Sweeping the Airway for a Foreign Object
Radiology Cases in Pediatric Emergency Medicine
Volume 2, Case 16
Martin I. Herman, MD
LeBonheur Children's Medical Center
University of Tennessee School of Medicine
     A 4 month old male infant is brought to the 
emergency department by a fire and rescue squad after 
responding to a 911 call for respiratory distress.  He 
was sucking on a pacifier when his caretakers noticed 
that he had sucked the pacifier into his mouth.  A home 
health nurse was present and unsuccessfully attempted 
to retrieve the pacifier using a blind finger sweep.  911 
was called.  At the scene, paramedics found the infant 
with a tracheostomy and a home ventilator (former 28 
week twin with a stormy neonatal course).  Ventilation 
through the tracheostomy was continued with a 
self-inflating bag.
     Exam  VS T37.0 (tympanic), P145, R50 (positive 
pressure ventilation), oxygen saturation 100% 
(supplemental oxygen).  He is small and obese in 
moderate distress.  His pertinent exam finding is a hard 
plastic object wedged into his oropharynx.  His air 
exchange is satisfactory.  Good color and perfusion.
     Direct visualization of the airway with a 
laryngoscope is attempted.  The back side of a plastic 
pacifier is identified.  It is firmly impacted into the child's 
pharynx.  Soft tissue radiographs of the airway are 

View airway radiographs.

     Are there any foreign bodies visible ?
     Is the epiglottis normal ?
     Is the trachea normal ?


     The obvious foreign object seen here is the 
tracheostomy tube itself.  The coiled structure of the 
body of the tracheostomy tube is easily seen on the 
radiograph.  The other foreign object is not as obvious 
radiographically.  There appears to be three structures 
that can be identified in the upper airway region.  These 
are outlined as A, B, and C.  A drawing of the pacifier is 
also shown.  Item A is probably the rubber nipple.  Item 
B is probably the plastic dome of the pacifier.  Both of 
these identifications are not certain.  One could argue 
that perhaps item C is the plastic dome or ring of the 
pacifier.  Although the parts of the pacifier cannot be 
identified with certainty on the radiograph, it is evident 
that the pacifier is in this area.  The epiglottis is difficult 
to identify.  The trachea above the tracheostomy is 
difficult to see.  The trachea distal to the tracheostomy 
is not visible on the image.
     Review the original radiographs again to see if you 
can identify the findings described above.

     When confronted with an airway foreign body, it is 
important to know where it is located and how many 
objects might be involved.  It is also helpful to see if any 
complications have occurred from the object (such as 
air leaks).
     The infant was ventilated via his tracheostomy tube, 
and his oxygen saturation was maintained at 100%.  He 
was awake but appeared to be hurting.  An attempt was 
made to remove the object under direct visualization, 
but because the object was so large and firmly 
impacted, it could not be easily removed.  A pediatric 
surgeon was called.  The infant was given lorazepam 
and vecuronium for sedation and muscle relaxation.  
The pacifier was removed in the emergency 

Discussion and Teaching Points
     Airway management is an essential skill in the 
emergency care of children.  Many cardiopulmonary 
arrests in childhood are the result of a primary airway 
emergency.  When confronted with a child who is in 
distress, rapid and efficient management of the airway 
is mandatory.
     Since 1986, the American Heart Association (AHA) 
and the American Academy of Pediatrics (AAP) have 
collaborated to produce the Pediatric Advanced Life 
Support (PALS) course materials.  PALS places a fair 
amount of emphasis on the airway and its 
management, with procedures for the approach to a 
compromised pediatric patient detailed in the manual.  
First, after recognizing that the child is in trouble, an 
attempt should be made to open the airway by a chin 
lift-head tilt or jaw thrust maneuver.  The integrity of the 
cervical spine must be considered and if in doubt, the 
chin lift-head tilt should be avoided.  If the airway 
cannot be opened, the rescuer should move on to more 
advanced airway techniques.
     If the patient has a forceful cough or at least is 
ventilating sufficiently, a partial airway obstruction may 
be present and no further intervention should be done 
until the patient is in a place where more advanced 
airway control can be performed.
     When faced with a patient who cannot be ventilated 
by rescue breathing or mask ventilation, an obstructed 
airway must be considered.  If the patient demonstrates 
the signs of a completely obstructed airway (cyanosis, 
loss of consciousness, ineffective cough, and 
inadequate ventilation), then steps must be taken to 
provide an airway immediately.
     For infants, begin with five back blows followed by 
five chest thrusts.  Attempt to ventilate, and if 
unsuccessful, repeat the chest thrusts and back blows.  
Continue until help arrives or the child succumbs.
     For children older than 12 months, substitute the 
Heimlich maneuver for the chest thrusts.  Blind finger 
sweeps once taught for situations where the child could 
not be ventilated are now considered to be dangerous.  
Sweeping the oropharynx for foreign objects may result 
in pushing the object further into the airway and 
worsening the severity of the obstruction.  If the rescuer 
can visualize the foreign object in the oropharynx, 
he/she may then attempt to retrieve it.  If no object is 
seen and the child cannot be ventilated after multiple 
attempts to dislodge the foreign object, then a surgical 
airway should be attempted.  Advanced airways could 
include a tracheostomy, cricothyrotomy, or needle 
cricothyrotomy.  The actual method used will depend on 
the level of skill of the rescuer and their training.  In 
general, all emergency surgical airways are highly 
prone to complications.  Surgical cricothyrotomies are 
not recommended for children under eight years of age.  
Needle cricothyrotomies (using an over the needle 12 
or 14 gauge IV catheter) require an adapter to connect 
the ventilation bag to the ventilating catheter's hub.  A 3 
ml syringe can be cut so that the ventilating bag ETT 
connector will fit snugly over the barrel of the syringe 
and the syringe tip can be inserted into the hub of the 
needle.  A 3.0 or 3.5 endotracheal tube connector can 
also be used to fit the small end into the catheter's hub 
and the large end onto the ventilation bag.  Ventilating 
through a small catheter results in substantial flow 
resistance and inadequate ventilation.  If a larger airway 
cannot be secured expeditiously, it may be preferable to 
use a transtracheal ventilation setup using the oxygen 
wall outlet pressure to force more oxygen through the 
transtracheal catheter.
     Although many recommendations for transtracheal 
ventilation have appeared in the literature, two 
suggestions are diagrammed here.

