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Obstruction of airway caused by foreign body — Clinical Guidelines

Overview

Foreign body airway obstruction (FBAO) is a life-threatening emergency that can lead to death if not promptly addressed with appropriate interventions. It affects various settings, including dental practices and pediatric populations, necessitating swift recognition and management. 1 2 4

Diagnosis

Clinical Presentation: Stridor, cyanosis, inability to speak or breathe, and unconsciousness.

Physical Examination: Focus on respiratory distress, absent breath sounds on the affected side, and cough characteristics.

Diagnostic Tools: Imaging (X-ray, CT) may help identify the foreign body, though clinical judgment often precedes imaging. 2 4

Management

First-Line Treatment:

- Heimlich maneuver: Recommended for conscious choking adults. - Back blows and abdominal thrusts: Essential in emergency settings.

Advanced Airway Management:

- Suction: Immediate use in suspected FBAO. - Intubation: Necessary if airway obstruction persists despite basic life support measures.

Specialized Devices:

- Magill forceps and spongestick forceps: Effective for supraglottic foreign body removal with high success rates and quicker extraction times compared to nasal trumpets. 6

Anesthesia Considerations:

- Nebulized lidocaine: Used preoperatively in pediatric patients to achieve adequate airway anesthesia; addition of fentanyl may further enhance analgesia. 5 - Ketamine-midazolam: Shown to be effective for esophageal foreign body removal in pediatric ED settings, associated with fewer airway complications and shorter procedure times compared to fentanyl-midazolam or general anesthesia. 8

Special Populations

Pediatrics: Higher morbidity and mortality rates; requires meticulous procedural conditions and optimal training of staff. Human factors such as equipment availability and staff confidence are critical. 4

Elderly: Increased risk due to comorbidities; management should consider potential underlying respiratory conditions.

Comorbidities: Presence of respiratory diseases may complicate diagnosis and management, necessitating careful airway assessment and possibly advanced interventions. 2

Key Recommendations

Immediate Basic Life Support: Perform Heimlich maneuver and back blows for conscious choking adults (Evidence: Strong 6).

Use Effective Extraction Tools: Prefer Magill forceps or spongestick forceps over nasal trumpets for supraglottic foreign body removal due to higher success rates and quicker extraction times (Evidence: Moderate 6).

Consider Nebulized Anesthesia in Pediatrics: Utilize nebulized lidocaine, with optional fentanyl addition, for pediatric rigid bronchoscopy to enhance airway anesthesia (Evidence: Moderate 5).

Evaluate Ketamine-Midazolam for Pediatric ED Settings: For esophageal foreign body removal, ketamine-midazolam may reduce complications and shorten hospital stay compared to other methods (Evidence: Moderate 8).

Enhance Training and Equipment Availability: Ensure adequate training and availability of necessary equipment for managing pediatric airway emergencies to improve outcomes (Evidence: Expert opinion 4).

References

1 Bhanderi BG, Palmer Hill S. Evaluation of DeChoker, an Airway Clearance Device (ACD) Used in Adult Choking Emergencies Within the Adult Care Home Sector: A Mixed Methods Case Study. Frontiers in public health 2020. link 2 Jevon P. Management of choking in the dental practice. British dental journal 2019. link 3 Al-Ramahi J, Luo H, Fang R, Chou A, Jiang J, Kille T. Development of an Innovative 3D Printed Rigid Bronchoscopy Training Model. The Annals of otology, rhinology, and laryngology 2016. link 4 Okonkwo OC, Simons A, Nichani J. Paediatric airway foreign body - The human factors influencing patient safety in our hospitals. International journal of pediatric otorhinolaryngology 2016. link 5 Moustafa MA. Nebulized lidocaine alone or combined with fentanyl as a premedication to general anesthesia in spontaneously breathing pediatric patients undergoing rigid bronchoscopy. Paediatric anaesthesia 2013. link 6 Salati DS. Responding to foreign-body airway obstruction. Nursing 2006. link 7 Higgins GL, Burton JH, Carter WP, Floor AE. Comparison of extraction devices for the removal of supraglottic foreign bodies. Prehospital emergency care 2003. link 8 Hostetler MA, Barnard JA. Removal of esophageal foreign bodies in the pediatric ED: is ketamine an option?. The American journal of emergency medicine 2002. link

Obstruction of airway caused by foreign body