Acute Management of Laryngospasm in Pediatric Patients After Congenital Teratoma Resection

1. Immediate Response (Difficult Airway Society)

Call for help and ensure continuous monitoring as soon as laryngospasm is recognized. 1
Apply CPAP with 100 % oxygen via a reservoir bag and facemask while maintaining upper‑airway patency. 1
Avoid any unnecessary upper‑airway stimulation that could aggravate the spasm. 1

Place the middle finger of each hand in the “laryngospasm notch” (posterior mandibular border to mastoid) and perform a simultaneous jaw‑thrust; deep pressure at this point can help terminate the spasm. 1

Propofol 1–2 mg kg⁻¹ IV for laryngospasm that persists or when oxygen saturation is falling. Low doses are effective for early spasm; larger doses are required for severe or total cord closure. 1
Suxamethonium 1 mg kg⁻¹ IV for refractory total cord closure unresponsive to propofol; it provides rapid cord relaxation, allowing ventilation, re‑oxygenation and possible intubation. 1
If IV access is unavailable, suxamethonium may be given IM 2–4 mg kg⁻¹, intralingual 2–4 mg kg⁻¹, or intra‑osseous 1 mg kg⁻¹. 1
Atropine should be prepared to treat bradycardia that can accompany suxamethonium administration. 1
In extremis, a surgical airway (cricothyrotomy or tracheostomy) should be considered. 1

The risk of laryngospasm peaks during light planes of anesthesia; therefore, maintain an adequate depth of anesthesia throughout airway manipulation. 1
Extubate either while the patient is deeply anesthetized or fully awake, avoiding the intermediate stage. 1
Perform suction under direct vision while the patient is deeply anesthetized to ensure the airway is clear of debris. 1
Refrain from any further airway stimulation until the patient is fully awake. 1

Sevoflurane and propofol are the least irritating agents and are associated with lower laryngospasm rates compared with other inhalational agents. 1

Topical lidocaine sprayed onto the vocal cords at induction reduces laryngospasm risk after short procedures. 1
French guidelines note that evidence for topical lidocaine in children is controversial; some studies report increased desaturation and bronchospasm. 7
Intravenous lidocaine, doxapram, magnesium, and ketamine have been employed as adjuncts to prevent laryngospasm, though the French guidelines consider the evidence for IV lidocaine insufficient in high‑risk pediatric populations. [1][7]
For children with an active upper‑respiratory infection, inhaled salbutamol (2.5 mg < 20 kg, 5 mg ≥ 20 kg) given 30 min before anesthesia is probably recommended; it reduces peri‑operative cough and bronchospasm by ~50 % and shows a trend toward fewer laryngospasms. 7

Overall laryngospasm incidence is 8.7 per 1 000 patients, with a higher rate in pediatric populations. 1
Procedures that involve airway manipulation, abundant secretions, or blood/surgical debris around the glottic area markedly increase the risk of laryngospasm. 1

Post‑obstructive pulmonary edema occurs in > 50 % of laryngospasm episodes where forceful inspiratory effort against a closed airway is present. 1
Clinical features include dyspnea, agitation, cough, pink frothy sputum, and falling oxygen saturations. 1
Prompt recognition and treatment usually lead to resolution within hours. 1

Do not wait for spontaneous resolution; the vocal cords rarely reopen before severe hypoxia or death ensues. 5
Avoid using an inadequate propofol dose; low doses suffice for early spasm, but larger doses are required for severe cases. 1
Do not delay suxamethonium when hypoxia worsens with total cord closure. 1
Extubation during light anesthesia is the highest‑risk period and should be avoided. 1
Secure IV access before any anesthetic procedure in high‑risk patients; alternative routes (IM, intralingual, intra‑osseous) are only backups. 1