- Case report
- Open Access
A case in which a capnometer was useful for diagnosing laryngospasm following administration of sugammadex
© The Author(s) 2017
Received: 1 May 2017
Accepted: 7 August 2017
Published: 15 August 2017
Sugammadex has been reported to cause upper-airway obstruction, such as laryngospasm or bronchospasm. These two conditions are treated using different approaches, but the differential diagnosis is difficult.
We describe a case in which general anesthesia was administered via endotracheal intubation, in combination with brachial-plexus block, for arthroscopic surgical treatment of a rotator-cuff tear caused by recurrent shoulder dislocation. The total dose of rocuronium administered was 90 mg, and the last dose of 10 mg was given 15 min before the end of the surgery. Sugammadex was intravenously administered at 100 mg to reverse the effect of rocuronium after the operation ended. After extubation in this case, we placed a mask firmly around the patient’s mouth, and thus, there was no air leakage around the mask. We detected upper-airway obstruction that was presumably attributable to administration of sugammadex. The end-tidal carbon dioxide (EtCO2) concentration was undetectable on a capnometer. Although 100% oxygen was administered at 10 L/min via a facemask, oxygen saturation (SpO2) decreased to approximately 70%. With suspected onset of laryngospasm, continuous positive airway pressure with 100% oxygen at 10 L/min was started at 30 cm H2O. The patient’s airway obstruction resolved after a short time.
The use of a capnometer facilitated the diagnosis of laryngospasm and allowed us to administer appropriate treatment after administration of sugammadex.
Sugammadex, an antagonist of muscle relaxants, has been reported to cause upper airway obstruction, such as laryngospasm [1–3] or bronchospasm [3, 4]. We herein report our experience with a case in which a capnometer was useful for the differential diagnosis of upper airway obstruction following administration of sugammadex.
This patient presented with retractive breathing, stridor, and decreased SpO2 immediately after extubation. We suspected that these symptoms were attributable to bronchospasm or laryngospasm associated with administration of sugammadex. It has been reported that sugammadex may cause bronchospasm . This is reportedly more likely in patients with a history of respiratory disease, such as bronchial asthma. Meanwhile, bronchospasm is triggered by various mechanical (e.g., endotracheal intubation), chemical, and pharmacological stimuli. While its intraoperative respiratory adverse event is approximately 1.7%, bronchospasm and laryngospasm are complications in which deaths have been reported in some severe cases [5–7]. The most common pathological condition recognized as bronchospasm is asthma. When considering the treatment for bronchospasm, volatile anesthetic agents are useful because with the exception of desflurane, they have a bronchodilator effect . Desflurane increases airway resistance at a high alveolar concentration . When bronchospasm is severe, it is difficult to use volatile anesthetic agents. Propofol relaxes the airway reflex . Beta-stimulants, such as salbutamol and epinephrine, can also be administered intravenously . Anticholinergic drugs, such as tiotropium bromide, block parasympathetic constriction of bronchial smooth muscle . Intravenous magnesium sulfate is also effective for bronchospasm .
Laryngospasm is defined as glottis narrowing caused by reflective contraction of the laryngeal muscles. It is classified into complete and incomplete types. The complete type is referred to as a condition in which the immobility of the back leads to complete failure of ventilation, whereas the incomplete type is referred to as a condition in which the motion of the thorax is accompanied by inspiratory stridor and limited motion of the back. When incomplete laryngospasm progresses to the complete type, inspiratory stridor disappears [13, 14]. Laryngospasm frequently occurs in ambulatory anesthesia , while its occurrence has also been reported during orthopedic surgery [16, 17], laparotomy , and craniotomy . Laryngospasm is more common in young people than in adults. In fact, its incidence has been reported to reach 14% in those aged less than 6 years . A definitive diagnosis of this condition is made by examination of the vocal cords with a bronchial fiberscope . When laryngospasm is diagnosed, the irritating stimulus by any triggering factor should be removed. Positive-pressure ventilation with 100% oxygen, which forces the chin forward with strong pressure from behind the ascending rami of the jaw, is required for laryngospasm . When this fails, endotracheal intubation is required. Anesthesia should be deepened with an intravenous anesthetic. For endotracheal intubation, succinylcholine is widely used as a muscle relaxant . It has been reported that succinylcholine is administered to avoid significant hypoxia in approximately 25 to 50% of these cases . If it is difficult to intubate using an endotracheal tube, cricothyroidotomy or tracheotomy is needed to access the airway rapidly . Prolonged laryngospasm may cause serious complications, such as cardiac arrest, aspiration, and negative pressure pulmonary edema . Bronchospasm and laryngospasm should be differentiated soon after onset because they differ in terms of treatment strategies and subsequent complications.
In our case, a capnometer was useful for differentiating between bronchospasm and laryngospasm. Although a definitive diagnosis of laryngospasm is made by examination of the vocal cords with a bronchial fiberscope , there was insufficient time to perform bronchial fiberscopy in order to prevent progression to NPPE. No waveform appears in capnometer readings of laryngospasm, which causes complete occlusion of the upper respiratory tract; however, they reveal waveform patterns of occlusive respiratory disorders and provide EtCO2 values in most cases of bronchospasm. In our case, laryngospasm was diagnosed because EtCO2 waveforms were absent on the capnometer readings, and continuous positive airway pressure with 100% oxygen was applied through a facemask, resulting in relief of symptoms.
Because there are reported cases of NPPE that occurred a few hours after extubation , adequate follow-up is necessary. However, our patient presented with neither subjective symptoms nor abnormal radiographic findings after surgery.
