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Pediatric Anesthesia 2008 18: 289–296 doi:10.1111/j.1460-9592.2008.02447.

Risk factors for laryngospasm in children during


general anesthesia
RANDALL P. FLICK MD*, ROBERT T. WILDER MD*,
S T E P H E N F. P I E P ER S R N A * , KE VIN V AN KO EV ERD EN
S R N A * , K Y L E M . EL L I S O N S R N A * , M A R Y E . S . M A R I E N A U
C R N A M S * , A N D R E W C . H A N S O N B S †, D A R R E L L R .
SCHROEDER MS† AND JURAJ SPRUNG MD, PhD*
*Department of Anesthesiology, College of Medicine and †Department of Health Sciences,
Mayo Clinic, Rochester, MN, USA

Summary
Background: Laryngospasm is a common and often serious adverse
respiratory event encountered during anesthetic care of children. We
examined, in a case control design, the risk factors for laryngospasm
in children.
Material and Methods: The records of 130 children identified as having
experienced laryngospasm under general anesthesia were examined.
Cases were identified from those prospectively entered into the Mayo
Clinic performance improvement database between January 1, 1996
and December 31, 2005. Potential demographic, patient, surgical and
anesthetic related risk factors were determined in a 1 : 2 case–control
study.
Results: No individual demographic factors were found to be signi-
ficantly associated with risk for laryngospasm. However, multivariate
analysis demonstrated significant associations between laryngospasm
and intercurrent upper respiratory infection (OR 2.03 P = 0.022) and
the presence of an airway anomaly (OR = 3.35, P = 0.030). Among
those experiencing laryngospasm during maintenance or emergence,
the use of a laryngeal mask airway was strongly associated even when
adjusted for the presence of upper respiratory infection and airway
anomaly (P = 0.019). Ten patients experienced postoperatively one or
more complications whereas only three complications were observed
among controls (P = 0.008). No child required cardiopulmonary
resuscitation and there were no deaths in either study cohort.
Conclusions: In our pediatric population, the risk of laryngospasm was
increased in children with upper respiratory tract infection or an
airway anomaly. The use of laryngeal mask airway was found to be
associated with laryngospasm even when adjusted for the presence of
upper respiratory tract infection and airway anomaly.

Keywords: laryngospasm; children; general anesthesia; laryngeal


mask; endotracheal tube; mask

Correspondence to: J. Sprung, Department of Anesthesiology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905,
USA (email: sprung.juraj@mayo.edu).

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2 90 R . P . F LI C K E T A L .

