Laryngospasm suspected
Anaesthesia or procedural sedation: obstruction at induction, emergence or after extubation. Adult or child. Stridor from croup, anaphylaxis or foreign body: use that pathway.
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AnesthesiologyEmergency
Laryngospasm Management
Laryngospasm Management: Laryngospasm suspected → Recognise laryngospasm → Call for help → 100% oxygen, CPAP and jaw thrust → Spasm relieved with CPAP a...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Recognise laryngospasm
Partial: inspiratory stridor. Complete: silent, no bag movement, no capnography trace.
- Paradoxical chest and abdominal movement, tracheal tug, recession
- Desaturation, often rapid; bradycardia (common in infants)
- Triggers: light anaesthesia, secretions, blood, regurgitation, airway instrumentation, extubation
- Consider other causes: bronchospasm, foreign body, laryngeal oedema, vocal cord palsy
03Action Call for help
Senior anaesthetist and anaesthetic assistant now.
- Stop surgical stimulus
- Draw up propofol, suxamethonium and atropine
- Bring difficult airway trolley
04Action 100% oxygen, CPAP and jaw thrust
First-line for all patients. Remove the stimulus.
- 100% oxygen by tight-fitting face mask with firm CPAP
- Two-hand jaw thrust with chin lift
- Larson manoeuvre: firm pressure in the notch behind the ear lobe, between the mandible ramus and the mastoid
- Suction blood and secretions from the pharynx
- An oropharyngeal airway can help CPAP but can also trigger spasm
- CPAP can inflate the stomach: watch for regurgitation
05Decision Spasm relieved with CPAP and jaw thrust?
Air entry returns, capnography trace present and SpO2 rising.
- If Yes
06Action Spasm relieved: stabilise
Continue 100% oxygen. Spasm can recur.
- Suction secretions; watch for recurrence
- Surgery ongoing: keep anaesthesia deep enough
- Stomach inflated by CPAP: consider orogastric tube
- Muscle relaxant given: ventilate until full recovery of neuromuscular function
07Action Observe for complications
Observe in recovery for at least 2-3 hours.
- Negative pressure pulmonary oedema: hypoxia, pink frothy sputum, crackles
- Pulmonary aspiration: hypoxia, new infiltrates
- Chest X-ray if hypoxia persists
- NPPE or aspiration needing ventilation: ICU
- Tell the patient or family; report the incident (hospital system, webAIRS)
08Outcome Airway patent: continue anaesthetic or recovery care
Hand over the event and the plan for the next anaesthetic.
If No09Action Not relieved: deepen anaesthesia with propofol
No IV access: do not wait. Go straight to IM suxamethonium (next steps).
- Propofol 0.25-0.8 mg/kg IV (10 mg/mL), adult or child
- Continue 100% oxygen and CPAP
- Small dose: aim to break the spasm without apnoea
10Decision Spasm relieved after propofol?
Not relieved, or SpO2 falling: give suxamethonium without delay.
- If Yes
- Path rejoins step 06Shared downstream outcome
If No11Warning Before suxamethonium: check contraindications
Not relieved after propofol, or no IV access.
- Do not give: MH history, myopathy (e.g. Duchenne, myotonia), cholinesterase deficiency, suxamethonium allergy
- Do not give: hyperkalaemia risk (burns or major trauma after acute phase, denervation, long immobility, raised K+)
- If contraindicated: rocuronium IV or IO instead (next step)
12Action Suxamethonium to break spasm
Child or second dose: atropine first. Awake patient with IV access: propofol first.
- IV: 0.1 mg/kg can break the spasm; if intubation is needed, full dose (adult 0.6 mg/kg, range 0.3-1.1; child 1-2 mg/kg)
- No IV access: IM 4 mg/kg, max 150 mg (100 mg/2 mL); onset 2-3 min, continue CPAP. IO access: use IV doses
- Atropine 20 mcg/kg IV, max 0.5 mg (600 mcg/mL), in children and before any second dose; IM if no IV access
- Suxamethonium contraindicated: rocuronium IV or IO, adult 1 mg/kg, child 0.6-1.2 mg/kg; adult: have sugammadex 16 mg/kg ready
13Warning Bradycardia or arrest: oxygenate first
Bradycardia is usually from hypoxia or suxamethonium. Fix the airway.
- Atropine: child 20 mcg/kg IV (max 0.5 mg); adult 0.4-1 mg IV
- Child: HR <60/min with poor perfusion despite oxygenation: start CPR
- No pulse: CPR and adrenaline per ANZCOR ALS
14Decision Mask ventilation effective and SpO2 rising?
After suxamethonium or rocuronium.
- If Yes
- Path rejoins step 06Shared downstream outcome
If No15Action Cannot oxygenate: intubate
Mask ventilation fails after muscle relaxation.
- Tracheal intubation, even through closed cords
- Cannot intubate, cannot oxygenate: adult scalpel cricothyroidotomy; child under 12 y: surgeon tracheostomy or needle technique per paediatric CICO guideline
- Confirm tube with capnography; suction the trachea
- Plan further relaxant and sedation
- Path rejoins step 06Shared downstream outcome
Guideline Source
Silva CR, Pereira T, Henriques D, Lanca F. Comprehensive Review of Laryngospasm. WFSA Update in Anaesthesia 2020;35
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Suxamethonium IM 4 mg/kg (WFSA review) is above the Australian PI suggestion of up to 2.5 mg/kg; the 150 mg maximum applies to both. Follow local policy.
- Rocuronium 1.2 mg/kg in children is above the Australian PI intubating dose (0.6 mg/kg; paediatric RSI not recommended in PI). Sugammadex 16 mg/kg is an adult dose.
- Evidence base is expert review and incident analysis, not a formal national guideline.
- Needs skilled airway management and a senior anaesthetist.
Contraindicated Populations
Suxamethonium: malignant hyperthermia susceptibility, myopathy (e.g. Duchenne), plasma cholinesterase deficiency, suxamethonium allergy, hyperkalaemia risk (burns or major trauma after acute phase, denervation, prolonged immobilisation, raised K+): use rocuronium instead
Applicable Regions
AUglobal
AU: Suxamethonium is the Australian name for succinylcholine (100 mg/2 mL). Australian PI suggests IM up to 2.5 mg/kg, max 150 mg. Report events to the hospital incident system and webAIRS.
Global: Based on WFSA Update in Anaesthesia review (2020) and the Australian AIMS laryngospasm crisis algorithm (Visvanathan 2005).
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Laryngospasm Management?
The Laryngospasm Management is a emergency clinical algorithm for Anesthesiology. It provides a structured decision tree to guide clinical decision-making, based on Silva CR, Pereira T, Henriques D, Lanca F. Comprehensive Review of Laryngospasm. WFSA Update in Anaesthesia 2020;35.
What guideline is the Laryngospasm Management based on?
This algorithm is based on Silva CR, Pereira T, Henriques D, Lanca F. Comprehensive Review of Laryngospasm. WFSA Update in Anaesthesia 2020;35.
What are the limitations of the Laryngospasm Management?
Known limitations include: Suxamethonium IM 4 mg/kg (WFSA review) is above the Australian PI suggestion of up to 2.5 mg/kg; the 150 mg maximum applies to both. Follow local policy.; Rocuronium 1.2 mg/kg in children is above the Australian PI intubating dose (0.6 mg/kg; paediatric RSI not recommended in PI). Sugammadex 16 mg/kg is an adult dose.; Evidence base is expert review and incident analysis, not a formal national guideline.; Needs skilled airway management and a senior anaesthetist.. Individual patient factors may require deviation from these recommendations.
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