Choking Overview

Choking is a blockage of the upper airway by food or other objects, which prevents a person from breathing effectively. Choking can cause a simple coughing fit, but complete blockage of the airway may lead to death.

Choking is a true medical emergency that requires fast, appropriate action by anyone available. Emergency medical teams may not arrive in time to save a choking person's life.

• Breathing is an essential part of life. When we inhale, we breathe in a mix of nitrogen (75%), oxygen (21%), carbon dioxide, and other gases (4%).
• In the lungs, oxygen enters the bloodstream to travel to the rest of the body. Our bodies use oxygen as a fuel source to make energy from the food we eat. Carbon dioxide, a waste product, enters the bloodstream and travels back to the lungs.
• When we exhale, we breathe out carbon dioxide (8%), nitrogen (71%), and oxygen (16%).
• When someone is choking with a completely blocked airway, no oxygen can enter the lungs. The brain is extremely sensitive to this lack of oxygen and begins to die within four to six minutes. It is during this time that first aid must take place. Irreversible brain death occurs in as little as 10 minutes.

Choking Causes

• Choking is caused when a piece of food or other object gets stuck in the upper airway.
• In the back of the mouth are two openings. One is the esophagus, which leads to the stomach; food goes down this pathway. The other is the trachea, which is the opening air must pass through to get to the lungs. When swallowing occurs, the trachea is covered by a flap called the epiglottis, which prevents food from entering the lungs. The trachea splits into the left and right mainstem bronchus. These lead to the left and right lungs. They branch into increasingly smaller tubes as they spread throughout the lungs.
• Any object that ends up in the airway will become stuck as the airway narrows. Many large objects get stuck just inside the trachea at the vocal cords.
• In adults, choking most often occurs when food is not chewed properly. Talking or laughing while eating may cause a piece of food to "go down the wrong pipe." Normal swallowing mechanisms may be slowed if a person has been drinking alcohol or taking drugs, and if the person has certain illnesses such as Parkinson's disease.
• In older adults, risk factors for choking include advancing age, poor fitting dental work, and alcohol consumption.
• In children, choking is often caused by chewing food incompletely, attempting to eat large pieces of food or too much food at one time, or eating hard candy. Children also put small objects in their mouths, which may become lodged in their throat. Nuts, pins, marbles, or coins, for example, create a choking hazard. In the United States, almost 200 children die each year from choking, most of them younger than four years of age, according to the Centers for Disease Control and Prevention. It is estimated that more than 17,500 children 14 years of age or younger are treated in U.S. emergency departments for choking episodes annually.

Choking Symptoms

If an adult is choking, you may observe the following behaviors:

• Coughing or gagging

• Hand signals and panic (sometimes pointing to the throat)

• Sudden inability to talk

• Clutching the throat: The natural response to choking is to grab the throat with one or both hands. This is the universal choking sign and a way of telling people around you that you are choking.

• Wheezing

• Passing out

• Turning blue: Cyanosis, a blue coloring to the skin, can be seen earliest around the face, lips, and fingernail beds. You may see this, but other critical choking signs would appear first.

• If an infant is choking, more attention must be paid to an infant's behavior. They cannot be taught the universal choking sign.
• Difficulty breathing
• Weak cry, weak cough, or both

When to Seek Medical Care

Choking is an emergency. It can quickly result in death if not treated promptly. Call your local emergency medical services at 911 instead of your doctor. Do not hesitate to call for emergency help if you believe a person is choking. Do not attempt to drive a choking person to a hospital emergency department.

Although it only takes one person to administer first aid to the choking victim, there are other duties to perform. As you prepare to help the choking victim always shout for help. Have other bystanders call the 911 emergency medical system.

• While waiting for the ambulance, follow the steps listed in the Self-Care at Home section of this article.

• If the choking episode is successfully treated at home and there is no fear that other objects may still be in the airway, a visit to the hospital may not be necessary.

If you are alone and no one responds to your calls for help, do not leave the choking person to call 911. Begin first aid immediately.

Exams and Tests

Life support to help the person breathe will be done by emergency personnel in the ambulance and at the hospital emergency department.

At the hospital, the doctor may perform several tests and procedures to find out what caused the choking and to make sure no other objects are blocking the airway.

• X-rays are often helpful to find out why a person's airway may be partially blocked. Not all objects show up on x-rays, but if they do, they are called radiodense. Radiodense objects in the airway will easily be seen on chest or neck x-rays. Some examples are coins, tacks, nails, and glass.

• Bronchoscopy involves inserting a flexible fiberoptic scope into the airway (trachea) so that the doctor can look for any foreign bodies in the airway. If something is found, this scope also has attachments that the doctor can use to remove the object.

Choking Treatment

Self-Care at Home

Choking is an emergency. Call 911 emergency medical services. Do not attempt to drive a choking person to a hospital emergency department.

