Foreign body aspiration (FBA) is a potentially life-threatening emergency that most commonly occurs in children 1–3 years of age. A foreign body (FB) can become lodged in either the upper or lower airway and cause either a partial or complete airway obstruction. Complete obstruction of the larynx or upper trachea is a potentially life-threatening situation that causes severe respiratory distress, cyanosis, and suffocation; it should be managed with first-aid maneuvers (e.g., CPR in unresponsive patients or in responsive patients) and, if needed, emergency airway procedures for FBA. Partial obstructions that do not cause significant respiratory distress can be removed via laryngoscopy, nasal endoscopy, or bronchoscopy if coughing fails to dislodge the FB. Lower airway FBA typically manifests with sudden-onset coughing and choking, followed by wheeze and dyspnea. Most commonly, the FB becomes lodged in the main and intermediate bronchi; approx. 60% of foreign bodies become lodged in the right main bronchus because of its more vertical orientation compared to the left main bronchus. If initial maneuvers fail to dislodge the FB and the patient is stable, imaging (e.g., x-ray of the neck or chest, CT chest, bronchoscopy) to localize the FB should be obtained, followed by a . If an FB remains undetected, it may result in chronic cough and recurrent pulmonary infections.
- 80% of all cases occur in children < 3 years. 
- Peak incidence: 1–2 years
Epidemiological data refers to the US, unless otherwise specified.
- Children and infants 
- Aspiration of an FB → airway obstruction
- Upper airway obstruction: a minority of FB are lodged in the larynx or trachea
Bronchi: the right main bronchus is more often affected than the left main bronchus
- Aspirated particles are most likely to become lodged at the junction of the right inferior and right middle bronchi → right lower and middle lobe aspiration pneumonia
- Upper right lobe affected in bedridden patients, particularly while lying on their right side.
- In children, the two main bronchi are affected with similar frequency (compared to adults); however, there is still a slight right-sided predominance.
- Less severe than upper airway obstructions
|Clinical features in FBA|
|Complete airway obstruction ||Partial airway obstruction||Chronic FB airway obstruction|
Findings can change as organic foreign bodies absorb water and swell in the lung, converting a partial obstruction into a complete one. 
All ages 
- Tracheal blunt trauma, tumor, or stenosis
- Laryngeal trauma, tumor/papilloma
- Acute bilateral vocal cord paralysis
- Bronchial asthma (presents with bilateral wheezing, as opposed to the unilateral wheeze seen in FBA)
- Spontaneous pneumothorax
- Tracheobronchial tumor
- Extrinsic compression or infiltration of a large airway from an adjacent mass
The differential diagnoses listed here are not exhaustive.
Initial management (overview)
- Prioritize airway management and respiratory stabilization. 
- Defer diagnostic imaging if there are signs of respiratory distress or respiratory failure.
In patients with signs of life-threatening airway obstruction, immediately initiate critical interventions such as first aid (e.g., CPR), basic airway maneuvers, and emergency airway procedures for FBA (see “Unresponsive patients” below for details).
|Overview of diagnostic and therapeutic approach to FBA|
|Upper airway FB obstruction ||Lower airway FB obstruction |
Advanced imaging and/or
dual diagnostic/therapeutic procedures
|Management: unresponsive patient with suspected FBA|
|Management: responsive patient with suspected FBA|
- Chest compressions may dislodge the object by raising intrapulmonary pressure. 
- Attempt to remove the FB while CPR is ongoing.
Emergency airway procedures in FBA
- Indication: failed first-aid attempts to dislodge the FB
- Unresponsive patients: none required
- Responsive patients: See “Planned removal of upper airway FB.”
- Laryngoscopy-guided FB retrieval: Under direct laryngoscopy, attempt to remove any visible FB with Magill forceps.
- Inability to remove FB with forceps: Intubate using an endotracheal tube (ETT) to displace the FB as distally as possible into either main bronchus.
