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BigMAC - Army
02-19-2010, 02:56 PM
What are some defining characteristics between broncho vs laryngospasm both intubated and post intubations (how can you tell which is which)?

What treatments do you use for each? Do you treat differently if pt still intubated?

SuccsDrugs&Rocuron
02-19-2010, 03:40 PM
ok, off the top of my little head with no references (scary):
1) laryngospasm=upper airway obstruction can be broken by positive pressure and/or low-dose succinylcholine (possible stridor)

2) bronchospasm=lower airway obstruction, need bronchodilators (your epi/terbutaline/albuterol), (bronchi are smooth muscles are not susceptible to paralytics) and positive pressure (possible wheezing)

fyi (I've had one big bronchospasm and a few laryngospasms as a newbie student, and was told BronchoSpasm can be more deadly (and if often underestimated) because an emergency trach/cricothyrotomy will not resolve this as it would a persistent LaryngoSpasm)...

SuccsDrugs&Rocuron
02-19-2010, 03:56 PM
Here's from M&M:
1) Laryngospasm= "a forceful, involuntary spasm of the laryngeal musculature caused by sensory stimulation of the superior laryngeal nerve (SLN). Triggering stimuli include pharyngeal secretions or passing a ET through the larynx during extubation. Laryngospasm is usually prevented by extubating pts either deeply asleep or fully awake, but it can occur--albeit rarely--in an awake pt. Tx includes providing gently positive-pressure ventilation with an anesthesia bag and ask using 100% oxygen or administering intravenous lidocaine (1-1.5 mg/kg). If laryngospasm persists and hypoxia develops, succinylcholine (0.25-1 mg/kg) (usually the lower dose range) should be given to relax the laryngeal muscles and allow controlled ventilation. The large negative intrathoracic pressures generated by a struggling pt during laryngospasm can result in development of negative-pressure pulmonary edema even in healthy young adults.

2) Bronchospasm= Another reflex response to intubation and is most common in asthmatic pts. Bronchospasm can sometimes be a clue to bronchial intubation."

Morgan, G. E., Mikhail, M. S., & Murray, M. J. (2006). Clinical Anesthesiology (4th ed.). New York: McGraw-Hill.

SoonerFan
02-19-2010, 04:05 PM
What are some defining characteristics between broncho vs laryngospasm both intubated and post intubations (how can you tell which is which)?

What treatments do you use for each? Do you treat differently if pt still intubated?

This is just one person's opinion, but here goes.

It can be difficult to discern sometimes before & after intubation. However, once the tube is in, laryngospasm isn't gonna happen, right? (Or if it does, I wouldn't know it). As for bronchospasm, I've intubated patients before, absolutely certain I'd seen the tube pass through the cords, yet got negligible CO2 tracing on the capnograph. If you haven't ever seen it you need to, because it's impressive. You can't hardly ventilate them no matter how hard you squeeze the bag. Cranking up the VA usually fixes it. Great bronchodilators, those volatiles. Albuterol or atrovent work well too.

Once you pull the tube, you have to be able to differentiate between airway obstruction & laryngospasm, & the only thing that will help you is experience & even then it can be a guessing game @ times. Were they easy to mask ventilate before paralysis? Are they high risk for laryngospasm? Definitely, positive pressure ventilation is your 1st go to, & I usually crank the Sevo up to 8% during, just because if it's a bronchospasm you'll get the bronchodilational benefit, & if it's laryngospasm it may have occurred because the patient was "light", so a few big breaths of Sevo could help, if possible. But you might just have to push some sux & retube. From experience, I'd tell you that if they laryngospasmed before intubation, expect them to afterwards. And if it's a kid, be sure you're comfortable w/PALS because kids aren't very forgiving. I'd rather retube, then be able to feel an easy bag ventilation while intubated, then deep extubate, then sit w/a Peds patient in the OR after extubation rather than dump them off in the PACU.

Edited to correct: ALBUTEROL or Atrovent work well

SoonerFan
02-19-2010, 04:23 PM
fyi was told BronchoSpasm can be more deadly (and if often underestimated) because an emergency trach/cricothyrotomy will not resolve this as it would a persistent LaryngoSpasm)...

Hmmm. I might have to disagree. I've seen some really ugly bronchospasms that eventually resolved w/either albuterol or atrovent or even epi, (although if it's a result of aspiration, you & your patient are probably f_cked). Maybe it's the patient population that each tends to occur w/in typically, so I may be talking numbers/incidence. The ugliest laryngospasms I've seen were in peds patients. Did I mention they can be ugly?

