| Laryngospasm | |
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| Specialty | ENT surgery |
Laryngospasm is an uncontrolled or involuntary muscular contraction (spasm) of the vocal folds. [1] It may be triggered when the vocal cords or the area of the trachea below the vocal folds detects the entry of water, mucus, blood, or other substance. It may be associated with stridor or retractions.
Laryngospasm is characterized by involuntary spasms of the laryngeal muscles. It is associated with difficulty or inability to breathe or speak, retractions, a feeling of suffocation, which may be followed by hypoxia-induced loss of consciousness. [2] It may be followed by paroxysmal coughing and in partial laryngospasms, a stridor may be heard. [3] It requires prompt identification to avoid possibly fatal complications. It may present with loss of end-tidal carbon dioxide (for mechanically ventilated patients), chest or neck retractions and paradoxical chest wall movements. [3]
The condition typically lasts less than 60 seconds, but in cases partial blocking it may last 20 to 30 minutes and hinder inspiration, while exhalation remains easier. [1]
Laryngospasm is a primitive protective airway reflex that functions to protect against aspiration. However, it may be detrimental if there is sustained closure of the glottis resulting in blockage of respiration that hinders the free flow of air. It may be triggered when the vocal cords or the area of the trachea below the vocal folds detects the entry of water, mucus, blood, or other substance. [1]
It is most often reported 1) post-operatively after endotracheal extubation or 2) after sudden reflux of gastric contents. [2] [4] [1] It is common in drowning. It is estimated that in 10% of cases of drowning as a response to inhalation of water, death occurs due to asphyxia due to laryngospasm without any water in the lungs. [5] It is also a symptom of hypoparathyroidism. [6] It can sometimes occur during sleep, waking up the affected person. These episodic interruptions of sleep have been attributed to acute irritation due to gastro-oesophageal reflux. [2] [7] Laryngospasm is also an unlikely but possible side effect of ketamine administration. [8]
In children, rapid detection and management are imperative to prevent deadly complications such as cardiac arrest, hypoxia and bradycardia. [9]
Patients with a history of significant aspiration, asthma, exposure to airway irritants (smoke, dust, mold, fumes, use of Desflurane), upper respiratory infections, airway anomalies, light anesthesia and patients with acute mental status depression may be at increased risk. [2] [4]
When gastroesophageal reflux disease (GERD) is the trigger, treatment of GERD can help manage laryngospasm. Proton pump inhibitors such as Dexlansoprazole (Dexilant), Esomeprazole (Nexium), and Lansoprazole (Prevacid) reduce the production of stomach acids, making reflux fluids less irritant. Prokinetic agents reduce the amount of acid available by stimulating movement in the digestive tract. [2]
Patients who are prone to laryngospasm during illness can take measures to prevent irritation such as antacids to avoid acid reflux. [3]
For acute context, making an upright position of the upper part of the body has been shown to shorten the spasm episodes. Fixation of the arms on stabilization of the body and slowing of breathing is also recommended. [3]
Incidence has been estimated at approximately 1% in both adult and pediatric populations. Its incidence is reported to be more than triple in the very young (birth to 3 months of age), increasing to 10% in those with reactive airways. Other sub-populations with high incidence of laryngospams include patients undergoing tonsillectomy and adenoidectomy (25%). [10]
It is likely that more than 10% of drownings involve laryngospasm, but the evidence suggests that it is not usually effective at preventing water from entering the trachea. [11]
Minor laryngospasm will resolve spontaneously in the majority of cases. [1]
Laryngospasm is one of the most common intraoperative complications. It may be life-threatening as it involves reflex closure of the laryngeal muscles and thus results in inability to ventilate the patient. [12] Treatment requires clearing secretions from the oropharynx, applying continuous positive airway pressure with 100% oxygen, followed by deepening the plane of anaesthesia with propofol, and/or paralyzing with succinylcholine. [10]
The larynx, commonly called the voice box, is an organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal inlet is about 4–5 centimeters in diameter. The larynx houses the vocal cords, and manipulates pitch and volume, which is essential for phonation. It is situated just below where the tract of the pharynx splits into the trachea and the esophagus. The word 'larynx' comes from the Ancient Greek word lárunx ʻlarynx, gullet, throat.ʼ
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction.
