Foreign Body Airway Obstruction (FBAO) Management
Perform five back slaps followed by five chest thrusts immediately—this is a 2-year-old child with complete airway obstruction requiring mechanical relief maneuvers, not abdominal thrusts which are contraindicated in children under 1 year and should be avoided in very young toddlers. 1
Immediate Recognition and Action
This clinical presentation is classic for complete foreign body airway obstruction during a family gathering (high-risk setting for choking):
- Acute onset of severe respiratory distress in a previously healthy child 1
- Weak/ineffective cough indicating inability to generate adequate airflow 1
- Cyanosis signaling critical hypoxemia 1
- Suprasternal AND subcostal retractions together indicate severe upper airway obstruction with maximal accessory muscle recruitment 1, 2
The combination of suprasternal and subcostal retractions specifically denotes a greater level of respiratory compromise than isolated retractions, signaling the need for immediate mechanical airway relief rather than supportive measures. 1
Why Back Slaps and Chest Thrusts (Not Abdominal Thrusts)
For infants and very young children (under 1 year, and preferably extended to toddlers around 2 years):
- Five back blows should be performed with the child prone and head lower than chest 1
- Followed by five chest thrusts (not abdominal thrusts) 1
- Check the mouth for visible foreign bodies after each cycle 1
- Repeat the cycle until the airway is cleared 1
Abdominal thrusts (Heimlich maneuver) carry specific risks in young children:
- Can cause internal organ damage in small children with compliant abdominal walls 3
- May dislodge the foreign body into the trachea rather than expelling it, potentially worsening obstruction 3
- Can cause severe complications including pneumomediastinum, pneumopericardium, and surgical emphysema 3
- Success rates are only 46.6% overall, with better outcomes (60.2%) in children ≤15 years, but the technique is still not first-line for toddlers 4
Why Other Options Are Incorrect
Option A (Oxygen and chest X-ray): This approach wastes critical time in a child with complete airway obstruction and impending cardiopulmonary arrest. Oxygen cannot reach the lungs when the airway is completely obstructed. 1
Option B (Nebulized adrenaline): This is appropriate for croup or laryngotracheobronchitis causing inflammatory airway narrowing, not for mechanical obstruction by a foreign body. 1
Option C (Encourage strong cough): The child already has a weak cough, which is a danger sign indicating inability to generate adequate expiratory force—this means the obstruction is severe/complete and spontaneous coughing will not clear it. 1 Encouraging coughing is only appropriate for mild FBAO where the child can still cough effectively. 5
Critical Pitfalls to Avoid
- Never perform blind finger sweeps of the pharynx in infants and young children, as this can impact a foreign body deeper into the larynx 1
- Do not delay emergency medical services activation after initial assessment if the child shows any signs of respiratory distress 1
- Do not use abdominal thrusts as first-line in children under 1 year; chest thrusts are safer 1
- If the child becomes unconscious during your attempts, immediately call for emergency medical services and initiate chest compressions (CPR) 5
Physiologic Rationale
Back blows generate high initial peak pressures that may dislodge objects from the larynx, while chest thrusts generate more sustained increases in intrathoracic pressure to move the object out of the airway. 6 The combination of maneuvers is more effective than any single technique. 6
After Successful Clearance
Even if the foreign body is successfully removed, the child requires: