What is the recommended approach for managing foreign bodies in the airway?

Management of Foreign Bodies in Airways: A Literature Review

The recommended approach for managing foreign bodies in the airway follows a stepwise algorithm that begins with early recognition and prompt intervention, with backslaps as the initial maneuver for conscious patients with ineffective cough, followed by abdominal thrusts if backslaps are ineffective. 1

Initial Assessment and Recognition

• Recognition signs: Sudden onset of respiratory distress, coughing, choking, stridor, or wheezing
• Risk factors: Young children (especially under 3 years), elderly, impaired consciousness
• Severity assessment:
  • Mild obstruction: Patient can cough effectively
  • Severe obstruction: Ineffective cough, increasing respiratory difficulty, silent cough, cyanosis

Management Algorithm for Conscious Patients

1. Encourage coughing if the patient has an effective cough

   • This is a normal physiological response that may clear the obstruction 1

2. Back blows (5 sharp blows between the shoulder blades) for patients with ineffective cough

   • Position: Lean patient forward or hold infant prone with head lower than trunk
   • Evidence shows high success rates with minimal injuries 1

3. Abdominal thrusts (5 thrusts) if back blows are ineffective

   • Not recommended for infants under 1 year due to risk of internal injuries
   • Apply just above the umbilicus in a quick upward motion
   • Demonstrated high relief of obstruction rates in observational studies 1

4. Manual extraction of visible foreign bodies

   • Only attempt if the object is clearly visible in the mouth
   • Do not perform blind finger sweeps as these can push objects deeper or cause injury 1

5. Alternate between back blows and abdominal thrusts until the obstruction is relieved or the patient becomes unconscious

Management for Unconscious Patients

1. Position the patient supine on a firm surface
2. Activate emergency medical services
3. Begin CPR with chest compressions (which can serve as chest thrusts)
   • Chest compressions create pressure gradients that may dislodge the foreign body 1
4. Check the mouth before each ventilation attempt
5. Remove visible foreign bodies only if clearly seen
6. Healthcare providers should use Magill forceps to remove visible foreign bodies 1

Advanced Management Techniques (Healthcare Providers)

• Direct laryngoscopy and Magill forceps for visible foreign bodies
• Bronchoscopy is the gold standard for diagnosis and removal of lower airway foreign bodies 2, 3
  • Rigid bronchoscopy is preferred in children due to higher success rates 4
  • Emergency physician-performed flexible bronchoscopy has shown success in cardiac arrest cases due to foreign body obstruction 2
• Surgical airway (cricothyroidotomy or tracheostomy) may be necessary in complete obstruction cases where other methods fail 3, 5

Special Considerations

• Pediatric patients: Back blows and chest thrusts are preferred over abdominal thrusts in infants under 1 year 1
• Tracheostomy patients: For blocked tracheostomy tubes, attempt immediate tube change rather than upper airway management 1
• Prolonged presence: Foreign bodies can remain undetected for extended periods causing chronic symptoms 6

Common Pitfalls and Caveats

• Avoid blind finger sweeps which can push objects deeper or cause injury 1
• Do not delay intervention - bystanders should act immediately upon recognition 1
• Beware of partial obstruction - patients with partial obstruction may have minimal symptoms initially but can progress to complete obstruction
• Suction-based airway clearance devices are not recommended for routine use 1
• Post-removal monitoring is essential as complications like laryngeal edema, pneumonia, or atelectasis can develop

Foreign body airway obstruction is a life-threatening emergency requiring immediate action. The evidence supporting specific interventions is of very low certainty, but the current recommendations are based on the best available evidence and clinical experience. Early recognition and prompt intervention are crucial for preventing mortality and reducing morbidity.