Skip to main content
SpringerLink
Log in

Dynamic vocal cord behavior and stridor during emergence from general anesthesia in small children with supraglottic airway

  • Original Article
  • Published:
Journal of Anesthesia Aims and scope Submit manuscript

Abstract

Purpose

Stridor during emergence from anesthesia is not rare in children managed with supraglottic airway (SGA). However, we know little about the mechanisms of stridor and behavior of the vocal cords (VC). This study aimed to clarify patterns of VC movement and laryngeal airway maintenance function during recovery from anesthesia in children with SGA.

Methods

This is a secondary analysis of data collected from an observational study involving 27 anesthetized children. Using a multi-panel recording system, endoscopic VC image, vital sign monitor, multi-channel tracings of respiratory variables and respiratory sound and patient’s view were simultaneously captured in one monitor. Inspiratory and expiratory VC angles formed by lines connecting anterior and posterior commissures were measured at the first spontaneous breath and the breath one minute after the first breath. VC narrowing and dilation were assessed by differences of VC angles.

Results

Inspiratory VC narrowing (median (IQR): 5.3 (2.7, 9.1) degree at the first breath) and dilation (− 2.7 (− 3.8, − 1.7) degree at the first breath) were observed in 15 and 12 out of 27 children, respectively. The former group achieved greater tidal volume compared to the latter in one minute. Five children (19%) temporarily developed stridor-like sound from outside with inspiratory VC narrowing. The stridor-like sound was captured by microphones attached to the neck and anesthesia circuit, but was not evident from the chest.

Conclusion

Laryngeal narrowing occurs in half of the children with SGA during emergence from anesthesia, and temporal stridor-like sound is relatively common.

Clinical trial registration

UMIN (University Hospital Information Network) Clinical Registry: UMIN000025058 (https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000028697).

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at Chiba University Hospital.

References

  1. Bhananker SM, Ramamoorthy C, Geiduschek JM, Posner KL, Domino KB, Haberkern CM, Campos JS, Morray JP. Anesthesia-related cardiac arrest in children: update from the Pediatric perioperative cardiac arrest registry. Anesth Analg. 2007;105(2):344–50.

    Article  PubMed  Google Scholar 

  2. Tait AR, Malviya S, Voepel-Lewis T, Munro HM, Siewert M, Pandit UA. Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Anesthesiology. 2001;95:299–306.

    Article  CAS  PubMed  Google Scholar 

  3. Burgoyne LL, Anghelescu DL. Intervention steps for treating laryngospasm in pediatric patients. Paediatr Anaesth. 2008;18(4):297–302.

    Article  PubMed  Google Scholar 

  4. Luce V, Harkouk H, Brasher C, Michelet D, Hilly J, Maesani M, Diallo T, Mangalsuren N, Nivoche Y, Dahmani S. Supraglottic airway devices vs tracheal intubation in children: a quantitative meta-analysis of respiratory complications. Paediatr Anaesth. 2014;24(10):1088–98.

    Article  PubMed  Google Scholar 

  5. Flick RP, Wilder RT, Pieper SF, van Koeverden K, Ellison KM, Marienau ME, Hanson AC, Schroeder DR, Sprung J. Risk factors for laryngospasm in children during general anesthesia. Paediatr Anaesth. 2008;18(4):289–96.

    Article  PubMed  Google Scholar 

  6. Alalami AA, Ayoub CM, Baraka AS. Laryngospasm: review of different prevention and treatment modalities. Paediatr Anaesth. 2008;18(4):281–8.

    Article  PubMed  Google Scholar 

  7. Isono S. Interaction between upper airway muscles and structures during sleep. In: Marcus C, editor. Sleep and breathing in children: a developmental approach. 2nd ed. Florida: Boca Raton; 2008. p. 131–56.

    Google Scholar 

  8. Fregosi RF, Ludlow CL. Activation of upper airway muscles during breathing and swallowing. J Appl Physiol. 2014;116(3):291–301.

    Article  PubMed  Google Scholar 

  9. Eikermann M, Malhotra A, Fassbender P, Zaremba S, Jordan AS, Gautam S, White DP, Chanmberlin NL. Differential effects of isoflurane and propofol on upper airway dilator muscle activity and breathing. Anesthesiology. 2008;108:897–906.

    Article  CAS  PubMed  Google Scholar 

  10. Tanaka A, Isono S, Ishikawa T, Sato J, Nishino T. Laryngeal resistance before and after minor surgery endotracheal tube versus laryngeal mask airway™. Anesthesiology. 2003;99:252–8.

    Article  PubMed  Google Scholar 

  11. Isono S, Shiba K, Yamaguchi M, Tanaka A, Hattori T, Konno A, Nishino T. Pathogenesis of laryngeal narrowing in patients with multiple system atrophy. J Physiol. 2001;536(Pt 1):237–49.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Ishibashi K, Kitamura Y, Kato S, Sugano M, Sakaguchi Y, Sato Y, Isono S. Changes in laryngeal airway patency in response to complete reversal of rocuronium-induced paralysis with sugammadex in small children with a supraglottic airway: protective effect of fentanyl? Br J Anaesth. 2020;125(1):e158–60. https://doi.org/10.1016/j.bja.2019.09.006.

    Article  PubMed  Google Scholar 

  13. Hollingsworth HM. Wheezing and stridor. Clin Chest Med. 1987;8(2):231–40.

    Article  CAS  PubMed  Google Scholar 

  14. Isono S. Upper airway muscle function during sleep. In: Marcus C, editor. Sleep and breathing in children: a developmental approach. 2nd ed. Florida: Boca Raton; 2008. p. 261–91.

