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. 2023 Oct 27;33(4):11471.
doi: 10.4081/ejtm.2023.11471.

Risk factors and prevention of choking

Sabina Saccomanno  1 , Stefano Saran  2 , Licia Coceani Paskay  3 , Martina De Luca  4 , Augusto Tricerri  5 , Samuele Mafucci Orlandini  6 , Francesca Greco  7 , Giuseppe Messina  8
Affiliations

Risk factors and prevention of choking

Sabina Saccomanno et al. Eur J Transl Myol. .

Abstract

Choking (or foreign body airway obstruction) is a widespread phenomenon with serious consequences of morbidity and mortality. Choking (often also called suffocation) can be caused by food or inedible objects and leads to various degrees of asphyxiation or lack of oxygen in the blood stream. The incidence is very high in both young children and adults, especially seniors. However, since not all choking episodes end up in the emergency room or become fatalities, they often escape statistics. Although episodes of choking from non-edible bodies are infrequent, they affect mostly young children. Three of the most common risks for choking in general are neurological disorders, dysphagia and dental issues (few or no teeth, unstable or unsuitable prosthesis or orthodontic appliances). The purpose of this study was to evaluate the risk factors of choking and ways to reduce/avoid this event. We reported data on a series of 138 patients admitted to the emergency department following a choking event, at a hospital in Rome, Italy. The age group of the analyzed population ranged from 1 to 88 years, with the most represented age group of these between 40 and 59, with a similar distribution between males and females. The types of foods on which people choked reflected the seasonal, traditional and local foods: 67% of patients reported choking on fish bones followed by meat bones (9%) and artichokes (3%). Three relevant non-food choking elements reported were: orthodontic items, toothpicks and pins (one occurrence each). We also reported on two clinical cases of patients choking on meat and a chicken bone. In conclusion, choking awareness and prevention are essential for implementing potential life-saving precautions. Prevention is the first tool to reduce the occurrence of this event, therefore it is necessary to analyze the risk factors and educate the population to eliminate them. Proper chewing and oral manipulation are paramount functions in preventing choking, along with meal-time supervision if little children and elderly. Then, it behooves the healthcare professionals to disseminate knowledge.

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Conflict of interest statement

We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.

Choking, also defined as foreign body airway obstruction (FBAO), is a phenomenon that occurs when a foreign body (food, little hard objects, candies, etc.) prevents the air passage in the respiratory tract. Technically, choking usually occurs when a person is eating (internal obstruction of the airways), as opposed to drowning in water, or suffocating (external obstruction of the airways) with a plastic bag or a pillow, or strangulation (external compression of the airways) with a sting or a scarf. An obstruction that prevents oxygen from entering the lungs results in oxygen deprivation (asphyxia), that often leads to life-long neurological consequences and death if not quickly solved. See Tables 1 and 2.

[Table: see text]

Approximately 66 to 77 children younger than 10 years die from choking on food each year in the United States. More than 10,000 ER visits annually can be attributed to choking on food among children aged 14 years and younger. Canada saw an increase in children’s choking death in 2006-2012 compared to past decades. In the USA, of over 76,000 deaths from choking, in adults over 65 years of age, 6.5% of deaths were classified ad food choking. A study conducted in San Diego County, indicated that many choking deaths were due to meat and 45% of choking episodes happened at home. According to the National Safety Council (NSC), in the US, choking is the 4th leading cause of unintentional deaths, with two-thirds of choking deaths happening in people over 75. The Office for UK National Statistics reported 289 deaths in 2016 because of choking, with a 17% increase from the year before, with 85% of those deaths being caused by food and with about 91% of all choking deaths happening to adults over 45 years of age. The extra-hospital mortality rate is about 36.4%. The in-hospital mortality rate for airway foreign bodies is between 0.26% and 13.6% after complications due to delayed hypoxia, a severe laryngeal edema or bronchospasm requiring a tracheotomy or re-intubation, pneumothorax, pneumomediastinum, cardiac arrest, tracheal or bronchial laceration, and hypoxic brain damage. Although these statistics are worrisome, anecdotally, the number of chocking episodes not resulting in ER visits and death certificates is much higher and almost anybody will experience some degree of choking episodes during a lifetime.

[Table: see text]

Causes and risk factors of choking deaths involving food are often related to traditional foods and cultural circumstances:

  1. Eating some foods at birthday parties;

  2. Eating mochi rice cake in Japan;

  3. Eating nuts and seeds for “Autumn day” in Spain;

  4. Eating hot dogs in the USA;

  5. Eating at home more that at the restaurant;

Choking tends to occur during eating due to the specific properties of some food (hot dogs, cut meat, hard candies, peanut butter, popcorn, chewing gum, marshmallows), especially in young children, whose choking may also be caused by inedible objects such as, coins, beads, balloons, little toys or parts of toys.

