anesthetic implications of vocal cord paralysis case presentation by: hannah scheppf and leia martin
TRANSCRIPT
Anesthetic Implications of Vocal Cord Paralysis
Case PresentationBy: Hannah Scheppf and Leia Martin
Objectives
Understand the pathophysiology of vocal cord dysfunction
Identify patient risk factors associated with pre-existing vocal cord dysfunction
Differentiate between treatment of laryngospasm vs bronchospasm
Vocal Cord Paralysis:
Vocal cord dysfunction that involves inappropriate vocal cord motion that produces partial airway obstruction. Patients may present with respiratory distress that is often mistakenly diagnosed as asthma.
(Hagberg, C., Georgi, R., & Krier, C., n.d.).
Vocal Cord Paralysis:
(VocalHealth.org, 2014)
http://youtu.be/pLtz34uNnSY
Vocal Cord Paralysis
Normal vocal cords move away from midline during inspiration and only slightly toward midline during expiration
With vocal cord dysfunction, the vocal cords move toward midline during inspiration or expiration, which creates varying degrees of obstruction
(Hagberg, et al., n.d.)
Vocal Cord Paralysis
Typical symptoms include: hoarseness. breathy voice. inability to speak loudly. limited pitch and loudness variations. voicing that lasts only for a very short
time (around 1 second) choking or coughing while eating.
Patient Profile 65 y/o female
Bronchoscopy w/ brushing, endobronchial ultrasound with biopsies
Hx of thyorid CA with metastasis to lungs
Paralyzed right vocal cord secondary to injury recurrent laryngeal nerve
Patient Profile
Horner’s syndrome (listed as non reactive right pupil)
Asthma
GERD
Cerebral Aneurysm with titanium clipping
Physical Findings
Resting 02 saturation 95%, HR 66, BP 168/88
Mallampati Class III airway, normal opening, normal neck flexion
Lungs slightly decreased in bases, pt states is “short of breath” every day
PCV 40, K 3.8, Cr 1.1
Case Details Smooth IV induction, Size 3 IGEL LMA
placed without incidence
TV 500-600, procedure underway without complication
15 minutes into procedure decreased TV
Procedure stopped to assess TV without stimulation, resolved able to ventilate, procedure continued, lungs CTA
Case Details 5 minutes later decreased TV again,
procedure stopped, no return of TV
Wheezing in upper lobes, Sevoflurane concentration increased, positive pressure attempted with inability to improve TV
Reassessed lung sounds with minimal stridor
Still unable to ventilate, 5 mg of Succinylcholine administered, able to ventilate following administration
Case Details
10 minutes later, unable to ventilate, repeat succinylcholine dose given
Procedure complete, wheezing resolved, slight stridor, decision to remove IGEL
Stridor post removal, 02 sats 94%, Dexamethasone 10 mg given, 02 applied, pt supporting airway, transferred to PACU
What do we think happened?
Laryngospasm
vs.
Bronchospasm
Laryngospasm “ A subtype of vocal cord dysfunction,
is a brief involuntary spasm of vocal cords that often produces aphonia and acute respiratory distress” (Hagberg, et al., n.d.)
Spastic closure of vocal folds
Occurs due to reflex during Stage II of anesthesia
https://youtu.be/gmNwpJf1zUQ
(Fauquier ENT, 2012)
Bronchospasm Reflex spasm of bronchial smooth
muscle
More common to occur in asthmatics
Caused by: Histamine or a number of irritants
Laryngoscope
Inhaled irritants
Cold air
(Open Anesthesia, n.d.)
TreatmentsLaryngospas
m
Firm jaw thrust
Positive mask pressure
Ventilate with 100% 02
Increase volatile agent
Short acting relaxant
Propofol
Bronchospasm
Deepen anesthesia with volatile agent, sedation or a combination
Increase FI02
Administer a beta 2 or alpha 2 agonist
Administer IV epi in doses of 10mcg/kg
Administer IV corticosteroids
Terminate offending agent (Hagberg, et al., n.d.)
Questions?
What is the appropriate dose of succinylcholine for treatment of laryngospasm in an adult?
A. 0.5 mg/kg IV
B. 0.1 mg/kg IV
C. 1.0 mg/kg IM
D. 0.01 mg/kg IV
Questions?
What is not an appropriate treatment when attempting to break a Laryngospasm?
A. Positive Pressure Ventilation
B. Administer a Non-Depolarizer
C. Turn on 100% 02
D. Increase Depth of Anesthesia
References Fauquier ENT . (2012, January 6). Laryngospasm and Vocal Cord
Dysfunction [Video file]. Retrieved from https://www.youtube.com/watch?v=gmNwpJf1zUQ&feature=em-share_video_user
Hagberg, C., Georgi, R., & Krier, C. (n.d.). Complications of Managing the Airway. Benumof's Airway Management, 19(4), 1181-1216. doi:10.1016/j.bpa.2005.08.002
Open Anesthesia. (n.d.). Bronchospasm: Acute Treatment. Retrieved from https://www.openanesthesia.org/bronchospasm_acute_treatment/
VocalHealth.org. (2014, January 10). Unilateral Vocal Fold Paralysis: Presentation Video [Video file]. Retrieved from https://www.youtube.com/watch?v=pLtz34uNnSY&feature=em-share_video_user