What is the difference between a bronchospasm and laryngospasm? Jenny Finnell, CRNA, discusses this subject in this Quick Hit Session. While laryngospasm affects your vocal cords, bronchospasm affects your bronchi. This is an extremely important distinction that will help you decide what action to take for either case. Learn more about bronchospasm and laryngospasm in this quick hit session with Jenny Finnell!
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What Is The Difference Between A Bronchospasm & Laryngospasm?
Bronchospasm Vs. Laryngospasm
A quick disclaimer, in this episode, we are doing a little more clinically-based type of topic. I want to make sure I’m throwing it out there to make sure you are always fact-checking me and you are equally looking up the doses of medications prior to administering any drugs. I hope you enjoy this episode.
What is the difference between a laryngospasm and a bronchospasm? In this episode, we are going to start doing something new, which are Quick Hits: Anatomy, Pathophysiology and Pharmacology Sessions. I hope you enjoy it. Let’s get into this episode.
This episode marks a brand new series that we are starting to do, which is anatomy, pathophysiology, pharmacology “Quick Hit Session” where I pick a singular topic and we discuss it in detail. We are going to talk about the difference between a laryngospasm and a bronchospasm. If you are starting your CRNA journey, whether you are still in the ICU or getting ready to start your program, it is fun to know this knowledge because it is only going to help you in the long run. The sooner you can learn how to differentiate between a laryngospasm and a bronchospasm, the better off you are going to be once you enter into your clinical realm of training.
Let’s get into some of the basics. A laryngospasm is an upper airway spasm. It is when your vocal cords are completely shut. It is a muscular spasm of your vocal cords. You can have complete or incomplete closure, incomplete laryngospasm or complete laryngospasm. How you know whether one is complete or incomplete is based on the symptoms.
If you have an incomplete laryngospasm, you will still hear air movement. It is because the air is going to still be moving through the vocal cords. You are going to hear the cooing or a humming sound coming from their vocal cords. That is an incomplete spasm. That is ideal. An incomplete spasm is relatively easily broken with some positive pressure. Usually, around 20 to 30 centimeters of water is enough to break that spasm.
Keep in mind, if you are going over 20 centimeters of water pressure on your Ambu bag, your pop-off value, close it to 30 centimeters of water. If you are going much higher than that, keep in mind that you are going to be blowing air into the stomach, which also equally can set your patient up for aspiration once you do regain air movement.
However, in my experience, I have seen more than 20 centimeters needed to break a partial laryngospasm. Usually, 30 seems to be the sweet spot for that. You can get some air movement. You are going to see some end-tidal CO2 in a partial laryngospasm. You are going to hear air movement. I love hearing those sounds because that means that I’m still moving some air but it is critical that you take steps to break it. Other than positive pressure, some of the reasons why they would be spasming at this point are because of secretions that are on their vocal cords and they are also light. When I say light, that means on a light plane of anesthesia.
Most laryngospasms will happen with induction or emergence. Most commonly, it is almost always emergence because, in induction, you are in the process of getting them deeper. However, with that being said, in pediatric anesthesia, when you are doing inhalation induction and you break a seal during the inhalation induction and they go through this prolonged stage two, you equally can risk a spasm during that time.
In adults, you are typically giving IV medications. The risk of laryngospasm at that point is relatively low, considering you are giving propofol via IV. Usually, the propofol is enough to get you deep, to get you through stage two. You also equally can mask an adult down with some gas out as you are giving the propofol.
In a pediatric induction, you don’t have an IV. You rely heavily on your gas. For those of you who haven’t embarked on your pediatric rotation, ideally, we would want the bigger Paeds to get an IV but sometimes it doesn’t always work out or sometimes you have a child who is morbidly obese. You are putting someone with a body habitus of an adult to sleep with no IV.
What I will say from experience is stage two can be violent to mask someone through stage two. Their body usually heaves up and down off the bed. They get squirrely and squirmy. They want to throw their head back and forth. You have to anchor your elbows to the bed with the face mask on and go with them. Make sure you are keeping a good seal.
The key for a pediatric induction or any inhalation induction is to make sure you are keeping that seal. If you break the seal at any given time, they are going to lighten back up quickly and you are going to prolong the stage two equally risk spasm. Let’s face it. If you have to slam a face mask on a crying baby, they are usually snotty and goopy because they are not happy. You do have a high risk of laryngospasm with secretions.The key for a pediatric induction, or any inhalation induction, is to ensure you're keeping that seal because, if you break the seal any given time, they will lighten back up very quickly and prolong the stage two and equally risk spasm. Click To Tweet
In most cases, when you are emerging and taking the endotracheal tube out, they show signs of life. They are awake. They are opening their eyes. They look like they are ready to be extubated and you decide to take the tube. Maybe they were not quite through stage two and you pulled it out inopportune time to where they are still in that stage two or their eyes are a little still disconjugate.
When you enter stage two, you are going to see the heart rate increase pretty acutely. Maybe if their heart rate was maybe 90 during emergence, it is going to jump up to 110 to 115. That is usually a sign of entering that stage two of more excitement. Look at their pupils. If they are disconjugate, meaning one is looking at the right corner of the room and one is looking at the left corner of the room, that means don’t pull. Give them some time until their pupils become midline and they look like they are looking straight ahead versus two different directions.
We all make that mistake and it will all happen. You get the tube out. You go to put the mask on their face. 1 or 2 things happen. Either you hear no air of movement. You are looking for fog in the mask. You are like, “They are moving.” You see their chest rising. You realize, “Their chest is rising but I don’t have end-tidal CO2.” You see their suprasternal notch going like this. If you are on YouTube, you can see it but if you are reading, use your imagination.
If you put your finger at the base of your neck in dents a little bit and you suck in, you will feel that depressed. If you have a complete spasm, you will see that suprasternal notch sucked in. You will also see their chest heave at the same time. That is a complete spasm. That means no air is being moved. That means you are not getting end-tidal CO2. If you try to mask a brick wall, that is a complete laryngospasm. It is something that should be taken seriously and actions should be taken to break it.
We will get into that in a little bit but recap a little bit: A complete spasm is if the same situation were to happen and you were to take the tube out. What I always see coincides with laryngospasm and it always seems to be 9 times out of 10 is they cough. It is because there are secretions on their cords. It causes them to cough. That cough is an instant signal spasm.
You want cough to happen with extubation but if you extubate someone and the first thing they do is take a cough or something like that, you should always confirm that they can fully exhale from that cough. If they don’t, be suspicious if it is a laryngospasm. Coughing tends to coincide with laryngospasm during emergence and sometimes it is to be expected because you are taking a tube out and they are coughing. Unless you are fully awake, that cough could equally trigger that laryngospasm. Keep that in mind. It always seems to be the case when I hear that cough.
Keep your guard up on that. Let’s say you take the tube. You have a partial laryngospasm. You can hear air movement. You can hear it cooing through the cords. Keep the positive pressure on. That is all you have to do to break that. You can always give some propofol, lidocaine and things like that to help speed the process of that and deepen them up a little bit to get them through. Positive pressure with that type of partial laryngospasm and also suctioning to make sure you get secretions out from the back of the throat is all you need to do to break those types of spasms.
A total spasm means there is no air of movement. You want to make sure, with any type of laryngospasm, whether that is partial or complete, you want 100% O2. If you are inducing or emerging, you are going to have 100% O2. Hopefully, that is the standard. I want to make sure I mention that. It is important to make sure you are giving 100% O2. This is why it is important when you are emerging someone under anesthesia that you pre-oxygenate them with 100% O2 to where their end-tidal O2 is above 85%, as close as that number or higher if possible if you can get it up that high.
All too often, I will see trainees, students and RRNAs not pre-oxygenate enough at the end. They might be getting ready to pull a tube and they put them on 100%. The patient is only going to get a few breaths of 100%. They are going to want to take the tube out. That is a big mistake. You need to be thinking through that ahead of time and make sure you are taking them up. If they do spasm in a complete spasm, you are working with time. You have time before they desat, get hypoxic and things of that nature.
You will buy yourself more time if you pre-oxygenate the patient well. It is something to keep in mind. You want to keep continuous pressure on them. Typically, they say not more than 20 centimeters. However, in my experience, sometimes a little bit more than that is required to break that total spasm with a complete spasm. You want to turn your APL valve or pop-off valve to 20 centimeters of water and provide continuous pressure.
You need to have a good seal on the mask to do that. This is also why when you are emerging someone from anesthesia, you need to start thinking, “Were they easy to mask? Did I require an oral airway?” Don’t be afraid to make sure you secure that oral airway as you take the tube out, which is why it is nice to have one in before you extubate for a couple of reasons.
1) You can easily mask them, shall that arise. 2) It prevents them from biting on their endotracheal tube and causing reverse laryngospasm where they obstruct their airway because they are biting on their tube and you can’t ventilate them, which is no fun. We can talk about it in another episode but that can happen.
The downside of using an oral airway is the secretions because if you don’t do a good job at removing oral secretions prior to extubation, that oral airway can trickle it back right onto the cord. It can also equally be setting you up. You can get around that by doing a good oral suction. Some of the mistakes I see they made early on, including myself, was when you go to suction, you are gently suctioning and you are hitting the back roof of the mouth. Sometimes that can even cause the roof of the mouth to bleed.
You want to be going for the gutters and twist as you go in so the end of the tip goes along with the airway. It’s almost like you are intubating the patient. That is going to follow the path of the tube and where the airway structures are to get the secretions that are pulling the back of the airway in the throat. If you do good suctioning like that, you will make sure that you can combat this problem as much as possible prior to taking the tube.
Depending on the type of case and surgery, maybe there is a lot of trickling blood. Those are always higher-risk extubations because of that reason. Sometimes a technique you will see done is you will aggressively suction as best you can. Some surgeons were like, “Don’t suction.” They are paranoid about their suture lines and don’t want to cause a major bleed.
You can use little tiny soft suction catheters or have the surgeon aggressively suction before they come out of the oral before they are done operating. Make them do the aggressive suctioning so they can make sure they do it the way that feels good for them. You can’t be afraid to suction the patient more if need be and you can use a little tiny fine tip.
The key to putting suction to your endotracheal tube during extubation is not to do it too soon. If you do it before you come through the core, picture in your mind what you are going to do to the lungs. You are going to collapse the lungs and cause massive atelectasis right before extubation. It is not ideal. This is where it comes into play of knowing your anatomy and the depths that it takes for the endotracheal to come out of the chord to be in the oral perinix. You pay attention to the length. Pay attention when you are putting the tube in and you are starting the endotracheal tube, the distance between taking the tube out and when the cuff comes through the cords.
As you are taking the tube out, you want to gauge when you think that moment would be. You can feel it; you eventually develop a feel for what it feels like to come through the cords. That is when you stick the suction on and rip it the rest of the way out. It will get all the goop that is piled up back there. That way, you can avoid or decrease the risk of laryngospasm at that point.
If you are doing positive pressure and it is a complete spasm, they are starting to desat. You are trying to deepen them back up. You can give some propofol IV lidocaine. I have never seen IV lidocaine break a true, complete spasm but it still is listed in potential toolbox things you can use. Propofol is the best drug of choice to break a spasm. That would be the drug of choice I would go for first. Succinylcholine is the gold standard.
If you have a complete spasm and they are desatting, they are turning purple on you. You can’t break the spasm. I have seen and heard different rules of thought. I’m going to share them both. I’m saying this open-endedly about what I have seen in practice. The hypoxia itself does eventually lead to breaking a spasm because the hypoxia causes the muscles themselves that become hypoxic and they naturally will break the spasm.
It is not ideal to watch someone turn purple before your eyes and before you can ventilate them but I have seen that work. It is more torture to watch it but I would be 100% ready to go to do IM sucts or IV sucts. If you don’t have an IV, you would be ready to go with that at any given moment to break it and not let them decompensate with their heart rate and things of that nature.
Depending on the health of the patient, whether they are a pediatric patient, adult patient, cardiac patient or whatever they are, use your best judgment on how far you would take it to before you break it and how low you let them go. You want to always keep the patient’s ultimate safety and recovery in mind.
There is no set number to magically give sucts. I wish I could say, “When they get to 70%, that is when you give sucts.” It doesn’t work that way because you are giving propofol. As long as you stay consistent with the positive pressure and if it requires a two-hand mass jaw thrust, you are putting pressure on the back of their jaw. I rarely have seen succinylcholine needed to be given with that type of aggressive resuscitation from a complete spasm but I have seen it given.
The problem with succinylcholine, especially after the end of the case where you have given neostigmine and Rubinol to reverse the paralytic, is that the succinylcholine will make the patient even weaker. If you are going to a 20-milligram dose of succinylcholine for a complete spasm that will not break and you have already reversed with neostigmine and Rubinol, you better be prepared for the patient to have muscle weakness at this point. They need support and a BiPAP machine until they can fully recover in PACU.
