Foreign Body Airway Obstruction

FBAO is a potentially treatable cause of death that often occurs while playing or eating. It is more common in children.
It is characterised by the sudden onset of respiratory distress.
If the patient is coughing effectively, encourage them to cough.
If coughing is ineffective, back blows should initially be given.
Use chest thrusts in infants and abdominal thrusts in children and adults.
Avoid finger sweeps; use suction and/or McGill forceps.
Check after each manoeuvre to see if the obstruction is removed.
If the object is expelled successfully, assess the patient’s clinical condition. It is possible that part of the object may remain in the respiratory tract and cause complications.
Abdominal thrusts may cause internal injury – patients who have received abdominal thrusts require further hospital assessment.

Introduction

Foreign body airway obstruction (FBAO) is an uncommon but potentially treatable cause of accidental death.
Most cases occur when eating or playing (in children) and are consequently witnessed. Therefore, interventions are usually initiated when the patient is conscious.
The signs and symptoms vary, depending on the degree of airway obstruction (refer to Table 2.9).
FBAO is characterised by the sudden onset of respiratory distress associated with coughing, gagging or stridor.
Similar signs and symptoms may also be associated with other causes of airway obstruction such as laryngitis or epiglottitis, which tend to be of slower onset and require different management.
This guideline covers:
infants (defined as under one year old)
children (defined as between one year and 18 years of age)
adults (aged >18 years of age).
In this guideline, the term ‘child’ includes infants, unless specified otherwise.

General Management Principles

When a foreign body enters the airway, the patient will usually react immediately by coughing in an attempt to expel it.
A spontaneous cough is likely to be more effective and safer than any manoeuvre a rescuer might perform.
If coughing is absent or ineffective and the object completely obstructs the airway, the patient will rapidly become asphyxiated.
Active interventions to remove FBAO are only required when coughing becomes ineffective; but when required, these should be commenced confidently and rapidly.
A high index of suspicion of airway obstruction must be maintained where airway compromise is noted, and paramedics should examine the oropharynx with a laryngoscope at an early stage if chest rise is not witnessed.
Finger sweeps are not recommended, particularly when paramedics have the benefit of McGill forceps and suction, as they may drive any foreign body deeper into the airway. If an obstruction is seen and it can be grasped easily, attempt to remove it with forceps and/or suction.

Adult, Child > 1 year and Infant < 1 year

Mild Airway Obstruction

Adult and Child > 1 year

Infant < 1 year

Adult and Child > 1 year

Give up to 5 back blows – after each back blow, check to see if the obstruction has been relieved.
If 5 back blows do not relieve the airway obstruction, give up to 5 abdominal thrusts.
These manoeuvres increase intrathoracic pressure and may dislodge the foreign body.
Alternate these until the obstruction is relieved or the patient loses consciousness.

Infant < 1 year

Give up to 5 back blows – after each back blow, check to see if the obstruction has been relieved.
If 5 back blows do not relieve the airway obstruction, give up to 5 CHEST thrusts.
These manoeuvres increase intrathoracic pressure and may dislodge the foreign body.
Alternate these until the obstruction is relieved or the infant loses consciousness.

Adult, Child > 1 year and Infant < 1 year

Open the mouth and look for any obvious obstruction.
Attempt to visualise the vocal cords with a laryngoscope.
If an obstruction is seen and it can be grasped easily, make an attempt to remove it with forceps, or suction.
DO NOT attempt finger sweeps – these can cause injury and force the object more deeply into the pharynx.
If the patient is unconscious or becomes unconscious, begin basic life support
If all other measures fail and airway remains obstructed, also consider cricothyroidotomy or surgical airway (not infants) where trained and authorised.
During CPR, the patient's mouth should be checked for any foreign body that has been partly expelled each time the airway is opened.

Adult, Child and Infant

Chest thrusts/compressions generate a higher airway pressure than back blows.
Following successful treatment for FBAO, foreign material may remain in the upper or lower respiratory tract and cause complications later.
Patients with a persistent cough, difficulty swallowing or the sensation of an object being stuck in the throat must be assessed further.
Abdominal thrusts can cause serious internal injuries and all patients who receive them must be assessed for injury in hospital.
Infants (< 1 year of age): 5 back blows, alternating with 5 chest thrusts. Child (> 1 year of age): 5 back blows, alternating with 5 abdominal thrusts.

Child > 1 year

Back blows are more effective if the child is positioned head down.
A small child may be placed across the rescuer’s lap.
If this is not possible, support the child in a forward-leaning position and deliver the back blows from behind.

Infant < 1 year

Support the infant in a head-down, prone position, to allow gravity to assist the removal of the foreign body.
Support the infant’s head by placing the thumb of one hand at the angle of the lower jaw, with one or two fingers from the same hand at the same point on the other side of the jaw.
Do not compress the soft tissues under the infant’s jaw, as this will exacerbate the airway obstruction.
Deliver up to 5 sharp back blows with the heel of one hand in the middle of the back between the shoulder blades, aiming to relieve the obstruction with each blow.

Abdominal thrusts ‒ children

Stand or kneel behind the child. Place your arms under the child’s arms and encircle their torso.
Clench your fist and place it between the umbilicus and the xiphisternum. Grasp this hand with the other hand and pull sharply inwards and upwards.
Repeat up to 5 times (if required).
Ensure that pressure is not applied to xiphoid process or lower rib cage (as this may result in abdominal trauma).

Chest thrusts ‒ infants

Turn the infant into a head-down, supine position (this can be safely achieved by placing the paramedic’s arm along the infant’s back and encircling the occiput with the hand). Rest this arm against a solid surface or the paramedic’s thigh.
Identify the landmark for chest compression (lower sternum, approximately a finger’s breadth above the xiphisternum).
Deliver 5 chest thrusts (if required).
These are similar to external chest compressions but sharper in nature and delivered at a slower rate.

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