Laryngospasm

Note: Not all choking episodes are laryngospasm. While laryngospasm is generally not an emergency, knowing when “choking” is laryngospasm and when it is something more dangerous is not usually apparent, especially to the layperson. If solid material is or could be present in the throat, such as with choking during a meal, the cause of choking should not be assumed to be laryngospasm. Keep in mind that the following information is not medical advice, but rather is educational material for use in a non-urgent setting.

Laryngospasm is a sudden event in which the vocal cords close involuntarily, temporarily closing or nearly closing the airway. This event is a protective reflex induced to protect the lungs from solids or liquids spilling into the lower airway. Laryngospasm can be a frightening event because the individual affected and those around fear for the worst, but it is almost always much less dangerous than it seems.

What is going on during laryngospasm?

Normally, the vocal cords open during breathing and close during swallowing and speaking. During laryngospasm, the vocal cords close and stay closed even as a person tries to breathe. This is a reflex meant to protect the lower airway from aspiration. Initially, the laryngospasm may be complete and strong, preventing any airflow. Subsequently, a small amount of airflow may occur through slightly opened vocal cords, leading to a characteristic high pitched sound of breathing called stridor. Gradually, the airway opens fully and breathing is restored. While it is rare for a person to loose consciousness during laryngospasm, it could occur, and if it does, then the laryngospasm “breaks” or releases on its own and breathing resumes. A key safety measure to avoid injury from a fall, such as head trauma, is to sit down during a laryngospasm event.

What does laryngospasm look and sound like?

An episode of laryngospasm is characterized by a sudden and involuntary contraction of the muscles that close the vocal cords.

During an episode, the individual may exhibit several signs:

1. Breathing Difficulty: Breathing may become labored or may stop momentarily, leading to a feeling of suffocation. The person may struggle to inhale and exhale. There may be no sound of air movement (the initial phase in a severe episode) or (in a less severe situation), high pitched sound of air moving through the tight space between barely open vocal cords.

2. Voice Changes: Initially, during laryngospasm, the affected individual cannot talk or produce a voice. In some cases, there may initially be no sound at all due to complete closure of the vocal cords. Once laryngospasm begins to resolve (or “break”), the voice may return partially, with a weak and often wet sound before more complete normalization occurs.

3. Panic or Anxiety: The inability to breathe properly can lead to feelings of panic or anxiety. The person may become visibly distressed.

4. Physical Manifestations: There may be physical signs such as sweating, increased heart rate, or even a blue tint to the skin (cyanosis) if the episode is severe and prolonged.

An episode typically lasts from a few seconds to a couple of minutes and often resolves spontaneously. After the spasm subsides, the individual may experience a coughing fit as the airways reopen or may feel fatigued.

Is laryngospasm dangerous?

Laryngospasm can be a concerning condition, though it is almost always not dangerous. Laryngospasm during anesthetic for a procedure is, however, potentially fatal. Keep in mind that causes of choking other than laryngospasm may be dangerous. Laryngospasm proper typically resolves within a few seconds to minutes without medical intervention.

However, in some situations, particularly if it occurs repeatedly or in individuals with pre-existing respiratory conditions, laryngospasm can become more serious. For example, laryngospasm may follow an aspiration event; in this scenario, the laryngospasm may resolve, but the consequence of aspiration (for example, prolonged coughing, pneumonia, blockage of a deep air passage) may develop after laryngospasm has resolved. Rarely, severe laryngospasm with forceful breathing effort against a closed airway can lead to a condition called negative pressure pulmonary edema, in which the lungs fill with fluid and is usually associated with clear frothy sputum.

Individuals who believe they have experienced laryngospasm may gain important information by consulting with their physician for evaluation and to discuss potential underlying causes or triggers, which can include gastroesophageal reflux, asthma, or swallowing errors.

Management of a laryngospasm event

When experiencing laryngospasm, some people find benefit from the following approach:

1. Stay Calm: Panic can exacerbate the situation. Focus on controlling your breathing.

2. Breathe Through Your Nose: Inhale gently through your nose. This can help regulate your breathing and reduce the spasm.

3. Pursed Lip Breathing: If possible, try pursed lip breathing by inhaling deeply through your nose and exhaling slowly through pursed lips, such that the airway between the lips is small. This technique can help ease the tension.

4. Physical Positioning: Sit dow, and tilt your head slightly forward and try to relax your shoulders. Sometimes, a change in position can help relieve symptoms.

5. Call for Help: Using your judgement, if symptoms persist for more than a few minutes or if breathing becomes significantly compromised, you may choose to seek medical attention immediately.

6. Follow Up: After the episode, consider discussing your experience with a healthcare provider for potential underlying causes and management strategies.

It's important to note that repeated episodes of laryngospasm may require further evaluation.

What causes laryngospasm?

Laryngospasm is a normal and protective reflex that may be triggered at inconvenient times. The trigger of this reflex is a sensation of material on the vocal cords or within the trachea. Causes of material contacting these sensitive tissues include the following:

1. Gastroesophageal Reflux Disease (GERD) and Laryngopharyngeal Reflux (LPR): Reflux of stomach contents up the esophagus can spill over onto the vocal cords and initiate the laryngospasm reflex. This may occur while asleep or awake, and is the most common cause of laryngospasm.

2. Aspiration: Food, beverage, or saliva may incorrectly route to the windpipe (trachea) instead of passing down the esophagus. While solid food may cause an airway obstruction and this must be managed emergently, laryngospasm may be triggered by any material contacting the vocal cords or upper trachea. Everyone experiences occasional aspiration, but certain conditions affecting swallowing predispose to frequent or significant aspiration, including neurologic conditions (such as multiple sclerosis and Parkinson’s), prior cancer treatment of the neck, and advanced age.

3. Irritants: Exposure to smoke, strong odors, cold air, or pollutants can irritate the throat and laryngeal area, triggering spasms. Additionally, exposure to irritants, including second hand smoke, makes laryngospasm more easily activated by other causes; this is called laryngeal hypersensitivity.

4. Trauma or Contact: Physical contact to the larynx or upper trachea may initiate a laryngospasm event. While rare, this is most often described in an operating room setting with use of a breathing tube. Talking loudly, yelling, or vigorous breathing with physical exertion may be enough stimulation to induce a laryngospasm event.

5. Asthma and allergies have been cited as predisposing factors for laryngospasm.

6. Stress or anxiety seem to play a role in the predisposition for laryngospasm.

How is laryngospasm diagnosed?

Laryngospasm is diagnosed primarily through a combination of patient history, physical examination, and sometimes additional diagnostic procedures.

1. Patient History: A healthcare provider will first gather a detailed history of the patient's symptoms, including the frequency, duration, and triggers of the episodes. Patients may describe sudden episodes of difficulty breathing, a feeling of choking, or a hoarse voice.

2. Physical Examination: A thorough examination of the throat and neck can help identify any visible abnormalities. Doctors may also check for signs of respiratory distress during an episode.

3. Direct Laryngoscopy: This procedure involves using a flexible scope or a rigid laryngoscope to visualize the larynx directly. Given the unpredictable timing of a laryngospasm event, laryngoscopy is rarely performed during an event, but direct laryngoscopy may reveal findings that support or detract from a diagnosis of laryngospasm.

4. Pulmonary Function Tests: These tests can help assess the overall function of the lungs and rule out other respiratory conditions that may mimic laryngospasm, such as asthma.

5. Swallow Evaluation: Evaluation for swallowing dysfunction, especially aspiration, may identify a cause of laryngospasm.

6. Other testing: Allergy evaluation, bronchoscopy, CT scan of the chest, a trial of inhalers, or other testing may be utilized in an individual situation.

Confirming a diagnosis may require correlating the findings with the patient's reported experiences and ruling out other potential causes of similar symptoms.