choking choking choking, also known as foreign body airway obstruction (fbao), is a phenomenon that occurs when breathing is impeded by a blockage inside of the respiratory tract. an obstruction that prevents oxygen from entering the lungs results in oxygen deprivation. although oxygen stored in the blood and lungs can keep a person alive for several minutes after breathing stops, choking often leads to death. chokingother namesforeign body airway obstructiona demonstration of abdominal thrusts on a person showing signs of chokingspecialtyemergency medicinesymptomsgasping, wheezing, cyanosis, difficulty speaking, involuntary coughing, clutching of throat, severe respiratory distress, stridor, tachypneacomplicationsatelectasis, post-obstructive pneumonia, or bronchiectasisusual onsetminutes to dayscausesforeign body aspirationdiagnostic methodbased on symptoms, imaging, bronchoscopytreatmentforeign body removal over 4,000 choking-related deaths occur in the united states every year. deaths from choking most often occur in the very young (children under 2 years old) and in the elderly (adults over 75 years). foods that can adapt their shape to that of the pharynx (such as bananas, marshmallows, or gelatinous candies) are more dangerous. various forms of first aid are used to address and resolve choking. choking is the fourth leading cause of unintentional injury death in the united states. many episodes go unreported because they are brief and resolve without needing medical attention. of the reported events, 80% occur in children younger than 15 years, and 20% occur in children older than 15 years. choking on a foreign object resulted in 162,000 deaths (2.5 per 100,000) in 2013, compared with 140,000 deaths (2.9 per 100,000) in 1990. signs and symptoms choking victims may present very subtly, especially in the setting of long term foreign body aspiration. cough seen in 80% of foreign body aspiration cases, and shortness of breath is seen in 25%. people may be unable to speak, attempt to use hand signals to indicate they are choking, attempt to force vomiting, or clutch at their throat. respiratory respiratory symptoms can include involuntary cough, gurgling, shortness of breath, labored breathing, or wheezing. loss of consciousness may occur if breathing is not restored. in the setting of lower airway aspiration, patients may have pneumonia like symptoms such as fever, chest pain, foul smelling sputum, or blood in sputum (hemoptysis). in the case of long term foreign body aspiration, patients may present with signs of lobar pneumonia or pleural effusion. the time a choking victim is still alive without brain damage can vary, but typically brain damage can occur when the patient remains without air for approximately three minutes (it is variable). death can occur if breathing is not restored in six to ten minutes (varies depending on the person). however, life can be extended by using cardiopulmonary resuscitation for unconscious victims of choking (see more details further below). skin the face turning blue (cyanosis) from lack of oxygen if breathing is not restored. cyanosis may also be seen on the fingertips. causes respiratory tract choking occurs when a foreign body blocks the airway. this obstruction can be located in the pharynx, the larynx, trachea, or lower respiratory tract. the blockage can be either partial (insufficient air passes through to the lungs) or complete (complete blockage of airflow). foods that are small, round, or hard pose a high risk of choking. examples include hard candy, chunks of cheese or hot dogs, nuts, grapes, marshmallows, and popcorn. among children, the most common causes of choking are food, coins, toys, and balloons. in one study, peanuts were the most common object found in the airway of children evaluated for suspected foreign body aspiration. small, round non-food objects such as balls, marbles, toys, and toy parts are also associated with a high risk of choking death because of the potential to completely block a child's airway. children younger than age three are especially at risk of choking due to lack of fully developed chewing habits, and the tendency to insert object in their mouth as they explore the environment. because a child's airway is smaller in diameter than that of an adult's, smaller objects can more often cause airway obstruction in children. additionally, infants and young children generate a less forceful cough than adults, so coughing may not be as effective in relieving airway obstruction. risk factors of foreign body airway obstruction for people of any age include the use of alcohol or sedatives, procedures involving the oral cavity or pharynx, oral appliances, or medical conditions that cause difficulty swallowing or impair the cough reflex. conditions that can cause difficulty swallowing and/or impaired coughing include neurological conditions such as stroke, alzheimer's disease, or parkinson's disease. in older adults, risk factors also include living alone, wearing dentures, and having difficulty swallowing. children and adults with neurological, cognitive, or psychiatric disorders are at an increased risk of choking and may experience a delay in diagnosis because there may not be a known history of a foreign body entering the airway. choking on food is only one type of airway obstruction; others include blockage due to tumors, swelling and inflammation of the airway tissues from organic foreign bodies, and compression of the laryngopharynx, larynx, or vertebrate trachea in strangulation. foreign bodies can