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|Other names||Foreign body airway obstruction|
|A demonstration of abdominal thrusts on a person showing signs of choking|
Choking occurs when breathing is impeded by a constricted or obstructed throat or windpipe. In some cases, the airflow is completely blocked, and in other cases, insufficient air passes through to the lungs, resulting in oxygen deprivation. Although oxygen stored in the blood and lungs can keep a person alive for several minutes after breathing stops, choking often leads to death. Choking was the fourth most common cause of unintentional injury-related death in the US in 2011.
Deaths from choking most often occur in the very young (children under 2 years old) and in the elderly (adults over 75 years). Obstruction of the airway can occur at the level of the pharynx or the trachea. Foods that can adapt their shape to that of the pharynx (such as bananas, marshmallows, or gelatinous candies) commonly cause choking in people of all ages.
Choking is one type of airway obstruction; others include blockage due to tumors, swelling of the airway tissues, and compression of the laryngopharynx, larynx, or vertebrate trachea in strangulation.
Providing immediate, appropriate first-aid can save a choking victim from death (see below).
Among children, the most common causes of choking are food, coins, toys, and balloons. In one study, peanuts were the most common object found in the airway of children evaluated for suspected foreign body aspiration. Foods that pose a high risk of choking include hot dogs, hard candy, nuts, seeds, whole grapes, raw carrots, apples, popcorn, peanut butter, marshmallows, chewing gum, and sausages. In a 1984 US study, 29% of choking deaths in children were associated with latex balloons, and these were the leading cause of choking death among children's products. Small, round non-food objects such as balls, marbles, toys, and toy parts are also associated with a high risk of choking death because of their potential to completely block a child's airway.
Children younger than age three are especially at risk of choking because they explore their environment by putting objects in their mouths. Also, young children are still developing the ability to chew food completely. Molar teeth, which come in around 1.5 years of age, are necessary for grinding food. Even after molar teeth are present, children continue developing the ability to chew food completely and swallow throughout early childhood. A child's airway is smaller in diameter than an adult's airway, which means that smaller objects can cause airway obstruction in children. Infants and young children generate a less-forceful cough than adults, so coughing may not be as effective in relieving airway obstruction. Children with neuromuscular disorders, developmental delay, traumatic brain injury, and other conditions that affect swallowing are at an increased risk of choking.
In adults, choking often involves food blocking the airway. Risk factors include using alcohol or sedatives, undergoing a procedure involving the oral cavity or pharynx, wearing oral appliances, or having a medical condition that causes difficulty swallowing or impairs the cough reflex. Conditions that can cause difficulty swallowing and/or impaired coughing include neurological conditions such as strokes, Alzheimer's disease, or Parkinson's disease. In older adults, risk factors also include living alone, wearing dentures, and having difficulty swallowing.
Children and adults with neurological, cognitive, or psychiatric disorders may experience a delay in diagnosis because there may not be a known history of a foreign body entering the airway.
Choking often happens when large or abundant mouthfuls of food are poorly chewed and swallowed. This risk is minimized by adopting the discipline of cutting food into moderately sized pieces and chewing them completely before swallowing. Whenever a food can be chewed, it must be chewed, even if it is very soft or gelatinous, such as spreads and soft desserts.
It is helpful to have some liquid available to drink to make swallowing easier. Eating in handfuls (as with foods such as popcorn, nuts, etc.), requires chewing with more control than normal; excessive amounts of food should not enter the mouth. To swallow well, it is recommended that the neck be in a normal position, with the head looking forward and aligned with the eater's body, and that the eater be seated or standing rather than reclining.
The foods that produce the highest risk of choking are those whose shape adapts to the shape of the pharynx or trachea: hot dogs and sausages, bananas, food in blocks, etc. It is easier to choke on foods that are dry in the mouth (overcooked meat, sponge cake, cold pizza, etc.), which require the help of drinking liquid, or to be accompanied of purees or sauces. It is also easier to choke on foods that are tough (octopus or cuttlefish, for example); they may need to be eaten together with something that helps the teeth to grind them (like bread), or cooked in a way that softens them.
