Laryngospasm

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

1. 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.

2. General recommendation. Jaw thrust with firm pressure in the laryngospasm notch behind the earlobe, the Larson maneuver, with chin lift; place an oral or nasal airway if the tongue is the obstruction. Widely taught and not verified against a primary source by this project; it carries no ledger entry. Follow your institution's protocol.

3. General recommendation. Continuous positive airway pressure by a tight-fitting mask with the reservoir bag. 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.

4. General recommendation. If it is not breaking, deepen anesthesia: propofol about 0.5 to 1 mg/kg intravenously in a patient with access. Widely taught and not verified against a primary source by this project; it carries no ledger entry. Follow your institution's protocol.

5. General recommendation. If still obstructed or desaturating, succinylcholine. Doses commonly quoted are 0.1 to 0.5 mg/kg intravenously at low dose, or 1 to 1.5 mg/kg with intubation. No trial compares these sequences. Widely taught and not verified against a primary source by this project; it carries no ledger entry. Follow your institution's protocol. 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.

6. General recommendation. In a child, give atropine for the bradycardia that accompanies hypoxia and succinylcholine. Widely taught and not verified against a primary source by this project; it carries no ledger entry. Follow your institution's protocol. 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.