THE CLINICAL CHALLENGE
Airway obstruction caused by a foreign body presents a unique series of challenges to the practitioner. First, when incomplete obstruction is present, there exists the possibility that a particular action, or the failure to take specific action, could aggravate the situation by converting a partial obstruction to a complete obstruction. Second, when complete obstruction is present, instinctive interventions, such as bag-mask ventilation, have the potential to make the situation worse, for example, by causing a supraglottic obstruction to move below the cords making retrieval more difficult or impossible. Third, a common maneuver, such as the endotracheal intubation with bag ventilation, may meet with an unexpected result, such as the complete inability to move any air, defying the provider’s attempts to find a solution to a problem perhaps never before encountered. Finally, the completely or partially obstructed airway is a unique clinical situation, unlike other airway threats, and requires a specific set of evaluations and interventions, often in a very compressed period of time.
The patient with a foreign body in the airway may present with signs of upper airway obstruction or may present comatose and apneic, with only the history of onset to provide clues as to the cause of the crisis. The obstruction may be complete, as in the patient who aspirates a food bolus, and is unable to move sufficient air to phonate. Although these situations usually arise in the out-of-hospital setting, they may occasionally present to the emergency department (ED), usually when an incomplete obstruction converts to a complete obstruction. A partially obstructing foreign body will cause symptoms and signs of incomplete upper airway obstruction, specifically stridor, altered phonation, subjective difficulty breathing, and often a sense of fear or panic on the part of the patient. In many cases, there will be a preceding condition that has increased the risk of aspiration. Many patients who aspirate food are physically or mentally impaired, elderly, or intoxicated with drugs or alcohol.
APPROACH TO THE AIRWAY
Management of the suspected or known foreign body in the adult airway follows similar rationale to that used in the pediatric patient (see Chapter 27) and depends on the location of the foreign body and whether the obstruction is incomplete or complete. Location may be supraglottic, infraglottic, or distal to the carina. Because the precise location of the foreign body is usually not known, the following discussion focuses on the approach to the foreign body whose location is uncertain.
Incomplete Obstruction by a Foreign Body
When the patient presents with an incompletely obstructing foreign body, the objective is to reestablish a fully patent airway and prevent the conversion of a partial obstruction to a complete obstruction. If the patient is cooperative, breathing spontaneously and oxygen saturation adequate (possibly with supplemental oxygen), then the best approach often is to have emergency airway equipment immediately accessible in case the patient deteriorates while efforts are made to rapidly mobilize the necessary providers for prompt removal in the operating room (OR). Some foreign bodies are obviously accessible and can be removed in the ED. There is risk, however, with an incompletely obstructing supraglottic foreign body, that attempts at removal in the ED might result in displacement of the foreign body into the trachea, where it is no longer amenable to removal with common ED instruments. If transfer to the OR is not an option (e.g., because it would require transfer to another hospital), then a decision must be made as to whether the foreign body should be removed in the ED. If so, the best approach is to handle the airway much as one would handle awake laryngoscopy for a difficult intubation (see Chapter 23
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