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Table 1. Prevention and Treatment of Laryngospasm in the Pediatric Patient: A Literature Review. ANESTHESIOLOGY 2006; 105:4550, Meier S, Geiduschek J, Paganoni R, Fuehrmeyer F, Reber A: The effect of chin lift, jaw thrust, and continuous positive airway pressure on the size of the glottic opening and on stridor score in anesthetized, spontaneously breathing children. Principal effectors are respiratory muscles (diaphragm, intercostals, abdominals, and upper airway). It persists for a longer period in the context of respiratory syncytial virus infection, hypoxia, and anemia.21, The diagnosis of laryngospasm depends on the clinical judgment of the anesthesiologist. Past medical history was unremarkable except for an episode of upper respiratory tract infection 4 weeks ago. These cookies will be stored in your browser only with your consent. If you or someone youre with is having a laryngospasm, you should: In addition to the techniques outlined above, there are breathing exercises that can help you through a laryngospasm. To avoid significant morbidity and mortality, the use of a structured algorithm has been proposed.8,70One study suggests that if correctly applied, a combined core algorithm recommended for the diagnosis and management of laryngospasm would have led to earlier recognition and/or better management in 16% of the cases.70These results should encourage physicians to implement their own structured algorithm for the diagnosis and management of laryngospasm in children in their institutions. Fig. The patient is unconscious and initially breathing easily with an oral airway in place. The anesthesia staff has called for the fiberoptic intubation set and is preparing to perform fiberoptic intubation. Plan A:" 3.5 ETT ready, size 1 Macintosh laryngoscope blade" Small orange Bougie (pre bent), have a size 1 Miller blade available" Have a shoulder roll ready, but I wont put it in place" Have a white guedel airway available if I am having difculty with ventilation" If that doesnt work I will do the 2 person technique" If these medications help, please consult your doctor before taking them long term. Laryngospasm, particularly during inhalational induction and after extubation, is an important cause of apnea that all anesthesiologists who care for pediatric patients should understand and anticipate. Anaesthesia 1993; 48:22930, Seah TG, Chin NM: Severe laryngospasm without intravenous accessa case report and literature review of the non-intravenous routes of administration of suxamethonium. ANESTHESIOLOGY 1997; 87:136872, Mazurek AJ, Rae B, Hann S, Kim JI, Castro B, Cot CJ: Rocuronium, Cheng CA, Aun CS, Gin T: Comparison of rocuronium and suxamethonium for rapid tracheal intubation in children. , the overall incidence of respiratory adverse events seems to be higher in children who were awake when their LMA was removed and lower in those who were awake when their endotracheal tube was removed.5In summary, evidence seems to favor deep LMA and awake ETT removal. Larson CP Jr. Laryngospasmthe best treatment. (https://pubmed.ncbi.nlm.nih.gov/34817079/), Visitation, mask requirements and COVID-19 information, chronic obstructive pulmonary disease (COPD). This paper discusses a case study where the patient had laryngospasm, it also looks at the pathophysiology, risk factors and management of . Paediatr Anaesth 2004; 14:21824, Alalami AA, Ayoub CM, Baraka AS: Laryngospasm: Review of different prevention and treatment modalities. Evidence on this subject is scarce, but the study by von Ungern-Sternberg et al. From: Encyclopedia of . Broaddus VC, et al. acute dystonic reactions; rarely associated with ketamine procedural sedation. Int J Pediatr Otorhinolaryngol 2010; 74:4868, Al-alami AA, Zestos MM, Baraka AS: Pediatric laryngospasm: Prevention and treatment. He is a co-founder of theAustralia and New Zealand Clinician Educator Network(ANZCEN) and is the Lead for theANZCEN Clinician Educator Incubatorprogramme. Sufentanil (1 mcg) was given intravenously and the surgeon was allowed to proceed 5 min later. We decided to omit it in the preventive and/or treatment algorithms of laryngospasm, although other authors have included it.3,8,66. Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press. If the diagnosis is laryngospasm or other vocal cord dysfunction, your doctor may refer you to a speech-language pathologist to help you learn breathing exercises. Laryngospasm may be preceded by a high-pitched inspiratory stridor some describe a characteristic crowing noise followed by complete airway obstruction. Example Plan for a neonate! Paediatr Anaesth 2008; 18:297302, Cohen MM, Cameron CB: Should you cancel the operation when a child has an upper respiratory tract infection? The locations of involved nerve receptors vary as a function of the upper airway reflex: pharyngeal mucosa for the swallowing reflex, supraglottic larynx for laryngeal closure reflex,19larynx and trachea for cough, and any part of the upper airway (but mainly nose and larynx) for apnea. We also use third-party cookies that help us analyze and understand how you use this website. A laryngospasm is a muscle spasm in the vocal cords that can lead to problems with speaking and breathing. information submitted for this request. Exhale through pursed lips. Laryngospasm is a frightening condition that happens when your vocal cords suddenly seize up, making breathing more difficult. Laryngospasm in amyotrophic lateral sclerosis. He is retaining oxygen saturations > 94 percent. Relative Risk (95% CI) of Laryngospasm in Children According to the Presence of Cold Symptoms, Household exposure to tobacco smoke was shown to increase the incidence of laryngospasm from 0.9% to 9.4% in children scheduled for otolaryngology and urologic surgery.12This strong association between passive exposure to tobacco smoke and airway complications in children was also observed in another large study.13. On the other hand, attempts to provide positive-pressure ventilation with a facemask may distend the stomach, increasing the risk of gastric regurgitation. Management of refractory laryngospasm. Am J Med 2001; 111(Suppl 8A):69S77S, Shannon R, Baekey DM, Morris KF, Lindsey BG: Brainstem respiratory networks and cough. Am J Respir Crit Care Med 1998; 157:81521, von Ungern-Sternberg BS, Boda K, Schwab C, Sims C, Johnson C, Habre W: Laryngeal mask airway is associated with an increased incidence of adverse respiratory events in children with recent upper respiratory tract infections. Suxamethonium injection in a hypoxic patient may lead to severe bradycardia and even to cardiac arrest. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event. border: none; Laryngospasm is usually defined as partial or complete airway obstruction associated with increasing abdominal and chest wall efforts to breathe against a closed glottis.3,5,7In both partial and complete laryngospasm, signs of varying degrees of airway obstruction, such as suprasternal retraction, supraclavicular retractions, tracheal tug, paradoxical chest, and abdominal movements may be seen.3In addition, inspiratory stridor may be heard in partial laryngospasm but is absent in complete spasm. Can J Anaesth 1988; 35:938, Fink BR: The etiology and treatment of laryngeal spasm. Learning objectives should be based on recommended management algorithms and used as inputs and events embedded into one (or several) case scenario that form the basis for the simulated exercise. The purpose of this case scenario is to highlight keypoints essential for the prevention, diagnosis, and treatmentof laryngospasm occurring during anesthesia. Review. Br J Anaesth 2001; 86:21722, Mark LC: Treatment of laryngospasm by digital elevation of tongue (letter). ANESTHESIOLOGY 1996; 85:47580, Nishino T: Physiological and pathophysiological implications of upper airway reflexes in humans. Treatment of laryngospasm. As a result, your airway becomes temporarily blocked, making it difficult to breathe or speak. Anaesthesia 1983; 38:3935, Sibai AN, Yamout I: Nitroglycerin relieves laryngospasm. This topic is beyond the scope of this article but was recently described elsewhere.37Eighty percent of negative pressure pulmonary edema cases occur within min after relief of the upper airway obstruction, but delayed onset is possible with cases reported up to 46 h later. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. It is not the same as choking. He has a known allergy to peanuts. The patient develops laryngospasm and is ventilated by hand-bag. However, a systematic approach based on the model of translational research has recently been proposed in medical education.79In this model, successive rigorous studies are conducted to evaluate the acquisition of skills and knowledge at different outcome levels. Rarely, negative pressure pulmonary edema may occur and requires specific treatment.37The high chest wall to lung compliance ratio observed during infancy, which disappears by the second year of life because of increased chest wall stiffness, may explain why negative pressure pulmonary edema is less frequent in infants