See also

Emergency airway management
Acute upper airway obstruction
Resuscitation: Hospital management of cardiopulmonary arrest
Foreign body ingestion

Key points

1. Inhalation of a foreign body (FB) into the trachea or larynx is a potentially life-threatening event requiring immediate emergency airway management
2. FB inhalation is frequently unwitnessed, a high degree of suspicion is required in young children with respiratory symptoms
3. Seek a history of inhalation or choking which may have occurred days or weeks before presentation with symptoms
4. Normal respiratory examination or chest x-ray (CXR) does not exclude an inhaled FB
5. Low dose CT chest may provide high diagnostic accuracy for select children with suspected FB aspiration when clinical suspicion is uncertain or plain x-ray is inconclusive, but should not delay bronchoscopy when clinical suspicion is high

Background

• The signs and symptoms of FB inhalation will vary depending upon the site of impaction, degree of blockage and type of object
• The majority of FB inhalation events occur in children <5 years and are commonly due to nuts, raw carrot or apple, seeds, popcorn, coins, balloons and pieces of toys. Older children with developmental impairment may continue to be at risk
• Button batteries are more commonly ingested than inhaled, but recognition and management is critical
• Most inhaled FB are located in the bronchi rather than the larynx or trachea
• Children may be asymptomatic initially, with symptoms presenting days to weeks after FB inhalation including persistent focal wheeze, recurrent pneumonia in the same lobe or unexplained chronic respiratory symptoms

Assessment

History

• Detailed description of timing, nature of event and possible FB inhaled, if witnessed
• The site of impaction may be suggested by the clinical presentation

Clinical features based on impaction location

Examination

• May be normal
• Observe and maintain child’s preferred position (eg sniffing or tripod) and minimise distress
• Work of breathing
• Stridor
• Drooling and altered voice quality
• Asymmetrical chest movement
• Tracheal deviation
• Focal wheeze or decreased breath sounds
• Check for other FB in ears, nose and throat (once child is stable)

Assessment of likelihood of FB inhaled

Management

If required, provide emergency resuscitation prior to other management. Ongoing close observation is required in all children until FB removed, as any movement of FB may cause sudden airway compromise

Investigations

• Consider CXR with inspiratory/expiratory films (if child can cooperate) or lateral decubitus views (useful in younger children)

	Radio-opaque FB Segmental or lobar collapse
	Asymmetry in lung inflation caused by a ball-valve obstruction and air trapping
	On inspiratory/expiratory films, one lung will fail to deflate on expiration Flattening of hemidiaphragm Mediastinal shift
	On lateral decubitus views, dependent lung fails to collapse and remains lucent and expanded
	Consolidation suggesting pneumonia
	Pneumothorax
	Pulmonary abscess or bronchiectasis, which may indicate a chronic impacted FB

• A normal CXR does NOT exclude an inhaled FB. Most aspirated objects in children are radiolucent (eg nuts, seeds, plastic)
• Modern low dose CT chest has very high sensitivity and specificity (91-100% sensitivity, 93-100% specificity) and radiation exposure is similar to a CXR. However, CT must not delay bronchoscopy when clinical suspicion is high
• Consultation with a senior clinician is essential prior to sedation, as suspected FB aspiration is associated with risk of acute airway obstruction
• CT is recommended after consultation with ENT/Respiratory when
  • CXR is normal or inconclusive, but suspicion remains high
  • child can safely undergo scanning
  • goal is to avoid unnecessary bronchoscopy in borderline or unclear cases
  • suspected FB is radiolucent and not visible on x-ray
  • symptoms are chronic or atypical, and diagnosis is uncertain
• CT should be avoided when
  • child is showing signs of airway compromise; seek urgent ENT and/or anaesthetics review
  • there is clear clinical evidence requiring urgent bronchoscopy
  • imaging would delay definitive intervention

Diagnostic algorithm for suspected FB inhalation

Treatment

Airway emergency management

• Back blows: check to see if each back blow has relieved the airway obstruction. The aim is to relieve the obstruction with each blow rather than to give all 5 blows.
• Chest thrusts: these are similar to chest compressions but sharper and delivered at a slower rate. In an infant, the thumb-encircling technique or even the heel of one hand may provide more effective force 
  
• Attempts at removal of a FB +/- advanced airway management using laryngoscopy, Magill forceps, cricothyroidotomy and other procedures should ideally be performed by the most senior clinician experienced in advanced airway management. However, it may be reasonable for a less experienced clinician to proceed if a child is deteriorating
• If it is not felt to be safe to attempt these procedures, basic resuscitation should be continued while awaiting senior assistance

Subacute management

• In children who have a stable airway where there is intermediate or high suspicion of an inhaled FB after history and assessment, refer to ENT/Respiratory consideration laryngoscopy/bronchoscopy

Consider consultation with local paediatric team when

A secondary consultation may assist before speciality review

Consider consultation with ENT or respiratory team when

Intermediate or high suspicion for inhaled FB

Consider transfer when

Local services unable to perform procedures or investigations

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

FB removed and/or child stable after period of observation

Parent information

Prevention strategies

• Young children should not be offered hard round foods such as popcorn, hard lollies, uncut grapes, peanuts or other nuts, raw carrot or apples
• Encourage children to sit calmly while eating, and offer food one piece at a time
• Avoid toys with small parts for children <3 years

Choking, suffocation and strangulation prevention handout

Last updated September 2026