Recognize
Stridor, paradoxical chest and abdominal movement, no air at the mouth, a falling saturation. It is often obvious, but not always: in the incident registry the presentation was clinically obvious in 77% of reports, airway obstruction in 14%, regurgitation or vomiting in 5%, and desaturation alone in 4% visvanathan-2005-laryngospasm.
Obstruction from the tongue looks the same from the end of the bed and is commoner in a recovering patient than spasm of the larynx visvanathan-2005-airway.
Act, in order
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Call for help. Give 100% oxygen. General recommendation. Remove the stimulus: suction blood and secretions, stop any airway manipulation, and take out an airway device the patient is fighting. Widely taught and not verified against a primary source by this project; it carries no ledger entry. Follow your institution's protocol.
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Jaw thrust with firm pressure in the laryngospasm notch, with chin lift, and an oral or nasal airway if the tongue is the obstruction. Know what that rests on. The notch is described in a 1998 letter as lying behind the lobule of the pinna, bounded in front by the ascending ramus of the mandible next to the condyle, behind by the mastoid process, and above by the base of the skull; the technique is to press very firmly inward toward the base of the skull with both fingers while lifting the mandible at a right angle to the body, and the author writes that properly performed it converts laryngospasm to stridor within one or two breaths larson-1998. That letter reports no cases and no data. Its author states that he was shown the technique almost forty years earlier and has used it countless times with complete success, that a thorough literature search revealed no mention of it, and that a sound scientific answer cannot be provided for why it works larson-1998. A later letter agrees there is insufficient published data to evaluate it systematically, and adds that the line between the maneuver and a simple jaw thrust is blurred abelson-2015.
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Continuous positive airway pressure by a tight-fitting mask with the reservoir bag, as part of that first step abelson-2015. General recommendation. Avoid vigorous positive pressure, which inflates the stomach and makes everything worse. Widely taught and not verified against a primary source by this project; it carries no ledger entry. Follow your institution's protocol.
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Propofol is where this card has been teaching something the evidence does not support, and the correction matters. The trial usually cited for it gave propofol 0.5 mg/kg intravenously 60 s before extubation to children who had not developed laryngospasm, and found it in 20% of 60 controls against 6.6% of 60 given propofol batra-2005. That is prevention at extubation, not rescue of a spasm in progress, and the paper says so in its title and its conclusion batra-2005. Deepening anesthesia with propofol to break an established spasm is widely taught, and this is the paper cited for it batra-2005. A rescue-facing study exists and has not been retrieved, so this card claims nothing about propofol as rescue.
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If still obstructed or desaturating, succinylcholine. A dose as small as 0.1 mg/kg intravenously relieved three episodes of vocal cord spasm seen during direct laryngoscopy, which is the whole of the primary evidence for the low-dose approach: three episodes, described by their authors as reliable on that basis chung-rowbottom-1993. Larger doses are also quoted. The 1998 letter records what textbooks recommended at the time, 0.25 to 1 mg/kg intravenously or 4 mg/kg intramuscularly, which is one author characterizing textbooks rather than evidence larson-1998. No trial compares these sequences. The label gives an average intravenous dose of 0.6 mg/kg to produce blockade and facilitate intubation, and for the intramuscular route up to 3 to 4 mg/kg not exceeding 150 mg in total, with onset usually in about 2 to 3 min fda-succinylcholine-label-2022.
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In a child, watch for the bradycardia that accompanies hypoxia and succinylcholine. Six retrieval rounds have found no source supporting atropine as the treatment for it, so this card names the problem and not the drug. Bradycardia occurred in 6% of registry cases overall and in 23% of patients under one year visvanathan-2005-laryngospasm.
After it breaks
Do not treat resolution as the end. The registry names post-obstructive pulmonary edema, aspiration and severe hypoxemia as the morbidity of poorly managed laryngospasm visvanathan-2005-laryngospasm.
Watch for negative-pressure pulmonary edema: pink frothy sputum, hypoxemia, bilateral infiltrates. In a recovery-room series the precipitant was glossoptosis after extubation in four of five cases and laryngeal mask displacement in one, and none had a poor outcome bmc-nppe-2025. General recommendation. Treat it with oxygen and continuous positive airway pressure, and reintubate if the patient cannot maintain oxygenation; it usually settles within 12 to 24 hours. Widely taught and not verified against a primary source by this project; it carries no ledger entry. Follow your institution's protocol.
The registry authors judged that a structured approach would have brought earlier recognition or better management in 16% of their cases visvanathan-2005-laryngospasm.
Where the ladder comes from
It is not a society recommendation. The Difficult Airway Society extubation guideline is the nearest society document and it states no sequence: it treats laryngospasm only as a risk, warns that if it is not relieved promptly it may result in post-obstructive pulmonary edema and hypoxic cardiac arrest, and its single pharmacological statement is that robust evidence for doxapram in this indication is lacking das-extubation-2012. It contains no jaw thrust, no laryngospasm notch and no succinylcholine for post-extubation laryngospasm. The paediatric anaesthesia association has no laryngospasm guideline at all. The steps marked as general recommendations above are a textbook construction whose individual rungs have primary support that has not yet been retrieved. Use your institution’s protocol where it differs.
