For laryngospasm, should a bag‑valve‑mask (BVM) with a positive end‑expiratory pressure (PEEP) valve be used instead of non‑invasive ventilation (NIV) or continuous positive airway pressure (CPAP)?

Management of Laryngospasm: BVM with PEEP vs NIV/CPAP

For acute laryngospasm, use bag-valve-mask (BVM) ventilation with gentle positive pressure, but avoid CPAP/NIV as positive pressure can actually trigger or worsen laryngospasm rather than relieve it.

Critical Evidence Against Positive Pressure in Laryngospasm

The fundamental problem with using CPAP or continuous positive pressure for laryngospasm is that positive pressure itself can provoke and sustain laryngeal muscle spasm. Animal studies demonstrate that CPAP (20 mmHg) following airway irritation induced laryngospasm in 25-50% of cases, with an incidence comparable to mechanical glottic irritation 1. This challenges the widely held belief that positive pressure can "break" laryngospasm 2.

Recommended Approach for Laryngospasm Management

Immediate Management Algorithm

• First-line: Remove the triggering stimulus, ensure jaw thrust with head extension, and administer 100% oxygen via facemask with gentle positive pressure ventilation 3

• Neuromuscular blockade: If laryngospasm persists despite airway maneuvers, administer small doses of succinylcholine (0.1-0.5 mg/kg) or full-dose neuromuscular blocking agents 3

  • Neuromuscular block is superior to alternative strategies and improves facemask ventilation effectiveness 3
  • However, reversal with sugammadex during laryngospasm is not reliable and carries significant risks including recurrent laryngospasm and pulmonary aspiration 3

• Reintubation: For severe, refractory laryngospasm with inadequate oxygenation, proceed to reintubation rather than relying on CPAP/NIV 4

Why BVM is Preferred Over NIV/CPAP

• BVM allows titrated pressure control: You can apply gentle, intermittent positive pressure rather than continuous pressure that may worsen laryngospasm 1, 2

• BVM with PEEP valve (5-10 cmH₂O) can improve oxygenation during routine ventilation and reduce hypoxia during intubation 5, but this is distinct from managing active laryngospasm

• NIV generates fixed CPAP that cannot be easily adjusted and may perpetuate laryngeal closure 4

Special Consideration: High-Flow Nasal Oxygen (HFNO)

One exception exists for refractory laryngospasm during emergence: HFNO (also called THRIVE) has been successfully used as it generates gentler, more tolerable CPAP than tight-fitting masks 4. However, this is specifically for emergence scenarios, not acute laryngospasm management, and requires a patent airway 3.

Common Pitfalls to Avoid

• Do not apply aggressive CPAP/NIV thinking it will "force open" the larynx—this can worsen spasm 1, 2

• Do not delay neuromuscular blockade in persistent laryngospasm while attempting various ventilation strategies 3

• Do not attempt sugammadex reversal as a rescue strategy for laryngospasm—it is unreliable and potentially dangerous 3

• Ensure adequate depth of anesthesia before applying any positive pressure, as light anesthesia increases laryngospasm risk 1