laryngospasm scenario

Experimental evidences and anecdotal reports indicate that intraosseous and IV injection behave similarly, resulting in adequate intubating conditions within 45 s (1 mg/kg).57In children in whom succinylcholine is contraindicated, rocuronium administered at a dose of two to three times the ED95(0.9 to 1.2 mg/kg) may represent a reasonable substitute when rapid onset is needed.58,,60In addition, there is a possibility to quickly reverse the neuromuscular blockade induced by rocuronium using sugammadex if necessary.61. If these medications help, please consult your doctor before taking them long term. Laryngospasm is an emergency situation and must be promptly recognized. Principal effectors are respiratory muscles (diaphragm, intercostals, abdominals, and upper airway). ANESTHESIOLOGY 2001; 95:299306, Lakshmipathy N, Bokesch PM, Cowen DE, Lisman SR, Schmid CH: Environmental tobacco smoke: A risk factor for pediatric laryngospasm. It is mandatory to procure user consent prior to running these cookies on your website. 21,22. . Difficulty breathing ( dyspnea) Fatigue and exhaustion are other less-common and more subtle symptoms that may be associated with bronchospasm. In the study by von Ungern-Sternberg et al. Case Scenario: Acute Postoperative Negative Pressure Pulmonary Edema Such a conservative attitude has already been proposed for otolaryngology patients, whose surgery is expected to have an effect on the recurrence of URI episodes.11Premedication with anticholinergic agents may decrease secretions but has no demonstrated influence on the incidence of laryngospasm.7,29. Paediatr Anaesth 2004; 14:21824, Alalami AA, Ayoub CM, Baraka AS: Laryngospasm: Review of different prevention and treatment modalities. Paediatr Anaesth 2008; 18:3037. ANESTHESIOLOGY 1963; 24:585, Al-Metwalli RR, Mowafi HA, Ismail SA: Gentle chest compression relieves extubation laryngospasm in children. To provide you with the most relevant and helpful information, and understand which According to Phil Larson: This notch is behind the lobule of the pinna of each ear. You might experience multiple laryngospasms in a brief time but in most cases, each episode ends after about a minute. Stimulation of upper airway mucosa also produces cardiovascular (alterations of the arterial pressure, bradycardia, etc.) Anaesthesia 2008; 63:3649, Bruppacher HR, Alam SK, LeBlanc VR, Latter D, Naik VN, Savoldelli GL, Mazer CD, Kurrek MM, Joo HS: Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac surgery. The patient develops laryngospasm and is ventilated by hand-bag. Broaddus VC, et al. As a result, your airway becomes temporarily blocked, making it difficult to breathe or speak. can occur spontaneously, most commonly associated with extubation or ENT procedures, extubation especially children with URTI symptoms, intubation and airway manipulation (especially if insufficiently sedated), drugs e.g. Search for other works by this author on: 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. Laryngospasm (Pediatric) | SpringerLink Paediatr Anaesth 2002; 12:6258, Batra YK, Ivanova M, Ali SS, Shamsah M, Al Qattan AR, Belani KG: The efficacy of a subhypnotic dose of propofol in preventing laryngospasm following tonsillectomy and adenoidectomy in children. If the diagnosis is laryngospasm or other vocal cord dysfunction, your doctor may refer you to a speech-language pathologist to help you learn breathing exercises. Laryngospasm. Realistic training with high-fidelity mannequins and other types of simulations represent unique educational tools that can be fully integrated in a residency program based on competency.72Similarly, simulation-based education is being increasingly used for continuing medical education. The anesthesiologist assesses that the head/neck could be placed in a more ideal position . Effective management of laryngospasm in children requires appropriate diagnosis,4followed by prompt and aggressive management.8Many authors recommend applying airway manipulation first, beginning with removal of the irritant stimulus38and then administering pharmacologic agents if necessary.8. , the overall incidence of respiratory adverse events seems to be higher in children who were awake when their LMA was removed and lower in those who were awake when their endotracheal tube was removed.5In summary, evidence seems to favor deep LMA and awake ETT removal. Designing a Simulation Scenario - StatPearls - NCBI Bookshelf . Despite a jaw thrust maneuver, positive pressure ventilation with 100% O2, and administration of two bolus doses (5 mg) of IV propofol (0.6 mg/kg), the obstruction was not relieved and SpO2decreased to 52%. PubMed PMID: Orliaguet GA, Gall O, Savoldelli GL, Couloigner V. Case scenario: perianesthetic management of laryngospasm in children. Laryngospasm mechanism - OpenAnesthesia The locations of involved nerve receptors vary as a function of the upper airway reflex: pharyngeal mucosa for the swallowing reflex, supraglottic larynx for laryngeal closure reflex,19larynx and trachea for cough, and any part of the upper airway (but mainly nose and larynx) for apnea. A characteristic crowing noise may be heard in partial laryngospasm but will be absent in complete laryn-gospasm. If you think youve experienced laryngospasm, talk to your healthcare provider. Best Pract Res Clin Anaesthesiol 2005; 19:71732, McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ: A critical review of simulation-based medical education research: 20032009. Undefined cookies are those that are being analyzed and have not been classified into a category as yet. Laryngospasm may be preceded by a high-pitched inspiratory stridor some describe a characteristic crowing noise followed by complete airway obstruction. Copyright 2012, the American Society of Anesthesiologists, Inc. Perianesthetic Management of Laryngospasm in Children, A Tool to Screen Patients for Obstructive Sleep Apnea, ACE (Anesthesiology Continuing Education), https://doi.org/10.1097/ALN.0b013e318242aae9, 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting DurationA Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting, 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade, 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway, Perianesthetic Dental Injuries : Frequency, Outcomes, and Risk Factors, Understanding the Mechanics of Laryngospasm Is Crucial for Proper Treatment, Fentanyl Does Not Reduce the Incidence of Laryngospasm in Children Anesthetized with Sevoflurane. Even though laryngospasm isnt usually serious or life-threatening, the experience can be terrifying. It is bounded anteriorly by the ascending ramus of the mandible adjacent to the condyle, posteriorly by the mastoid process of the temporal bone, and cephalad by the base of the skull.. Laryngospasm can sometimes occur after an endotracheal tube is removed from the throat. It should be suspected whenever airway obstruction occurs, particularly in the absence of an obvious supraglottic cause. Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press. A new episode of laryngospasm was immediately suspected. ANESTHESIOLOGY 2005; 103:11428, Patel RI, Hannallah RS, Norden J, Casey WF, Verghese ST: Emergence airway complications in children: A comparison of tracheal extubation in awake and deeply anesthetized patients. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. Both conditions result in sudden, frightening spasms and both conditions can temporarily affect your ability to breathe and speak. In: Murray and Nadel's Textbook of Respiratory Medicine. health information, we will treat all of that information as protected health This site uses Akismet to reduce spam. However, to our knowledge, no study has evaluated the effect of such a training approach on the management of laryngospasm. The authors also thank Frank Schneider (Editing Coordinator, Division of Communication and Marketing of the Geneva University Hospitals, Geneva University Hospitals) and Justine Giliberto (Editing, Division of Communication and Marketing of the Geneva University Hospitals) for editing the video material. stroke, hypoxic encephalopathy), Attempt to break the laryngospasm by applying painful inward and anterior pressure at , If hypoxia supervenes consider administering, Laryngospasm is usually brief and may be followed by a. To confirm the diagnosis, your healthcare provider may look at your vocal cords with a laryngeal endoscope. At 11:23 PM, an inspiratory stridulous noise was noted again. It is most commonly occurring on induction or emergence phases and can have serious life threatening consequences. Simulation-based Training Scenario Laryngospasm during Induction of General Anesthesia in a 10-month-old Boy. In addition, a video of a simulated layngospasm scenario is available (See video, Supplemental Digital Content 1, http://links.lww.com/ALN/A807, which demonstrates the management of a simulated laryngospasm in a 10-month-old boy). } The next line of therapy would be to administer a low dose of succinylcholine (10Y20 mg) to relax the . Breathe in slowly through your nose. Mayo Clinic. Laryngospasm is a rare but frightening experience. Thus, the potential window for safe administration of general anesthesia is frequently very short. Journal of Voice. Acta Anaesthesiol Scand 1999; 43:10813, Visvanathan T, Kluger MT, Webb RK, Westhorpe RN: Crisis management during anaesthesia: Laryngospasm. The SimBaby simulator represents a 9-month-old pediatric patient and provides a highly realistic manikin that meets specific learning objectives focusing on initial assessment and treatment. As they correctly point out, laryngospasm is a serious complication and must be promptly managed to avoid serious physiological disturbance. Thereafter, surgery was quickly completed, while tracheal extubation and postoperative recovery were uneventful. Example Plan for a neonate! (#2) With steroid and antibiotic, most patients will gradually improve. Laryngospasms are rare and typically last for fewer than 60 seconds. This means that if nothing has occurred 46 h after the occurrence of a laryngospasm it is likely that the course will be uneventful. Med Educ 2010; 44:5063, Savoldelli GL, Naik VN, Park J, Joo HS, Chow R, Hamstra SJ: Value of debriefing during simulated crisis management: Oral, Russo SG, Eich C, Barwing J, Nickel EA, Braun U, Graf BM, Timmermann A: Self-reported changes in attitude and behavior after attending a simulation-aided airway management course. Pulmonary complications. In most cases, a laryngospasm lasts for up to one minute, but it may feel much longer. Identifying the risk factors and planning appropriate anesthetic management is a rational approach to reduce laryngospasm incidence and severity. Paediatr Anaesth 2002; 12:1405, Plaud B, Meretoja O, Hofmockel R, Raft J, Stoddart PA, van Kuijk JH, Hermens Y, Mirakhur RK: Reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric and adult surgical patients. 3, 5, 7 In both partial and complete laryngospasm, signs of varying degrees of airway obstruction, such as suprasternal retraction, supraclavicular retractions, tracheal tug, Evaluation and Management of Psychiatric Emergencies in the - JEMS Acid reflux may cause a few drops of stomach acid backwash to touch the vocal cords, setting off the spasm. Paediatr Anaesth 2008; 18:2818, Hampson-Evans D, Morgan P, Farrar M: Pediatric laryngospasm. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. Children are more prone to laryngospasm than adults, with laryngospasm being reported more commonly in children (17.4/1,000) than in the general population (8.7/1,000).2,5,,7In fact, the incidence of laryngospasm has been found to range from 1/1,000 up to 20/100 in high-risk surgery (i.e. Paediatr Anaesth 2002; 12:7629, Tait AR, Pandit UA, Voepel-Lewis T, Munro HM, Malviya S: Use of the laryngeal mask airway in children with upper respiratory tract infections: A comparison with endotracheal intubation. Can J Anaesth 2010; 57:74550, Sanikop C, Bhat S: Efficacy of intravenous lidocaine in prevention of post extubation laryngospasm in children undergoing cleft palate surgeries. Used with permission of John Wiley and Sons. In the largest study published in the literature (n = 136,929 adults and children), the incidence of laryngospasm was 1.7% in 09 yr-old children and only 0.9% in older children and adults.7The highest incidence (more than 2%) was found in preschool age groups. A simulation scenario is an artificial representation of a real-world event to achieve educational goals through experiential learning. All rights reserved. PDF Airway Management: Use of Succinylcholine or Rocuronium We do not endorse non-Cleveland Clinic products or services. PDF Postanesthesia Care Unit Simulation - WordPress.com This function involves several upper airway reflexes: the laryngeal closure reflex, which consists of vocal fold adduction; apnea; swallowing; and coughing.19To efficiently protect the airway, laryngeal closure reflex must be coordinated with swallowing. Many methods and techniques of airway manipulation have been proposed. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. Nasal foreign body, ketamine and laryngospasm, Clinical Adjunct Associate Professor at Monash University, Australia and New Zealand Clinician Educator Network, Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Anesthesiology. Discover the causes, such as anesthesia and gastroesophageal reflux disease (GERD). Like any other crisis, such management requires the application of appropriate knowledge, technical skills, and teamwork skills (or nontechnical skills). Laryngospasm (luh-RING-go-spaz-um) is a transient and reversible spasm of the vocal cords that temporarily makes it difficult to speak or breathe. Keep the airway clear and monitor for negative pressure pulomnary oedema. Last reviewed by a Cleveland Clinic medical professional on 02/11/2022. (Staff Anesthesiologist, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland), and Jos-Manuel Garcia (Technical Coordinator, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals) for their contribution in the video of the simulated scenario. Laryngospasm in anaesthesia | BJA Education | Oxford Academic Advertising on our site helps support our mission. 2012 Feb;116(2):458-71. doi: 10.1097/ALN.0b013e318242aae9. The question of whether using propofol or muscle relaxant first is a matter of timing. This topic is beyond the scope of this article but was recently described elsewhere.37Eighty percent of negative pressure pulmonary edema cases occur within min after relief of the upper airway obstruction, but delayed onset is possible with cases reported up to 46 h later. J Appl Physiol 1998; 84:202035, Menon AP, Schefft GL, Thach BT: Apnea associated with regurgitation in infants. If positive-pressure ventilation is to be performed, then moderate intermittent pressure should be applied. Even though you may feel like you cant breathe, try to remember that the episode will pass. Hobaika AB, Lorentz MN. | INTENSIVE | RAGE | Resuscitology | SMACC. SimBaby is a tetherless simulator designed to help healthcare providers effectively recognize and respond to critically ill pediatric patients. PDF Paediatric Airway Management: A few tips and tricks - Royal Children's This category only includes cookies that ensures basic functionalities and security features of the website. Von Ungern-Sternberg et al. During observation, she exhibits a sudden increase in respiratory effort and noise with ventilation. Pediatr Emerg Care 1990; 6:1089, Woolf RL, Crawford MW, Choo SM: Dose-response of rocuronium bromide in children anesthetized with propofol: A comparison with succinylcholine. First, the introduction of working hour limitations in virtually all Western countries has decreased the number of pediatric cases performed by trainees.71Second, most anesthetics given to children are administered by nonspecialists whose lack of experience and inability to maintain their skill set for children is a problem. The vocal cords are two fibrous bands inside the voice box (larynx) at the top of the windpipe (trachea). Laryngospasms that are caused by other conditions like asthma, stress or hypersensitivity arent usually dangerous or life-threatening. Laryngospasm was treated by 50 mg propofol and manual positive pressure mask ventilation with 100% inspired oxygen. Plan A:" 3.5 ETT ready, size 1 Macintosh laryngoscope blade" Small orange Bougie (pre bent), have a size 1 Miller blade available" Have a shoulder roll ready, but I wont put it in place" Have a white guedel airway available if I am having difculty with ventilation" If that doesnt work I will do the 2 person technique" This content does not have an English version. Both reflexes are sometimes considered as a single phylogenetic reflex.20The neuronal pathways underlying upper airway reflexes include an afferent pathway, a common central integration network, and an efferent pathway.19. Prevention and Treatment of Laryngospasm in the Pediatric Patient: A Literature Review. PEEP! Common triggers of reflex laryngeal response during anesthesia are secretions, blood, insertion of an oropharyngeal airway suction catheter, and laryngoscopy. An example of such a simulation-training scenario of a laryngospasm, including a description of the session and the debriefing, can be found in the appendix. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. Airway simulators and high fidelity mannequins are important teaching tools.73Simple bench models, airway mannequins, and virtual reality simulators can be used to learn and practice basic and complex technical skills. Laryngospasm: Causes, symptoms, and treatments - Medical News Today retained throat pack). Ann Otol Rhinol Laryngol 2005; 114:25863, Thach BT: Maturation and transformation of reflexes that protect the laryngeal airway from liquid aspiration from fetal to adult life. He had been fasting for the past 6 h. Preoperative evaluation was normal (systemic blood pressure 85/50 mmHg, heart rate 115 beats/min, pulse oximetry [SpO2] 99% on room air). Common presenting signs and symptoms include tachypnea, tachycardia, diaphoresis, trembling, palpitations, shortness of breath and chest pain. The . Prospective studies supported the use of LMA over ETT in children with URI.3031However, these studies were underpowered to detect differences in laryngospasm. J Clin Anesth 2007; 19:51722, Kuduvalli PM, Jervis A, Tighe SQ, Robin NM: Unanticipated difficult airway management in anaesthetised patients: A prospective study of the effect of mannequin training on management strategies and skill retention. suggests that maintenance with sevoflurane was associated with a higher incidence of laryngospasm compared with propofol (relative risk 2.37, 95% CI 1.493.76; P< 0.0001).5In our case, the second episode of laryngospasm occurred while the patient was under light anesthesia. Laryngospasm is potentially life-threatening closure of the true vocal chords resulting in partial or complete airway obstruction unresponsive to airway positioning maneuvers. Description The patient requires intubation, but isn't actively crashing. #Management #EM #Anesth #PCC #Laryngospasm #Algorithm #Complete #Partial. He coordinates the Alfred ICUs education and simulation programmes and runs the units educationwebsite,INTENSIVE. Table 1. PubMed PMID: 19669024. Laryngospasm usually isnt life-threatening, but it can be a terrifying experience. } Laryngospasm scenario. information is beneficial, we may combine your email and website usage information with Below a cardiac temperature of 28C, the heart may suddenly and spontaneously arrest. Two min after loss of eyelash reflex, a first episode of airway obstruction with inspiratory stridor and suprasternal retraction was successfully managed by jaw thrust and manual positive pressure ventilation. The anesthesia staff has called for the fiberoptic intubation set and is preparing to perform fiberoptic intubation. , otolaryngology surgery).2,5,,7Many factors may increase the risk of laryngospasm. An IV line was obtained at 11:15 PM, while the child was manually ventilated. Singapore Med J 1998; 39:32830, Warner DO: Intramuscular succinylcholine and laryngospasm. Case Scenario: Perianesthetic Management of Laryngospasm in Children Case Scenario: Perianesthetic Management of Laryngospasm in Children Case Scenario: Perianesthetic Management of Laryngospasm in Children Case Scenario: Perianesthetic Management of Laryngospasm in Children Anesthesiology. 14%, relative risk 1.2, 95% CI 1.11.3; P= 0.001). A recent retrospective study has assessed the incidence of laryngospasm in a large population and characterized the interventions used to treat these episodes.8The results have shown that treatment followed a basic algorithm including CPAP, deepening of anesthesia, muscle relaxation, and tracheal intubation. If you have any of the conditions listed above, talk to your healthcare provider about ways to reduce your risk for laryngospasms. Insufficient depth of anesthesia is one of the major causes of laryngospasm. 5 of 7 This document is not intended to provide a comprehensiv e discussion of each drug. They can determine the cause of your laryngospasms and recommend an appropriate treatment plan. By clicking Accept, you consent to the use of ALL the cookies. Minimally invasive anti-reflux procedures, Advertising and sponsorship opportunities. The purpose of this case scenario is to highlight key points essential for the prevention, diagnosis, and treatment of laryngospasm occurring during anesthesia. Postoperative management of the difficult airway | BJA Education Risk Factors Associated with Perioperative Laryngospasm, Young age is one of the most important risk factors. If IV access cannot be established in emergency, succinylcholine may be given by an alternative route.5354Intramuscular succinylcholine has been recommended at doses ranging from 1.5 to 4 mg/kg.53The main drawback of intramuscular administration is the slow onset in comparison with the IV route. A "can't ventilate, can't intubate" scenario may be prolonged when rocuronium is administered. Even though laryngospasms are scary when they happen, they usually dont cause serious problems. 1. Definition. Although described in the conscious state and associated with silent reflux, laryngospasm is a problematic reflex which occurs often under general anaesthesia. Anaesthesia 1993; 48:22930, Seah TG, Chin NM: Severe laryngospasm without intravenous accessa case report and literature review of the non-intravenous routes of administration of suxamethonium. These cookies track visitors across websites and collect information to provide customized ads. Drowning is an international public health problem that has been complicated by . The child was placed over a forced air warmer (Bear Hugger, Augustine Medical, Inc., Eden Prairie, MN). Finally, third-level studies evaluate the effect of education on patient outcomes. Functional cookies help to perform certain functionalities like sharing the content of the website on social media platforms, collect feedbacks, and other third-party features. If this happens to you, talk to your healthcare provider. PDF Appendix 3: Protocols For Emergencies - American Association of Oral Attempt airway maneuvers such as jaw thrust and nasal airway. Hold your breath for five seconds, then repeat until the laryngospasm stops. Afferent nerves converge in the brainstem nucleus tractus solitarius. https://www.aaaai.org/conditions-treatments/related-conditions/vocal-cord-dysfunction. Indian J Anaesth 2010; 54:1326, Behzadi M, Hajimohamadi F, Alagha AE, Abouzari M, Rashidi A: Endotracheal tube cuff lidocaine is not superior to intravenous lidocaine in short pediatric surgeries. A 10-month-old boy (8.5 kg body weight) was taken to the operating room (at 11:00 PM), without premedication, for emergency surgery of an abscess of the second fingertip on the right hand. For example, you might be able to exhale and cough, but have difficulty breathing in. These are the reasons why inhalational induction conducted by nonspecialized anesthetists remains associated with an increased risk of laryngospasm.2,5,18In children with hyperactive airways, there are now several arguments in favor of IV induction with propofol versus inhalational induction. Anesth Analg 2007; 104:26570, Bordet F, Allaouchiche B, Lansiaux S, Combet S, Pouyau A, Taylor P, Bonnard C, Chassard D: Risk factors for airway complications during general anaesthesia in paediatric patients. A competence-based training that includes a structured curriculum and regular workplace-based assessment may help mitigate the effects of caseload reduction. Their motoneurons are located in the brainstem nucleus ambiguous and the adjacent nucleus retroambigualis. Because these symptoms can be frightening, it is good to have a clear medical plan for prevention and treatment if you have any of these symptoms. Extubation guidelines: management of laryngospasm anaesthesia: laryngospasm. Learn more about the symptoms here. They can help figure out whats causing them. Acta Anaesthesiol Scand 2009; 53:19, Larson CP Jr: Laryngospasmthe best treatment. Laryngospasm is the sustained closure of the vocal cords resulting in the partial or complete loss of the patient's airway. Rev Bras Anestesiol. People with laryngospasm are unable to speak or breathe. Laryngospasm scenario. More needed than oxygen! PEEP! Eur Respir J 2001; 17:123943, Holm-Knudsen RJ, Rasmussen LS: Paediatric airway management: Basic aspects. Accessed Nov. 5, 2021. ANESTHESIOLOGY 1981; 55:599602, Walker RW, Sutton RS: Which port in a storm? Case Scenario Perianesthetic Management of Laryngospasm In; Hazard Identification and Risk Assessment; Permit to Work Ensuring a Safe Work Environment Introduction Industrial Workers Face Many Hazards in Their Daily Routines; Health Surveillance Employer's Pack; Incidence and Associated Factors of Laryngospasm Among Pediatric It should be noted that hypoxia ultimately relaxes the vocal cords and permits positive pressure ventilation to proceed easily.

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