Foreign Body Airway Obstruction
in Children
Arnol D. Magbanua, RN, MAN
Introduction
• Between 2014 and 2016 there were 30
deaths from choking in infants and
children aged <14 years in England and
Wales (Office for National Statistics, 2017).
The causes of foreign-body airway
obstruction (FBAO) are split equally
between food and small objects
• A quick response can prevent death from
choking, so nurses should be able to
recognise and respond to FBAO. Those
working with families should also ensure
parents know how to prevent, recognise
and respond to it.
CHOKING
• Choking is a life-threatening emergency
that nurses must be able to recognise and
treat
FBAO
• Is clinical emergency that may be life
threatening. Nurses should be confident in
assessing the severity of airway
obstruction, delivering interventions to
relieve the airway obstruction and
knowing when to call for assistance.
Signs of FBAO
• Recognising the signs of FBAO in infants
and children is the key to early, effective
intervention. The context may provide
important clues – for example, choking is
common at mealtimes, or a child may
have been playing with small objects that
easily fit into the mouth. The most common
signs and symptoms of choking are:
• ·A cough;
• ·Struggling to breathe or talk (cry in
infants);
• ·Gagging – the infant/child may go silent
and hold or point to their throat.
• If the obstruction is only partial, the child
may be able to vocalise/cry, cough and
breathe
NCM 118 ENDTERM
Causes of FBAO
• Other causes of airway obstruction in
children – including laryngitis and
epiglottitis – present with similar symptoms.
The presence of a foreign body should be
suspected if the symptoms have a sudden
onset and there are no other systemic
signs of illness such as pyrexia.. If FBAO is
suspected, it is important to assess the
severity by establishing whether the
infant/child has an effective or ineffective
cough. In older children it is useful to ask
“are you choking?”; their response will
help distinguish between a mild or severe
obstructive airway
Causes of FBAO
• Altered level of consciousness
• Drug and/or alcohol intoxication
• Neurological impairment, with reduced
swallowing and cough reflexes (for
example, stroke)
• Respiratory disease
• Mental impairment
• Dementia
• Poor dentition
• Geriatrics
• Use of Metered Dose Inhalers
Signs of FBAO
Recognising the signs of FBAO is the key to early
and effective intervention. The context may
provide important clues – for example, choking is
common at mealtimes or a child may have been
playing with small objects.
• A cough
• Struggling to breathe or talk
• Cyanosis
• Grasping or reaching for the throat.
• The patient may go silent and hold or
point to their throat (Universal Sign of
Choking).
Assessment of FBAO
• If FBAO is suspected, it is important to
assess its severity and always ask the
patient “are you choking?”. Their response
will help distinguish between a mild or
severe obstructive airway
Lelah Faye P. Vidal BSN 4C
Severity of airway obstruction
Mild obstruction (effective cough)
The infant/child:
• ·Is crying/able to verbally respond to
questions
• ·Has a loud cough
• ·Is able to take a breath before coughing
and is fully responsive
Severe obstruction (ineffective cough)
Typically the infant/child:
• ·Is unable to vocalise
• ·Is quiet
• ·Has a silent cough
• ·Is unable to breathe
• ·Shows signs of cyanosis and decreasing
levels of consciousness
Severity of Airway Obstruction
• Mild airway obstruction (effective cough):
patient able to talk and has an effective
cough
• Severe airway obstruction (ineffective
cough): typically, patient responds “yes”
by nodding their head without speaking;
unable to cough effectively
Back Slaps in infants
NCM 118 ENDTERM
Prevention of choking in infants and children
Nurses should advise parents to:
• ·Always cut up food: infants and young
children can choke on small, sticky or
slippery foods
• ·Keep small objects out of reach: infants
and small children examine objects by
putting them in their mouths. Ensure small
toys/objects such as building bricks, button
batteries, coins and marbles are stored out
of reach
• ·Sit children down to eat
• ·Always supervise infants and young
children
Mild Airway Obstruction
• Coughing generates high and sustained
airway pressures and may expel a foreign
body, so it is important to encourage the
patient to cough. A patient with mild
airway obstruction should remain under
continuous observation until they improve
as a severe obstruction may subsequently
develop.
• Aggressive treatment with back blows and
chest and abdominal thrusts at this stage is
unnecessary – it may cause harm and
could exacerbate the airway obstruction.
These interventions should only be used if
the patient shows signs of severe airway
obstruction
Mild Airway Obstruction (Effective Coufh)
• Coughing generates high and sustained
airway pressures, and may expel a foreign
body, so it is important to encourage the
child to cough. Children with an effective
cough will be able to cry or verbally
respond to questions. In these situations,
no external manoeuvres – such as back
blows – are needed but close observation
is required until the infant/child improves,
as severe airway obstruction may
develop.
