The management of foreign-body aspiration (Fig.
118-1) varies according to presentation of the disorder and
age of the patient. If the child presents with acute signs and symptoms of
airway obstruction due to foreign-body aspiration but is conscious
and can cough, breathe, or speak, then the child should proceed
to the hospital for foreign-body removal. However, if the child
appears to have complete obstruction of the airway, and becomes unconscious
and cyanotic, then the rescuer should intervene. Blind finger sweeps
are to be avoided in infants and children because the foreign body
could be pushed back into the airway, causing further obstruction.
If the foreign body can be visualized, it should be manually removed,
using Magill or other large forceps if available. When initial interventions fail,
a jaw thrust should be performed, with the hope of partially relieving
the obstruction. In the unconscious, nonbreathing child, a tongue-jaw
lift can be performed by grasping both the tongue and lower jaw
between the thumb and finger and lifting. If these maneuvers fail,
and based on current American Heart Association recommendations,
the most appropriate intervention for infants under the age of 1
year consists of holding the infant face down along the rescuer’s
arm and delivering a series of sharp back blows between the shoulder
blades. For children over the age of 1 year, the Heimlich maneuver
(subdiaphragmatic abdominal thrusts) should be the first mode of intervention.
If all of these methods of reestablishment of adequate air exchange
fail, and the child remains cyanotic, unconscious, and obstructed
and is not ventilating adequately, an attempt to establish a surgical
airway, such as a tracheotomy or cricothyroidotomy distal to the
suspected site of obstruction, should be considered. Although the
performance of both tracheotomy and cricothyroidotomy can be technically
challenging, cricothyroidotomy may be even more difficult than tracheotomy due
to the performance of the technique through a very small opening
and the marked mobility of the laryngeal, tracheal, and esophageal
structures in young children.