01Approach to the Critical Patient/attcp51

Immediate life threat recognition

›Severe foreign body airway obstruction (FBAO) triggers

›Ineffective or silent cough

›Inability to vocalize or cry

›Cyanosis or mottling

›Rapidly declining SpO2

›Apnea or near-apnea

›Loss of consciousness

›Stridor at rest with increased work of breathing

›Suprasternal and subcostal retractions

›Nasal flaring

Prehospital and initial ED response

›Infant (<1 year) FBAO response per AHA/AAP 2025

›5 back blows alternating with 5 chest thrusts

›Heel-of-hand technique for chest thrusts

›Abdominal thrusts contraindicated in infants

›If unresponsive, begin CPR immediately

›Start with chest compressions

›Remove visible FB when opening airway for breaths

›Child (>=1 year) FBAO response per AHA/AAP 2025

›5 back blows alternating with 5 abdominal thrusts

›Back blows now precede abdominal thrusts in 2025 update

›Blind finger sweeps contraindicated

›If unresponsive, begin CPR immediately

›No pulse check before compressions

›Remove visible FB when opening airway

Stabilization and escalation

›Oxygen delivery

02History/hx58

Choking event characterization

›Witnessed event details

›Witnessed choking episode

›Present in approximately 89 to 93% of confirmed FBA cases

›Single most important historical feature

›Activity at time of event

›Eating nuts, seeds, grapes, or hot dogs

›Playing with small toys, coins, batteries, or balloons

›Timing since event

›Acute (<24 hours) vs delayed presentation

›Only 23% of cases present within 24 hours of event

›7% present >1 month after aspiration

Symptom progression

›Initial and evolving symptoms

›Sudden onset cough, gagging, or choking without prodrome

›Abrupt onset distinguishes FBA from infectious causes

›Absence of fever helps differentiate from croup or tracheitis

›Asymptomatic interval

›Initial choking episode may resolve transiently

›Recurrent cough, wheeze, or pneumonia follows in delayed cases

›Chronic or recurrent presentations

›Recurrent or unresolved pneumonia as key predictor of delayed FBA

›Persistent wheeze without prior asthma diagnosis

›Chronic cough not responding to standard therapy

Object identification

›Foreign body type

›Organic material

›Peanuts, seeds, popcorn most common overall

03Physical Exam/exam53

Vital signs

›Hemodynamic and oxygenation snapshot

›SpO2

›Mean SpO2 97.3% in confirmed FBA cases in one series

›SpO2 <92% indicates significant respiratory compromise

›Respiratory rate

›Tachypnea as marker of increased work of breathing

›Rising rate indicates impending fatigue

›Heart rate

›Tachycardia from hypoxia or distress

›Bradycardia is ominous sign of impending arrest

›Temperature

›Fever suggests secondary infection not primary FBA

›Afebrile status supports FBA over infectious cause

Respiratory exam

›Auscultation findings

›Unilateral decreased or absent breath sounds

›Strong predictor of confirmed FBA (OR 2.9 to 5.48)

›Most foreign bodies lodge in right mainstem bronchus

›Unilateral wheeze

›Highly predictive of confirmed FBA (OR 7.38)

›Bilateral wheeze more consistent with asthma or bronchiolitis

›Stridor

›Suggests laryngotracheal location

›Inspiratory stridor more common with supraglottic or tracheal FB

›Work of breathing assessment

›Subcostal and intercostal retractions

›Present in approximately 81% of confirmed FBA cases

04Differential Diagnosis/ddx48

Immediate life threats

›Critical airway diagnoses

›Epiglottitis

›ICD-10 J05.1

›Toxic appearance, drooling, tripoding, dysphagia

›More common in under-immunized children

›Bacterial tracheitis

›ICD-10 J04.1

›Initial viral illness worsening after 2 to 7 days

›Toxic appearance, high fever, pseudomembrane on laryngoscopy

›Anaphylaxis with angioedema

›ICD-10 T78.2

›Rapid onset, urticaria, allergen exposure history

›No choking event or witnessed aspiration

Upper airway mimics

›Infectious causes with stridor

›Croup (laryngotracheobronchitis)