It does complicate the recovery process a little bit but it is what you have to do. 9 times out of 10, you can usually break a full spasm with aggressive propofol treatment and positive pressure. In a partial spasm, you can break with some aggressive positive pressure with plus or minus propofol. It is never wrong to give propofol but you will always need it for a total spasm. Sometimes you can even turn your gas back on too. Try to get them deep. Here is where laryngospasm and bronchospasm are different. We are going to get into it because sometimes it can be a fusion is what you are dealing with between a bronchospasm and a laryngospasm.
Let’s go into bronchospasm. Laryngospasm is the upper airway and bronchospasm is the lower airway. Here’s a big one for you. Write this down. Every time this happens, I’m like, “I knew it.” Ask your patient if they had a recent upper respiratory infection, meaning a cold. “Have you had a cold in the last few weeks?” I don’t care if it was two weeks ago. They could still have some remnants from that cold. That is a big red flag that they are at higher risk for bronchospasm, which is also equally why if they actively have an upper respiratory infection, we don’t do anesthesia. We have canceled cases for that before.
Sometimes patients are like, “I had the sniffles. I had a little cough but I’m fine.” They are still always a little bit irritated down there. They are always a little bit higher risk. High alert, high guard. It never hurts to give those types of patients a nebulizing treatment or some albuterol. Make them take some albuterol before they go to sleep. That is never a bad idea to do that as a preventative measure. It is a lower involuntary contraction of the bronchial tree.
What you will notice is an inability to ventilate in the absence of upper airway obstruction if you only had X-ray vision. Sometimes when you see the symptoms of bronchospasm depends on what where you are at in the case. It could be pre-bronchospasm. Meaning if they are already intubated, you have a secured airway and maybe the surgeon makes an incision. You think you have them deep enough. You lose untitled CO2. The tube is not king twelve. That is probably bronchospasm.
I have seen that happen where that little bit of stimulation in the beginning if they are not quite deep enough. I’m not saying always but I’m saying there are different types of levels of anesthesia you can have. Sometimes when you have higher levels of anesthesia, you have no blood pressure. Typically, in the beginning, you might get amnesia and no memory. Maybe that is not ready for surgical stimulation. They can trigger bronchospasm from that stimulation. It is an easy way to say, “I know what this is. I have secured an airway. We were making end-tidal CO2 but now we are not. They are tachycardic and now they are reacting.” It is a clear bronchospasm. It is a clear picture of what is going on.
It doesn’t always tend to be that clear. When it can be less clear is when it happens during induction or emergence. During induction, it is similar to laryngospasm. It is them going through stage two and a little more agitated. If someone is already more prone to asthma and things of that nature, they are more likely to experience this.
Keep in mind that anesthetic gases themselves are a bronchodilator. It can happen during induction but it’s not as common as it is to happen during emergence when you are taking away the bronchodilator, which is the gas. It is way more common. One of the things that would be the biggest red flag if it happened during induction is thinking about allergies. A lot of times, patients roll back in the room with a bag of antibiotics up and ready but not started yet. What do you do? You wide open the antibiotics when they come back and you start your induction.
If they all of a sudden have a bronchospasm, you need to immediately think and rule out, “Is this anaphylaxis? Are they having a reaction to the antibiotic?” Rocuronium has also been known to be a trigger for anaphylaxis. Think about, “Are there any causative agents that could be triggering this other than the fact they are light and they are having bronchospasm?” This is an allergic reaction.
The patient is going to be sound wheezy. Depending on how severe the bronchospasm is, you are going to hear a lot of wheezes. Sometimes, if you try to bag someone who is intubated with bronchospasm, it is going to feel like a brick wall. Even though you are going to have access to their lungs or a direct pathway, it is going to feel stiff. You are not going to move anything. It is impressive how stiff your lungs can become with a release of your bronchospasm. You will not have any end-tidal or little end-tidal. You will see the shark fin on your end-tidal CO2 if you are lucky enough to get end-tidal CO2.
Where this becomes a problem during induction is because you are trying to rule out, “Are we through the cords or did we intubate the esophagus?” The key difference between the two is if you are in this and you have enough pressure on your pop-off valve, you try to give a big breath because the esophagus is more compliant and pliable. You are going to hear a little bit of a farting noise, the goose honk or whatever you want to call it. You aren’t going to hear it always but you do sometimes. You will also see the end-tidal depending on how long you mask the patient.
