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User:Hopper1828/Choking

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Lead edit

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,[1] choking often leads to death.

Around 4,500-5000 choking-related deaths occur in the United States every year.[2][3] Deaths from choking most often occur in the very young (children under 3 years old) and in the elderly (adults over 75 years).[4][5] Foods that can adapt their shape to that of the pharynx (such as bananas, marshmallows, or gelatinous candies) are more dangerous.[6] 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.[7][3] Many episodes go unreported because they are brief and resolve without needing medical attention.[8] Of the reported events, 80% occur in people under 15 years of age, and 20% occur in people older than 15 years of age.[7] Worldwide, 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.[9]

Signs and symptoms edit

Choking victims may present very subtly, especially in the setting of long term foreign body aspiration. Cough is seen in 80% of foreign body aspiration cases, and shortness of breath is seen in 25%.[10] 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.

History of Episode edit

An observed or recalled episode of choking, with sudden onset of any of the below respiratory and skin signs and symptoms while eating or handling small objects is seen in around 90% of choking episodes.[11] Initial episodes typically last seconds to several minutes, but can be followed by symptom improvement that can be mistaken as resolution.[12]

Respiratory edit

Initial respiratory symptoms can include involuntary cough, gurgling, gagging, shortness of breath, labored breathing, or wheezing.[13] Children often present with excessive drooling and stridor (high pitched breathing sounds).[3] Classic triad of choking symptoms in children is coughing, wheezing, and diminished breath sounds, however, a 10-year review showed that this grouping of symptoms was be present together in only about 60% of patients.[14]

Loss of consciousness may occur if breathing is not restored. In the setting of lower airway aspiration, patients may develop 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.[10]

The time a choking victim is still alive without brain damage[15] 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 edit

The face turning blue (cyanosis) from lack of oxygen if breathing is not restored. Cyanosis may also be seen on the fingertips. In a healthy child or adult, this sign is highly sensitive, but is only observed in 15-20% of choking episodes.[12][16]

Diagnosis edit

Recognition and diagnosis of choking primarily involves identification of the signs and symptoms like coughing and wheezing (see Signs and Symptoms). Immediate recognition of the symptoms is important, but based on the short length of some episodes, diagnosis during the first 24 hours only occurs in 50-60% of cases.[17]

After the initial episode, choking can lead to an obstruction of the airway that prompts further diagnostic steps.[18] For choking episodes that require emergent evaluation by a doctor, several tools can be used for diagnosis, each with their advantages and drawbacks.

Imaging and visualization methods edit

 
Use of bronchoscopy to visualize the respiratory tract.
Bronchoscopy
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.[18] Bronchoscopy also is a crucial tool in foreign body removal after supportive care has been provided and the person who is choking is stable.[19] However, bronchoscopy is an invasive form of imaging and intervention in comparison to the below diagnostic tools, and requires sedation to perform.[19]
X-ray
An X-ray uses high-frequency electromagnetic radiation to visualize the human body. In the case of choking, a chest X-ray is obtained to visualize the lungs and upper airway. However, many objects do not show up on X-ray (radiolucent).[20] About 10% objects are radio-opaque 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.[21] Chest fluoroscopy is a real-time X-ray image (sometimes referred to as an X-ray movie) to view breathing and coughing.[22]
Computerized tomography (CT)
A CT scan uses a tube with multiple X-ray machines to build a 3D image from 2D X-ray images of multiple cross-sections. Radiolucent objects can be better captured on CT than X-ray.[23] Additionally, modern imaging analysis software allows for airway reconstruction following a chest CT, creating a model of the airway network in the lungs that can better visualize the exast location of a foreign body.[24] 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.[25] MRI does not expose the person to radiation. Drawbacks of MRI include claustrophobia and high cost.[26] For children, sedation may be required to undergo MRI imaging, which is an increased risk when the airway is already potentially compromised.

Particular cases edit

Infants edit

The majority of choking injuries and fatalities occurs in children aged 0–4,[27] highlighting the importance for widespread dissemination of the appropriate anti-choking techniques for these age groups. In fact, it has been shown that increased parental education may decrease choking rates among children.[28]

For infants under 1 years old, the American Heart Association recommends adapted procedures.[29] The size of the children's body is the most important aspect in determining the correct anti-choking technique. Children who are too large for the babies' procedures require the normal first aid techniques against choking.

