Every year, hundreds of children die, particularly in the preschool age group, after inhaling a foreign body, the commonest cause of accidental death in the under 1-year-old group.
[1] Consumer product safety standards have helped decrease this number by dictating the minimum size of toys and their components suitable for this at-risk under 4-year-old age group,
[2] or by modifying previously dangerous items such as ballpoint pen tops. In addition, responsible manufacturers have withdrawn some of the dangerous elements of their product range. Tragically, however, children still choke on a host of things around the home, including food such as hot dog, crisps, nuts and buttons with resultant avoidable deaths. Small children will put almost any object in their mouths and the potential for a choking accident always exists.
Diagnosis
The diagnosis of foreign body inhalation is not always obvious, especially if unwitnessed. It should be suspected in any infant or child who develops sudden onset respiratory distress, particularly if associated with coughing, gagging, stridor or wheeze. A collapsed apnoeic child with foreign body aspiration may also present with a chest that cannot beinflated despite adequate airway opening manoeuvres and rescue breaths. The differential diagnosis includes a number of important infections, such as croup and epiglottitis with upper airway edema and obstruction. They should be suspected in children who, in addition to upper airway obstruction, present with features such as fever, lethargy, hoarseness or drooling. Incorrect diagnosis leading to inappropriate management can be disastrous and may result in worsening obstruction and possible death. These children should be taken to an appropriate hospital facility as a matter of urgency.
Small inhaled objects may well pass down into the distal bronchial tree and, if a careful history and examination are not performed, they could be mistaken for asthma. Unilateral wheeze and air trapping on chest X-ray are helpful clues. Bronchoscopic retrieval of even a small asymptomatic foreign body is necessary to prevent infection developing.
Treatment
A child suspected of foreign body inhalation should be managed as a priority in a calm and reassuring manner. When foreign body aspiration is either witnessed or strongly suspected and the child is still able to cough, he or she should be encouraged to do so for as long as a forceful cough is maintained.
In the absence of an effective cough or respiratory effort with the development of stridor, cyanosis and unconsciousness and in the presence of obstructed breathing, other techniques are used to try and dislodge an inhaled foreign body. The technique depends on the age of the victim. They are all designed to create an artificial cough by rapidly increasing intrathoracic pressure, thereby expelling air to expel the foreign body.
Blind finger sweeps in a child’s mouth are not recommended and should not be performed. They are likely to cause the child to panic all the more or even push a foreign body at the back of the throat further down into the airway making it more difficult to remove. In addition the soft palate is easily damaged and blood tracking down into the airway increases obstruction.
In the unconscious apnoeic child, airway opening manoeuvres should be performed. In addition to the standard techniques, the tongue-jaw lift is useful and is achieved by grasping the tongue and lower jaw between finger and thumb and pulling forwards. This pulls the tongue off the back of the throat and may relieve the obstruction and make visualisation of a foreign body easier. If the foreign body is visible it should be removed preferably with Magill’s forceps.
a. Infants
A combination of back blows and chest thrusts only is recommended in this age group. Infants have a relatively large liver and abdominal thrusts could potentially result in abdominal injury.
The rescuer should place the baby prone and head down over the outstretched arm with the forearm resting on the thigh, supporting the baby’s head. Five back blows, with the heel of the free hand, are then delivered between the baby’s shoulder blades. Should this be unsuccessful the baby is turned over, again head down and cradled on the outstretched arm. Five chest thrusts are then delivered using the same landmarks and techniques as for cardiac massage, only more slowly. Larger infants can be dealt with the same way but with the child resting over the lap.
b. Children
In the older child, back blows are carried out as in the larger infant with the child lying over the lap. If the victim is conscious, abdominal thrusts (the Heimlich manoeuvre) [3] can then be used with the child sitting, standing, lying or kneeling. If unconscious, the victim should be managed lying in the supine position. When the child is in other than the lying position, the rescuer should stand behind and place the arms around the child’s torso with a clenched fist against the abdominal wall between the xiphisternum and umbilicus. The other hand is then placed over the fist and both hands are thrust rapidly upwards into the abdomen. This is performed five times or less if the foreign body is expelled.
To carry out abdominal thrusts with the child lying supine, the rescuer kneels to one side or astride the child and places the heel of one hand on the abdominal wall between the umbilicus and xiphisternum. The free hand is then placed onto the first hand and five vigorous midline upward thrusts are carried out or until the foreign body is expelled.