In 2002, candy containing konjac gel was banned by the Food and Drug Administration due to several high-profile choking cases. In one case, Michelle Enrile, 12, of San Jose, CA, choked on a piece of konjac candy in April of 1999. She spent 2 years in a coma and passed away on July 30, 2001.
Groups at risk
Some population groups have a higher choking risk, such as the elderly, children, persons with disabilities (physically or mentally), people under the effects of alcohol or drugs, people who have taken medications that reduce the ability to salivate or react, patients with difficulties in swallowing (dysphagia), suicidal individuals, epileptics, people on the autism spectrum, individuals with disorders such as pica that lead them to consume inedible objects, etc. They may require more assistance to feed themselves and it may be necessary to supervise them while they eat. People who are unable to chew properly should not be served hard food. In cases where a person is unable to safely eat, food can be supplied by feeding syringes that pour a liquid content into the patient's mouth. People who have taken any medication that reduces saliva should not eat solid food until their salivation is restored.
In babies and children
All young children require care in eating. They must learn to chew their food completely to avoid choking. Feeding them while they are running, playing, laughing, etc. increases the risk of choking. Caregivers must supervise children while eating or playing. Pediatricians and dentists can provide information by age to parents and caregivers about what food and toys are appropriate to prevent choking. The American Academy of Pediatricians recommends waiting until 6 months of age before introducing solid foods to infants. Caregivers should avoid giving children younger than 5 years old foods that pose a high risk of choking, such as hot dog pieces, bananas, cheese sticks, cheese chunks, hard candy, nuts, grapes, marshmallows or popcorn. Later, when they are accustomed to these foods, it is recommended to give them split into small pieces: for example, hot dogs, bananas, or grapes may be split lengthwise, sliced, or both. Parents, teachers, and other caregivers for children are advised to be trained in choking first-aid and cardiopulmonary resuscitation (CPR).
Children readily put small objects into their mouths, which can lead to choking. Obstructions such as deflated balloons, marbles, small pieces, buttons, coins, button batteries, or plastic bags (like nappy sacks, which are often placed near babies), should be directly removed with the fingers, if visible. To prevent children from swallowing things, precautions should be taken to keep dangerous objects out of their reach. Small children must be supervised closely and taught to avoid putting things into their mouths. Toys and games may indicate on their packages the ages for which they are safe. In the US, manufacturers of children's toys and products are required by law to apply appropriate warning labels to their packaging. However, toys that are resold may not be marked with warning labels. Caregivers can try to prevent choking by considering the features of a toy (such as size, shape, consistency, small parts) before giving it to a child. Children's products that are found to pose a choking risk can be taken off the market.
Symptoms and signs
The symptoms of choking include:
- Difficulty or inability to speak or cry out.
- Inability to breathe or difficulty in breathing. Labored breathing, including gasping or wheezing, may be present.
- Violent and largely involuntary coughing, gurgling, or vomiting noises may be present.
- More serious choking victims will have a limited (if any) ability to produce these symptoms since they require at least some air movement.
- The person may begin clutching the throat, mouth, or attempting to induce vomiting by putting fingers down the throat.
- The person's face may turn blue (cyanosis) from lack of oxygen if breathing is not restored.
- The person may become unconscious if breathing is not restored.
Times of asphyxia
The time a choking victim is still alive and without brain damage can vary. But, typically:
- Brain damage can occur when the victim remains without air for approximately three minutes (it is variable).
- Death can occur if breathing is not restored in six to ten minutes (varies depending on the victim). However, life can be extended by using cardiopulmonary resuscitation (CPR) on the unconscious victims of choking (see more details further below).
Choking is treated with several different procedures, which form the airway management. In a general view, this consists of the anti-chocking techniques available for first aiders in the stage of a basic airway management, and of complex methods available for health professionals working in an advanced airway management.
Basic treatment (First-Aid)
Basic treatment of choking includes several non-invasive techniques to help remove foreign bodies from the airways.
