What is the best treatment for a 6-month-old infant choking on food, for a paramedic capable of using a Laryngeal Mask Airway (LMA), Igel (Igel airway), and endotracheal intubation?

From the Guidelines

For a 6-month-old infant choking on food, the best initial treatment approach for a paramedic is to perform back blows and chest thrusts rather than immediately attempting advanced airway management with LMA, iGel, or intubation. This approach is based on the principle of prioritizing simple, non-invasive maneuvers to dislodge the foreign body before considering more invasive techniques that carry additional risks, as highlighted in the management of pediatric airway obstruction 1.

Initial Steps

The paramedic should begin with five back blows between the infant's shoulder blades while holding them face down with their head lower than their trunk. If this is unsuccessful, the paramedic should turn the infant face up and deliver five chest thrusts using two fingers in the center of the chest just below the nipple line. This sequence of back blows and chest thrusts should be continued until the object is expelled or the infant becomes unresponsive.

Advanced Airway Management Considerations

Advanced airway management techniques, such as the use of a laryngeal mask airway (LMA) or intubation, are considered high-risk procedures in pediatric patients due to their smaller airways and the potential for complications, as noted in the guidelines for pediatric advanced life support 1. The French guidelines for management of the child's airway under anesthesia also emphasize the importance of careful consideration before proceeding with advanced airway interventions, highlighting the potential for inadequate ventilation and the need for a structured approach to managing airway complications 2, 3.

CPR and Foreign Body Removal

If the infant becomes unresponsive, the paramedic should begin CPR with chest compressions and visual inspection of the mouth before rescue breaths, removing any visible foreign body. This approach prioritizes the restoration of circulation and oxygenation while minimizing the risk of pushing the foreign body further into the airway.

Conclusion on Best Approach

The focus on dislodging the object through external maneuvers first is crucial due to the anatomical differences in infants, including their smaller airways and relatively larger tongues, which make foreign body airway obstruction particularly dangerous in this age group. Advanced airway techniques should only be considered if basic maneuvers fail and the infant remains in respiratory distress or arrest, emphasizing the importance of a stepwise approach to airway management in pediatric patients.

From the Research

Airway Management for a 6-Month-Old Choking on Food

• The best approach for a paramedic with the capability to use LMA, Igel, and intubation is to follow a staged strategy, starting with high-quality chest compressions and defibrillation, then optimizing mask ventilation while preparing for advanced airway management with a supraglottic airway device 4.
• There is no evidence that any single advanced airway technique is superior to the other in terms of survival and neurological outcomes, and the choice of technique should be based on the individual patient's needs and the paramedic's expertise 5.
• The use of a supraglottic airway device, such as a laryngeal mask airway (LMA), can be an effective way to establish an airway in a patient with a difficult airway, and has been shown to be successful in airway rescue situations 6.
• The ProSeal Laryngeal mask airway (PLMA) is a type of LMA that has been shown to be useful in managing difficult airways and for airway rescue, with potential advantages including improved airway seal and reduced risk of aspiration 6.

Considerations for Airway Management in a 6-Month-Old

• The American Heart Association and the International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care provide updated recommendations related to airway management during CPR, which may be relevant to the management of a 6-month-old choking on food 5.
• The use of capnography is recommended to monitor ventilation and chest compression quality, and to help guide airway management decisions 4.
• The choice of airway management technique should take into account the individual patient's needs and the paramedic's expertise, as well as the potential risks and benefits of each technique 5.

Note: Study 7 is not relevant to the question of airway management for a 6-month-old choking on food.