After extubation in this case, we detected upper airway obstruction that was presumably attributable to administration of sugammadex. The treatment strategies for upper airway obstruction vary depending on the cause. The use of a capnometer facilitated the diagnosis of laryngospasm and allowed us to administer appropriate treatment.
KK and TO collected the data and drafted the manuscript. SW and SS revised the manuscript. All authors read and approved the final manuscript.
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- Takazawa T, Mitsuhata H, Mertes PM. Sugammadex and rocuronium-induced anaphylaxis. J Anesth. 2016;30:290–7.View ArticlePubMedGoogle Scholar
- Komasawa N, Nishihara I, Minami T. Relationship between timing of sugammadex administration and development of laryngospasm during recovery from anaesthesia when using supraglottic devices: a randomised clinical study. Eur J Anaesthesiol. 2016;33:691–2.View ArticlePubMedGoogle Scholar
- Amao R, Zornow MH, Cowan RM, Cheng DC, Morte JB, Allard MW. Use of sugammadex in patients with a history of pulmonary disease. J Clin Anesth. 2012;24:289–97.View ArticlePubMedGoogle Scholar
- Yoshioka N, Hanazaki M, Fujita Y, Nakatsuka H, Katayama H, Chiba Y. Effect of sugammadex on bronchial smooth muscle function in rats. J Smooth Muscle Res. 2012;48:59–64.View ArticlePubMedGoogle Scholar
- Woods BD, Sladen RN. Perioperative considerations for the patient with asthma and bronchospasm. Br J Anaesth. 2009;103(Suppl 1):i57–65.View ArticlePubMedGoogle Scholar
- Lauer R, Vadi M, Mason L. Anaesthetic management of the child with co-existing pulmonary disease. Br J Anaesth. 2012;109(Suppl 1):i47–59.View ArticlePubMedGoogle Scholar
- Subramanyam R, Yeramaneni S, Hossain MM, Anneken AM, Varughese AM. Periopetative respiratory adverse events in pediatric ambulatory anesthesia: development and validation of a risk prediction tool. Anesth Analg. 2016;122:1578–85.View ArticlePubMedGoogle Scholar
- Dikmen Y, Eminoglu E, Salihoglu Z, Demiroluk S. Pulmonary mechanics during isoflurane, sevoflurane and desflurane anaesthesia. Anaesthesia. 2003;58:745–8.View ArticlePubMedGoogle Scholar
- Eikermann M, Malhotra A, Fassbender P, Zaremba S, Jordan AS, Gautam S, White DP, Chamberlin NL. Differential effects of isoflurane and propofol on upper airway dilator muscle activity and breathing. Anesthesiology. 2008;108:897–906.View ArticlePubMedPubMed CentralGoogle Scholar
- Pleasants RA. Review of guidelines and the literature in the treatment of acute bronchospasm in chronic obstructive pulmonary disease. Pharmacotherapy. 2006;26:156S–63S.View ArticlePubMedGoogle Scholar
- Hvizdos KM, Goa KL. Tiotropium bromide. Drugs. 2002;62:1195–203.View ArticlePubMedGoogle Scholar
- Rowe BH, Camargo CA Jr. The role of magnesium sulfate in the acute and chronic management of asthma. Curr Opin Pulm Med. 2008;14:70–6.View ArticlePubMedGoogle Scholar
- Hartley M, Vaughan RS. Problems associated with tracheal extubation. British Anaesth. 1993;71:561–8.View ArticleGoogle Scholar
- Halow KD, Ford EG. Pulmonary edema following postoperative laryngospasm. A case report and review of the literature. Am Surg. 1993;59:443–7.PubMedGoogle Scholar
- Kollef MH, Pluss J. Noncardiogenic pulmonary edema following upper airway obstruction 7 cases and review of the literature. Medicine. 1991;70:91–8.View ArticlePubMedGoogle Scholar
- Koch SM, Abramson DC, Ford M, et al. Bronchoscopic findings in post-obstructive pulmonary oedema. Can J Anaesth. 1991;43:73–6.View ArticleGoogle Scholar
- Broccard AF, Liaudet L, Aubert J-D, et al. Negative pressure post-tracheal extubation alveolar hemorrhage. Anesth Analg. 2001;92:273–5.View ArticlePubMedGoogle Scholar
- Dohi S, Okubo N, Kondo Y. Pulmonary oedema after airway obstruction due to bilateral vocal cord paralysis. Can J Anaesth. 1991;38:492–5.View ArticlePubMedGoogle Scholar
- Flick RP, et al. Risk factors for laryngospasm in children during general anesthesia. Paediatr Anaesth. 2008;18:289–96.View ArticlePubMedGoogle Scholar
- Tagaito Y, Isono S, Nishino T. Upper airway reflexes during a combination of propofol and fentanyl anesthesia. Anesthesiology. 1998;88:1459–66.View ArticlePubMedGoogle Scholar
- Joshi GP, Desai MS, Gayer S, Vila H Jr; Society for Ambulatory Anesthesia (SAMBA). Succinylcholine for emergency airway rescue in class B ambulatory facilities: the Society for Ambulatory Anesthesia Position Statement. Anesth Analg 2017;124:1447-1449.Google Scholar
- Burgoyne LL, Anghelescu DL. Intervention steps for treating laryngospasm in pediatric patients. Paediatr Anaesth. 2008;18:297–302.View ArticlePubMedGoogle Scholar
- Bhattacharya M, Kallet RH, Ware LB, Matthay MA. Negative-pressure pulmonary edema. Chest. 2016;150:927–33.View ArticlePubMedGoogle Scholar
- Glasser SA, Siler JN. Delayed onset of laryngospasm-induced pulmonary edema in the adult outpatient. Anesthesiology. 1985;62:370–1.View ArticlePubMedGoogle Scholar