For a conscious choking victim, most protocols recommend encouraging the victim to cough, followed by hard back slaps and, if none of these techniques are effective, abdominal thrusts (the Heimlich maneuver, see details further below) or chest thrusts (see details further below). Most modern protocols, including those of the American Heart Association and the American Red Cross, recommend alternating series of back slaps and thrusts for a better effect.
It is mandatory that, if the choking is not being solved, somebody calls for emergency medical services, but continuing the first-aid.
If the choking victim loses consciousness, a cardiopulmonary resuscitation (CPR) is recommended.
First-aid methods against choking include the following:
If the choking individual is conscious and coughing, the American Red Cross recommends encouraging the individual to stay calm and continue coughing freely. It may be easier to take air through the nose to refill the lungs. If the person choking is unable to cough or if coughing is not effective, the American Red Cross recommends moving onto other methods, detailed below.
Back blows (back slaps)
Many associations, including the American Red Cross and the Mayo Clinic, recommend the use of back blows (back slaps) to aid in the rescue of choking victims. This technique starts by bending the choking victim forward as much as possible, even trying to place their head lower than the chest, to avoid the risk of the slaps driving the object deeper into the person's throat (a rare complication, but possible). The bending is in the back, while the neck should not be excessively bent. Back blows are performed by delivering forceful slaps with the heel of the hand on the victim's back, between the shoulder blades.
The back slaps push behind the blockage to expel the foreign object out. In some cases, the physical vibration of the action may cause enough movement to clear the airway.
Abdominal Thrusts (Heimlich Maneuver)
Abdominal thrusts are performed with the rescuer standing behind the choking victim. The rescuer closes his dominant hand, grasps it with the other hand, and presses forcefully inwards and upwards with both hands on the area located between the chest and the belly button of the victim. The pressure is not focused directly against the ribs, to avoid breaking any of them. If the first thrust does not solve the choking, it can be repeated several times.
Usage of abdominal thrusts is not recommended in infants under 1 year of age due to risk of causing injury; there are adapted techniques for babies (see more details further below), and, when the children are too big for them, they require normal abdominal thrusts (according to their bodies). Abdominal thrusts should not be used when the victim's abdomen presents problems to receive them, such as pregnancy or excessive size; in these cases, chest thrusts are advised (see more details further below).
In the case of choking alone, abdominal thrusts are one of the possibilities that can be tried on oneself (see more details further below).
The purpose of abdominal thrusts is to create a pressure capable to expel the object lodged upwards in the airway, relieving the obstruction. This method was discovered by Dr. Henry Heimlich in 1974, so it is referred to as "The Heimlich Maneuver." Dr. Heimlich claimed that his maneuver was better than the back blows, arguing that back blows could cause the obstruction to become more deeply lodged in the victim's airway. That started a debate into the medical community, that ended up with the recommendation of alternating both techniques, but making the patient to bend the back before receiving the slaps. So the Heimlich Maneuver itself uses only abdominal thrusts, but is also part of anti-choking protocols that include the back blows (back slaps) technique.
When abdominal thrusts cannot be performed on the victim (in case of pregnant or too much obese victims, and others), chest thrusts are advised instead.
Chest thrusts are performed with the rescuer standing behind the choking victim. The rescuer closes his dominant hand and grasps it with the other hand. This can produce several kinds of fists, but any of them can be valid if they can be placed on the victim's chest without sinking the knuckle too painfully. Keeping the fist with both hands, the rescuer uses it to press forcefully inwards on the lower half of the chest bone (approximately), but not in the very endpoint (which is the xiphoid process). The pressure is not focused against the xiphoid process to avoid breaking it. As a general reference, it can be noted that, when the victim is a woman, the zone of the pressure of the chest thrusts would be normally upper than the level of the breasts. If the first thrust does not solve the choking, it can be repeated several times.
"Five and Five" strategy
The American Red Cross recommends a protocol of alternating five back blows and five abdominal thrusts for conscious choking victims until the object blocking the airway is dislodged. For pregnant or obese victims, the protocol is the same, but chest thrusts are advised instead of the abdominal ones.
