What is the treatment for laryngospasm?

Treatment of Laryngospasm

The treatment of laryngospasm requires a stepwise approach starting with continuous positive airway pressure with 100% oxygen while ensuring airway patency, followed by Larson's maneuver, and if unsuccessful, administration of propofol (1-2 mg/kg IV) and suxamethonium (1 mg/kg IV) for persistent cases. 1

Recognition of Laryngospasm

Laryngospasm presents with:

• Characteristic inspiratory "crowing" sound
• Suprasternal recession ("tracheal tug")
• Use of accessory respiratory muscles
• Paradoxical movements of thorax and abdomen
• Complete obstruction may present with silent inspiration 1

If unrecognized or untreated, laryngospasm can lead to:

• Post-obstructive pulmonary edema
• Hypoxic cardiac arrest
• Death 1

Immediate Management Algorithm

1. Call for help

2. Apply continuous positive airway pressure (CPAP) with 100% oxygen using reservoir bag and facemask

   • Ensure upper airway is patent
   • Avoid unnecessary upper airway stimulation 1

3. Perform Larson's maneuver:

   • Place middle finger of each hand in the "laryngospasm notch" (between posterior border of mandible and mastoid process)
   • Displace mandible forward in a jaw thrust
   • Apply deep pressure at this point 1

4. If laryngospasm persists and/or oxygen saturation is falling:

   • Administer propofol (1-2 mg/kg IV)
   • Note: Low doses may be effective in early laryngospasm, but larger doses are needed for severe laryngospasm or total cord closure 1

5. For worsening hypoxia with continuing severe laryngospasm:

   • Administer suxamethonium 1 mg/kg IV
   • This provides cord relaxation, permitting ventilation, re-oxygenation, and intubation if necessary 1

6. If no intravenous access:

   • Administer suxamethonium via:
     • Intramuscular route (2-4 mg/kg)
     • Intralingual route (2-4 mg/kg)
     • Intra-osseous route (1 mg/kg) 1

7. Consider atropine to treat bradycardia (particularly important in pediatric patients) 1, 2

8. In extreme cases, consider surgical airway 1

Alternative Approaches for Refractory Cases

For refractory laryngospasm, consider:

• Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) - a noninvasive ventilation technique that provides apneic oxygenation and generates CPAP 3
• Reintubation may be necessary in severe cases to maintain adequate oxygenation and ventilation 3

Prevention of Laryngospasm

Preventive measures include:

• Performing suction under direct vision with patient deeply anesthetized
• Avoiding stimulation until patient is awake
• Using topical lidocaine sprayed onto vocal cords at induction
• Considering less irritant anesthetic agents (sevoflurane and propofol)
• Using adjuncts such as IV lidocaine, magnesium, or ketamine 1

Special Considerations

• Pediatric patients: Higher incidence of laryngospasm (17.4/1000) compared to general population (8.7/1000) 2, 4
• Risk factors: Smoking, pre-existing airway infections, airway manipulation, increased secretions, blood/surgical debris around glottic area 1
• Monitoring: Watch for post-obstructive pulmonary edema, which occurs in approximately 0.1% of all general anesthetics and is most commonly caused by laryngospasm (>50% of cases) 1

Common Pitfalls

• Delayed recognition: Laryngospasm may present atypically as airway obstruction, regurgitation/vomiting, or desaturation 5
• Inadequate treatment: Failure to escalate treatment promptly can lead to severe hypoxemia, pulmonary aspiration, and post-obstructive pulmonary edema 5
• Overlooking bradycardia: Particularly important in patients under 1 year of age, where bradycardia occurs in up to 23% of laryngospasm cases 5

Remember that laryngospasm is a potentially life-threatening complication that requires immediate recognition and appropriate management to prevent serious morbidity and mortality.