What is Foreign Body Airway Obstruction?
Choking, also known as foreign body airway obstruction (or FBAO, a situation where an object is blocking your airway), is a serious problem common to many people, leading to considerable health issues and deaths. Choking can be caused by food as well as non-food items, both of which can limit oxygen supply, leading to various extents of suffocation.
The problem is particularly common among young children and older adults. Many choking incidents may not be severe enough to warrant a visit to the emergency room or result in death, so they often go unnoticed. Choking on non-food items happens less, but when it does, it primarily impacts young children.
There are several major risk factors for choking, including neurological disorders and dysphagia (difficulty swallowing), and dental issues like having few or no teeth, unstable dental prostheses (artificial devices to replace lost teeth), or inappropriate orthodontic appliances.
According to the National Safety Council, choking is the 4th leading cause of unintentional death, with over 5,000 recorded fatalities in 2015. It’s also a significant cause of accidental deaths in children under 16. Given its prevalence and how quickly choking can lead to unconsciousness or death, everyone, even those not in healthcare, should at least know the basic first aid for a choking victim. Simple methods such as the Heimlich maneuver, a technique performed to dislodge an object from a person’s airway, can potentially save lives.
A complete choking incident, where the airway is totally blocked, is an immediate threat to life. Even a partial choking incident can cause considerable issues, like hindering gas exchange (critical process for breathing), and may lead to shortness of breath, pneumonia (a chest infection causing inflammation in the lungs), and the formation of abscesses (collections of pus).
What Causes Foreign Body Airway Obstruction?
Choking happens when something obstructs the airway and makes it hard to breathe. While our bodies have natural methods to prevent choking, these aren’t always enough. This is particularly true for adults with muscle weakness and children with narrow airways. Two main ways our bodies help prevent choking include the closure of the voice box and a reflex that forces us to expel anything stuck in our throats, known as the expiration reflex.
The expiration reflex is different from the cough reflex because it starts when we breathe out, whereas the cough reflex starts when we breathe in. Both reflexes have different roles. The expiration reflex stops things from going down into our lungs, while the cough reflex helps clear mucus and anything blocking our airways by sucking air into the lungs.
Understanding the differences between these two actions is important for medical treatment. For instance, codeine, a type of drug, does not affect the expiration reflex like it does the cough reflex. Anesthesia, used during surgery, can slow down the expiration reflex more than it does the cough reflex.
Children are especially at risk when it comes to choking. A child’s airway is much smaller than an adult’s, making it easier for even a small object to block their breathing. Also, children can’t cough as forcefully as adults, making it harder for them to dislodge something stuck in their throat. Moreover, kids tend to explore their environment by putting things in their mouth.
Round food items are known to be the most likely to cause serious choking incidents in children. Hotdogs lead to the most choking incidents, followed by candy, nuts, and grapes. Among non-food objects, latex balloons are the main non-food item leading to choking incidents in children. The way balloons can mold to the shape of the airway and create a tight seal makes them particularly hazardous. In adults, meat products like fish and sausages were found to be the primary cause of choking incidents, accounting for 71% of cases. Breads and fruits and vegetables were other common causes.
Risk Factors and Frequency for Foreign Body Airway Obstruction
Nonfatal choking incidents are tricky to track since they often don’t result in hospital visits. Among kids treated for nonfatal choking, food is the top cause at around 59.5% of cases. Following food is non-food items like coins, marbles, balloons, and paper making up 31.4% of cases. In 9.1% of cases, the cause is unknown. Choking is most common in babies under 1 year old. Over 75% of choking incidents occur in kids under 3 years old. Choking rates don’t noticeably differ between boys and girls.
For adults, risk of choking is higher with Alzheimer’s disease, Parkinson’s disease, a history of stroke, intellectual or developmental disability, poor teeth, intoxication, swallowing difficulties, use of mental health medications, and advanced age. Similar to children, studies haven’t noted a significant difference in choking rates between men and women. For adults, fatal choking rates are estimated at 0.1 per 100,000 for individuals aged between 18 to 64 years, and 0.7 per 100,000 for those older than 65.
Past research has linked the length of airway blockage to outcomes in patients with foreign bodies trapped in their airway. But the effect of bystander intervention hasn’t been extensively researched. Studies suggest bystander efforts can greatly improve patient outcomes, a finding that matches research on bystander intervention in cardiac arrest cases. But, like in cardiac arrest cases, many people who choke don’t get help from bystanders. Studies on cardiac arrest have pointed out barriers to bystander intervention, including physical and emotional challenges and a lack of necessary life-saving knowledge.
Signs and Symptoms of Foreign Body Airway Obstruction
If someone is choking, the first things to check are their airway, breathing, and circulation. It’s important to look at the person’s skin color, their level of consciousness, and their breathing rate. Things like chest retractions, nasal flaring, and strained breathing muscles might be noticed. If a full airway blockage isn’t noticed and dealt with quickly, it can lead to respiratory failure.
