Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 2  |  Page : 148-150

Comparative study between propofol and midazolam in treatment of postextubation laryngospasm


Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain-Shams University, Cairo, Egypt

Date of Submission18-Nov-2013
Date of Acceptance31-Dec-2013
Date of Web Publication31-May-2014

Correspondence Address:
Dina Salah
Faculty of Medicine, Ain Shams University, Abbassia, Cairo 11566
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.133357

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  Abstract 

Background
Laryngospasm is the most common cause of airway obstruction after tracheal extubation. Propofol is known to inhibit airway reflexes and is used in treating laryngospasm in subhypnotic doses. Diazepam also decreases airway reflexes and was used in treating hysterical stridor. In this study, we aimed to compare the effectiveness of both drugs in treating laryngospasm.
Patients and methods
This study was conducted over a period of 3 years. We enrolled 40 patients, 20 in each group, of American Society of Anesthesiologists (ASA) grades I and II, undergoing elective oropharyngeal surgeries. Patients who received drugs before extubation such as lidocaine or a supplemental dose of narcotics were excluded from the study; patients of ASA grade III/IV, those above 60 years or below 12 years, and those with a full stomach were also excluded. The anesthetic technique was the same in all patients. Anesthesia was induced using 4 mg/kg thiopental, 0.5 mg/kg atracurium, and 1 μg/kg fentanyl. A cuffed tracheal tube was inserted and the lungs were ventilated with oxygen and 1% isoflurane. At the end of the surgery, residual neuromuscular blockade was antagonized. The presence of laryngospasm after extubation was detected, and the patients were randomly allocated to either group P that received 0.5 mg/kg propofol intravenously or group M that received 0.03 mg/kg midazolam intravenously. In both groups 100% O 2 and manual ventilation was continued until the spasms were relieved and the saturation returned to normal. Response of patients to both drug therapies was recorded. The mean arterial pressure and heart rate were measured.
Results
In the propofol group, 15 of 20 patients responded well to the dose of propofol, whereas in the midazolam group, 17 of 20 patients responded to treatment. The other patients in the two groups, who were not relieved by either propofol or midazolam, were intubated after administration of succinylcholine. There was a significant decrease in the mean arterial pressure and heart rate in both groups after administration of the study drugs, and this decrease was comparable and similar in both groups.
Conclusion
In patients in whom the use of succinylcholine is contraindicated (as in those with burns or muscular dystrophy), propofol or midazolam can be an alternative option.

Keywords: Adult airway obstruction, laryngospasm, propofol


How to cite this article:
Salah D, Azzazi H. Comparative study between propofol and midazolam in treatment of postextubation laryngospasm. Ain-Shams J Anaesthesiol 2014;7:148-50

How to cite this URL:
Salah D, Azzazi H. Comparative study between propofol and midazolam in treatment of postextubation laryngospasm. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2021 Apr 11];7:148-50. Available from: http://www.asja.eg.net/text.asp?2014/7/2/148/133357


  Introduction Top


Laryngospasm and airway complications such as coughing and oxygen desaturation are serious complications after tracheal extubation [1]. Laryngospasm is considered a physiological exaggeration of the glottis closure reflex. This complication is more frequent in

  1. Children,
  2. Patients with airway infection,
  3. Those undergoing manipulation of the airway,
  4. Those using specific anesthetics,
  5. Those undergoing oral or pharyngeal surgeries, and
  6. Smokers [2].


Laryngospasm can lead to hypercarbia, hypoxia, negative pressure pulmonary edema, cardiac collapse, and death. Many techniques have been developed to prevent and manage laryngospasm, including the use of succinylcholine [3], topical lignocaine [4], aerosolized lignocaine [5], nitroglycerine [6], a small dose of propofol [7], and magnesium [8]. These techniques may produce unwanted side-effects or may not be fully effective [9].

As laryngospasm is considered a life-threatening condition, it may increase the level of anxiety and in turn cause panic in most individuals; panic in turn triggers an episode of asthma, making this a vicious cycle, which can be broken by midazolam.