Severe Airway Obstruction
Ineffective Cough (Infants Less than 1 year)
If the patient shows signs of severe airway
obstruction:
• Call for help/pull the emergency buzzer
immediately and encourage the patient
to cough;
• Deliver up to five back blows (slaps) using
the following procedure:
Lelah Faye P. Vidal BSN 4C
 • ·Place the infant in a prone position
(usually over the lap) with the head
downwards to enable gravity to help
remove the foreign body;
• ·Stabilise the infant’s (floppy) head: place
the thumb of one hand at the angle of the
lower jaw and one or two fingers on the
opposite side of the jaw (take care not to
compress the soft tissues under the infant’s
jaw, as this could exacerbate the
obstruction of the airway);
• ·Deliver up to five sharp back blows (slaps)
with the heel of one hand in the middle of
the back between the shoulder blades.
Following each back blow, check to see
whether it has relieved the obstruction.
If back blows fail to dislodge the object and the
infant is still conscious, deliver up to five chest
thrusts
• ·Turn the infant supine with head in a
downwards position, using your arm to
support the infant’s back and your hand
to support the head. Your thigh can
provide additional support;
• ·Locate the ‘landmark’ for chest
compressions – this is the lower sternum
approximately a finger-width above the
xiphisternum;
• ·Perform up to five chest thrusts – these are
like chest compressions, but sharper in
nature and delivered at a slower rate;
• ·Following each chest thrust, check to see
whether the obstruction has been
dislodged;
• ·If the obstruction remains, continue
alternating up to five back blows with up
to five chest thrusts.
Severe airway obstruction (ineffective cough) in
children (>1 year)
If a child shows signs of severe airway obstruction:
NCM 118 ENDTERM
• Call for help/pull the emergency buzzer
immediately if in the hospital;
• Deliver up to five back blows (slaps) Figure
4
• ·Deliver up to five sharp back blows (slaps)
with the heel of one hand in the middle of
the back between the shoulder blades
(Fig 4). Following each back blow, check
to see whether the obstruction has been
dislodged.
• Position the child with their head down (a
small child may be placed over the lap, as
described above). If this is not feasible,
support the child into the leaning-forward
position recommended for adults (Fig 5);
If back blows fail to dislodge the object and the
child is still conscious, deliver up to five abdominal
thrusts (Fig 5) using the following procedure:
• ·Position yourself behind the child either
standing or kneeling. Place your arms
under the child’s arms;
• ·Place a clenched fist between the
umbilicus and xiphisternum;
• ·Hold the clenched fist with your other
hand; pull sharply inwards and upwards;
• ·Deliver up to five abdominal thrusts.
Following each abdominal thrust, check to
see whether the obstruction has been
dislodged;
• ·Take care not to apply pressure to the
xiphoid process or the lower rib cage as
this may cause abdominal trauma;
• ·If the obstruction remains, continue
alternating up to five back blows with up
to five abdominal thrusts.·
Lelah Faye P. Vidal BSN 4C

If the patient loses consciousness you should:
• ·Carefully support them to a flat surface;
• ·Summon help if it is still not available (do
not leave the infant/child);
• ·Open the infant’s/child’s mouth. If an
obvious object is seen, attempt to remove
it with a single finger sweep. Blind or
repeated finger sweeps are not
recommended because the object could
be pushed deeper into the pharynx;
• Open the airway and attempt five
ventilations. Determine the effectiveness
of each ventilation – if the chest fails to
rise, reposition the head;
• If the infant/child remains unresponsive,
commence chest compressions
immediately. It is advised for a lone
rescuer to perform cardiopulmonary
resuscitation for one minute before
summoning assistance;
• Before repeating ventilations, check the
mouth for the presence of an object and
remove it if this is possible (see above)
(Maconochie et al, 2017).
Aftercare and referral
• After successful treatment for a FBAO, the
foreign body may still be present in the
airways and can cause complications.
Advise parents/carers that they should
seek medical advice if the infant/child has
dysphagia or a persistent cough, or
complains of having something stuck in
their throat.
• As chest/abdominal thrusts and chest
compressions can cause serious internal
injury, patients must be examined for
injuries after these interventions have been
performed (Perkins et al, 2017).
Conclusion
• Professional responsibilities – These
procedures should be undertaken only
after approved training, supervised
practice and competency assessment,
NCM 118 ENDTERM
and carried out in accordance with local
policies and protocols.
Foreign Body Airway Obstruction
Arnol D. Magbanua, RN, MAN
Introduction
• Foreign-body airway obstruction (FBAO)
(choking) is a life-threatening emergency.
In England and Wales in 2016, 252 deaths
from choking were reported, with almost
30% of these in people aged 80 years and
over. Alarmingly, over 60% of deaths from
choking in 2016 occurred in hospitals and
other healthcare settings (Office for
National Statistics, 2017).
• In the Philippines, FBAO ranks as one of the
major cause of mortalities.
• Nurses must be able to recognise and
effectively treat FBAO. As most FBAO
events are associated with eating, they
are often witnessed, thereby providing an
opportunity for early intervention while the
patient is still conscious.