The Red Cross does not specifically refer to its choking victim protocol as the "Five and Five Technique". And its protocol differs from the Heimlich Maneuver, since it includes administering back blows to the victim, contrary to Dr. Heimlich's procedure which specifically omitted back blows and was based only on his technique.
Since 2015, several anti-choking devices were developed and released to the market. The design of these devices is based on a vacuum mechanical effect, with no need for batteries or electric current. They usually present an attached mask, to make a vacuum from the patient's nose and mouth. The current models of anti-choking devices are quite similar: a direct plunger tool (LifeVac), or a vacuum syringe (backward syringe) that also keeps the tongue in place by inserting a tube in the mouth (Dechoker). Both of them have received certifications, and its effectiveness is proven in real cases, some of them appeared in the media. Other mechanical models are in development, such as Lifewand, which makes the vacuum by direct pressure against patient's face.
Reasons supporting these devices include: ease of usage, convenience in public places, being helpful for difficult cases (unconscious victims, disabled patients, elderly people, or when the victim is oneself), and achieving levels of pressure in suction that can not be matched by manual methods. In the worst choking cases, no manual technique would dislodge the foreign object, being necessary the usage of one of these devices or a sort of surgery. That is the reason why physicians recommend some care in eating.
Nevertheless, contrary visions exist: according to a 2020 systematic review of the effectiveness of these three devices, "There are many weaknesses in the available data and few unbiased trials that test the effectiveness of anti-choking suction devices resulting in insufficient evidence to support or discourage their use. Practitioners should continue to adhere to guidelines authored by local resuscitation authorities which align with ILCOR recommendations."
A choking victim that becomes unconscious must be caught to prevent falling and placed lying on a surface. This surface should not be too hard or too soft, and should be appropriated for the victim's anatomy (it is possible to put a layer of something above the floor and place the victim on it). Emergency medical services must be called, if this has not already been done.
While waiting for emergency services to arrive, the unconscious choking victim should receive a cardiopulmonary resuscitation (CPR) for choking victims, that is quite similar to the CPR for any other non-breathing patient. Infants less than one year old require a special adaptation of the procedure (described further below).
The anti-choking CPR is a cycle that alternates series of compressions with series of breaths. Each round of compressions applies 30 rhythmic compressions (approximately) on the lower half of the chest bone. The CPR chest compressions produce the same anti-choking effect as the chest thrusts anti-choking technique, so the CPR itself could expel the object. At the end of each compressions round, the rescuer must look for the obstructing object and try to remove it, usually by using a finger sweeping when the object is already visible (a difference between anti-choking CPR and normal CPR). If there is no success, a round of 2 rescue breaths is applied, pinching the victim's nose and puffing air inside of the mouth. It is recommended, at the end of the series of breaths, to tilt the victim's head up or down and give 2 extra breaths, in order for the air to find an entrance through the blockage (the second difference between anti-choking CPR and normal CPR). That cycle of compressions and breaths repeats continuously. If the object is expelled and subsequently removed, CPR must continue until the victim recovers breathing.
An anti-choking device can unblock the airway on unconscious victims, but does not necessarily remove the obstructing object from the mouth, which may need a manual removal. The victim will then require a normal cardiopulmonary resuscitation (CPR), in the manner that has been described above but only alternating the 30 compressions and the 2 rescue breaths.
About the finger sweeping in unconscious victims
In unconscious victims of choking, the American Medical Association advocates sweeping the fingers across the back of the throat to attempt to dislodge airway obstructions. However, many modern protocols recommend against the use of the finger sweep. Red Cross procedures specifically direct rescuers not to perform a finger sweep unless an object can be clearly seen in the victim's mouth due to the risk of driving the obstruction deeper into the victim's airway. Other protocols suggest that if the patient is conscious they will be able to remove the foreign object themselves, or if they are unconscious, the rescuer should simply place them in the recovery position as this allows (to a certain extent) the drainage of fluids out of the mouth instead of down the trachea due to gravity. There is also a risk of causing further damage (inducing vomiting, for instance) by using a finger sweep technique. There are no studies that have examined the usefulness of the finger sweep technique when there is no visible object in the airway. Recommendations for the use of the finger sweep have been based on anecdotal evidence.
