Chapter 187. Relief of Choking and Acute Upper Airway Foreign Body Removal

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

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

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

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

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.

No prospective clinical trials have been reported on the various techniques used to relieve an airway foreign body obstruction. Physiologic data demonstrate that each technique produces varying effects on intrathoracic pressure and airflow to overcome the static resistance of the obstructing foreign body.9 Back blows generate a substantial increase in intrathoracic pressure over a very short period of time, potentially dislodging an airway foreign body without its expulsion from the airway. Conversely, abdominal thrusts generate more prolonged increases in airway pressure and flow rates, theoretically allowing for expulsion of the dislodged foreign body. Rescuers must be prepared to quickly utilize a combination of these techniques for the dislodgement and expulsion of an airway foreign body obstruction.4

Perform digital removal of an intraoral foreign body only when it is directly visualized in the patient's mouth or oropharynx. Blind finger sweeps are contraindicated to prevent inadvertently pushing the foreign body into a more distal location, thereby converting an incomplete supraglottic obstruction into a difficult to remove and complete infraglottic obstruction.7

Open the patient's mouth and airway using the thumb and fingers of the nondominant hand to grab the tongue and mandible then lift it anteriorly. Use a hooking action with the index finger of the dominant hand to dislodge and remove the foreign body.

The most important potential complication is the conversion of a partial airway obstruction into a complete airway obstruction. Local trauma can result in intraoral abrasions, bleeding, and dental trauma. The rescuer can sustain digital abrasions and lacerations from the patient's teeth. Do not place your fingers into the mouth of a conscious patient as this can result in a significant bite injury.

An uncoordinated swallow mechanism and the lack of molar dentition predispose the infant to an airway foreign body obstruction within their narrow and pliable glottis and trachea.10 Perform back blows and chest thrusts on the infant with a witnessed or suspected airway foreign body obstruction who suddenly develops respiratory distress, appears cyanotic, or becomes unconscious. This technique should be used on infants less than 1 year of age. Use the Heimlich maneuver if the patient is over 1 year of age. Continue to closely observe the infant but do not intervene if they are maintaining their airway as indicated by clear breathing and an effective cough. Their cough reflex may allow them to dislodge and expel the foreign body.

Place the choking infant with their head angled down in a prone position over the arm or thigh of the rescuer (Figure 187-1A). This head-down position allows gravity to assist in the expulsion of the dislodged foreign body. Perform five firm back blows with the heel of a hand between the infant's shoulder blades (Figure 187-1A). Turn the infant around into the supine position with their head angled down. Perform five chest thrusts with the heel of a hand applied to sternum (Figure 187-1B). Repeat this sequence of back blows and chest thrusts until the foreign body is expelled or the infant becomes unresponsive.

Chest thrusts may also be performed using two other methods. The first is to apply the index and middle fingers just below the intermamillary line and compress the chest (Figure 187-1C). This is usually performed when there is one rescuer. The second method is to use both thumbs on the infant's sternum (Figure 187-1D). This method is performed when one or two rescuers are present. Place both thumbs together over the lower half of the infant sternum just below the intermamillary line. Encircle the infant's chest with both hands, spreading the fingers around the posterior thorax. Compress the sternum while squeezing the thorax to apply counterpressure.

The procedure is successful when the foreign body is expelled. Closely observe the infant after expulsion of the foreign body for any signs of persistent respiratory distress due to an incompletely expelled foreign body or injury from the removal techniques.

For the unresponsive infant, first check their mouth and remove any obvious foreign body. Blind finger sweeps are always contraindicated. Case reports describe wedging of foreign bodies into more distal locations and converting a partial airway obstruction into a complete airway obstruction.7 In the apneic infant, immediately begin more advanced pediatric procedures as described below as well as Basic Life Support and Advanced Life Support maneuvers.

Back blows often result in back and chest wall contusions. The use of acetaminophen or nonsteroidal anti-inflammatory drugs should relieve any discomfort. Vigorous back blows can result in rib fractures. Occasionally, nausea and vomiting can result. Chest thrusts may result in rib and sternal fractures, myocardial contusions, punctured lungs, pneumothoraces, and intraabdominal injury.4 While these potential complications are serious, not relieving an airway foreign body obstruction can result in death.

Maintain a low threshold for performing back blows and chest thrusts to relieve an airway foreign body obstruction in infants. An airway foreign body obstruction in an infant is more likely, more difficult to assess, and more often fatal than in an older child, adolescent, and adult. The key steps to remember include positioning the infant head down over the rescuer's arm or leg with their head lower than their trunk, performing five back blows alternating with five chest thrusts, and repeating this sequence continuously until the foreign body is expelled.

