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Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.58 no.6 Campinas Nov./Dec. 2008
Treatment of laryngeal spasm in pediatric anesthesia by retroauricular digital pressure. Case report*
Tratamiento del laringoespasmo en anestesia pediátrica por digitopresión retroauricular. Relato de casos
Raquel Reis Soares, TSA, M.D.; Eliana Guimarães Heyden, M.D.
Anestesiologista do Biocor Instituto
OBJECTIVES: Problems with pediatric airways are among the greatest challenges
an anesthesiologist can face. Laryngeal spasm, which is twice or three times
more frequent in the pediatric population, is paramount. The objective of this
work was to report the treatment of laryngeal spasm applying digital pressure
on a specific area behind the ear lobe. The technique is old, easy, but little
known. It is safe and can be promptly done, and does not require peripheral
venous access, which might not be present in some situations.
CASE REPORT: We report two cases of pediatric anesthesia, in a three-year old and six month-old patients, who developed laryngeal spasm. Both patients were treated by applying retroauricular digital pressure with immediate improvement of the breathing pattern and arterial oxygen saturation. Since laryngeal spasm is a common and potentially severe complication due to its morbimortality, it requires a safe, effective, and fast treatment.
CONCLUSION: The classical treatment of laryngeal spasm includes the administration of 100% oxygen with positive pressure per ventilatory unit (balloon and mask) and, in the absence of response, intravenous succinylcholine, 0.25 to 1 mg.kg-1. The technique presented here for the treatment of laryngeal spasm is easy to perform, safe and effective, and consists of bilateral digital pressure behind the ear lobes, which reversed the laryngeal spasm in a few seconds, avoiding the development of complications.
Key Words: COMPLICATIONS: Laryngeal spasm; SURGERY: Pediatric.
Y OBJETIVOS: Los problemas con la vía aérea pediátrica
están entre los más grandes retos que el anestesiólogo
puede encontrar en su práctica clínica. Entre ellos se destaca
el laringoespasmo, que ocurre con frecuencia de dos a tres veces más
en la población pediátrica. El objetivo de este trabajo fue relatar
el tratamiento de laringoespasmo realizado con digitopresión de punto
localizado detrás del lóbulo de la oreja. La técnica es
fácil, antigua, pero poco divulgada. Puede ser utilizada de forma segura
y rápida sin necesidad del acceso venoso periférico que, en algunas
situaciones, puede estar ausente.
RELATO DE LOS CASOS: Dos casos de anestesia pediátrica en pacientes de tres años y de seis meses de edad, en los cuales ocurrió laringoespasmo. Los dos fueron tratados apenas con la digitopresión de la depresión retroauricular y evolucionaron con una rápida mejora del estándar respiratorio y de la saturación arterial de oxígeno. Como el laringoespasmo es una complicación común y potencialmente grave por su morbimortalidad, se hace necesario un tratamiento seguro, eficaz y rápido.
CONCLUSIÓN: El tratamiento clásico del laringoespasmo es la administración de oxígeno a 100% con presión positiva por unidad ventilatoria (globo y máscara) y si no hay respuesta, administración venosa de 0,25 a 1 mg.kg-1 de succinilcolina. La técnica presentada para el tratamiento del laringoespasmo es fácil, segura y eficaz, realizada con digitopresión bilateral de la región localizada detrás del lóbulo de las orejas. El laringoespasmo cedió en pocos segundos y los pacientes tuvieron una evolución favorable.
Airways complications are frequent in pediatric anesthesia. Risk factors include age below six years, recent respiratory infection, and recent use of a laryngeal mask 1. Laryngeal spasm, characterized by a decrease in the distance between the aryepiglottic and vestibular regions, decreasing the space between the vocal cords due to contraction of the pharyngeal muscles, is foremost. The presence of secretions or foreign bodies in pharyngeal tissues or vocal cords is the stimulus for this contraction. It can occur at any time during anesthesia and not only after extubation 2. Delaying treatment of laryngeal spasm is potentially dangerous because it can lead to: post-obstructive pulmonary edema (4% of the cases), hypoxic lesions, bronchospasm, cardiac arrhythmias, pulmonary aspiration, respiratory insufficiency, and cardiac arrest 3,4.
The objective of this report was to present and old, safe, and effective technique rarely used to treat laryngeal spasm, which was successful in both cases presented here.