than in older children or adults. Also find out about . This means that if nothing has occurred 46 h after the occurrence of a laryngospasm it is likely that the course will be uneventful. During observation, she exhibits a sudden increase in respiratory effort and noise with ventilation. ANESTHESIOLOGY 1998; 89:12934, Reber A, Paganoni R, Frei FJ: Effect of common airway manoeuvres on upper airway dimensions and clinical signs in anaesthetized, spontaneously breathing children. Below a cardiac temperature of 28C, the heart may suddenly and spontaneously arrest. Paroxysmal Laryngospasm: A Rare Condition That Respiratory Physicians Must Distinguish from Other Diseases with a Chief Complaint of Dyspnea. 14%, relative risk 1.2, 95% CI 1.11.3; P= 0.001). Identifying the risk factors and planning appropriate anesthetic management is a rational approach to reduce laryngospasm incidence and severity. In the study by von Ungern-Sternberg et al. Paediatr Anaesth 2002; 12:6258, Batra YK, Ivanova M, Ali SS, Shamsah M, Al Qattan AR, Belani KG: The efficacy of a subhypnotic dose of propofol in preventing laryngospasm following tonsillectomy and adenoidectomy in children. Anesthesiology. (https://pubmed.ncbi.nlm.nih.gov/31587728/), (https://academic.oup.com/bjaed/article/14/2/47/271333). The video and the script are intended to illustrate the proper application of the management algorithm, to illustrate the technical and the nontechnical skills required in clinical practice, and to be a resource for the readers who wish to develop their own training sessions. 2). A simulation scenario is an artificial representation of a real-world event to achieve educational goals through experiential learning. The treatment includes opening and clearing the oropharynx, applying CPAP with 100% oxygen, followed by deepening of anaesthesia usually with an i.v . #mc-embedded-subscribe-form input[type=checkbox] { Hold your breath for five seconds, then repeat until the laryngospasm stops. Upper airway disorders. In most cases, a laryngospasm lasts for up to one minute, but it may feel much longer. suggests that maintenance with sevoflurane was associated with a higher incidence of laryngospasm compared with propofol (relative risk 2.37, 95% CI 1.493.76; P< 0.0001).5In our case, the second episode of laryngospasm occurred while the patient was under light anesthesia. Laryngospasm scenario. Anaesthesia 2007; 62:7579, Tobias JD, Nichols DG: Intraosseous succinylcholine for orotracheal intubation. Elsevier; 2022. https://www.clinicalkey.com. You might experience multiple laryngospasms in a brief time but in most cases, each episode ends after about a minute. Therefore, giving IV atropine before IV injection of suxamethonium to treat laryngospasm is mandatory.66. Upper respiratory tract infection (URI) is associated with a twofold to fivefold increase in the risk of laryngospasm.5,9Anesthesiologists in charge of pediatric patients should be aware that the risks associated with a URI in an infant are magnified in this age group, especially in those with respiratory syncytial virus infection.10Children with URI are prone to develop airway (upper and bronchial) hyperactivity that lasts beyond the period of viral infection. Simulation-based Training Scenario Laryngospasm during Induction of General Anesthesia in a 10-month-old Boy. Pediatr Emerg Care 1990; 6:1089, Woolf RL, Crawford MW, Choo SM: Dose-response of rocuronium bromide in children anesthetized with propofol: A comparison with succinylcholine. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. Best Pract Res Clin Anaesthesiol 2005; 19:71732, McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ: A critical review of simulation-based medical education research: 20032009. However, onset time to effective relief of laryngospasm is shorter than onset time to maximal twitch depression, enabling laryngospasm relief and oxygenation (within 60 s) in less time than time to maximum twitch depression.55Therefore, intramuscular succinylcholine is the best alternative approach if IV access is not readily available.56Another alternative for succinylcholine administration is the intraosseous route. J Anesth 2010; 24:8547, Schroeck H, Fecho K, Abode K, Bailey A: Vocal cord function and bispectral index in pediatric bronchoscopy patients emerging from propofol anesthesia. But if you have laryngospasms often, you should schedule an appointment with your healthcare provider. The onset of a vocal cord spasm is sudden, and just as suddenly, it goes away, usually after . anaesthesia: laryngospasm. In fact, when