Milk or vomit can cause breathing difficulty and choking for a little child. However, is anytime mandatory airway obstruction removal procedure?

There are some who claim to “never try to proceed with airway obstruction removal procedures in case of liquids or semi-liquids”, and the ones who state to “follow the guidelines, perform the procedure even in the event of liquids or semi-liquids”.

As all of us know, the airway obstruction removal is a medical practice that has made possible to save the life of dozens, if not hundreds, of babies that have had their airways obstructed by foreign bodies over the years.

But when is pediatric airway obstruction removal to be performed?

The answer to this question seems to be unmistakably easy because that’s how it has to be: understandable by anyone. Whether you are housewives, farmers, lawyers or diplomats, the guidelines are written to be understood, whether you studied medicine or you couldn’t be bothered by reading a 360 pages handbook about airway obstruction removal and cardiopulmonary reanimation. The answer to this question is: airway obstruction removal has to be performed when airways are obstructed.

But when can someone say that airways really are obstructed?

When do I decide that airways are obstructed? When do I have to start to think about airway obstruction manoeuvres? On one hand, there are those who think that airways get obstructed only if a foreign body is swallowed or inhaled. Therefore, regurgitation cannot obstruct airways because it’s not a foreign body and it’s not solid, but a semi-liquid. On the other hand, there are those who claim that semiliquids too can obstruct airways in a lethal manner and that you should act nonetheless. The highest scientific body in the cardiopulmonary reanimation and un-obstruction field, ILCOR, claimed something slightly different and much, much more effective, that revolves around a completely different parameter: cough.

And that’s because the cough is an automatic reflex of our body when a foreign object is blocking our airways. And so what? You just need to cough? Sometimes yes, and in these cases, we are talking about an effective cough. In other cases, unfortunately, it’s not enough. There are scientific studies that tried to understand why coughing – sometimes – is not effective. It’s for this very reason that when airway obstruction removal courses are held there is a lot of talk about SIDS, a syndrome connected to milk regurgitation and that can lead to asphyxiation. Without getting too technical, to keep focused on the topic of “airway obstruction removal yes/no”, let’s see what is written in the European Resuscitation Council guidelines:

• Assess the gravity of the situation (how long has the baby been obstructed? How long has he been coughing? Has he turned cyanotic/blue?)
• If cough is ineffective and the baby is conscious give 5 dorsal blows and 5 thorax compressions.
• If cough is ineffective and the baby is unconscious and doesn’t breathe, open the airways, proceed with 5 ventilations and start the C.P.R.
• If the baby keeps coughing and you notice that he can still breathe between coughs, encourage him to keep coughing and keep evaluating if any sign of sensory obnubilation appears, and whether the cough becomes ineffective or if the obstruction resolves itself.

So, is there clarity?

Yes, the procedures have to be performed in complete obstructions when the baby is not able to cough, cry or talk, but is still conscious. If he becomes unconscious, proceed with the cardiopulmonary reanimation. There is no evidence to do otherwise.

The real problem is panic in the bystander, whether a first responder or rescuer. Why?

To better resolve the argument, we asked many anaesthesists, so we could provide a more complete and more truthful picture of the situation. As of today, it’s true that sensibilization towards life-saving manoeuvres has made avoiding multiple tragedies possible, but in some cases – when the techniques are badly taught or a way to prevent panic is not explained – excesses have occurred that led to real clinical problematics. In fact, the data provided by the Ministry add to the deaths caused by airway obstruction, also the ones caused by asphyxiation, meconium ingestion or digestive juices inhaling. This has exaggerated the issue’s proportion creating – apart from the right and due attention – panic too, most of the times due to faulty information. The only data available on actual foreign body obstructions – in Italy – are the one provided by ISTAT, and they are reported in the tables below.

Who is right, then?

Following ILCOR’s guidelines, there’s no way to tell who is right and who is wrong in the distinction between liquid/solid, because the guidelines distinguish between obstruction and non-obstruction. Any doctor (and we consulted 5 of them before writing this article) will tell you that before proceeding with any obstruction removal procedure, it is necessary to well evaluate the situation, because the percentage of liquid or regurgitation caused obstructions that resolve themselves thanks to the automatic reflexes that our bodies set in motion is very high. It is different, on the other hand, for foreign body obstructions (watch batteries, olives, etc.). Anyway, the guidelines, on page 117, state that causes of airway obstruction are:

“Airway obstruction could be partial or complete. It can occur at any level, from nose to mouth, to trachea. In an unconscious patient, the more frequent sites of airway obstruction are the soft palate and the epiglottis. The obstruction can also be caused by vomit or blood (gastric regurgitation or trauma) or by foreign bodies. A larynx obstruction could be secondary to burn oedema, inflammation or anaphylaxis. Stimulation of upper airways could cause a laryngeal spasm. Airways obstruction inferior to the larynx is less common, but could arise in case of excessive bronchial secretion, mucosal oedema, bronchospasm, pulmonary oedema or suction of gastric contents.”

So, should I try any airway obstruction manoeuvre or not?

Yes, airway obstruction manoeuvres have to be done when you are sure that the baby is not breathing and not coughing in an effective way to get rid of the obstruction by himself, giving clear signs of suffocation. And they have to be done without giving in to panic, which is the true real enemy of every first responder. When you are dealing with a baby with partial or complete obstruction, the most is important thing is to keep calm, wait for the clear signs of obstruction that enable the starting of the official unblocking procedures, and in the meantime encourage the victim to cough. Panic and intervention anxiety are the culprits of not needed obstruction removal manoeuvres. And they can make us give unnecessary hard blows on the back, that could interfere with cough or cause traumas to the baby, causing another very, very dangerous condition; the so-called shaken baby syndrome. Always be careful and do not be confused: follow the guidelines and never lose your temper.