SuccsDrugs&Rocuron
02-19-2010, 04:23 PM
Definitely, positive pressure ventilation is your 1st go to, & I usually crank the Sevo up to 8% during, just because if it's a bronchospasm you'll get the bronchodilational benefit, & if it's laryngospasm it may have occurred because the patient was "light", so a few big breaths of Sevo could help, if possible. But you might just have to push some sux & retube. From experience, I'd tell you that if they laryngospasmed before intubation, expect them to afterwards. And if it's a kid, be sure you're comfortable w/PALS because kids aren't very forgiving. I'd rather retube, then be able to feel an easy bag ventilation while intubated, then deep extubate, then sit w/a Peds patient in the OR after extubation rather than dump them off in the PACU.
Thanks so much! Will remember this~appreciate your insight ](not much at all on this important topic in many of our main student references)

BigMAC - Army
02-19-2010, 04:28 PM
One of the reasons I'm asking is to see what tx's for brocho were given if unable to bag or get inhalent to lungs and if anyone has seen propofol used for laryngospams??

BigMAC - Army
02-19-2010, 04:37 PM
Thanks so much! Will remember this~appreciate your insight ](not much at all on this important topic in many of our main student references)

Yes I agree. We are expected to know how to handle this for our simulation but can not find much either other than small ref to laryngospasm in Anes Secrets and Stoelting and a study ArmyGas posted that referenced the use of propofol for laryngospasm post extubation but no dose given.

SoonerFan
02-19-2010, 04:39 PM
Thanks so much! Will remember this~appreciate your insight ](not much at all on this important topic in many of our main student references)

So help us all out & share what you're learning in school.

SuccsDrugs&Rocuron
02-19-2010, 04:58 PM
One of the reasons I'm asking is to see what tx's for brocho were given if unable to bag or get inhalent to lungs and if anyone has seen propofol used for laryngospams??
Throwin this out there:
1) if intubated, N-A-V-E-L can go down the ETT right? (ACLS),
so you could put 2-2.5 times the amount mixed in with 5-10 cc NS of Epinephrine or Lidocaine down the tube--

2) a CRNA I precepted with opened the drug cart and said, "your pt has a bronchospasm, what drugs could you use NOW", here's our list:
-epi 1:1000 0.3 mg SQ, albuterol, terbutaline 0.5 mg SQ, solucortef, 1 gram mag as smooth muscle dilator, nitro as smooth muscle dilator, theophylline, lidocaine"

3) haven't heard Propofol (but what I do know, I'm just a freakn junior!)

4) what the hell DO you do if the bronchospasm does NOT break with + pressure and an entire barrage of meds? :pray:

SuccsDrugs&Rocuron
02-19-2010, 05:07 PM
..another thing that awesome CRNA told me was that "Atrovent and soybean or peanut allergies are contraindicated" so if you give your bronchospasm pt Atrovent that has these allergies--could be baaad juju! (and the plot thickens...)

"For example, few health professionals are aware that the prescribing information for ATROVENT (ipratropium) Inhalation Aerosol states that it is contraindicated in patients with hypersensitivity to soya lecithin or related products such as soybean and peanut. Neither the package label nor the tear-off patient instruction sheet attached to the package insert mentions a contraindication with peanut allergy.

Complicating this problem, patients with peanut allergy can use Atrovent Nasal Spray or Atrovent Inhalation Solution because neither contains soya lecithin. We received a report about a patient with severe allergy to peanuts who suffered an anaphylactic reaction after using Atrovent Inhalation Aerosol. "

http://www.ismp.org/newsletters/acutecare/articles/19981021.asp

pdsr
02-19-2010, 05:10 PM
Throwin this out there:
1) if intubated, ......

4) what the hell DO you do if the bronchospasm does NOT break with + pressure and an entire barrage of meds? :pray:

If intubated, the first thing I would do is pull the tube back a little. I've been my own worst enemy at times. The only "bronchospasm" I've had that would not at least partially respond to halothane, forane, or sevo was actually just a displaced tube. Pulled it back to the original position, and looked like a genius.

SuccsDrugs&Rocuron
02-19-2010, 05:13 PM
and looked like a genius.
Awesome! Thanks so much to you and SoonerFan
(and looking like a genius would be a first!) :pound:

Mobilenurse
02-19-2010, 05:25 PM
While being "pimped" yesterday I was asked what drug in my narcotics box would be useful in the event of a bronchospasm. I failed to answer the question correctly but was told Ketamine 1mg/kg is a great bronchodilator.

Am J Emerg Med. 1994 Jul;12(4):417-20.
Ketamine in the treatment of bronchospasm during mechanical ventilation.

Hemmingsen C, Nielsen PK, Odorico J.

Department of Anesthesiology, Rigshospitalet, University of Copenhagen, Denmark.

