1. Anesthetic Implications of Vocal Cord Paralysis Case Presentation By: Hannah Scheppf and Leia Martin

2. 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

3. 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.).

4. Vocal Cord Paralysis: (VocalHealth.org, 2014) http://youtu.be/pLtz34uNnSY

5. 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.)

6. 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.

7. 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

8. Patient Profile  Horner’s syndrome (listed as non reactive right pupil)  Asthma  GERD  Cerebral Aneurysm with titanium clipping

9. 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

10. 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

11. 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

12. 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

13. What do we think happened? Laryngospasm vs. Bronchospasm

14. 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)

15. 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.)

16. Treatments Laryngospasm  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.)

17. 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

18. 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

19. 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/ 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 https://www.youtube.com/watch?v=pLtz34uNnSY&feature=em-share_video_user