What to do if a person starts to choke:

• It is best not to do anything if the person is coughing forcefully and not turning a bluish color. Ask, "Are you choking?" If the person is able to answer you by speaking, it is a partial airway obstruction. Stay with the person and encourage him or her to cough until the obstruction is cleared.

• Do not give the person anything to drink because fluids may take up space needed for the passage of air.

Someone who cannot answer by speaking and can only nod the head has a complete airway obstruction and needs emergency help.

The American Heart Association recommends the following:

• The treatment for a choking person who begins to turn blue or stops breathing varies with the person's age. In adults and children older than one year of age, abdominal thrusts (formerly referred to as the "Heimlich maneuver") should be attempted. This is a thrust that creates an artificial cough. It may be forceful enough to clear the airway.

• The quick, upward abdominal thrusts force the diaphragm upward very suddenly, making the chest cavity smaller. This has the effect of rapidly compressing the lungs and forcing air out. The rush of air out will force out whatever is causing the person to choke.

How to perform abdominal thrusts

• Lean the person forward slightly and stand behind him or her. Make a fist with one hand. Put your arms around the person and grasp your fist with your other hand in the midline just below the ribs. Make a quick, hard movement inward and upward in an attempt to assist the person in coughing up the object. This maneuver should be repeated until the person is able to breathe or loses consciousness.

• If the person loses consciousness gently lay him or her flat on their back on the floor. To clear the airway, kneel next to the person and put the heel of your hand against the middle of the abdomen, just below the ribs. Place your other hand on top and press inward and upward five times with both hands. If the airway clears and the person is still unresponsive, begin CPR.

• For babies (younger than one year of age), the child will be too small for abdominal thrusts to be successful. Instead, the infant should be picked up and five back blows should be administered, followed by five chest thrusts. Be careful to hold the infant with the head angled down to let gravity assist with clearing the airway. Also be careful to support the infant's head. If the infant turns blue or becomes unresponsive, CPR should be administered.

• If you are in doubt about what to do, and you are witnessing someone choking, call for emergency help immediately, do not delay. You may be able to successfully stop the choking before help arrives using techniques discussed here, but it is best for the choking person to be evaluated by the emergency medical team when they arrive. If something is still in the person's throat, the emergency medical team can begin care immediately and take the person to the hospital for further treatment.

• Variations of abdominal thrusts for special circumstances:
• The victim is seated: The maneuver may be performed with the victim seated. In this instance, the back of the chair acts as a support for the victim. The rescuer still wraps his or her arms around the victim and proceeds as described above. The rescuer will often have to kneel down. In the event that the back of the chair the victim is sitting in is too high, either stand the victim up or rotate the victim 90 degrees, so that the back of the chair is now to one side of the victim.
• For small rescuers and large victims, particularly children rescuing an adult: Instead of standing behind the victim, have the victim lie down on his or her back. Straddle the victim's waist. Place one hand on the belly, halfway between the belly button and the edge of the breastbone. Thrust inward and upward. This is the same technique used in unconscious people.
• You are choking and you are alone: You may deliver an abdominal thrust on yourself. This can be done in one of two ways.
• You can deliver a true "self"-abdominal thrust with your own hands. This is done by positioning your hands in the same fashion as if you were performing the maneuver on another person and delivering an inward and upward thrust.
• Another option is to bend your belly over a firm object, such as the back of a chair, and thrust yourself into the object.
• Pregnant/obese people: Abdominal thrusts may not be effective in people who are in the later stages of pregnancy or who are obese. In these instances, chest thrusts can be administered. For the conscious person sitting or standing, take the following steps:
• Place your hands under the victim's armpits.
• Wrap your arms around the victim's chest.
• Place the thumb side of your fist on the middle of the breastbone.
• Grab your fist with your other hand and thrust backward. Continue this until the object is expelled or until the person becomes unconscious.
• For the unconscious pregnant or obese person: The sequence of events is the same as those for an unconscious adult. Chest thrusts, rather than abdominal thrusts, are delivered. To position yourself for chest thrusts, take the following steps:
• Kneel on one side of the victim.
• Slide two fingers up the bottom edge of the rib cage until you reach the bottom edge of the breastbone called the xiphoid process.
• With your two fingers on the xiphoid, place your other hand on the breastbone, just above your fingers. The thrusts should be quick and forceful to remove the object.
• Care should be taken because complications such as rib fractures and heart muscle damage have been known to occur with chest thrusts.
• If at all possible, subdiaphragmatic (below the ribcage) abdominal thrusts should be used in the pregnant woman, especially if there is still room between the enlarging uterus and baby, and the rib cage to perform the maneuver.

The American Red Cross recommends the following first aid for the conscious choking adult:

1. Have someone call Emergency.

2. Obtain consent from the victim.

3. Lean the person forward and give 5 black blows with the heel of your hand.

4. Give 5 quick, upward abdominal thrusts.

(NOTE: You can give yourself abdominal thrusts by using your hands, just as you would do to another person, or lean over and press your abdomen against any firm object such as the back of a chair.)

5. Continue alternating back blows and abdominal thrusts until:

• The obstructing object is forced out.

• The person can breathe or cough forcefully.

• The person becomes unconscious.

What to do next: If the victim becomes unconscious, call emergency, if not already done, and follow the steps for an unconscious choking adult below.

The American Red Cross recommends the following for the unconscious choking adult:

1. Try 2 rescue breaths. (If available, use protective barrier airway, resuscitation mask or face shield. The American Red Cross recommends that rescue breaths should not be delayed because you do not have a barrier or do not know how to use one).

To give a rescue breath:

• Tilt the head and lift the chin, then pinch the nose shut.

• Take a breath and make a complete seal over the person's mouth.

• Blow in to make the chest clearly rise.

(TIP: Each rescue breath should last about 1 second.)

2. If breaths do not go in, tilt the head farther back. Try 2 rescue breaths again.

3. If the chest does not rise – give 30 chest compressions. (TIP: Remove breathing barrier when giving chest compressions.)

To give a chest compression:

1. Place two hands in center of the chest (on lower half of sternum).

2. Compress 1-1/2 to 2 inches.

3. Compress 30 times in about 18 seconds (100 compressions per minute).

4. Look for an object in the airway.

5. Remove if one is seen.

6. Try 2 rescue breaths.

7. Repeat until EMS responders arrive or the obstruction is removed and the patient begins to breathe on his or her own.

The American Red Cross guidelines for treating choking in infants or babies one year or younger are similar to the guidelines mentioned above for the American Heart Association.

Medical Treatment

Treatment begins when local emergency medical services (EMS) arrive on the scene. They have several ways to treat a choking person. In addition to being skilled in the choking treatment and CPR, they also may have several tools to assist them in clearing the airway.

• Intubation: a breathing tube is passed into a person's windpipe (trachea). This may push the object that is obstructing the airway out of the way enough to provide air to the lungs.
• To perform intubation, a metal scope is inserted into the back of the throat to aid in seeing the vocal cords, which mark the opening of the trachea.
• If, while using this scope, the object causing the obstruction can be seen, it may then be removed with a long instrument called a Magill forceps.
• If attempts to intubate a person with a complete airway obstruction are unsuccessful, EMS personnel may have to perform a surgical procedure called a cricothyrotomy. This involves cutting the neck and making a hole in the trachea just below the Adam's apple, through which a breathing tube is inserted. This tube should enter the trachea below the spot that is blocked by the foreign body.

• Once at the hospital, a doctor may use a bronchoscope to remove the object. Bronchoscopy involves inserting a flexible fiberoptic scope into the airway (trachea). If something is found, this scope also has attachments that the doctor can use to remove the object.
• To perform this procedure, the person is heavily sedated and the nose numbed with a topical gel. The flexible scope is placed through the nose into the back of the throat and then guided into the trachea.
• Most people do not remember this procedure being done. It can be performed quickly if a person is in distress, and sedation is always used.
• If all of these maneuvers fail, the choking person will be taken to the operating room to have the foreign body removed and a clear airway established surgically.

Next Steps

Follow-up

Follow-up care is rarely needed if the object blocking the airway is removed quickly. Choking victims who require surgery or who suffer brain damage from lack of oxygen will require more extensive follow-up care.

Prevention

Be prepared to help: If you are ever in this situation as an observer you will want to be trained in the simple, yet life-saving choking treatment methods and CPR.

Attend a training class: Many are available through the American Heart Association, the American Red Cross, hospitals, worksites, and other local organizations.

• Prevention tips for children
• Don't give young children hard foods or small objects that are likely to become lodged in their airways. This includes nuts, seeds, gum, hard candy, peas, and tough meats. It is recommended that foods such as these not be given to any child younger than four years of age.
• Cut foods such as hot dogs, sausages, and grapes into small pieces before serving them to young children.
• Look over toys to find small pieces (eyes and noses on stuffed animals, for example) that the child might be tempted to place in his or her mouth.
• Choking on a rubber balloon is the leading cause of choking death in children who choke on objects other than food. Clean up right after parties. Toddlers are prone to stick anything they find on the floor into their mouths, including dangerous objects.
• Store small objects, such as buttons and batteries, out of a child's reach.
• Do not allow children to play sports with food or gum in their mouths.
• Tell babysitters and older brothers and sisters what foods and objects should not be given to young children.
• Instruct children to chew their food thoroughly before swallowing.
• Prevention tips for adults
• Avoid placing objects such as nails or pins in your mouth for quick access.
• Take small bites and chew food thoroughly.
• Be aware that alcohol may impair your ability to chew and swallow, and increase your risk of choking.

Outlook

The lack of oxygen caused by choking can result in brain damage or death in four to six minutes. Unless immediate action is taken to open a completely obstructed airway, the chances for survival and complete recovery decrease rapidly. If the object can be removed quickly and breathing returns to normal, recovery should be complete.