Synopsis
Treat complete airway obstruction immediately, recognise partial or occult aspiration after choking, understand that normal examination and radiography do not exclude it, and obtain urgent specialist rigid bronchoscopy when clinical suspicion remains.
- With an effective cough, encourage coughing and watch continuously; do not strike a child who can still move air effectively.
- With an ineffective cough in a conscious infant, alternate 5 back blows and 5 chest thrusts. In a child older than 1 year, alternate 5 back blows and 5 abdominal thrusts.
- If unconscious, begin paediatric basic life support with 5 rescue breaths and CPR. Look in the mouth before breaths and remove only a visible object; never sweep blindly.
- After successful emergency manoeuvres, arrange medical assessment for residual object, airway injury and complications, particularly after abdominal thrusts.
- Classic partial aspiration is abrupt choking followed by cough, unilateral wheeze or reduced air entry. The initial crisis may settle while the object remains.
- First-line stable investigation is inspiratory chest radiography; add expiratory views in a cooperative child or bilateral decubitus views in a young child to reveal unilateral air trapping.
- Radiography can be normal because nuts, food and plastic are radiolucent. Do not use normal imaging to overrule a compelling history or focal examination.
- Reference standard and definitive treatment for suspected central airway foreign body is rigid bronchoscopy by an experienced paediatric airway team, with anaesthesia and retrieval equipment prepared.
- CT may reduce negative bronchoscopy in selected stable diagnostically uncertain cases, but must not delay bronchoscopy when suspicion is high or obstruction is unstable.
- Do not offer food or drink when bronchoscopy is likely. Keep the child calm, monitor closely and involve ENT or paediatric respiratory and anaesthesia early.
- Antibiotics and bronchodilators may temporarily change secondary symptoms but do not remove the object. Persistent focal wheeze should not be labelled asthma.
- Prevent aspiration through age-safe food preparation, seated supervised eating, keeping small objects and button batteries inaccessible and avoiding whole nuts under 5 years.
Key red flags
Ineffective or silent cough, inability to cry or speak, cyanosis or reduced consciousness requires the RCUK choking sequence immediately.
Sudden coughing or choking during eating or play with persistent unilateral wheeze or reduced air entry requires urgent bronchoscopy referral.
A normal chest radiograph does not exclude a radiolucent object; convincing history remains decisive.
Stridor, voice change or biphasic noise suggests a laryngeal or tracheal object capable of sudden complete obstruction.
Persistent cough, fever, focal collapse or recurrent same-lobe pneumonia after an unwitnessed event suggests retained foreign body.
Button battery, sharp object or caustic material in the aerodigestive tract requires immediate specialist localisation and removal.
Investigation priorities
Find radiopaque material, unilateral hyperinflation, collapse or mediastinal shift in a stable child.
Directly identify and remove a central airway foreign body while controlling the airway.
Management branches
A choking child remains able to cough loudly and breathe.
- Encourage coughing and keep the child under continuous observation.
- Do not give blind sweeps, drinks or back blows while cough remains effective.
- Escalate immediately to the ineffective-cough sequence if sound or airflow falls.
Choking history or focal signs persist after the immediate crisis.
- Keep nil by mouth, monitor and obtain appropriate inspiratory and air-trapping radiographs.
- Discuss urgently with the paediatric airway team even if radiography is normal.
- Perform rigid bronchoscopy when suspicion is high and manage infection or air leak after complete removal.