Prevention and Treatment of Laryngospasm in

the Pediatric Patient: A Literature Review

Shawn Collins, PhD, DNP, CRNA

Paul Schedler, MS, CRNA
Brad Veasey, MS, CRNA
Andrea Kristofy, MD
Mason McDowell, DNAP, CRNA

Laryngospasm is an exaggeration of a protective rhythmias, cardiac arrest, and ultimately death. This
reflex that prevents aspiration of foreign objects into evidence-based literature review explores the patho-
the lower airway (eg, during swallowing). This results physiology of laryngospasm and covers mechanical
in complete or partial closure of the glottis, and imped- and pharmacologic prevention and treatment modali-
ance or total obstruction of airflow to the trachea and ties in pediatric patients.
lungs. Often, the resulting hypoxia will by itself break a
laryngospasm; however, if the spasm continues with- Keywords: Laryngospasm, pediatric, prevention, pro-
out relief, it can lead to pulmonary edema, cardiac dys- tective reflex, treatment.

P
ediatric laryngospasm is a life-threatening event Complete, SocINDEX, Military & Government Collection,
that results in complete or partial blockage of PsycINFO, and PsycARTICLES. Article search criteria
the airway. This blockage can lead to hypox- were limited to articles in English, published in the last
emia, negative-pressure pulmonary edema, pul- 15 years, and with available full text. Certain articles
monary aspiration, and cardiac arrest.1 The published before 2002 were necessary to include for the
treatment of laryngospasm has traditionally been suc- literature review as they contained foundational knowl-
cinylcholine, a short-acting, depolarizing neuromuscular edge pertinent to our topic. Searches were conducted
blocking agent that relaxes muscle tension and breaks the using keywords, phrases, and specific subject headings,
laryngospasm.1 Succinylcholine, although very effective at including pediatric, laryngospasm, treatment, break, phar-
treating laryngospasm, comes with potential serious side macology, prevention, incidence, propofol, lidocaine, magne-
effects such as bradycardia and arrhythmias.2 In recent sium, succinylcholine, extubation, maintenance, induction,
years, articles have been published that suggest different risk factors, surgery, LMA [laryngeal mask airway], ETT
treatment modalities for pediatric laryngospasm, but pro- [endotracheal tube], pathophysiology, airway, and maneu-
viders have been slow to incorporate them into practice. vers. The initial search yielded 3,275 results, 32 of which
Pharmacologic interventions such as the use of lidocaine, were included in this literature review once our inclu-
midazolam, or propofol have emerged as potentially use- sion criteria—pediatric focus, anesthesia related, full text
ful treatments for breaking or preventing laryngospasm.3,4 form, peer-reviewed journals published in English—were
This literature review revisits principles in anesthesia applied. The evidence was evaluated using the method
regarding pathophysiology of laryngospasm, followed by described by Melnyk and Fineout-Overholt.5 This review
methods for its prevention and treatment. The goal is to consists of 1 meta-analysis, 9 randomized controlled
compile newer studies regarding pediatric laryngospasm trials (RCTs), 1 nonrandomized controlled study, 7 pro-
and to present data and interventions that the anesthe- spective cohort studies, 7 retrospective cohort studies, 8
tists can incorporate in their practice, with the ultimate literature reviews, and 1 animal study.
goal of improving patient outcomes.
Results
Methods • Pathophysiology of Laryngospasm. Laryngospasm is an
This systematic review of the literature began with a exaggeration of a protective reflex that prevents aspiration
search for articles pertinent to this topic. Multiple literary of foreign objects into the lower airway (eg, during swal-
search engines were used to find these articles includ- lowing). This results in complete or partial closure of the
ing: Academic Search Complete, CINAHL Complete, glottis, and impedance or total obstruction of airflow to
MEDLINE Complete, EBSCO host, Environment the trachea and lungs. Often, the resulting hypoxia will by
Complete, SPORTDiscus, Education Source, Business itself break a laryngospasm; however, if the spasm contin-
Source Complete, Communication & Mass Media ues without relief it can lead to pulmonary edema, cardiac

