Suspected Airway Foreign Body (Choking)
Witnessed choking, sudden cough, stridor or breathing distress, or a history of inhaling an object. Swallowed object with normal breathing (food bolus, button battery): oesophageal FB, not this pathway.
All Pathways
OtolaryngologyEmergency
Airway Foreign Body Management
Airway Foreign Body Management: Suspected Airway Foreign Body (Choking) → Responsive? → Cough Ineffective (Severe Obstruction)? → Ineffective Cough: Bac...
Pathway Overview
19 steps
Algorithm Steps
19 total
01Start 02Decision Responsive?
Unresponsive and not breathing normally: start CPR. A responsive patient who cannot breathe: back blows and chest thrusts, not CPR.
- If Yes
03Decision Cough Ineffective (Severe Obstruction)?
Ineffective (severe): weak or silent cough, cannot speak, cry or breathe, cyanosis. Effective (mild): can cough forcefully, speak or cry, and breathe.
- If Yes
- Ineffective cough
04Action Ineffective Cough: Back Blows + Chest Thrusts
Call an ambulance (000); in hospital, call a MET or code blue. Up to 5 sharp back blows between the shoulder blades, then up to 5 chest thrusts at the CPR compression point (lower half of sternum), sharper and slower than compressions. Check after each. Alternate until relieved or unresponsive. Infant <1 y: head down across your lap for back blows; on the back, head down along your thigh for chest thrusts. Never abdominal thrusts in infants.
- Late pregnancy or obesity: back blows and chest thrusts, never abdominal thrusts
- Laryngectomy or tracheostomy: the block is at the stoma or tube; remove cap or inner tube, suction, oxygen to the stoma
- Infant chest thrusts: two-thumb encircling or heel of one hand (ANZCOR 12.1, 2026)
- ANZCOR: no abdominal thrusts. AHA and ERC 2025 (age ≥1 y): 5 back blows, then 5 abdominal thrusts
- Child or adult: sitting or standing
05Decision Becomes Unresponsive?
Still responsive and not relieved: keep alternating 5 back blows and 5 thrusts. Object out, or breathing and effective cough return: medical assessment.
- If Yes
- Becomes unresponsive
06Warning Unresponsive, Not Breathing Normally: Start CPR
Lower the patient to the ground. Call for help and an AED. Unresponsive and not breathing normally: start CPR (ANZCOR Guideline 8; child: Guideline 12.1). Unresponsive but breathing normally: recovery position, look in the mouth, and watch breathing closely.
- Call the emergency number (000 in Australia)
- No blind finger sweeps
- Remove only an object you can see in the mouth
07Action CPR With Airway Checks
Adult: 30 compressions to 2 breaths. Infant or child: 15:2 if trained in paediatric BLS, otherwise 30:2. Before breaths, look in the mouth and remove only a visible object. Compressions can also expel the object. Continue until the patient responds or clinicians take over.
- Do not delay compressions to search for the object
- Clinicians with equipment: laryngoscopy next
08Action Clinicians: Laryngoscopy + Magill Forceps
Skilled clinicians: look at the airway with a laryngoscope. Remove a visible object with Magill forceps. Suction. Then ventilate with bag-mask, supraglottic airway or tracheal tube.
- Keep CPR going during attempts if there is no pulse
09Decision Cannot Ventilate or Oxygenate?
After the removal attempt: no chest rise, falling SpO2 or no end-tidal CO2 despite bag-mask, supraglottic airway or tracheal tube.
- If Yes
- Cannot oxygenate
10Warning Cannot Oxygenate: Front-of-Neck Access or Push FB Into One Bronchus
Object at or above the cords and cannot intubate or oxygenate: emergency front-of-neck access by a trained clinician. Object in the trachea (below the cords): front-of-neck access will not bypass it. Intubate, advance the tube to push the object into one main bronchus, pull the tube back into the trachea and ventilate the other lung. Then urgent rigid bronchoscopy.
- Front-of-neck access helps only if the object is at or above the cords
- Adult: scalpel cricothyroidotomy
- Child: follow the paediatric CICO guideline (young child: needle cricothyroidotomy)
11Action Bronchoscopy (Rigid or Flexible)
For retained FB, or FB below the cords after an emergency airway. Children: rigid bronchoscopy under general anaesthetic is the standard. Adults: flexible bronchoscopy is often first; rigid if it fails or for a large central FB.
- Anaesthetist and airway team; rigid equipment ready
- Look for fragments after removal (nuts can break up)
12Outcome FB Removed: Post-Bronchoscopy Care
Observe for airway oedema, bleeding, pneumothorax and pneumonia. Discharge when stable.
If No- Can oxygenate
13Action Relieved or Breathing Adequately: Medical Assessment
Object out, effective cough that has not cleared, or airway restored. Assess everyone who needed back blows, thrusts or CPR: these can cause internal injury.
