A response to a previously published article or letter can be submitted to the Online Correspondence section at http://www.anaesthesiacorrespondence.com. Please note that a selection of this correspondence will be reproduced (possibly in modified form) in the journal. All correspondence intended for publication in Anaesthesia should be addressed to Dr Steve Yentis, Editor-in-Chief, and submitted as an email attachment to email@example.com. Copy should be prepared in the usual style of the Correspondence section. Authors must follow the advice about references and other matters contained in the Guidance for Authors at http://wileyonlinelibrary.com/journal/anae. Correspondence presented in any other style or format will be returned to the author for revision. All correspondence submissions should be accompanied by a completed Author Declaration Form which can be accessed via a link under ‘Covering letter’ in the Guidance for Authors (as above). The completed Author Declaration Form should be sent either by e-mail with the submission or by fax to (0)207 681 1008.
Laryngospasm in an unsedated patient during elective cannula cricothyroidotomy
Article first published online: 16 DEC 2010
Anaesthesia © 2010 The Association of Anaesthetists of Great Britain and Ireland
Volume 66, Issue 1, pages 65–66, January 2011
How to Cite
Mayer, J., Heard, A., Dinsmore, J. and Lacquiere, D. (2011), Laryngospasm in an unsedated patient during elective cannula cricothyroidotomy. Anaesthesia, 66: 65–66. doi: 10.1111/j.1365-2044.2010.06579.x
Visit the Anaesthesia Correspondence website at http://www.anaesthesiacorrespondence.com and comment on any article or letter in this issue of the Journal.
- Issue published online: 16 DEC 2010
- Article first published online: 16 DEC 2010
We report a case of laryngospasm during performance of a cannula cricothyroidotomy in a conscious patient who may have been at increased risk of this complication.
A 61-year-old woman presented for mandibular eminectomy. Clinical examination suggested that intubation and ventilation might be difficult, so an awake intubation was proposed. The patient declined this procedure, but did consent to placement of a cricothyroid cannula before intravenous induction of anaesthesia. Therefore, after pre-oxygenation, we performed an awake cricothyroidotomy with a 14-G Insyte™ cannula (Becton Dickinson UK Ltd, Oxford, UK) but following this, the patient coughed and developed severe laryngospasm. We immediately performed intravenous induction of anaesthesia and found that the patient’s lungs could be easily ventilated. Conventional intubation was possible and surgery proceeded uneventfully. Nothing was injected through the cannula at any stage. At the end of surgery, we viewed the cannula with fibreoptic laryngoscopy and found it to be positioned well below the vocal cords with the tip pointing caudally, suggesting no direct contact with the cords.
When the episode of laryngospasm was discussed with the patient afterwards, she described experiencing similar, self-terminating ‘attacks’ of an inability to breathe that typically would wake her from sleep and occurred several times per year. Such episodes are consistent with paroxysmal laryngospasm, in which patients experience bouts of sudden-onset, forceful adduction of the vocal cords . The primary risk factor is laryngopharyngeal reflux of gastric acid, which precipitates a highly irritable, ‘spasm-ready’ airway . The patient was therefore referred to an ear, nose and throat specialist who identified characteristic acid damage to the larynx with nasendoscopy. In view of the history and this finding the specialist concurred with the diagnosis of paroxysmal laryngospasm.
We postulate that this patient had an irritable larynx due to silent acid reflux and that the stimulus of the cannula touching the wall of the airway was sufficient to trigger laryngospasm. Given that other disease processes, such as upper respiratory tract infections, may also precipitate an irritable larynx [2, 3], and that many of the symptoms of laryngopharyngeal reflux are non-specific, the spasm-prone patient may well not declare themselves pre-operatively. With this in mind, we suggest conscious patients should be pre-oxygenated before placement of cricothyroid cannulae and the anaesthetist should be prepared to manage laryngospasm by immediately inducing anaesthesia if necessary.
No external funding and no competing interests declared. Published with the written consent of the patient. Previously presented as a poster at the Difficult Airway Society Annual Meeting, November 2010.