Laryngeal Mask Airway as an Appropriate Option in Pediatric Laparoscopic Inguinal Hernia Repair: A Systematic Review and Meta-Analysis.

OBJECTIVE: To elucidate the safety and effectiveness of laryngeal mask airway (LMA) use in pediatric patients undergoing laparoscopic inguinal hernia repair. METHODS: Studies were searched on the PubMed, EMBASE, and Cochrane Library databases. Only randomized controlled trials (RCTs) were included. Primary outcomes were major perioperative respiratory adverse events (PRAEs), namely laryngospasm, bronchospasm, desaturation, and aspiration. Secondary outcomes were minor PRAEs, anesthesia time, and recovery time. A meta-analysis was performed to calculate risk ratios (RR), weighted mean difference (WMD), and 95 % confidence intervals (CI) by using random effects models. RESULTS: In total, 5 RCTs comprising 402 patients were included. Regarding major PRAEs, laryngospasm (RR: 0.43, 95 % CI: 0.12 to 1.47; p = 0.18), bronchospasm, and aspiration all demonstrated no difference between the laryngeal and endotracheal groups. Desaturation exhibited a trend, but this trend was not sufficiently supported with statistical evidence (p = 0.09). For minor PRAEs, fewer patients experienced incidence of cough after laryngeal mask use (RR: 0.27, 95 % CI: 0.11 to 0.67; p = 0.005). Other PRAE, namely hoarseness (p = 0.06), sore throat (RR: 1.88, 95 % CI: 0.76 to 4.66; p = 0.18), and stridor, did not differ between the 2 groups. Additionally, both anesthesia time (WMD: -6.88 min, 95 % CI: -11.88 to -1.89; p < 0.00001) and recovery time (WMD: -4.85 min, 95 % CI: -6.51 to -3.19; p < 0.00001) were shortened in the LMA group. CONCLUSION: LMA used in pediatric laparoscopic inguinal hernia repair demonstrated no greater safety risks than endotracheal tube intubation did. Thus, anesthesiologists may shift from conventional endotracheal tube use to LMA use. Moreover, anesthesia and recovery times were shortened in the LMA group, which resulted in more efficient use of the operating room. Because of these benefits, LMA could be an appropriate option for pediatric patients undergoing laparoscopic inguinal hernia repair. LEVEL OF EVIDENCE: Treatment Study, LEVEL III.

Remimazolam and Remifentanil Use Induced Severe Respiratory Depression and Laryngeal Spasm During Intravenous Sedation and Analgesia: A Case Report.

INTRODUCTION: Intravenous sedation and analgesia are widely used in minor surgeries. Remifentanil and remimazolam are advantageous in this setting because of their rapid onset of action, and short duration of action leading to a rapid recovery. However, the two drugs combined need to be titrated to avoid airway-related adverse events. CASE PRESENTATION: This article reports a case of severe respiratory depression and severe laryngeal spasm induced by remifentanil and remimazolam when they were used for analgesia and sedation in a patient undergoing oral biopsy. CONCLUSION: We aim to improve awareness about the safety of these drugs among anesthesiologists and increase their ability to manage the risk associated with their use.

[New progress in diagnosis and treatment of congenital laryngomalacia in infants].

Congenital laryngomalacia is the most common disease causing laryngeal stridor in infants. The pathogenesis has not yet been clearly concluded. It may be related to abnormal development of laryngeal cartilage anatomical structure, neuromuscular dysfunction, gastroesophageal and laryngeal reflux disease, etc. The typical manifestations of the disease are inspiratory laryngeal stridor and feeding difficulties, which can be divided into mild, moderate and severe according to the severity of symptoms. The diagnosis is mainly based on clinical symptoms, signs and endoscopy, among which endoscopy is an important diagnostic basis. The treatment of laryngomalacia depends on the severity of symptoms. Mild and some moderate congenital laryngomalacia children can be relieved by conservative treatment, and severe and some moderate congenital laryngomalacia children should be treated by surgery. Supraglottic plasty is the main surgical method, which can effectively improve the symptoms of laryngeal stridor, dyspnea, feeding difficulties and growth retardation in most children, and the surgical effect is good.

