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Choking

Dislodge the obstruction in the person’s throat so they can breathe.

Choking occurs when the airway is partially or completely blocked by a foreignbody, such as a piece of food or an object (a magnet or small toy). Choking is alsoreferred to as a foreign body airway obstruction and is a common cause ofbreathing emergencies, especially in young children. Deaths related to chokingunderline the importance of preventive and first aid measures. It is one of the mostcommon life-threatening emergencies seen by first aid providers. The techniqueused to help someone who is choking depends on the person’s age, size and level ofresponsiveness.

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NOTE

In this topic, a baby refers to someone who is less than one year old. A child refersto someone who is one year or older.

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Guidelines

Immediately after recognition, bystanders can carry out interventions tosupport the removal of a foreign body airway obstruction. *Back blows may be used initially on people with a foreign body airwayobstruction and an ineffective cough. *Abdominal thrusts may be used on adults and children with a foreign bodyairway obstruction and an ineffective cough where back blows are ineffective.*First aid providers may consider the manual extraction of visible items in themouth. *

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First aid providers should not use blind finger sweeps on a person with aforeign body airway obstruction, as this may push the object further down theperson’s airway. *First aid providers should use standard CPR, consisting of both chestcompressions and rescue breaths if possible, on an unresponsive person with aforeign body airway obstruction. *

Good practice points

When helping a responsive person, first aid providers must be able torecognise the signs of partial airway obstruction (the person can speak, coughand breathe) and complete airway obstruction (the person is unable to speak,has a weakened cough and has difficulty breathing).A person with partial airway obstruction should be monitored until theyimprove, as it could develop into a complete airway obstruction.Responsive babies may receive a combination of back blows followed by chestthrusts to clear the obstruction from the airway.Back blows and abdominal thrusts or chest thrusts should be applied in quicksuccession until the obstruction has been cleared from the airway.In responsive adults and children who are choking, chest thrusts, back blowsor abdominal thrusts are equally effective.An unresponsive baby should receive a combination of rescue breaths andchest compressions to clear the obstruction from the airway. (SeeUnresponsive and abnormal breathing baby or child.)

Guideline classifications explained

Chain of survival behaviours

Prevent and prepare

Understand the difference between partial or complete choking and Asthmaattack, Allergic reaction and anaphylaxis and other conditions that may causesudden breathing difficulties.Be aware when people are eating as this is usually when choking occurs.

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Monitor a baby who is eating or might put something in their mouth.Be aware that people who have reduced responsiveness, a neurologicalimpairment that affects their swallowing and coughing reflexes (e.g., Stroke,Parkinson’s disease, cerebral palsy or dementia) or respiratory disease are atan increased risk of choking. People are also at a higher risk if they areintoxicated (due to drugs or alcohol), if their teeth are in poor condition or ifthey are an older adult.

Early recognition

The person may have had something in their mouth, such as food. Ask the person:“Are you choking?”.

Mild choking

Weak or forceful coughing.Can speak or cry out.Makes high-pitched noises while inhaling, but is still able to breathe.

Severe choking

Unable to cough, speak, cry or breathe.Clutches the throat with one or both hands.Panic.Bluish colour to the skin of the lips, ears, fingers and toes.Becomes unresponsive if the blockage is not removed.

First aid steps

Adults and children

Mild choking

Encourage the person to cough to clear the blockage.1.

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Monitor the person until they improve, as it could develop into a complete2.airway obstruction.

Severe choking

If the person cannot cough, speak or breathe, give up to five firm blows1.between their shoulder blades.If the back blows are unsuccessful, give up to five abdominal thrusts by2.putting your fist between their ribs and their belly button and pulling itsharply inward and upward using the other hand.If the abdominal thrusts are unsuccessful, immediately access emergency3.medical services (EMS).Continue alternating between five back blows and five abdominal thrusts until4.the blockage clears or the person becomes unresponsive.

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NOTE

If the person has mild choking, avoid taking action as they may be able to clearthe airway more effectively on their own.If the person becomes unresponsive, give standard CPR.Only remove solid material in the airway with your fingers if you can see it. Donot blindly sweep the mouth with your fingers.

