Minimizing Laryngospasm During Pediatric LMA Anesthesia

By Andre Motie, MD

  River Seine - photo by Andre Motie, MD

 Laryngospasm is one of the most common complications encountered in pediatric anesthesia. Risk factors for laryngospasm include: use of a laryngeal mask airway (LMA), light anesthesia, potent inhalational agents, upper respiratory tract infections, and blood or secretions in the oropharynx. Children’s airways are especially sensitive to the above factors placing them at highest risk. Persistent laryngospasm may lead to hypoxia, hypercarbia, pulmonary edema, arrhythmias, and even cardiac arrest.

We all know how to treat laryngospasm once it occurs, but how can we prevent it during general anesthesia with LMA in pediatric patients? 

Induction: Most patients undergo inhalational induction followed by intravenous placement. A bolus of propofol prior to LMA placement works well to blunt airway reflexes.

Maintenance: Sevoflorane is the least irritating potent inhalational agent. Maintain a deep plane of anesthesia with adequate opioid coverage.

Emergence: Titrate opioid to adequate respiratory rate and maintain a deep plane of anesthesia.  Place the child in the lateral position after surgical end*. This helps to drain blood and secretions out of the oropharynx, away from the larynx. Next, turn off your inhalational agent. Remove the LMA and replace with oral airway. Transfer the child to the stretcher. Place a rolled blanket along their back to help maintain their lateral position. Allow them to wake up gradually.

Under deep anesthesia, placing the child in the lateral position prior to LMA removal, followed by insertion of an oral airway are two simple tricks we can all use to decrease our incidence of laryngospasm. This is in contrast to GETA where it is often most prudent to perform an awake extubation.

* Ensure the child is deep enough, not undergoing Stage 2 anesthesia prior to positioning them laterally: check that eyes are midline, conjugate and without erythematous conjunctiva.