Comparing the effectiveness of topical dexamethasone emollient, lidocaine gel, and glycerin emollient on the endotracheal tube for postoperative hoarseness of voice, sore throat, and laryngospasm.

During general anesthesia, inserting a relatively stiff endotracheal tube using a metallic laryngoscope through the soft tissues of the pharynx and larynx, along with applying a pressured cuff, can result in varying degrees of tissue trauma and adverse outcomes. Anesthesiologists commonly encounter post-operative issues such as hoarseness, sore throat, and laryngospasm. This study aimed to compare the effectiveness of topical applications of dexamethasone emollient, lidocaine gel, and glycerin emollient in reducing these complications. One hundred patients were randomly assigned to four groups of 25 patients each: the control group (Group C), lidocaine gel group (Group L), glycerin emollient group (Group G), and dexamethasone emollient group (Group D). The assigned medication was topically applied to the endotracheal tube, and patients were monitored for postoperative laryngospasm, hoarseness, and sore throat within the first 24 hours. No statistically significant differences were found among the four groups in terms of demographic characteristics, postoperative sore throat, hoarseness, or laryngospasm (p>0.05). Lidocaine gel was an effective drug that can be used to attenuate the incidence rate of post-operative sore throat.

Vagal nerve stimulator-associated sleep disordered breathing secondary to vagal-induced laryngospasm in pediatric populations: Case presentation and systematic review.

OBJECTIVES: Sleep disordered breathing (SDB) is a well-documented complication of vagus nerve stimulation (VNS) in the literature. Yet, a formal consensus on its management has not been established, particularly in the pediatric population. This study aims to evaluate the current literature on VNS-associated SDB in order to further characterize its presentation, pathogenesis, diagnosis, and treatment. METHODS: A literature review from 2001 to November 8, 2021 was conducted to search for studies on SDB during vagal nerve stimulation in pediatric populations. RESULTS: Of 277 studies screened, seven studies reported on pediatric patients with VNS-associated SDB. Several investigators found on polysomnogram that periods of apnea/hypopnea correlated with VNS activity. When VNS settings were lowered or turned off, symptoms would either improve or completely resolve. CONCLUSION: VNS-associated SDB is a well described complication of VNS implantation, occurring due to an obstructive process from vagal stimulation and laryngeal contraction. Diagnosis can be made via polysomnogram. Recommended treatment is through adjustment of VNS settings. However, those who are unable to tolerate this, or who have had pre-existing obstructive issues prior to VNS, should pursue other treatment options such as non-invasive positive pressure or surgery directed by DISE findings.

Subacute Horizontal Diplopia, Jaw Dystonia, and Laryngospasm.

Jaw dystonia and laryngospasm in the context of subacute brainstem dysfunction have been described in a small number of diseases, including antineuronal nuclear antibody type 2 (ANNA-2, also known as anti-Ri) paraneoplastic neurologic syndrome. Severe episodes of laryngospasms causing cyanosis are potentially fatal. Jaw dystonia can also cause eating difficulty, resulting in severe weight loss and malnutrition. In this report, we highlight the multidisciplinary management of this syndrome associated with ANNA-2/anti-Ri paraneoplastic neurologic syndrome and discuss its pathogenesis.

Feasibility and Safety of Remazolam versus Propofol When Inserting Laryngeal Masks Without Muscle Relaxants During Hysteroscopy.