• Back blows (slaps), chest thrusts and
abdominal thrusts are manoeuvres that
can increase intra-thoracic pressure and
expel foreign bodies from the airway. In
50% of FBAO episodes, back blows alone
are effective at relieving the obstruction;
however, in 50% of cases more than one
technique is needed to relieve the
obstruction (Perkins et al, 2017).
Causes of FBAO
Choking usually occurs while the person is eating
or drinking and can be associated with muscle,
neurological or cerebral impairment (Pavitt et al,
2017). Most deaths from choking are caused by
food (87%), while small objects – a particular
problem in children – are the cause of 13% of
choking-related deaths (ONS, 2017).
People at increased risk of FBAO include those
with any of the following conditions or
characteristics:
• Altered level of consciousness
• Drug and/or alcohol intoxication
• Neurological impairment, with reduced
swallowing and cough reflexes (for
example, stroke)
Lelah Faye P. Vidal BSN 4C
 • Respiratory disease
• Mental impairment
• Dementia
• Poor dentition
• Geriatrics
• Use of Metered Dose Inhalers
Signs of FBAO
Recognising the signs of FBAO is the key to early
and effective intervention. The context may
provide important clues – for example, choking is
common at mealtimes or a child may have been
playing with small objects.
• A cough
• Struggling to breathe or talk
• Cyanosis
• Grasping or reaching for the throat.
• The patient may go silent and hold or
point to their throat (Universal Sign of
Choking).
Assessment of FBAO
If FBAO is suspected, it is important to assess its
severity and always ask the patient “are you
choking?”. Their response will help distinguish
between a mild or severe obstructive airway
Severity of Airway Obstruction
• Mild airway obstruction (effective cough):
patient able to talk and has an effective
cough
NCM 118 ENDTERM
• Severe airway obstruction (ineffective
cough): typically, patient responds “yes”
by nodding their head without speaking;
unable to cough effectively
Mild Airway Obstruction
• Coughing generates high and sustained
airway pressures and may expel a foreign
body, so it is important to encourage the
patient to cough. A patient with mild
airway obstruction should remain under
continuous observation until they improve
as a severe obstruction may subsequently
develop.
• Aggressive treatment with back blows and
chest and abdominal thrusts at this stage is
unnecessary – it may cause harm and
could exacerbate the airway obstruction.
These interventions should only be used if
the patient shows signs of severe airway
obstruction
Severe Airway Obstruction
If the patient shows signs of severe airway
obstruction:
• Call for help/pull the emergency buzzer
immediately and encourage the patient
to cough;
• Stand at the patient’s side, slightly behind
them;
• Support the patient’s chest with one hand
and lean them forward – if this dislodges
the foreign body, it will hopefully fall out of
the mouth instead of slipping further down
the airway;
If symptoms continue, deliver up to five back
blows (slaps) between the scapulae using the
heel of the hand.
• Following each back blow, check to see if
the obstruction has been dislodged;
If the back blows fail, proceed to abdominal
thrusts.
• Stand behind the patient, placing both
arms around the upper abdomen;
• Lean the patient forward;
• Place a clenched fist between the
patient’s umbilicus and the ribcage, and
clasp it with the other hand;
Lelah Faye P. Vidal BSN 4C
 • Deliver up to five sharp thrusts to the
abdomen, inwards and upwards;
• Take care not to apply pressure to the
xiphoid process or the lower ribcage as
this may cause abdominal trauma;
• If the obstruction remains, alternate up to
five back blows with up to five abdominal
thrusts.
If the patient loses consciousness you should:
• Carefully support them to the ground;
• If you have not done so already, summon
help following local protocols – call for an
ambulance or contact your cardiac arrest
team;
• Start cardiopulmonary resuscitation (CPR)
– do 30 chest compressions first as these
may relieve the obstruction;
After 30 compressions, attempt two ventilations,
then continue CPR until the patient recovers and
starts to breathe normally.
Abdominal thrusts in an obese or pregnant patient
• It may be difficult to carry out abdominal
thrusts on a patient who is obese or
pregnant. If you cannot encircle their
NCM 118 ENDTERM
abdomen, stand behind the patient,
position your hands over the lower end of
the sternum and pull hard into the chest
with quick thrusts (chest thrusts)
Aftercare and referral
• Following successful treatment for an
FBAO, a foreign body may still be present
in the airways; if someone has dysphagia,
a persistent cough or complains of having
something stuck in their throat, they should
seek medical advice.
• Performing abdominal thrusts and chest
compressions has the potential to cause
serious internal injury, including ruptures or
laceration of abdominal or thoracic
viscera, so patients must be examined for
injuries.
Use of airway clearance devices
• Although there are several airway clearing
devices for the treatment of FBAO
currently available, their routine use is not
recommended. However, appropriately
trained health professionals can use
advanced techniques – such as suction or
laryngoscopy and forceps – to remove a
foreign body from the airway.
Conclusion
• FBAO is a life-threatening emergency that
nurses must be able to recognize and
effectively treat.
Lelah Faye P. Vidal BSN 4C