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: http://www.americanheart.org.

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

WEB SITES

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

"Heimlich Maneuver." American Heart Association , 2004. Available online at http://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 http://www.babycenter.com/general/9298.html (accessed December 8, 2004).

National Safe Kids Campaign . Available online at http://www.safekids.org (accessed December 8, 2004).

Jennifer E. Sisk, M.A.