Pulmonary aspiration is the entry of material such as pharyngeal secretions, food or drink, or stomach contents from the oropharynx or gastrointestinal tract, into the larynx and lower respiratory tract, the portions of the respiratory system from the trachea (windpipe) to the lungs. A person may inhale the material, or it may be delivered into the tracheobronchial tree during positive pressure ventilation. When pulmonary aspiration occurs during eating and drinking, the aspirated material is often colloquially referred to as "going down the wrong pipe".
General anaesthesia (UK) or general anesthesia (US) is a method of medically inducing loss of consciousness that renders a patient unarousable even with painful stimuli. This effect is achieved by administering either intravenous or inhalational general anaesthetic medications, which often act in combination with an analgesic and neuromuscular blocking agent. Spontaneous ventilation is often inadequate during the procedure and intervention is often necessary to protect the airway. General anaesthesia is generally performed in an operating theater to allow surgical procedures that would otherwise be intolerably painful for a patient, or in an intensive care unit or emergency department to facilitate endotracheal intubation and mechanical ventilation in critically ill patients. Depending on the procedure, general anaesthesia may be optional or required. Regardless of whether a patient may prefer to be unconscious or not, certain pain stimuli could result in involuntary responses from the patient that may make an operation extremely difficult. Thus, for many procedures, general anaesthesia is required from a practical perspective.
Laryngitis is inflammation of the larynx. Symptoms often include a hoarse voice and may include fever, cough, pain in the front of the neck, and trouble swallowing. Typically, these last under two weeks.
A laryngeal mask airway (LMA), also known as laryngeal mask, is a medical device that keeps a patient's airway open during anaesthesia or while they are unconscious. It is a type of supraglottic airway device. They are most commonly used by anaesthetists to channel oxygen or inhalational anaesthetic to the lungs during surgery and in the pre-hospital setting for unconscious patients.
Airway management includes a set of maneuvers and medical procedures performed to prevent and relieve airway obstruction. This ensures an open pathway for gas exchange between a patient's lungs and the atmosphere. This is accomplished by either clearing a previously obstructed airway; or by preventing airway obstruction in cases such as anaphylaxis, the obtunded patient, or medical sedation. Airway obstruction can be caused by the tongue, foreign objects, the tissues of the airway itself, and bodily fluids such as blood and gastric contents (aspiration).
Awareness under anesthesia, also referred to as intraoperative awareness or accidental awareness during general anesthesia (AAGA), is a rare complication of general anesthesia where patients regain varying levels of consciousness during their surgical procedures. While anesthesia awareness is possible without resulting in any long-term memory of the experience, it is also possible for victims to have awareness with explicit recall, where they can remember the events related to their surgery.
Respiratory arrest is a serious medical condition caused by apnea or respiratory dysfunction severe enough that it will not sustain the body. Prolonged apnea refers to a patient who has stopped breathing for a long period of time. If the heart muscle contraction is intact, the condition is known as respiratory arrest. An abrupt stop of pulmonary gas exchange lasting for more than five minutes may permanently damage vital organs, especially the brain. Lack of oxygen to the brain causes loss of consciousness. Brain injury is likely if respiratory arrest goes untreated for more than three minutes, and death is almost certain if more than five minutes.
In anaesthesia and advanced airway management, rapid sequence induction (RSI) – also referred to as rapid sequence intubation or as rapid sequence induction and intubation (RSII) or as crash induction – is a special process for endotracheal intubation that is used where the patient is at a high risk of pulmonary aspiration. It differs from other techniques for inducing general anesthesia in that several extra precautions are taken to minimize the time between giving the induction drugs and securing the tube, during which period the patient's airway is essentially unprotected.
