Laryngospasm
Angela Mordecai, DNP, CRNA
Background
- Laryngospasm is an obstruction of the larynx due to inappropriate laryngeal or vocal cord tension or spasm.
- May result in partial or complete airway obstruction.
- Can be supraglottic (epiglottis and/or arytenoids) or true vocal cord spasm.
- Common triggers: laryngoesophageal reflux, airway irritation, inadequate suctioning prior to extubation, recurrent laryngeal nerve injury.
- Symptoms: dyspnea, inspiratory/expiratory stridor, dysphonia, complete or partial obstruction, inability to ventilate.
- Anesthesia-related risk factors:
- Excessive airway secretions
- Unprotected airway with loss of reflexes (e.g., LMA)
- Airway stimulation/irritation, especially during stage II
- Recurrent laryngeal nerve injury can lead to vocal cord paralysis (unilateral or bilateral).
Quick Facts
- Definitive diagnosis requires flexible laryngoscopy for direct visualization.
- Emergent cases (complete obstruction) are diagnosed clinically and require immediate intervention.
- Treatment depends on the underlying cause and severity.
Procedure Guide
Recognition
- Early recognition is critical, especially at extubation.
- Apply circuit mask and assess for ventilation.
- If no spontaneous ventilation, attempt bag-mask ventilation.
- Inability to ventilate suggests laryngospasm.
Management
- Apply positive airway pressure with face mask.
- Attempt synchronous breaths with diaphragmatic effort (often effective in partial laryngospasm).
- If unsuccessful:
- Administer propofol 30–50 mg IV to relax airway.
- OR administer succinylcholine 10–20 mg IV.
- If obstruction persists:
- Give RSI dose of paralytic and hypnotic, attempt reintubation.
- If unable to intubate and SpO₂ acceptable, consider fiberoptic intubation.
- If fiberoptic exam shows paramedial vocal cord position (e.g., RLN injury):
- Ventilation adequate → start CPAP with close monitoring.
- Ventilation inadequate → emergent surgical airway (percutaneous cricothyrotomy or tracheostomy).
Confirmation Steps
- ETCO₂ waveform present
- Visible chest rise
- Fog in mask
- Bilateral breath sounds
- Patient able to cough and/or phonate
Documentation Requirements
- Initial symptoms of laryngospasm
- Initial and subsequent attempts to re-establish ventilation
- All providers present and assisting
- Vital signs throughout the event
- Transfer of care notes with ongoing plan if needed
SCOPe Guide
Strategies
- Use positive pressure with proper mask seal (1- or 2-person technique).
- Time attempted breaths with patient effort.
- If inadequate ventilation → give propofol or paralytics.
- If unresolved → induce and intubate.
- If unable to intubate → proceed to surgical airway.
- Ensure adequate sedation during reintubation attempts.
Clinical Optimization
- Monitoring: SpO₂, ETCO₂.
- Position: sniffing position, HOB elevated.
- PACU: continuous CPAP may be indicated, especially with OSA.
Pearls
- Always assess airway patency immediately after extubation.
- Have airway equipment (blade, ETT) available at extubation.
- Ask patient to cough after extubation to clear secretions.
- Call for help early if laryngospasm suspected.
- Recognize laryngospasm can also occur in recovery (e.g., after tonsillectomy).
- SpO₂ should be the last monitor removed in OR and first placed in PACU.
References
- UpToDate: Inducible Laryngeal Obstruction / Paradoxical Vocal Fold Motion
- Gropper MA, Cohen NH, Eriksson LI, et al., eds. Miller’s Anesthesia. 9th ed. Elsevier; 2024: 1380.