the inspiratory stridulous noise was noted again, the patient was receiving 2% end-tidal sevoflurane and 50% N2O, representing barely 1 minimum alveolar concentration in an infant. Review/update the Used with permission of John Wiley and Sons. 1).3The second step relies on the emergent treatment of established laryngospasm occurring despite precautions (fig. font: 14px Helvetica, Arial, sans-serif; Complete airway obstruction is characterized by: Where is the laryngospasm notch? Afferent nerves converge in the brainstem nucleus tractus solitarius. Anesthesiology 2012; 116:458471 doi: https://doi.org/10.1097/ALN.0b013e318242aae9. Laryngospasm can happen suddenly and without warning, lasting up to one minute. Laryngospasm is a rare but frightening experience. Like any other crisis, such management requires the application of appropriate knowledge, technical skills, and teamwork skills (or nontechnical skills). Prospective studies supported the use of LMA over ETT in children with URI.3031However, these studies were underpowered to detect differences in laryngospasm. Laryngospasm usually isnt life-threatening, but it can be a terrifying experience. margin-top: 20px; Many methods and techniques of airway manipulation have been proposed. It is bounded anteriorly by the ascending ramus of the mandible adjacent to the condyle, posteriorly by the mastoid process of the temporal bone, and cephalad by the base of the skull.. Accessed Nov. 5, 2021. 2009 Jul-Aug;59(4):487-95. Review. The purpose of this case scenario is to highlight key points essential for the prevention, diagnosis, and treatment of laryngospasm occurring during anesthesia. For laryngeal closure reflex, several types of receptors can be distinguished, according to their specific sensitivities to cold, pressure, laryngeal motion, and chemical agents.19,21The chemoreceptors are sensitive to fluids with low chloride or high potassium concentrations, as well as to strong acidic or alkaline solutions.19,21. This scenario illustrates the potential risks of not managing your resources properly. There is a need to fill this knowledge gap and to answer questions about what types of clinical education and what type of management algorithm result in better outcome. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Table 2. To provide you with the most relevant and helpful information, and understand which Minimally invasive anti-reflux procedures, Advertising and sponsorship opportunities. Identifying patients at increased risk for laryngospasm and taking recommended precautions are the most important measures to prevent laryngospasm (fig. It is mandatory to procure user consent prior to running these cookies on your website. People with laryngospasm are unable to speak or breathe. Singapore Med J 1998; 39:32830, Warner DO: Intramuscular succinylcholine and laryngospasm. | INTENSIVE | RAGE | Resuscitology | SMACC. Learn more about the symptoms here. If youve experienced a laryngospasm, schedule an appointment with your healthcare provider. Common triggers of reflex laryngeal response during anesthesia are secretions, blood, insertion of an oropharyngeal airway suction catheter, and laryngoscopy. Qual Saf Health Care 2005; 14:e3, Fernandez E, Williams DG: Training and the European Working Time Directive: A 7 year review of paediatric anaesthetic trainee caseload data. He is on the Board of Directors for theIntensive Care Foundationand is a First Part Examiner for theCollege of Intensive Care Medicine. This site uses Akismet to reduce spam. Acid reflux may cause a few drops of stomach acid backwash to touch the vocal cords, setting off the spasm. This is because your vocal cords are contracted and closed tight during a laryngospasm. Anesth Analg 1991; 72:2828, Garca CG, Bhore R, Soriano-Fallas A, Trost M, Chason R, Ramilo O, Mejias A: Risk factors in children hospitalized with RSV bronchiolitis, Tait AR, Malviya S, Voepel-Lewis T, Munro HM, Seiwert M, Pandit UA: Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Do Children Who Experience Laryngospasm Have an Increased Risk of Upper Respiratory Tract Infection? It normally passes quickly and is not dangerous, but some . If you have any of the conditions listed above, talk to your healthcare provider about ways to reduce your risk for laryngospasms. Von Ungern-Sternberg et al. It may be difficult for a nonspecialist pediatric anesthesiologist to adequately manage an inhalational induction, because of the possibility to fail to manage the airway properly or the inability to recognize and treat early a