Choking

Causes Of Choking 

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

1. Mechanical 

Choking is the result of mechanical obstruction of the airways preventing normal breathing can be due to eating food too quickly, laughing while eating, or consuming a large chunk of food.

2. 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 and lead to choking. 

3. Allergic 

A few allergic reactions can cause swelling at the back of the mouth that can block airflow and cause a choking sensation.

4. Musculoskeletal

Weakening of the muscles of the mouth or throat can make swallowing less effective and can lead to choking.

5. Other causes of choking 

• Stroke 

• Head injury 

• Dementia 

• Multiple sclerosis 

Symptoms Of 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 

Types Of Choking 

Choking can be classified into two types:

Partial airway obstruction or mild choking

In partial airway obstruction, the patient may be able to breathe and cough, although there may be a 'crowing' noise coming as the air passes through a narrowed space. In this case, the person could clear the blockage by coughing. 

Complete airway obstruction or severe choking 

In the case of severe choking, the person won't be able to speak, cry, cough, or breathe, and without help, they'll eventually become unconscious.

Risk Factors For Choking 

1. Inattention while eating 

If a person is laughing, not chewing the food properly, or distracted by other people's activities then it can easily increase the risk of choking. 

2. Swallowing inedible objects 

Swallowing inedible objects can sometimes pass through your system without notice. In some cases, the objects can get stuck in the food pipe that connects the mouth and stomach or can block the airway causing choking.

3. Dysphagia (difficulty swallowing)

In the case of dysphagia,  there's a risk of food, drink, or saliva going down the wrong way. Ultimately this can block the airway, making it difficult to breathe and causing a person to cough or choke.

4. Neurological and muscular disorders 

Neurological disorders like cerebral palsy and seizure disorder increase the chances of choking. Any damage to the nervous system can interfere with the nerves responsible for controlling swallowing. 

5. Gastroesophageal reflux disease (GERD)

GERD is a condition in which acid-containing contents in the stomach persistently leak back up into the esophagus (the tube from the throat to the stomach). In some cases of GERD, a person may experience pain in the chest or trouble swallowing. A feeling of food stuck or tightness in the throat might be experienced.

6. Dentures 

Dentures can make it difficult to sense whether food is fully chewed before it is swallowed. If dentures are poorly fit, individuals are unable to chew their food properly which can lead to choking. 

Diagnosis Of Choking 

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

1. History 

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

2. Lab tests 

• Swallow tests: These tests can be helpful in the initial assessment of swallowing abilities. The doctor will tell the [patient to swallow water and the time taken to drink water and the number of swallows required will be recorded.
• Manometry and 24-hour pH study: This test helps in evaluating 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. This can help in determining the cause of choking difficulties.

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3. Imaging tests 

• Barium X-ray: In this test the patient is told to drink a barium solution that coats the esophagus, making it easier to visualize on X-rays. This test helps in visualizing the changes in the shape of your esophagus. The results are recorded, allowing the choking problems to be studied in detail.
  
  
• Endoscopy: In this test, a thin, flexible lighted instrument (endoscope) is passed down the throat so that the doctor can visualize the esophagus.
  
  
• Fiber-optic endoscopic evaluation of swallowing (FEES): This test is usually a first choice for studying swallowing disorders as it is easy to use and well tolerated with no radiation exposure. First, an endoscope (a thin and flexible tube with a light and a camera at one end)is used to look down and identify any blockages in the nose and upper airways. Second, swallowing is assessed with different textures and sizes of food and liquid.
  
  
• Videofluoroscopic Swallow Study (VFSS): This test, also known as a modified barium swallow, is another gold standard that allows dynamic x-ray examination of the oral cavity, pharynx, and esophagus. It permits 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 make a series of detailed pictures of areas inside the body. A neck CT scan uses a special X-ray machine to make images of the soft tissues and organs of the neck, including the muscles, throat, tonsils, airways, thyroid, and other glands.
  
  
• Magnetic resonance imaging (MRI) scan: The procedure uses strong magnetic fields and radio waves to produce detailed images of the inside of the body. A neck MRI scan makes images of the soft tissues and organs of the neck, including the muscles, throat, tonsils, airways, thyroid, and other glands.

Prevention Of Choking 

Prevention of choking in adults:

1. Cut or chop food into smaller pieces.

2. Chew food slowly.

3. Avoid laughing and talking while eating. 

4. Avoid intake of alcohol before and after meals. 

5. 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 with some chronic illness 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 that are required for grinding hard food down to small pieces. They are easily distracted while eating and have small airways that can easily block. Foods that are needed to be avoided if your child is under 4 years of age: 

• Hard fruits and vegetables like raw carrot

• Small and round fruits and vegetables like whole cherry tomatoes, whole grapes, 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 the fruits. Grate hard fruits and vegetables such as raw carrots and apples or cook to soften and cut into smaller pieces.

• In the case of meat, serve tender, moist meat that is cut into smaller pieces. Remove all bones from the meat before serving.

• Give them finely chopped or crushed nuts and seeds until they are 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 while in a moving car as this reduces the risk of choking

• Keep the mealtime calm with minimal distractions and encourage the child to chew properly

• Avoid giving the baby a milk bottle in bed. As soon as the 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 and everything in their mouths. Keep the children out of reach of a few things to create a safer environment.

• Keep small and round-shaped objects out of reach of children including buttons, bottle caps, coins, jewelry, small magnets, and marbles

• Check for broken pieces of toys or games around the space where the child is playing.

• Follow age recommendations on toy packages

• Teach children not to put small objects in their mouths during their 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 of your home for a kid's-eye view. 

• Remove or lock away items that could be dangerous.

Specialist To Visit

Choking can be caused due to several reasons. In case of frequent choking, doctors can help you diagnose the exact cause and provide treatment including

• General physicians

• Neurologists 

• Gastroenterologists 

• Pediatrician (in the case of children)

A neurologist is a specialist in conditions that affect the brain, nerves, and spinal cord

A gastroenterologist is a specialist who is a medical practitioner qualified to diagnose and treat disorders of the stomach and intestines.

A pediatrician is a doctor who specializes in child care from birth until age 18.

When to see a doctor?

You should contact your doctor immediately if you have the following symptoms:

• Difficulty in breathing 

• Difficulty in swallowing 

• Confusion or disorientation 

• Neck or throat pain 

• Coughing  

• Fatigue 

• Noisy breathing 

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Treatment Of Choking 

The primary management of choking is to expel objects or foods blocking the throat. Also, treating the underlying causes is important to stop the 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 backflows by bending them forward and hitting firmly on their back with the heel of your hand between the shoulder blades to dislodge the object. 

• In the case that a person is not able to cough, speak or breathe, however, needs immediate help. Give them 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 the waist and bend them forward

• Clench your fists and place them above the belly of the person 

• 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. 

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2. Cardiopulmonary resuscitation (CPR)

• CPR is given when the person is unresponsive and is not breathing or only gasping for air. It is a vital and essential skill that can save someone’s life. 

• The two key elements of CPR are pressing on the chest, also called compressions, and providing breaths. 
  
  

CPR on adults 

Unless someone is trained in CPR including rescue breaths and feels confident using these skills, then only the person should give chest compressions with rescue breaths.

CPR on adults can be classified into two types:

• Hands-only CPR 
• CPR with rescue breaths

Hands-only CPR (Chest compression)

To carry out hands-only CPR, the steps are: 

• 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 right on the top of the hand placed above the chest to interlock the fingers
• Position yourself in such a way that your shoulders are directly above your hands
• Using your own body weight press straight down by 2 to 2.5 inches on their chest
• Keeping your hands on their chest, and allow their chest to return to its original position
• Repeat these compressions at a rate of 100 to 120 times a minute until the help arrives
  
  

 CPR with rescue breaths

Giving breaths during CPR can help maintain a supply of oxygen in the lungs. This helps in the circulation of oxygen in the vital organs. The preferred method to give breaths is by using a mask; however, mouth-to-mouth breaths can also be given.

To carry out CPR with rescue breaths, the steps are as follows: 

• 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 and give 100-120 compression at a steady rate
• After every 30 chest compressions, give 2 rescue breaths
• For giving rescue breaths, tilt the person's head gently and lift the chin up with 2 fingers and pinch the person’s nose. Seal your mouth over their mouth and blow steadily into their mouth for about 1 second
• Continue with this pattern of 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). This helps push the object obstructing the airway out of the way enough to provide air to the lungs. 
• If intubation is unsuccessful in a person then the 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. 

Complications Of Choking 

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

1. 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. 

2. Hypoxia

The most feared complication of foreign body airway obstruction is hypoxia which results in respiratory arrest, anoxic brain injury, and death.

3. Abdominal injury 

The complications with the Heimlich maneuver include injury to the abdomen and regurgitation of stomach contents.