Treatment of Laryngospasm
Immediate treatment of laryngospasm follows a stepwise escalation algorithm starting with continuous positive airway pressure (CPAP) with 100% oxygen, progressing through Larson's manoeuvre, propofol administration, and ultimately succinylcholine if hypoxia worsens, with surgical airway as a last resort. 1
Initial Management Steps
Call for help immediately upon recognizing laryngospasm, as this is a potentially life-threatening emergency that can progress to hypoxic cardiac arrest and death if not promptly managed. 1
Apply continuous positive airway pressure with 100% oxygen using a reservoir bag and facemask while ensuring the upper airway is patent, and avoid unnecessary upper airway stimulation that could worsen the spasm. 1 This initial intervention resolves approximately 38% of laryngospasm cases without further treatment. 2
Larson's Manoeuvre
Perform Larson's manoeuvre if CPAP alone is ineffective: place the middle finger of each hand in the 'laryngospasm notch' (located between the posterior border of the mandible and the mastoid process) while simultaneously displacing the mandible forward in a jaw thrust, applying deep pressure at this point. 1
Pharmacological Intervention
Propofol Administration
If laryngospasm persists and/or oxygen saturation is falling, administer propofol 1-2 mg/kg intravenously. 1 While low doses may be effective in early laryngospasm, larger doses are needed in severe laryngospasm or total cord closure unresponsive to initial propofol dosing. 1
Succinylcholine (Suxamethonium)
Worsening hypoxia in the face of continuing severe laryngospasm with total cord closure requires immediate treatment with intravenous succinylcholine 1 mg/kg. 1 The rationale for this dose is to provide complete vocal cord relaxation, permitting ventilation, re-oxygenation, and intubation if necessary. 1
In the absence of intravenous access, succinylcholine can be administered via alternative routes:
Atropine
Atropine may be required to treat bradycardia, particularly in pediatric patients where bradycardia occurs in 23% of laryngospasm cases in infants under 1 year of age. 1, 3
Surgical Airway
In extremis, consider a surgical airway if all other interventions have failed and the patient remains severely hypoxic. 1
Clinical Presentation Recognition
Laryngospasm presents in several ways that require recognition:
- Classic presentation: Characteristic inspiratory 'crowing' sound 1
- Progressive obstruction: Marked suprasternal recession ('tracheal tug'), use of accessory respiratory muscles, and paradoxical thoracoabdominal movements 1
- Complete obstruction: Silent inspiration (no air movement despite respiratory effort) 1
- Atypical presentations: May present as simple airway obstruction (14%), regurgitation/vomiting (5%), or isolated desaturation (4%) 3
Critical Complications to Monitor
Post-obstructive pulmonary oedema develops in approximately 4% of laryngospasm cases and presents with dyspnoea, agitation, cough, pink frothy sputum, and low oxygen saturations. 1, 3 This occurs when forceful inspiratory efforts against an obstructed airway create negative intrathoracic pressure, leading to non-cardiogenic pulmonary oedema. 1
Desaturation occurs in over 60% of laryngospasm cases, emphasizing the urgency of prompt intervention. 3
Pulmonary aspiration occurs in 3% of cases, particularly when laryngospasm is precipitated by regurgitation or vomiting. 3
Important Clinical Pitfalls
Do not delay escalation of treatment if initial measures fail—laryngospasm can progress rapidly to complete airway obstruction and hypoxic cardiac arrest. 1 The Difficult Airway Society guidelines provide a clear stepwise algorithm precisely to prevent hesitation in critical moments. 1
Avoid unnecessary airway stimulation during treatment, as this can worsen or prolong the laryngospasm. 1 This includes avoiding repeated suctioning or airway manipulation once CPAP is applied. 1
Recognize that laryngospasm is always complete according to recent endoscopic studies, meaning that even partial-appearing obstruction represents total vocal cord closure requiring aggressive management. 4