Children with FBA who have the ability to cough, cry, or speak are demonstrating adequate air exchange, and therefore have incomplete airway obstruction. Beyond infancy, children will naturally hold themselves in a position that maximizes airway patency. In addition, they possess a reflexive cough, which is the most effective means of clearing the airway. These patients, therefore, should be managed “expectantly.” That is, no attempts at relief maneuvers should be attempted to avoid dislodgement of the foreign body to a location that aggravates the degree of obstruction.

Resources should be summoned to provide removal in the operating room setting whenever possible. If an operating room or pediatric expert resources are unavailable, an alternative plan must be initiated. Appropriately sized equipment should be gathered for foreign body removal, as well as for more definitive airway management in the event that the child progresses to complete airway obstruction (discussed below).

Attempts at removal of the foreign body for children with partial airway obstruction are rarely performed in the emergency department. Children are unlikely to cooperate with efforts to remove an airway foreign body even with effective topical anesthesia. Furthermore, unintentionally placing
a laryngoscope blade too deeply in small children will risk placing direct pressure on the foreign body which can further obstruct the airway. Therefore, in most cases, the child should be allowed to continue to attempt to clear the foreign body reflexively as long as possible, or until an operating room is available. Only when the patient is showing signs of tiring or progression toward complete obstruction, should attempts at removal be made. In such circumstances, sedation with ketamine titrated intravenously to effect if possible (or 4 mg per kg IM if not) reliably produces dissociative sedation while maintaining respiratory drive and airway reflexes. Once sedated, the laryngoscope is methodically inserted a small distance at a time, while attempting to identify any supraglottic foreign body.

If the patient progresses to complete obstruction, either because of unavoidable progression or as a result of attempts at removal, immediate intervention is required.

The loss of the ability to phonate in an awake child with a suspected FBA indicates complete airway obstruction. Chest wall movement will persist with attempted respiratory efforts; however, no sounds will be heard on inspiration or expiration. Conscious children will appear scared, although infants will not reliably place their hands to their neck to signify choking as older children or adults will. Instead, they will often raise clenched fists above their heads with eyes wide open as an expression of distress.