01Approach to the Critical Patient/attcp50

Immediate airway threats

›Complete airway obstruction recognition

›Inability to speak, cough, or breathe

›Cyanosis or rapidly declining SpO2

›Loss of consciousness

›Immediate BLS/ACLS airway maneuvers required

›Infants less than 1 year: 5 back blows then 5 chest thrusts, repeat cycle

›Children 1 year and older: 5 back blows then 5 abdominal thrusts, repeat cycle

›If unresponsive, begin CPR immediately

›2025 AHA/AAP guidelines

›Partial obstruction with severe distress

›Stridor with worsening respiratory effort

›Accessory muscle use and nasal flaring

›SpO2 less than 92%

›Allow patient to assume position of comfort

›Avoid agitation — may convert partial to complete obstruction

›Prepare for emergent intubation or surgical airway

›Button battery or magnet aspiration

›Caustic injury can begin within 15 minutes

›Emergent removal required regardless of symptoms

›Do not delay for imaging if airway is compromised

Monitoring and targets

›Monitoring bundle

›Continuous pulse oximetry

›SpO2 target greater than 95%

›Any declining trend prompts immediate escalation

›Cardiac monitor

›Hypoxia-related arrhythmia risk

02History/hx66

Presenting symptoms

›Classic penetration syndrome triad

›Acute onset choking or gagging

›Paroxysmal cough

›Wheeze or stridor

›Three clinical phases of FBA

›Phase 1: initial impaction — choking, gagging, paroxysmal cough

›Acute onset is the most diagnostically useful phase

›Witnessed choking episode OR 3.1 for confirmed FBA

›Phase 2: asymptomatic or latent phase

›Reflexes fatigue, symptoms calm

›May be misinterpreted as resolution

›Phase 3: complications phase

›Recurrent or non-resolving pneumonia

›Atelectasis, abscess, bronchiectasis

›Timing

›75% of pediatric patients present within 1 day of the event

›Delayed presentation greater than 24 hours occurs in 40 to 77% of cases

›Witnessed choking episode sensitivity is only approximately 46%

Foreign body characterization

›Object type and risk

›High-risk foods in children: peanuts, sunflower seeds, nuts, grapes, hot dogs, popcorn, raw carrots, hard candy

›Peanuts are the most commonly aspirated FB worldwide

›Exposure to nuts and seeds OR 1.99 for confirmed FBA

›Adult culprits: bone fragments, seeds, food boluses, dental hardware

›Broken teeth are the most common adult FB, 37.7% of iatrogenic cases

›Iatrogenic FB accounts for approximately 37% of adult cases

›Button batteries and disc magnets

03Physical Exam/exam59

Vital signs and general appearance

›Stability snapshot

›Respiratory rate

›Tachypnea as primary distress marker

›Retractions: subcostal or intercostal present in 80.8% of one series

›Oxygen saturation

›Mean SpO2 97.3% in FBA-positive patients vs higher in negative

›Any desaturation in a child with choking history is urgent

›Heart rate

›Tachycardia from hypoxia or distress

›Temperature

›Fever suggests post-obstructive pneumonia or complications phase

›General appearance

›Respiratory distress

›Accessory muscle use

›Inability to speak full sentences

›Tripod position or drooling suggests epiglottitis or upper airway FB

›Cyanosis

›Perioral or central — emergent intervention

Auscultation and chest exam

›Lung auscultation — most valuable exam component

›Unilateral decreased or absent breath sounds

›OR 4.8 to 5.48 for confirmed FBA

›Sensitivity 58%, specificity 69 to 88%

›Focal unilateral wheeze

›OR 7.38 on exam — highly suggestive of FBA

›New wheeze without prior asthma history in a toddler is FBA until proven otherwise

›Stridor

04Differential Diagnosis/ddx51

Life-threatening diagnoses

›Immediate airway threats

›Complete foreign body airway obstruction (FBAO)