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dysrhythmias, cardiac arrest, and ultimately death.6 dren. Preferred Reporting Items for Systematic Reviews and
The laryngospasm reflex is controlled by the extrinsic Meta-analyses (PRISMA) was adhered to throughout the
and intrinsic muscles of the larynx, and innervated by the data collection process, and Grading of Recommendations
internal branch of the superior laryngeal nerve, a branch Assessment, Development and Evaluation (GRADE) was
of the vagus nerve.6 Abnormal excitation of this pathway used to evaluate the quality of evidence for each study.
occurs most commonly during lightened anesthesia (ie, The meta-analysis combined 9 different studies with
stage 2) and thus poses the greatest threat during induc- a total of 787 patients. Studies examining both IV and
tion and emergence.7,8 topical lidocaine routes of administration were included.
Furthermore, there are 3 mechanisms to laryngo- The results demonstrated a statistically significant reduc-
spasm—expiratory stridor, inspiratory stridor, and ball- tion in the incidence of laryngospasm for both the IV and
valve obstruction.9 Expiratory stridor involves the intrinsic topical lidocaine routes. The authors postulated that the
muscles of the larynx, and results in adduction of the vocal most efficacious time to administer IV lidocaine is within 5
cords. Inspiratory stridor, also controlled by the intrinsic minutes of tracheal extubation. Gharaei et al12 specifically
muscles, results from failure of the abductor muscles. Ball- compared IV vs topical lidocaine and found the difference
valve obstruction is controlled by the extrinsic muscles, in the prevention of pediatric laryngospasm to not be sta-
and involves closure of the false and true vocal cords, as tistically significant.
well as collapse of soft tissue above the glottis.9 • Intermediate-Acting Muscle Relaxants. There has been
• Prevention of Pediatric Laryngospasm. Agents used minimal research done evaluating the use of intermediate-
to prevent laryngospasm in pediatric patients include acting muscle relaxants in the prevention of pediatric
magnesium, lidocaine, and intermediate-acting muscle laryngospasm. A study done by Martin-Flores et al13 evalu-
relaxants, such as rocuronium. ated the use of rocuronium on prevention of laryngospasm
• Magnesium. Magnesium is an intracellular cation in cats. The researchers gave 8 cats anesthesia 4 separate
and smooth muscle inhibitor.10 A study by Gulhas et times and used IV rocuronium at doses of 0.1 mg/kg, 0.2
al10 was performed on the efficacy of magnesium in the mg/kg, 0.3 mg/kg, and 0.6 mg/kg. A videoendoscope was
prevention of pediatric laryngospasm in patients un- inserted through an LMA and recorded the laryngeal re-
dergoing adenotonsillectomy. This was a double-blind sponse to a sterile water spray. A response was recorded at
study in 40 patients between the ages of 3 and 12 years. baseline without rocuronium, and then after the rocuroni-
Twenty participants in the magnesium group were given um was given. The results showed a significant decrease in
15 mg/kg of magnesium sulfate 2 minutes after intuba- the completeness and duration of laryngeal responses with
tion. The other 20 patients were given 30 mL of normal the rocuronium doses of 0.3 mg/kg and 0.6 mg/kg.
saline. The results concluded there was no incidence Although this study was done in cats and not pe-
of laryngospasm observed in the group that received diatric patients, another study’s authors believed that
magnesium, whereas the placebo group had a 25% rate long-acting muscle relaxants could facilitate better in-
(P < .05). The authors believe the mechanism of action tubating conditions and lower laryngospasm rates fol-
of breaking laryngospasm is by deepening the anesthetic lowing a failed laryngoscopy. A 2016 study by Spaeth
and enhancing muscle relaxation. This study had a small et al14 focused on reducing serious airway events and
sample population and used intravenous (IV) lidocaine airway cardiac arrests during pediatric anesthesia. The
(1 mg/kg) on induction, which could be a confounding authors used 3 main quality indicators: nondepolarizing
factor on magnesium’s prevention efficacy.11 muscle relaxants in children younger than 2 years of age,
Savran-Karadeniz et al11 conducted a similar study in for cases lasting less than 30 minutes, having succinyl-
2016 that eliminated lidocaine from the anesthetic and choline and atropine out and available, and assessing
used higher preventive magnesium doses (30 mg/kg). ventilation after extubation by auscultation or end-tidal
The surgical procedure studied was esophageal dilation carbon dioxide. The finding of the study showed a 44%
in children between 2 and 12 years of age. The findings reduction in serious airway events and a 59% reduction
of this study showed that the incidence of laryngospasm in airway cardiac arrests. This study did not specifically
in the group that received magnesium vs the control look at the reduction of laryngospasm, but it did use
group was 10% and 33.3%, respectively (P = .057). This long-acting muscle relaxants to decrease airway events
study’s findings corroborated the earlier study by Gulhas such as laryngospasm.
et al,10 but more studies are needed. • Subhypnotic Dose of Propofol. Propofol is known to
• Lidocaine. Lidocaine has been a controversial and inhibit airway reflexes and deepen anesthesia.15 Batra et
highly studied pharmacologic agent in the prevention al15 researched propofol’s ability to be prevent pediatric
of pediatric laryngospasm.6 Because of the uncertainty laryngospasm. This RCT had 120 patients randomly
concerning the benefit of lidocaine, in 2014 Mihara et al3 assigned to receive either propofol, 0.5 mg/kg, before
conducted a systematic literature review and meta-analysis extubation or a control dose of the equivalent amount of
of the efficacy of lidocaine to prevent laryngospasm in chil- saline. The presence of laryngospasm was evaluated by