The effect of ketamine on bronchospasm during mechanical ventilation was evaluated in a prospective, placebo-controlled, double-blind trial. Fourteen mechanically ventilated patients with bronchospasm were randomly allocated to either ketamine 1 mg/kg or saline placebo. In the ketamine-treated patients, PO2 increased from 10.5 (+/- 0.5) kPa to 16.4 (+/- 2.7) kPa (P < .05), whereas PO2 in the placebo-treated patients remained unchanged. The PCO2 was constant in the ketamine group, although it increased from 5.6 (+/- 0.9) kPa to 6.1 (+/- 0.9) kPa in the placebo group (P < .05). The pulmonary stethoscopic bronchospasm improved immediately after the administration of ketamine, whereas the thoracic compliance remained unchanged. In conclusion, the ketamine-treated patients showed an improvement by stethoscopic examination, in PO2 and in PCO2, suggesting that ketamine might be useful in the treatment of bronchospasm during mechanical ventilation. However, further studies are required to decide whether ketamine should be considered the drug of choice in patients with severe bronchospasm during ventilator treatment.

SuccsDrugs&Rocuron
02-19-2010, 05:39 PM
While being "pimped" yesterday I was asked what drug in my narcotics box would be useful in the event of a bronchospasm. I failed to answer the question correctly but was told Ketamine 1mg/kg is a great bronchodilator.

Great! Thanks--hey, you're the famous cartoon dude--too funny--How's the "Queen" doing? ;)

RAYMAN
02-19-2010, 06:27 PM
Gas won't always do it. Had a kido bronchospasm on me in school...took some epi and time.

MmacFN
02-19-2010, 06:31 PM
hehe

Well...


Real simple way to define which is which. PPV does not work, put a blade in and look at the cords.

Closed = laryngospasm
Open = Bronchospasm

RAYMAN
02-19-2010, 06:35 PM
hehe

Well...


Real simple way to define which is which. PPV does not work, put a blade in and look at the cords.

Closed = laryngospasm
Open = Bronchospasm


Tru dat...I've learned to appreciate what being able to stick a blade in and take a look can teach you since I've been in practice. I'd rather deal with a laryngospasm than a bronchospasm. If PPV doesn't fix it, then 1/4-1/2 cc of suxx usually does. A bronchospasm can present a challenage that will take a considerable amount of you time and ability to resolve.

SuccsDrugs&Rocuron
02-19-2010, 06:43 PM
Closed = laryngospasm
Open = Bronchospasm
Thanks Mike! Taking a look-see didn't occur to me, but it will now~ (also the freakn inhalational agent that's right thar & adjusting the tube & time sweet time)...

MmacFN
02-19-2010, 06:47 PM
Well remember, if they have an ETT it is ALWAYS bronchospasm (tube is proof against laryngospasm)...

If its an LMA, and PPV does not work, take it out and look. Its fast and works.



Thanks Mike! Taking a look-see didn't occur to me, but it will now~ (also the freakn inhalational agent that's right thar & adjusting the tube & time sweet time)...

SoonerFan
02-19-2010, 06:56 PM
One of the reasons I'm asking is to see what tx's for brocho were given if unable to bag or get inhalent to lungs and if anyone has seen propofol used for laryngospams??

I've given propofol in several kids I "masked down" w/8% Sevo, then initially tried to intubate after the mask induction, who then had a laryngospasm likely due to "light" anesthesia, i.e., I saw their cords close upon DL. So I gave them propofol, & it almost always works well to relax their cords. It makes sense if you think about it ... the deeper they are, the less likely their cords will react when you go poking around them, therefore the less likely they'll have a laryngospasm. However, if their sat is plummeting, you may just have to push some sux & get 'em tubed. No big deal in the long run, right? Kids can be amazingly resilient to insult, but then will try to crash on you w/in seconds, so you can't be criticized for tubing them using MR. But if they crash & burn because you were hesitant to paralyze them ... let's not go there. Peds patients seem to behave as a different species, so be wary of them, IMHO.

I've also done a very few adults who I planned to intubate w/o MR. Sometimes less is more, so if I can avoid MR & then reversal agents, so much the better. I admit it can be a guessing game, though. But if I really felt the patient would benefit from no MR, I'd go w/more propofol if I didn't see open cords the 1st time I looked.

As for ventilating a patient who is having a severe bronchospasm, the dynamics are different, as I'm sure you're aware, if they're tubed or not. If they're tubed, 99% of the time I'm home free, meaning if my volatile doesn't ameliorate the bronchospasm, & if albuterol &/or atrovent aren't effective, epi will be, or they may be hosed beyond my redemption capabilities. SQ terbutaline might help, or might not. Also, as someone else said, sometimes it's just as simple as the tube being ever-so-slightly too deep, therefore only one lung is being ventilated, hence the bronchospasm when the tube is repositoned.

