Intra-operative crises13 / 21
Laryngospasm and negative-pressure pulmonary oedema after septoplasty24-year-old man, 92 kg, muscular, otherwise fit; smokes 15 cigarettes a day
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Know this first
- Laryngospasm risk rises with smoking, secretions or blood on the cords, and upper airway surgery.
- Persistent laryngospasm: small-dose suxamethonium, 0.1 mg/kg or 5–10 mg.
- NPPE follows hard breathing efforts against shut vocal cords; muscular young men are most at risk.
- Hypoxaemia usually appears within 90 minutes; CPAP is the mainstay.
- Resolves in 12–48 hours if treated early; mortality reaches 40% if missed.
The patient
24-year-old man, 92 kg, muscular, otherwise fit; smokes 15 cigarettes a day.
Day-case nasal septoplasty under general anaesthesia with a tracheal tube and throat pack.
Drugs: none.
Vitals: BP 126/74, HR 68, SpO2 98% on air, RR 14.
The examiner asks
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Consider
What are your airway concerns for this day case?
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- A fit 24-year-old smoker for day-case septoplasty: a shared airway with blood in his pharynx. Patient
- Smoking and upper airway surgery both raise his risk of laryngospasm at emergence. Airway
- Blood or secretions reaching his cords at extubation are the usual trigger. Stem trigger
- As a strong young man he can pull hard against a closed glottis, causing pulmonary oedema. Disease
- Nasal packs after surgery mean he can only breathe through his mouth. Surgery
Plan
How will you plan his emergence?
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- While he is still deep: throat pack out, pharynx suctioned, and a gauze bite block in. Airway
- A bite block matters: biting the tube can itself cause negative-pressure oedema.
- Extubate him fully awake; pulling the tube in light stage-two anaesthesia invites laryngospasm.
- Head-up, 100% oxygen, facemask and suction ready before the tube comes out.
- Suxamethonium and propofol drawn up in case his cords close. Crisis
Crisis
As the tube comes out he gives a high-pitched crow, then goes silent with chest heaving; SpO2 falls to 85%, HR 54. What do you do?
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- Laryngospasm: call for help, stop stimulating him, suction blood from his pharynx. Crisis
- Jaw thrust and CPAP through a tight mask on 100% oxygen. Airway
- Firm pressure in the laryngospasm notch, between his mandibular condyle and mastoid.
- Not breaking: deepen him with propofol. Crisis
- Still closed and desaturating: suxamethonium 0.1 mg/kg, or 5–10 mg, then mask ventilate.
- His slow heart rate is hypoxic; it should recover once oxygen gets in.
- If spasm recurs or he can't be oxygenated, full-dose relaxant and reintubation. Airway
Crisis
Forty minutes later in recovery he is breathless, coughing pink frothy sputum; SpO2 88% on 6 L by mask, RR 30, HR 112, BP 142/88. What now?
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- Negative-pressure pulmonary oedema after his laryngospasm, until shown otherwise. Crisis
- Sit him up, high-flow oxygen, then CPAP; intubate with PEEP if he tires.
- I also consider aspirated blood, fluid overload and anaphylaxis.
- Chest X-ray for bilateral fluffy shadows, and an arterial blood gas.
- A diuretic may help, but oxygen and positive pressure are the main treatment.
- No discharge today: admit him to a monitored bed; it usually clears in 12–48 hours. After surgery
Fatal mistakes
- Sending him home as a day case after pulmonary oedema.
- Persisting with CPAP alone in complete laryngospasm while he desaturates.
- A diuretic alone while he stays hypoxic.
- Extubating him in a light plane of anaesthesia.
Checked against: Barash 9e · Miller 10e
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