‘laryngospasm’ coded in database (n = 9) who lacked


Introduction
written documentation of its existence in either
Respiratory adverse events (RAE) are common, the anesthesia or medical record were excluded.
occurring in up to 53% of children undergoing We studied the risk factors for laryngospasm by
noncardiac procedures under anesthesia (1). Laryn- using a 1 : 2 matched case–control study design.
gospasm is one of the most serious as well as Each patient with laryngospasm was matched with
frequent RAEs. It is more prevalent in younger up to two controls with regard to: i) type of
children (1) with incidence ranging from 14% in anesthesia (all general), ii) type of surgery (ICD-9
<6 years old to 3.6% in >6 years old (2). Several risk procedural codes), iii) age (± 3 months) and iv) year
factors for laryngospasm have been identified: of surgery (±1 year). To avoid inclusion of non-
younger age (1), higher American Society of Anes- documented laryngospasm as controls, a patient was
thesiologists Physical Status (ASA PS) and the type eliminated as a potential control if the anesthesia
of airway device used during anesthesia (1,3–5). record showed oxyhemoglobin desaturation by
Upper respiratory tract infection (URI) has been pulse oximetry £93% for undisclosed reasons.
found to be a risk factor for laryngospasm in many Medical records of cases and controls were
but not all studies (1,4,6–8). In majority of studies, reviewed by one of the three abstractors (SFP,
laryngospasm was not analyzed as a separate entity, KVK, KEM). All abstractors reviewed the initial 15
but was included within a more broad definition of charts to unify data extraction. This enabled the
RAEs (4,9–11). The number of patients with laryn- evaluators to identify and correct problems in data
gospasm in these studies ranged between 4 and 123 collection, interpretation of definitions and applica-
(1,4,7–11). The power for analysis of risk factors for tion of study criteria. Throughout the data collection
laryngospasm in some of the studies was limited. phase, all questionable issues were discussed with
Only one prospective study has reported a large consultants and the final decision regarding data
enough number of pediatric laryngospasms to allow values was made by the mutual consensus.
for multivariate modeling of risk factors (7). The patient or disease related risk factors consi-
The objective of our case–control study was to dered in the analysis included, gender, ASA PS scores
analyze the association between demographic, 1–3, elective or emergency surgery and whether the
patient and procedure-related factors among 130 surgery was performed on inpatient or outpatient
children who experienced perioperative laryngo- basis. The following preexisting co-morbidities were
spasm. also considered: i) congenital heart disease, ii) history
of URI (recorded in medical records within 30 days
from the day of surgery), iii) asthma, iv) airway
Methods
anomalies (e.g., subglottic stenosis and cysts,
After Mayo Clinic (Rochester, MN, USA) Institu- laryngeal papillomatosis, cleft palate, Pierre Robin
tional Review Board approval, we examined the syndrome, tracheal stenosis, vocal cord paralysis,
medical records of patients younger than 18 years laryngomalacia), v) lung disease (e.g., cystic fibrosis,
who developed laryngospasm during general anes- pneumonia, atelectasis, bronchopulmonary dys-
thesia. Cases were identified by electronic search of plasia, chronic bronchial obstruction, pulmonary
the Anesthesia Performance Improvement Database hypertension, restrictive airway disease), vi) neuro-
from January 1, 1996 and December 31, 2005. This logical disease (e.g., seizure, cerebral palsy, etc),
database serves as a repository of all critical inci- vii) syndromes (e.g., Down, DiGeorge, Vater,
dents, including laryngospasm. An event was deter- Bartter’s, Goldenhar’s, Rubinstein-Taybi, Beckwith-
mined to be laryngospasm in the clinical judgment Weidemann) and viii) history of gastroesophageal
of the anesthesiologist caring for the child and was reflux disease. Medications taken into consideration
then recorded in the database. We included in included scheduled preoperative therapy with anti-
review all ASA PS from one to three children biotics, bronchodilators, steroids, anticonvulsants
younger than 18 years with documented laryngo- and H1 ⁄ H2 receptor antagonists. In addition we
spasm during induction, maintenance or emer- examined the role of anesthesiologists’ experience
gence from general anesthesia. Patients with (pediatric vs nonpediatric anesthesiologist) to

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L A R Y N G O S P A S M , C H I L D R E N A N D A N E S T H E S IA 291

