What is the best approach for removing a foreign body from the airway?

Best Approach for Removing a Foreign Body from the Airway

The best approach for removing a foreign body from the airway begins with encouraging coughing in conscious patients, followed by a sequence of back slaps and abdominal thrusts if coughing is ineffective, while unconscious patients should receive chest thrusts and appropriately skilled healthcare providers should use Magill forceps for removal. 1, 2

Initial Assessment and Management in Conscious Patients

Step 1: Encourage Coughing

• Encourage coughing as the first intervention for a conscious patient with foreign body airway obstruction
• This is a natural physiological response that may effectively expel the object and is unlikely to cause harm 1, 2

Step 2: Back Slaps

• If coughing is ineffective, administer up to 5 sharp back blows between the shoulder blades
• Position yourself to the side and slightly behind the patient
• Support the chest with one hand and deliver firm blows with the heel of your other hand 1, 2

Step 3: Abdominal Thrusts (Heimlich Maneuver)

• If back slaps fail, perform up to 5 abdominal thrusts
• Stand behind the patient, wrap your arms around their waist
• Make a fist with one hand, place it just above the navel
• Grasp your fist with your other hand and pull inward and upward with quick thrusts 1, 2

Step 4: Repeat Sequence

• Continue alternating between 5 back slaps and 5 abdominal thrusts until the object is expelled or the patient becomes unconscious 1

Management in Unconscious Patients

For Unconscious Patients:

• Position the patient on a firm surface
• Begin chest thrusts/compressions immediately (similar to CPR compressions) 1, 2
• Look in the mouth for visible objects that can be safely removed
• Do not perform blind finger sweeps as they may push the object further or cause injury 1, 2
• If appropriately trained, use Magill forceps to remove visible foreign bodies 1

Advanced Management Techniques

Healthcare Provider Interventions:

• Direct visualization with appropriate equipment is essential
• For skilled healthcare providers, Magill forceps are recommended for foreign body removal in patients with out-of-hospital cardiac arrest from airway obstruction 1
• Bronchoscopy is the definitive intervention for foreign body removal:
  • Flexible bronchoscopy is effective for distal foreign bodies 3, 4
  • Rigid bronchoscopy is traditionally used but may not reach distal airways 3
  • Selection of technique depends on the foreign body's location and properties 4

Special Considerations:

• Suction-based airway clearance devices are not recommended for routine use due to limited evidence of effectiveness 1, 2
• Specialist consultation (otolaryngology) is recommended even with low suspicion of foreign body 2, 5
• Imaging studies (radiographs, CT scans) should be obtained in stable patients to identify the foreign body and assess for complications 2, 5

Pitfalls and Caveats

• Foreign bodies can remain undetected for long periods, especially if they cause only partial obstruction 6
• Delayed diagnosis can lead to serious complications including pneumonia, abscess, or perforation 2
• Up to 20% of bronchoscopies performed for suspected foreign bodies are negative, but this is preferable to missing a foreign body 2
• In extreme circumstances where no medical equipment is available and traditional methods have failed, alternative techniques such as mouth-to-mouth aspiration have been reported, though this should be considered only as a last resort 7

Special Populations

Pediatric Considerations:

• Foreign body aspiration is more common in children 5
• The same sequence of interventions applies, but technique must be adjusted for age and size
• For infants under 1 year, use back blows and chest thrusts instead of abdominal thrusts 2
• Specialized pediatric equipment should be used for bronchoscopy in children 4