stridor/laryngospasm. If youve had recurring laryngospasms, you should see your healthcare provider to find out whats causing them. If this happens to you, talk to your healthcare provider. J Appl Physiol 1998; 84:202035, Menon AP, Schefft GL, Thach BT: Apnea associated with regurgitation in infants. Laryngospasm is identied by varying degrees of airway obstruction with paradoxical chest move-ment, intercostal recession and tracheal tug. Dry drowning has been explained by mechanisms such as protracted laryngospasm and vagally mediated cardiac arrest triggered by contact of liquid with the upper airways. This category only includes cookies that ensures basic functionalities and security features of the website. Analytical cookies are used to understand how visitors interact with the website. Indian J Anaesth 2010; 54:1326, Behzadi M, Hajimohamadi F, Alagha AE, Abouzari M, Rashidi A: Endotracheal tube cuff lidocaine is not superior to intravenous lidocaine in short pediatric surgeries. Anaphylaxis (+/- Laryngospasm) A 7-year-old male presents with wheeze, rash and increased WOB after eating a birthday cake. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Hobaika AB, Lorentz MN. Management There are a number of ways reported to reduce the incidence of laryngospasm (9). SimBaby is a tetherless simulator designed to help healthcare providers effectively recognize and respond to critically ill pediatric patients. Manual facemask ventilation became difficult with an increased resistance to insufflation and SpO2dropped rapidly from 98% to 78%, associated with a decrease in heart rate from 115 to 65 beats/min. Despite a jaw thrust maneuver, positive pressure ventilation with 100% O2, and administration of two bolus doses (5 mg) of IV propofol (0.6 mg/kg), the obstruction was not relieved and SpO2decreased to 52%. In the case of laryngospasm, basic appropriate airway manipulations such as chin lift, jaw thrust, and oral airway insertion in combination with CPAP can be demonstrated and practiced with these models. Effective management of laryngospasm in children requires appropriate diagnosis,4followed by prompt and aggressive management.8Many authors recommend applying airway manipulation first, beginning with removal of the irritant stimulus38and then administering pharmacologic agents if necessary.8. Anesth Analg 2002; 94:4949, Reber A, Bobbi SA, Hammer J, Frei FJ: Effect of airway opening manoeuvres on thoraco-abdominal asynchrony in anaesthetized children. They can perform an examination and find out if there are ways to prevent laryngospasm from happening in the future. Rev Bras Anestesiol. 1998 Nov;89(5):1293-4. We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits. min-height: 0px; The goal is to slow your breathing and allow your vocal cords to relax. PubMed PMID. PubMed PMID: 19669024. Anesthesia was induced by a resident under the direct supervision of a senior anesthesiologist with inhaled sevoflurane in a 50/50% (5 l/min) mixture of oxygen and nitrous oxide. , partial or complete) and of the bradycardia as well as the existence of contraindication to succinylcholine. other information we have about you. In children, an artificial cough maneuver, including a single lung inflation maneuver with 100% O2immediately before removal of the ETT, is useful at the time of extubation because it delays or prevents desaturation in the first 5 min after extubation in comparison with a suctioning procedure.36Although not demonstrated in this study, this technique could reduce laryngospasm because when the endotracheal tube leaves the trachea, the air escapes in a forceful expiration that removes residual secretions from the larynx. Shortness of breath. Many describe a choking sensation. 1. 2021; doi: 10.1016/j.jvoice.2020.01.004. , otolaryngology surgery).2,5,,7Many factors may increase the risk of laryngospasm. Among all upper airway reflexes, it is the most resistant to deepening anesthesia, whereas the coughing reflex is the most sensitive. The first step of laryngospasm management is prevention. The cause of vocal cord spasms is often unknown, and it is usually in response to a trigger such as anxiety or acid reflux. Adults may be less prone to development of laryngospasm. width: auto; Although third-level studies may prove very difficult or subject to bias, first- and second-level studies are feasible but have yet to be performed for laryngospasm and pediatric airway training. Although the efficacy of subhypnotic doses of propofol has been suggested in children, there is a possibility that these doses are inadequate in