examine whether laryngospasm may be provider nance ⁄ emergence. In all cases, two-tailed P-values
dependent. Surgery or anesthesia related factors £0.05 was considered as statistically significant.
analyzed included type of anesthetic induction
(intravenous vs inhalational), maintenance volatile
Results
agent (halothane, sevoflurane, isoflurane), use of
nitrous oxide and muscle relaxant (any). Definitive Between 1996 and 2005, there were 130 patients with
airway management included either endotracheal research authorization younger than 18 who had
tube (ETT), laryngeal mask airway (LMA) or face ‘laryngospasm’ coded in the Performance Improve-
mask. The patients who experienced laryngospasm ment Database and also had documentation of a
during LMA or face mask anesthesia and required laryngospasm in their anesthesia records. Three
endotracheal intubation were counted as their initial patients did not have written research authorization
airway device (LMA or mask, respectively). Timing and were, therefore, excluded from review. Two
of laryngospasm was noted as at induction, mainte- patients had laryngospasm noted during two sur-
nance or emergence. Postoperative outcomes geries (recurrent laryngospasm). For these patients
monitored were: pulmonary aspiration, unplanned we abstracted information from only the first occur-
mechanical ventilation, unplanned intensive care unit rence. Of the 130 laryngospasm events identified as
admission for observation, unplanned chest radio- cases, 60 (46%) occurred during induction, 13 (10%)
graph and death. during maintenance and 57 (44%) during emer-
gence. The majority occurred in children £5 years of
age (57% £3 years of age, 68% £5 years of age).
Data analysis
Mean patient weights were 22.9 ± 18.9 and
All analyses were performed using conditional 24.9 ± 23.5 (OR 1.02, 95% CI 1.00–1.04, P = 0.062)
logistic regression, taking into account the 1 : 2 in laryngospasm and control groups, respectively.
matched study design. Findings are summarized Two matched controls were identified for each
using odds ratios (OR) and corresponding 95% laryngospasm case with the exception of 10 cases for
confidence intervals. Initial univariate analyses were whom only one matched control could be identified.
performed to assess each risk factor individually. Thus the 130 laryngospasm cases were matched to
Patient demographics, comorbidities and preopera- 250 controls. From univariate analyses, no indivi-
tive medications were assessed in an overall analysis dual demographic variable, comorbidity, or preoper-
that utilized all matched sets of cases and controls. In ative medication was found to be significantly
addition, two subset analyses were performed. For associated with laryngospasm (Table 1). However,
one subset analysis, premedication and induction when variables with some evidence (P £ 0.15) of a
agents were analyzed as risk factors for laryngo- univariate association were considered simul-
spasm in the subset of matched sets where the case taneously in a multivariable analysis, URI (OR =
experienced laryngospasm during induction. For 2.03, P = 0.022) and airway anomaly (OR = 3.35,
the second subset analysis, maintenance agents P = 0.030) were found to be significant risk factors
and airway devices were assessed as risk factors for laryngospasm (Table 2).
for laryngospasm that occurred during mainte- In an analysis restricted to case-control sets where
nance ⁄ emergence. In addition to assessing univariate the case patient experienced laryngospasm on
associations, a series of multivariate analyses were induction, preoperative use of midazolam was
also performed. Patient demographics and comor- found to be associated with an increased risk of
bidities found to have some evidence (P £ 0.15) of a laryngospasm on induction (OR = 4.44, P = 0.030)
univariate association with laryngospasm were (Table 3). In a multivariable model adjusting for
included in a multiple conditional logistic regression upper respiratory infection and airway anomaly this
model using all matched sets. Variables found to be finding was no longer statistically significant
statistically significant in this multivariable model (OR = 3.68, P = 0.076).
were included as adjustor variables in additional In an analysis restricted to case-control sets
multivariable models to assess risk factors for laryn- where the case experienced laryngospasm during
gospasm during induction and also during mainte- maintenance ⁄ emergence the risk for laryngospasm

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2 92 R . P . F LI C K E T A L .

Table 1
Odds ratioa Association of demographics,
Controls Laryngospasm
comorbidities and preoperative
(n = 250) No. (%) (n = 130) No. (%) Estimate 95% C.I. P-value
medications with laryngospasm
Gender 0.077
Male 154 (61.6) 69 (53.1) 1.00
Female 96 (38.4) 61 (46.9) 1.50 0.96–2.36
ASA PS 0.862
1 117 (46.8) 60 (46.2) 1.00
2 96 (38.4) 52 (40.0) 0.98 0.59–1.64
3 37 (14.8) 18 (13.8) 0.81 0.36–1.82
Urgency 0.619
Elective 240 (96.0) 126 (96.9) 1.00
Emergency 10 (4.0) 4 (3.1) 0.68 0.15–3.09
Admission status 0.256
Inpatients 88 (35.2) 40 (30.8) 1.00
Outpatients 162 (64.8) 90 (69.2) 1.46 0.76–2.82
Comorbidities
Asthma 31 (12.4) 14 (10.8) 0.85 0.44–1.63 0.625
URI 28 (11.2) 25 (19.2) 1.77 0.99–3.16 0.055
Airway anomaly 9 (3.6) 12 (9.2) 2.56 0.91–7.19 0.075
Lung disease 5 (2.0) 5 (3.8) 2.20 0.58–8.36 0.249
CHD 28 (11.2) 9 (6.9) 0.49 0.21–1.18 0.111
Neurologic disease 54 (21.7) 34 (26.2) 1.37 0.75–2.49 0.305
Syndrome 21 (8.5) 7 (5.4) 0.57 0.24–1.40 0.221
GERD 14 (5.6) 11 (8.5) 1.61 0.62–4.14 0.325
Preoperative Medications
Antibiotics 41 (16.5) 15 (11.5) 0.64 0.32–1.26 0.195
Bronchodilators 32 (12.9) 11 (8.5) 0.61 0.29–1.25 0.175
Steroids 8 (3.2) 8 (6.1) 1.75 0.62–4.94 0.287
Anticonvulsants 13 (5.2) 4 (3.1) 0.52 0.16–1.71 0.284
H1 ⁄ H2 blockers 13 (5.2) 12 (9.2) 1.57 0.62–3.98 0.340
Provider
Pediatric anesthesiologist 111 (44.4) 63 (48.5) 1.33 0.80–2.21 0.268
a
Univariate analyses were performed to assess each variable as a potential risk factor for
laryngospasm using conditional logistic regression taking into account the matched set study
design.
URI, upper respiratory tract infection; CHD, congenital heart disease; ASA PS, American Society of
Anesthesiologist Physical Status; GERD, gastroesophageal reflux disease; CI, confidence interval.

