Chapter 224: Relief of Choking and Acute Upper Airway Foreign Body Removal

INTRODUCTION

The National Safety Council reports that airway foreign body (FB) obstruction accounts for over 4800 adult and pediatric deaths per year in the United States.¹ Accidental FB obstruction of the airway is the fourth leading cause of accidental death in children less than 6 years of age.¹ Contemporary data are lacking regarding the type of obstructing object in fatal cases. Older research data for nonfatal choking episodes in children reported a more common association with food to nonfood objects by a 2:1 ratio. There is some variation but the most common objects are candy (e.g., hard candy which leads softer candy and gum); peanuts which lead the food items category; and coins which lead the nonfood group.² Mortality due to airway FB obstruction is bimodal and increases again in the elderly.¹ Food impaction is the primary etiology in the elderly, institutionalized, and those with cognitive impairment or intoxication.^2-4

ANATOMY AND PATHOPHYSIOLOGY

Developmental differences in the pediatric airway make visualization and removal of FBs more difficult than in the adult patient. The pediatric tongue occupies a larger percentage of the oral cavity and the oropharynx. The pediatric epiglottis is larger, U-shaped, and more cephalad. The pediatric epiglottis does not attain the adult position until age 4. The narrowest portion of the pediatric airway and a likely site of obstruction is below the vocal cords at the level of the cricoid cartilage, making removal more difficult and more likely to require endoscopy.^3-6

The clinical presentation and patient management are dependent on the anatomic site of obstruction, the degree of obstruction, and the size of the FB. Patients with a supraglottic obstruction classically present with inspiratory stridor while those with an infraglottic obstruction present with expiratory wheezes. Infraglottic FBs usually lodge in the trachea or the main stem bronchus and will require instrument removal. A FB simply contacting the vocal cords while moving through the glottis may result in laryngospasm which can completely obstruct the airway, even after the expulsion of the FB.^5,6

Partial airway obstructions generally allow at least limited amounts of air passage and the potential for removal by the patient’s cough reflex. Complete airway obstructions can result in a silent cough followed by loss of consciousness if not cleared by coughing or assistive maneuvers. A larger FB is more likely to lodge at or above the vocal cords where it can cause a complete airway obstruction. Sharp, small, and thin FBs are more likely to partially obstruct between or below the vocal cords and result in difficulty breathing and dysphonia.^5,7-9

Pediatric and adult patients provide different clues to airway FB 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. The symptoms in an infant or toddler ...