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Referral and warning signs
When to refer
IMMEDIATE EMERGENCY REFERRAL/TRANSPORT for: Any child with ongoing respiratory distress after choking event. ANY child with suspected retained foreign body (even if currently asymptomatic). Child requiring bronchoscopy.
Red flags
- Inability to cough, speak, or cry.
- Cyanosis.
- Stridor.
- Loss of consciousness.
- Persistent wheezing or cough after a choking episode.
Signs and symptoms
- Acute Choking Episode: Sudden onset of coughing, gagging, choking, stridor, wheezing, cyanosis, inability to speak or cry, respiratory distress, potential loss of consciousness.
- Post-Aspiration (If object lodges distally):
- - Persistent cough.
- - Unilateral wheezing (may be localized).
- - Recurrent or persistent pneumonia (often in same lung lobe).
- - Decreased breath sounds on affected side.
- - May be asymptomatic initially if object small and non-obstructing.
- - Hoarseness (if laryngeal FB).
Risk factors
- Age <5 years (especially 1-3 years).
- Access to small objects (nuts, seeds, small toys, coins, buttons).
- Eating while running, playing, laughing, crying.
- Neurological impairment affecting swallowing/cough reflex.
Diagnosis
Clinical assessment
Acute Choking: Diagnosis based on witnessed event and signs of airway obstruction. Suspected Retained FB: History of choking episode (may be forgotten/unwitnessed) followed by persistent cough, wheeze, or recurrent pneumonia. Physical exam may reveal localized wheeze or decreased air entry.
Investigations
- Acute Setting: Focus on immediate life support, investigations deferred.
- Suspected Retained FB:
- - Chest X-ray (Inspiratory and Expiratory/Lateral Decubitus views): May show radio-opaque FB. May show indirect signs like unilateral hyperinflation (air trapping on expiration), atelectasis/collapse, mediastinal shift.
- Normal CXR does NOT rule out FB.
- - Bronchoscopy (Rigid preferred): Gold standard for diagnosis and removal. Performed by specialist under general anaesthesia.
Diagnostic criteria
Witnessed choking event with obstruction OR High clinical suspicion based on history/exam +/- suggestive CXR findings. Definitive diagnosis by bronchoscopy.
Differential diagnosis
- Asthma exacerbation.
- Croup.
- Epiglottitis.
- Bronchiolitis.
- Pneumonia.
- Anaphylaxis.
- Laryngomalacia/Tracheomalacia.
- Vocal cord paralysis.
- External airway compression (tumour, node).
Management
Non-pharmacological management
- Acute Complete Airway Obstruction (Child unable to cough/speak/cry):
- - Infant (<1 year): 5 Back Slaps followed by 5 Chest Thrusts. Repeat cycle.
- - Child (>1 year) / Adult: Heimlich Maneuver (Abdominal Thrusts). Repeat until object expelled or patient becomes unresponsive.
- - If Unresponsive: Start CPR. Check mouth for visible object ONLY before giving rescue breaths - remove if easily seen (NO blind finger sweeps).
- Acute Partial Airway Obstruction (Child coughing effectively):
- - Encourage coughing.
- - Do NOT interfere with back slaps/thrusts.
- - Monitor closely, be prepared to intervene if obstruction worsens.
- After Successful Dislodgement or if Retained FB Suspected:
- - Transport to hospital for assessment (even if object seemingly expelled) to rule out complications or retained fragments.
- Removal of Retained FB:
- - Requires Bronchoscopy (usually rigid) under general anaesthesia by ENT or Thoracic surgeon.
Pharmacological treatment
- Oxygen therapy if hypoxic.
- Antibiotics may be needed if secondary pneumonia develops.
Monitoring
Monitor respiratory status closely after choking event or removal.
Complications
- Hypoxia, Brain damage.
- Respiratory arrest, Cardiac arrest.
- Death.
- Pneumonia (post-obstructive).
- Bronchiectasis.
- Lung abscess.
- Pneumothorax / Pneumomediastinum.
- Airway trauma from FB or removal attempts.
Prevention
- Keep small objects (foods like whole nuts/grapes, toys, batteries, coins) out of reach of young children (<3-4 years).
- Supervise children while eating.
- Discourage running/playing while eating.
- Cut food into small pieces for young children.
- Age-appropriate toys.
- Caregiver education on choking hazards and first aid.
Patient education
- Choking prevention strategies (food safety, toy safety, supervision).
- Basic choking first aid (back blows, chest/abdominal thrusts).
- Importance of seeking medical evaluation after any significant choking episode, even if object seems expelled.
- Signs of retained foreign body (persistent cough/wheeze).
Uganda-specific notes
Common emergency, especially with groundnuts, beans, maize seeds. High risk of mortality/morbidity if not managed promptly. Access to bronchoscopy limited to referral hospitals. Prevention through caregiver education is key.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 21, Section 21.3.1
- Basic Life Support / Pediatric Advanced Life Support Guidelines
(Standard choking algorithms)