Table 2 1.06–42.43) compared with mask ventilation whereas


Multivariable analysis of demographics, comorbidities and pre-
no difference was observed when ETT was com-
operative medications potentially associated with laryngospasm
pared with face mask (OR = 1.31 95% C.I. 0.31–5.57)
Odds ratio (Table 4). In a multivariable model adjusting for
Variable Estimate 95% C.I. P-value upper respiratory infection and airway anomaly, the
risk for laryngospasm during maintenance ⁄ emer-
Male gender 1.55 0.96–2.50 0.073
Upper respiratory tract infection 2.03 1.11–3.71 0.022
gence was still found to differ significantly across
Airway anomaly 3.35 1.13–9.96 0.030 airway management groups (P = 0.013) with LMA
Congenital heart disease 0.50 0.20–1.24 0.136 having increased risk (OR = 8.80, 95% C.I. 1.30–
Multivariable analysis was performed using conditional logistic 59.76) compared with mask ventilation.
regression taking into account the matched set study design. All There were 10 of 130 (7.7%) cases who experi-
variables from Table 1 found to have some evidence (P £ 0.15) of a enced one or more postoperative complications
univariate association were included in this multivariable model.
CI, confidence interval.
compared with only three of 250 (1.2%) controls
(P = 0.008) (Table 5). Table 5 shows demographics,
was found to differ significantly (P = 0.019) across clinical information and type of complications in 10
airway management groups (ETT, face mask, LMA) patients who had laryngospasm. The complications
with LMA having increased risk (OR = 6.7, 95% C.I. experienced by the 10 laryngospasm cases included

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L A R Y N G O S P A S M , C H I L D R E N A N D A N E S T H E S IA 293

Table 3
Association of type of anesthetics Controls (n = 115) Laryngospasm Odds Ratioa
with laryngospasm during Variable No. (%) (n = 60) No.(%) Estimate 95% C.I. P-value
induction
Preoperative midazolam 5 (4.4) 9 (15.0) 4.44 1.15–17.09 0.030b
Type of induction 0.509
Intravenous 23 (20.0) 14 (23.3) 1.00
Inhalation 92 (80.0) 46 (76.7) 0.75 0.32–1.76
Anesthetic Agent
Volatilec 0.370
Sevoflurane 82 (89.1) 37 (80.4) 1.00
Halothane 6 (6.5) 6 (13.0) 2.22 0.67–7.33
Other 4 (4.3) 3 (6.5) 1.66 0.35–7.80
Intravenousc 0.260
Propofol 11 (47.8) 7 (50.0) 1.00
Thiopental 11 (47.8) 4 (28.6) 0.57 0.13–2.53
Other 1 (4.3) 3 (21.4) 4.71 0.40–54.83
a
Univariate analyses were performed to assess each variable as a potential risk factor for
laryngospasm using conditional logistic regression taking into account the matched set study
design. The analyses presented in this table include only the matched sets in which the case
experienced laryngospasm during induction.
b
In a multivariable model adjusting for URI and airway anomaly, premedication with midazolam
was not found to be statistically significant P = 0.076.
c
Analyses of types of volatile and intravenous agents were restricted to those receiving inhalation
and intravenous induction respectively. When assessing these risk factors unmatched analyses
were performed.
CI, confidence interval.