›ICD-10 T17.9

›Managed with BLS maneuvers and emergent airway

›Epiglottitis

›Toxic appearance, drooling, tripod positioning, muffled voice

›No choking event, usually URI prodrome

›Bacterial tracheitis

›High fever, toxic appearance after croup-like illness

›Pseudomembrane on laryngoscopy

›Anaphylaxis

›Urticaria, angioedema, exposure history

›Respond to epinephrine

›Retropharyngeal or peritonsillar abscess

›Fever, neck stiffness, trismus

›Neck imaging with contrast

Common mimics

›Respiratory mimics

›Asthma or reactive airway disease

›Most common misdiagnosis in FBA

›Prior asthma history, bilateral wheeze, responds to bronchodilators

›FBA if new-onset unilateral wheeze without prior history

›Croup

›Barking cough, stridor, URI prodrome

›No choking event

›Pneumonia

›Especially if FBA presents late with post-obstructive consolidation

05Laboratory Tests/lt32

Core laboratory studies

›Infection markers

›WBC with differential

›WBC greater than 10 x 10^9/L associated with FBA — OR 3.3

›Leukocytosis supports post-obstructive pneumonia

›Labs are generally not required for acute FBA diagnosis

›CRP or ESR

›If post-obstructive infection or delayed presentation suspected

›Not diagnostic for FBA itself

›Procalcitonin

›Elevated in post-obstructive bacterial infection

›Not useful in pure mechanical obstruction

Gas exchange and hemodynamic labs

›Respiratory and metabolic status

›Arterial blood gas

›PaO2 mmHg assessment for oxygenation failure

›PaCO2 mmHg for ventilatory failure

›Reserved for significant respiratory distress or hypoxia

›Venous blood gas

›pH and CO2 trend assessment

›Less invasive alternative to ABG when severe distress absent

›Lactate

›Greater than or equal to 2 mmol/l indicates organ hypoperfusion

›Relevant if post-obstructive sepsis suspected

Pre-procedural labs

›Bronchoscopy preparation

›Type and screen

›Anticipated surgical intervention or rigid bronchoscopy

06Diagnostic Tests/dt66

Scoring Systems

›Clinical prediction scores for FBA

›Foreign Body Aspiration Score (FOBAS)

›Validated in pediatric cohorts

›Parameters: witnessed choking, age less than 3 years, stridor, unilateral decreased breath sounds, unilateral wheeze, WBC greater than 10 x 10^9/L, unilateral hyperinflation on CXR

›Higher scores correlate with confirmed FBA on bronchoscopy

›Clinical prediction model components from meta-analysis

›Witnessed choking OR 3.1

›Unilateral decreased breath sounds OR 4.8 to 5.48

›Focal wheeze on exam OR 7.38

›Unilateral hyperinflation on CXR OR 8.3

›Exposure to nuts or seeds OR 1.99

›Prior FBA episode OR 5.46

›JAMA Otolaryngology 2021 systematic review and meta-analysis

›Score limitations

›No single score has sufficient accuracy to replace clinical judgment

›Scores supplement but do not replace bronchoscopy decision

›High clinical suspicion mandates bronchoscopy regardless of score

MRI

›MRI role in foreign body aspiration

›Limited acute utility

›Availability constraints in emergency settings

›Motion artifact in children requiring sedation

›Not first-line for acute FBA evaluation

›Problem-solving indications

›Retained soft-tissue foreign body characterization

›Suspected vascular ring or structural anomaly

›Complex pleural or mediastinal disease

07Disposition/dispo43

Admission indications

›Admission required

›Confirmed or strongly suspected FBA requiring bronchoscopy

›All patients with FBA requiring intervention are admitted

›Target bronchoscopy within 24 hours

›Respiratory distress or hypoxia

›SpO2 less than 95% with supplemental oxygen

›Escalating oxygen requirement

›Post-obstructive complications

›Pneumonia with fever and leukocytosis

›Sepsis physiology — lactate greater than or equal to 2 mmol/l

›Post-bronchoscopy observation required

›Airway edema monitoring

›Re-obstruction risk

›Pneumothorax after procedure

ICU admission

›ICU-level criteria

›Hemodynamic instability

›SBP less than 90 mmHg

›Vasopressor requirement

›Ventilatory support requirement

›Post-bronchoscopy respiratory failure

›HFNC with rising FiO2 requirement

›Post-obstructive pneumonia with sepsis

›Significant hemoptysis with vascular injury

›Large airway granulation tissue with reobstruction risk

Observation and discharge criteria

›Observation may be appropriate

08Treatment/t73

Immediate airway interventions

›BLS choking maneuvers (2025 AHA/AAP guidelines)

›Infants less than 1 year

›5 back blows with heel of hand

›5 chest thrusts — no abdominal thrusts in infants

›No blind finger sweeps

›Repeat cycles until FB expelled or infant loses consciousness

›Children 1 year and older and adults

›5 back blows then 5 abdominal thrusts (Heimlich maneuver)