    Google Scholar 

  15. Bluher AE, Darrow DH. Stridor in the newborn. Pediatr Clin North Am. 2019;66(2):475–88.

    Article  PubMed  Google Scholar 

  16. Naguib ML, Streetman DS, Clifton S, Nasr SZ. Use of laryngeal mask airway in flexible bronchoscopy in infants and children. Pediatr Pulmonol. 2005;39(1):56–63.

    Article  PubMed  Google Scholar 

  17. Pluijms WA, van Mook WN, Wittekamp BH, Bergmans DC. Postextubation laryngeal edema and stridor resulting in respiratory failure in critically ill adult patients: updated review. Crit Care. 2015;19:295.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Nishino T. Physiological and pathophysiological implications of upper airway reflexes in humans. Jpn J Physiol. 2000;50:3–14.

    Article  CAS  PubMed  Google Scholar 

  19. Ishikawa T, Isono S, Tanaka A, Tagaito Y, Nishino T. Airway protective reflexes evoked by laryngeal instillation of distilled water under sevoflurane general anesthesia in children. Anesth Analg. 2005;101(6):1615–8.

    Article  PubMed  Google Scholar 

  20. Tagaito Y, Isono S, Nishino T. Upper airway reflexes during a combination of propofol and fentanyl anesthesia. Anesth Analg. 1998;88(6):1459–66.

    Article  CAS  Google Scholar 

  21. Mimoz O, Benard T, Gaucher A, Frasca D, Debaene B. Accuracy of respiratory rate monitoring using a non-invasive acoustic method after general anaesthesia. Br J Anaesth. 2012;108(5):872–5.

    Article  CAS  PubMed  Google Scholar 

  22. Erb TO, von Ungern-Sternberg BS, Moll J, Frei FJ. Impact of high concentrations of sevoflurane on laryngeal reflex responses. Paediatr Anaesth. 2017;27(3):282–9.

    Article  PubMed  Google Scholar 

  23. Erb TO, von Ungern-Sternberg BS, Keller K, Rosner GL, Craig D, Frei FJ. Fentanyl does not reduce the incidence of laryngospasm in children anesthetized with sevoflurane. Anesthesiology. 2010;113:41–7.

    Article  CAS  PubMed  Google Scholar 

  24. Oberer C, von Ungern-Sternberg BS, Frei FJ, Erb TO. Respiratory reflex responses of the larynx differ between sevoflurane and propofol in pediatric patients. Anesthesiology. 2005;103:1142–8.

    Article  PubMed  Google Scholar 

  25. Bergmann I, Crozier TA, Roessler M, Schotola H, Mansur A, Büttner B, Hinz JM, Bauer M. The effect of changing the sequence of cuff inflation and device fixation with the LMA-Supreme® on device position, ventilatory complications, and airway morbidity: a clinical and fiberscopic study. BMC Anesthesiol. 2014;14:2.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Kundra P, Deepak R, Ravishankar M. Laryngeal mask insertion in children: a rational approach. Paediatr Anaesth. 2003;13(8):685–90.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Sara Shimizu M.D. (Shimizu Orthopedic Plastic Surgery Clinic, Tokyo, Japan) greatly helped to improve this manuscript.

Funding

Japan Society for the Promotion of Science, 17K16722, Katsuhiko Ishibashi, 20K17830, Katsuhiko Ishibashi.

Author information

Author notes

  1. Yuji Kitamura

    Present address: Department of Anesthesiology, Matsudo City General Hospital, Matsudo, Japan

  2. Shinichiro Kato

    Present address: Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

  3. Miri Sugano

    Present address: Department of Anesthesiology, Funabashi Central Hospital, Funabashi, Japan

  4. Yuichi Sakaguchi

    Present address: Department of Anesthesiology, Saitama prefectural Children’s Medical Center, Saitama, Japan

Authors and Affiliations

  1. Department of Anesthesiology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan

    Katsuhiko Ishibashi, Yuji Kitamura, Shinichiro Kato, Miri Sugano & Yuichi Sakaguchi

  2. Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan

    Yasunori Sato

  3. Department of Anesthesiology, Graduate School of Medicine, Chiba University, Chiba, Japan

    Shiroh Isono

Authors
  1. Katsuhiko Ishibashi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yuji Kitamura
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shinichiro Kato
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Miri Sugano
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yuichi Sakaguchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Yasunori Sato
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Shiroh Isono
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Study design: KI, YK, SI. Data collection: KI, YK, SK, MS, YS (Sakaguchi). Data analysis: KI, SK. Statistical analysis and advice: YS (Sato), SI. Writing up the draft of the manuscript: KI, YK, SI, YS (Sato). Approval of the final version: KI, YJ, MS, YS, YS, SI.

Corresponding author

Correspondence to Katsuhiko Ishibashi.

Ethics declarations

Conflict of interest

This study was supported by JSPS KAKENHI Grant number 17K16722 and 20K17830 (Katsuhiko Ishibashi). Other authors have no conflict of interest. 

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ishibashi, K., Kitamura, Y., Kato, S. et al. Dynamic vocal cord behavior and stridor during emergence from general anesthesia in small children with supraglottic airway. J Anesth 37, 672–680 (2023). https://doi.org/10.1007/s00540-023-03218-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00540-023-03218-z

Keywords

Search

Navigation