Sudden breathing problems that come with coughing, stridor (a high-pitched wheezing sound), wheezing, or gagging require immediate action. These signs should alert you to the possibility of a foreign body airway obstruction (FBAO). Often, someone who is choking will grab their neck with both hands. If the person is stable and able to communicate, you’ll want to take note of their age (it’s usually very young or older people), if they have any intellectual or neuromuscular disabilities, and if there was a preceding event such as eating or playing with toys.
Physical signs can vary depending on where the foreign body is lodged. If it’s in the larynx or trachea, you might notice stridor or hoarseness. If it’s in the bronchi, symptoms may include one-sided wheezing or weaker breath sounds. It’s important to carefully check the throat for visible foreign bodies. Never perform blind finger sweeps as these can push the object further down. Also, check the throat for other potential causes of stridor and breathing problems, such as an inflamed epiglottis or a peritonsillar abscess.
Sudden coughing and choking are strong indicators of FBAO. However, even if these signs aren’t present, it’s important to remain vigilant, particularly in people who are having difficulty breathing or are low on oxygen. Many people may not present with cough, stridor, or wheezes. If these symptoms aren’t evident, providers should focus on risk factors such as age or disability and look for signs of atelectasis (collapsed lung), lung hyperinflation, or pneumonia on a chest X-ray. It’s also important to understand that while symptoms often come on suddenly, some people might not show any signs until 24 hours after they’ve inhaled a foreign body.
Testing for Foreign Body Airway Obstruction
If your doctor suspects you have a foreign body airway obstruction (FBAO), they’ll likely base their diagnosis on your symptoms and a physical examination. A FBAO occurs when an object blocks your airway either partially or completely, making it difficult to breathe.
X-ray images can be helpful for confirming the diagnosis, but they can’t always be trusted to rule out FBAO on their own. This is because the chest x-ray might appear normal or show changes that aren’t typical for foreign body aspiration, especially in kids.
When the obstruction is believed to be in your upper airway, your doctor could ask for standing side and front view x-rays of your neck. If they suspect the blockage is in your lower airway, they might add x-rays of your chest while you breathe in and out. Most foreign bodies don’t show up on x-rays, so your doctor will look for indirect signs of blockage like an overly stretched hypopharynx (the part of the throat connecting the mouth and nose to the esophagus) or swelling in the soft tissues in front of your spine.
Depending on where the foreign body is lodged in the lower part of your airway, your chest x-ray might show a single overinflated lung, collapse of a segment or the whole lung (atelectasis), or a shift of the space between the lungs (mediastinum). The accuracy of diagnosis tends to improve with x-ray images taken when you breathe out. In these images, the affected lung often stays clear when there’s air trapped beyond the location of the foreign body.
Treatment Options for Foreign Body Airway Obstruction
If a child is suspected of having something blocking their airway but can still breathe a bit, they should be allowed to try to cough up the obstruction. However, if the child is not able to cough, speak or breathe, immediate steps to clear the airway should be taken. For babies less than one year old, the best way to clear the airway is by delivering five back blows and five chest thrusts repeatedly until either the object comes out or the infant becomes unresponsive. Babies should not receive abdominal thrusts because their livers are delicate and can be easily hurt.
For older children (more than a year old), abdominal thrusts are recommended. The procedure, also called the Heimlich maneuver, should continue until the child either coughs up the obstruction or becomes unresponsive. If the child becomes unresponsive, chest compressions should be initiated at that point. After 30 compressions, the airway should be looked at. If a foreign object is visible, it needs to be removed immediately. It’s important not to attempt to clear an obstruction that can’t be seen because unintentionally pushing it deeper into the throat can cause more harm. This cycle of 30 compressions and two breaths should be performed repeatedly until the foreign object is removed.
The technique for adults is similar to that for children. The Heimlich maneuver should be used until the foreign object is removed or the person passes out. If there’s nobody around to help, the individual can try and perform the abdominal thrusts themselves, either using their fists or by leaning forcefully against a firm object like a chair. However, for pregnant or extremely overweight individuals abdominal thrusts might be unsafe; in these cases, they can try sternal thrusts (thrusts applied to the chest bone).
If these basic life support methods fail to unblock the airway, a healthcare professional may use specialized tools like Magill forceps or suction under direct observation to try and remove the obstruction. If the foreign body is obstructing the airway above the vocal cords, a cricothyrotomy, a procedure that creates a direct airway through an incision in the neck, could be performed. If the foreign object is stuck below the vocal cords, the doctor might insert a tube into the windpipe to move the obstruction into a bronchus, one of the two main air passages to the lungs.
If there’s a suspicion of a foreign body not totally blocking the airway (partial FBAO), bronchoscopy (an examination of the breathing tubes) can be useful in diagnosing this. It’s essential to consider the patient’s clinical history, physical examination and imaging results collectively, not individually, when deciding on the best course of action. Research has shown combining all these factors results in a more accurate diagnosis of FBAO.
