Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

conscious

1st line – basic life support + encouragement of cough

Back
ACUTE
|
conscious
1st line – 

basic life support + encouragement of cough

Management should start with basic life support and confirmation of the diagnosis, where possible. People found face down, prone, or in neck- and torso-flexion positions associated with aspiration and positional asphyxia should be moved into the supine position for reassessment.[32]

Patients who are experiencing an acute choking episode and who are conscious should be encouraged to cough.[59] If the cough is effective and the foreign body expelled, no external maneuver is necessary.

2nd line – external maneuvers

Back
ACUTE
|
conscious
2nd line – 

external maneuvers

If coughing is ineffective, use back-slaps, abdominal thrusts (>1-year old), or chest thrusts.

Consider extracting visible items in the mouth, but avoid blind finger sweeps and the routine use of suction-based airway clearance devices; however, appropriately skilled healthcare providers can use Magill forceps.[26][32]​​​ 

Often more than one of these techniques is needed, but there is insufficient evidence to support one technique over another or for the order in which they should be used.[32]​​​

Avoid abdominal thrusts in choking infants; there is increased risk of trauma to the upper abdominal viscera. Significant complications have been reported in adults following abdominal thrusts.[60][61][62]

3rd line – removal of foreign body

Back
ACUTE
|
conscious
3rd line – 

removal of foreign body

In the initial assessment, consider extracting visible items in the mouth, but avoid blind finger sweeps and the routine use of suction-based airway clearance devices; however, appropriately skilled healthcare providers can use Magill forceps.[26][32]​​​​​​​​​ 

In children, prompt bronchoscopy is essential; delayed bronchoscopy (≥24 hours after arrival to the emergency department) is associated with a higher rate of complication.[33]​​

Rigid bronchoscopy should be performed in cases of stridor, asphyxia, radiopaque object on chest radiograph, a history of foreign body aspiration associated with unilaterally decreased breath sounds, localized wheezing, obstructive hyperinflation, or atelectasis.[14][45]​

In infants with very small airways, laryngeal suspension with 100% oxygen and the use of optical forceps has been recommended.[68]

In all other cases, flexible bronchoscopy should be performed initially to confirm the diagnosis and attempt removal of the foreign body​.[14][45]

Flexible bronchoscopy is the method of choice in adults with cervicofacial trauma. It is also a reasonable first therapeutic choice in a patient with a foreign body lodged in the distal airways.[4]

One selective literature review found that, in publicly reported cases, flexible bronchoscopy can be expected to be successful approximately 80% of the time.[71]

Patient cooperation facilitates foreign body retrieval using flexible bronchoscopy.

If flexible bronchoscopy fails, rigid bronchoscopy and/or SMDL is the next step. These procedures require general anesthesia. Large foreign bodies that are round or smooth are probably best approached with the rigid bronchoscope or SMDL. SMDL, where available, allows jet ventilation and increased operating angle of instruments compared with rigid bronchoscopy, but it requires a collaborative approach to the foreign body retrieval.

Surgery is indicated if repeated bronchoscopic attempts fail.

Thoracotomy with pulmonary resection is usually reserved for cases of destroyed segment, lobe, or lung.[24]​ Lung-sparing transverse bronchotomy through a transthoracic approach may also be considered.[63]

unconscious

1st line – secure airway

Back
ACUTE
|
unconscious
1st line – 

secure airway

In the unconscious patient, endotracheal intubation should be performed immediately (unless the foreign body is seen in the upper airway and can be removed easily). Blind or repeated finger sweeps should be avoided, as they can impact the object deeply into the pharynx and cause more injury.

In cases of asphyxia from laryngeal foreign bodies that cannot be dislodged or associated with severe edema that precludes endotracheal intubation, cricothyroidotomy should be performed by the most experienced physician available. In small children aged under 10 years, use of a 12- to 14-gauge catheter over a needle may be a safer procedure to establish an airway.

Obtaining an airway urgently is vital, as irreversible anoxic brain injury can occur if airway patency is not restored within 3-5 minutes. Paralytic agents should be avoided if possible until the airway is secured.

Plus – removal of foreign body

Back
ACUTE
|
unconscious
Plus – 

removal of foreign body

Treatment recommended for ALL patients in selected patient group

Consider extracting visible items in the mouth, but avoid blind finger sweeps and the routine use of suction-based airway clearance devices; however, appropriately skilled healthcare providers can use Magill forceps.[26][32]​​​​​

Flexible bronchoscopy is the method of choice in adults: with cervicofacial trauma; on mechanical ventilation; and when the foreign body is lodged in the distal airways.[4]

If flexible bronchoscopy fails, rigid bronchoscopy and/or SMDL is the next step.[14] These procedures require general anesthesia.

In children, prompt bronchoscopy is essential; delayed bronchoscopy (≥24 hours after arrival to the emergency department) is associated with a higher rate of complication.[33]

Rigid bronchoscopy should be performed in cases of stridor, asphyxia, radiopaque object seen on chest radiograph, a history of foreign body aspiration associated with unilaterally decreased breath sounds, localized wheezing, obstructive hyperinflation, or atelectasis.[14][45]

In infants with very small airways, laryngeal suspension with 100% oxygen and the use of optical forceps has been recommended.[68]

In all other cases, flexible bronchoscopy should be performed initially to confirm the diagnosis and attempt removal of the foreign body.[14][45]

Surgery is indicated if repeated bronchoscopic attempts fail.

Thoracotomy with pulmonary resection is usually reserved for cases of destroyed segment, lobe, or lung.[24]​ Lung-sparing transverse bronchotomy through a transthoracic approach may also be considered.[63]

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer