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
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
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
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
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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