Choking

Definition

Choking is a condition caused by inhalation of a foreign object that partially or fully blocks the airway.

Description

Choking is a major cause of respiratory emergencies and cardiac arrest in infants and children. Choking occurs when a foreign object, such as food, buttons, coins, or toy parts, are inhaled and partially or completely block the airway, preventing adequate breathing. In many cases of choking, particularly in adults, the individual actively coughs and is able to expel the foreign object with no assistance or medical attention. However, children and infants are at increased risk of choking and foreign body airway obstruction due to immature airway and dental anatomy, distraction and play during eating, and a natural tendency to put objects into their mouths.

A 1995 study of the characteristics of objects known to commonly cause choking deaths in children found that round objects are most dangerous. For example, a small ball or marble can completely seal a child's or infant's trachea (windpipe). Round or cylindrical foods, hard candy, chewing gum, and balloons also present choking hazards. In infants, choking usually results from inhalation of small objects (coins, small toys , deflated balloons, buttons) that they place in their mouths.

Demographics

Each year, more than 17,000 infants and children are treated in hospital emergency departments for choking-related incidents, and more than 80 percent of these occur in children aged four years and younger. Airway obstruction death and injury are especially prevalent in children under age four due to anatomy (small airway), natural curiosity and tendency to put objects in their mouths, and incomplete chewing. According to statistics from the Centers for Disease Control and Prevention, choking rates in 2001 were highest in infants.

Causes and symptoms

Choking is a major cause of death for children under three and is a hazard for older children as well. Young children naturally explore the world with their mouths, and they will readily put in their mouths anything that fits. If a small object slips back into the throat and blocks the trachea, the child may become unable to breathe, and unless the child is helped to eject the object quickly, the child may asphyxiate and die. Food is also a choking hazard, especially for children under three who do not know how to chew food thoroughly.

According to statistics from the Centers for Disease Control and Prevention, of the 17,000 or so cases of pediatric choking in 2001, 60 percent were related to food, 31 percent were related to non-food substances, and 9 percent were related to undetermined objects. Of the food-related choking incidents, 19 percent resulted from candy or gum. Of the choking incidents resulting from non-food objects, 13 percent were related to coins.

Food-related choking usually occurs because infants and young children do not chew their food well, and larger pieces can become stuck in their throat. The following foods have been identified by the American Academy of Pediatrics as presenting choking hazards:

• hot dogs
• hard candy
• chewing gum
• nuts and seeds
• chunks of meat or cheese
• whole grapes
• popcorn
• chunks of peanut butter
• raw vegetables
• raisins

The following objects have been identified as presenting choking hazards:

• coins
• buttons
• marbles
• small balls
• deflated balloons
• watch batteries
• jewelry
• ball point pen caps and paper clips
• arts and crafts supplies
• small toys and toys with small detachable parts

When to call the doctor

All infants, children, and adolescents who have a choking incident should see a doctor, since complications can occur even if the object causing the choking is successfully expelled. Sometimes, pieces can be aspirated into the lungs, and even though breathing returns to normal, wheezing, chest pain , persistent cough , and pneumonia can develop within a few days due to the foreign body in the lung. Foreign bodies may require removal by bronchoscopy or surgery.

Vomiting may occur after being treated with the Heimlich maneuver . All infants and children who experience a choking episode severe enough to require the Heimlich maneuver should be taken to the hospital emergency room to be examined for airway injuries.

Diagnosis

Choking is diagnosed by observation of the choking victim. Children able to actively cough should be watched to make sure they expel the object on their own and that their airways do not become blocked. Indications that a choking victim's airway is blocked include the following:

• inability to cough, cry, or speak
• blue or purple face color from lack of oxygen
• grabbing at throat
• weak cough and labored breathing that produces a high-pitched noise
• all of the above, followed by loss of consciousness

When the actual choking incident is not observed, choking can be diagnosed by observing the above symptoms. For children, infants, and adolescents who are unconscious, choking and foreign body obstruction can be diagnosed by attempting to give rescue breaths. If a breath administered to the victim does not inflate the chest, rescuers should assume that the airway is blocked and take steps to clear the airway.

Treatment

An emergency choking incident is treated using the Heimlich maneuver, usually administered by parents, caregivers and teachers, or bystanders. Children who have a choking incident that requires the Heimlich maneuver should be examined by a physician for potential injuries to their airway and aftereffects of oxygen deprivation.

The Heimlich maneuver is used when a child is choking on a foreign object to the extent that he/she cannot breathe. Oxygen deprivation from a foreign body airway obstruction can result in permanent brain damage or death in four minutes or less. Using the Heimlich maneuver can save a choking victim's life. The Heimlich maneuver is not performed on infants under one year of age; rather, a series of back blows and chest thrusts are used to attempt to dislodge the foreign object.