Keep this in mind. When you mask the patient, even if you don’t go above 20 centimeters of water, you will still blow some air into the stomach. When you tube the esophagus, you will still see a little bit of end-tidal on your tracing but it will never rise. It will get lower until it is nonexistent. That is a good indicator that you have tubed the goose. If you were like, “What if this is a bronchospasm?” Bronchospasms feel hard as a rock to ventilate. When you are pushing air into the stomach, it won’t feel hard as a rock.
One thing to ask yourself is, “What does it feel like to try to ventilate this situation? Did you see it go through the cord?” Unfortunately, I have seen bronchospasms where the assumption was we didn’t tube the right hole and the tubes were removed. It is a bronchospasm. We don’t have an airway and we have bronchospasm. We are trying to mask them through it. That is no fun and scarier. That is why I want to make sure I’m pointing this out to you when you have to rule out a differential. Did you tube the goose or are we experiencing bronchospasm?
One thing that can trigger bronchospasm after intubation is when you stick the tube in too far and you tickle the carina. It is right where the bronchos split a little bit. There is something called little carina. Google it to get your image imagery. If you tickle the carina, you can trigger a massive bronchospasm. This is more common in Paeds because Paeds’ airways are shallow, especially for people who are not used to it. You don’t have to go in that far. With adults, you are used to shoving the tube in there.
You are used to a much bigger tube. Paeds also tend to have more irritable airways in general. If you stick the tube in too far, whether you are an adult or not, you will risk tickling the carina and causing bronchospasm. The key to avoiding this is to be cognizant of how far down you are putting the tube and visually watch that tube go through the cords. Once you see that cuff or that balloon passes through the cords, stop.
That is the simplest way but with that being said, when you are under pressure and you are new at doing it, sometimes you have so much going on that you are like, “I don’t remember where it was. I think I did it all the way. I don’t remember putting a little bit more.” I get it because I have been there too. I’m speaking from experience on going in too far. If you can train yourself to pay attention to watching that cuff, you can never go wrong. If you start Paeds, there is a formula to figure out how deep to go and you need to be doing those calculations.
In adults, typically, it is 21 or 22, 21 for females and 22 for males. You follow those standards. For a taller person, you go to 23 with the lip. Unfortunately, with adults, you can get in the mindset of cookie-cutter things with length but note that doesn’t always apply. You still have to be cognizant of how far down you are sticking that tube. I challenge you to start paying attention to that if you are in clinical and you will be surprised. For some people, you might hit twenty. You are through the cords at twenty. You might be tempted to go to 22. If you go to 22, you could tickle the carina. Pay attention to that and see if it is enlightening or not.
We have explained the differences between laryngospasm and bronchospasm. Let’s go over the treatments for bronchospasm. Similar to laryngospasm, it is 100% O2 and deepens the anesthesia. I spoke to that gas bronchodilator. Giving propofol and trying to rule out, “Was this anaphylaxis?” I have seen one so severe that nothing else worked other than EPI. EPI is the gold standard for breaking any anaphylactic shock or anaphylaxis bronchospasm.
I have seen things such as ketamine tried in that scenario. We were like, “Ketamine is a bronchodilator.” EPI was the only thing. It ended up being a reaction to the vancomycin that was started at the beginning of the case. Nebulizing treatments, which is the beauty of having a tube, which is why I spoke to you when you had removed a tube and your mass ventilating, you don’t have an airway, your chances of getting good contact with albuterol or any bronchodilator are pretty slim to none.
That is why it is important to differentiate before you yank that too. Whether you saw it through the cord or you know for sure it is in the cords. You have a bad bronchospasm because you can treat it with bronchodilators like albuterol and things like that. Steroids and things like that are also treatments. Trying to rule out what caused this but deepening the anesthetic plane. If you have to last resort, give EPI to break it. Deepening the anesthetic and giving albuterol are usually the two key things to break a bronchospasm.
I hope you enjoyed this episode. I know that was an abrupt ending but I hope that gives you a better understanding of the difference between a laryngospasm and a bronchospasm. Thank you so much for reading. I appreciate you. Be sure to make sure you rate this on your favorite platform. I appreciate all the love and feedback you give. Until the next episode. Stay strong, future CRNA.
Get access to planning tools, valuable CRNA Faculty guidance & mapped out courses that have been proven to accelerate your CRNA success! Become a member of CRNA School Prep Academy here:
Book a mock interview, personal statement critique, resume review and more at https://www.TeachRN.com
Join the CSPA email list: https://www.cspaedu.com/podcast-email
Send Jenny an email or make a podcast request!