Although this article, Resource (1), discusses pediatric general anesthesia and pediatric laryngospasm, it is relevant to pediatric procedural sedation and analgesia.
The following are some excerpts from the article:
Treatment success mainly depends on the experience of the anesthesia provider. Removal of the offending stimulus alone may be sufficient to treat laryngospasm. Until recently, laryngospasm was classified into partial versus complete. The treatment was different for each type [103 ]. However, recent reviews [104,105] derived from endoscopy studies showed that partial laryngospasm does not exist and laryngospasm is complete; thus, treatment should be the same (Fig. 2).
Treatment with airway management
Airway management includes opening the mouth, tight sealing with facemask, extending the neck with jaw lift and applying CPAP ventilation with 100% oxygen . Airway management can be enhanced by two maneuvers. The first involves placing the middle finger of each hand in the laryngospasm notch located between the mastoid process and the ear lobule and pressing inward on the styloid process. This induces periosteal pain resulting in autonomic nervous system reflex and vocal cords relaxation [107,108]. The second maneuver consists of a vigorous forward pull of the mandible. This causes a painful stimulus and stretches the geniohyoid muscle to partially open the larynx . Incomplete oxygenation secondary to stomach insufflation may occur during CPAP. An orogastric tube may be inserted for stomach deflation following the resolution of the spasm .
Treatment using drugs
Recent studies have shown that laryngospasm is always
complete thus anesthesia with inhalational agents alone
is not therapeutic. Rather, airway management and intravenous therapy is indicated. Propofol administered at
0.25–0.8 mg/kg i.v. can treat laryngospasm in 76.9% of
cases. However, propofol is not studied in children
less than 3-year-old [57,111–113]. Succinylcholine is
still considered the gold standard for treatment of
laryngospasm. It can be given at 0.1–3 mg/kg i.v. together
with atropine at 0.02 mg/kg to avoid the possible succinylcholine-induced bradycardia and cardiac arrest .
Laryngospasm may recur after succinylcholine metabolism
and a second dose may be given following atropine . The use of a smaller dose of succinylcholine offers the advantage of the avoidance of bradycardia following repeated doses, while maintaining spontaneous breathing, which thus avoids further hypoxia .