Sources
[[visvanathan-2005-laryngospasm]] case series 2005 n: 189 laryngospasm incidents open era-limited
Visvanathan T, Kluger MT, Webb RK, Westhorpe RN. Crisis management during anaesthesia: laryngospasm. Qual Saf Health Care. 2005 Jun;14(3):e3.
189 reports of laryngospasm within the first 4000 incidents reported to the Australian Incident Monitoring Study; authors state that had a structured approach been used, earlier recognition or better management may have occurred in 16% of these cases; explicitly names post-obstructive pulmonary oedema, aspiration and severe hypoxaemia as the downstream morbidity of poorly managed laryngospasm
[[visvanathan-2005-airway]] case series 2005 n: UNVERIFIED open era-limited
Visvanathan T, Kluger MT, Webb RK, Westhorpe RN. Crisis management during anaesthesia: obstruction of the natural airway. Qual Saf Health Care. 2005 Jun;14(3):e2.
Companion AIMS analysis for obstruction of the natural airway; carries the observation that natural-airway obstruction may present simply as desaturation, which is the same-mechanism-different-timepoint framing the day rests on
[[fda-succinylcholine-label-2022]] advisory 2022 n: NA open
QUELICIN (succinylcholine chloride) Injection, USP [prescribing information]. Hospira, Inc. Revised 11/2022. DailyMed set ID fb08161e-7711-406d-e7b3-ea4515c07983.
FDA label. IV: 'The average dose required to produce neuromuscular blockade and to facilitate tracheal intubation is 0.6 mg/kg.' IM: 'up to 3 mg/kg to 4 mg/kg to infants, older pediatric patients, or adults. The total dose administered by the intramuscular route should not exceed 150 mg.' IM onset 'usually observed in about 2 to 3 minutes.' Boxed warning: hyperkalemic rhabdomyolysis/cardiac arrest in children with undiagnosed myopathy (Duchenne). Label carries no laryngospasm-specific dose.
[[bmc-nppe-2025]] case series 2025 n: 5 open
Negative pressure pulmonary edema resulting from upper airway obstruction during the post-anesthesia recovery period: a case series and literature review. BMC Anesthesiol. 2025. (author list UNVERIFIED)
Five NPPE cases during recovery from general anaesthesia at one institution: four attributed to glossoptosis after extubation, one to laryngeal mask displacement; all had typical clinical and imaging features; none had a poor outcome. Carries the point that the precipitant in the recovery period is not always laryngospasm.
[[das-extubation-2012]] guideline 2012 n: NA open
Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia. 2012 Mar;67(3):318-340.
NEGATIVE FINDING ROW. This is the society guideline nearest to the Day 2 laryngospasm ladder and IT DOES NOT CONTAIN ONE. It addresses laryngospasm only as a risk. VERBATIM: 'Laryngospasm is a protective exaggeration of the normal glottic closure reflex, and is produced by stimulation of the superior laryngeal nerve.' 'Typically, laryngospasm causes signs of upper airway obstruction (including stridor) that can precede complete airway obstruction and requires an immediate response.' 'If not relieved promptly, laryngospasm may result in post-obstructive pulmonary oedema (also known as negative pressure pulmonary oedema) and hypoxic cardiac arrest.' The only pharmacological statement is about doxapram: 'Doxapram has been used to prevent and/or treat laryngospasm, although it is associated with cardiovascular stimulation and robust evidence to support its use for this indication is lacking.' No jaw thrust, no laryngospasm notch, no succinylcholine for post-extubation laryngospasm. Currency checked on das.uk.com, which still lists this as the current DAS extubation guideline.
[[chung-rowbottom-1993]] case series 1993 n: 3 episodes of vocal cord spasm; the number of individual patients was not read open
Chung DC, Rowbottom SJ. A very small dose of suxamethonium relieves laryngospasm. Anaesthesia. 1993 Mar;48(3):229-230.
Primary support for the low-dose succinylcholine rung of the laryngospasm ladder, and it is thin. Summary VERBATIM: 'Intravenous suxamethonium, in a dose as small as 0.1 mg.kg-1, has been found to be reliable in the treatment of laryngeal spasm. Three episodes of vocal cord spasm observed during direct laryngoscopy were relieved by this dose of suxamethonium.' PubMed publication type Case Reports. QUALIFIER: this is three episodes. The Wiley HTML page carries only the Summary and the body did not render, so the number of individual patients was NOT READ. The word reliable is the authors claim about three episodes, not a measured reliability. DOI CORRECTION: the DOI ends tb06908; tb06907 is a different article entirely (Grace and Orr, continuous spinal anaesthesia, same issue, pages 226-228).
[[batra-2005]] randomized trial 2005 n: 120 children ASA I-II aged 3 to 14 paywalled
Batra YK, Ivanova M, Ali SS, Shamsah M, Al Qattan AR, Belani KG. The efficacy of a subhypnotic dose of propofol in preventing laryngospasm following tonsillectomy and adenoidectomy in children. Paediatr Anaesth. 2005 Dec;15(12):1094-1097.
THIS IS PREVENTION, NOT RESCUE, AND THE CARD MUST NOT CITE IT AS RESCUE. Round 3 flagged this and round 6 confirmed it. Timing VERBATIM: 'Before extubation, the patients were randomized and received in a blinded fashion either propofol 0.5 mg.kg(-1) or saline (control) intravenously. Tracheal extubation was performed 60 s after administration of study drug.' Result VERBATIM: 'Laryngospasm was seen in 20% (n = 12) of the 60 children in the control group and in only 6.6% (n = 4) of 60 children in the propofol group (P < 0.05).' Conclusion VERBATIM: propofol in a subhypnotic dose decreases the likelihood of laryngospasm upon tracheal extubation in children. PubMed publication type Randomized Controlled Trial; MeSH Laryngismus / prevention and control. The drug was given to children who had NOT developed laryngospasm. A rescue-facing paper exists and was not retrieved: Afshan G et al, Is there a role of a small dose of propofol in the treatment of laryngeal spasm, Paediatr Anaesth 2002;12(7):625-628.
[[abelson-2015]] case series 2015 n: 1 infant paywalled
Abelson D. Laryngospasm notch pressure (Larson maneuver) may have a role in laryngospasm management in children: highlighting a so far unproven technique. Paediatr Anaesth. 2015 Nov;25(11):1175-1176.
The rebuttal that keeps the Larson maneuver honest, and the only source found that places jaw thrust and CPAP in sequence. VERBATIM: 'Although LNP is an accepted technique advocated by eminent anesthesiologists, there is insufficient published data to systematically evaluate its efficacy. Furthermore, the line is blurred between LNP (which incorporates a special jaw thrust) and simple jaw thrust (which may inadvertently overlap LNP).' SEQUENCING, VERBATIM: 'First, one has optimized the upper airway with routine maneuvers (e.g., CPAP, chin lift, jaw thrust) to exclude supraglottic obstruction. Second, there is sufficient cardiopulmonary reserve to allow time to rescue the patient with paralysis if LNP was to fail. One should not wait for desaturation before changing course.' Single case: 8-month-old, 6.7 kg, born at 28 weeks, in whom the maneuver broke laryngospasm under continuous fiberoptic view of the larynx, which removes the usual diagnostic subjectivity. Calls for a controlled study with fiberoptic evaluation. PROVENANCE WARNING: its claim that paralysis treats or rules out laryngospasm in 100% of cases is cited to Weiss and Engelhardt 2012, which PubMed classifies as an Editorial with no abstract; that figure traces to an editorial, not a study.
[[larson-1998]] expert_opinion 1998 n: none; the author reports no cases paywalled
Larson CP Jr. Laryngospasm - the best treatment. Anesthesiology. 1998 Nov;89(5):1293-1294.
THE ORIGIN OF THE LARSON MANEUVER, AND IT CONTAINS NO DATA. Read in full 2026-09-08 under institutional entitlement. Notch location VERBATIM: This notch is behind the lobule of the pinna of each ear. It is bounded anteriorly by the ascending ramus of the mandible adjacent to the condyle, posteriorly by the mastoid process of the temporal bone, and cephalad by the base of the skull. Technique VERBATIM: The therapist presses very firmly inward toward the base of the skull with both fingers, while at the same time lifting the mandible at a right angle to the plane of the body (i.e., forward displacement of the mandible or jaw thrust). Properly performed, it will convert laryngospasm within one or two breaths to laryngeal stridor and in another few breaths to unobstructed respirations. THE EVIDENCE BASE, IN THE AUTHOR OWN WORDS, VERBATIM: Almost 40 years ago, Dr. N. P. Guadagni showed me a technique for prompt termination of laryngospasm, which I have used countless times with complete success. And: a thorough literature search has not revealed any mention of it. And on mechanism: The obvious question is, Why does it work? Unfortunately, a sound, scientific answer cannot be provided. NO CASES AND NO DATA ARE REPORTED; this is personal practice. It also summarises what textbooks said in 1998, VERBATIM: standard textbooks of anesthesiology suggest virtually the same sequence: namely jaw thrust at the angle of the mandible while applying positive-pressure ventillation with oxygen, 100%, by bag and mask and, if that fails, administering succinylcholine, the recommended dose varying from 0.25 to 1 mg/kg intravenously or 4 mg/kg intramuscularly. (The misspelling is the source own.) That is the author characterising textbooks, not primary evidence. CITATION TRAP: the publisher byline renders the author as Philip C. Larson; the signature block reads C. Philip Larson, Jr. Cite as Larson CP Jr.
[[weiss-engelhardt-2012]] expert_opinion 2012 n: none paywalled
Weiss M, Engelhardt T. Cannot ventilate - paralyze! Paediatr Anaesth. 2012 Dec;22(12):1147-1149.
PROVENANCE ROW ONLY. This is the source cited for the claim that paralysis treats laryngospasm, or otherwise rules it out, in 100% of cases. PubMed classifies it as an EDITORIAL with no abstract. The claim therefore traces to an editorial, not to a study, and any page repeating that figure should say so. Nothing else is quoted from it because nothing else was read.