First aid for infants alternates a special cycle of back blows (five back slaps) followed by chest thrusts (five adapted chest compressions).

 
Back blows and chest thrusts for babies.

In the back blows maneuver, the rescuer slaps on the baby's back. It is recommended that the baby receive them being slightly leaned upside-down on an inclination. There exist several ways to achieve this:

One modality is that the rescuer sits down on a seat with the baby, and supports the baby with a forearm and its respective hand. The baby's head must be carefully held with that hand, usually by the jaw. Then the baby's body can be leaned forward upside-down along the rescuer's thighs and receive the slaps.

As an easier alternative, the rescuer can sit on a bed or sofa, or even the floor, carrying the baby. Next, the rescuer should support the baby's body on the own lap, to lean the baby upside-down at the right or the left of the lap. Then the slaps would be applied on the back of the baby.

If the rescuer cannot sit down, at least it is possible to attempt the maneuver at a low height and over a soft surface. Then the rescuer would support the baby with a forearm and the hand of that side, holding the baby's head with that hand, usually by the jaw. The baby's body would be leaned upside-down in that position to receive the slaps.

In the chest thrusts maneuver, the baby's body is placed lying on a surface. Then, the rescuer does the compressions pressing with only two fingers on the lower half of the bone that is along the middle of the chest from the neck to the belly (on the chest bone, named sternum, on its part that is the nearest to the belly). Abdominal thrusts are not recommended in children less than one year old because they can cause liver damage.[30]

The back blows and chest thrusts are alternated in cycles of five back blows and five chest compressions until the object comes out of the infant's airway or until the infant becomes unconscious.[30]

If choking is unresolved despite these rescue attempts, it is vital that somebody calls to the emergency medical services and continue first aid until they arrive.

Unconscious infants edit

If the infant becomes unconscious, emergency medical services must be called, if this has not been done yet. Until emergency services arrives the American Heart Association[30] recommends starting an anti-choking cardiopulmonary resuscitation (CPR) adaptive to infants. In this procedure, the baby is placed face-up on a firm and horizontal surface (the floor can be used). The baby's head must be in a straight position, looking frontally, because tilting too much a baby's head backward can close the access to the trachea. Then, it is applied a cycle of resuscitation[31] that alternates compressions and rescue breaths, like in a normal CPR, but with some differences:

The rescuer makes 30 compressions pressing with only two fingers on the lower half of the bone that crosses the middle of the chest from the neck to the belly (on the chest bone, named sternum, on its part that is the nearest to the belly), at an approximate rhythm of nearly 2 per second. At the end of the round of compressions, the rescuer looks into the mouth for the obstructing object. And, if it is visible, the rescuer makes a try to extract it (mainly using a finger sweep). If the removal complicates and takes too much time, it may require to repeat compressions at some moments, without hindering to the extraction. A rescuer that already knows that the choking object is a bag (or similar) does not need to see the object before trying to extract it (because there is no risk of sinking it much deeper, and it is easy to detect by using the touch carefully). Being any object extracted or not, this CPR procedure must continue until the babies can breathe by themselves or emergency medical services arrive. Next, the rescuer makes a rescue breath, covering the baby's mouth and nose simultaneously with the own mouth, and blowing air inside. After that first rescue breath, it is recommended tilting the baby's head up and down (but leaving it approximately straight again), trying to open a space for the air in that manner, and then give an additional rescue breath. The rescue breaths usually fail while the object is still blocking, but then the rescuer has only to continue with the next step. Anyway, they can be successful, and then the chest of the baby would be seen rising. If a rescue breath reaches the baby's lungs, it is because the object has been moved to an unknown position that leaves some open space, so it can be useful making the next rescue breaths more softly to avoid moving the object to a new blocking position again, and, in case of those soft rescue breaths are not successful, increasing the strength of blowing in the next ones. The bodies of the babies are delicate, and, when the airway is not clogged, only a little strength in blowing is enough to fill their lungs. The baby's colour would improve after some successful rescue breaths. After the rescue breaths, the rescuer has to return to the 30 initial compressions, repeating the same resuscitation cycle again, continually, until the choking babies can breathe normally by themselves.