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another provider, who was not present during the admin- and administration of 100% oxygen. Gavel and Walker18
istration of the study drug. Laryngospasm was present in described that if a laryngospasm is suspected and there
20% of the control group and only 6.6% of the propofol is soft-tissue compression of the larynx, application of
group, which was statistically significant (P < .05). positive pressure may relieve the obstruction. The initia-
• Pharmacologic Treatment of Pediatric Laryngospasm. tion of positive-pressure ventilation could also relieve a
Treatment of laryngospasm in pediatric patients is with supraglottic obstruction or partial laryngospasm.6
pharmacologic or physical techniques. • Larson Maneuver. After positive-pressure ventilation
• Propofol. Salah and Azzazi4 suggested that a subhyp- has failed, the Larson maneuver is another technique that
notic dose of IV propofol at 0.5 mg/kg was effective in can be beneficial to help break a pediatric laryngospasm.
treating pediatric laryngospasm. In a group of 20 patients Abelson19 explains that this maneuver, also called laryn-
experiencing laryngospasm, Salah and Azzazi4 found that gospasm notch pressure, is the application of firm and
15 of those patients responded favorably to propofol. inward pressure at the laryngospasm notch. This notch
Propofol inhibits airway reflexes and relaxes tissues in the is located slightly cephalad to the earlobe and between
upper airway. Advantages of propofol include rapid onset the mastoid process (posterior) and mandibular condyle
(30-45 seconds), rapid clearance, and avoidance of side (anterior). Application of pressure here while simultane-
effects such as bradycardia and myalgias associated with ously performing a jaw thrust may resolve a pediatric la-
succinylcholine. However, the provider should be aware ryngospasm before the administration of pharmacologic
of side effects of propofol, including hypotension and tran- agents. Abelson19 further postulates that the anesthetist
sient apnea. Propofol is also useful in patients in whom should not wait until desaturation to administer paralytic
succinylcholine is contraindicated (eg, burn victims, mus- agents and that there are insufficient data to systemati-
cular dystrophies, cholinesterase deficiency).4 cally evaluate the Larson maneuver’s efficacy.
• Midazolam. In the same study, Salah and Azzazi4 • Gentle Chest Compression. Gentle chest compres-
found that IV midazolam at 0.03 mg/kg effectively treated sions have been described in the literature in the past,
postextubation laryngospasm. In a group of 20 patients but no clinical trials have examined the method’s ef-
experiencing laryngospasm, it was noted that 17 of the fectiveness.20 The mechanism for the relief of pediatric
subjects responded favorably to midazolam. In similar laryngospasm is unknown, but the thought is that chest
fashion to propofol, midazolam decreases upper airway compression pushes air cephalad from the lungs against
reflexes. Salah and Azzazi4 also mentioned that mid- the vocal cords to relieve the spasm.20 Al-Metwalli et al20
azolam was effective in managing recurrent postoperative conducted an RCT for 4 years in pediatric patients under-
laryngospasm in anxious children, a condition referred to going tonsillectomy procedures. A total of 632 patients
as hysterical stridor.4 were delegated to the standard-practice group, which
• Succinylcholine. Succinylcholine has long been a treated patients in whom a laryngospasm developed with
preferred pharmacologic agent for treating laryngospasm 100% oxygen and positive-pressure ventilation. A total
because of its rapid onset and short duration of action.16 of 594 patients were in the chest compression group,
Intravenous succinylcholine is the gold standard in the in which patients who experienced laryngospasm were
treatment of pediatric laryngospasm, with a dose of 1 to managed with 100% oxygen and gentle chest compres-
2 mg/kg. Succinylcholine is given along with atropine sions at a rate of 20 to 25 compressions per minute. In
(0.02 mg/kg) to prevent bradycardia.17 both groups, succinylcholine was given if the first inter-
When IV access is unavailable, succinylcholine may be ventions did not break the spasm. Results of the study
administered intramuscularly at a dose of 4 mg/kg. The showed that 73.9% of patients with laryngospasm were
disadvantage to this, however, is an onset time of 3 to 4 effectively treated by gentle chest compressions without
minutes for maximal twitch depression, although it has the need to use succinylcholine vs the standard-practice
been suggested that relaxation of airway tissue occurs group, which had only 38.4% with successful treatment
within 1 minute. Furthermore, at a dose of 4 mg/kg, suc- of laryngospasm (P < .001). Gastric distention devel-
cinylcholine may last upward of 20 minutes. Although oped in 86.5% of patients in the standard-practice group
sublingual and intraosseous routes also are acceptable, compared with none in the chest compression group (P
Walker and Sutton2 suggest that intramuscular succi- < .0001). This is the first known RCT evaluating gentle
nylcholine is probably the most reliable agent to break chest compressions for treatment of pediatric laryngo-
laryngospasm when IV access is unavailable. spasm, and more studies are needed to determine the
• Physical Techniques to Treat Pediatric Laryngospasm. optimal rate and force of compressions.
Different physical techniques can be attempted to break
laryngospasm before pharmacologic intervention. Discussion
• Positive-Pressure Ventilation. The most common Pediatric laryngospasm incidence has historically been
physical method described by clinical providers is the 1.74%, but more recent data suggest that incidence is
immediate application of positive-pressure ventilation decreasing to 0.53%.21,22 Although the incidence may be

