If a child who is presumed to have aspirated a foreign body has severe signs and symptoms but is maintaining the airway, alert, and able to speak, the predetermined obstructed airway protocol should be instituted. If local personnel are not able to remove the foreign body, a transport team experienced in the management of the difficult pediatric airway should be summoned to the patient's location. Ideally, the transport team will have a physician member trained and experienced in the removal of foreign bodies and in the management of the difficult pediatric airway. In general, the foreign body should be removed. If not possible, in the case of a supralaryngeal foreign body, the child should be electively intubated prior to transport. Exceptions may occur based on clinical circumstances. Racemic epinephrine or heliox may be an alternative.

The outcome of patients with laryngotracheal foreign-body aspiration and sudden collapse or cardiopulmonary arrest primarily depends upon appropriate bystander basic life support and emergency medical system response. Basic pediatric cardiopulmonary resuscitation (CPR) and foreign-body removal are discussed in Chap. 10. If no spontaneous breathing is detected, two slow breaths should be given. If air does not enter easily, causing a rise of the chest, then the head-tilt chin-lift maneuver should be reapplied and rescue breaths reattempted. If still no air enters the lungs, foreign-body obstruction is likely. The child's mouth should be opened, and if a foreign body is visualized, it should be removed.

Relief of obstruction in the infant is performed by holding the infant in the head-down prone position and giving up to five forceful back blows between the infant's shoulder blades with the heel of one hand. The infant is then turned to the supine position and given five quick chest compressions one finger's breadth below the intermammillary line. Once again, the oropharynx should be opened, and if a foreign body is visualized, it should be removed. If not, the airway should be opened by the jaw-thrust chin-lift maneuver and rescue breathing should be attempted. If air does not enter the lungs, the head should be repositioned and the jaw-thrust chin-lift maneuver reapplied and rescue breathing reattempted. If still no air enters the lungs, back blows and chest thrusts should once again be administered.

In a child over 1 year of age, the same sequence should occur with the exception that no back blows are given and the Heimlich maneuver is used instead of chest thrusts. The Heimlich maneuver should be performed in the standard fashion well below the tip of the xiphoid and slightly above the navel in the midline. Five distinct upward thrusts should be administered followed by reevaluation of the airway and another attempt at rescue breathing. If, after two cycles, the airway in the infant or child is not opened, allowing passage of air during rescue breathing, direct laryngoscopy should be used to locate and remove the foreign body, if possible using McGill forceps.

If, upon laryngoscopy the foreign body is noted to be below the cricoid ring within the trachea, an endotracheal tube should be placed. The child can often be ventilated after this maneuver. One must be absolutely certain that air is actually entering the lungs, however, and not just filling the pharynx and stomach. If, after an endotracheal tube is placed, the child still cannot be ventilated, the endotracheal tube should be gently advanced in hope of pushing the foreign body from the trachea into one of the mainstem bronchi. The endotracheal tube is then withdrawn to its normal position and ventilation is attempted. If the foreign body is visualized at the glottis but cannot be removed, a needle cricothyroidotomy may be lifesaving. Esophageal foreign-body removal is typically a semielective procedure. Those esophageal foreign bodies causing a respiratory embarrassment or serious potential for gastrointestinal injury due to puncture, laceration, or corrosion should be removed by endoscopy. Esophageal foreign bodies not causing respiratory distress and thought to be of low risk to the gastrointestinal system if allowed to pass should be monitored for progression toward the stomach over 8 to 12 h.

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