Stridor is a high-pitched extra-thoracic breath sound resulting from turbulent air flow in the larynx or lower in the bronchial tree. It is different from a stertor which is a noise originating in the pharynx.
Tracheitis is an inflammation of the trachea. Although the trachea is usually considered part of the lower respiratory tract, in ICD-10 tracheitis is classified under "acute upper respiratory infections".
Laryngeal papillomatosis, also known as recurrent respiratory papillomatosis (RRP) or glottal papillomatosis, is a rare medical condition in which benign tumors (papilloma) form along the aerodigestive tract. There are two variants based on the age of onset: juvenile and adult laryngeal papillomatosis. The tumors are caused by human papillomavirus (HPV) infection of the throat. The tumors may lead to narrowing of the airway, which may cause vocal changes or airway obstruction. Laryngeal papillomatosis is initially diagnosed through indirect laryngoscopy upon observation of growths on the larynx and can be confirmed through a biopsy. Treatment for laryngeal papillomatosis aims to remove the papillomas and limit their recurrence. Due to the recurrent nature of the virus, repeated treatments usually are needed. Laryngeal papillomatosis is primarily treated surgically, though supplemental nonsurgical and/or medical treatments may be considered in some cases. The evolution of laryngeal papillomatosis is highly variable. Though total recovery may be observed, it is often persistent despite treatment. The number of new cases of laryngeal papillomatosis cases is approximately 4.3 cases per 100,000 children and 1.8 cases per 100,000 adults annually.
Mendelson's syndrome, named in 1946 for American obstetrician and cardiologist Curtis Lester Mendelson, is a form of chemical pneumonitis or aspiration pneumonitis caused by aspiration of stomach contents during anaesthesia in childbirth. This complication of anaesthesia led, in part, to the longstanding nil per os recommendation for women in labour.
Bronchoscopy is an endoscopic technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument (bronchoscope) is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy. This allows the practitioner to examine the patient's airways for abnormalities such as foreign bodies, bleeding, tumors, or inflammation. Specimens may be taken from inside the lungs. The construction of bronchoscopes ranges from rigid metal tubes with attached lighting devices to flexible optical fiber instruments with realtime video equipment.
Laryngopharyngeal reflux (LPR) or laryngopharyngeal reflux disease (LPRD) is the retrograde flow of gastric contents into the larynx, oropharynx and/or the nasopharynx. LPR causes respiratory symptoms such as cough and wheezing and is often associated with head and neck complaints such as dysphonia, globus pharyngis, and dysphagia. LPR may play a role in other diseases, such as sinusitis, otitis media, and rhinitis, and can be a comorbidity of asthma. While LPR is commonly used interchangeably with gastroesophageal reflux disease (GERD), it presents with a different pathophysiology.
Vocal cord dysfunction (VCD) is a pathology affecting the vocal folds characterized by full or partial vocal fold closure causing difficulty and distress during respiration, especially during inhalation.
Procedural sedation and analgesia (PSA) is a technique in which a sedating/dissociative medication is given, usually along with an analgesic medication, in order to perform non-surgical procedures on a patient. The overall goal is to induce a decreased level of consciousness while maintaining the patient's ability to breathe on their own. Airway protective reflexes are not compromised by this process and therefore endotracheal intubation is not required. PSA is commonly used in the emergency department, in addition to the operating room.
A laryngeal cleft or laryngotracheoesophageal cleft is a rare congenital abnormality in the posterior laryngo-tracheal wall. It occurs in approximately 1 in 10,000 to 20,000 births. It means there is a communication between the oesophagus and the trachea, which allows food or fluid to pass into the airway.
Advanced airway management is the subset of airway management that involves advanced training, skill, and invasiveness. It encompasses various techniques performed to create an open or patent airway – a clear path between a patient's lungs and the outside world.