View Transtracheal Ventilation Setup.

     Both devices show the oxygen wall outlet (at 10 to 
15 liters per minute) connected to the transtracheal 
catheter by tubing of various types.  In the line of 
airflow, there is an opening.  By occluding this opening 
with your thumb or the palm of your hand, the oxygen 
flow will be forced through the transtracheal catheter.  
Although this may sound excessive, the actual flow 
through the small gauge catheter is still barely enough 
to deliver an adequate tidal volume.  Prove this to 
yourself by placing a glove or balloon over the end of 
the catheter to see how much oxygen is actually 
delivered through the catheter.  It is vital to have such a 
device pre-assembled for emergency use.  In the event 
of an emergency, there will not be enough time to 
assemble it then.  Exhalation generally occurs passively 
through the glottis (not through the transtracheal 
catheter), thus hyperexpansion is usually not a problem 
unless there is bi-directional airway obstruction.  In the 
case of a foreign object impacted into the airway 
causing bi-directional airway obstruction, needle 
cricothyrotomy will not succeed due to excessive air 
     Needle cricothyrotomy and transtracheal ventilation 
are highly complication prone.  For optimal success, 
team practice sessions can avoid mistakes.  One 
member of the team must dedicate him/herself to 
holding the transtracheal catheter in place.  If this 
catheter is ever released for a seemingly more 
important task, the catheter will kink or dislodge.  This is 
a fatal pitfall that must be avoided.  Quick airway kits 
are now available for use.  The larger airways provided 
in these kits are more optimal than a transtracheal 
catheter.  However, experience and familiarity with 
these kits are essential for success.  Decide which 
emergency airway method you prefer and practice it 
well to be prepared for such an emergency.
     Never utilize cautery techniques in such an 
emergency since it is highly likely that high 
concentrations of oxygen will be present around the 
airway and neck.  Any sparks or burns may result in 
spontaneous combustion manifesting as fire or an 
explosion.  The nursing staff should be taught to never 
allow surgical cautery in this situation.
     In the case of this infant, we are not told whether the 
home health nurse could see the foreign object, but if 
she could not, the blind finger sweep would not have 
been appropriate.  Also, remember that this child had a 
tracheostomy and was ventilating adequately, so no 
attempts for removal of the object should have been 
made prior to arrival at the emergency department.  It is 
possible that if the blind finger sweep was not done, the 
foreign object could have been removed more easily.  
When confronted with the possibility of an obstructed 
airway, utilize the chin lift-head tilt or jaw thrust first.  
Next, attempt to ventilate.  If necessary, proceed to 
chest thrusts/back blows (infants) or abdominal 
thrusts/back blows (children).  When these efforts fail, 
an advanced airway technique is indicated.  Blind finger 
sweeps are not recommended.

     Pediatric Basic Life Support.  In:  Chameides L, 
Hazinski MF (eds).  Textbook of Pediatric Advanced 
Life Support, 1994, American Heart Association.
     Seidel JS.  Respiratory Emergencies and 
Cardiopulmonary Arrest.  In:  Barkin RM (ed).  Pediatric 
Emergency Medicine Current Concepts and Clinical 
Practice, 1992, St. Louis, Mosby Year Book, pp. 73-83.
     Yamamoto LG.  Emergency Anesthesia and Airway 
Management.  In:  Fleisher GR, Ludwig S (eds).  
Textbook of Pediatric Emergency Medicine, third 
edition.  Baltimore, Williams and Wilkins, 1993, pp. 

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Web Page Author:
Loren Yamamoto, MD, MPH
Associate Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine