Airway 2: Airway Obstruction Portal
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For airway obstruction caused by food (such as steak, wieners, grapes,
etc), first try the Heimlich maneuver, which may be applied to a
standing patient as well as to a patient who has collapsed and is
supine. For a standing patient, 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.
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; 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.
In infancy, use 5 back blows and 5 chest thrusts. Do not perform a blind finger sweep.
- 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 foreign
body. Use the recommended liter flow and delivery method (ie, 10
liters/minute with a non-rebreather mask). (Vol III—AIR3 Heliox Treatment)
In addition to foreign body management, heliox is useful in the management of croup and in the initial management of tracheal obstruction caused by hematomas and tumors. Heliox is not useful when the airway difficulty is in the small airways, as in asthma or pulmonary edema.
- Do not attempt tracheal foreign body 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 in the case of complete obstruction, try the following procedures:
- 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.
- 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.
- If wall suction is not available, attach an esophageal intubation detector (EID) to the ET tube. Apply a vigorous pull on the plunger resulting in a vacuum seal between the ET tube and the foreign body. 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.
- An assistant is ready with a laryngoscope and Magill forceps in case the object is only partially pulled through the larynx.
- Even if the foreign body is not extracted, reattempt ventilation because it may have been dislodged or pushed into the right main stem bronchus.
Vacuum Extraction of a Balloon from a Child’s Trachea
PEDS: 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 parallel to the bevel but proximal to the Murphy eye.
- Insert the ET tube stylet in the modified ET tube and intubate using standard practice technique.
- 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 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 the 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.