Last updated: 01/13/2023
- Laryngospasm is a physiological exaggeration of the protective glottic closure reflex, but can be life-threatening, resulting in hypoxia, bradycardia, and even cardiac arrest.
- Early recognition and prompt treatment are crucial and include applying continuous positive airway pressure (CPAP) with 100% oxygen via a tight-fitting face mask, vigorous jaw thrust, and removing the offending stimulus.
- Succinylcholine is effective for the prompt treatment of laryngospasm.
- Laryngospasm is a potentially life-threatening complication causing hypoxia and bradycardia that typically occurs in patients during induction and emergence from general anesthesia.1-3
- Other less common causes are gastroesophageal reflux, severe hypocalcemia, vitamin D deficiency, and Parkinson’s disease.
- Laryngospasm is a physiological exaggeration of the protective glottic closure reflex that is characterized by sustained closure of the true and false vocal cords and redundant supraglottic tissue (Figure 1).1-3
- Sensory input is via the internal branch of the superior laryngeal nerve and motor response is via the intrinsic laryngeal muscles and is mediated by the recurrent laryngeal nerve.3
A combination of anesthesia, patient, and surgery-related risk factors increase the risk of laryngospasm.2,3
Anesthesia-Related Risk Factors
- Stimulation at a light depth of general anesthesia (laryngoscopy, extubation, blood or secretions irritating vocal cords)
- Volatile anesthetics (desflurane > isoflurane > halothane = sevoflurane)
- Multiple attempts at supraglottic airway insertion or direct laryngoscopy in patients in the lighter planes of anesthesia
- Inexperienced anesthesia provider
Patient-Related Risk Factors
- Age – Infants and young children are at greatest risk
- Asthma – up to 10-fold increased risk with active asthma
- Recent upper respiratory infection (up to 6 weeks) – up to 10-fold increased risk
- Second-hand smoke exposure – up to 10-fold increased risk in children
- Gastroesophageal reflux, obstructive sleep apnea
- Airway anomalies: subglottic stenosis, laryngeal papilloma, cleft palate, vocal cord paralysis, laryngomalacia, tracheal stenosis
Surgery-Related Risk Factors
- Shared airway: tonsillectomy and adenoidectomy (> 20% incidence), bronchoscopy
- Thyroid surgery: from superior laryngeal nerve injury or hypocalcemia
- Esophageal endoscopy: stimulation of distal afferent esophageal nerves
- Others: appendectomy, hypospadias repair, skin grafting, cervical dilatation
After ruling out other causes of airway obstruction, if laryngospasm is suspected, a clear plan of action and good communication is critical for improving patient outcomes (Figure 3).
- A vigorous jaw thrust lifts the epiglottis off the glottic opening, rocks the larynx forward, creates a gap between the vocal cords, and stimulates the patient since its very painful.
- Also known as Larson’s maneuver, this involves bilateral firm digital pressure on the styloid process behind the posterior ramus of the mandible. NEJM Video.
- Avoid vigorous attempts to mask ventilate as it may cause stomach insufflation.
- Consider succinylcholine 3-4 mg/kg IM if no IV access is present.
- Hampson-Evans D, Morgan P, Farrar M. Pediatric laryngospasm. Pediatr Anaesth. 2008:18:303-7. Link
- Alalami AA, Ayoub CM, Baraka AS. Laryngospasm: review of different prevention and treatment modalities. Pediatr Anaesth. 2008:18:281-88. Link
- Gavel G, Walker RWM. Laryngospasm in anaesthesia. Continuing Education in Anaesthesia Critical Care & Pain. 2014;14(2): 47-51. Link
- Holzki J, Laschat M. Laryngospasm. Paediatr Anaesth. 2008;18(11):1144-6. Link
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.