Emergency medicine - Treating airway obstruction

Combined techniques may be needed to force a foreign body from the airway. By Dr Anthony Handley

Lean the patient forward and give up to five blows between the shoulder blades with the heel of your other hand
Lean the patient forward and give up to five blows between the shoulder blades with the heel of your other hand

Choking is common, but it is not known how common because most cases are relieved spontaneously or with the help of an onlooker. Studies on the best means of emergency management are scarce, with most of the medical literature consisting of case histories and anecdotes.

Treatment for foreign body airway obstruction (FBAO) consists of increasing the intrathoracic pressure to force the obstructing material upwards and outwards.

Three such methods described are: abdominal thrusts (Heimlich manoeuvre), back blows (or 'slaps') and chest thrusts (a similar technique to chest compressions during CPR).

There is no convincing evidence that one technique is better than another, but several reports have suggested that it often takes more than one, in sequence, to achieve the desired result.

The following guidelines for the management of choking are taken from the Resuscitation Council (UK) Resuscitation Guidelines 2010.

Recognising choking
Recognising FBAO is the key to a successful outcome. It is important not to confuse this emergency with other conditions that may cause sudden respiratory distress, cyanosis or loss of consciousness.

General signs of choking would be if the attack occurs while eating and the patient may clutch at their neck. Ask a conscious patient if they are choking.

Signs of airway obstruction
Mild airway obstruction

  • Patient is able to speak, cough and breathe, and answers yes when asked if choking.

Severe airway obstruction

  • Patient is unable to speak.
  • Patient may respond by nodding yes when asked if choking.
  • Patient is unable to breathe.
  • Breathing sounds wheezy.
  • Attempts at coughing are silent.
  • Patient may be unconscious.

Adult choking sequence
This is for adults and children over the age of one year.

1. If the patient shows signs of mild airway obstruction, encourage him to continue coughing, but do nothing else.

2. If the patient shows signs of severe airway obstruction and is conscious, give up to five back blows.

  • Stand to the side and slightly behind the patient.
  • Support the chest with one hand and lean the patient forward so that when the obstructing object is dislodged it comes out of the mouth rather than going further down the airway.
  • Give up to five blows between the shoulder blades with the heel of your other hand.
  • Check to see if each back blow has relieved the airway obstruction. The aim is to relieve the obstruction with each blow rather than necessarily to give all five. If five back blows fail to relieve the airway obstruction give up to five abdominal thrusts.
  • Stand behind the patient and put both arms around the upper part of his abdomen.
  • Lean the patient forward.
  • Place your clenched fist between the umbilicus and the bottom end of the sternum.
  • Grasp this hand with your other hand and pull sharply inwards and upwards.
  • Repeat up to five times.
  • If the obstruction is still not relieved, continue alternating five back blows with five abdominal thrusts.

3. If the patient becomes unconscious, support the patient carefully to the ground. Immediately call an ambulance and begin CPR. Feel for a carotid pulse and initiate chest compressions even if a pulse is present in the unconscious choking patient.

Further complications
Following successful treatment, the foreign body may remain in the upper or lower respiratory tract and cause complications later. Patients with a persistent cough, difficulty swallowing or with the sensation of an object being still stuck in the throat should be referred.

Abdominal thrusts can cause internal injuries and all patients receiving abdominal thrusts should be examined for injury.

If these manoeuvres all fail, and the equipment and expertise are available, a foreign body may be removed by forceps under direct vision.

  • Dr Handley is an honorary consultant physician, past chairman of the Resuscitation Council (UK) and chairman, BLS/AED International Course Committee, European Resuscitation Council

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