Choking

Foreign body airway obstruction (FBAO) or choking is one of the most time-critical emergencies encountered in both pre-hospital and emergency department settings. Unlike many medical conditions, deterioration is measured in seconds rather than minutes. Recognition, decision-making, and intervention need to occur almost simultaneously if we are going to help our patients..

Epidemiology

The true incidence of choking is difficult to determine. Many cases resolve with bystander first aid and never enter healthcare statistics.

However, data from a study of 999 calls to the London Ambulance Service provides valuable insight:

0.2% of nearly 115,000 emergency calls were coded as choking
74% required conveyance to hospital
Of transported patients, 11% were in cardiac arrest secondary to choking
Roughly 5 presentations per day
Broadly equal male–female distribution
Clear bimodal age distribution:
- Peak: 0–4 years
- Peak: >75 years
- Incidence rises progressively with age

Spike at Sunday 13:00 hrs— likely related to traditional Sunday lunch
Highest single time point: Wednesday 19:00 hrs [1][2].

Pathophysiology

Choking occurs when a foreign object partially or completely obstructs airflow between the upper airway and the trachea.

Typical foreign bodies:

Children: Food, coins, toys, batteries
Elderly: Food

Round foods are especially dangerous in children:

Hot dogs (most common fatal)
Candy
Nuts
Grapes

Among non-food items, latex balloons are the leading cause of fatal aspiration [3]. Historical data showed balloons accounted for 29% of fatal foreign body aspiration deaths — likely because they conform to airway anatomy and are difficult to visualize or retrieve.

Location matters

Airway obstruction can occur anywhere from pharynx to bronchi.

Above vocal cords = Better prognosis; manual removal possible

Below vocal cords = Often requires bronchoscopy

The degree of obstruction is equally important:

Partial obstruction: airflow preserved → time critical transfer
Complete obstruction: rapid hypoxia → cardiac arrest

Physiological deterioration

As obstruction persists:

Airway spasm worsens
Mucosal oedema increases
Cough effectiveness decreases
Expulsion becomes unlikely
Hypoxia progresses to arrest

One critical determinant is trapped lung air volume — this directly affects the success of abdominal thrusts because pressure generation depends on residual intrathoracic gas.

Clinical Recognition

Classic presentation

Sudden onset of:

Coughing
Stridor
Gagging
Wheezing
Respiratory distress

Patients may perform the universal choking sign — grasping the neck with both hands.

Key risk factors

Extremes of age
Neuromuscular disease
Intellectual disability
Eating during event
Small object play

The silent or occult choking patient

Absence of cough does not exclude choking.

Some patients present only with:

Dyspnoea
Cyanosis
Altered consciousness

Children may present atypically — cases have been described where persistent cough, wheeze, or cyanosis mimicked respiratory infection but were actually foreign bodies. Petechial haemorrhage and congestion were common clues [4].

Café Coronary

A classic but under-recognized presentation.

Definition: Sudden collapse during eating caused by airway obstruction, often mistaken for myocardial infarction.

Features:

Occurs during meals
Rapid collapse
Often elderly
No prodrome

Consider —> “cardiac arrests” at restaurants may actually be hypoxic arrests.

Assessment Approach

Effective vs ineffective cough

Effective cough: -
- Loud cough - air moving
- Speaking maybe with a hoarse voice

Ineffective cough: -
- Silent,
- Cyanotic

Example: a pen lid in airway — if coughing effectively, observation is safer than intervention.

Additional red flags

Hyper-salivation
Inability to swallow
Rapid fatigue
Quiet chest

Management

Partial Obstruction

Goal: Do not convert partial obstruction into complete obstruction

Management:

Encourage coughing
Upright positioning
Oxygen
Continuous monitoring

Active Choking (Conscious)

Standard escalating maneuvers:

Back blows
Abdominal thrusts
Repeat cycle

Effectiveness depends heavily on residual lung volume.

Unconscious Patient

Treat as hypoxic arrest:

Start CPR
Airway inspection each cycle
Attempt removal if visible

Chest compressions generate higher airway pressures than abdominal thrusts and may expel the object.

Out-of-Hospital Advanced Airway Management

A useful principle:

“Slow is swift and swift is fast.”

Rushed laryngoscopy often pushes the object deeper.

Key technique: suction-guided laryngoscopy

Aggressive suction — saliva obscures view
Gentle blade insertion

Foreign bodies forced below cords often lodge at the carina or main bronchus — typically right sided in adults [3].

Video laryngoscopy can improve visualization and retrieval [5].

DNACPR and Choking [CHECK OUT OUR DNAR INFOGRAPHIC]

Guidance from the Resuscitation Council UK:

A DNACPR should not automatically prevent resuscitation when arrest results from a reversible cause not anticipated in the plan, such as choking.

Examples include:

Choking
Anaphylaxis
Blocked tracheostomy

Clinical judgment overrides paperwork.

The grey area: expected aspiration risk

In conditions like:

Advanced dementia
Parkinson’s disease
Chronic dysphagia

Aspiration risk is foreseeable. Whether CPR is appropriate is debatable, check out the podcast and our discussion around the case of Kathleen Gregory for more details on this.

Oesophageal Food Bolus (TMT)

Not choking. Different pathology. Different urgency.

Foreign body oesophageal impaction ranks third among gastrointestinal emergencies.

Incidence: 13 per 100,000 annually
Male predominance 1.7:1

Pathophysiology

Food becomes lodged in the oesophagus rather than airway.

Typical culprit: poorly chewed meat (“steakhouse syndrome”).

Airway remains patent.

Presentation

Patients often:

Cannot swallow saliva
Regurgitate liquids
Remain oxygenated

Is it an emergency?

Usually not immediately life-threatening — but prolonged obstruction risks:

Oesophageal perforation
Mediastinitis
Aspiration

Emergency department:

Carbonated or effervescent swallow (“bubbling liquids”) sometimes attempted
Pharmacologic relaxation (e.g., smooth muscle relaxants)
Endoscopy if unresolved

A significant proportion ultimately require endoscopic retrieval.

Special Considerations

Children

Most missed cases occur here.

Always consider foreign body in:

Persistent cough
Unilateral wheeze
sudden onset symptoms

Especially with balloon exposure.

Elderly

High risk due to:

Dentition
Neurological disease
Sedatives
Large meals

Final Takeaways

Always suspect choking in:

Sudden collapse while eating (café coronary)
Elderly diners
Children with unexplained respiratory symptoms
Silent hypoxic arrest

Remember, clinicians are responsible for their own practice. These podcasts are produced for informative purposes and should not be considered solely sufficient to adjust practice. We provide lots of learning resources, so don’t just take our word for it…navigate to these and reflect on this topic further. See "The Legal Bit" for more info.

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