›2025 update: back blows now precede abdominal thrusts

›Repeat cycles until FB expelled or patient loses consciousness

›Unconscious patient

›Begin CPR immediately — chest compressions may dislodge FB

›Remove visible FB when opening airway for rescue breaths

›Do not perform blind finger sweeps

Definitive airway management

›Bronchoscopic removal

›Rigid bronchoscopy

›Gold standard for large greater than 1.5 cm, sharp, or proximal FBs

›Preferred in asphyxiating presentations

›Performed under general anesthesia in OR

›Allows passage of larger instrumentation

›Flexible bronchoscopy

›First-line in many centers for stable patients

›Success rate 87 to 91% in adults

›Preferred for distal or peripheral FBs in adults

›Can be performed at bedside with sedation

›Bronchoscopic tools

›Forceps for metal or bone fragments

›Basket retrievers for smooth or round objects

›Balloon catheters for impacted distal FBs

›Cryoprobe for organic or semisolid material

›Post-removal steps

›Re-inspect airway for residual FB

›Suction secretions and assess mucosal injury

›If bronchoscopy fails, proceed to thoracotomy or surgical extraction

Pharmacological adjuncts

›Pre- and post-bronchoscopy medications

›Nebulized epinephrine

›Post-removal airway edema

›0.5 mL of 2.25% racemic epinephrine in 3 mL normal saline

›Observe for rebound edema 2 to 4 hours post-administration

›Systemic corticosteroids

›Dexamethasone 0.5 mg/kg IV or PO for airway inflammation

›Pre- or post-bronchoscopy edema reduction

›Maximum 10 mg per dose in children

›Antibiotics

›Not for acute FBA itself — definitive treatment is removal

›Indicated for post-obstructive pneumonia or abscess

›Ampicillin sulbactam 3 g IV every 6 hours for post-obstructive pneumonia

›Piperacillin tazobactam 4.5 g IV every 6 hours if severe or pseudomonas risk

Supportive care

›Non-procedural supportive measures

›Oxygen therapy

›Nasal cannula titration to SpO2 greater than 95%

›Non-rebreather mask for moderate hypoxia

›HFNC for severe hypoxia pending procedure

›NPO status

›Anticipate bronchoscopy under general anesthesia

›IV fluid maintenance while NPO

›Positioning

›Allow position of comfort

›Avoid supine in upper airway FB — may worsen obstruction

›Avoid bronchodilators as sole treatment

›May mask underlying FBA

›Use only if concurrent reactive airway disease confirmed

Treatment to avoid

›Contraindications and pitfalls

›Blind finger sweeps

›May push FB deeper

›Only remove FB if directly visualized

›Abdominal thrusts in infants less than 1 year

›Risk of visceral injury

›Use back blows and chest thrusts only

›Delayed bronchoscopy without strong justification

›Greater than 24 hours associated with 100% complication rate in one study

›Bronchodilators masking FBA in children

›Treat new-onset wheeze in toddler as FBA until proven otherwise

09Special Populations/sp57

Pregnancy

›FBA in pregnancy

›Aspiration risk considerations

›Delayed gastric emptying increases aspiration risk

›Increased intraabdominal pressure raises reflux risk

›Supine position worsens risk — elevate head of bed

›BLS maneuvers modification

›Chest thrusts instead of abdominal thrusts in late pregnancy

›Third trimester: abdominal thrusts less effective and risk uterine injury

›Imaging approach

›CXR with abdominal shielding when clinically indicated

›Low-dose CT acceptable if benefits outweigh risks

›Fetal radiation dose with CT chest is low

›Pharmacological considerations

›Dexamethasone acceptable for airway edema management

›Beta-lactam antibiotics generally preferred for post-obstructive infection

›Maternal oxygenation target SpO2 greater than or equal to 95%

›Fetal monitoring when viable gestation and significant maternal hypoxia

Geriatric

›Older adult FBA features

›Risk profile

›Age greater than 65 years is second peak incidence after early childhood

›Poor dentition — broken teeth most common adult FB (37.7% of iatrogenic cases)

