Synopsis
Recognise complete and partial foreign-body airway obstruction across ages, deliver correct immediate choking care, and arrange definitive bronchoscopic removal without delay.
- A sudden choking event followed by inability to speak, ineffective cough, stridor, cyanosis or collapse is a clinical diagnosis requiring action before tests.
- An effective cough and audible speech indicate airflow: encourage coughing, observe continuously and avoid manoeuvres that might convert partial obstruction to complete obstruction.
- For a conscious adult with ineffective cough, give up to five back blows then up to five abdominal thrusts, repeating according to the current RCUK algorithm.
- Use chest thrusts rather than abdominal thrusts in pregnancy or when the abdomen cannot be encircled; infants receive chest thrusts, never abdominal thrusts.
- Do not perform blind finger sweeps. Remove material from the mouth only when it is clearly visible and readily accessible.
- If the person becomes unresponsive, call or confirm 999, begin CPR and use an AED; trained clinicians may inspect with laryngoscopy during airway care.
- A distal aspirated object may present later with unilateral wheeze, reduced air entry, persistent cough, air trapping, lobar collapse or recurrent same-site pneumonia.
- Chest radiography may be normal because many objects are radiolucent; bronchoscopy remains definitive when the history and focal findings are convincing.
- CT can refine selected stable uncertain cases, especially in adults, but must not delay retrieval in a child or adult with high clinical probability.
- Anyone treated successfully with abdominal or chest thrusts should receive clinical assessment for retained material and manoeuvre-related injury.
Key red flags
The person can vocalise, breathe and cough forcefully despite distress. Encourage coughing and be ready to escalate immediately if the cough weakens, speech disappears or consciousness changes.
Inability to speak or cry, silent ineffective cough, minimal air movement, cyanosis and decreasing responsiveness indicate critical obstruction. A quiet chest is more dangerous than loud coughing.
Abrupt coughing, gagging, wheeze, stridor or apnoea while feeding or playing may be witnessed, but the event can be missed. Infants need back blows and chest thrusts.
Persistent unilateral monophonic wheeze, asymmetric air entry, local hyperresonance or focal crackles after choking suggests bronchial lodgement, commonly on the right but possible anywhere.
Button batteries, caustic tablets, sharp fragments, large objects and organic matter that absorbs water can cause necrosis, perforation, oedema or fragmentation and need immediate specialist planning.
Investigation priorities
Separate effective airflow from life-threatening obstruction.
Management branches
A conscious adult cannot speak or cough effectively after a sudden choking event.
- Ask if they are choking, call for help and give up to five firm back blows, checking after each attempt.
- If obstruction persists, give up to five abdominal thrusts; use chest thrusts for pregnancy or when the abdomen cannot be encircled.
- Call 999 if not already done and alternate back blows with thrusts until relief or unresponsiveness; never sweep blindly inside the mouth.
- If unresponsive, lower them safely, start CPR, attach an AED and have trained airway clinicians inspect for visible removable material.
Choking history, focal signs or recurrent same-site infection without current complete obstruction.
- Keep the patient nil by mouth, monitor oxygenation, take an exact event and object history and contact the age-appropriate airway specialists.
- Obtain appropriate radiographs and consider CT only if stable and useful; do not let a normal radiograph close a high-probability case.
- Plan rigid or flexible bronchoscopic retrieval with rescue airway equipment and surgical backup matched to the object and anticipated difficulty.