›ICD-10 J05.0

›Barking cough with URI prodrome and low-grade fever

›Gradual onset; no sudden choking event

›Retropharyngeal abscess

›ICD-10 J39.0

›Fever, neck stiffness, dysphagia, drooling

›Neck radiograph shows widened prevertebral space

›Peritonsillar abscess

›ICD-10 J36

›Unilateral tonsillar swelling, muffled voice, trismus

›Fever and odynophagia prominent

05Laboratory Tests/lt31

Acute phase labs

›Infection markers

›Complete blood count

›WBC >10x10(9)/L associated with confirmed FBA (OR 3.3 in one prediction model)

›Leukocytosis supports secondary pneumonia if delayed presentation

›Not required for acute uncomplicated FBA diagnosis

›C-reactive protein

›Elevated in secondary infection or prolonged retained FB

›Not specific for FBA diagnosis

›Blood cultures

›If secondary pneumonia with fever and systemic illness

›Prior to antibiotics when feasible

Gas exchange and metabolic labs

›Respiratory assessment

›Arterial blood gas

›PaO2 and PaCO2 in mmHg for significant respiratory compromise

›Hypercapnia signals impending respiratory failure

›Venous blood gas

›pH and CO2 trend for monitoring

›Less invasive alternative in stable child

›Pulse oximetry

›Continuous monitoring preferred over intermittent sampling

›SpO2 <92% requires immediate action

Pre-operative labs

›Bronchoscopy preparation

›Pre-operative panel per anesthesia protocol

›Electrolytes and renal function for drug dosing

›Coagulation studies if bleeding concern

06Diagnostic Tests/dt82

Scoring Systems

›Foreign Body Aspiration Score (FOBAS)

›Prospectively validated scoring system

›Incorporates history of choking, physical exam findings, and radiographic features

›Stratifies risk and guides bronchoscopy decisions

›Clinical prediction model components

›Witnessed choking episode

›Unilateral decreased air entry on exam

›Unilateral wheeze on exam

›Abnormal radiograph with indirect signs

›Radiopaque finding on imaging

›Score interpretation

›>=3 risk factors significantly increases probability of confirmed FBA

›Meta-analysis: combined clinical prediction models improve bronchoscopy yield

›AHA/AAP 2025 Severity Classification

›Mild FBAO criteria

›Effective cough with audible sounds

›Able to vocalize or cry

›Management: allow child to cough; observe

›Severe FBAO criteria

›Ineffective or silent cough

›Inability to vocalize, cyanosis

›Immediate intervention required per 2025 guidelines

›Unresponsive criteria

›Begin CPR immediately

›No pulse check before starting compressions

MRI

›MRI role in FBA

›Not standard first-line imaging for suspected FBA

›Limited availability, time requirements, and sedation needs

›Not appropriate in acute setting

›Potential role for complex retained FB cases

›Soft-tissue characterization of inflammatory changes

›Mediastinal involvement assessment in complicated cases

›Practical limitations

›Long acquisition time incompatible with respiratory distress

›Motion artifact degrades quality in uncooperative children

CT

›CT chest without contrast

›Indications

›Negative initial radiographs with persistent clinical suspicion

›ACR Appropriateness Criteria: CT chest without contrast usually appropriate in this setting

›Do not delay OR for CT in acutely ill patients with clear clinical evidence

›Performance characteristics

›Meta-analysis sensitivity 98.8%

›Specificity 96.6%

›With 3D virtual bronchoscopy: sensitivity 99.4%, specificity 99%

›Ultra-low-dose CT (ULDCT)