Table 4
Association of type of anesthetics Controls (n = 135) Laryngospasm Odds Ratioa
and airway device used with Variable No. (%) (n = 70) No. (%) Estimate 95% C.I. P-value
laryngospasm during
N2O 104 (77.0) 52 (74.3) 0.85 0.39–1.85 0.691
maintenance ⁄ emergence
Muscle relaxants used (any) 61 (45.2) 26 (37.1) 0.63 0.31–1.26 0.192
Agents for maintenance 0.586
Isoflurane 59 (43.7) 27 (38.6) 1.00
Halothane 5 (3.7) 3 (4.3) 1.67 0.29–9.51
Sevoflurane 61 (45.2) 37 (52.9) 1.51 0.70–3.26
Other 10 (7.4) 3 (4.3) 0.74 0.18–2.93
Type airway management 0.019b
Face mask 31 (23) 15 (21.4) 1.00
LMA 8 (5.93) 13 (18.6) 6.71 1.06–42.43
ETT 96 (71.1) 42 (60) 1.31 0.31–5.57
a
Univariate analyses were performed to assess each variable as a potential risk factor for
laryngospasm using conditional logistic regression taking into account the matched set study
design. The analyses presented in this table include only the matched sets in which the case
experienced laryngospasm during maintenance ⁄ emergence.
b
In a multivariable model adjusting for URI and airway anomaly, type of airway management was
still statistically significant P = 0.013.
N, number of patients; LMA, laryngeal mask airway, ETT, endotracheal tube; C.I., confidence
interval.

unplanned admission and unplanned postoperative pulmonary resuscitation and there were no deaths in
mechanical ventilation (n = 2), pulmonary aspira- either group.
tion (n = 3) (no such complications were identified
in the control group, P = 0.98 for all) and unplanned
Discussion
intensive care unit admission for observation (n = 6)
(three such complications were identified in our In a large retrospective study of pediatric laryngo-
control group, P = 0.054). No child required cardio- spasms, we examined demographics, comorbidities

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2 94 R . P . F LI C K E T A L .

Table 5
Demographics, type of surgery, timing of laryngospasm and complications that resulted from laryngospasm

Age Initial
gender airway Time of
ASA PS Type of surgery device laryngospasm Complication

7 years ⁄ F ⁄ 1 ENT, tonsillectomy ETT Induction Possible aspiration, unplanned chest radiogram
11 months ⁄ M ⁄ 3 ENT, microlaryngoscopy ETT Emergence ICU admission for observationa
(excision of subglottic cyst)
14 years ⁄ F ⁄ 2 Posterior spinal fusion ETT Emergence Tracheal reintubation and ICU admission for
unplanned postoperative mechanical ventilation
3 months ⁄ M ⁄ 3E Strangulated inguinal hernia ETT Induction ICU for postoperative mechanical ventilationa
23 months ⁄ F ⁄ 2 ENT, microlaryngoscopy Face mask Induction ICU admission for observation
17 months ⁄ F ⁄ 2 Magnetic resonance scan (arm) ETT Emergence Aspiration (admission for observation on ward)
2 years ⁄ M ⁄ 1 ENT, tonsillectomy ETT Emergence ICU admission for observation (aspiration)
20 months ⁄ M ⁄ 2 ENT, microlaryngoscopy ETT Emergence ICU admission for observationa
5 years ⁄ F ⁄ 3 ENT tonsillectomy Face mask Emergence ICU admission for observationa
5 years ⁄ F ⁄ 2 ENT, suspension laryngoscopy ETT Induction ICU admission for observationa
(excision subglottic papilloma)
a
Laryngospasm was a significant contributory factor for admission to ICU ⁄ mechanical ventilation.
F, female; M, male; E, emergency, ASA PS, American Society of Anesthesiologist Physical Status; ICU, Intensive Care Unit; ETT,
endotracheal tube; ENT, ear nose and throat surgery; MV, mechanical ventilation; ENT, ear, nose and throat surgery.

