Anaes · Paediatric anaesthesia
Stridor, acute upper airway obstruction, and laryngospasm in children
Also known as Paediatric laryngospasm · Paediatric stridor · Acute upper airway obstruction child · Epiglottitis anaesthesia
Paediatric laryngospasm and acute stridor: recognition and quantified risk factors (URTI OR 2.03, airway anomaly OR 3.35), the escalation ladder (oxygen and CPAP, jaw thrust, deepen anaesthesia, suxamethonium IV or 4 mg/kg IM with atropine 20 microg/kg), lidocaine prevention, negative-pressure pulmonary oedema, and the medical differentials (croup, epiglottitis, bacterial tracheitis, foreign body) with sourced management.
Checked against its sources on 5 Oct 2026
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Target exams
Red flags
- Recent URTI (OR 2.03) and airway anomaly (OR 3.35) multiply laryngospasm risk — have rescue drugs drawn.
- Complete obstruction is silent; climb the ladder in order — oxygen and CPAP first.
- IM suxamethonium 4 mg/kg is the no-IV-access rescue (IM, IO and intralingual routes described); atropine 20 microg/kg for bradycardia.
- Intense inspiratory effort against the obstructed airway causes negative-pressure pulmonary oedema — watch after relief.
- Suspected epiglottitis or bacterial tracheitis is a true airway emergency — senior team, theatre, airway before antibiotics.
Meet the patient
Thirty seconds after sevoflurane induction in a four-year-old, the chest stops moving, there is no sound, and the saturations begin to fall. You have no intravenous access. This is complete laryngospasm — silent, with no air movement — and the response follows a fixed order.[1]
Two facts explain the urgency: complete obstruction is silent (only partial obstruction stridors), and the infant desaturates fast.[1]
References18ShowHide
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- [2]Mihara T, Uchimoto K, Morita S, Goto T The efficacy of lidocaine to prevent laryngospasm in children: a systematic review and meta-analysis Anaesthesia, 2014.PMID 24992191
- [3]Sikich N, Lerman J Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale Anesthesiology, 2004.PMID 15114210
- [4]Davidson AJ, Disma N, de Graaff JC, et al. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial Lancet, 2016.PMID 26507180
- [5]McCann ME, de Graaff JC, Dorris L, et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial Lancet, 2019.PMID 30782342
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- [8]Sato PH, Ribeiro JD, Schivinski CIS, et al. Low-dose (0.15 mg/kg) versus high-dose (0.6 mg/kg) dexamethasone for pediatric croup: a meta-analysis with trial sequential analysis of RCTs. Frontiers in pediatrics, 2026.PMID 42698708
- [9]Ritu, Jhamb U Dexamethasone in Prevention of Postextubation Stridor in Ventilated Children: A Randomized, Double-blinded, Placebo-controlled Trial. Indian J Crit Care Med, 2020.PMID 33446978
- [10]Al-alami AA, Zestos MM, Baraka AS Pediatric laryngospasm: prevention and treatment. Curr Opin Anaesthesiol, 2009.PMID 19434787
- [11]Bhattacharya M, Kallet RH, Ware LB, Matthay MA Negative-Pressure Pulmonary Edema. Chest, 2016.PMID 27063348
- [12]Wick RR, Ball DR Severe laryngospasm without intravenous access--a case report and literature review of the non-intravenous routes of administration of suxamethonium. Singapore medical journal, 1998.PMID 9885697
- [13]Booth AWG, Pungsornruk K, Llewellyn S, et al. Airway management of adult epiglottitis: a systematic review and meta-analysis. Emergency medicine journal : EMJ, 2024.PMID 38230383
- [14]Mandal A, Kabra SK, Lodha R Upper Airway Obstruction in Children. Indian journal of pediatrics, 2015.PMID 26104110
- [15]Smith DK, McDermott AJ, Sullivan JF Croup: Diagnosis and Management. American family physician, 2018.PMID 29763253
- [16]Lee JH, Jung JY, Lee HJ, et al. Efficacy of low-dose nebulized epinephrine as treatment for croup: A randomized, placebo-controlled, double-blind trial. The American journal of emergency medicine, 2019.PMID 30878411
- [17]Smyk M, Szarpak L, Rafique Z, et al. Do We Actually Help Choking Children? The Quality of Evidence on the Effectiveness and Safety of First Aid Rescue Manoeuvres: A Narrative Review. Medicina, 2024.PMID 39597012
- [18]Bridwell RE, Koyfman A, Long B High risk and low prevalence diseases: Adult epiglottitis. The American journal of emergency medicine, 2022.PMID 35489220