Current Standards of Care for

LARYNGOSPASM
S. Alvey, L. Byrd, L. Gammenthaler,
M. Jones, L. Silva, J. Simms
Pathophysiology
Laryngospasm is defined as the involuntary
contraction of laryngeal muscles

It causes a partially obstructed airway when
the laryngeal muscle causes vocal cord
adduction (glottic shutter closure)

It can also completely obstruct the airway if
laryngeal muscles force the false vocal cords
and supraglottic soft tissue to constrict (ball-
valve closure)
Causes
Stimulation of the superior laryngeal nerve
Stimulation of the recurrent laryngeal nerve
Anything that stimulates the larynx, which includes:
o Secretions in the oral cavity
o Removal of ETT, LMA, oral gastric tube, or
esophageal temp probe while in Stage II
anesthesia
Hypocalcemia, especially after parathyroid surgeries
when laryngeal muscles are particularly sensitive to
tetanic spasms
Anaphylactic reactions
Any manipulations of the airway

Adverse Effects
Negative-pressure pulmonary edema
Hypoxia
Cardiac arrhythmias
Ischemic end organ injury
Stroke
Cardiac arrest
Death

Risk Factors
Irritative stimulus during light plane
Secretions, vomitus, blood, inhalation of pungent volatile
anesthetics, oropharyngeal of nasopharyngeal airway
placement, laryngoscopy, painful peripheral stimuli, and
peritoneal retraction during light anesthesia
Sudden administration of high doses of synthetic
narcotics
Incidence doubles in children, and triples in the very
young (birth to 3 months of age)
Incidence of 10% is reported in the very young pediatric
patient with reactive airways, such as asthma or upper
respiratory infection
As high as 25% in patients undergoing tonsillectomy and
adenoidectomy

Prevention
Identify patients at risk
Deep anesthesia before intubation
IV lidocaine prior to intubation (1.5 mg/kg)
Magnesium sulfate 15 mg/kg over 20 minutes
after tracheal intubation
Suction prior to extubation
Anticholinergics to decrease secretions
Avoid extubation in Stage II anesthesia

Prevention
Extubate while lungs are inflated by positive
pressure/ artificial cough technique
Extubate at end-inspiration when the glottis is
fully open
5% CO
2
inhalation for 5 minutes before
extubation
Topical and regional nerve block
Acupuncture with bloodletting at the Shao
Shang acupoint prior to extubation
Shao Shang Acupoint
Respiratory Signs & Symptoms
Abnormal or absent ETCO
2
waveform
Cyanosis
Desaturation
Hypercarbia
Hypoxemia
Inadequate chest rise
Inadequate facemask ventilation
Inspiratory or expiratory stridor (partial laryngospasm)
Intercostal and/or suprasternal inspiratory retractions
Negative-pressure pulmonary edema (bilateral rales,
radiographic evidence of pulmonary edema, pink frothy or
exudative pulmonary secretions
Oral secretions/ blood
Paradoxical movements of chest and abdomen

Laryngospasm
Cardiac Signs & Symptoms
Tachycardia
Bradycardia (late sign of hypoxia)
Increased BP
Management
Identify and remove stimulus
Apply jaw thrust maneuver
Positive pressure ventilation with 100% O2
Insert oral or nasal airway
Deepen anesthetic level with propofol
(20% of induction dose)
Laryngospasm notch


Management
If not relieved, IV succinylcholine 0.1-0.5 mg/kg
or IM succinylcholine 0.5-4 mg/kg
IV lidocaine 1.5 mg/kg 5 minutes before
extubation (extubation must occur before signs
of swallowing occur)
IV nitroglycerin (4 g/kg) for partial
laryngospasm in ASA I patients (relaxes airway
smooth muscle via the nitric oxide guanylate
cyclase pathway)
Assess for pulmonary aspiration/ negative
pressure pulmonary edema

Current Research
Intra-lingual succinylcholine, in the absence of IV access
(200 mg was injected into the tongue muscle and mask
ventilation was successfully established in 30 seconds)

Laryngospasm notch: Place the middle finger of each
hand behind each earlobe and apply firm and direct
pressure causing forward displacement of the mandible
o This stimulation not only produces a jaw thrust
but also provides a ventilatory sigh
o A common mistake is placing the fingers too low
at the angle of the jaw
o Provides a deep painful stimuli which causes the
VC to relax, stimulates the vagus nerve, and
simultaneously performs a jaw thrust maneuver
Laryngospasm Notch
Current Research
IV lidocaine is frequently used to prevent cough and
laryngospasm at the time of intubation or extubation
preponderance of evidence supports the use of lidocaine

Studies that did not document efficacy are sometimes
flawed by the lack of documentation that adequate
serum levels were reached -- the maximal efficacy of
lidocaine occurs 1 to 3 minutes after injection and
requires a dose of 1.5 mg/kg or more

Whether IV lidocaine suppresses laryngospasm remains
controversial, however a study in which tonsillectomy
patients were given 2 mg/kg of IV lidocaine and then
extubated 1 minute later found suppression of
laryngospasm
References
Alalami, A., Ayoub, C., Baraka, A., (2008). Laryngospasm: a review of
different prevention and treatment modalities. Pediatric Anesthesia, 18,
281-288.)
Aljonaieh, K.I. (July 11, 2012). Effect of Intravenous Lidocaine on the
Incidence of Post-Extubation Laryngospasm. Saudi Arabia: Ministry for
Higher Education. Retreived from
http://clinicaltrials.gov/ct2/show/results/NCT01445847?term=laryngospas
m&rank=1&sect=X0125#all
Allain, R. M., & Levine, W. C. (2010). Clinical anesthesia procedures of the
massachusetts general hospital. (8 ed., p. Chapter 18). Lippincott,
Williams & Wilkins
Chang, C.L., Chien T.J., Hsiao, J.M., Hsu, J.C., Huang, Y.R., Lee, C.K.,
Yang, C.Y., (1998). The effect of acupuncture on the incidence of
postextubation laryngospasm in children.Anaesthesia, 53 (9),917-920
Chawla, R., Ganjoo, P., Kalra, R., Setia S.,Tandon M. (2006) Management
of repeated postextubation laryngospasm: a case report. The Internet
Journal of Anesthesiology, 13 (1).
Elisha, S., Gabot, M., & Heiner, J. Critical Events in Anesthesia (pp. 131-
133). Park Ridge, IL: American Association of Nurse Anesthetists; 2012.



References
FauquierENT.net
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Goudra, B. G., Penugonda, L. C., & Sinha, A. C. (2013). Intra-lingual
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Kluger, M. T., Visvanathan, T., Webb, R. K., & Westhorpe, R. N. (2005).
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