If the foreign body cannot be expelled from the child's airway using the Heimlich maneuver, cardiac and/or respiratory arrest may occur, and the child may stop breathing. If this happens, cardiopulmonary resuscitation (CPR) is performed to restore and maintain breathing and circulation and to provide oxygen and blood flow to the heart, brain, and other vital organs. CPR can be performed by trained laypeople or healthcare professionals on infants, children, adolescents, and adults. CPR should be performed if an infant, child, or adolescent is unconscious and not breathing.

Prognosis

Incorrectly applied, the Heimlich maneuver can break bones or damage internal organs. Following the Heimlich maneuver, dysphagia (swallowing difficulty) and obstructive pulmonary edema (fluid accumulation in the lungs) may occur and require medical treatment.

In many cases the foreign material is dislodged from the throat, and the choking victim suffers no permanent effects of the episode. If the foreign material is not removed, the choking victim may suffer permanent brain damage from lack of oxygen or may die.

Prevention

Choking is easily preventable by taking the following steps:

KEY TERMS

Bronchoscopy —A procedure in which a hollow tube (bronchoscope) is inserted into the airway to allow visual examination of the larynx, trachea, bronchi, and bronchioles. It is also used to collect specimens for biopsy or culturing, and to remove airway obstructions.

Cardiopulmonary resuscitation (CPR) —An emergency procedure designed to stimulate breathing and blood flow through a combination of chest compressions and rescue breathing. It is used to restore circulation and prevent brain death to a person who has collapsed, is unconscious, is not breathing, and has no pulse.

Diaphragm —The thin layer of muscle that separates the chest cavity containing the lungs and heart from the abdominal cavity containing the intestines and digestive organs. This term is also used for a dome-shaped device used to cover the back of a woman's vagina during intercourse in order to prevent pregnancy.

Heimlich maneuver —An emergency procedure for removing a foreign object lodged in the airway that is preventing the person from breathing. To perform the Heimlich maneuver on a conscious adult, the rescuer stands behind the victim and encircles his waist. The rescuer makes a fist with one hand and places the other hand on top, positioned below the rib cage and above the waist. The rescuer then applies pressure by a series of upward and inward thrusts to force the foreign object back up the victim's trachea.

Trachea —The windpipe. A tube composed of cartilage and membrane that extends from below the voice box into the chest where it splits into two branches, the bronchi, that lead to each lung.

• supervising infants and children while they eat and play
• childproofing play areas by removing small objects
• cutting foods into very small pieces
• avoiding serving foods listed above as choking hazards to children under age four
• monitoring older children to make sure they do not give younger children hazardous foods or objects
• following age and safety guidelines on toys
• learning CPR and the Heimlich maneuver
• not letting children and infants play with coins

Parental concerns

Because most choking incidents occur in the home, all parents and infant/child caregivers should be trained in the Heimlich maneuver. Training is available through the American Red Cross and American Heart Association at local schools, YMCAs, and community centers.

The likelihood of choking incidents can be reduced by closely supervising infants and children while they eat and play. Most choking incidents are associated with food items, especially hot dogs, candies, grapes, nuts, popcorn, and carrots. Common non-food items that present choking hazards include deflated balloons, buttons, coins, small balls, small toys, and toy parts. All toys should be examined to make sure they are age-appropriate and do not have loose parts.

Resources

BOOKS

Basic Life Support for Healthcare Providers. Dallas, TX: American Heart Association, 2001.

PERIODICALS

Centers for Disease Control and Prevention. "Nonfatal Choking-Related Episodes among Children—United States, 2001." Journal of the American Medical Association 288 (November 20, 2002): 2400–02.

Vikle, Gary M., et al. "Airway Obstruction in Children Aged Less than Five Years: The Prehospital Experience." Prehospital Emergency Care 8 (2004): 196–99.

ORGANIZATIONS

American Heart Association. 7320 Greenville Ave., Dallas, TX 75231. Web site: <www.americanheart.org>.

The Heimlich Institute. 311 Straight St., Cincinnati, OH 45219–9957. Web site: <www.heimlichinstitute.org>.

WEB SITES

"Choking Episodes among Children." National Center for Injury Prevention and Control. Available online at <www.cdc.gov/ncipc/duip/spotlite/choking.htm> (accessed December 8, 2004).

"Heimlich Maneuver." American Heart Association, 2004. Available online at <www.americanheart.org/presenter.jhtml?identifier=4605> (accessed December 8, 2004).