In special populations
Babies (under 1 year old)
For babies (infants under 1 year old), the American Heart Association recommends some adapted procedures that have been developed. Children who are too big for the babies' procedures require the normal first-aid techniques against choking, according to the size of their bodies.
First aid for babies alternates a cycle of back blows (5 back slaps) followed by chest thrusts (5 chest compressions, that are adapted), as described below:
In the back blows maneuver, the rescuer slaps on the back of the baby. It is recommended that the baby receive them being slightly leaned upside-down on an inclination. There exist several ways to achieve this:
In the most depicted one, the rescuer sits down on any seat with the baby. The rescuer supports the baby with a forearm and its respective hand. The baby's head must be carefully held with that hand, usually by the jaw. Then the baby's body (supported in that manner) can be leaned forward upside-down along the rescuer's thighs and receive the slaps.
As an easier alternative, the rescuer can sit on a bed or sofa, or even the floor, carrying the baby. Next, the rescuer should support the baby's body on the lap, to lean the baby upside-down at the right or the left of the lap. Then the back blows would be applied.
If the rescuer cannot sit down, at least it is possible to attempt the maneuver at a low height and over a soft surface. Then the rescuer would support the baby with a forearm and the hand of that side, holding the baby's head with that hand, usually by the jaw. The baby's body would be leaned upside-down in that position to receive the slaps.
In the chest thrusts maneuver, the baby's body is placed lying on a surface. Then the rescuer does the compressions on the chest bone, pressing with only two fingers on its lower half (the nearest to the abdomen). Abdominal thrusts are not recommended in children less than 1 year because they can cause liver damage.
The back blows and chest thrusts are alternated in cycles of 5 back blows and 5 chest compressions until the object comes out of the infant's airway or until the infant becomes unconscious.
If the infant becomes unconscious, someone must call the emergency medical services (if this has not been done yet). While they come, the American Heart Association recommends starting a cardiopulmonary resuscitation (CPR) which must be adapted to babies. In that procedure, the baby is placed face-up on a horizontal surface (preferably not too hard or too soft). The baby's head must be in a straight position, looking frontally (tilting too much a baby's head backward can close the access to the trachea). Then it is applied a cycle of alternating 30 chest compressions and 2 rescue breaths, like in a normal CPR, but with some differences:
In the anti-choking CPR for babies, the chest compressions are adapted: the rescuer presses rhytmically about 30 times with only two fingers in the lower half of the chest bone. At the end of the round of compressions, the rescuer looks into the mouth, searching if the obstructing object has come out (because of the effect of the compressions) and, if it is visible, attempts to extract it (mainly using a finger sweeping). If there is no success, the round of 2 rescue breaths is applied. They are also modified: the rescuer's mouth puffs air covering the baby's mouth and nose simultaneously. That cycle of chest compressions and rescue breaths repeats continuously. When the object is extracted, the cardiopulmonary resuscitation must continue until the baby's breath is successfully recovered or until medical services arrive.
Pregnant or too obese people
Chest thrusts are performed in a similar way to the abdominal thrusts, but with the hands placed on the lower part of the choking victim's chest, at the lower half of the breast bone (sternum), rather than over the middle of the abdomen, as in the traditional abdominal thrusts. Strong inward thrusts are then applied. As a reference, in women, the zone of pressure of the chest thrusts (the lower half of sternum) would be normally upper than the level of the breasts. The chest thrusts can be alternated with back blows (back slaps), which are applied on the back of the victim when it is very bent forward.