Perform the Heimlich maneuver in the conscious patient over 1 year of age with a witnessed or presumed aspiration who cannot speak, cough, or breathe effectively. Older children and adult patients will often present and be grasping or pointing to their neck with the “universal choking sign” (Figure 187-2). Young children will often have a history or presentation consistent with an airway foreign body obstruction. As long as the patient is conscious and has signs of a complete airway obstruction, perform this technique from behind. Do not perform the Heimlich maneuver in patients less than 1 year of age due to the significant risk of liver injury.11 Observe the patient closely while their cough reflex attempts to expel the partial obstruction if they are able to cough, speak, and breathe effectively. Perform abdominal thrusts only for a complete airway obstruction.

Stand directly behind the patient (Figure 187-2). Wrap both arms around the patient's waist. Make a fist with one hand. Place this hand with the thumb side of the fist against the midline of the patient's upper abdomen, between the rib cage and umbilicus. Place the other hand over the fisted hand and grasp the fisted hand (Figure 187-2). Press inward with a deliberate and quick upward thrust. Confine the force of the thrust to the hands without squeezing the rib cage. Repeat the quick upward thrusts until the foreign body is expelled or the patient becomes unresponsive.

Closely observe the patient after the foreign body is expelled for signs of respiratory distress from persistent obstruction or from injury from the Heimlich maneuver. If the patient becomes unresponsive, lay them supine and perform abdominal thrusts as described below. Incorrect hand placement can result in sternal and rib fractures. Significant but rare complications include a punctured lung, pneumomediastinum, and intraabdominal trauma (e.g., liver laceration, splenic laceration, and bowel injury). While these potential complications are serious, not relieving an airway foreign body obstruction can result in death.

Perform abdominal thrusts in the patient with a witnessed or suspected airway foreign body obstruction, failure of the previously described maneuvers, or in the unresponsive patient. Do not perform this maneuver in patients less than 1 year of age due to the significant risk of liver injury.

Place the patient supine on a firm surface, usually on the floor. A bed is not firm enough to allow the appropriate generation of intraabdominal pressure. Open their mouth. Perform a finger sweep only if a foreign body is clearly visible. Place the heel of one hand in the midline of the abdomen and just above the umbilicus. Place the other hand over the first (Figure 187-3). Apply five rapid and forceful thrusts downward and upward, forcing the diaphragm upward and compressing the lungs. Reassess the patient's airway. Inspect their mouth for a foreign body. Remove the intraoral foreign body if it is visible. If the foreign body is not visible, repeat the abdominal thrusts or attempt another technique.

One case study reported that increased airway pressure was generated using a knees-to-chest approach in the supine position. While there are no further studies to support this technique, it may be a simple adjunct when other methods have failed.12

Frequently reassess the patient for spontaneous breathing. Each time the mouth and airway is opened, look for a foreign body prior to ventilation attempts. Closely observe the patient after the foreign body is expelled for signs of respiratory distress from persistent obstruction or from injury from the abdominal thrusts. Incorrect hand placement can result in sternal and rib fractures. After the foreign body is removed, place the patient in the semirecumbent position or sitting upright if no contraindications exist.

Reported complications include abdominal pain, vomiting, pharyngeal abrasions, esophageal lacerations, intraabdominal trauma (e.g., liver laceration, splenic laceration, and bowel injury), fractured ribs, punctured lung, pneumothoraces, a pneumomediastinum, and even retinal detachment. While these potential complications are serious, not relieving an airway foreign body obstruction can result in death.

Developmental differences in the pediatric airway make visualization and removal of foreign bodies more difficult than in the adult patient. The pediatric tongue occupies a larger percentage of the oral cavity and the oropharynx. Their epiglottis is larger, U-shaped, and more cephalad. The pediatric epiglottis does not attain the adult position until age four. 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.

The timing of endoscopy and airway foreign body retrieval must be based upon each individual patient. Do not waste time if impending airway obstruction exists. Immediately notify and mobilize an Anesthesiologist, Otolaryngologist, and the Operating Room, as this is an emergent situation. It is appropriate to wait for NPO status to be present and the stomach empty prior to proceeding to the Operating Room if the diagnosis of an airway foreign body is highly suspected and the patient is stable. This is considered a timely approach and may take up to 6 hours for children or 8 hours for adults. Waiting this time in the stable patient decreases the risk of aspiration and further compromising the situation. It is also appropriate to wait, in a stable patient, in order to assemble the appropriate and best nursing and anesthesia team to care for the patient. Using personnel who are unfamiliar with endoscopy can create a compromised and stressful situation.

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 may be 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.

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.

