Choking

The signs and symptoms of choking vary according to the severity of the obstruction. These include:

• Difficulty in breathing
• Difficulty in speaking
• Neck or throat pain
• Coughing
• Dizziness
• A red, puffy face
• Bluish tint to the lips, skin, or nails due to lack of oxygen
• Look of shock or confusion
• Strained or noisy breathing
• Squeaky sounds while breathing

Most episodes of choking are simply due to mistakes made while eating. The various causes of choking are discussed below:

• Mechanical: Choking results from mechanical obstruction of the airways, preventing normal breathing. This can occur due to eating food too quickly, laughing while eating, or consuming a large chunk of food.
• Neurological: Swallowing is a complex interplay of signals from the brain to the muscles of the mouth and throat. Disorders related to the brain and nerves can create an imbalance in this mechanism, leading to choking.
• Allergic: Certain allergic reactions can cause swelling at the back of the mouth, blocking airflow and creating a choking sensation.
• Musculoskeletal: Weakening of the muscles in the mouth or throat can make swallowing less effective, potentially leading to choking.
• Other causes of choking:
  • Stroke
  • Head injury
  • Dementia
  • Multiple sclerosis

• Inattention while eating: If a person is laughing, not chewing food properly, or distracted by others' activities, this can significantly increase the risk of choking.
• Swallowing inedible objects: Ingesting inedible objects may sometimes pass through the digestive system unnoticed. However, these objects can become lodged in the esophagus or block the airway, leading to choking.
• Dysphagia (difficulty swallowing): In cases of dysphagia, there is a risk of food, drink, or saliva entering the airway, which can obstruct breathing and result in coughing or choking.
• Neurological and muscular disorders: Conditions such as cerebral palsy and seizure disorders increase the likelihood of choking. Damage to the nervous system can disrupt the nerves responsible for swallowing.
• Gastroesophageal reflux disease (GERD): GERD is characterized by the persistent backflow of acid-containing contents from the stomach into the esophagus. Individuals with GERD may experience chest pain or difficulty swallowing, along with a sensation of food being stuck or tightness in the throat.
• Dentures: Dentures can impair the ability to determine if food is thoroughly chewed before swallowing. Poorly fitting dentures may hinder proper chewing, increasing the risk of choking.

A medical practitioner will carry out an initial assessment of swallowing to determine the reasons for choking. They may refer for further tests and treatments.

1. History

A medical practitioner will assess the history of swallowing difficulties by determining the ability to swallow solids, liquids, or both, and inquire about the symptoms the individual is experiencing.

2. Lab tests

• Swallow tests: These tests can be helpful in the initial assessment of swallowing abilities. The doctor will instruct the patient to swallow water, recording the time taken to drink and the number of swallows required.
• Manometry and 24-hour pH study: This test evaluates the functioning of the esophagus. A small tube with pressure sensors is passed through the nose into the esophagus to measure the amount of acid that flows back from the stomach, helping to determine the cause of choking difficulties.

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3. Imaging tests

• Barium X-ray: In this test, the patient is instructed to drink a barium solution that coats the esophagus, making it easier to visualize on X-rays. This test helps visualize changes in the shape of the esophagus, allowing choking problems to be studied in detail.
• Endoscopy: In this test, a thin, flexible lighted instrument (endoscope) is passed down the throat for the doctor to visualize the esophagus.
• Fiber-optic endoscopic evaluation of swallowing (FEES): This test is typically the first choice for studying swallowing disorders as it is easy to use, well-tolerated, and involves no radiation exposure. An endoscope is used to identify any blockages in the nose and upper airways, followed by an assessment of swallowing with different textures and sizes of food and liquid.
• Videofluoroscopic Swallow Study (VFSS): Also known as a modified barium swallow, this test allows dynamic X-ray examination of the oral cavity, pharynx, and esophagus, permitting evaluation of the patient’s airway before, during, and after swallowing.
• Computed Tomography (CT scan): This procedure uses a computer linked to an X-ray machine to create a series of detailed images of areas inside the body. A neck CT scan focuses on the soft tissues and organs of the neck, including muscles, throat, tonsils, airways, thyroid, and other glands.
• Magnetic resonance imaging (MRI) scan: This procedure uses strong magnetic fields and radio waves to produce detailed images of the inside of the body. A neck MRI scan captures images of the soft tissues and organs of the neck, including muscles, throat, tonsils, airways, thyroid, and other glands.

Prevention of choking in adults:

• Cut or chop food into smaller pieces.
• Chew food slowly.
• Avoid laughing and talking while eating.
• Avoid intake of alcohol before and after meals.
• If you wear dentures, take extra care to chew the food slowly and properly.

Prevention of choking in children:

Children under 4 years of age are at higher risk of choking, but older children can also choke. Children with disabilities or chronic illnesses might also be at higher risk of choking than other children.