Consistency, texture and shape of the food bite can also be risk factors, such as pieces of food too big to be manipulated within the oral cavity (like a chunk of an apple), round and slippery foods (some hard gelatins), cylindrical foods or foods cut into rounds (hot dogs, carrots), hard foods (candies, some fruits), sticky foods (peanut butter, some candies, potatoes), fibrous foods (meat, celery) or compressible foods (cakes, bread).

The risk depends not only on the type of food and its size, but also on the person's age, the amount taken and proper salivation. Indeed nuts, seeds, dry fruits are more dangerous in childhood (younger than 4) and in excessive amount (a pinch of them as opposed to a single one at the time). Air-way size foods: grapes, cherry tomatoes, apple chunks, carrots are only dangerous when they are too big to be chewed or not chewed properly. Saliva is of paramount importance in food bolus oral manipulation and formation and therefore in choking and yet we still don’t have good data on the impact of xerostomia (qualitative and quantitative changes in saliva) as well as the proper amount of saliva required to create a cohesive food bolus, easy to manipulate orally and swallow safely. The differences in risk between adults and children are also due to the different anatomy of the respiratory tract. The upper and lower airways of infants and children are smaller in diameter than in adults. They are shorter and positioned more anteriorly in the neck. The tongue is very thick in relation to the oropharynx. The trachea is very short and has little cartilaginous support. Mild edema or limited obstruction can reduce the diameter of the airways and determine a respiratory insufficiency. Moreover, children have an intense metabolic activity, the oxygen consumption in infants is twice that of adults, consequently, hypoxia develops more rapidly in the presence of respiratory insufficiency.

Especially in the adult patient, there are many risk factors that increase the risk of suffocation:

  1. Neurological, neuromuscular or psychiatric diseases (Dementia, Alzheimer’s, Parkinson’s, ALS, MS, Schizophrenia, ADHD, etc. (https://www.dhs.state.il.us/page.aspx?item=73374)

  2. Dysphagia (which can be both a risk factor or a consequence)

  3. Lung/breathing diseases or conditions (Emphysema, COPD, Asthma etc)

  4. Chronic obstructive sleep apnea

  5. Allergic reactions that cause swelling of the throat

  6. Excessive use of alcohol and/or drugs

  7. Risky behaviors (eating contests, dares, bravado)

  8. Use of certain medications that impact consciousness, alertness, sensory-motor coordination and that increase fatigue

  9. Surgery that compromised the integrity of the oro-pharyngolaryngeal complex

  10. Developmental disabilities.,

In particular, individuals with developmental disabilities, but also some institutionalized elderly people, can have increased choking risk because of:

  1. Decreased or absent protective airway reflexes.

  2. Decreased or disordered breathing/swallowing

  3. Poor coordination and oral stage dysphagia

  4. Poor or underdeveloped oral motor skills

  5. Gastro-esophageal reflux disorder (GERD)

  6. Epileptic seizures

  7. Inability to swallow certain fluid consistencies and/or food textures

  8. -Medication side effects

  9. Dental or skeletal malocclusion

  10. Impaired mobility

  11. Often need for feeding assistance

  12. Often inability to communicate problems in chewing, swallowing or protective mechanisms

Dental health has an impact of on choking too, due to teeth or muscle-related factors such as: orofacial/TMJ pain, denture instability, total dentures (upper and lower), severe malocclusion, edentulism or missing several teeth. For example, tooth loss or loose teeth is a chronic disability, which makes it difficult for patients to perform essential tasks such as chewing properly while eating. Dentures that cover the palate, impacting the lingual-palatal neurosensory interface, can make it difficult to sense whether the food is fully chewed before it is swallowed. If dentures fit poorly or hurt, individuals might not wear them, thus being unable to properly chew their food. In adults and in the elderly it is possible that some items get lodged at the laryngeal level, for example parts of dental prostheses. Small unfit temporary prosthesis may get dislodged during eating and get lodged instead in the upper airways often not closing them completely but causing distressing choking sensation.

Figures

Fig 1.
Fig 1.
The Heimlich maneuver can be a life-saving rescue technique, but it should only be used if the person can’t breathe and is conscious (Panels left, central, right). It can be used on adults and children but isn’t recommended for infants, for whom a different maneuver needs to be implemented. (Image realized by Dr. Samuele Mafucci Orlandini).
See this image and copyright information in PMC

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