What is the first line of treatment for laryngospasm?

First-Line Treatment for Laryngospasm

The first-line treatment for laryngospasm is to apply continuous positive airway pressure (CPAP) with 100% oxygen using a reservoir bag and facemask while ensuring the upper airway is patent. 1

Treatment Algorithm for Laryngospasm

1. Call for help - Laryngospasm is a potentially life-threatening emergency that may require additional assistance.

2. Apply CPAP with 100% oxygen

   • Use reservoir bag and facemask
   • Ensure upper airway is patent
   • Avoid unnecessary upper airway stimulation that could worsen laryngospasm

3. Perform Larson's maneuver

   • Place the middle finger of each hand in the 'laryngospasm notch' (between posterior border of mandible and mastoid process)
   • Simultaneously displace the mandible forward in a jaw thrust
   • Apply deep pressure at this point to help relieve laryngospasm

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

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

5. If still unresolved:

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

6. Alternative routes if no IV access:

   • Intramuscular suxamethonium: 2-4 mg/kg
   • Intralingual suxamethonium: 2-4 mg/kg
   • Intra-osseous suxamethonium: 1 mg/kg

7. Additional considerations:

   • Atropine may be required to treat bradycardia
   • In extreme cases, consider surgical airway

Pathophysiology and Clinical Presentation

Laryngospasm involves persistent apposition of the vocal cords through a protective exaggeration of the normal glottic closure reflex. Clinical presentation includes:

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

If unrelieved, laryngospasm can progress to:

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

Prevention Strategies

• Perform suction under direct vision with patient deeply anesthetized
• Avoid stimulation until patient is awake
• Consider topical lidocaine sprayed onto vocal cords at induction
• Use less irritant anesthetic agents (sevoflurane, propofol)
• Consider adjuncts such as intravenous lidocaine, magnesium, or ketamine

Common Pitfalls and Caveats

1. Delayed recognition - Failure to recognize early signs of laryngospasm can lead to rapid deterioration.

2. Inadequate oxygenation - Ensuring 100% oxygen delivery is critical during management.

3. Excessive airway manipulation - This can worsen laryngospasm; avoid unnecessary stimulation.

4. Inadequate depth of anesthesia - Extubation during light planes of anesthesia increases risk.

5. Failure to clear secretions - Blood, secretions, or surgical debris can trigger laryngospasm.

6. Delayed escalation of treatment - Don't hesitate to progress through the treatment algorithm if initial measures fail.

7. Overlooking post-obstructive pulmonary edema - This is a potential complication that may develop even after resolving the laryngospasm.

The Difficult Airway Society guidelines emphasize the importance of immediate recognition and treatment of laryngospasm, as it can rapidly progress to life-threatening complications if not properly managed 1.