1.3 Airway Obstruction Management

Foreign body airway obstruction (FBAO) is a life-threatening emergency that EMTs must manage quickly and effectively. Recognizing the type and severity of obstruction determines the correct intervention.

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Types of Airway Obstruction

Partial Obstruction

The patient can still move some air past the obstruction:

• Good air exchange: Forceful cough, able to speak, may have wheezing between coughs.
• Poor air exchange: Weak, ineffective cough, high-pitched noise on inhalation (stridor), difficulty breathing, possible cyanosis.

EMT Action for Partial Obstruction with Good Air Exchange: Encourage the patient to cough. Do NOT intervene with thrusts — let the patient attempt to clear the obstruction naturally. Monitor closely.

EMT Action for Partial Obstruction with Poor Air Exchange: Treat as a complete obstruction.

Complete Obstruction

No air can pass the obstruction:

• Cannot speak, cough, or breathe
• May display the universal sign of choking (both hands clutching the throat)
• Will quickly become cyanotic and lose consciousness if not cleared

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FBAO Management by Patient Type

Conscious Adult or Child (Over 1 Year) — Back Blows & Abdominal Thrusts (2025 AHA Update)

Per the 2025 AHA Guidelines Update, the recommended sequence for conscious choking in adults and children now includes back blows as a first-line intervention:

1. Stand behind or to the side of the patient.
2. Deliver 5 back blows between the shoulder blades using the heel of your hand.
3. If the obstruction is not cleared, perform 5 abdominal thrusts (Heimlich maneuver):
   • Wrap your arms around the patient's waist.
   • Make a fist with one hand and place the thumb side against the abdomen, above the navel and below the xiphoid process.
   • Grasp your fist with the other hand.
   • Deliver quick, inward and upward thrusts.
4. Alternate between 5 back blows and 5 abdominal thrusts until the object is expelled or the patient becomes unconscious.

For children, use the same technique but kneel behind the child and use less force.

Important: The 2025 AHA update added back blows for adults and children, aligning the protocol with existing infant FBAO management and international guidelines. Previously, back blows were only recommended for infants in AHA guidelines.

Unconscious Adult or Child — CPR Approach

If a choking patient becomes unconscious:

1. Lower the patient to the ground.
2. Call for additional help / activate EMS if not already done.
3. Begin CPR (starting with chest compressions).
4. Before each ventilation attempt, open the airway and perform a visual check — if you see an object, remove it.
5. Do NOT perform blind finger sweeps.
6. Continue CPR until the obstruction is cleared or advanced help arrives.

Choking Infant (Under 1 Year)

Do NOT use abdominal thrusts on infants — risk of organ damage.

For a conscious choking infant:

1. Support the infant face-down on your forearm, with the head lower than the body.
2. Deliver 5 back blows between the shoulder blades using the heel of your hand.
3. Turn the infant face-up, supporting the head.
4. Deliver 5 chest thrusts using two fingers on the center of the chest, just below the nipple line.
5. Alternate between 5 back blows and 5 chest thrusts until the object is expelled or the infant becomes unconscious.

For an unconscious choking infant:

• Begin infant CPR (30 compressions to 2 ventilations).
• Perform a visual airway check before each ventilation attempt.

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Special Populations

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Key Rules for FBAO Management

• Never perform blind finger sweeps in any patient (adult, child, or infant).
• Only remove an object you can see in the airway.
• Always reassess the airway after clearing an obstruction.
• Transport all patients who had an airway obstruction, even if it was cleared — delayed complications (swelling, aspiration) can occur.

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Why Compressions Help an Unconscious Choking Patient

When a choking adult or child becomes unconscious and you begin CPR, the chest compressions are not only circulating blood — each compression generates a burst of pressure in the chest that can act like an artificial cough and help expel the obstruction. This is why the unconscious-choking sequence uses standard CPR with one addition: before each ventilation attempt, open the airway and look inside; remove an object only if you can see it. You never perform a blind finger sweep, because sweeping a finger you cannot see can push the object deeper, convert a partial obstruction into a complete one, or injure the airway.

Recognizing Severity Quickly

The fastest field decision is mild (partial, good air exchange) versus severe (complete or poor exchange):

Do not interfere with a patient coughing forcefully and exchanging air — an effective cough generates far more pressure than your thrusts. Intervene the moment the cough weakens, the patient cannot speak, or the universal choking sign (both hands clutching the throat) appears.

After the Obstruction Clears

A cleared obstruction is not the end of care. Thrusts and chest compressions can injure internal organs, and material may have been aspirated. Reassess the airway and breathing, watch for delayed swelling or distress, and transport all patients who had a significant obstruction — especially anyone who received abdominal thrusts, became unconscious, or has a persistent cough or voice change.