An airway obstruction is a blockage that partially or totally prevents air from entering the lungs, creating a potentially life-threatening medical emergency. When a foreign body or other cause obstructs the airway, particularly the upper airway consisting of the larynx, vocal cords, and trachea, immediate action is essential to restore airflow and prevent a lack of oxygen to the brain.
In Australia, choking incidents are a common cause of emergency calls, with foreign bodies lodged in the throat accounting for hundreds of hospitalisations annually. Whether caused by food, small objects, or swelling due to an allergic reaction, understanding how to recognise and respond to an acute upper airway obstruction could mean the difference between life and death.
Types of Airway Obstructions
Airway obstruction comes in several forms, each requiring specific recognition and management approaches:
Foreign Body Airway Obstruction:
- Most commonly caused by food items like meat, nuts, and hard lollies
- Small objects like toy parts, coins, and batteries are frequent causes in children
- When inhaled, these objects may become lodged in the upper airway (larynx or trachea) or travel deeper to the lower airway (bronchi)
Inflammatory and Allergic Causes:
- Anaphylaxis can cause rapid swelling of the epiglottis and surrounding tissues
- Infections like epiglottitis and croup lead to airway narrowing through inflammation
- Burns to the face or inhalation of hot gases can cause rapid airway swelling
Traumatic Obstructions:
- Facial or neck trauma may cause bleeding or swelling that obstructs the airway
- Fractures of the larynx or trachea from blunt force injuries
- Post-surgical swelling, especially after procedures involving the throat or neck
Chronic Conditions:
- Obstructive sleep apnoea causes intermittent airway collapse during sleep
- Tumours or growths can progressively narrow the airway
- Vocal cord dysfunction may cause intermittent obstruction during breathing
Understanding the specific type of obstruction may affect the emergency response and subsequent medical management required. For foreign body obstruction, first aid techniques like back blows and chest thrusts are appropriate, while inflammatory causes often require medical intervention to reduce swelling and maintain airway patency.
Signs and Symptoms of an Airway Obstruction
Knowing the signs and symptoms of an airway obstruction is crucial for prompt treatment. The presentation may depend on the cause and whether the obstruction is partial or complete.
Signs of Partial Obstruction:
- Noisy breathing with high-pitched sounds (stridor)
- Ability to speak, cough or breathe, though with difficulty
- Wheezing or whistling sounds when breathing
- Airflow is restricted but not completely blocked
Signs of Complete Obstruction:
- Unable to breathe, speak, or make sounds
- The universal choking signal (hands clutching throat)
- Panic or distress
- Bluish discolouration of the lips or skin (cyanosis)
- No air movement through nose and mouth
- If untreated, loss of consciousness
When someone can still cough forcefully, encourage them to continue as this may dislodge the obstruction. However, if coughing becomes ineffective or the person is unable to breathe adequately, immediate intervention is required.
How is an Airway Obstruction Treated? Step-by-Step First Aid Response for Adults
When a foreign object creates an airway obstruction in adults, follow these guidelines:
Initial Assessment and Positioning:
- Ask, “Are you choking?” If the person can’t speak, cough, or breathe, act immediately.
- Position yourself slightly behind the person.
- Support their chest with one hand and lean them forward so the obstruction may fall out rather than further into the airway.
Back Blow Technique:
- Give five back blows between the shoulder blades with the heel of your hand.
- Check after each blow to see if the obstruction has cleared.
- The aim is to dislodge the foreign bodies through the force of the blow.
Chest Thrust Procedure:
- If back blows are unsuccessful, move to chest thrusts (also known as the Heimlich manoeuvre).
- Stand behind the person and place your arms under their armpits.
- Form a fist with one hand and place it on the middle of their breastbone (avoid the lower tip of the breastbone).
- Grasp your fist with your other hand and pull sharply inward and upward.
- Perform five separate chest thrusts.
When to Alternate Techniques:
- Continue alternating five back blows with five abdominal thrusts until the object is dislodged or the person becomes unconscious.
- The combination of different pressures may help dislodge the foreign object from where it obstructs the airway.
If the Person Becomes Unconscious:
- Lower them carefully to the ground.
- Immediately call triple zero (000) for emergency medical assistance.
- Begin CPR if you are trained—chest compressions may help to clear the airway obstruction.
- When opening the airway, check the mouth for any visible obstruction and remove it if you can see it clearly.
Modified Techniques for Special Populations
Airway obstruction management must be adapted for different age groups and special situations:
Infants (under 1 year):
- Support the infant face down along your forearm with their head lower than their chest.
- Give five gentle back blows between the shoulder blades with the heel of your hand.
- Turn the infant onto their back while supporting their head.
