Airway Skills 12:
Tracheal Foreign Body Removal
- For airway obstruction caused by food (such as steak, wieners, grapes, etc.) in an awake and standing person, first try the Heimlich maneuver. Stand behind the patient and encircle the torso with your arms. Place the thumb side of your fist in the midline just above the navel and below the rib cage. Place your other hand on the fist. Apply a quick thrust to the abdomen with the fist in an upward direction. Repeat this for a total of five thrusts. If the patient is awake, he or she should now be able to spit out the obstruction. PEDS: This is the same for pediatric patients. In very obese patients or pregnant patients, use chest thrusts instead.
For a supine, unconscious patient, opening the airway with a jaw-lift maneuver may allow visualization of the obstruction in the upper airway and may permit removal of the object with fingers or the Magill forceps. If not, straddle the patient’s legs and apply an open hand to the abdomen just above the navel, and place your other hand on top of the first hand. With the heel of your hand, apply five upward thrusts. Open the upper airway again, perform a finger sweep in adults, if possible, and remove the foreign material. If the obstructing material is beyond reach in the trachea below the vocal cords, it may not have been ejected.
In late pregnancy, use chest thrusts. PEDS: In infancy, use five back blows and five chest thrusts. Do not perform a blind finger sweep in small children because it may impact the foreign body (FB) into the trachea.
- For partial airway obstruction, attempt to temporize by administering oxygen with a BVM or blow-by. A gas composed of helium and oxygen may also be used to ventilate. The preferred gas mixture is 80% helium and 20% oxygen. This gas (called heliox) has low density and promotes laminar flow to produce an improved flow of gas around the FB. (Vol II—Breath Skills 4 Heliox)
Do not attempt tracheal FB removal unless the obstruction is complete or the patient decompensates and the Heimlich maneuver has failed. If there is partial obstruction, support ventilations as best as possible and arrange for emergency endoscopic removal.
- If the situation is life threatening or for complete obstruction,
try the following:
- Cut off the end of an ET tube appropriate for the size of the patient. A size 7.5 is appropriate for most adults. Cut it squarely, just proximal to the Murphy eye.
The needed equipment - an ET tube that has been cut off squarely
proximal to the Murphy eye, a syringe style esophageal intubation detector
(EID), and a meconium aspiration adaptor attached to wall suction
- Advance the ET tube down the trachea with the aid of an ET tube introducer (ETI) until slight pressure is felt. Cricoid pressure may ease this process.
- Use the wall suction outlet in the ED and adjust it to maximum vacuum. Attach a meconium aspirator to the suction tubing and to the ET tube and apply suction to pull the obstructing object from the trachea.
A fishing lure is being extracted from a glass trachea using wall suction.
- If wall suction is not available, attach an esophageal intubation detector (EID) to the ET tube. Stand to the patient's right side. Apply a vigorous pull on the plunger resulting in a vacuum seal between the ET tube and the FB. Do not pull out the syringe barrel completely. Pull out the ET tube while sensing the vacuum in the syringe. If the vacuum is lost, the rescuer pushes the plunger back into the EID without removing it, advances the ET tube back down the trachea, and then repeats the process.
Vacuum extraction using an
EID requires practice.
A glass model of the trachea is an invaluable training tool
- An assistant is ready with a laryngoscope and Magill forceps in case the object is only partially pulled through the larynx.
- Even if the FB is not extracted, reattempt ventilation because it may have been dislodged or pushed into the right main stem bronchus.
- PEDS: Vacuum extraction of a
balloon or other FB from an infant or
toddler's trachea:
If only partial obstruction is present, temporize until formal bronchoscopic removal can be arranged. If, however, the child is in mortal danger, proceed as follows:
- Cut off the tip of the appropriate size ET tube as above proximal to the Murphy eye.
- Insert a pediatric ETI (8 French PEDS ET tube exchanger) into the trachea and pass the modified ET tube over it into the trachea.
- If wall suction is available, attach the meconium aspiration adaptor to suction tubing and the ET tube. Adjust the vacuum greater than about 150 mm Hg negative pressure.
- Have an assistant ready with a laryngoscope and Magill forceps to grasp the balloon or other FB if it is only partially extracted.
- An esophageal intubation detector may be used if no vacuum source is available. The rescuer will not be able to sense a balloon on the ET tube, so it should be pulled out quickly while the plunger is being pulled out of the barrel of the syringe.
Reference
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Ruiz E, Stolzenberg BT, Bowker DD, McGill JW. Successful vacuum extraction of obstructing tracheal foreign bodies in a sheep model. 1997, unpublished report.