What is the management of foreign body aspiration?

Management of Foreign Body Aspiration

The management of foreign body aspiration requires immediate recognition and age-appropriate intervention techniques, including back blows and chest thrusts for infants, and abdominal thrusts for children and adults, followed by appropriate emergency medical care if the obstruction persists. 1

Recognition of Foreign Body Aspiration

Early recognition is crucial for successful management. Signs of foreign body airway obstruction (FBAO) include:

• Sudden onset of respiratory distress
• Coughing, gagging, stridor, or wheezing
• Silent cough (severe obstruction)
• Cyanosis
• Inability to speak or breathe
• Universal choking sign (clutching the neck)
• No fever or other respiratory symptoms (differentiating from infectious causes) 1

Initial Management Based on Severity and Age

Mild Obstruction

• If the victim can cough and make sounds, do not interfere
• Allow the victim to clear the airway by coughing
• Observe closely for signs of worsening obstruction 1

Severe Obstruction (unable to make sounds)

For Infants (<1 year):

1. Position the infant prone with head lower than chest
2. Deliver 5 back blows (slaps) to the middle of the back
3. Turn infant to supine position with head lower than chest
4. Deliver 5 chest thrusts (similar to chest compressions but sharper)
5. Check mouth and remove any visible foreign bodies
6. Do not perform blind finger sweeps as they may push objects further into the pharynx 1
7. Do not perform abdominal thrusts on infants as they may damage the relatively large and unprotected liver 1

For Children (>1 year):

1. Perform subdiaphragmatic abdominal thrusts (Heimlich maneuver)
2. Continue until the object is expelled or the victim becomes unresponsive 1

For Adults:

1. Perform abdominal thrusts (Heimlich maneuver)
2. Continue until the object is expelled or the victim becomes unresponsive 1

Management of Unresponsive Victims

If the victim becomes unresponsive:

1. Start CPR with chest compressions (do not perform a pulse check)
2. After 30 chest compressions, open the airway
3. If you see a foreign body, remove it
4. Attempt to give 2 breaths
5. Continue cycles of chest compressions and ventilations
6. After 2 minutes, if no one has already done so, activate emergency response system 1

Advanced Management in Healthcare Settings

Endoscopic Management

• Flexible endoscopy is recommended as first-line treatment for persistent esophageal foreign bodies 1
• Timing of endoscopy:
  • Emergent (within 2-6 hours): Sharp-pointed objects, batteries, magnets, and foreign bodies causing complete obstruction
  • Urgent (<24 hours): Other esophageal foreign bodies without complete obstruction 1

Bronchoscopic Management

• Rigid bronchoscopy is the standard approach for removal of tracheobronchial foreign bodies
• For unstable patients with severe respiratory distress, immediate intervention is required 2

Special Considerations

• In cases of life-threatening airway foreign body aspiration with unstable respiratory status, extracorporeal membrane oxygenation (ECMO) may be considered as a life-saving adjunct 3
• Laryngoscope and Magill forceps can be used in emergency departments for foreign bodies located below the vocal cords causing severe respiratory distress 4

Prevention Strategies

• Supervise children during mealtimes
• Avoid high-risk foods for young children (hot dogs, round candies, nuts, grapes)
• Remove dental prostheses before sleep
• Educate caregivers on proper resuscitation techniques 5, 6

Common Pitfalls to Avoid

1. Blind finger sweeps - may push objects further into the pharynx and damage the oropharynx 1
2. Abdominal thrusts in infants - may damage the infant's liver 1
3. Delayed recognition - foreign body aspiration can be mistaken for other respiratory conditions
4. Inadequate follow-up - even after successful removal, complications may develop
5. Rough movement of victims with potential spinal injuries 1

Foreign body aspiration remains a significant cause of morbidity and mortality, particularly in children under 5 years of age. Prompt recognition and appropriate management are essential for favorable outcomes.