›Sensitivity and specificity of 100% in recent series

›Effective dose 0.04 mSv

›Comparable to or lower radiation than multiview CXR

›Negative bronchoscopy rate impact

›CT-guided bronchoscopy negative rate 11%

›CXR-only guided bronchoscopy negative rate 21%

›CT neck

›For suspected laryngotracheal or hypopharyngeal foreign body

›Complements chest CT when upper airway symptoms predominate

›Lateral soft-tissue neck X-ray as initial screen if stable

Ultrasound

›Ultrasound role in FBA

›No established role for direct FB detection in airway

›Not validated for tracheobronchial foreign bodies

›Limited penetration for air-containing structures

›Adjunct applications

›Point-of-care lung ultrasound for complications

›Atelectasis: absent lung sliding with A-lines

›Consolidation: hepatization pattern

›Pleural effusion: anechoic collection

›Esophageal FB

›Ultrasound may detect esophageal coin or button battery

›Sensitivity lower than X-ray for metallic FBs

›Chest radiography (primary imaging tool)

›PA and lateral chest radiograph

›First-line imaging modality for stable patients

›Sensitivity only approximately 45% for FBA

›Specificity approximately 88%

›Indirect signs on CXR

›Focal hyperinflation or air trapping: most predictive (OR 8.3)

›Mediastinal shift away from affected side

›Atelectasis or consolidation on affected side

›Normal CXR pitfall

›Up to 41 to 80% of confirmed FBA cases have normal radiographs

›Normal CXR does NOT exclude FBA

›Decubitus views and fluoroscopy

›Usually not appropriate per ACR 2026 guidelines

›Replaced by CT in contemporary practice

07Disposition/dispo41

Admission criteria

›Hospital admission indications

›All confirmed or highly suspected FBA cases requiring bronchoscopy

›Any child with positive clinical prediction score

›Witnessed choking with persistent respiratory symptoms

›Post-bronchoscopy observation

›Minimum 12 to 24 hours observation after FB removal

›Monitor for airway edema, secondary pneumonia, and reaccumulation

›Complications requiring admission

›Post-obstructive pneumonia or atelectasis

›Pneumothorax or pneumomediastinum

›Significant airway edema requiring ongoing treatment

PICU criteria

›Intensive care indications

›Cardiac arrest or near-arrest secondary to complete obstruction

›Post-ROSC care and neurological monitoring

›Hemodynamic stabilization

›Significant respiratory compromise

›Requirement for mechanical ventilation post-extraction

›Refractory hypoxemia despite O2 therapy

›Complicated extraction

›Multiple attempts or prolonged procedure

›Thoracotomy performed

Consultation triggers

›Required specialist involvement

›Pediatric ENT/otolaryngology or pediatric pulmonology

›All confirmed or suspected FBA for bronchoscopy planning

›Flexible bronchoscopy diagnostics in stable cases

08Treatment/t62

Acute pre-hospital FBAO management

›Infant FBAO (<1 year)

›Back blows and chest thrusts cycle

›5 back blows with heel of hand between shoulder blades

›5 chest thrusts with 2 fingers over lower sternum

›Alternate cycles until FB expelled or infant becomes unresponsive

›Unresponsive infant

›Begin CPR immediately with chest compressions

›Open airway: look for visible FB before rescue breaths

›Remove FB only if directly visualized

›Child FBAO (>=1 year)

›Back blows and abdominal thrusts cycle (AHA/AAP 2025 update)

›5 back blows between shoulder blades

›5 abdominal thrusts (Heimlich maneuver)

›Back blows now precede abdominal thrusts per 2025 guidelines

›Unresponsive child

›Begin CPR without pulse check

›Remove visible FB when opening airway for breaths

›Blind finger sweeps contraindicated

In-hospital procedural management

›Rigid bronchoscopy

›Gold standard for both diagnosis and removal

›Preferred for definitive FB extraction in children

›General anesthesia required

›Timing

›Within 24 hours for stable patients with suspected retained FB

›Delays >24 hours associated with higher complication rates

›Immediate for unstable patients or clear clinical evidence

09Special Populations/sp52

Pregnancy

›Pregnancy considerations for FBA

›Modified Heimlich maneuver in late pregnancy (>20 weeks)

