11.5 Foreign Body Airway Obstruction: Recognition & Relief Across the Lifespan

11.5 Foreign Body Airway Obstruction: Recognition & Relief Across the Lifespan

CPCF Appendix A skill #21 lists two distinct competencies that candidates routinely conflate: remove airway foreign bodies by indirect techniques (back blows, abdominal thrusts, chest thrusts, chest compressions) and remove airway foreign bodies by direct techniques (direct laryngoscopy with Magill forceps). Both are minimum entry-to-practice skills for the Primary Care Paramedic. Foreign body airway obstruction (FBAO) is also one of the few genuinely reversible causes of cardiac arrest a PCP can fix outright at the bedside.

Partial Versus Complete Obstruction: The Decision That Drives Everything

[!CAUTION] The single most common error is intervening in a mild obstruction. A forceful cough generates far higher airway pressures than any thrust you can deliver; interrupting it can convert a partial obstruction into a complete one by displacing the object. Stay with the patient, encourage coughing, give oxygen, and be ready — but keep your hands off.

The Conscious Adult and Child

Current Canadian resuscitation guidance, updated in the 2025 guidelines published through the Heart and Stroke Foundation of Canada, sequences relief of severe FBAO in the responsive adult or child as:

1. Five back blows. Support the patient leaning forward; deliver firm blows between the scapulae with the heel of the hand. Evidence reviewed for the 2025 update associated back blows with improved relief rates and fewer injuries than abdominal thrusts, which is why they now lead the sequence.
2. Five abdominal thrusts. Stand behind the patient, fist thumb-side in just above the umbilicus and well below the xiphoid, grasp with the other hand, and deliver sharp inward-and-upward thrusts.
3. Alternate cycles of 5 and 5 until the object is expelled or the patient becomes unresponsive.

Modifications:

• Pregnancy (late) and marked obesity: substitute chest thrusts for abdominal thrusts — hand position as for chest compressions, over the lower half of the sternum.
• Wheelchair users or patients who cannot stand: deliver back blows and thrusts with the patient seated, or from a kneeling position behind them.
• Self-treatment: a lone choking adult can deliver self-abdominal thrusts against the back of a chair.

The Infant (Under One Year)

Abdominal thrusts are never used in infants — the liver is proportionally large, unprotected by the rib cage, and easily lacerated.

1. Support the infant prone, head lower than the trunk, along the forearm with the jaw supported and the airway not compressed.
2. Deliver 5 back blows between the scapulae with the heel of the hand.
3. Turn the infant supine, head lower than the trunk, and deliver 5 chest thrusts with two fingers or the heel of one hand over the lower half of the sternum, at roughly one per second, each with enough force to dislodge the object.
4. Alternate 5 and 5 until relief or unresponsiveness.

The Unresponsive Patient of Any Age

When a choking patient becomes unresponsive, the management changes completely:

1. Lower the patient to the ground in a controlled manner and call for additional resources and the defibrillator.
2. Begin CPR, starting with chest compressions, even if a pulse is present. Chest compressions generate higher airway pressures than abdominal thrusts and are the most effective relief manoeuvre in the unresponsive patient.
3. Each time the airway is opened for ventilation, look in the mouth. Remove a visible object with a finger sweep or forceps.
4. Never perform a blind finger sweep — it drives objects deeper and risks injury to the rescuer and the patient.
5. If ventilations do not produce chest rise, reposition the airway and try again, then resume compressions.

Direct Techniques: Laryngoscopy and Magill Forceps

Where the PCP is authorized and equipped, direct visualization is the definitive relief for a supraglottic or glottic foreign body that thrusts and compressions have not cleared.

1. Position the unresponsive patient, suction as needed, and insert the laryngoscope blade to visualize the oropharynx, hypopharynx, and glottic inlet.
2. Identify the object before grasping. Grasping blindly with forceps produces mucosal trauma, bleeding, and further obstruction.
3. Grasp with Magill forceps (curved, designed to keep the operator's hand out of the line of sight) and withdraw under direct vision.
4. Suction, then ventilate and confirm chest rise and waveform capnography.
5. Limit attempts and ventilate between them; hypoxia kills faster than a retained object that is being partly ventilated around.

After Relief: Nobody Is "Fine"

Every patient who has been given abdominal thrusts or chest thrusts requires assessment and, in most systems, transport:

• Abdominal thrust complications: gastric rupture, liver or splenic laceration, mesenteric tear, diaphragmatic injury. Delayed presentation is well described.
• Chest thrust and compression complications: rib and sternal fracture, pulmonary contusion.
• Post-obstructive pulmonary edema may develop after relief of a severe obstruction, from the large negative intrathoracic pressures generated against a closed airway.
• Retained fragments and mucosal injury cause ongoing stridor, voice change, drooling, or pain on swallowing.
• Hypoxic injury may have occurred even when the patient now appears well.

Special Considerations

• Stridor without a witnessed choking event in a febrile child should raise epiglottitis or croup rather than FBAO. Do not inspect the airway or agitate a child with suspected epiglottitis; keep them calm, upright, with a parent, and provide oxygen as tolerated.
• Lower-airway foreign bodies that have passed the carina produce unilateral wheeze or decreased air entry — usually on the right — and cannot be relieved by thrusts. These patients need oxygen, calm, and transport to bronchoscopy.
• Dentures and vomit are the commonest adult "foreign bodies" in the unresponsive patient. Suction is the first tool, not forceps.