Purpose: This study aimed to evaluate the efficacy and safety of remazolam compared with propofol in patients who underwent laryngeal mask airway (LMA) insertion without the use of muscle relaxant agents during hysteroscopic surgery. Patients and Methods: A total of 72 patients undergoing hysteroscopy with LMA insertion were assigned to two groups. The patients in the remazolam group received 0.3 µg/kg sufentanil, 0.3 mg/kg remazolam and 1.2 mg/kg remifentanil, whereas the patients in the propofol group received 0.3 µg/kg sufentanil, 2.0 mg/kg propofol and 1.2 mg/kg remifentanil for insertion of the LMA. The primary endpoint was the summed score of the insertion conditions. The secondary endpoints included hemodynamics, the duration of induction, the duration of insertion, tidal volume, plateau pressure and adverse events. Results: No difference was identified between the propofol group and remazolam group in the median summed score [18.0 (18.0, 18.0), 18.0 (17.0, 18.0), respectively, P > 0.05]. The induction duration was significantly longer (P < 0.05) in the remazolam group than propofol group. The cost of dopamine (P < 0.05) was significantly lower in the remazolam group compared with the patients in the propofol group, while the plateau pressure (P < 0.05) and the incidence of transient mild laryngospasm (P < 0.05) were significantly higher in the remazolam group. No differences were identified between the two groups in terms of heart rate, tidal volume, injection pain or hiccups (P > 0.05). Conclusion: Remazolam provided similar insertion conditions and better hemodynamic stability than propofol during LMA insertion without the use of muscle relaxant agents. However, a higher incidence of transient mild laryngospasm was found in the remazolam group, which should be considered.

A Case of Suspected Negative Pressure Pulmonary Edema after General Anesthesia.

Negative pressure pulmonary edema (NPPE) can occur rapidly after the release of an upper airway obstruction. In general anesthesia, NPPE can be caused by laryngospasm after extubation. This report describes a case in which NPPE was thought to have occurred after extubation during general anesthesia in a disabled person. The patient was a 28-yearold man, 160 cm in height and 56 kg in weight, who was scheduled for dental caries treatment under ambulatory general anesthesia due to intellectual disability. After induction of general anesthesia, nasal intubation was performed after sufficient oral suctioning to remove a large amount of serous secretion. After completion of dental treatment, pressurized extubation was performed after oral suctioning as sufficient spontaneous breathing and body movement were observed. Immediately after extubation, SpO2 dropped to 80%, subsequently recovering to 99% under oxygen administration at 5 liter/min with an oxygen mask. It dropped to approximately 85% again, however, when administration of oxygen was discontinued. Although communication with the patient was difficult, no expression of anguish or dyspnea was observed. A chest radiograph showed symmetric middle-lobe and lingular segment infiltrates, and the patient was transferred to the nearest general hospital. No obvious clinical findings other than a decrease in SpO2 were observed, suggesting NPPE as a result of airway narrowing due to secretions.

Topical Pharyngeal Anesthesia in Sedated Pediatric Patients Undergoing Esophagogastroduodenoscopy.

OBJECTIVES: Pediatric patients undergoing esophagogastroduodenoscopy (EGD) commonly receive procedural sedation for comfort and to facilitate the procedure. EGD with procedural sedation carries the risk of several airway incidents and/or adverse events (AIAE). Topical pharyngeal anesthetics (TPAs) can blunt the airway reflexes and decrease the incidence of laryngospasm but has not been well studied with EGD under procedural sedation. We aimed to study the effect of adding a TPA to propofol-based sedation on the rate of AIAE. METHODS: This is a single-center, retrospective, observational cohort study. We compare AIAE rates (coughing, gagging, apnea, airway obstruction, and laryngospasm) in children who received TPA as part of their propofol-based procedural sedation for EGD with those who did not receive TPA. RESULTS: In 2021, 73 patients received TPA as part of the procedural sedation for EGD and 123 did not. The overall rate of AIAE was high with 75 (38%) patients experiencing 1 or more AIAE. Patients who received benzocaine spray experienced more AIAE than the control group [adjusted odds ratio (aOR) = 1.16; 95% confidence interval (CI): 1.01-1.34; P = 0.037]. Coughing, gagging, apnea with desaturation rates, and laryngospasm were similar in both groups (coughing aOR = 1.01; 95% CI: 0.91-1.13; P = 0.814; gagging aOR = 1.01; 95% CI: 0.91-1.13; P = 0.814; apnea aOR = 0.99; 95% CI: 0.95-1.04; P = 0.688; laryngospasm OR = 1.01; 95% CI: 0.95-1.07; P = 0.71). The rate of airway obstruction requiring jaw thrust was higher in the benzocaine group but did not reach statistical significance (aOR = 1.11; 95% CI: 0.97-1.26; P = 0.133). CONCLUSION: The use of topical pharyngeal benzocaine in children undergoing EGD with propofol-based sedation is associated with a higher overall AIAE rate. Most of the AIAE were mild incidents and only 7 patients experienced true adverse events.