"Infant First Aid for Choking and CPR: An Illustrated Guide." BabyCenter, 2004. Available online at <www.babycenter.com/general/9298.html> (accessed December 8, 2004).

National Safe Kids Campaign. Available online at <www.safekids.org> (accessed December 8, 2004).

Jennifer E. Sisk, M.A.

Choking

Definition

Choking is the inability to breathe because the trachea is blocked, constricted, or swollen shut.

Description

Choking is a medical emergency. When a person is choking, air cannot reach the lungs. If the airways cannot be cleared, death follows rapidly.

Anyone can choke, but choking is more common in children than in adults. Choking is a common cause of accidental death in young children who are apt to put toys or coins in their mouths, then unintentionally inhale them. According to Safe Kids USA, about 750 children die each year from choking. Eighty percent of them are under age four.

People also choke because infection causes the throat tissue to swell shut. It is believed that this is what caused George Washington's death. Allergic reactions can also cause the throat to swell shut. Acute allergic reactions are called anaphylactic reactions and may be fatal. Strangulation puts external pressure on the trachea causing another form of choking.

Finally, people can choke from obstructive sleep apnea. This is a condition where tissues of the body obstruct the airways during sleep. Sleep apnea is most common in obese men who sleep on their backs. Smoking, heavy alcohol use, lung diseases such as emphysema, and an inherited tendency toward a narrowed airway and throat all increase the risk of choking during sleep.

Causes and symptoms

There are three reasons why people choke. These are:

• mechanical obstruction
• tissue swelling
• crushing of the trachea.

Regardless of the cause, choking cuts off the air supply to the lungs. Indications that an individual's airway is blocked include:

• the person cannot speak or cry out
• the person's face turns blue from lack of oxygen
• the person desperately grabs at his or her throat
• the person has a weak cough and labored breathing that produces a high-pitched noise
• the person has all of the above symptoms, then becomes unconscious
• during sleep, the person has episodes of gasping, pauses in breathing, and sudden awakenings.

Diagnosis

Diagnosing choking due to mechanical obstruction is straightforward since the symptoms are obvious even to an untrained person. In choking due to infection, the person, usually a child, will have a fever and signs of illness before labored breathing begins. If choking is due to an allergic reaction to medication or insect bites, the person's earlobes and face will swell, giving an external sign that internal swelling is also occurring.

Choking due to sleep apnea is usually diagnosed on reports of symptoms by the person's sleep partner. There are also alarm devices to detect the occurrence of sleep apnea. Eventually sleep may be interrupted so frequently that daytime drowsiness becomes a problem.

Treatment

Choking, except during sleep apnea, is a medical emergency. If choking is due to allergic reaction or infection, people should summon emergency help or go immediately to an emergency room. If choking is due to obstructed airways, the Heimlich maneuver (an emergency procedure in which a person is grasped from behind in order to forcefully expel the obstruction) should be performed immediately. In severe cases a tracheotomy (an incision into the trachea through the neck below the larynx) must be performed.

Individuals who suffer airway obstruction during sleep can be treated with a device similar to an oxygen mask that creates positive airway pressure and delivers a mixture of oxygen and air.

Prognosis

Many people are treated successfully for choking with no permanent effects. However, if treatment is unsuccessful, the person dies from lack of oxygen. In cases where the airway is restored after the critical period passes, there may be permanent brain damage.

Health care team roles

Choking can be treated by anyone with first aid training or who has been trained to perform the Heimlich maneuver. This includes everyone from physicians and nurses to paramedics, fire and police officers, and trained lay people. Choking do to infection or allergic reaction is normally treated by emergency medical personnel, ideally in a hospital emergency room. It is preferable that a tracheotomy be performed by a physician, but in emergency circumstances where death is imminent, it can be performed by with less medical training others such as paramedics and military medics. Once the airway is no longer obstructed there is no ongoing role for the heath care team.

Prevention

Watching children carefully to keep them from putting foreign objects in their mouth and avoiding giving young children food such as raisins, round slices of hot dogs, and grapes that stick easily in the trachea can reduce the chance of choking in children. Adults should avoid heavy alcohol consumption when eating and avoid talking and laughing with food in their mouths. The risk of obstructive sleep apnea choking can be reduced by avoiding alcohol, tobacco smoking, tranquilizers, and sedatives before bed. Medic alert bracelets can help prevent anaphylactic reactions due to drug allergies. Individuals severely allergic to insect stings should avoid insect exposure and may carry an EpiPen that supplies an epinephrine (adrenaline) to slow the allergic response.