Laryngoscopy risks converting a partial obstruction into a total obstruction by displacing the object or causing laryngeal trauma and/or hemorrhage 
- Indication: failure of the above maneuvers to remove the FB in an unresponsive patient
Further management (after establishing an emergency airway)
- Urgently consult the relevant department (e.g., ENT, anesthesia) for a definitive airway as needed.
Suspected cough) (patient unable to speak, cry, or 
- Initiate (see table below for technique instructions).
- Failure to dislodge the FB with repeated back blows and chest/abdominal thrusts
- Patient becomes unresponsive
|Maneuvers to dislodge an aspirated foreign body|
|Infants||Adults and children ≥ 1 year old|
|Initial maneuver: Back blows|
| || |
|Next step: chest thrusts||Next step: abdominal thrusts |
- Sit the patient upright.
- Encourage coughing to dislodge FB.
- Monitor for signs of deterioration.
- Inability to dislodge the FB and patient remains stable: urgent ENT referral for planned removal of an upper airway FB
- Optimize oxygenation (see “Basic oxygen delivery systems”).
- Encourage coughing to dislodge the FB.
- Inability to dislodge the FB and patient remains stable: urgent pulmonology referral for planned removal of a lower airway FB
Imaging in suspected
- Indications: suspected upper airway FB 
- Indications: next management step after failed first-aid attempts to dislodge an upper airway FB
- Additional considerations: Nasal endoscopy can be used to remove a nasal FB or ensure there is no FB remnant in the upper airway that can be re-aspirated.
Imaging in suspected
Chest x-ray 
- Initial screening modality in suspected lower airway FBA
- Exclusion of alternative diagnoses
- False reassurance if chest x-ray is normal
- Insufficient detail for planning removal of FB; further imaging usually necessary
|Chest x-ray findings suggestive of FBA |
|Early findings||Late findings|
|Partial airway obstruction|
|Complete airway obstruction|
CT chest without contrast (∼ 100% sensitivity) 
- Disadvantages: false-negative CT if the FB is very small or in patients with severe dyspnea 
- Direct visualization of the FB
- Granulation tissue if localized irritation has occurred
- Disadvantages: requires sedation and/or anesthesia
Investigation of the underlying causes
Emergency management of suspected FBA is covered in the “Initial management” sections above.
This section describes procedures to remove a FB in stable/stabilized patients if CPR or initial have failed.
Planned removal of an upper airway FB
- Indication: stable patients with an upper airway FB if attempted have failed
- Anesthetic considerations 
- Modalities: laryngoscopy (or nasal endoscopy)
- Procedure: Under direct visualization, the object is grasped and removed with forceps.
- Risks: Dislodgement of the object can lead to complete airway obstruction; keep equipment on hand to create an emergency surgical airway if needed.
Planned removal of a lower airway FB
Bronchoscopy (gold standard) 
- Indication: stable patients with confirmed/suspected lower airway FB if first-aid attempts to dislodge the FB have failed
- Type: flexible bronchoscopy or rigid bronchoscopy (see “Bronchoscopy choice in FBA”)
- Procedure: retrieval of the FB under direct vision 
- Risks 
- Additional considerations: management of granulation tissue 
|Bronchoscopy choice in FBA |
|Flexible bronchoscopy|| |
|Rigid bronchoscopy|| || || |
Surgical management 
- Initiate .
- Initial maneuver (all ages): Perform back blows.
- If ineffective
Suspected partialor suspected
- Encourage coughing.
- Provide oxygen if hypoxic.
- Urgent ENT consult (upper airway) or pneumology (lower airway)
- Stable patients: Obtain imaging to assist in planned removal of FB.
- All patients will require removal of the FB.
- Consider steroid therapy in lower airway FBA with granulation tissue.
- Adult patients with FBA should receive a workup for an underlying cause.
- Postobstructive pneumonia, lung abscess
- In complete obstruction
We list the most important complications. The selection is not exhaustive.