Complete obstruction signs (Silent cough, inability to speak/cry, severe distress, cyanosis, weak/absent air movement — immediate choking algorithm (ERC, AHA PALS))
First-line therapy
Choking resuscitation — age-specific • procedure
Duration: Immediate · Infant <1 yr: 5 back blows + 5 chest thrusts alternating · Child ≥1 yr: up to 5 abdominal thrusts — repeat cycles until relieved or unresponsive (ERC 2021, AHA PALS)
• Infant <1 year: 5 back blows (support head/neck, head-down) then 5 chest thrusts — alternate until FB expelled or child becomes unresponsive (ERC, AHA).
• Child ≥1 year: abdominal thrusts (Heimlich) — stand/kneel behind child, thrust upward on abdomen; up to 5 thrusts per cycle; repeat until relieved (ERC, AHA).
• Complete obstruction: silent cough, cannot speak/cry, cyanosis, severe distress — start maneuvers immediately; call emergency services if not relieved after cycles or if deteriorating.
• If becomes unresponsive: lower to ground, call EMS, start CPR — 30 compressions then open airway and look in mouth; remove visible FB only, do NOT blind finger sweep (ERC, AHA).
• Visible FB in oropharynx: direct laryngoscopy removal if easily seen — NEVER finger sweep in infants; do NOT perform blind finger sweeps in any age with partial obstruction (AAP, ERC).
Duration: After relief or if maneuvers fail · Call EMS early if not relieved; urgent rigid bronchoscopy when obstruction relieved but FB still suspected, or persistent symptoms after choking event (AAP, ESPR, pediatric ENT)
• Maneuvers fail or child becomes unresponsive — activate EMS, continue CPR with airway checks between cycles.
• Obstruction relieved but aspiration suspected — urgent ENT/pulmonology rigid bronchoscopy; do not discharge without evaluation if high clinical suspicion.
• Persistent cough, wheeze, stridor, or unilateral decreased breath sounds after choking episode — bronchoscopy even if transient improvement.
• Witnessed choking with complete obstruction history — hospital observation and bronchoscopy if symptomatic or high suspicion.
• Post-removal complications (atelectasis, pneumonia) — antibiotics only if secondary infection confirmed; not routine (AAP, ESPR).
Clinical notes
• Complete vs partial: complete = silent cough, cannot vocalize, cyanosis → immediate choking maneuvers; partial = stridor, wheeze, productive cough, can cry → do NOT blind finger sweep (ERC, AHA).
• Age algorithm: infant <1 yr back blows + chest thrusts; child ≥1 yr abdominal thrusts; unconscious → CPR with mouth check before breaths (ERC 2021, AHA PALS).
• Oropharynx: remove only clearly visible FB under direct vision — no finger sweep in infants; blind probing risks pushing FB distally (AAP, ERC).
• After relief: observe for persistent symptoms; urgent rigid bronchoscopy if unilateral wheeze, ongoing cough, or witnessed complete obstruction (ESPR, pediatric ENT consensus).
• Return precautions: worsening breathing, persistent cough >24 h, fever, cyanosis, inability to feed — emergency reassessment; antibiotics only for confirmed post-aspiration infection (AAP).
• ERC — European Resuscitation Council Guidelines (paediatric choking) (2021)
• AHA — Pediatric Advanced Life Support (choking algorithm) (2020)
• AAP — Foreign body aspiration clinical principles (2024)
+ 1 more
• ESPR — European Society of Paediatric Research (paediatric airway FB) (2023)