First Case: A 3-year old female, weighing 21 kg, ASA II, without diseases associated to the pathology that required surgical treatment (serous otitis media and hypertrophy of the tonsils and adenoids). The patient was scheduled to undergo adenotonsyllectomy and bilateral tympanotomy to insert a ventilation tube in the middle ear due to important chronic respiratory obstruction. The patient was calm and without pre-anesthetic medication upon arrival to the operating room. She was monitored with continuous ECG, pulse oximeter, capnograph, and non-invasive blood pressure. Inhalation of 5% sevoflurane with a face mask was used for anesthetic induction. After venoclysis, 2 µg.kg-1 of fentanyl and 0.5 mg.kg-1 of atracurium were administered. The patient was intubated and anesthesia was maintained with 1.5% sevoflurane. Prophylactic medication for pain, nausea, and vomiting was also used (20 mg.kg-1 of dypirone, 150 µg.kg-1 of dexamethasone, and 100 µg.kg-1 of ondansetron). Intraoperative intercurrences were not observed; at the end of surgery the neuromuscular blockade was reversed, she was extubated, and ventilated with a face mask with an inspired fraction of oxygen (FiO2) of 1. The patient presented signs of upper airways obstruction with a decrease in oxygen saturation (SpO2) to 62%. Pressure with the finger tips was applied to the retroauricular depression, the "laryngeal spasm trigger point" (Figure 1), while maintaining the oxygen mask over her face and elevating the mandible; the patient showed rapid improvement of the breathing pattern and SpO2. She was transferred to the post-anesthetic care unit (PACU) and from there she was transferred to a regular hospital bed without further complications.
Second Case: This is a six-month old female weighing 8 kg, with complex congenital cardiopathy with IB tricuspid atresia and pulmonary stenosis, ASA III, without medication for the treatment of the cardiopathy, SpO2 of 80% in room air. The patient underwent cardiac catheterization for more accurate assessment of her cardiopathy. She was monitored with pulse oximeter, cardioscope, capnograph, and non-invasive blood pressure, and a thermal blanket was used to keep the patient warm. The procedure was done under general anesthesia with inhalation of 2% sevoflurane with face mask and oropharyngeal cannula, on spontaneous ventilation assisted manually with Mapleson D circuit. Peripheral venous access was maintained with crystalloid solution. A few minutes after the beginning of the procedure, the patient developed signs of laryngeal spasm and progressive reduction in SpO2, which reached 55%, and was treated immediately with bilateral pressure of the "laryngeal spasm trigger point" 8 maintaining the face mask with FiO2 of 1. She had an excellent and fast response, with return of regular breathing, but, due to the possibility of prolonging the exam, the patient was intubated after the intravenous administration of 0.5 mg.kg-1 of atracurium. At the end of the procedure, the patient was extubated after reversion of the neuromuscular blockade and, to prevent post-extubation laryngeal spasm, the pressure technique described above was applied once more. She was transferred to the PACU and then to a regular hospital bed in good clinical conditions.
Laryngeal spasm is common in the pediatric population undergoing general anesthesia. Since it increases the morbimortality of anesthesia, several methods for its prevention and treatment have been suggested. Prophylactic techniques range from extubation methods (patient more awaken or still in the anesthetic plane) 5 to intraoperative acupuncture6 and use of intravenous drugs, such as magnesium sulfate or lidocaine, or inhalational carbon dioxide 7. Treatment includes low doses of intravenous succinylcholine, doxapram hydrochloride, or nytroglicerin 7.
The technique reported here for the treatment of laryngeal spasm consists of applying firm pressure on the depression behind the ear lobe, the "laryngeal spasm trigger point" 8, with the third finger of both hands. It was described by Philip Larson 8, being simple and effective, since it does not require venous access. The author reported the successful use of this technique for more than 40 years. It consists on applying pressure on both sides of the head, simultaneously, on the depression located behind the ear lobes, which is limited anteriorly by the ascending ramus of the mandible adjacent to the condilus, posteriorly by the mastoid process of the temporal bone, and superiorly by the base of the skull (Figures 1, 2, and 3), while at the same time dislocating the mandible anteriorly. It has been described that applying pressure on the mandibular ramus or angle is the most common mistake while performing this procedure. But this pressure does not reverse the laryngeal spasm, since it should be applied more superiorly. Oxygen should be used during the procedure.
The objective of the cases reported here was to disseminate this simple, readily applied, and innocuous technique as a treatment for laryngeal spasm. Literature reports on this technique and its mechanism of action are very scarce. Possible mechanisms include intense painful stimulus and stimulation of the glossopharyngeal nerve, which, by carrying impulses through the vagus nerve and upper cervical plexus, would favor the relaxation of the vocal cords 8. The technique proved to be effective and safe in the cases reported here.
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Correspondence to: Submitted em 9
de outubro de 2007 *
Received from Biocor Instituto, Nova Lima, MG
Dra. Raquel Reis Soares
Rua Groelândia, 375/704 - Sion
30.320-060 Belo Horizonte, MG
Accepted para publicação em 18 de agosto de 2008
Submitted em 9
de outubro de 2007
* Received from Biocor Instituto, Nova Lima, MG