and anesthesia as risk factors for the occurrence of ratio 2.1, 95% confidence interval 1.21–3.45) (7).
laryngospasm. Our main findings were that the Finally, a just published prospective study con-
presence of URI, upper airway anomaly and the use firmed that the history of recent (<2 weeks) URI
of LMA were significant risk factors for laryngosp- doubles the rate of laryngospasm (odds ratio 2.6) in
asm. Furthermore, children who experienced laryn- patients who had LMA-based anesthesia (8).
gospasm had higher overall number of The type of device used to maintain airway may
postoperative complications, although none had be associated with increased risk of RAE. For
cardiac arrest or died. example, Cohen and Cameron (12) demonstrated
Known risk factors for laryngospasm, such as that the use of an ETT increased by 11-fold the
younger age and the type of surgery (1,2,7,8,10) were chance of RAE in children with URI. LMA has been
not examined in the present study as they were the considered as a superior airway device compared
matching variables in our case–control study. How- with ETT to reduce the incidence of RAE in children
ever, 68% and 83% of laryngospasm were recorded with URI (14,15). Only one study (9) reported
in children younger than 5 and 10 years old, respec- association between LMA and increased incidence
tively. of various RAE. However, within the examined
It is widely accepted among anesthesiologists that patient cohort, the rate of laryngospasm was com-
the URI poses a risk for RAE including laryngo- parable between different airway devices (1.12%
spasm. In a prospectively collected pediatric anes- ETT, 1.7% LMA and 1.5% face mask).
thesia database Cohen and Cameron (12) found that We found that the LMA poses higher risk for
children with URI had two to seven times higher laryngospasm compared with ETT and face mask,
chance to experience perioperative RAE. Schreiner even after adjusting for the presence of URI and
et al. (7) showed that the children who experienced airway anomaly. The cause of increased risk is
laryngospasm were twice as likely to have an active unclear although one may speculate that the use of
URI as defined by their parents. However, in a study an LMA and ⁄ or accumulated secretions may repre-
by Tait and Knight, (13) the presence of URI was not sent a potent stimulus to the airway during emer-
associated with an increased incidence of perioper- gence. Our database does not allow us to determine
ative respiratory complications. whether the LMA was removed prior to or after
We identified a 2.3-fold higher risk of laryngo- emergence. This may be an important factor in the
spasm in children with URI, which is in close genesis of laryngospasm and deserves future study.
agreement with the findings of Schreiner et al. (odds Furthermore, in the present study we do not have

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L A R Y N G O S P A S M , C H I L D R E N A N D A N E S T H E S IA 295