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Babies

Mild choking

If the baby is coughing, wait to see if they can cough to clear their own airway.1.Monitor the baby until they improve, as it could develop into a complete2.airway obstruction.

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Severe choking

If the baby cannot cough or breathe, give up to five firm blows between their1.shoulder blades.If the back blows are unsuccessful, turn the baby over and give up to five chest2.thrusts by pushing sharply downwards in the centre of their chest.If the chest thrusts are unsuccessful, access EMS immediately.3.Continue alternating between five back blows and five chest thrusts until the4.blockage clears or the baby becomes unresponsive.

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NOTE

If the baby becomes unresponsive, start standard CPR.Only remove solid material in the airway with your fingers if you can see it. Donot blindly sweep the mouth with your fingers.

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Access help

In the case of severe choking, always access EMS. The person may haveinternal injuries from the abdominal thrusts, or the object may have causedsome damage to their airway. Even if they are no longer choking, they mayhave a piece of the object in their lungs that can later cause complications.In the case of mild choking, the person should seek medical care if theycontinuously cough, experience difficulty swallowing or feel as though theobject is still stuck in their throat.

Education considerations

Context considerations

Consider which contexts learners are most likely to encounter choking and ifthere are specific signs to which they should be more alert. For example, those

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working with older adults at an assisted living residence should recognisewhat it looks like to choke. Conversely, the signs of choking present differentlyin babies so learners caring for this age group will need to be aware of thosesigns.Because choking often happens while eating, a choking emergency couldhappen in a public place. Programme designers may consider framing this as a“helping behaviour” topic as it is one where the Bystander Effect could resultin people feeling uncomfortable to step forward and help. Emphasise the firststep as asking the person if they are choking.In babies and children, reported cases of choking occur while eating or playingwith non-food items such as coins or small toys. Learners should explore waysto reduce the risk of babies and children putting objects in their mouths; forexample, placing small items out of reach.

Learner considerations

Some babies experience mild choking frequently when they are learning to eatsolids. While usually not serious, the experience can be very distressing forcaregivers. Include an opportunity for caregivers to share their fears and theirexperiences as a way of building confidence to help babies effectively.Learning to give back blows can be challenging as it is not possible to practisethis on another person for fear of hurting them. Stress that a gentle slap willnot expel the object stuck in someone’s throat: force is needed to dislodge theobject even if this might hurt the person.If the learners are likely to need to help a pregnant or obese person withchoking, see the Facilitating choking skills resource for an adaptation forabdominal thrusts.

Facilitation tips

Focus choking education on the prevention and first aid domains within theChain of survival behaviours.Explain why it is important to do the different actions on someone who ischoking. Back blows create a strong vibration and pressure in the airway whileabdominal thrusts and chest thrusts squeeze the air out of the lungs, creatingadditional pressure in the airway. These techniques may dislodge the object

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and help the person to breathe again.Explore how using gravity (by bending over or holding the baby’s head lowerthan the body) can help dislodge the foreign object or liquids drain out.Learners practising back blows and chest thrusts for a choking baby should sitor kneel. Although it can be easy to hold a manikin baby in one arm (straddlearm technique), it can be more challenging with a real baby, especially foryounger learners. Supporting the baby on their lap can be more effective andsafer (Gesicki & Longmore, 2019).Explain that learners should not use abdominal thrusts for babies as theirorgans are still developing and may get damaged.While facilitators may include participants in demonstrating how to positiononeself to give back blows and abdominal or chest thrusts, the real actionsshould be demonstrated on a manikin.If teaching children or demonstrating for a child, the facilitator should go ontheir knees at the child’s height to demonstrate back blows and abdominalthrusts.Explore and address any misconceptions about choking, such as giving theperson a drink to clear the blockage or hanging a baby upside down.

Facilitation tools

When instructing learners on how to do back blows and abdominal or chestthrusts, refer to the resource Facilitating choking skills.Use videos or demonstrations to help learners understand how to do backblows, chest thrusts or abdominal thrusts. Emphasise that while these actionsmay seem aggressive, they could save the person’s life. Explain that learnersshould adapt the force of their actions depending on the size of the person, butthat those actions still need to be forceful enough to clear the airway.In addition to manikins, use objects such as punching bags or stuffed sacks topractise back blows and abdominal or chest thrusts.Develop scenarios to practise recognising and helping someone who ischoking. These scenarios may be used to assess learners’ knowledge and skillson this topic.

