Foreign Body Airway Obstruction Care

Last Full Review: ILCOR 2020; American Red Cross Scientific Advisory Council 2019
Last Update: 2023

Are any techniques for removing a foreign body obstruction more effective and safer than other techniques?

 

Evidence Summary

A 2020 ILCOR systematic review (Couper et al. 2020, 174) and Consensus on Science with Treatment Recommendations (Olasveengen et al. 2020, S41) evaluated interventions to remove foreign body airway obstruction in adults and children with foreign body airway obstruction (FBAO) in any setting using finger sweeps, back blows/slaps, abdominal thrusts, chest thrusts and suction-based airway clearance devices. Outcomes included survival, survival with good neurological outcome, return of spontaneous circulation, relief of airway obstruction, injury, and complications. The 2020 International Liaison Committee on Resuscitation (ILCOR) review agrees with existing American Red Cross Scientific Advisory Council reviews on this topic.

 

Back Blows/Slaps

Observational studies were identified for the outcomes of survival, relief of FBAO, and injuries/complications but were judged to be at very serious risk of bias and to have a high degree of heterogeneity. Thus, meta-analysis was not performed, and results of individual studies were felt to be difficult to interpret. Very low-certainty evidence from one case series reported survival in 13 children under the age of 5 treated for FBAO with the use of back blows (Vilke et al. 2004, 196). Three case series reported relief of FBAO in 75 persons with the use of back blows (Vilke et al. 2004, 196; Igarashi et al. 2017, 1396; Redding 1979, 475). Four case reports (Guinane and Lee 2018, 1272; Nowitz et al 1998, 129; Patterson et al. 1993, 741; Rakotoharinandrasana et al. 2003, 43) describe injuries/complications in persons who received back blows (Olasveengen et al. 2020, S41).

 

Abdominal Thrusts

The review of abdominal thrusts for FBAO (Olasveengen et al. 2020, S41) identified observational studies evaluating outcomes of survival, relief of FBAO, and injuries or complications, with an overall very low certainty of evidence due primarily to very serious risk of bias due to confounding for the individual studies. No meta-analysis was performed because of this and heterogeneity. Two case series reported survival in 189 persons treated using abdominal thrusts; six case series reported relief of FBAO in 417 persons cared for using abdominal thrusts, and 49 case reports identified 52 reports of injuries/complications in those cared for using abdominal thrusts (Olasveengen et al. 2020, S41).

 

Chest Thrusts/Compressions

Only observational studies were identified evaluating use of chest thrusts and compressions for the outcomes of survival with favorable neurological outcome, relief of FBAO, and injuries/complications (Olasveengen et al. 2020, S41). Because of heterogeneity and very serious risk of bias due to confounding, meta-analysis was not performed, and results of individual studies were felt difficult to interpret. Very low-certainty evidence from one observational study (Kinoshita et al. 2015, 63) of 138 persons with FBAO was reported to show benefit for the outcome of survival with favorable neurological outcome with use of chest thrusts/compressions compared with control. One case series reported 28 cases with relief of FBAO using chest thrusts/compressions, while four studies reported five cases of injuries/complications following use of chest thrusts/compressions for FBAO (Olasveengen et al. 2020, S41).

 

Finger Sweep

Only observational studies were identified for the outcomes of survival, relief of FBAO, and injuries/complications. Because of heterogeneity and very serious risk of bias due to confounding, meta-analysis was not performed, and it was felt that individual studies were difficult to interpret. One case series was included that reported survival in six FBAOs with use of a finger sweep, while two case series reported relief of 36 FBAOs with use of a finger sweep. Injuries/complications were reported in 10 cases of FBAO from eight case reports following blind finger sweeps (Olasveengen et al. 2020, S41).

 

Magill Forceps

One observational study enrolled 240 FBAOs and reported an association with increased survival with favorable neurological outcome with the use of Magill forceps by Emergency Medical Services personnel compared with no use of Magill forceps (RR, 3.96; 95% CI, 1.12–13.00;107 more/1000 survived with the intervention, 95% CI, 8 more persons/1000 to 324 more/1000 survived with the intervention) (Sakai et al. 2014, 53). This same study did not show a benefit from the intervention for the outcomes of survival. Four case series reported relief of FBAO in 417 patients treated with Magill forceps (Olasveengen et al. 2020, S41).

 

Suction-Based Airway Clearance Devices

A single convenience sample case series with very low-certainty evidence reported survival and relief of FBAO in nine adults with use of a suction-based airway clearance device (Olasveengen et al. 2020, S41).

 

FBAO Removal by Bystanders

A single observational study (Igarashi et al. 2017, 1396) with very low-certainty evidence from 41 patients with FBAO found benefit for the outcome of survival with favorable neurological outcome following FBAO removal by bystanders (74% versus 32% in the control, P=0.0075) (Olasveengen et al. 2020, S41). A weak recommendation is made by ILCOR (Olasveengen et al. 2020, S41) for the initial use of back slaps in persons with FBAO and an ineffective cough. It is suggested that abdominal thrusts be used in adults and children with an FBAO and an ineffective cough where back slaps are ineffective (Olasveengen et al. 2020, S41).

It is suggested by ILCOR that (Olasveengen et al. 2020, S41):
• Rescuers consider the manual extraction of visible items in the mouth, and is it suggested to not use a blind finger sweep with FBAO.
• Appropriately skilled individuals consider the use of Magill forceps to remove FBAO in out-of-hospital cardiac arrest with an FBAO.
• Chest thrusts are used in unconscious persons with an FBAO.
• Bystanders undertake interventions to support FBAO removal as soon as possible after recognition.

An updated scientific review by American Red Cross Scientific Advisory Council (American Red Cross Scientific Advisory Council 2020) on FBAO completed in 2019 included additional case series and reports describing successful use of back blows/slaps, chest thrusts and abdominal thrusts, as well as one study in healthy volunteers that evaluated airway pressure changes during different methods of applying abdominal thrusts. No change was made to guidelines with this updated review.

 

Insights and Implications

The Red Cross guidelines and ILCOR recommendations are similar for the initial efforts to resolve a complete FBAO with use of back slaps/blows. Red Cross provides the option for abdominal and/or chest thrusts and provides guidance for management of unconscious patients with complete foreign body airway obstruction using cardiopulmonary resuscitation (CPR), similar to treating any other unresponsive person who is not breathing normally. The ILCOR systematic review noted reports of harm associated with use of back blows, abdominal thrusts, chest thrusts/compressions and blind finger sweeps and suggests that management should balance the benefits and harms of interventions (Couper et al. 2020, 174). In conscious individuals, ILCOR also notes that encouraging coughing at first may be effective and is felt unlikely to cause harm (Olasveengen et al. 2020, S41). Use of CPR for an unconscious patient is a simple method to allow lay responders and healthcare professionals to incorporate the techniques of assessment, chest thrusts, finger sweeps as indicated, and re-assessment.