Prevention edit

Prevention for babies and children edit

All young children require care in eating, and they must learn to chew their food completely to avoid choking. Feeding them while they are running, playing, laughing, etc. increases the risk of choking. Caregivers must supervise children while eating or playing.[32] Pediatricians and dentists can provide information on various age groups to parents and caregivers about what food and toys are appropriate to prevent choking.[33] The American Academy of Pediatricians recommends waiting until 6 months of age before introducing solid foods to infants.[34] Caregivers should avoid giving children younger than 5 years old foods that pose a high risk of choking, such as hot dog pieces, bananas, cheese sticks, cheese chunks, hard candy, nuts, grapes, marshmallows, or popcorn.[32] Later, when they are accustomed to these foods, it is recommended to serve them split into small pieces. Some foods as hot dogs, bananas, or grapes are usually split lengthwise, sliced, or both. Parents, teachers, and other caregivers for children are advised to be trained in choking first aid and cardiopulmonary resuscitation (CPR).[33]

Children readily put small objects into their mouths (deflated balloons, marbles, small pieces, buttons, coins, button batteries, etc.), which can lead to choking. A complicated obstruction for babies is choking on deflated balloons (including preservatives) or plastic bags. This also includes the nappy sacks, used for wrapping the dirty diapers, which are sometimes dangerously placed near the babies.[35] To prevent children from swallowing things, precautions should be taken in the environment to keep dangerous objects out of their reach. Small children must be supervised closely and taught to avoid putting things into their mouths. Toys and games may indicate on their packages the ages for which they are safe. In the US, children's toy and product manufacturers are required by law to apply appropriate warning labels to their packaging,[33] but toys that are resold may not have them.[33] Caregivers can try to prevent choking by considering the features of a toy (such as size, shape, consistency and small parts) before giving it to a child.[33] Children's products that are found to pose a choking risk can be taken off the market.[33]

 
Small Parts Test Fixture (SPTF) used to determine whether toys and other products pose a choking hazard to children under 3 years old

Anticipatory guidance from pediatricians edit

As a part of well-visits, pediatricians provide education to parents and their children regarding their development. Included in these visits is anticipatory guidance, which provides advice to parents and children as primary prevention of disease and illness including choking. For example, for a child that is 7–9 months old, children start to develop a pincer grasp allowing them to reach for objects.[36] The ability to place these objects in their mouths significantly increases choking risk.

Example anticipatory guidance for children 7–9 months old:[37]

  • Infants should avoid moving when feeding like riding in a car or stroller. Infants should be sitting upright and remain still.
  • Infants should be supervised when feeding including children younger than 3 years old
  • Infants will try to feed themselves. Avoid foods such as grapes, popcorn, carrots, nuts, and hard candies. Difficult to swallow foods like peanut butter and marshmallows should be given with caution.
  • Specifically, toys like marbles, balls, balloons should not be given including children younger than 3 years old.[38]

Regulations for children in the United States edit

Several laws and commissions are aimed at preventing choking hazards in children. Formed in 1972, alongside the passing of the Consumer Products Safety Act, the U.S. Consumer Product Safety Commission (CPSC) regulates consumer projects that may pose "unreasonable risk" of injury to its users.[39] The Consumer Products Safety Act allowed the CPSC to ban or place warnings on objects that could harm consumers. A Small Parts Test Fixture (SPTF) is a cylinder measuring 2.25 inches long by 1.25 inches wide determines whether a choking hazarding warning will be placed on the product.[40] Furthermore, in 2008, the Consumer Product Safety Improvement requires any advertisements or websites regarding sale of a product to display choking hazard warnings.[41]  

According to a 1991 study, warning labels are an effective preventive measure against choking accidents. Items that contain many parts may include pieces that are considered choking hazards. Labels on children's toys may state recommended age ranges, and other items may carry a warning to parents to keep them out of the reach of children. Warning labels are clearly placed and written, usually including an obvious image.[42]

While products are protected, there are currently no Food and Drug Administration (FDA) regulations regarding food choking hazards.[38]

References edit

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  39. ^ "About Us". U.S. Consumer Product Safety Commission. Retrieved 2022-09-12.
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