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decreasing, there is still a need to further lower the inci-
dence to achieve the best possible outcomes for pediatric
patients undergoing anesthesia. Randomized controlled
trials can help identify the most efficacious treatment
options for laryngospasm, but algorithms help combine
the RCTs’ findings into a tool that can help the practitio-
ner make the best treatment decisions. There are a variety
of algorithms for pediatric laryngospasm, but we want to
build one that uses the most current RCTs and support-
ing evidence to provide the most up-to-date information
on risk factors, prevention, and treatment options.
Many algorithms focus on treatment of laryngospasm,
and not the prevention aspect. A focus on prevention
is important because it can help eliminate the negative
outcomes associated with pediatric laryngospasm such
as oxygen desaturation, negative-pressure pulmonary
edema, and death.3 There are many different pharmaco-
logic therapies (eg, lidocaine, midazolam, propofol) that
can be used to lower the incidence of laryngospasm. We
created an algorithm (Figure) that has both the preven-
tion and treatment options to provide the best outcomes
for our pediatric patients. The rationale for this algorithm
is explained here.
• Risk Factors. Pediatric laryngospasm that is un-
anticipated can be difficult to treat.23 Knowing and
identifying risk factors for increased incidence of laryn-
gospasm (see Figure) in the pediatric population must
be of paramount importance. In our literature review,
we identified several prominent risk factors that were
prevalent in recent studies. Age of the pediatric patient is
a major risk factor, with younger children more suscep-
tible to laryngospasm.21,24 Another risk factor identified
was obesity. Children at or above the 85th percentile of Figure. Algorithm for Laryngospasm Treatment by
BMI and with a diagnosis of sleep-disordered breathing Sequence in Pediatric Population
were found to have a significantly increased incidence of Abbreviation: IV, intravenous.
laryngospasm.25 Environmental tobacco smoke exposure
and recent upper respiratory tract infections (within past of laryngospasm in either group. We did not recommend
30 days) both were shown to increase rates of laryngo- the use of muscle relaxants during induction to prevent
spasm in the pediatric population.21,22,24,26,27 Finally, laryngospasm in our algorithm (see Figure).
the last risk factor identified was the type of procedure The risk of using an LMA vs ETT is controversial,
that the pediatric patient was undergoing. Several types with different studies showing different results on which
of procedures with increased incidence of laryngospasm method has a higher incidence of pediatric laryngo-
include appendectomy, otolaryngology (especially ad- spasm.7,22,24,30 There are no definitive studies that con-
enotonsillectomy), plastic surgery, hypospadias repair, sistently show one is superior to the other in terms of
and esophageal endoscopy.8,10,15,21 laryngospasm in the pediatric population. Because of the
• Prevention. A study by Lee et al28 saw the adverse lack of consensus among the studies, we elected to not
events and laryngospasm incidence increase with an in- use that in our prevention algorithm.
creased number of attempts of pediatric laryngoscopy. This Magnesium was shown to be effective in 2 different
can vary greatly depending on provider experience and RCTs.10,11 Magnesium is believed to help deepen the
competency level.28 We recommend that intubation at- anesthetic and enhance muscle relaxation.11 Both studies
tempts be limited to the least possible number of attempts. used magnesium doses of 15 mg/kg and 30 mg/kg.10,11 We
Several RCTs compared how ideal the intubating used the range of 15 to 30 mg/kg of magnesium before
conditions were, with or without the use of muscle relax- induction.
ants.16,29 The studies showed that intubating conditions Intermediate-acting muscle relaxants for procedures
were ideal, but more importantly there was no incidence have not been studied enough to include in a prevention

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Source Study design Sample size Results and conclusions
Oofuvong et al,22 Retrospective N = 14,153 pediatric • Laryngospasm incidence 0.53% for children ≤ 15 years
2014 cohort study patients over 6-year • URI increased the incidence of laryngospasm 1.7 times (95%
period CI = 0.78-3.7)
• LMA with assisted ventilation carried twice the risk of laryngo-
spasm (95% CI = 1.2-3.3, P < .001).
Drake-Brockman et RCT LMA group: n = 85 • 3.82 times the incidence of laryngospasm in ETT vs LMA (95%
al,30 2017 ETT group: n = 95 CI = 1.13-12.96, P = .02).
Gulhas et al,10 2003 Double-blind RCT IV magnesium before • Group that received IV magnesium had no laryngospasms,
induction: n = 20 whereas group that received normal saline had a 25% incidence
Normal saline before of laryngospasm (P < .05)
induction: n = 20
Mihara et al,3 2014 Meta-analysis Combined 9 studies: • Demonstrated that IV or topical lidocaine is an effective medi-
N = 787 cation in preventing pediatric laryngospasm

Batra et al,15 2005 RCT Propofol group: n = 60 • Propofol group had a 6.6% incidence of laryngospasm vs a
Control group: n = 60 20% incidence of laryngospasm in control group (P < .05)
Al-Metwalli et al,20 Nonrandomized Gentle chest compres- • Gentle chest compressions effectively treated 73.9% of laryn-
2010 controlled study sion: n = 594 gospasms that developed (P = .0005), but the standard-practice
Standard-practice group treated only 38.4% (P < .001)
group: n = 632

