Management of Bronchospasm / Laryngospasm

Question 1

Signs of bronchospasm in an intubated patient:

Answer 1

1. Increased peak airway
pressures.
2. Wheezing on lung exam.
3. Increased expiratory time.
4. Increased ETCO2 with
upsloping ETCO2 waveform.
5. Decreased tidal volumes if pressure control.

Question 2

Bronchospasm treatment: Vent changes

Answer 2

1. Increase to 100% O2, high flow.
2. Change I:E ratio to allow for adequate exhalation.

patients who develop sudden
hypotension may be air-trapping – disconnect
patient from the circuit to allow for complete exhalation.

Question 3

Troubleshooting problems that may present similar to bronchospasm

Answer 3

Rule out problems with ETT via auscultation & suction
catheter (mainstem intubation, kinked ETT, mucus plug)

Rule out anaphlyaxis

Question 4

Bronchospasm treatment: Inhaled agents

Answer 4

Give a Beta 2 agonist (albuterol, multiple puffs required)

and possibly an anticholinergic (Ipratropium).

consider nebulized racemic epi

Question 5

Bronchospasm treatment: IV meds

Answer 5

• If severe consider epinephrine (start with 10 mcg IV and escalate, monitor for tachycardia and hypertension)
• Consider ketamine: 0.2 – 1.0 mg/kg IV
• Consider hydrocortisone 100 mg IV.

Question 6

Nerve associated with Laryngospasm

Answer 6

Superior Laryngeal N.

Question 7

Treatment of laryngospasm

Answer 7

forward displacement of the jaw and positive pressure ventilation with 100% oxygenation is often effective in breaking spasm

• hypoxia and hypercarbia that develop will decrease postsynaptic potentials and brainstem output to the superior laryngeal nerve
• laryngospasm will eventually cease as hypercarbia and hypoxia develop

Question 8

Treatment of severe laryngospasm

Answer 8

may require small doses (20mg IV) of Sux and re-intubation

Sux may be given IM (40-60mg) or SL

Question 9

Bronchospasm: differential dx

Answer 9

Is this anaphylaxis?!

Discontinue potential allergens: muscle relaxants, latex, antibiotics, protamine, blood products, contrast, chlorhexidine…

• Give fluid bolus
• Give Epi at escalating doses 10mcg-100 mcg IV
• Start epi infusion
• consider additional IV access and invasive monitors
• H1 antagonist (diphenhydramine 25-50 IV)
• H2 antagonist (Ranitidine 50 IV)
• Corticosteroids (methylpred 125 IV)