Copyright EMAP Publishing 2018 This article is not for distribution except for journal club use
Clinical Practice Keywords Choking/Adults/Back slap/ Abdominal thrust Practical procedures This article has been Emergency care double-blind peer reviewed Choking 1: foreign-body airway obstruction in adults
oreign-body airway obstruction l Respiratory disease; Author Phil Jevon is academy manager, (FBAO) (choking) is a life-threat- l Mental impairment; Manor Hospital, Walsall Hospitals Trust. ening emergency. In England and l Dementia; Wales in 2016, 252 deaths from l Poor dentition; F l Abstract Foreign-body airway choking were reported, with almost 30% of Older age (Wong and Tariq, 2011). obstruction is a clinical emergency that these in people aged 80 years and over. Choking incidents associated with the may be life threatening. Nurses should Alarmingly, over 60% of deaths from use of pressurised metered-dose inhalers be confident to assess the severity of choking in 2016 occurred in hospitals and (pMDIs) have been reported, with patients airway obstruction, deliver interventions other healthcare settings (Office for inhaling objects including mouthpiece to relieve that obstruction and know National Statistics, 2017). covers into the back of the pharynx, when to call for assistance. This article Each year in the UK, approximately resulting in coughing and, in some cases, outlines the procedure for assessing 16,000 adults and children are treated in aspiration resulting in airway obstruction and managing adult patients with a emergency departments for FBAO (Handley (Medicines and Healthcare products Regu- foreign-body airway obstruction. et al, 2005). In 2016 in London, there were latory Agency, 2018). Since 1987, 22 cases 1,916 choking episodes of such severity that have been reported relating to accidental Citation Jevon P (2018) Choking 1: a 999 call was made to request an ambu- inhalation of inhaler mouthpiece covers or foreign-body airway obstruction in lance; 999 calls for choking generally coin- objects that have become trapped in the adults. Nursing Times [online]; 114: cide with mealtimes (Pavitt et al, 2017). inhaler (MHRA, 2018). 12, 24-26. In adults, the incidence of choking appears It is important to teach patients the cor- to increase with age (Soroudi et al, 2007). rect technique for using their inhaler, Nurses must be able to recognise and including advising them to remove the effectively treat FBAO. As most FBAO mouthpiece cover fully as well as shaking events are associated with eating, they are the inhaler to remove loose objects that often witnessed, thereby providing an may not be visible. Patients should also opportunity for early intervention while check that the inside and outside of the the patient is still conscious. mouthpiece are clear before inhaling a dose Back blows (slaps), chest thrusts and (MHRA, 2018). abdominal thrusts are manoeuvres that can increase intra-thoracic pressure and Signs of FBAO expel foreign bodies from the airway. In Recognising the signs of FBAO is the key to 50% of FBAO episodes, back blows alone early and effective intervention. The con- are effective at relieving the obstruction; text may provide important clues – for however, in 50% of cases more than one example, choking is common at mealtimes technique is needed to relieve the obstruc- or a child may have been playing with tion (Perkins et al, 2017). small objects. The most common signs and symptoms Causes of FBAO of choking are: Choking usually occurs while the person is l A cough; eating or drinking and can be associated l Struggling to breathe or talk; with muscle, neurological or cerebral l Cyanosis; impairment (Pavitt et al, 2017). Most l Grasping or reaching for the throat deaths from choking are caused by food (Perkins et al, 2015). (87%), while small objects – a particular The patient may go silent and hold or problem in children – are the cause of 13% point to their throat. of choking-related deaths (ONS, 2017). If the obstruction to the airway is only Professional responsibilities People at increased risk of FBAO include partial, the patient may be able to speak, those with any of the following conditions cough and breathe (Perkins et al, 2017). This procedure should be undertaken or characteristics: only after approved training, supervised l Altered level of consciousness; Treatment of FBAO in adults practice and competency assessment, l Drug and/or alcohol intoxication; The Resuscitation Council (UK)’s (2017) and carried out in accordance with local l Neurological impairment, with adult choking algorithm (Fig 1) (Perkins et policies and protocols. reduced swallowing and cough reflexes al, 2017) provides guidance on the treat- (for example, stroke); ment of choking in adults. If FBAO is
Nursing Times [online] December 2018 / Vol 114 Issue 12 24 www.nursingtimes.net Copyright EMAP Publishing 2018 This article is not for distribution except for journal club use Clinical Practice Practical procedures
Fig 1. Adult choking algorithm Box 1. Severity of airway obstruction
l Assess severity Mild airway obstruction (effective cough): patient able to talk and has an effective cough l Severe airway obstruction (ineffective cough): typically, patient responds “yes” by nodding their head without speaking; unable to cough effectively Severe Mild Airway obstruction Airway obstruction (ineffective cough) (effective cough) ventilations, then continue CPR until the patient recovers and starts to breathe normally (Perkins et al, 2017).