Table. Conclusions From Most Pertinent Studies in Literature Review

Abbreviations: ETT, endotracheal tube; IV, intravenous; LMA, laryngeal mask airway; RCT, randomized controlled trial; URI, upper
respiratory tract infection.

algorithm, but this drug class was shown to be effective administration of 100% oxygen is the most common and
in a randomized controlled trial in felines.13 There have earliest method to treat laryngospasm.18 This treatment
been some attempts to use intermediate-acting neuro- is recommended if there is a soft-tissue blockage that is
muscular blocking agents in different algorithms,14 but compressing the larynx.
further studies are needed before we recommend them Larson maneuver is another quick early treatment
in our algorithm. option that has been used by providers. This technique
Lidocaine has been shown by a large meta-analysis uses the application of pressure slightly cephalad to the
to help prevent pediatric laryngospasm.3 This analysis earlobe to facilitate patency of the upper airway. Larson
included studies that used doses of 1.0 to 2.0 mg/kg of maneuver should be used before pharmacologic agents,
lidocaine intravenously and should be given within 5 but a provider should not wait until desaturation of the
minutes of tracheal extubation. Mihara et al3 also con- patient to use other forms of treatment.19
cluded that topically administered lidocaine lowers the Gentle chest compressions is a treatment option for
incidence of laryngospasm, and the time of administra- laryngospasm that has been studied in the literature. This
tion was either before intubation or during the airway treatment is thought to push air from the lungs against
device insertion. Mihara et al3 did not have a clear rec- the vocal cords.20 The results of the study showed that
ommendation for the dose of topically applied lidocaine. gentle chest compressions could be an alternative and
(See Table.) We elected to use 1.0 to 2.0 mg/kg of IV effective treatment compared with traditional methods to
lidocaine for our recommendation. break laryngospasm. More studies are needed to deter-
Propofol was shown to be highly effective in the pre- mine the rate and force of the compressions, so we do not
vention of pediatric laryngospasm.15 The study by Batra recommend this treatment in our algorithm yet.
et al15 administered 0.5 mg/kg of propofol 60 seconds Propofol has been studied and recommended as a
before extubation, which decreased the incidence of la- preventive pharmacologic agent used for pediatric la-
ryngospasm. This dose helps deepen the anesthetic and ryngospasm, but an RCT in 2014 found that it can be an
inhibit airway reflexes, preventing laryngospasms.15 effective treatment once a laryngospasm is present.4 This
There was no clear evidence that extubating a patient study used a subhypnotic dose of IV propofol (0.5 mg/
who is awake vs under deep anesthesia had any advan- kg) and found that it was effective in 75% of pediatric
tage in preventing laryngospasm.31,32 There were no patients who had laryngospasm.4
differences in laryngospasm rates in the studies that we The same study that found that midazolam was
included in our study.32 Therefore, we did not indicate also effective at treating postextubation laryngospasm.
an extubation preference for our prevention algorithm. Benzodiazepines have been previously shown in the lit-
• Treatment. The positive-pressure ventilation or erature to decrease upper airway reflexes.4 Of 20 patients
continuous positive airway pressure (CPAP) with the who were experiencing laryngospasm, 17 responded

