START

❶ Call for help and inform theatre team of problem.

❷ Perform jaw thrust and stop any other stimulation.

❸ Remove airway devices and anything else that may be stimulating or obstructing the airway, e.g. suction catheters, blood or vomit (direct visualisation and suction if in doubt).
A correctly positioned tracheal tube rules out laryngospasm.

❹ Give CPAP with 100% oxygen and face mask:
• Avoid over-vigorous attempts at lung inflation, as this may inflate the stomach.
• Insert an oro-pharyngeal and/or nasal airway if you are not sure that the airway is clear above the larynx.

❺ If problem persists:
• Continue CPAP.
• Deepen anaesthesia.
• Give a neuromuscular blocker (See Box A).

❻ Consider tracheal intubation particularly if likely to recur.

❼ Use nasogastric tube to decompress the stomach.

❽ Consider other causes (Box B).

❾ Consider whether guideline 2-3 Increased airway pressure may help.

❿ Consider the appropriate strategy, location and support needed for waking the patient.

⓫ Continued airway and ventilation support may be necessary if aspiration has occurred or if the patient has developed negative-pressure pulmonary oedema.

Box A: DRUG DOSES FOR TREATMENT OF LARYNGOSPASM

0.25-0.5 mg.kg^-1 i.v.:
• Propofol
• Rocuronium
• Atracurium
• Suxamethonium (also i.m. including tongue 4.0 mg.kg^-1)

Box B: ALTERNATIVES AND MIMICS

• Foreign body
• Infection of larynx/upper respiratory tract
• Anaphylaxis
• Airway tumour
• Vocal cord paralysis
• Intrinsic laryngeal or tracheal obstruction
• Extrinsic laryngeal or tracheal compression
• Sub-glottic stenosis
• Laryngo/tracheomalacia

Box C: CRITICAL CHANGES

• Cardiac arrest → 2-1
• Hypoxia/desaturation/cyanosis → 2-2
• Increased airway pressure → 2-3
• Hypotension → 2-4
• Bradycardia → 2-6