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Accidental foreign body obstruction of the airway is the leading cause of accidental death in children less than 6 years of age.1 Airway foreign body obstruction accounts for over 4000 adult and pediatric deaths per year in the United States.1 Tragically, 90% of these deaths occur in children less than 4 years of age, with 65% occurring in infants.2 The most common cause of an airway foreign body obstruction in infants are feeding liquids while the most common etiologies in older children are candy, grapes, peanuts, and vegetables. Mortality due to airway foreign body obstruction is bimodal and increases again in the elderly, with 13.6 deaths per 100,000 people greater than 75 years of age.3,4 Food impaction is the primary etiology with the elderly, with those intoxicated and institutionalized being at an increased risk.3,4

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The clinical presentation and patient management is dependent on three related factors: the anatomical site of obstruction, the degree of obstruction, and the size of the foreign body. Autopsy reports have found the foreign body obstruction to be located supraglottic in 32% and infraglottic in 68%.5 Patients with a supraglottic obstruction classically present with inspiratory stridor while those with an infraglottic obstruction present with expiratory wheezes. Infraglottic foreign bodies lodge in the trachea or the mainstem bronchus and require instrument removal. A foreign body that simply contacts the vocal cords while moving through the glottis may result in laryngospasm that can completely obstruct the airway, even after the expulsion of the foreign body.6

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Partial airway obstructions often allow limited amounts of air passage and their removal by the patient's cough reflex. Complete airway obstructions can result in a silent cough followed by loss of consciousness, thus requiring higher pressures for removal. A larger foreign body is more likely to lodge above or at the vocal cords causing a complete airway obstruction. Sharp, small, and thin foreign bodies are more likely to obstruct between or below the vocal cords and result in difficulty breathing and odynophagia.7

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Pediatric and adult patients provide different clues to an airway foreign body obstruction. Adults and older children typically indicate the “universal choking sign” by clutching or pointing to their neck and nodding affirmatively when asked if choking. An infant or toddler will present after a witnessed or suspected acute foreign body ingestion. Their symptoms range anywhere on a spectrum from subtle stridor and wheezing to cyanosis and unconsciousness.8

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Dr. Henry Heimlich first proposed the Heimlich maneuver in 1974. Controversy soon followed as he publicly denounced the recommendations made by the American Red Cross and the American Heart Association. He claimed that back blows previously listed as a first-line treatment were “death blows” and that various national organizations were involved in “Watergate cover-ups” intended to prevent acceptance and widespread use of his maneuver.

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No prospective clinical trials have been reported on ...

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