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favorably to a midazolam dose of 0.03 mg/kg intrave- lidocaine in children with upper respiratory infection undergoing
anesthesia: a randomized, double blind, clinical trial. Anesth Pain Med.
nously.4 2015;5(4):e23501. doi:10.5812/aapm.23501v2
Succinylcholine has long been the classic treatment of 13. Martin-Flores M, Sakai DM, Portela DA, Borlle L, Campoy L, Gleed RD.
a patient having a laryngospasm.17 Because of the adverse Prevention of laryngospasm with rocuronium in cats: a dose-finding
side effects (eg, bradycardia, arrhythmias), it is usually study. Vet Anaesth Analg. 2016;43(5):511-518. doi:10.1111/vaa.12342
the last option, but the most reliable pharmacologic agent 14. Spaeth JP, Kreeger R, Varughese AM, Wittkugel E. Interventions
designed using quality improvement methods reduce the incidence of
to break a laryngospasm.2 The recommended dose of suc- serious airway events and airway cardiac arrests during pediatric anes-
cinylcholine is 1.0 to 2.0 mg/kg intravenously or 4 mg/kg thesia. Paediatr Anaesth. 2016;26(2):164-172. doi:10.1111/pan.12829
for the intramuscular route.2,17 15. Batra YK, Ivanova M, Ali SS, Shamsah M, Al Qattan AR, Belani
KG. The efficacy of a subhypnotic dose of propofol in preventing
laryngospasm following tonsillectomy and adenoidectomy in chil-
Conclusion dren. Paediatr Anaesth. 2005;15(12):1094-1097. doi:10.1111/j.1460-
Laryngospasm is still a potentially life-threatening event 9592.2005.01633.x
that occurs in the pediatric population. Although many 16. Naziri F, Amiri HA, Rabiee M, et al. Endotracheal intubation without
studies have looked at the prevention and treatment of muscle relaxants in children using remifentanil and propofol: com-
parative study. Saudi J Anaesth. 2015;9(4):409-412. doi: 10.4103/
laryngospasm, researchers need to continue studying the 1658-354X.159465
issue until laryngospasm is eliminated. We believe that 17. Hampson-Evans D, Morgan P, Farrar M. Pediatric laryngospasm.
our algorithm combines evidence from the most recent Paediatr Anaesth. 2008;18(4):303-307. doi:10.1111/j.1460-9592.
studies to prevent and treat pediatric laryngospasm in the 2008.02446.x
18. Gavel G, Walker RW. Laryngospasm in anaesthesia. Contin Educ Anaesth
most effective manner. There has been a vast improve- Crit Care Pain. 2014;14(2):47-51. doi:10.1093/bjaceaccp/mkt031
ment in the incidence of pediatric laryngospasm and 19. Abelson D. Laryngospasm notch pressure (‘Larson’s maneuver’) may
its treatment options with the advancements of surgical have a role in laryngospasm management in children: highlighting
techniques, pharmacologic options, and a better under- a so far unproven technique. Paediatr Anaesth. 2015;25(11):1175-
1176. doi: 10.1111/pan.12731
standing of the phenomenon. We believe that as more
20. Al-Metwalli RR, Mowafi HA, Ismail SA. Gentle chest compres-
funding is obtained and studies are conducted on pediat- sion relieves extubation laryngospasm in children. J Anesth.
ric laryngospasm, the incidence will continue to decline. 2010;24(6):854-857. doi:10.1007/s00540-010-1036-9
21. Olsson GL, Hallen B. Laryngospasm during anaesthesia. A computer-
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31. Baijal RG, Bidani SA, Minard CG, Watcha MF. Perioperative respira- sonville, North Carolina.
tory complications following awake and deep extubation in children Brad Veasey, MS, CRNA is employed at Pardee Hospital in Hender-
undergoing adenotonsillectomy. Paediatr Anaesth. 2015;25(4):392- sonville, North Carolina.
399. doi:10.1111/pan.12561
Andrea Kristofy, MD, is affiliated with the Department of Anesthesiol-
32. von Ungern-Sternberg BS, Davies K, Hegarty M, Erb TO, Habre W. ogy, Norton Children’s Hospital, Louisville, Kentucky.
The effect of deep vs. awake extubation on respiratory complications
in high-risk children undergoing adenotonsillectomy: a randomised Mason McDowell, DNAP, CRNA is on faculty in the nurse anesthesia
controlled trial. Eur J Anaesthesiol. 2013;30(9):529-536. doi:10.1097/ program at Western Carolina University, Asheville, North Carolina.
EJA.0b013e32835df608
DISCLOSURES
AUTHORS The authors have declared no financial relationships with any commercial
Shawn Collins, PhD, DNP, CRNA, is associate dean—graduate nursing, Loma entity related to the content of this article. The authors did not discuss
Linda University, Loma Linda, California. Email: [email protected]. off-label use within the article. Disclosure statements are available for
Paul Schedler, MS, CRNA is employed at Pardee Hospital in Hender- viewing upon request.

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