Laryngopharyngeal reflux induced sleep-related laryngospasm.

BACKGROUND: Sleep-related laryngospasm (SRL) has been defined as the sustained closure of the vocal cords during sleep. Studies have suggested that it is a rare manifestation of laryngopharyngeal reflux (LPR). Difficulties in diagnosing SRL and LPR have led to the condition being under-recognised in the clinical setting. AIMS: The aim of this study was to determine if LPR was the cause of the SRL symptoms seen in our patients. METHODS: A retrospective chart assessment of patients with SRL. Patients with risk factors for LPR were identified. These included smoking status, alcohol intake, a history of dyspepsia or history of gastroesophageal reflux disease, a history of late-night eating and a history of eating spicy or fatty foods before bed. A clinical diagnosis based on the history and response to management was made for the diagnosis of LPR. All were advised to refrain from late meals and those with signs of nasopharyngitis were commenced on proton pump inhibitor therapy. RESULTS: Nineteen patients (mean age ± SD: 57.21 ± 15.18) were included in the study. All had at least one risk factor for LPR. Ten (52.6%) had signs of nasopharyngitis on nasendoscopy. Following treatment, 17 (89.5%) reported no further SRL symptoms at 1-year follow-up. CONCLUSION: SRL is a largely unknown and under-diagnosed condition. We believe this study provides supportive evidence for the causal relationship between LPR and SRL.

Should rocuronium and sugammadex replace succinylcholine for airway emergencies in class B ambulatory anesthesia settings?

INTRODUCTION: In class B surgical facilities, where only oral or intravenous (IV) sedation is employed without the administration of volatile anesthetics, laryngospasm is among the most common airway complications. However, these facilities generally do not stock succinylcholine to avoid the cost of storing dantrolene for the treatment of malignant hyperthermia (MH). High dose IV rocuronium with sugammadex reversal has been suggested as an alternative to succinylcholine for airway emergencies. The aim of this paper was to evaluate the clinical utility, patient safety, and financial implications of replacing succinylcholine with rocuronium and sugammadex in lieu of stocking dantrolene in class B facilities. EVIDENCE ACQUISITION: A systematic review of the literature concerning neuromuscular blockade for airway emergencies in class B settings in adult patients was conducted. The MEDLINE and EMBASE databases were searched for published studies from January 1, 1990, to October 1, 2021. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to assess the certainty of evidence. EVIDENCE SYNTHESIS: The search strategy yielded 1124 articles. After review, 107 articles were included, with 49 graded as "strong" evidence to provide recommendations for the posed questions. CONCLUSIONS: The use of succinylcholine in isolation without volatile agents has a low incidence of triggering MH. Laryngospasm is a common airway emergency that requires immediate treatment to avoid morbidity and mortality. Both succinylcholine and rocuronium-sugammadex provide adequate treatment of airway emergencies and rapid return of spontaneous ventilation, but succinylcholine has a superior economic and clinical profile.

Safety of office-based flexible endoscopic procedures of the pharynx and larynx under topical anesthesia.