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Learning connections

If someone who is choking becomes unresponsive it is necessary to start CPRas the chest compressions or rescue breaths may dislodge the object fromtheir airway and help them to breathe again. See Unresponsive and abnormalbreathing adolescent and adult or baby and child.

Scientific foundation

The International Liaison Committee on Resuscitation (ILCOR) conducted asystematic review on foreign body airway obstruction (Olasveengen et al., 2020).

Back blows

One case series reported the survival of all people treated with back blows. Threecase series reported relief of airway obstruction in all people treated with backblows. Four studies reported four cases of injuries or complications in peopletreated with back blows. Very low-certainty evidence downgraded for very seriousrisk of bias and/or serious indirectness.

Abdominal thrusts

Six case series reported survival with the relief of a foreign body airwayobstruction in all people treated with abdominal thrusts. However, in 49 studies,cases of injuries or complications were reported in people treated with abdominalthrusts. Very low certainty evidence downgraded for very serious risk of bias.

Chest thrusts/ compressions

For the critical outcome of survival with a favourable neurological outcome, oneobservational study showed a benefit to using chest compressions. One case seriesreported relief of a foreign body airway obstruction in people treated with chestthrusts or compressions. Four studies reported five cases with injuries orcomplications in people treated with chest thrusts or compressions. Very low-certainty evidence downgraded for very serious risk of bias and/or very serious

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imprecision.

Finger sweep

ILCOR identified ten observational studies (mainly case series) regarding using afinger sweep. One case series reported survival in all people treated with a finger sweep. Twocase series reported relief of foreign body airway obstruction in all people treated with a fingersweep. Very low-certainty evidence downgraded for very serious risk of bias and seriousindirectness. Eight studies reported ten cases of injuries or complications in people treated witha blind finger sweep. Very low-certainty evidence downgraded for very serious risk of bias. Thestudies could therefore not conclude a benefit to using this approach.

Foreign body airway obstruction removal by bystanders

For the critical outcome of survival with a good neurological outcome, oneobservational study showed a benefit to foreign body airway obstruction removal bybystanders, compared with no bystander attempts. Very low-certainty evidencedowngraded for very serious risk of bias.

Other

The evidence about the use of Magill forceps or suction-based airway clearancedevices is not provided here.

Education review

The papers we reviewed raised important considerations for learners, particularlyconcerning a choking baby. Gesicki and Longmore (2019) compared the length of astandard baby manikin with the length of adult forearms. Based on data, they foundthat the traditional straddle-arm technique was not physically possible for manyfirst aid providers and recommended a more supported version with a seated orkneeling first aid provider.

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References

Systematic reviews

Olasveengen, T. M., Morley, P.T. (2020). Adult Basic Life Support: 2020International Consensus on Cardiopulmonary Resuscitation and EmergencyCardiovascular Care Science With Treatment Recommendations. Circulation, 142(suppl 1), S41–S91. DOI 10.1161/CIR.0000000000000892

Olasveengen, T. M., Mancini, M. E., Perkins, G. D., Avis, S., Brooks, S., Castrén, M.,… Morley, P.T. (2020). Adult Basic Life Support: 2020 International Consensus onCardiopulmonary Resuscitation and Emergency Cardiovascular Care Science WithTreatment Recommendations. Resuscitation, 156, A35-A79. DOI10.1016/j.resuscitation.2020.09.010

Education references

Gesicki, A. & Longmore, S. (2019). Time to reconsider the straddle-arm technique:Providing care for the conscious infant who is choking. International Journal ofFirst Aid Education, 2(2) 67. DOI 10.21038/ ijfa.2019.0008.

Related topicsAsthma attackUnresponsive and abnormal breathing (adolescent and adult)Unresponsive and abnormal breathing (baby and child)

Explore the guidelines

Published: 15 February 2021

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