- Give five chest thrusts using two fingers in the middle of the breastbone, about a finger’s width below the nipple line.
- Alternate between back blows and chest thrusts until the obstruction clears or help arrives.
Children (1-8 years):
- The technique is similar to adults but gentler and adjusted for the child’s size.
- For chest thrusts, use less force than for an adult.
- Never perform blind finger sweeps on children, as this may push the obstruction further into the airway.
Pregnant Women or People with Larger Body Sizes:
- For pregnant women, perform chest thrusts rather than abdominal thrusts.
- Position your hands at the centre of the breastbone rather than the upper abdomen.
- For people with larger body sizes whom you cannot reach around, have them lean forward against a sturdy chair back while you deliver back blows.
Self-Rescue Techniques When Alone:
- Call emergency services if possible.
- Use a firm, fixed object such as a chair back, table edge, or railing.
- Press your upper abdomen against the edge with quick, upward thrusts.
- Continue until the obstruction is dislodged.
- Alternatively, deliver self-administered chest thrusts by making a fist and placing it on your breastbone, then pushing inward and upward with your other hand.
After the Obstruction is Cleared
Airway obstruction follow-up is important even after the foreign body has been removed and the person can breathe normally again. The management of upper airway obstruction doesn’t end when the immediate crisis is resolved.
Signs that Require Medical Follow-up:
- Persistent coughing, gagging, or sensation of something still stuck
- Difficulty or pain when swallowing
- Chest or throat pain
- Blood in saliva or phlegm
- Symptoms of infection following the episode
Potential Complications to Watch For:
- Damage to the vocal cords or larynx from the foreign object
- Infection or inflammation in the airway
- Aspiration pneumonia if contents entered the lower airway
- Trauma from the rescue techniques themselves
When to Seek Emergency Care Even After Successful Removal:
- If there’s any doubt whether the obstruction is completely cleared
- If the person experienced a loss of consciousness, even briefly
- If there’s suspicion that part of an object remains in the airway
- For any breathing difficulties that persist after the obstruction is removed
- In cases where intubation or bronchoscopy might be needed to assess damage
Some situations may require advanced airway management techniques such as endotracheal or nasotracheal tube placement, or in rare cases, an emergency cricothyrotomy to bypass an obstruction that cannot be removed by standard methods.
Prevention Strategies
Preventing airway obstruction is always preferable to treating one. Here are strategies to reduce the risk of choking incidents:
High-Risk Foods and Proper Preparation:
- Cut round foods (like grapes and cherry tomatoes) into quarters for young children
- Avoid giving hard lollies, nuts, popcorn, and similar items to children under 4
- Be cautious with foods that are common causes of obstruction: hot dogs, grapes, hard candy, nuts, seeds, and chewing gum
Creating Safe Eating Environments:
- Encourage everyone to sit down while eating and drinking
- Discourage talking, laughing, or playing with food in the mouth
- Ensure proper denture fit for older adults, as ill-fitting dentures can contribute to choking
- Cut food into appropriate sizes, especially for those with swallowing difficulties
Special Considerations for Vulnerable Groups:
- Children: Keep small objects like coins, batteries, and toy parts away from young children
- Elderly: Be aware that aging affects swallowing coordination, increasing choking risks
- People with neurological conditions: Those with conditions like Parkinson’s disease, stroke, or cerebral palsy may need special attention during meals
- Individuals with obstructive sleep apnoea or other chronic conditions affecting the airway require additional vigilance
Understanding both the causes of upper airway obstruction and the proper response techniques ensures you’re prepared to act quickly and effectively in a choking emergency.
Frequently Asked Questions
How long can the brain survive during a complete airway obstruction?
During a complete airway obstruction, the brain can only survive 4-6 minutes before permanent damage begins. Without airflow, brain cells quickly deteriorate, making immediate intervention critical. After 6 minutes without oxygen, survival chances diminish rapidly, highlighting why quick recognition and response to airway obstruction are essential.
Can allergic reactions cause acute upper airway obstruction?
Yes, severe allergic reactions (anaphylaxis) can cause rapid airway obstruction through swelling, particularly affecting the larynx and epiglottis. This type of obstruction may develop within minutes of exposure to an allergen. Unlike foreign body obstruction, management requires immediate administration of adrenaline via an auto-injector and urgent medical assistance to help get oxygen through swollen airways.
Can croup cause an acute upper airway obstruction in children?
Yes, croup causes inflammation of the larynx, vocal cords, and trachea, potentially leading to airway obstruction in children under 5. The characteristic “barking” cough and stridor occur when airflow becomes restricted. Unlike choking on a foreign object, croup develops gradually and requires different management including humidity, cool air, and sometimes medications.
