Foreign Body Airway Obstruction (Choking)

Relieve a severe obstruction in the order below. Time-critical: a patient who cannot cough or speak is losing air now. Reassess after every cycle and call EMS early.

Foreign body airway obstruction (FBAO), or choking, means an object is blocking the airway. It got there by being inhaled or swallowed. Young children are most at risk. The pediatric airway page gives the peak age and the sudden-onset pattern.

How It Works

• Partial obstruction: some air still gets through. The patient coughs, speaks or cries. That cough is the first line of clearance.
• Severe obstruction: little or no air gets through. The cough is weak or silent. The patient cannot speak.
• Back blows and thrusts: sudden force is what moves the object. Abdominal and chest thrusts squeeze the chest to push air out.
• Unresponsive patient: the airway may still be blocked. CPR and a look in the mouth come first.

Where It Fits

Bystander first aid comes first, and EMS basic life support follows it. Advanced airway steps wait on the local protocol, and they come in only if the obstruction is not relieved (Figure 1).

Indications

• Severe obstruction: cannot speak, cry or breathe
• Weak or silent cough with cyanosis or falling consciousness
• Suspected obstruction after a witnessed choking episode, when the cough is not clearing the object

Absolute Contraindications

None when severe obstruction is present.

Relative Contraindications & Cautions

• Mild obstruction: a strong cough or speech means air is moving. Encourage coughing. No thrusts
• Infant under 1 year: no abdominal thrusts
• Known or suspected rib or abdominal injury: thrusts carry a risk of injury. Use the sequence per protocol
• Pregnancy or large abdomen: chest thrusts replace abdominal thrusts (see Special Populations)

Consider an Alternative

• Button battery or magnet ingestion: not an airway obstruction. Urgent ED transfer (see Special Populations)
• Airway not relieved after the sequence: advanced airway per protocol. See Supraglottic Airway and Endotracheal Intubation

Team Roles During the Procedure

• Rescuer: gives the back blows and thrusts
• Caller: activates EMS and tells the crew the time and age
• Monitor: watches color, SpO₂ if available, and level of consciousness
• Recorder: counts cycles and records the object and response

Severity Check

Age Check

• Infant (under 1 year): back blows and chest thrusts
• Child (1 year and older) and adult: back blows and abdominal thrusts
• Witnessed or unwitnessed: sudden choking while eating or playing is a witnessed event. A cough or wheeze that shows up later, with one-sided breath sounds, needs a foreign-body check

Equipment

• No equipment is needed for back blows or thrusts
• Suction, if available and in the protocol, for a visible object in the mouth
• Pulse oximeter and EtCO₂ capnography, if available, for monitoring after relief
• Magill forceps: an airway-team tool used under direct laryngoscopy, not a first-aid item

Patient Positioning

• Conscious child or adult: stand or kneel behind the patient, arms around the waist for thrusts
• Infant: face-down along the forearm, supported on the thigh, head lower than the chest

Phase 1: Recognize and Call

1. Check for severe obstruction: ask "Are you choking?" A patient who nods but cannot speak or cough is severely obstructed.
2. Call for EMS: call early; a caller stays with the patient.

Phase 2: Perform (Child 1 Year and Older, Adult)

3. Give 5 back blows: strike firmly between the shoulder blades with the heel of the hand while supporting the chest.
4. Check after each blow: look for the object, a cough, or speech. Stop the cycle as soon as the object is expelled or the patient coughs or breathes effectively. Otherwise complete the 5 blows, then move to the thrusts.
5. Give 5 abdominal thrusts: if the object is still in place, place a fist above the navel and thrust sharply inward and upward.
6. Alternate and repeat: 5 back blows then 5 abdominal thrusts, until the object is out or the patient becomes unresponsive.

Phase 3: Perform (Infant Under 1 Year)

7. Position face-down: support the infant along your forearm with the head lower than the chest.
8. Give 5 back blows: between the shoulder blades, with the heel of the hand.
9. Turn face-up and give 5 chest thrusts: two fingers on the lower half of the breastbone, as for infant compressions.
10. Alternate and repeat: never give abdominal thrusts to an infant.

Phase 4: Unresponsive Patient

11. Lower to the floor and start CPR: call for help and start CPR per BLS or ACLS protocol.
12. Look before each breath: open the mouth and remove only a visible object. Do not perform blind finger sweeps.

Primary Confirmation

The object is out, or the patient coughs, speaks and breathes effectively. That is how you confirm relief.

Secondary Confirmation

• Color improving; SpO₂ rising if measured
• Clear voice or crying; no stridor on inspiration
• Level of consciousness normal or improving

Ongoing Monitoring

• Reassess after every 5-and-5 cycle
• Check SpO₂ and mental status until handover, if available
• Re-check the airway after each move during transport

Pediatrics

Age decides the sequence. An infant under 1 year gets back blows and chest thrusts, and never abdominal thrusts. From age 1 year up, the child follows the adult sequence.

When a child goes unresponsive, the pediatric cardiac arrest pathway takes over. Respiratory distress has its own cause-by-cause approach in Respiratory Distress and Failure.

Pregnancy or Large Abdomen

• In late pregnancy, or with a patient too large to reach around, abdominal thrusts may be hard to deliver or may not be appropriate
• Substitute chest thrusts: chest thrusts take the place of abdominal thrusts. Hands go on the lower half of the breastbone, as for adult CPR compressions. The rescuer may need to stand or kneel beside the patient
• Follow local protocol for the exact technique and cycle count

Ingested Button Batteries and Magnets (Not an Airway Obstruction)

• Button battery: localization can't wait. Esophageal removal is preferably within 2 hours (ESPGHAN 2021 position paper). Call Poison Help at 1-800-222-1222 (US) or your regional poison center (poison.org) and follow medical direction. Home remedies are outside this page
• Multiple magnets: urgent ED referral; bowel obstruction and perforation risk
• EMS action: urgent transfer; do not attempt removal in the field

Immediate Aftercare

• Relief does not end the risk: reassess breathing and color until handover
• Any patient who needed thrusts, or whose object was not seen to leave, should be assessed in hospital

Ongoing Maintenance

• Observe breathing, color and consciousness
• Keep the patient positioned upright if breathing is comfortable

Transport Considerations

• Reassess the airway after every move
• Rely on monitors and reassessment in noisy vehicles
• Re-obstruction can occur: be ready to repeat the sequence

Pearls

• Cough first: a strong cough is the most effective clearance. Encourage it.
• Count the cycles: 5 and 5, then reassess. The count keeps the sequence going.
• Infants differ: no abdominal thrusts.
• Silence is worse than coughing: a silent patient cannot move air.
• Batteries are urgent: an esophageal button battery is not a watch-and-wait case.

Common Pitfalls

• Blind finger sweeps → look first, and remove only a visible object
• Thrusts on a limp patient → lower to the floor and start CPR
• Abdominal thrusts for an infant → use chest thrusts with back blows
• Quiet patient taken as improving → reassess the airway and breathing

Skill Maintenance

• Practice the 5-and-5 sequence on adult and infant manikins at least once per training cycle
• Rehearse the transition from thrusts to CPR when the patient becomes unresponsive
• Debrief timing, cycle count and the look-in-the-mouth step

Patient & Family Teaching

• Keep button batteries and magnets out of reach of young children
• Cut food into small pieces for young children and supervise eating