INTRODUCTION: Flexible endoscopic procedures (FEP) using a working channel allowed otolaryngologists to perform more procedures on the pharynx and the larynx under local anesthesia. The purpose of this work is to demonstrate the feasibility and safety of this technique by studying the adverse effects of this practice in an office-based setting. METHODS: This is a monocentric retrospective cohort study. We searched the database using the French procedural code for FEP performed in an outpatient setting between January 2005 and December 2020. Data regarding the patient's characteristics, indications, and periprocedural complications were extracted. RESULTS: In total, we included 231 patients with a total of 308 FEP: 36% biopsy, 20% hyaluronic acid injection (including 3.5% at the level of the cavum), 20% injection of other substances (in descending order: botulinum toxin, cidofovir, physiological serum, cortisone), 20% exploration for an occult tumor, 3% samples for microbiological analysis, 1% other procedures. Of the 308 FEP included in this study, 24 patients (10.3%) had complications corresponding to 7.8% of the procedures performed. During the procedures, reported complications include minor laryngeal bleeding (n = 5), vasovagal syncope (n = 5), laryngospasm (n = 1) or nausea (n = 3), dysphagia (n = 3), and voice disorders (n = 3). Post-procedural complications were hypertensive crisis (n = 1), asthma attack (n = 1), pneumonia (n = 1), laryngitis (n = 1). Using the Clavien-Dindo classification system, these complications could be defined as grade I (laryngeal bleeding, vasovagal syncope, laryngospasm, dysphagia, nausea, voice disorders, and laryngitis) and grade II (hypertensive crisis, asthma attack, pneumonia) in 9.1% and 1.2% of cases, respectively. Most of these complications were self-limiting, while asthma attacks, pneumonia, laryngitis, and voice disorders required a medical intervention. All complications were managed without sequelae. There was no serious complication grade (no grade III, IV or V). CONCLUSIONS: FEP, which is now well standardized in our institution, makes it possible to carry out a wide range of interventions with little morbidity. These results are in line with those of literature but this technique remains out of nomenclature in France. Our experience led to the development of an evidence-based standard of care that can serve as a framework for practitioners on a nationwide level, while the work to establish official guidelines by the French society of phoniatrics and laryngology is in progress.

Negative-pressure pulmonary edema after mammoplasty: a case report.

Negative-pressure pulmonary edema (NPPE) is a rare but life-threatening postoperative complication that occurs due to the acute obstruction of the upper airway. In our case report, we present a 25-year-old female patient who underwent elective mammoplasty under general anesthesia and developed NPPE 4 hours after extubation. The patient had a preoperative mallampati score of 3. After routine anesthesia induction, the patient was intubated with an endotracheal tube with a guide wire. Aspiration wasn't observed during extubation. The patient was followed in the post-anesthesia care unit (PACU) for 30 minutes with a saturation of 95% and was subsequently transferred to the service. Four hours after the operation, the patient was re-examined due to dyspnea and shortness of breath. Due to oxygen saturation of 88% and pO2of 56mmHg despite mask ventilation, the patient was admitted to the intensive care unit (ICU). A computed tomography (CT) scan revealed extensive diffuse ground-glass opacities and consolidations in both lungs. She did not respond to mask ventilation and was given non-invasive ventilation with continuous positive airway pressure (CPAP). Forced diuresis was induced with furosemide. Tachypnea resolved within 2 hours after CPAP was initiated, the patient did not require oxygen support and COVID-19 polymerase chain reaction (PCR) testing was negative. Subsequently, the patient was discharged to the clinical ward on postoperative day 1. When considering NPPE, early diagnosis and respiratory support are associated with reduced mortality and rapid recovery. Patients who develop laryngospasm during extubation must be closely monitored, and in the case of pulmonary edema, NPPE should be considered in the differential diagnosis.

Addition of magnesium sulfate to bupivacaine improves analgesic efficacy after tonsillectomy: A randomized trial and a CONSORT analysis.

OBJECTIVES: The main objective of this study was to compare the wound infiltration (peritonsillar fossa) of magnesium sulphate combined with bupivacaine, bupivacaine alone and saline solution on post-tonsillectomy pain in children. The accessory objectives were to evaluate the effect of magnesium sulphate infiltration on prevention of laryngospasm and occurrence of nausea/vomiting. METHODS: This study is a prospective; double blinded and randomized clinical trial. Seventy-five children undergoing tonsillectomy were enrolled. Patients were randomized into three groups using closed envelop technique. Group 1 (N=24) received saline solution (NaCl), group 2 (N=25) received 0.25% bupivacaine (1mg/kg) and group 3 received magnesium sulphate (5mg/kg) and 0.25% bupivacaine (1mg/kg) after tonsillectomy using three-point technique. Pain was evaluated using mCHEOPS scale. The occurrence of laryngospasm, nausea and vomiting was monitored. RESULTS: The mCHEOPS scores of the group 3 were significantly lower than those of the group 2 and 1 (P<0.001). Time to first analgesic administration was longer for the group 3 than for the groups 2 and 1 (P<0.001). The mean consumption of additional analgesic drugs was lower for the group 3 than the other groups (P<0.001). There were no episodes of laryngospasm in the group 3 in comparison with the other groups. The difference of the incidence of nausea and vomiting was not statistically significant (P=0.628). CONCLUSION: The adjunction of magnesium sulphate to bupivacaine proved to provide more efficient pain control than bupivacaine alone. However, the small number of participants and the absence of sampling at the P level of 0.005 do not allow to conclude with absolute certainty.

Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation.

STUDY OBJECTIVE: Laryngospasm is a rare but potentially life-threatening complication of sedation. The objective of this study was to perform a predictor analysis of biologically plausible predictors and the interventions and outcomes associated with laryngospasm. METHODS: Secondary analysis of prospectively collected data from consecutively sedated patients, less than or equal to 22 years of age, at multiple locations at 64 member institutions of the Pediatric Sedation Research Consortium. The primary outcome was laryngospasm. The independent variables in the multivariable model included American Society of Anesthesiologists category, age, sex, concurrent upper respiratory infection, medication regimen, hospital sedation location, whether the procedure was painful, and whether the procedure involved the airway. The analysis included adjusted odds ratios (aORs) and predicted probabilities. RESULTS: We analyzed 276,832 sedations with 913 reported events of laryngospasm (overall unadjusted prevalence 3.3:1,000). A younger age, a higher American Society of Anesthesiologists category, a concurrent upper respiratory infection (aOR 3.94, 2.57 to 6.03; predicted probability 12.2/1,000, 6.3/1,000 to 18.0/1,000), and airway procedures (aOR 3.73, 2.33 to 5.98; predicted probability 9.6/1,000, 5.2/1,000 to 13.9/1,000) were associated with increased risk. Compared with propofol alone, propofol combination regimens had increased risk (propofol+ketamine: aOR 2.52, 1.41 to 4.50; predicted probability 7.6/1,000, 3.1/1,000 to 12/1,000; and propofol+dexmedetomidine: aOR 2.10, 1.25 to 3.52; predicted probability 6.3/1,000, 3.7,/1,000 to 8.9/1,000). Among patients with laryngospasm, the resulting outcomes included desaturation less than 70% for more than 30 seconds (19.7%), procedure not completed (10.6%), emergency airway intervention (10.0%), endotracheal intubation (5.3%), unplanned admission/increase in level of care (2.3%), aspiration (1.1%), and cardiac arrest (0.2%). CONCLUSION: We found increased associations of laryngospasm in pediatric procedural sedation with multiple biologic factors, procedure types, and medication regimens. However, effect estimates showed that the laryngospasm prevalence remained low, and this should be taken into consideration in sedation decisionmaking.

The effect of passive smoking on the laryngospasm rate in children sedated during the esophagogastroduodenoscopy.

OBJECTIVES: To investigate the rate of laryngospasm with sedation during the esophagogastroduodenoscopy (EGD) procedure in children exposed to passive smoking and to examine the frequency of complications due to laryngospasm. METHODS: A single-blind, prospective, observational study with a total of 518 patients evaluated according to the American Society of Anesthesiologists (ASA) physical status as classification I-II, aged between 1-18 years, and planned to undergo an EGD procedure, were included. Age, gender, weight, ASA assessment, exposure to smoking (the mother, the father, both parents were smokers, or not exposed to smoking), drug doses used in sedation, and anesthesia-related complications, such as cough, decrease in oxygen saturation, and laryngospasm were recorded. RESULTS: Of the 518 patients included in the study, 213 had no smoking exposure history. Oxygen saturation did not decrease below 90% in patients who did not have any smoking exposure. In addition, no laryngospasm was observed in this group. However, 4 (11.4%) of 31 patients whose mother only smoked, 10 (5.1%) of 187 child patients whose father only smoked, and 12 (16.4%) of 61 patients whose mother and father both smoked experienced laryngospasm during the procedure. CONCLUSION: The rate of cough, laryngospasm, and hypoxia development increased during the sedation carried out in the EGD procedure in children who were exposed to passive smoke.Clinicaltrial.gov ID: NCT03920046.