Everyone has their absolutes they check out when they induce then intubate a patient. Mine are the oximeter, which tells me about oxygenation & even BP, another is BP via the NIBP or art line, another is a change in or questionable eTCO2, & another is peak inspiratory pressure on the ventilator: PIPs can be sky high if the patient is mainstemmed or is having a bronchospasm or if they've aspirated, or all of the above. If you have a 5'5" patient w/high PIPs, w/the tube taped @ 23 or deeper @ the lip, very possibly she's main-stemmed. Maybe she smokes 2ppd, but maybe the tube is just slightly too deep.

Something else I was taught ... if a patient has been main-stemmed, they're gonna be atelectactic in that one lung (obviously the left usually), therefore bronchospastic, therefore puff 'em before extubation. And if at all possible, do a 3 or more HUGE recruitment breaths before you extubate them. When I do recruitment breaths, I hold sustained positive pressure breaths w/PIPs of 40cm or more for as many seconds as the patient will tolerate, & I usually have to do this before the patient is too light to not tolerate them. Occasionally, I'll push some propofol just to render them apneic for the short time I need to do those recruitment breaths. Any advice would be welcomed.

jwk
02-19-2010, 07:01 PM
If its an LMA, and PPV does not work, take it out and look. Its fast and works.

You really want to instrument someone's airway just to LOOK and see if it's laryngospasm? Nah. Give a little sux and hold PP for 30 sec. If it doesn't break, THEN think about taking a look.

I'll take a tight laryngospam ANY day over big-time bronchospasm. I can fix the first very quickly. And BTW - DO NOT struggle with laryngospasm for a minute or two just trying PP. That will lead to negative pressure pulmonary edema. If you can't break it in 30 sec with PP and some lidocaine, reach for the sux.

MmacFN
02-19-2010, 07:10 PM
Its an LMA..... who cares? They will be deep anyway.

Now having said that, I agree with yah, I have no problem going right to suxx.


You really want to instrument someone's airway just to LOOK and see if it's laryngospasm? Nah. Give a little sux and hold PP for 30 sec. If it doesn't break, THEN think about taking a look.

I'll take a tight laryngospam ANY day over big-time bronchospasm. I can fix the first very quickly. And BTW - DO NOT struggle with laryngospasm for a minute or two just trying PP. That will lead to negative pressure pulmonary edema. If you can't break it in 30 sec with PP and some lidocaine, reach for the sux.

SoonerFan
02-19-2010, 08:02 PM
Gas won't always do it. Had a kido bronchospasm on me in school...took some epi and time.

Just curious ... what kind of pre-existings did the kid have?

RAYMAN
02-20-2010, 06:52 AM
Just curious ... what kind of pre-existings did the kid have?


Nothing...URI about a month prior.

Anthony
02-20-2010, 07:01 AM
So what guidelines are you all using for preop screening in kiddos with URIs?

Anthony
02-20-2010, 07:24 AM
Yes I agree. We are expected to know how to handle this for our simulation but can not find much either other than small ref to laryngospasm in Anes Secrets and Stoelting and a study ArmyGas posted that referenced the use of propofol for laryngospasm post extubation but no dose given.

0.5/mg/kg

SoonerFan
02-20-2010, 04:07 PM
Obviously bronchospasm has the potential to be the scariest scenario. And while I saw some sh_t in the ICU, I don't see as much life-threatening bronchospasm in the OR. But I've seen some ugly laryngospasms, usually in kids, & kids can go south on you fast.

SoonerFan
02-20-2010, 04:11 PM
Wow. I didn't know that. Glad you posted it.


..another thing that awesome CRNA told me was that "Atrovent and soybean or peanut allergies are contraindicated" so if you give your bronchospasm pt Atrovent that has these allergies--could be baaad juju! (and the plot thickens...)

"For example, few health professionals are aware that the prescribing information for ATROVENT (ipratropium) Inhalation Aerosol states that it is contraindicated in patients with hypersensitivity to soya lecithin or related products such as soybean and peanut. Neither the package label nor the tear-off patient instruction sheet attached to the package insert mentions a contraindication with peanut allergy.

Complicating this problem, patients with peanut allergy can use Atrovent Nasal Spray or Atrovent Inhalation Solution because neither contains soya lecithin. We received a report about a patient with severe allergy to peanuts who suffered an anaphylactic reaction after using Atrovent Inhalation Aerosol. "

http://www.ismp.org/newsletters/acutecare/articles/19981021.asp