What else can Foreign Body Airway Obstruction be?
If a person is experiencing symptoms like wheezing (stridor), breathing difficulties, and a cough, there are many possible causes for these symptoms. The initial symptoms and whether the person has a fever can help narrow down what could be causing these health issues.
- Immediate wheezing, choking or gagging without a fever might be due to a foreign body airway obstruction (FBAO), an allergic reaction resulting in sudden bodily changes (anaphylaxis), physical injury to the throat, a burn, or swelling from allergies (angioedema).
- If a child quickly starts to show these symptoms and has a fever, they could have a throat infection (epiglottitis), bacterial tracheitis, an abscess behind the throat or tonsils (retropharyngeal abscess, peritonsillar abscess).
- A cough that gradually sounds like barking can be due to a viral infection (viral croup).
- For kids younger than 6 months, structural problems like ‘floppy’ windpipe (laryngotracheomalacia), paralyzed vocal cords, narrowing below the vocal cords (subglottic stenosis), abnormal blood vessels (vascular rings), or tumors comprised of mostly blood vessels (airway hemangioma) should be considered.
- Foreign bodies in the food pipe (esophagus) are generally more common than those in the airway. These can also lead to breathing difficulties due to the mass and inflammation they cause.
- Toddlers might also display choking symptoms after swallowing caustic substances like cleaning supplies, bottled laundry detergent, or detergent pods.
What to expect with Foreign Body Airway Obstruction
The outlook for a patient who has a foreign body airway obstruction (FBAO) varies and depends on how severe the obstruction is and how long the patient has gone without oxygen (referred to as hypoxia). If the obstruction is partial and the patient can clear their airway, they often face few, if any, complications. Their treatment will then be guided by their risk factors for future similar events.
However, if the obstruction is complete, the patient may lose consciousness very quickly, within seconds or minutes. Those who require CPR, unfortunately, have a high mortality rate of 90% for events happening outside of a hospital setting. Even those who survive and are admitted to the hospital face mortality rates between 60% and 70%.
As the period of hypoxia lengthens, the chances of having negative effects on the brain increase. However, it’s often hard to predict just how severe these effects will be. Some signals that the outcome may be worse include the absence of pupil light response, no corneal reflex, a kind of epilepsy called myoclonus status epilepticus, and harmful patterns in brain waves (shown on an EEG). Despite these signals, doctors usually wait at least 72 hours after a patient’s spontaneous circulation returns before considering the withdrawal of life-supporting measures. This is simply due to the challenges in predicting a patient’s recovery.
Possible Complications When Diagnosed with Foreign Body Airway Obstruction
The most severe complication feared during a foreign body airway obstruction (FBAO) is low oxygen levels in the blood, which can result in the stopping of breathing, damage to the brain due to lack of oxygen, and even death. If a foreign body in the airway goes unnoticed, it can cause long-term complications. These could include lung collapse, pneumonia, and damage to the bronchial tubes sometimes leading to the need for surgical removal of a part or an entire lung lobe.
If the Heimlich maneuver is used to treat FBAO, complications can occur which include injury to the abdominal or chest organs and vomiting of stomach contents. Patients who have a bronchoscopy, which is a procedure to look into the airways, may experience bleeding, infection, airway puncturing, and pneumothorax (a condition when air leaks into the space between the lung and chest wall).
Common complications include:
- Low oxygen levels in the blood
- Stopped breathing
- Brain damage due to lack of oxygen
- Death
- Lung collapse
- Pneumonia
- Damage to the airways
- Surgical removal of part of a lung
- Injury to the abdomen or chest from the Heimlich maneuver
- Vomiting of stomach contents
- Bleeding from bronchoscopy
- Infections
- Airway puncturing
- Pneumothorax (air leakage into the chest)
Preventing Foreign Body Airway Obstruction
To prevent choking, several methods can be used. For adults, modifying the texture of the food they eat can play a significant role. This depends on how well their airway can protect itself and the power of their cough. It’s also recommended to avoid food types that often cause problems, to better posture during meals, to ensure that those at higher risk are well-supervised during meals, and to maintain proper dental care. It’s also important to monitor any side effects from medication that could lead to choking.
For children, the American Academy of Pediatrics (AAP) advises introducing pureed, or well-blended, foods to infants between ages 4 and 6 months. Certain behaviors can increase the risk of choking in children, like walking, talking, laughing, or eating quickly. The AAP has also suggested public health actions like mandatory labels on foods that have a high risk of causing choking. The Child Safety Protection Act also requires toys and games that pose a choking hazard to carry warning labels.
Foreign Body Airway Obstruction (FBAO) – which is when an object blocks the airway – is a common emergency and it can cause sudden death in both children and older adults. The immediate response from people nearby can have a big impact on how the person chokes recovers. Many essential life support training programs have recently been set up for school children. However, these programs currently lack detailed training on how to evaluate and handle FBAO. Including such education in Basic Life Support training programs for school children is considered crucial.