Perform a forceps removal of an airway foreign body in the patient with a complete airway obstruction or severe respiratory distress due to partial obstruction when less invasive measures have failed.13 Do not try to blindly grasp for a presumed airway foreign body. Observation and removal in the Operating Room, and not an Emergency Department intervention, is indicated in the patient who is coughing, speaking, or otherwise breathing effectively. Begin with less invasive techniques before performing direct laryngoscopy and manual removal. Be ready to utilize multiple laryngoscope blades, clamps, and forceps to safely visualize and remove accidental foreign body obstruction.

Equipment

• Topical anesthetic spray (e.g., Cetacaine)
• Laryngoscope
• Laryngoscope blades, Miller and Macintosh, various sizes
• Tracheal suction catheter
• Magill forceps
• Pulse Oximeter
• Cardiac Monitor
• Noninvasive blood pressure cuff
• Oxygen
• Video laryngoscope, optional
• Surgical airway equipment

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 and/or percutaneous transtracheal jet ventilation device immediately available. All equipment must be selected, assembled, and ready for use. Place the patient in full monitoring (i.e., pulse oximeter, cardiac monitor, and noninvasive blood pressure cuff). Apply a topical anesthetic spray to the oropharynx and the base of the tongue to blunt the gag reflex. Place the patient supine or semirecumbent. Administer a small dose of an intravenous sedative if required and not contraindicated.

Slowly and gently insert the 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 Magill forceps. If the foreign body is too large or impacted, it may need to be crushed with the forceps to securely grasp it as a whole piece.14 Withdraw the McGill forceps followed by the laryngoscope.

One case report describes passing a Foley catheter distal to the foreign body under direct visualization with a laryngoscope.14 The balloon was then inflated with 5 mL of air and subsequently pulled back until the foreign body could be grasped and removed with a Magill forceps. There were no reported complications. However, it should be noted the foreign body in this case was impacted within the esophagus at the level of the cricoid cartilage. Do not use this technique with subglottic airway foreign bodies since retraction of a dilated catheter balloon through the glottic structures may cause injury, edema, bleeding, and further worsen the obstruction.

Observe the patient for persistent or delayed respiratory distress resulting from incomplete removal or procedural complications. The severity of the obstruction determines whether a patient may be safely discharged home or admitted for observation.

One review reported no complications with subglottic foreign body removal when utilizing Magill forceps under direct laryngoscopy.13 Potential complications include oropharyngeal trauma resulting in glottic edema and bleeding.

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 passing a smaller size endotracheal 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.

After the extraction, removal, or retrieval of an airway foreign body, most patients should be breathing spontaneously. An endotracheal tube may rarely, in the presence of significant laryngeal or tracheobronchial edema, need to remain in place temporarily. This would require admission to an intensive care unit. Humidified oxygen is helpful to keep the airway moist and prevent mucous crusts from forming. A postprocedural radiograph will help to determine any subcutaneous air, air in the soft tissues, a pneumothorax, or any changes to the lung fields following the extraction.

All patients who have undergone foreign body extraction, removal, or retrieval require at least a few hours of airway observation in a monitored setting. Racemic epinephrine treatments and intravenous Decadron can be administered as needed. Discharge from the hospital is acceptable when the patient is breathing comfortably and no longer in danger of airway compromise. Some patients may be discharged home the same day, while others may require multiple days of airway support and observation.

Complications from the foreign bodies themselves include hypoxia leading to cerebral anoxia if not identified. Cardiac arrhythmias can occur from hypoxia or direct pressure on the left main-stem bronchus. Other complications include laryngeal or tracheobronchial edema from the foreign body or the instrumentation of the airway. Mucosal irritation can instigate a bronchitis, pneumonia, or tracheitis. A pneumomediastinum and/or a pneumothorax is possible. The complications specific for each technique have been described previously in the respective sections.

A foreign body in the hypopharynx can be pushed distally and result in a total airway obstruction. The foreign body needs to be quickly removed, pushed back down into one of the mainstem bronchi to allow ventilation of at least one lung, or a surgical airway performed. Failure to react appropriately in this situation can result in asphyxiation and death.

An airway foreign body obstruction is a significant cause of preventable morbidity and mortality in the pediatric, debilitated, and elderly patients. Prompt recognition and management is vital to preventing cardiopulmonary arrest. Do not intervene in the awake patient who is talking, coughing, or otherwise breathing effectively. Observe these patients to determine if their own cough reflex can expel the foreign body. Perform the age and condition appropriate maneuvers with a complete airway obstruction or severe respiratory distress with a partial airway obstruction. Multiple attempts with a combination of procedures are often required for the successful removal of an airway foreign body. Back blows and chest thrusts are first line for infants while abdominal thrusts may be performed on all others. Blind finger sweeps are always contraindicated. Perform manual removal with finger sweeps or direct laryngoscopy under direct visualization.