KEY TERMS

Heimlich maneuver— An emergency procedure in which a person who is choking is grasped from behind and administered a series of abdominal thrusts to forcibly eject material blocking the airways.

Trachea— The windpipe. A tube extending from below the voice box into the chest where it splits into two branches, the bronchi, that go to each lung.

Tracheotomy— The surgical creation of an opening in the trachea that functions as an alternative airway so that the patient may breathe.

Resources

BOOKS

American Red Cross. First Aid Fast. Washington, DC: American Red Cross, 2002.

ORGANIZATIONS

American Red Cross, P.O. Box 37243, Washington, D.C. 20013. 800-435-7669. http://www.redcross.org.

OTHER

"Choking: First Aid." First Aid Guide. MayoClinic.com. January 9, 2006. http://www.mayoclinic.com/health/first-aid-choking/FA00025.

Choking

Definition

Choking is the inability to breathe because the trachea is blocked, constricted, or swollen shut.

Description

Choking is a medical emergency. When a person is choking, air cannot reach the lungs. If the airways cannot be cleared, death follows rapidly.

Anyone can choke, but choking is more common in children than in adults. Choking is a common cause of accidental death in young children who are apt to put toys or coins in their mouths, then unintentionally inhale them. About 3,000 adults die each year from choking on food.

People also choke because infection causes the throat tissue to swell shut. It is believed that this is what caused George Washington's death. Allergic reactions can also cause the throat to swell shut. Acute allergic reactions are called anaphylactic reactions and may be fatal. Strangulation puts external pressure on the trachea causing another form of choking.

Finally, people can choke from obstructive sleep apnea. This is a condition where tissues of the body obstruct the airways during sleep. Sleep apnea is most common in obese men who sleep on their backs. Smoking, heavy alcohol use, lung diseases such as emphysema, and an inherited tendency toward a narrowed airway and throat all increase the risk of choking during sleep.

Causes and symptoms

There are three reasons why people choke. These are:

• mechanical obstruction
• tissue swelling
• crushing of the trachea.

Regardless of the cause, choking cuts off the air supply to the lungs. Indications that a person's airway is blocked include:

• the person cannot speak or cry out
• the person's face turns blue from lack of oxygen
• the person desperately grabs at his or her throat
• the person has a weak cough and labored breathing that produces a high-pitched noise
• the person has all of the above symptoms, then becomes unconscious
• during sleep, the person has episodes of gasping, pauses in breathing, and sudden awakenings.

Diagnosis

Diagnosing choking due to mechanical obstruction is straightforward, since the symptoms are obvious even to an untrained person. In choking due to infection, the person, usually a child, will have a fever and signs of illness before labored breathing begins. If choking is due to an allergic reaction to medication or insect bites, the person's earlobes and face will swell, giving an external sign that internal swelling is also occurring.

Choking due to sleep apnea is usually diagnosed on reports of symptoms by the person's sleep partner. There are also alarm devices to detect the occurrence of sleep apnea. Eventually sleep may be interrupted so frequently that daytime drowsiness becomes a problem.

Treatment

Choking, except during sleep apnea, is a medical emergency. If choking is due to allergic reaction or infection, people should summon emergency help or go immediately to an emergency room. If choking is due to obstructed airways, the Heimlich maneuver (an emergency procedure in which a person is grasped from behind in order to forcefully expel the obstruction) should be performed immediately. In severe cases a tracheotomy (an incision into the trachea through the neck below the larynx) must be performed.

Patients who suffer airway obstruction during sleep can be treated with a device similar to an oxygen mask that creates positive airway pressure and delivers a mixture of oxygen and air.

Prognosis

Many people are treated successfully for choking with no permanent effects. However, if treatment is unsuccessful, the person dies from lack of oxygen. In cases where the airway is restored after the critical period passes, there may be permanent brain damage.

Prevention

Watching children carefully to keep them from putting foreign objects in their mouth and avoiding giving young children food like raisins, round slices of hot dogs, and grapes can reduce the chance of choking in children. Adults should avoid heavy alcohol consumption when eating and avoid talking and laughing with food in their mouths. The risk of obstructive sleep apnea choking can be reduced by avoiding alcohol, tobacco smoking, tranquilizers, and sedatives before bed.

Resources

ORGANIZATIONS

American Heart Association. 7320 Greenville Ave. Dallas, TX 75231. (214) 373-6300. 〈http://www.americanheart.org〉.

KEY TERMS

Trachea— The windpipe. A tube extending from below the voice box into the chest where it splits into two branches, the bronchi, that go to each lung.

Tracheotomy— The surgical creation of an opening in the trachea that functions as an alternative airway so that the patient may breathe.