Disabled people in wheelchair
If the choking victim is a disabled person and is using a wheelchair, the first-aid procedure is quite similar than in the case of the other victims. The difference is in trying to apply the techniques directly, while the victim is still seated on the wheelchair. Besides, the presence of an anti-choking device at hand can be especially useful when a disabled person is near. But the first-aid techniques without devices are also possible:
The back blows (back slaps) can be used after bending forward the back of the victim very much, as much as possible.
The thrusts techniques are also possible. To perform the abdominal thrusts (Heimlich maneuver), the back of the victim must be bent too, and the rescuer must get behind the wheelchair. Then, the rescuer can embrace the victim's abdomen from behind and above, leaning over the top of the wheelchair's backrest. If this is too difficult, the rescuer can get down to embrace from behind the victim's abdomen and the wheelchair's backrest all together. Other possitions can be tried turning the victim to a side or in another way. Next, the rescuer would use the hands to apply sudden inward and upward manual pressures on the area located between the chest and the belly button. It must be remembered that, if the victim cannot receive abdominal thrusts (this is the case of the pregnant or too obese people), chest thrusts must be used instead. They are applied while the victim is in the wheelchair too, but making sudden inward pressures on the lower half of the breast bone against the wheelchair's backrest and the rescuer's body. If there are difficulties for this, the same pressures can be tried turning the victim to a side or in another way.
When a victim of choking in wheelchair becomes unconscious, it is required an anti-chocking cardiopulmonary resuscitation (CPR), but it is exactly the same procedure than in the case of the victim was not disabled. Anyway, it can be noted that the victim needs to be taken from the wheelchair and placed lying face-up on a appropiated surface (not too hard or too soft, it is possible to put a layer of something above the floor and place the victim on it). And somebody must call to the emergency medical services, if this has not already been done. While they arrive, the rescuer has to apply the anti-chocking CPR for unconscious victims (see details further above).
As a preventive measure, it is convenient to avoid placing the disabled in too narrow and encased spaces at the mealtimes. The opened spaces give an easier access to them for the rescuers.
Some of the first-aid techniques can be applied on oneself, so they can be useful in the case of choking when alone. On the other hand, having a modern anti-choking device nearby is one of the best, and most realistic, options to solve choking. But trying first-aid techniques on oneself, by hand and without any device, is also possible:
The abdominal thrusts (Heimlich Maneuver) can be self-applied with the hands: making a fist, grasping it with the other hand, and pressing forcefully, inwards and upwards, with both of them on the area located between the chest and the belly button. It can be repeated as many times as needed. This serves as a substitute for the thrusts made with the hands by another person. One study showed that these self-administered abdominal thrusts were just as effective as those performed by another person, although obese individuals were not included in the study. Another manner of self-administration of this maneuver requires positioning of one's own abdomen over the border of an object: a chair, railing, or countertop, and driving the abdomen upon the border with sharp, upward thrusts. It is possible to try to fall on the border to increase pressure.
Other variation of the self-administration of abdominal thrusts (Heimlich Maneuver) consist in pressing the own belly, inwards and upwards, with an appropriated object.
When a problem makes impossible to receive pressures on the belly, it is possible to try to apply the chest thrusts on oneself, despite it would be more difficult. The chest thrusts would be self-applied making a fist, grasping it with the other hand, and pressing inwards forcefully on the lower half of the chest bone. They can be repeated as many times as needed. Making attempts to cough until achieving it can also clear the airway.
Alternatively, multiple sources of evidence suggest that one of promising approaches for self-treatment during choking could be applying the head-down (inverse) position. To make that position, it is possible to put the hands on the floor and then place the knees on an upper seat (as on a bed, a sofa, or an armchair).
There are many advanced medical treatments to relieve choking or airway obstruction. These include inspection of the airway with a laryngoscope or bronchoscope and removal of the object under direct vision. Severe cases where there is an inability to remove the object may require cricothyrotomy (emergency tracheostomy). Cricothyrotomy involves making an incision in a patient's neck and inserting a tube into the trachea to bypass the upper airways. The procedure is usually only performed when other methods have failed. In many cases, an emergency tracheostomy can save a patient's life, but if performed incorrectly, it may end the patient's life.
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