kg
 Topical lidocaine? 8
5/8/2013
Management
 Recognition
 Removal of offenders
 No further stimulation of the airway
Management
 Maintain clear airway
 CPAP with 100% O2
 IPPV with high pressure can cause gastric distension
 decreased FRC, compliance  even more difficult to ventilate  worsening hypoxemia
  regurgitation  more airway stimulation
 Even CPAP may cause gastric distension  OG suction after resolution
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P
IPPV
Esophageal Opening press. (20‐25 cmH2O)
Laryngospasm
0
t
P
Esophageal Opening press. (20‐25 cmH2O)
CPAP (15‐20 cmH2O)
Laryngospasm
0
t
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5/8/2013
Management
 Techniques that may be used along with CPAP
 Pressure in the laryngospasm notch
 Jaw thrust
Management
 Treatment with drugs
 Propofol 0.25‐0.8 mg/kg IV
 Sux 0.1‐2 mg/kg IV  After atropine 0.02 mg/kg – esp if already hypoxemic
 Choosing propofol vs sux is a matter of timing
 Propofol has some benefits over sux
 Patient may be apneic, and need IPPV + intubation
 Intubation if still refractory
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Management
 Treatment with no IV access
 IM sux
 Intraosseous Sux
 Intubation without relaxant. May cause trauma
Post‐laryngospasm
 Humidified O2 to decrease laryngeal irritation
 Observed for 2‐3 hrs to ensure no pulmonary edema
Bronchospasm
 Constriction of small intrathoracic airway, causing obstruction of expiratory air flow
 Signs
 Bilateral expiratory wheezing
 Diminished or absent breath sounds if critically low air flow
 Prolonged expiratory phase
 Slow or lack of chest fall during expiration
 Increased peak airway pressures
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Differential Diagnosis
 Not every wheezing is bronchospasm
 Albuterol is not the answer for every wheezing
 Other causes of airway obstruction
 Endobronchial intubation
 Pneumothorax
 Pulmonary edema
 Esophageal intubation
 Pulmonary aspiration
Cardiopulmonary Effects
 Air trapping  Lung hyperinflation 
 V/Q mismatch and hypoxemia
 Right ventricular overload and failure
 Decreased venous return and hypotension
Dewachter P, et al. Anesthesiology 2011; 114: 1200‐10
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Decreased Expiratory Air Flow
Decreased Dynamic Compliance
Air Trapping
Dynamic Hyperinflation
Decreased Venous Return
Accessory Muscles Recruitment
Excessive PEEP
V/Q mismatch
Systemic Hypotension
Increased Pulmonary Vascular Resistance
Increased Work of Breathing
Hypoxia
RV Overload
Acute Heart Failure
Increased O2 Consumption
Increased CO2 Production
Pathophysiologic Mechanisms
 Allergic
 As part of IgE mediated anaphylaxis
 Hypotension is very early in the process
 Latex, antibiotics, muscle relaxants
 Non‐allergic
 Susceptible airways
 Precipitating factors
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Non‐Allergic Bronchospasm
 Susceptible Airways
 Asthma
 Passive smoking
 Respiratory tract infection
 Precipitating Factors
 Airway irritation with inadequate depth of anesthesia
 Pharmacologic‐induced histamine release
Management of Bronchospasm
 Pre‐operative
 Intra‐operative
 Post‐operative
Woods BD, et al. BJA 2009; 103: i57‐65.
Doherty GM, et al. Pediatric Anesthesia 2005; 15: 446‐54.
Dewachter P, et al. Anesthesiology 2011; 114: 1200‐10.
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Management of Bronchospasm
 Pre‐operative
 Identify risk factors
 Postpone if possible, until patient’s condition is optimized
 Patient should continue their usual asthmatic medications until the day of surgery
 Consider premedication
 Consider inhaled albuterol prior to induction
Management of Bronchospasm
 Intra‐operative
 Consider steroid supplement in patients on systemic steroid therapy
 Minimize airway instrumentation
 If possible, use local or regional anesthesia
 If possible, consider face mask > LMA > ETT
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Management of Bronchospasm
 Intra‐operative
 Ensure adequate depth of anesthesia before airway instrumentation
 Intubation
 Deep extubation
 Topical lidocaine to the airway?
 Consider not using muscle relaxant
 Potential allergic reactions
 Problems from reversal agents
Management of Bronchospasm
 Intra‐operative
 Choice of anesthetic agents
 Maintain adequate depth of anesthesia
 If bronchospasm occurs