infants, especially in those younger than 1 yr. Rutt AL, et al. Common presenting signs and symptoms include tachypnea, tachycardia, diaphoresis, trembling, palpitations, shortness of breath and chest pain. Here are some important features to keep in mind: Complete blockage may present as just apnea; Can be preceded by high-pitched inspiratory stridor, followed by complete airway obstruction For instance, coughing can be voluntarily inhibited. Airway management training, including management of laryngospasm, is an area that can significantly benefit from the use of simulators and simulation.73These tools represent alternative nonclinical training modalities and offer many advantages: individuals and teams can acquire and hone their technical and nontechnical skills without exposing patients to unnecessary risks; training and teaching can be standardized, scheduled, and repeated at regular intervals; and trainees' performances can be evaluated by an instructor who can provide constructive feedback, a critical component of learning through simulation.7475. None of the children in the chest compression group developed gastric distension (86.5% in the standard group). 3, 5, 7 In both partial and complete laryngospasm, signs of varying degrees of airway obstruction, such as suprasternal retraction, supraclavicular retractions, tracheal tug, information and will only use or disclose that information as set forth in our notice of CPAP = continuous positive airway pressure; FiO2= fractional inspired oxygen tension; IM = intramuscular; PACU = postanesthesia care unit. Preference cookies are used to store user preferences to provide content that is customized and convenient for the users, like the language of the website or the location of the visitor. Taking an antacid or acid inhibitor for a few weeks may help diagnose the problem by the process of elimination. Understanding the mechanics of laryngospasm is crucial for proper treatment. During the exercise, the instructor can observe and measure the performance of the trainees and compare them with the standards of performance mentioned in the algorithms. Their motoneurons are located in the brainstem nucleus ambiguous and the adjacent nucleus retroambigualis. Search for other works by this author on: Bhananker SM, Ramamoorthy C, Geiduschek JM, Posner KL, Domino KB, Haberkern CM, Campos JS, Morray JP: Anesthesia-related cardiac arrest in children: Update from the Pediatric Perioperative Cardiac Arrest Registry. }, #FOAMed Medical Education Resources byLITFLis licensed under aCreative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Most of the time, your healthcare provider can diagnose laryngospasm by reviewing your symptoms and medical history. Paediatr Anaesth 2002; 12:7629, Tait AR, Pandit UA, Voepel-Lewis T, Munro HM, Malviya S: Use of the laryngeal mask airway in children with upper respiratory tract infections: A comparison with endotracheal intubation. (#2) With steroid and antibiotic, most patients will gradually improve. J Clin Anesth 2007; 19:51722, Kuduvalli PM, Jervis A, Tighe SQ, Robin NM: Unanticipated difficult airway management in anaesthetised patients: A prospective study of the effect of mannequin training on management strategies and skill retention. Drowning is an international public health problem that has been complicated by . The mother volunteered that he was exposed to passive smoking in the home. #mergeRow-gdpr { Acta Anaesthesiol Scand 2009; 53:19, Larson CP Jr: Laryngospasmthe best treatment. Furthermore, the efficacy of propofol to break complete laryngospasm when bradycardia is present has been questioned.4In our case, two bolus doses of 5 mg IV propofol (each representing a dose of 0.6 mg/kg) were administered but did not relieve airway obstruction. Laryngospasms are rare and typically last for fewer than 60 seconds. Children are more prone to laryngospasm than adults, with laryngospasm being reported more commonly in children (17.4/1,000) than in the general population (8.7/1,000).2,5,,7In fact, the incidence of laryngospasm has been found to range from 1/1,000 up to 20/100 in high-risk surgery (i.e. Any stimulation in the area supplied by the superior laryngeal nerve, during a light plane of anesthesia, may produce laryngospasm. Elsevier; 2021. https://www.clinicalkey.com. More needed than oxygen! Adapted from Hampson-Evans D, Morgan P, Farrar M: Pediatric laryngospasm. } ANESTHESIOLOGY 2001; 95:299306, Lakshmipathy N, Bokesch PM, Cowen DE, Lisman SR, Schmid CH: Environmental tobacco smoke: A risk factor for pediatric laryngospasm.