Laryngospasm

What it is (definition) and why it matters

• Laryngospasm = reflex closure of the vocal cords (and surrounding laryngeal muscles) causing partial or complete upper airway obstruction.
• Most common around induction or emergence from anaesthesia, especially when the airway is “light” (insufficient depth) and stimulated.
• It can rapidly cause hypoxia, bradycardia, negative-pressure pulmonary oedema (NPPE), aspiration, and cardiac arrest if not treated promptly.

When to suspect it (typical presentation)

• Sudden difficulty ventilating: tight bag, poor/absent chest rise.
• Noisy breathing: inspiratory stridor with partial closure; complete closure may be silent with no air movement.
• Falling SpO2; may see paradoxical chest/abdominal movement and tracheal tug.
• Capnography: reduced/absent ETCO2 trace despite attempted ventilation.
• Often triggered by suctioning, airway manipulation, secretions, blood, vomit, or surgical stimulation (e.g., ENT).

Common triggers and risk factors (new-starter level)

• Airway stimulation when anaesthesia is too light: LMA insertion/removal, laryngoscopy, suctioning, oral airway insertion.
• Secretions, blood, regurgitation/vomit, or irrigation fluid near the cords.
• Upper respiratory tract infection (especially recent), asthma/atopy, smoking exposure, paediatrics.
• Painful stimulation during light anaesthesia (e.g., skin incision without adequate depth/analgesia).
• ENT and airway surgery; shared airway; full stomach/aspiration risk increases consequences.

Immediate actions (first 30–60 seconds)

• Call for help early; ask for 100% oxygen and emergency drugs (propofol, suxamethonium, atropine if child).
• Stop the trigger: stop stimulation/surgery; remove suction catheter; clear blood/secretions if safe.
• Airway manoeuvres: jaw thrust, head tilt/chin lift; ensure a good mask seal; consider oropharyngeal airway if tolerated.
• Apply continuous positive airway pressure (CPAP) with 100% O2 (e.g., 10–20 cmH2O) while maintaining jaw thrust.
• Deepen anaesthesia promptly (e.g., IV propofol in small boluses) if IV access and haemodynamics allow.

If it persists: stepwise escalation (safe, practical approach)

• If partial and improving: continue CPAP + jaw thrust, deepen anaesthesia, suction/clear airway, reassess continuously.
• If complete or not resolving quickly: give a fast-acting neuromuscular blocker to break the spasm (commonly suxamethonium).
• After paralysis: ventilate with 100% O2; consider intubation if aspiration risk, ongoing obstruction, or surgery requires it.
• Treat bradycardia (often hypoxia-driven): oxygenation first; consider atropine (especially in children) as per local practice.
• If cannot ventilate/cannot oxygenate: follow the difficult airway algorithm and prepare for emergency front-of-neck access.

Drug options (typical choices; follow local guidelines)

• Propofol: deepens anaesthesia and can relieve laryngospasm (use small boluses; watch hypotension).
• Suxamethonium: rapid, reliable relief for persistent/complete laryngospasm; be ready to ventilate and manage apnoea.
• Rocuronium: alternative if suxamethonium contraindicated; ensure you can ventilate and have a reversal plan if needed.
• Atropine: consider for significant bradycardia, particularly in children; treat hypoxia as the priority.

Aftercare and complications to look for

• Reassess airway and lungs: auscultate for wheeze/crackles; check capnography and oxygenation.
• Negative-pressure pulmonary oedema (NPPE): suspect if pink frothy sputum, crackles, increasing oxygen requirement after a severe episode; may need CPAP/PEEP and supportive care.
• Aspiration risk: consider if regurgitation/vomit present; manage per aspiration guidance and consider intubation and suctioning.
• Document the event clearly: trigger, signs, interventions, drugs/doses, response, complications, and plan for future anaesthetics.
• Communicate to recovery staff: what happened, current respiratory status, and what to watch for.

Prevention (simple habits that reduce risk)

• Avoid airway stimulation when light: time suctioning and airway device removal for adequate depth or fully awake (choose one strategy and do it well).
• Clear secretions/blood before emergence; ensure good analgesia and smooth emergence.
• Use gentle airway handling; minimise repeated attempts and unnecessary suctioning.
• Have a plan and drugs drawn up/available for high-risk cases (ENT, children, recent URTI).
• Maintain vigilance with capnography and clinical signs during emergence and transfers.