100% O2
Deepen anesthesia
Manual ventilation to assess compliance
Provide adequate expiratory time
Avoid PEEP
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5/8/2013
Management of Bronchospasm
 Intra‐operative
 If bronchospasm occurs
 Inhalation of rapid acting beta‐2 selective agonist – albuterol
 Epinephrine should only be used for anaphylactic bronchospasm
 If still persists, MgSO4 40 mg/kg IV over 20 min
 Consider corticosteroid therapy (4 mg/kg hydrocortisone IV)
Management of Bronchospasm
 Emergence/ postoperative
 Consider repeating inhaled beta‐2 agonist
 Ensure adequate analgesia
 Dexmedetomidine may help smooth out emergence
 Careful use of reversal agent
 Control secretion
 Reduce risk of regurgitation
 Consider deep extubation (careful)
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Summary
 Laryngospasm and bronchospasm can cause hypoxemia and other morbidities in children
 URI, reactive airway, passive smoking, and airway irritation are main risk factors for both
 Management of both conditions involve prevention, and elimination of offenders
 Major management points for laryngospasm
 CPAP
 Propofol, sux
 Major management points for bronchospasm:
 Rule out other more serious causes  Inhaled beta‐2 agonist
danai‐[email protected]
References

Hampson‐Evans D, Morgan P, Farrar M. Pediatric Anesthesia 2008; 18: 303‐7

Alalami AA, Ayoub CM, Baraka AS. Pediatric Anesthesia 2008; 18: 281‐8

Burgoyne LL, Anghelescu DL. Pediatric Anesthesia 2008; 18: 297‐302

Al‐alami AA, Zestos MM, Baraka AS. Current Opin Anesthesiol 2009; 22: 388‐95

Holzki J, Laschat M. Pediatric Anesthesia 2008; 18: 976‐8

Orliaguet GA, Gall O, Savoldelli GL, Couloigner V. Anesthesiology 2012; 116: 458‐71

Von Ungern‐Sternberg BS, Boda K, Chambers N, Rebmann C, Johnson C, Sly PD, Harbe W. Lancet 2010; 376: 773‐83

Flick RP, Wilder RT, Pieper SF, Vankoeverden K, Ellison KM, Marienau MES, Hanson AC, Schroeder DR, Sprung J. Anesthesia 2008; 18: 289‐96

Homer JR, Elwood T, Peterson D, Rampersad S. Pediatric Anesthesia 2007; 17: 154‐61

Bordet F, Allaouchiche B, Lansiaux S, Combet S, Pouyau A, Taylor P, Bonnard C, Chassard D. Pediatric Anesthesia 2002; 12: 762‐9
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References

Walker RWM, Sutton RS. Anaesthesia 2007; 62: 757‐9

Von Ungern‐Sternberg BS, Davies K, Hegarty M, Erb TO, Habre W. Eur J Anaesthesiol
2013; 30: 1‐8

BartaYK, Ivanova M, Ali SS, Shamsah M, Al Qattan AR, Belani KG. Pediatric Anesthesia 2005; 15: 1094‐7

Hamilton ND, Hegarty M, Calder A, Erb TO, Von Ungern‐Sternberg BS. Pediatric Anesthesia 2012; 22: 345‐50

Dewachter P, Mouton‐Faivre C, Emala CW, Beloucif S. Anesthesiology 2011; 114: 1200‐10.

Dones F, Foresta G, Russotto V. Pediatrics Reports 2012; 4: 70‐7.

Woods BD, Sladen RN. BJA 2009; 103(Suppl. 1): i57‐65.

Doherty GM, Chisakuta A, Crean P, Shields MD. Pediatric Anesthesia 2005; 15: 446‐54.

Von Ungern‐Sternberg BS, Habre W, Erb TO, Heaney M. Pediatric Anesthesia 2009; 19: 1064‐9.

Scalfaro P, Sly PD, Sims C, et al. Anesth Analg 2001; 93: 898‐902.
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