(continued from page 29)
We can never fully understand where
those we treat are coming from, their life
experiences, or what their home situations,
thoughts, fears, dreams, and worries entail;
this was a reminder for me. He stated that
his daughter was healthy, woke up without
issue on that day, but later developed difficulty breathing and wheezing. She was
diagnosed with an acute asthma attack. She
had one episode in the distant past but did
not take any routine medications. She was
given albuterol and experienced a negative
reaction to the albuterol and completely
stopped breathing. She was brain dead by
the time she was intubated. They withdrew
care in the emergency department.
After my wife shared this with me, I
searched to find any case reports of paradoxical reactions to albuterol. Below are
three related cases, however bronchospasm
becoming worse with beta-agonists is exceptionally rare.
Case reports of paradoxical bronchospasm
to inhaled beta agonists:
• h t t p : / / w w w. n c b i . n l m . n i h . g o v /
pubmed/16553105 – Paradoxical bronchospasm: a potentially life threatening
adverse effect of albuterol (2006).
• h t t p : / / w w w. n c b i . n l m . n i h . g o v /
pubmed/18443029 – Paradoxical response to levalbuterol (2008).
• h t t p : / / w w w. n c b i . n l m . n i h . g o v /
pubmed/23173379 – Paradoxical reaction to salbutamol in an asthma patient
(2012).
What I think more probable, and possibly
related to the above case reports, is acute
laryngospasm. The albuterol she received
may have further irritated her vocal cords.
Both Resus.me and LITFL (Life In The Fast
Lane) blogs have very useful articles describing management (see below for links).
Here is a brief synopsis:
Laryngospasm
What is it?: a potentially life-threatening
closure of the vocal cords (can occur spontaneously). Often misdiagnosed as asthma—
especially exercise-induced asthma (more
common in white females).
How to diagnose (and differentiate from
asthma):
• Stridorous sounds are usually loudest
over the anterior neck, beware wheezing
sounds transmit throughout the lungs
• Typically, albuterol has minimal to no
beneficial effect.
• Subjectively more difficulty on inspiration
than expiration
Clues in history: recent exercise, GERD,
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LOUISVILLE MEDICINE
ENT procedures, or extubation
Common causes & some that are not-so
common:
• Post extubation
• Exercise
• GERD
• Medications (e.g., (1) ketamine sedation,
incidence 1-2 %; (2) versed (very rarely),
which can be reversed with flumazenil)
• Near drowning/ aspiration
• Inhalants (smoke, ammonia, dust, cleaning chemicals)
• Related to anxiety
• Strychnine (plant based poison, sometimes used as a pesticide for birds and
rodents, also the poison reportedly used
to kill Alexander the Great in 323 BC)
angle to the plane of the body (perform
jaw thrust).
Reportedly will convert laryngospasm within one or two breath cycles to laryngeal
stridor, and in after a couple more breath
cycles, to unobstructed respirations. As proposed by Larson, it is likely that the painful
stimulus relaxes the vocal cords by way of
either the parasympathetic or sympathetic
nervous systems through the glossopharyngeal nerve.
Diagram from LITFL
Treatment of laryngospasm:
Emergent Cricothyrotomy is always an
option –
Initially:
1 Jaw thrust with Larson Maneuver
2 CPAP/ NIPPV
3 Heliox might be helpful if available, (also
topical lidocaine can be applied to larynx
if available)
If conservative measures fail:
1 Low dose propofol (0.1 mg/kg) ~ give
10 mg
2 Low dose succinylcholine: 0.1-0.5 mg/
kg IV
3 All else fails: intubation with succinylcholine 1.5 mg/kg IV
• If no IV access, then succinylcholine IM
(3-4 mg/kg). Experts advocate IM injection into the tongue.
• Perform chest thrust maneuver immediately preceding intubation to open the
vocal cords and allow passage of the ET
tube.
• Monitor for negative pressure pulmonary edema—(from patient pulling hard
against closed glottis in the setting of
acute asphyxia).
Flow chart from Resus.me
What is the Larson Maneuver? (Published
1998 in Anesthesiology)
It is a manipulation jaw thrust technique
targeted at the ‘Larson’s point’ AKA: laryngospasm notch.
• Place middle finger of each hand in the
laryngospasm notch, located behind the
lobule of each ear, between ascending
ramus of the mandible and the mastoid
process.
• Press very firmly inward toward the base
of the skull with both fingers
• At the same time lift the mandible at a right
References:
1 Resus.Me: http://resus.me/laryngospasm-after-ketamine/
2 LITFL (Life In The Fast Lane): http://
lifeinthefastlane.com/ccc/laryngospasm/
3 UpToDate: