Abstract Introduction Acute upper airway obstruction has many etiologies, including infection, angioedema, foreign body, and reflux. Depending on the location and severity, acute upper airway obstruction can be a life-threatening emergency. Case Presentation A 14-month-old female with complex medical history including ineffective airway clearance, dysphagia and aspiration, GJ tube dependence, global developmental delay, focal epilepsy, hypotonia, and compound heterozygous ZNF407 variants presented for a choking episode with associated acute hypoxic respiratory failure responsive to brief bag valve mask ventilation (BMV) and placement on nasal cannula (NC) support. Initial concerns for the etiology of her episode were related to findings of her GJ tube being malpositioned in the esophagus and a positive viral panel for rhino/enterovirus. Her GJ tube was repositioned on admission. However, she continued to have ongoing episodes of severe acute hypoxic respiratory failure including one episode with brief associated bradycardic arrest. During the episodes, recovery would occur after several minutes of BMV, following which she would return to high flow nasal cannula support (HFNC) or standard NC. An extensive evaluation was conducted to determine etiology which included dual-channel impedance pH probe and continuous EEG monitoring during event to rule out reflux and seizures. During rigid and flexible bronchoscopy, she was noted to have episodes of laryngospasm with associated hypoxemia, as well as mildly tortuous proximal trachea. CT neck and chest with contrast demonstrated normal anatomy of the airway, tortuosity being likely related to patient positioning. Despite optimizing medical management, including secretion management and HFNC, episodes of presumed idiopathic laryngospasm with hypoxemia responsive to BMV and the Larson maneuver continued. Discussions regarding tracheostomy placement were initiated due to the severity of the episodes. Concurrently, a trial of a bilateral superior laryngeal nerve block was pursued for these episodes. Following the nerve block, her episodes gradually lessened in severity and were managed with position changes and stimulation as opposed to BMV. She was ultimately discharged home on continuous pulse oximetry, with no requirement for supplemental oxygen support, and planned close monitoring for need for repeat nerve block in the outpatient setting. Discussion Recurrent laryngospasm is a potentially life-threatening emergency. Typical management includes application of positive pressure, airway maneuvers, and anesthetic agents and/or neuromuscular blockade. There are few case reports regarding idiopathic recurrent laryngospasm and their treatment in young children. This case presents a possible novel treatment for pediatric patients while continuing to evaluate for an underlying etiology. This abstract is funded by: None
Hawkins et al. (Fri,) studied this question.