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Three Part Question

In [unconscious choking patients in the pre-hospital enviroment] is [the use of magills forceps under direct vision of a laryngoscope more successful than the use of Basic Airway Techniques (Finger Sweeps, Back Slaps, Abdominal Thrusts or Chest Compressions)] at [removing an obstruction from the compromised airway]?

Clinical Scenario

A four year old child swallowed a piece of lego, mother was unable to remove with backslaps and finger sweep. The paramedic arrived some minutes later and found a cyanosed child unconscious, the lego was removed by magills forceps.

Search Strategy

Medline 1966-01/04 using the OVID interface.
[{exp Airway Obstruction/ OR airway obstruction.mp. OR chok$.mp} AND {magill$.mp. OR forcep$.mp OR instrument$.mp}] LIMIT to human and English

Search Outcome

Altogether 149 papers were found of which 144 were irrelevant the five remaining papers are shown in the table

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Westfal R, 1997, USA	2 Original cases (75 and 79 year old) with compromised airway due to food inhalation Treated in emergency department	Case study	A food foreign body was successfully removed from compromised airways by magills forcepsunder the direct vision of a laryngoscope.1 of the cases after bystander use of basic techniques failed	A quicker more effective removal of a foreign body from a compromised airway even after the use of more basic airway techniques	Small numbers involved in the papers
Rubio Quinones F et al, 1995, Spain	3 Infants and toddlers three cases of foreign body aspiration Treatment in emergency department	Case Study	In the three original cases of infants having aspirated a snail and small toy parts, successful removal was attributed to the use of magills forcepsunder the direct vision of a laryngoscope having previously used basic airway clearence techniques	The use of magills forcepsunder the direct vision of a laryngoscope, has proven to be successful after previous efforts to remove the obstruction using basic airway clearence techniques proved unsuccessful noting the fact that on some occasions the obstruction was below the vocal cords	Small numbers involved in the papers Small numbers involved Infant and Toddler patient group

Comment(s)

The pre-hospital incidence of unconscious choking patients is small, when most choking episodes resolve spontaneously. However two albeit small studies have shown the advantages of using magills forceps effectively when basic airway clearence techniques have been unsuccessful. Also, a study by Higgins et al (1) of the upper airways of euthanized swine which were occluded with a rubber ball, glass marble, or grape showed similar success from the use of Magill forceps, and spongestick forceps, although spongestick were overall more successful . Therefore training in the use of magills forceps under the direct vision of a laryngoscope can save lives, and training should be considered for all frontline A/E staff in UK Ambulance services.

Editor Comment

search updated in april 04 - awaiting 3 papers for appraisal

Clinical Bottom Line

Magills Forceps under the direct vision of a laryngoscope have shown to be more successful at removing foriegn bodies from obstructed airways pre-hospital and in emergency departments than traditional basic airway techniques.

References

1. Westfal R. Foreign body airway obstruction: when the Heimlich maneuver fails. Am J Emerg Med 1997;15(1):103-5.
2. Rubio Quinones F, Munoz Saez M, Povatos Serrano EM, et al. Magill forceps: a vital forceps. Pediatr Emerg Care 1995;11(5):302-3.
3. Higgins GL 3rd, Burton JH, Carter WP, et al. Comparison of extraction devices for the removal of supraglottic foreign bodies Prehospital Emergency Care 2003;7(3):316-21.