Managing laryngospasm during anesthesia requires a rehearsed and prompt action plan, especially when oxygen saturation drops below 80%. After ruling out other causes of airway obstruction, immediate treatment should focus on removing triggers, ensuring airway patency, and applying CPAP with 100% oxygen.
A vigorous jaw thrust, also known as Larson’s maneuver, lifts the epiglottis off the glottic opening, rocks the larynx forward, and creates a gap between the vocal cords. This maneuver, which involves applying bilateral firm digital pressure on the styloid process behind the posterior ramus of the mandible, also stimulates the patient due to its painful nature, potentially aiding in the resolution of laryngospasm. The use of airway adjuncts like an oropharyngeal or nasopharyngeal airway may assist in maintaining an open airway.
Avoid making vigorous attempts to mask ventilate, as this can lead to stomach insufflation. When excessive force is applied during mask ventilation, it can cause air to enter the stomach rather than the lungs. This not only reduces the effectiveness of ventilation but also increases the risk of complications such as gastric distension, aspiration, and diaphragmatic splinting, which can further complicate the patient's airway management and overall condition. Therefore, gentle and controlled ventilation is essential to avoid these potential issues.
If laryngospasm persists, deepening anesthesia with IV propofol (0.5 - 1.0 mg/kg) is recommended. Succinylcholine remains the drug of choice if propofol is ineffective, administered via IV (0.1 - 1.0 mg/kg). Intramuscular injection (4.0 mg/kg - MAX 200mg) is also a good alternative where IV access is otherwise unavailable. While full paralysis from IM succinylcholine takes 3–4 minutes, laryngospasm can be relieved within 45 seconds to 1 minute. Research indicates that the laryngeal muscles relax before skeletal muscles, making IM succinylcholine an effective option for quickly managing laryngospasm.
Following successful treatment, ventilation should be supported with 100% oxygen, with further airway management as needed.
| Step | Intervention | Key detail |
|---|---|---|
| First response | Remove triggers, ensure airway patency, apply CPAP with 100% oxygen | Rule out other causes of airway obstruction first |
| Jaw thrust (Larson's maneuver) | Vigorous bilateral firm digital pressure on the styloid process behind the posterior ramus of the mandible | Lifts the epiglottis off the glottic opening, rocks the larynx forward, and creates a gap between the vocal cords; also a painful stimulus |
| Airway adjuncts | Oropharyngeal or nasopharyngeal airway | May assist in maintaining an open airway |
| Avoid | Vigorous attempts to mask ventilate | Forces air into the stomach, risking gastric distension, aspiration, and diaphragmatic splinting |
| If spasm persists | Deepen anesthesia with IV propofol 0.5–1.0 mg/kg | — |
| If propofol is ineffective | Succinylcholine 0.1–1.0 mg/kg IV | Drug of choice at this point |
| No IV access | Succinylcholine 4.0 mg/kg IM (max 200 mg) | Spasm relieved within 45 seconds to 1 minute; full paralysis takes 3–4 minutes, as laryngeal muscles relax before skeletal muscles |
| After resolution | Support ventilation with 100% oxygen | Further airway management as needed |