›Neuromuscular disease, hemiparesis, sedating medications

›GERD, alcohol use, altered consciousness

›Atypical presentation

›Subacute or chronic cough without clear choking history

›Recurrent pneumonia in the same lobe

10Background/b58

Epidemiology

›Incidence and demographics

›Approximately 116,000 cases per year in the United States

›Bimodal age distribution: children 6 months to 5 years and adults over 65 years

›Male predominance: M:F ratio 1.6 to 2.6:1

›Delayed presentation common

›Delayed presentation greater than 24 hours in 40 to 77% of cases

›75% of pediatric patients present within 1 day in other series

›Mortality

›Up to 4% in infants

›Cardiac arrest in 4.1% of one pediatric case series

›Chronic retained FBs cause significant morbidity including bronchiectasis

›Adult epidemiology

›Iatrogenic FBA accounts for approximately 37% of adult cases

›Broken teeth from dental procedures most common adult FB at 37.7%

Pathophysiology

›Mechanisms of injury

›Mechanical obstruction

›FB lodges at level of cords, subglottis, carina, or main bronchi

›Right main bronchus more commonly affected due to less acute angle

›Partial obstruction causes valve effect — air trapping and hyperinflation

›Complete obstruction causes atelectasis distal to FB

›Three clinical phases

›Phase 1: acute impaction — violent coughing, gagging, choking

›Phase 2: latent or asymptomatic — reflex fatigue, temporary symptom resolution

›Phase 3: complications — post-obstructive pneumonia, abscess, bronchiectasis

›Organic vs inorganic FB behavior

›Organic FBs (peanuts, seeds) absorb moisture, swell, and fragment

11Patient Discharge Instructions/pdi37

copy discharge instructions

›Home care after foreign body aspiration evaluation

›If FB was successfully removed by bronchoscopy

›Rest and light activities for 24 to 48 hours

›Soft diet if throat or airway soreness

›Avoid strenuous activity for 24 hours

›Medications if prescribed

›Antibiotics: complete the full course even if feeling better

›Steroid taper if prescribed: do not stop abruptly

›Warning signs — return to emergency department immediately

›Breathing problems

›Trouble breathing at rest or with minimal activity

›Noisy breathing, wheezing, or new stridor

›Lips or face turning blue

›Airway symptoms

›Worsening cough not improving

›New or worsening hoarse voice

›Choking sensation returning

›Infection signs

›Fever not improving or new fever after initial improvement

›Coughing up blood (hemoptysis)

›Increasing chest pain

›General deterioration

›Confusion or unusual drowsiness

›Persistent vomiting or inability to keep fluids down

›Follow-up instructions

›Post-bronchoscopy: follow-up with the proceduralist (ENT, pulmonologist, or surgeon) within 1 to 2 weeks

›If FB ruled out but symptoms persist, return for reassessment

12References/r34

Guidelines and key sources

›Primary guidelines

›ACR Appropriateness Criteria: Ingested or Aspirated Foreign Body, Child — 2026

›CT chest without contrast "usually appropriate" when CXR negative and FBA suspected

›Journal of the American College of Radiology 2026

›2025 AHA/AAP Pediatric Basic Life Support Guidelines

›Back blows now precede abdominal thrusts in children 1 year and older

›Chest thrusts only for infants less than 1 year

›Pediatrics and Circulation 2025 to 2026

›ACEP Clinical Guidelines

›Imaging and bronchoscopy decision-making in FBA

›Evidence levels applied per category

Key studies

›Evidence summaries

›Lee JJW et al. Clinical Prediction Models for Suspected Pediatric FBA. JAMA Otolaryngology Head and Neck Surgery. 2021

›Systematic review and meta-analysis identifying key OR values for clinical predictors

›Unilateral decreased breath sounds OR 4.8 to 5.48, focal wheeze OR 7.38

›White JJ et al. Evaluation and Management of Airway Foreign Bodies in the ED. Journal of Emergency Medicine. 2023

›Unilateral hyperinflation on CXR OR 8.3, prior FBA OR 5.46

›Jang G et al. Foreign Body Aspiration Into the Lower Airways in Adults. PLoS One. 2022

›Multicenter adult series, flexible bronchoscopy success rate 87 to 91%

›Bajaj D et al. Foreign Body Aspiration. Journal of Thoracic Disease. 2021

›CT sensitivity 98.8%, specificity 96.6% in meta-analysis of 2,056 pediatric patients

›Raviv I et al. FOBAS Score in Children. European Journal of Pediatrics. 2023

›Foreign Body Aspiration Score validation in pediatric cohort

›Bjerregaard AT et al. Time From Suspected FBA to Bronchoscopy. Acta Anaesthesiologica Scandinavica. 2025

›Timing data supporting early bronchoscopy within 24 hours

›Chi J, Bai Y. Bronchoscopic Management of Airway Foreign Bodies in Adults. Frontiers in Medicine. 2026

Evidence & Review

Evidence & Review