Emergency Department Techniques
The foreign body airway obstruction protocol based upon the Pediatric Basic Life Support textbook treats conscious infants (younger than 1 year of age) with four back blows while the infant is in a prone position on the rescuer's forearm, face down, and the head lower than the trunk. This is combined with four rapid chest thrusts (as in infant CPR), if the obstruction persists, while the infant is supine with the head lower than the body.11 Treat unconscious infants by opening the airway and attempting rescue breathing based on basic life support protocols.11 Treat children and adults with the standard Heimlich maneuver, using gentle thrusts in smaller children to decrease the likelihood of injury to the abdominal organs. Finger sweeps to remove a foreign body in the oral cavity should only be performed if the foreign body is directly visualized. Blind finger sweeps are not recommended as they can further impact the foreign body and obstruct the airway.
It is always best not to manipulate the airway or attempt intubation in a stable patient with an airway foreign body and who is moving air and breathing. The airway is best controlled in the Operating Room at the time of the actual foreign body removal. Once the airway is manipulated a foreign body can become dislodged, turning a partial airway obstruction into a complete airway obstruction. If this occurs in the Operating Room, the bronchoscopy equipment is available for urgent use by the endoscopist if needed.
Attempt orotracheal intubation in the Emergency Department if the airway obstruction progresses rapidly and the patient cannot ventilate. Intubation can be used to force the foreign body into one mainstem bronchus and allow ventilation of the other lung. One-lung ventilation will keep the patient alive until the foreign body can be removed in the Operating Room. Position the laryngoscope to visualize the larynx. If a foreign body is visualized, grasp the foreign body with a McGill forceps and remove it. If no foreign body is visualized, intubate the patient. Insert and advance the endotracheal tube as far as it will advance if the foreign body is not visualized or unable to be grasped. If the endotracheal tube will not pass, try a smaller size tube. Withdraw and position the endotracheal tube with the tip above the carina to optimize ventilation. As an alternative, properly insert and position the endotracheal tube above the carina then advance a bougie through the endotracheal tube in an attempt to move the foreign body distally. Always be prepared to perform a cricothyroidotomy or transtracheal jet ventilation. Transtracheal jet ventilation allows for short-term oxygenation, is temporary, and may allow time for safe transport to the Operating Room so that endoscopy and foreign body retrieval can be performed in a more controlled environment with appropriate equipment at hand. Refer to Chapters 11, 25, and 24 regarding the details of orotracheal intubation, cricothyroidotomy, and transtracheal jet ventilation, respectively.
Direct laryngoscopy and bronchoscopy in a child or adult with an airway foreign body is a dangerous situation. The procedure may result in a partial airway obstruction becoming a complete airway obstruction. Always have a cricothyroidotomy tray immediately available. All equipment must be selected, assembled, and ready for use.
It is possible to remove foreign bodies located within the hypopharynx in the Emergency Department. Typical foreign bodies that may be removed include pieces of food and fishbones. The patient must be stable and in no risk of airway compromise. Obtain anteroposterior and lateral soft tissue radiographs of the neck to localize, if possible, the foreign body. The use of CT scans to attempt to identify potential fish or chicken bones that may be lodged in the pharynx, hypopharynx, or esophagus is an option in the stable patient. Perform indirect laryngoscopy to identify the foreign body and its location. Refer to Chapter 173 regarding the complete details of laryngoscopy. Obtain intravenous access.
Place the patient in full monitoring (i.e., pulse oximeter, cardiac monitor, noninvasive blood pressure cuff). Apply a topical anesthetic spray to the oropharynx and the base of the tongue. Place the patient supine. Administer a small dose of an intravenous sedative if required. Slowly and gently insert a #3 Miller laryngoscope blade. An alternative to a traditional laryngoscope, if available, is a video laryngoscope. The video laryngoscope may provide a better field of view with less manipulation. Do not immediately insert the laryngoscope blade all the way. Stop frequently to lift the laryngoscope and look for the foreign body. This slow insertion and frequent looks will prevent the laryngoscope blade from pushing the foreign body further into the airway. Elevate the patient's tongue and jaw. Grasp the foreign body with a McGill forceps. Withdraw the McGill forceps followed by the laryngoscope.
Operating Room Techniques
The procedure begins with the induction of general anesthesia. It cannot be overemphasized that anesthesia should only be administered by an Anesthesiologist who is competent and comfortable with the situation. Pediatric patients require an Anesthesiologist with pediatric airway experience if the patient is stable. Full monitoring and mask induction allow the patient to maintain spontaneous respiration. Muscle relaxants are avoided as they can induce complete airway obstruction.
The Otolaryngologist begins the procedure. Place the patient supine with a shoulder roll to position the airway. Insert the laryngoscope into the larynx. Expose the larynx by elevating the laryngoscope. Topical anesthetic is applied to the larynx to avoid laryngospasm. The bronchoscope with telescope is then passed under direct vision through the mouth and into the laryngeal introitus. Ventilation can continue via a port on the scope. The foreign body is visualized. Forceps are inserted through the scope and used to grasp the foreign body. Small objects can be removed directly through the scope, whereas larger objects require simultaneously removing the bronchoscope along with the forceps and foreign body. The bronchoscope is passed again, after removal of the foreign body, to identify any mucosal injury or second foreign body that may occur in as many as 5% of patients.4 If purulent secretions are noted, a culture may be obtained and antibiotics administered appropriately.
A specific type of foreign body, such as a tack or sharp object, may become lodged in the larynx or upper trachea. Extraction with the forceps using standard endoscopic techniques may not be possible. Patients may require a tracheotomy and an open approach (laryngotomy) to remove the foreign body.