1. Avoidance of food choking hazards

Children under four years of age are at higher risk of choking on food because they do not have the back teeth required for grinding hard food into small pieces. They are easily distracted while eating and have small airways that can easily block. Foods that should be avoided for children under 4 years of age include:

• Hard fruits and vegetables like raw carrots
• Small and round fruits and vegetables like whole cherry tomatoes, whole grapes, and berries
• Smooth and sticky foods like peanut butter or some sticky spreads
• Pieces and bones of meat, chicken, and fish
• Round and cylindrical foods like hot dogs and sausages
• Whole nuts and seeds
• Hard-to-chew foods like hard cookies, chips, candies, and popcorn

2. Make food safer to eat

Peel the skin and remove the seeds of fruits. Grate hard fruits and vegetables such as raw carrots and apples, or cook to soften and cut into smaller pieces.

For meat, serve tender, moist meat that is cut into smaller pieces. Remove all bones from the meat before serving.

Give finely chopped or crushed nuts and seeds until the child is four years old.

3. Watch the child while eating and drinking

• Seat your child comfortably in a chair while eating and drinking.
• Do not let the child eat while walking, running, lying down, or in a moving car, as this reduces the risk of choking.
• Keep mealtime calm with minimal distractions and encourage the child to chew properly.
• Avoid giving the baby a milk bottle in bed. If babies fall asleep with a bottle in their mouth, this can draw liquid into their lungs and choking can occur.

4. Avoidance of non-food choking hazards

Toddlers and young children explore the world by putting anything in their mouths. Keep the following items out of reach to create a safer environment:

• Small and round-shaped objects including buttons, bottle caps, coins, jewelry, small magnets, and marbles.
• Check for broken pieces of toys or games around the child's play area.
• Follow age recommendations on toy packages.
• Teach children not to put small objects in their mouths during playtime.
• Encourage kids not to put pencils, crayons, or erasers in their mouths when coloring or drawing.
• Make your home a "Childproof home" by getting down on your hands and knees in every room for a kid's-eye view.
• Remove or lock away items that could be dangerous.

The primary management of choking is to expel objects or foods blocking the throat. Treating the underlying causes is also important to prevent future episodes of choking.

1. The Heimlich Maneuver

In the case of a person coughing forcefully, encourage them to continue coughing to clear the object.

Give the person 5 back blows by bending them forward and hitting firmly on their back with the heel of your hand between the shoulder blades to dislodge the object.

If a person is unable to cough, speak, or breathe, they need immediate help. Administer abdominal thrusts, also known as the Heimlich maneuver, to prevent suffocation.

Steps of The Heimlich Maneuver:

• Stand behind the person who is choking.
• Place your arms around their waist and bend them forward.
• Clench your fists and place them above the person's belly.
• Put the other hand on top of your fist and pull sharply inwards and upwards.
• Repeat the above steps at least 5 times.

Learn more about first aid for choking and how you can save a person's life.

2. Cardiopulmonary Resuscitation (CPR)

CPR is administered when a person is unresponsive and is not breathing or only gasping for air. It is a vital skill that can save a life.

The two key elements of CPR are chest compressions and providing breaths.

CPR on Adults

Unless someone is trained in CPR, including rescue breaths, they should only provide chest compressions.

CPR on adults can be classified into two types:

• Hands-only CPR
• CPR with Rescue Breaths

Hands-only CPR (Chest Compression)

To perform hands-only CPR, follow these steps:

• Kneel down next to the person and place the heel of your hand at the center of their chest. Place the palm of the other hand on top of the first hand to interlock the fingers.
• Position yourself so that your shoulders are directly above your hands.
• Using your body weight, press straight down by 2 to 2.5 inches on their chest.
• Keep your hands on their chest and allow it to return to its original position.
• Repeat these compressions at a rate of 100 to 120 times a minute until help arrives.

CPR with Rescue Breaths

Giving breaths during CPR helps maintain a supply of oxygen in the lungs, promoting circulation in vital organs. The preferred method is to use a mask, but mouth-to-mouth breaths can also be given.

To perform CPR with rescue breaths, follow these steps:

• Place the heel of your hand on the center of the person's chest, then place the other hand palm on top and press down by 5 to 6 cm while giving 100-120 compressions at a steady rate.
• After every 30 chest compressions, give 2 rescue breaths.
• For rescue breaths, gently tilt the person's head back, lift the chin with two fingers, and pinch the nose. Seal your mouth over theirs and blow steadily for about 1 second.
• Continue with cycles of 30 chest compressions and 2 rescue breaths until the person begins to recover or help arrives.

Note: For children, it is recommended to carry out CPR with rescue breaths.

3. Intubation

A breathing tube is passed into a person's windpipe (trachea) to help push the object obstructing the airway out of the way, allowing air to reach the lungs. If intubation is unsuccessful, a doctor may perform a surgical procedure called cricothyrotomy, which involves placing a tube through an incision in the cricothyroid membrane (CTM) to establish an airway for oxygenation and ventilation.

Choking, if not addressed immediately, can lead to the following complications:

• Aspiration Pneumonia: This is a chest infection that can develop after accidentally inhaling something, such as a small piece of food. It causes irritation in the lungs or damages them.
• Hypoxia: The most feared complication of foreign body airway obstruction is hypoxia, which can result in respiratory arrest, anoxic brain injury, and death.
• Abdominal Injury: Complications associated with the Heimlich maneuver include injury to the abdomen and regurgitation of stomach contents.