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MarkkuKuisma

Foreign Body in the Respiratory Passages

Essentials

  • Personnel at emergency telephone service and health care facilities should know simple measures to remove foreign bodies from the upper respiratory passages.
  • Mouth-to-mask or mouth-to-mouth ventilation should always be tried after unsuccessful removal of a foreign body, as increased pressure in the respiratory passages may lead air past the foreign body.
  • If emergency equipment (laryngoscope, Magill forceps) is at hand, first explore and if necessary empty with the Magill forceps the pharynx and the supralaryngeal area where the largest foreign bodies (typically a piece of food in adults) get stuck. Blind exploration by sweeping a finger in the patient's mouth and pharynx is not recommended.

Removing a foreign body

  • See picture 1.
  • If the patient is able to cough, encourage him/her to continue coughing without other interventions.
  • If the patient is not able to cough http://www.dynamed.com/management/pediatric-basic-life-support-bls#GUID-A4759E79-4554-4E6C-A793-E07C0065700D but is conscious
    1. Stand to the side and slightly behind the patient, lean his/her upper body well forwards so that the head comes below the waist level, and simultaneously support the patient by the chest with your other arm.
    2. Give five sharp blows between the shoulder blades with the heel of your other hand.
    3. After every blow, check whether the foreign body has come loose and the airway obstruction is relieved.
  • The instructions given above may also be applied in children over one year of age. Infants less than one year of age: place the infant on the palm of your hand in prone position with the head downwards and give five sharp slaps on the back (adjust the force to the size of the infant).
  • If the obstruction is not relieved by the blows, abdominal thrusts (Heimlich manoeuvre, picture 2) may be tried in patients who are awake. It should not be used in infants as it may cause visceral injuries.
    • Grasp the patient's upper abdomen from the back by crossing your hands above the navel and thrust upwards and backwards towards yourself so that the patient's intra-abdominal pressure rises, the diaphragm is elevated, and air is blown from the lungs.
    • Repeat five times if needed.
  • If the patient remains conscious but the foreign body does not come loose, continue alternating five back blows with five abdominal thrusts until the foreign body is loosened.
  • If the patient becomes unconscious, place him/her in recumbent position and begin CPR.
  • See ERC Guidelines 1.

Laryngoscopy or bronchoscopy

Opening an airway with a needle and emergency tracheotomy

  • If the upper airway has been blocked, e.g., by facial trauma and intubation is unsuccessful, the trachea can be cannulated with a thick Viggo® needle (G14) just below the thyroid cartilage. This method is easier and quicker than emergency tracheostomy. A commercially available ready-to-use coniotomy set may also be used for the intervention.
    1. If quickly available, attach a syringe partially filled with saline solution to a needle.
    2. Insert the needle into the trachea in the midline aspirating continuously. Bubbling of air in the syringe indicates that the needle is in the trachea. Be careful not to puncture the back wall of the trachea.
    3. Remove the mandrine and attach the cannula to a breathing bag using e.g. a 20-ml syringe.
    4. Ensure that the cannula remains in the trachea by keeping it in place manually (do not bend the cannula).
    5. If necessary, place another cannula next to the first one to hasten expiration.
  • For emergency tracheotomy, see videos Cricothyrotomy Using an Intubation Tube (Emergency Tracheotomy) and Cricothyrotomy Using a Mini-Trach Cannula (Emergency Tracheotomy).

Foreign body in lower respiratory passages

  • Most common in children less than 10 years of age, especially during the second year of life
  • The foreign body may in principle be any tiny object, but different food stuffs, especially nuts and nut chocolate are the most common causes.

Symptoms

  • Often begin with a forceful coughing spell. The initial phase often also includes wheezing and even cyanosis.
  • The symptoms continue for a few minutes and then stop, even though the foreign body remains in the bronchus.
  • An asymptomatic phase will then follow, lasting hours or even days, before the pneumonia phase; at this point the initial event may already have been forgotten, which delays and complicates diagnosis. The physician should therefore actively ask about the early history of the condition.

Diagnosis

References

  • The European Resuscitation Council Guidelines for Resuscitation 2021 http://cprguidelines.eu/
  • Couper K, Abu Hassan A, Ohri V et al. Removal of foreign body airway obstruction: A systematic review of interventions. Resuscitation 2020;(156):174-181. [PubMed]