also enter the reparatory tract through the chest wall, such as in the setting of a gunshot injury. diagnosis recognition and diagnosis of choking involves recognition of the signs and symptoms like coughing and wheezing (see signs and symptoms). choking can indicate a full obstruction of the airway and can prompt further action from anyone witnessing a choking episode. for choking episodes that require emergent evaluation by a doctor, several other tools can be used by diagnosis. imaging and visualization methods bronchoscopy use of bronchoscopy to visualize the respiratory tract. imaging modalities in the healthcare setting each have their advantages and drawbacks. according to the american heart association, bronchoscopy is a reliable method used to visualize the cause of choking when not resolved via oxygen and supportive care. prior to bronchoscopy, an invasive procedure, other imaging modalities may be used. x-ray an x-ray uses high-frequency electromagnetic radiation to visualize the human body including the lungs via chest x-ray. many objects do not show up on x-ray (radiolucent). about 10% objects are radio-opaque like and can be visualized using x-ray. x-rays are more accessible than other imaging modalities but expose a person to radiation. in cases where x-ray is inconclusive, fluoroscopy may be able to demonstrate radiolucent or smaller foreign bodies. chest fluoroscopy is a real-time x-ray image (sometimes referred to as an x-ray movie) to view breathing and coughing. computerized tomography (ct) a ct scan uses a tube with multiple x-ray machines to build a 3d image from 2d x-ray images from multiple cross-sections. radiolucent objects can be better captured on ct than x-ray. since a ct is multiple x-rays, the exposure to radiation is significantly greater. magnetic resonance imaging (mri) an mri scan uses radio-frequency pulse under a magnetic field to create a high-resolution image of the body. mris can detect foreign bodies with higher accuracy than x-ray or ct. mri does not expose the person to radiation. drawbacks of mri include claustrophobia and high cost. for children, sedation may be required to undergo mri imaging. treatment airway management is used to restore a person's ventilation which consists of severity assessment, procedural planning, and may consist of multiple treatment modalities to restore airway. treatments will vary based on severity and stage of airway blockage. in basic airway management, treatment generally consists of anti-choking first aid techniques, such as the heimlich maneuver. in advanced airway management, complex methods are used. basic treatment (first aid) us medic teaches the abdominal thrusts to afghansbasic treatment of choking includes several non-invasive techniques to help remove foreign bodies from the airways. general strategy: "five and five" for a conscious choking victim, most institutions such as the american heart association and the american red cross, recommend the same general protocol of first-aid: encouraging the victim to cough, followed by hard back slaps. if these attempts are not effective, abdominal thrusts (the heimlich maneuver) or chest thrusts (if the victim cannot receive abdominal pressure) are used. there are additional procedures available for victims who cannot receive pressure to the abdomen such as babies or people with disabilities (discussed in detail further below). if none of these techniques are effective, protocol by various institutions recommend alternating series of back slaps and series of thrusts (these on the abdomen or chest, depending on the victim), 5 times of each technique and repeat ("five and five"). scenarios in which the general first aid procedures are not resolving the choking, involvement of emergency medical services is crucial and administration of first aid should be continued until emergency services arrive. choking can change the colour in the victim's faces due to lack of oxygen, which puts them at risk for loss of consciousness and falling to the ground. it is recommended to avoid panic and begin appropriate resuscitation techniques. each one of the techniques in the first aid protocol against choking are detailed below: cough if the choking victim is conscious and can cough, the american red cross and the mayo clinic recommend encouraging them to stay calm and continue coughing freely . between coughs, it may be easier to take air through the nose to refill the lungs. back blows (back slaps) back slaps depiction. the rescuer supports the victim's chest (for improving the effectivity) with the hand that will not slap, and bends the victim's body as much as possible. then the other hand applies firm slaps. many associations, including the american red cross and the mayo clinic, recommend the use of back blows (back slaps) to aid a choking victim. this technique is performed by bending the choking victim forward as much as possible, even trying to place their head lower than the chest, to avoid the blows driving the object deeper into the person's throat (a rare complication, but possible). the bending is in the back, while the neck should not be excessively bent. it is convenient that one hand supports the victim's chest. then the back blows are performed by delivering forceful slaps with the heel of the hand on the victim's back, between the shoulder blades. the back slaps push behind the blockage to expel the foreign object out. in some cases, the physical vibration of the action may cause enough movement to clear the airway. abdominal thrusts (heimlich maneuver)