The aim of this study was to compare the efficacy and safety of small doses of propofol and midazolam in the treatment of postextubation laryngospasm. This comparison has not been reported in previous studies.


  Patients and methods Top


This prospective randomized controlled study was conducted over a period of 3 years on American Society of Anesthesiologists (ASA) grade I or II patients undergoing elective oropharyngeal surgeries, after approval of the Ethical Committee of Ain-Sham University Hospital and obtaining written informed consent from the patients.

During the 3-year study period, 573 patients, ASA I and II, were anesthetized for oropharyngeal surgeries. Of them, 40 patients who developed laryngeal spasm were included in the trial.

All 40 patients included in the study were managed using 100% oxygen and positive pressure ventilation.

Patients who received drugs such as lidocaine or a supplemental dose of narcotics before extubation were excluded from the study; patients of ASA grade III/IV, those above 60 years or below 12 years, and those with a full stomach were also excluded.

All patients were admitted on the day of surgery and were asked to fast for at least 6 h before surgery. They were randomly allocated equally, using computer-generated codes that were kept in sequentially numbered opaque envelopes, to either the propofol group (P group) or the miadazolam group (M group).

The anesthetic technique was the same in all patients. Anesthesia was induced using 4 mg/kg thiopental, 0.5 mg/kg atracurium, and 1 μg/kg fentanyl. A cuffed tracheal tube was inserted, and the lungs were ventilated with oxygen and 1% isoflurane. At the end of surgery, residual neuromuscular blockade was antagonized using 0.05 mg/kg neostigmine and 0.01 mg/kg atropine.

The presence of laryngospasm after extubation was detected on the basis of SpO 2 of less than 85% for more than 10 s; stridor with paradoxical abdominal movement (respiratory efforts with no air movement) was recorded by a research doctor and managed using 100% O 2 with gentle positive pressure ventilation through a face mask, and the patients were randomly allocated to:

  1. Group P: received 0.5 mg/kg propofol intravenously.
  2. Group M: received 0.03 mg/kg midazolam intravenously.


In both groups, 100% O 2 administration and manual ventilation were continued until spasms were relieved and saturation returned to normal. Response of patients to both drug therapies was recorded.

In the case of prolongation of laryngeal spasm for more than 2 min after treatment or a drop of saturation to less than 70%, intubation is performed by administering 1 mg/kg succinylcholine and ventilating with 100% O 2 .

The mean arterial pressure (MAP) and heart rate (HR) were measured 1 min (T 1 ), 5 min (T 2 ), and 10 min (T 3 ) after injection of study drugs.

Statistical analysis

Data were analyzed using SPSS version 18.0 (SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as mean ± SD. Qualitative data were expressed as frequency and percentage.

The following tests were performed:

Independent-samples Student's t-test was used when comparing two means; the c2 -test was used to compare two qualitative parameters.

Probability (P-value)

  1. P-value less than 0.05 was considered significant.
  2. P-value greater than 0.05 was considered nonsignificant.



  Results Top


There were no significant differences between both groups with regard to demographic data or types of surgeries, as shown in [Table 1] and [Table 2]. [Table 3] shows that in group P, 15 of 20 patients responded well to the dose of propofol, whereas in group M, 17 of 20 patients responded to treatment. The other patients in the two groups, who were not relieved by either propofol or midazolam, were intubated after administration of succinylcholine.
Table 1: Demographic data

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Table 2: Type of surgery

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Table 3: Effect of midazolam or propofol therapy on laryngeal spasm

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[Table 4] and [Table 5] show that there was a significant decrease in MAP and HR in both groups after administration of the study drug, and this decrease was comparable and similar in both groups.
Table 4: Mean arterial blood pressure (in mmHg) in both groups

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Table 5: Heart rate (beats/min) in both groups

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  Discussion Top


This study shows that 50 mg propofol and 3 mg midazolam are both effective treatments for postextubation laryngospasm.

Laryngospasm is one of the complications seen in the perioperative period, especially during induction of anesthesia or during extubation. It can be serious, causing fatal cardiac or cerebral complications. Multiple factors have been attributed to its cause, for example, light anesthesia, hyperactive airway, secretions, and gastrointestinal reflux. Management involves using different medications and maneuvers.

Various intravenous anesthetic agents, in combination with narcotics, have been found to suppress these laryngeal reflexes [10],[11].

Subhypnotic doses of propofol (0.25-0.8 μg/kg) have been used previously for the treatment of postextubation laryngospasm [7],[12] and have proven effective. Propofol showed rapid action with no side-effects such as bradycardia or hypotension.

Benzodiazepines like diazepam also decrease upper airway reflexes and have been previously used orally by Muphg et al. [13]. In the management and treatment of recurrent postoperative laryngospasm, midazolam has been described to treat what is called psychogenic or hysterical stridor, which is most often seen in anxious adolescents and young adults [14].

Our study also showed that the use of both midazolam and propofol is associated with a significant and comparable decrease in HR and MAP (but still within normal ranges), which is directly attributed to the relief from anxiety and hypoxia associated with laryngospasm.


  Conclusion Top


In patients in whom the use of succinylcholine is contraindicated (such as those with burns or muscular dystrophy), propofol or midazolam can be an alternative option.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

1.Blair JM, Hill DA, Free JP. Tracheal intubating conditions after induction with sevoflurane 8% in children. A comparison of two intravenous techniques. Anaesthesia 2000; 55:774-778.  Back to cited text no. 1
    
2. Hobaika ABS, Lorentz MN. Laryngospasm. Rev Bras Anestesiol 2009; 59:491-495.  Back to cited text no. 2
    
3. Koc C, Kocamon F, Aygenec E, Ozdem C, Cekie A. The use of preoperative lidocaine to prevent stridor and laryngospasm after tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1998; 118:880-882.  Back to cited text no. 3
    
4. Staffel JG, Weissler MC, Tyler EP, Drake AF. The prevention of postoperative stridor and laryngospasm with topical lidocaine. Arch Otolaryngol Head Neck Surg 1991; 117:1123-1128.  Back to cited text no. 4
    
5. Zeiden A, Halabi D, Baraka A. Aerosolized lidocaine for relief of extubation laryngospasm. Anesth Analg 2005; 101:1563.  Back to cited text no. 5
    
6. Sibai AN, Yamout I. Nitroglycerin relieves laryngospasm. Acta Anaesthesiol Scand 1999; 43:1081-1083.  Back to cited text no. 6
    
7. Afshan G, Chohan U, Qamar UI, Kamal RS. Is there a role for a small dose of propofol in treatment of laryngeal spasm? Paediatr Anaesth 2002; 12:625-628.  Back to cited text no. 7
    
8. Gulhas N, Durmas M, Demerbilek S, et al. The use of magnesium to prevent laryngospasm after tonsillectomy and adenoidectomy: a preliminary study. Paediatr Anaesth 2003; 13:43-47.  Back to cited text no. 8
    
9. Lewis KE. Transtracheal lignocaine: effective treatment for postextubation stridor. Anaesth Intensive care 2007; 35:128-131.  Back to cited text no. 9
[PUBMED]    
10.1Brown GW, Patel N, Ellis FR. Comparison of propofol and thiopentone for laryngeal mask insertion. Anaesthesia 1991; 46:771-772.  Back to cited text no. 10
    
11.1Bailey PL, Stanely TH. In: Miller RD, editor. Intravenous opioids anesthetics. Anesthesia. 4th ed New York: Churchill Livingstone; 1994. 291-388.  Back to cited text no. 11
    
12.1Nawfal M, Baraka A. Propofol for relief of extubation laryngospasm. Anaesthesia 2002; 57:1028.  Back to cited text no. 12
    
13.1Muphg PJ, Langton JA, Barker P, et al. Effect of oral diazepam on the sensitivity of upper airway reflexes. Br J Anaesth 1993; 70:131-134.  Back to cited text no. 13
    
14.1Golden SE. The management and treatment of recurrent postoperative laryngospasm. Anesth Analg 1997; 84:1389-1396.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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  In this article
   Abstract
  Introduction
  Patients and methods
  Results
  Discussion
  Conclusion
  Acknowledgements
   References
   Article Tables

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