Laryngospasm: The Silent Menace

and Richard A. Jaffe2



(1)
David Geffen School of Medicine at UCLA, Los Angeles, California, USA

(2)
Stanford University School of Medicine, Stanford, California, USA

 



Electronic supplementary material:

The online version of this chapter (doi:10.​1007/​978-3-319-42866-6_​5) contains supplementary material, which is available to authorized users. Videos can also be accessed at http://​link.​springer.​com/​chapter/​10.​1007/​978-3-319-42866-6_​5.


Keywords
LaryngospasmLaryngeal anatomyLaryngospasm notch



Introduction


Laryngospasm is defined as the involuntary spasm or contraction of the muscles of the larynx resulting in total occlusion of the airway. It occurs most commonly during emergence from general anesthesia, usually immediately after removal of a tracheal tube, laryngeal mask airway, or other airway device. Rarely, it may also occur in unanaesthetized subjects should they be at risk for pulmonary aspiration from, for example, gastroesophageal reflux disease . The reason that “silent” is in the title of this chapter is because laryngospasm does not create any sound. Laryngeal stridor is accompanied by a high-pitched, striderous sound of varying intensity as gas transgresses the glottic opening. In contrast, laryngospasm is totally noiseless because no gas passes the tightly closed glottis. The deceiving part is that the chest appears to be moving in a regular manner, suggesting ventilation. However, the experienced eye immediately recognizes that the pattern of movement of the chest is quite abnormal. Instead of rising normally with inhalation, the upper chest and suprasternal neck collapse inward in response to the negative intrathoracic pressure generated by the inspiratory effort. At the same time, the lower chest and abdomen may move downward and outward, again suggesting that ventilation is occurring, which it is not.


Signs of Laryngospasm





  • Absence of ventilatory sounds


  • Inward movement of upper chest with inhalation


  • Downward, outward movement of lower chest and abdomen with inhalation


  • Inability to ventilate the lungs with bag-mask


  • Deteriorating oxygen saturation despite oxygen administration by mask


  • Presence of pink-tinged fluid in the oropharynx

Although the Chest and Abdomen are Moving, There are No Breath Sounds When Laryngospasm is Present

The reason that the word “menace” is used in the title of this chapter is because laryngospasm can cause serious complications and even death. Three actual cases are cited as examples of what can happen when laryngospasm is not promptly diagnosed and treated.


Case 1


A 22 year old, otherwise healthy man was admitted to hospital for removal of nasal polyps under general anesthesia. After placement of standard monitors, anesthesia was induced with fentanyl, propofol, and succinylcholine, and an endotracheal tube was inserted. Anesthesia was maintained with sevoflurane–oxygen. At the conclusion of the 55-min operation, spontaneous ventilation was established and the sevoflurane was discontinued. Soon thereafter, he responded to commands to take a deep breath and the endotracheal tube was removed. A mask from the anesthesia circuit was placed on his face with an oxygen flow of 8 L/min. He appeared to be breathing adequately, but after a few minutes, the oxygen saturation began to decline below 90 %. Positive pressure ventilation via mask with jaw thrust was attempted without success. The patient was given succinylcholine 60 mg i/v, and after 2–3 min positive pressure ventilation was established. Shortly thereafter, pink-stained fluid began to come out of his mouth. His airway was suctioned; he was placed on a CPAP mask with 100 % oxygen; put in a semi-sitting position; and given a single dose of furosemide. Over the next 12 h, his oxygen saturation, which was in the mid-80s gradually increased to the mid-90s. He was admitted to hospital and discharged on the second postoperative day with a normal saturation breathing room air. The finding of pink-tinged fluid in the oropharynx several minutes after extubation of the trachea suggests that laryngospasm may have caused negative pressure pulmonary edema .


Case 2


A 72 year old, 188-pound man was admitted to hospital for radiation treatment for cancer of the prostate. His other medical problems were hypertension and non-insulin dependent diabetes. His vital signs and laboratory values were within normal limits and he was rated an ASA II. The surgical plan was to place radiation seeds into the prostate, and the anesthetic plan was general anesthesia with insertion of an LMA. Anesthesia was induced with midazolam, fentanyl, propofol, and low dose rocuronium. An LMA #4 was inserted and anesthesia was maintained with desflurane–oxygen. Controlled ventilation was instituted and the patient was placed in lithotomy position. Shortly thereafter, peak airway pressure, which had been below 20 cmH2O, rapidly increased to greater than 30 cmH2O. The LMA was repositioned without improvement, so it was removed and replaced. Ventilation still could not be established so the LMA was removed and bag-mask ventilation attempted after insertion of an oral airway. This was also unsuccessful. Direct laryngoscopy was attempted but only the tip of the epiglottis could be visualized. Multiple subsequent attempts at intubation using a blind technique, the Fastrach LMATM, and fiberoptic intubation were unsuccessful. The patient went into cardiac arrest and cardiopulmonary resuscitation was started. Ultimately, a #6 endotracheal tube was passed under direct laryngoscopy, but the patient died several days later. The cause of death was deemed to be prolonged hypoxemia secondary to mechanical obstruction of the airway from laryngospasm and subsequent inability to ventilate the lungs or intubate the trachea .


Case 3


This case is that of Joan Rivers, the famous comedienne who had an untoward event in an outpatient facility in New York City. The facts cited here are those widely circulated in the press and on television following the event. Ms. Rivers went into an outpatient facility for an esophagoscopy under intravenous sedation because of a history of gastroesophageal reflux. During the esophagoscopy, a lesion was noted on a vocal cord, and an ear, nose and throat specialist was consulted. A biopsy of the lesion was performed, and immediately thereafter Ms. Rivers went into complete airway obstruction. Attempts to reestablish ventilation failed and she went into cardiopulmonary arrest. Ultimately an airway and circulation were established, but she did not regain consciousness and died about a week later in a nearby hospital.

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Jul 14, 2017 | Posted by in Uncategorized | Comments Off on Laryngospasm: The Silent Menace

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