information regarding the stage of patients’ URI and ASA PS scores, emergency ⁄ elective status,
it is possible that the severity of URI may be inpatient ⁄ outpatient status and preoperative medi-
associated with the reported difference in respira- cations scheduled until the day of surgery. Nor did
tory complications related to LMA (7,8). we find an association between comorbidities (con-
Finally, we found that the ETT only modestly genital heart disease, syndromes, pulmonary disease
increased the risk for laryngospasm compared with or asthma, presence of gastric reflux, neurologic
face mask. While this may be surprising, Mamie disease) and the risk for laryngospasm.
et al. (10) reported that the use of muscle relaxants Our children with laryngospasm had increased
concomitant with tracheal intubation reduces the number of postoperative complications, therefore,
risk of laryngospasm and most of our children who their overall morbidity was increased compared
received tracheal intubation received muscle relax- with controls. At the same time some of the patients
ants. in this group had preexisting airway pathology
In our univariate analysis the use of midazolam (Table 5) which could have contributed to the ICU
premedication was found to be associated with an admission.
increased risk for laryngospasm, however, in an
analysis that adjusted for the presence of either
Limitations of the study
upper airway anomaly or URI, the association of
midazolam with laryngospasm was no longer Although event data was entered prospectively (as
statistically significant. In one recent study (5) the a part of our Performance Improvement database)
use of midazolam premedication increased RAE this is a retrospective study with the inherent
(which included ‘any degree of laryngospasm’) limitation related to retrospective design. First, we
upon emergence from anesthesia; however, authors cannot exclude that relevant information was
did not specify the proportion of laryngospasm (if omitted from the description of events. Second,
any) in these adverse events. In contrast Schreiner the presence of mandatory reporting for perioper-
et al. (7) reported a nonsignificant trend toward a ative laryngospasm does not assure that all events
decreased likelihood of laryngospasm (P = 0.06) if were recorded and that case ascertainment was
the midazolam was used before induction. It is complete, therefore, we did not attempt to calcu-
difficult to retrospectively interpret these divergent late the incidence of laryngospasm. Third, Mayo
findings. In our study absence of significance of Clinic is a tertiary referral institution and this
midazolam in our final multivariable model sug- practice is likely not representative of the general
gests the univariate association of midazolam with population of children undergoing surgery. Our
laryngospasm may be at least partially explained by surgical population as a whole is weighted
other covariates. towards fewer routine procedures. This factor can
The role of anesthesiologists’ experience in pedi- potentially bias toward different risk factors com-
atric anesthesia, as a potential risk factor for laryn- pared with a less complex pediatric population.
gospasm, remains controversial. Mamie et al. (10) Fourth, there are no criteria for the diagnosis and
reported that children not anesthetized by pediatric recording of laryngospasm in our database, there-
anesthesiologist have a 1.7 times greater risk of fore we had to rely on assessment accuracy of
perioperative RAE (these events included laryn- anesthesia consultant involved with the respective
gospasms) (10). Similarly, children who developed case.
laryngospasm were more likely to have their anes- In conclusion, in our surgical population the
thesia supervised by a less experienced anesthesia administration of general anesthesia to children with
supervisor (7). In the present case–control study, we an URI or airway anomalies increases the risk for
could not confirm that procedures supervised by laryngospasm. The risk is also determined by the
pediatric anesthesiologist reduced the risk for laryn- type of airway used rather than by the child’s past
gospasm. A most recent study reported similar medical history. The use of LMA was associated
findings (8). with the highest risk for laryngospasm even
As was observed by Cohen (12) we did not when adjusted for the presence of URI or airway
confirm an association between laryngospasm and anomalies.

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Journal compilation  2008 Blackwell Publishing Ltd, Pediatric Anesthesia, 18, 289–296
2 96 R . P . F LI C K E T A L .

Implication 6 Maceri DR, Zim S. Laryngospasm: an atypical manifestation of


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7 Schreiner MS, O’Hara I, Markakis DA, Politis GD et al. Do
with an URI or airway anomaly increases the risk for children who experience laryngospasm have an increased risk
laryngospasm. Amongst airway devices, the use of of upper respiratory tract infection? Anesthesiology 1996; 85:
LMA was associated with the highest risk for 475–480.
8 Von Ungern-Sternberg BS, Boda K, Schwab C et al. Laryngeal
laryngospasm even when adjusted for the presence
mask airway is associated with an increased incidence in ad-
of URI or airway anomalies. verse respiratory events in children with recent upper respi-
ratory tract infections. Anesthesiology 2007; 107: 714–719.
9 Bordet F, Allaouchiche B, Lansiaux S et al. Risk factors for
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We are grateful to David O Warner, MD for his 10 Mamie C, Habre W, Delhumeau C et al. Incidence and risk
suggestions and for the critical reading of the factors of perioperative respiratory adverse events in children
undergoing elective surgery. Pediatr Anesth 2004; 14: 218–224.
manuscript. 11 Pappas AL, Sukahni R, Lurie J et al. Severity of airway hyp-
erreactivity associated with laryngeal mask airway removal:
correlation with volatile anesthetic choice and depth of anes-
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 2008 The Authors


Journal compilation  2008 Blackwell Publishing Ltd, Pediatric Anesthesia, 18, 289–296

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