›Chest thrusts substituted for abdominal thrusts

›Landmark: lower half of sternum

›Apply same force as standard chest thrusts

›Positioning considerations

›Left lateral decubitus preferred for resuscitation

›Uterine displacement to relieve aortocaval compression

›Fetal monitoring

›Continuous fetal monitoring if >24 weeks gestation during procedural intervention

›Obstetric consultation for bronchoscopy under general anesthesia

›Drug safety considerations

›Dexamethasone: generally considered safe; used for fetal lung maturity

›Racemic epinephrine: use with caution; monitor for maternal tachycardia

Geriatric

›Geriatric-specific FBA considerations

›Altered presentation

›May not recall choking event due to cognitive impairment

›Dysphagia from neurological disease increases aspiration risk

›Chronic cough or recurrent pneumonia may be presenting feature

›Common causative objects

›Dentures or dental prostheses

›Pills or tablets

›Food bolus from dysphagia

›Comorbidity considerations

›Anticoagulation increases bleeding risk during bronchoscopy

›Chronic lung disease alters baseline exam and imaging interpretation

10Background/b62

Epidemiology

›Incidence and demographics

›Estimated 116,000 cases of FBA per year in the US

›Leading cause of morbidity and mortality in children from airway obstruction

›Approximately 17,000 emergency department visits annually in children

›Age distribution

›Peak incidence 6 months to 5 years

›Highest risk at 1 to 2 years old

›Children <3 years account for majority of cases

›Sex distribution

›Male-to-female ratio approximately 2 to 2.6:1

›No clear biological explanation; likely behavioral

›Object type distribution

›Organic material most common: peanuts, seeds, food items

›Older children aspirate more inorganic objects: plastic, LEGO pieces

›Button batteries: rare but high-consequence injury

›Location of lodgment

›Right mainstem bronchus most common due to less acute angle

›Laryngotracheal location in approximately 10 to 15% of cases

Pathophysiology

›Mechanism of airway obstruction

›Ball-valve mechanism

›Partial obstruction allows air entry but impedes expiration

›Leads to focal hyperinflation and air trapping distal to FB

›Most predictive radiographic finding: OR 8.3 for confirmed FBA

›Complete obstruction

›Distal atelectasis develops

›Mediastinal shift toward affected side (atelectasis pattern)

›Mediastinal shift away from affected side (hyperinflation pattern)

›Progressive complications

›Secondary bacterial colonization: pneumonia

›Retained FB >24 hours: higher complication rate including pneumonia and PICU admission

›Prolonged retention: bronchiectasis, granulation tissue formation, perforation

›Organic vs inorganic FB behavior

›Organic material (nuts, seeds)

›Absorb moisture; swell and become more impacted over time

›Release oils: cause lipoid pneumonitis

›More difficult to extract; crumble with rigid forceps

›Inorganic material (coins, plastics)

›No swelling; more amenable to extraction

›Button batteries: generate hydroxide ions via electrolysis; liquefactive necrosis within hours

›Button battery impaction requires true emergency extraction

Therapeutic Considerations

›Evidence basis for management

›Rigid bronchoscopy as gold standard

›Superior visualization and extraction capability

›Allows management of airway edema and bleeding concurrently

›General anesthesia required: multidisciplinary team essential

›CT scan role

›Ultra-low-dose CT has sensitivity and specificity of 100% in recent series

›Effective dose 0.04 mSv: comparable to or lower than multiview CXR

›Reduces negative bronchoscopy rate from 21% (CXR-only) to 11% (CT-guided)

›Timing of bronchoscopy

›Delay >24 hours from suspected FBA to bronchoscopy increases complication risk

›ACR and AHA/AAP guidelines support imaging workup prior to bronchoscopy in stable patients