- After abdominal thrusts: check for abdominal injury
- After CPR: post-resuscitation care
- Examine for stridor, wheeze, one-sided chest signs and hypoxia
14Decision Signs of Retained FB or Injury?
Persistent cough, wheeze or stridor; reduced or one-sided breath sounds; hypoxia; chest or abdominal pain; or cough not cleared.
- If Yes
- Signs present
15Action Retained FB or Injury Suspected: Imaging if Stable
Stable patient only. CXR; in young children add expiratory or decubitus views. Most FBs are radiolucent; up to 50% of CXRs are normal. CXR equivocal and stable: CT chest. Strong history or signs: do not delay bronchoscopy for imaging.
16Action Retained FB Suspected: Urgent ENT/Respiratory Referral
ENT for children and upper airway FB. Respiratory or thoracic team for adult lower airway FB. Nil by mouth. Arrange bronchoscopy, even if imaging is normal.
- Path rejoins step 11Shared downstream outcome
If No- No signs
17Outcome No Residual Signs: Discharge With Advice
Return at once for cough, wheeze, fever or breathing difficulty: a retained FB can present late. Give choking prevention advice.
If No- Relieved
- Path rejoins step 13Shared downstream outcome
If No- Effective cough
18Action Effective Cough: Encourage Coughing
Reassure and encourage coughing. Do not give back blows or thrusts while the cough is effective. Stay and watch for a weakening cough. Not cleared: call an ambulance (000 in Australia).
- Stay with the patient
- Stridor, distress or cyanosis: call an ambulance now
- In hospital with stridor: keep upright and calm, no throat examination; oxygen as tolerated; call senior anaesthetist and ENT for removal in theatre
- Swallowed object, breathing normally (food bolus, button battery): use the oesophageal FB pathway
19Decision Cough Becomes Ineffective?
Weak or silent cough, cannot speak or breathe, cyanosis, or tiring.
- If Yes
- Cough becomes ineffective
- Path rejoins step 04Shared downstream outcome
If No- Cough stays effective
- Path rejoins step 13Shared downstream outcome
If No- Path rejoins step 06Shared downstream outcome
Guideline Source
ANZCOR Guideline 4 - Airway (Management of Foreign Body Airway Obstruction), approved April 2021
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Techniques differ by region: ANZCOR uses back blows then chest thrusts; AHA and ERC 2025 use back blows then abdominal thrusts
- Does not cover swallowed (oesophageal) foreign bodies such as food bolus or button battery
- Laryngoscopy, front-of-neck access and bronchoscopy need trained staff and equipment
- Evidence for choking manoeuvres is observational (no randomised trials)
Contraindicated Populations
Swallowed (oesophageal) foreign body with a clear airwayNasal or ear foreign body
Applicable Regions
AUNZUSEU
AU: ANZCOR Guideline 4 (adults) and 12.1 (children, April 2026): up to 5 back blows, then up to 5 chest thrusts; abdominal thrusts not recommended. Emergency number 000.
EU: ERC 2025: up to 5 back blows, then up to 5 abdominal thrusts; assess every patient treated with abdominal thrusts or chest compressions. Emergency number 112.
NZ: ANZCOR Guideline 4 applies. Emergency number 111.
US: AHA 2025 Adult and Pediatric BLS: 5 back blows then 5 abdominal thrusts (age 1 year or older); infants: back blows and chest thrusts; chest thrusts in late pregnancy or obesity. Emergency number 911.
Version 2Next review: 2027-09-30
Next steps
Finish the workflow by opening the most relevant calculator, then convert the session into a live account when you are ready.
Related Resources
Frequently Asked Questions
What is the Airway Foreign Body Management?
The Airway Foreign Body Management is a emergency clinical algorithm for Otolaryngology. It provides a structured decision tree to guide clinical decision-making, based on ANZCOR Guideline 4 - Airway (Management of Foreign Body Airway Obstruction), approved April 2021.
What guideline is the Airway Foreign Body Management based on?
This algorithm is based on ANZCOR Guideline 4 - Airway (Management of Foreign Body Airway Obstruction), approved April 2021.
What are the limitations of the Airway Foreign Body Management?
Known limitations include: Techniques differ by region: ANZCOR uses back blows then chest thrusts; AHA and ERC 2025 use back blows then abdominal thrusts; Does not cover swallowed (oesophageal) foreign bodies such as food bolus or button battery; Laryngoscopy, front-of-neck access and bronchoscopy need trained staff and equipment; Evidence for choking manoeuvres is observational (no randomised trials). Individual patient factors may require deviation from these recommendations.
Get AI-Powered Analysis Alongside This Algorithm
In AttendMe.ai, the Airway Foreign Body Management appears automatically when your clinical question matches — alongside evidence from 3M+ peer-reviewed articles.
Try AttendMe Free