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