›Unstable patients proceed directly to OR without imaging delay

›Post-bronchoscopy management

›Dexamethasone reduces post-procedural airway edema

›Nebulized epinephrine provides temporizing relief for rebound stridor

›Antibiotic therapy reserved for confirmed secondary infection

›Prevention evidence

›Dietary modification: avoid nuts, seeds, popcorn, whole grapes, hot dogs in children <4 years

›Environmental modification: keep objects <3.17 cm (1.25 inches) diameter out of reach

›Caregiver education on choking first aid per AHA/AAP 2025 guidelines

›Supervise meals; children should sit upright while eating

11Patient Discharge Instructions/pdi42

copy discharge instructions

›Diagnosis and procedure explanation

›Your child had a foreign body removed from their airway

›This is called foreign body aspiration

›A bronchoscopy procedure was performed to remove the object

›What to expect after the procedure

›Mild cough or hoarse voice for 1 to 2 days is normal

›Fever within 24 hours may occur; temperature >38.5 C (101.3 F) warrants contact with your doctor

›Medications and activity

›Medications prescribed

›Take all prescribed antibiotics for the full course even if symptoms improve

›Dexamethasone or other steroid: complete as directed

›Activity restrictions

›No vigorous activity for 24 to 48 hours after bronchoscopy

›Normal diet when tolerating fluids well

›Prevention counseling

›Foods to avoid in children under 4 years

›Whole nuts and peanuts

›Whole grapes and cherry tomatoes; cut into quarters

›Hot dogs and sausage rounds; cut lengthwise and into small pieces

›Popcorn, raw carrots, hard candy, large chunks of meat

›Safe eating habits

›Always sit upright while eating

›No eating while running, playing, or in a moving vehicle

›Supervise all meals in young children

›Environmental safety

›Keep objects smaller than a toilet paper roll (3.17 cm or 1.25 inch diameter) away from young children

›Button batteries and coins are especially dangerous

12References/r40

Guidelines and key sources

›ACR Appropriateness Criteria 2026

›Expert Panel on Pediatric Imaging, Meyers ML, Moore MM, et al.

›ACR Appropriateness Criteria: Ingested or Aspirated Foreign Body-Child

›Journal of the American College of Radiology. 2026

›CT chest without contrast usually appropriate for suspected FBA with negative initial radiographs

›AHA/AAP 2025 Pediatric Basic Life Support Guidelines

›Joyner BL, Dewan M, Bavare A, et al.

›Part 6: Pediatric Basic Life Support: 2025 AHA and AAP Guidelines for CPR and ECC

›Circulation. 2025; Pediatrics. 2026

›Updated FBAO management: back blows now precede abdominal thrusts in children >=1 year

›Clinical prediction model evidence

›Lee JJW, Philteos J, Levin M, et al.

›Clinical Prediction Models for Suspected Pediatric Foreign Body Aspiration: A Systematic Review and Meta-analysis

›JAMA Otolaryngology Head Neck Surgery. 2021

›Janahi IA, Khan S, Chandra P, et al.

›A New Clinical Algorithm Scoring for Management of Suspected Foreign Body Aspiration in Children

›BMC Pulmonary Medicine. 2017

Imaging and procedural evidence

›CT performance meta-analysis

›Azzi JL, Seo C, McInnis G, et al.

›A Systematic Review and Meta-Analysis of CT in the Diagnosis of Pediatric Foreign Body Aspiration

›International Journal of Pediatric Otorhinolaryngology. 2023

›CT sensitivity 98.8%, specificity 96.6%; 3D virtual bronchoscopy sensitivity 99.4%, specificity 99%

›Li R, Niec J, Zhao S, et al.

›Reduced-Dose CT vs Multiview Radiographs in Pediatric Foreign Body Aspiration

›The Journal of Pediatrics. 2026

›ULDCT: sensitivity and specificity 100%, effective dose 0.04 mSv

Evidence & Review

Evidence & Review