Abdominal thrusts in an obese Encourage cough or pregnant patient Conscious Unconscious Continue to check for It may be difficult to carry out abdominal 5 back blows Start CPR deterioration to thrusts on a patient who is obese or preg- 5 abdominal thrusts ineffective cough or nant. If you cannot encircle their abdomen, until obstruction stand behind the patient, position your relieved hands over the lower end of the sternum and pull hard into the chest with quick CPR = cardiopulmonary resuscitation. thrusts (chest thrusts) (Perkins et al, 2017). Source: Perkins et al (2017) Aftercare and referral for suspected, it is important to assess its dislodges the foreign body, it will medical review severity and always ask the patient “are hopefully fall out of the mouth instead Following successful treatment for an you choking?”. Their response will help of slipping further down the airway; FBAO, a foreign body may still be present distinguish between a mild or severe l If symptoms continue, deliver up to five in the airways; if someone has dysphagia, a obstructive airway, as described in Box 1. back blows (slaps) between the scapulae persistent cough or complains of having using the heel of the hand (Fig 2). something stuck in their throat, they Mild airway obstruction Following each back blow, check to see should seek medical advice. (effective cough) if the obstruction has been dislodged; Performing abdominal thrusts and Coughing generates high and sustained l If the back blows fail, proceed to chest compressions has the potential to airway pressures and may expel a foreign abdominal thrusts (Fig 3); cause serious internal injury, including body, so it is important to encourage the l Stand behind the patient, placing both ruptures or laceration of abdominal or patient to cough. A patient with mild arms around the upper abdomen; thoracic viscera, so patients must be exam- airway obstruction should remain under l Lean the patient forward; ined for injuries. continuous observation until they l Place a clenched fist between the improve as a severe obstruction may sub- patient’s umbilicus and the ribcage, Fig 2. Back blows sequently develop (Perkins et al, 2017). and clasp it with the other hand; Aggressive treatment with back blows l Deliver up to five sharp thrusts to the and chest and abdominal thrusts at this abdomen, inwards and upwards; stage is unnecessary – it may cause harm l Take care not to apply pressure to the and could exacerbate the airway obstruc- xiphoid process or the lower ribcage as tion. These interventions should only be this may cause abdominal trauma; used if the patient shows signs of severe l If the obstruction remains, alternate up airway obstruction (Perkins et al, 2017). to five back blows with up to five abdominal thrusts. Severe airway obstruction If the patient loses consciousness you (ineffective cough) should: If the patient shows signs of severe airway l Carefully support them to the ground; Support the patient’s chest with one obstruction: l If you have not done so already, hand and lean them forward – this may l Call for help/pull the emergency buzzer summon help following local protocols dislodge the foreign body. If symptoms immediately and encourage the patient – call 999 for an ambulance or contact continue deliver up to five back blows to cough; your cardiac arrest team; (slaps) between the scapulae using l Stand at the patient’s side, slightly l Start cardiopulmonary resuscitation the heel of the hand. After each blow, behind them; (CPR) – do 30 chest compressions first check whether the obstruction has l Support the patient’s chest with one as these may relieve the obstruction; been dislodged. l PETER LAMB PETER hand and lean them forward – if this After 30 compressions, attempt two
Nursing Times [online] December 2018 / Vol 114 Issue 12 25 www.nursingtimes.net Copyright EMAP Publishing 2018 This article is not for distribution except for journal club use Clinical Practice For more articles on respiratory care, go to Practical procedures nursingtimes.net/respiratory
external defibrillators. Resuscitation; Suppl 1, S7-23. Fig 3. Abdominal thrusts Medicines and Healthcare produces Regulatory Agency (2018) Pressurised Metered Dose Inhalers (pMDI): Risk of Airway Obstruction from Aspiration of Loose Objects. Bit.ly/MHRAInhalers Office for National Statistics (2017) Number of Choking Deaths by Placement of Occurrence and Age, Registered in England and Wales 2014 to 2016. Bit.ly/Choking2016 Pavitt MJ et al (2017) London ambulance source data on choking incidence for the calendar year 2016: an observational study. BMJ Open Respiratory Research; 4: e000215. Perkins GD et al (2015) European Resuscitation Council Guidelines for Resuscitation 2015: section 2. Adult basic life support and automated external defibrillation.Resuscitation; 95: 81-99. Place a clenched fist between the patient’s umbilicus and the ribcage and clasp it with Perkins G et al (2017) Adult Basic Life Support and the other hand. Deliver up to five sharp thrusts to the abdomen, inwards and upwards. Automated External Defibrillation. Bit.ly/RCUK ChokingResus Soroudi A et al (2007) Adult foreign body airway obstruction in the prehospital setting. Prehospital Use of airway clearance devices Conclusion Emergency Care; 11: 1, 25-29. Wong SC, Tariq SM (2011) Cardiac arrest following Although there are several airway clearing FBAO is a life-threatening emergency that foreign-body aspiration. Respiratory Care; 56: 4, devices for the treatment of FBAO cur- nurses must be able to recognise and effec- 527-529. rently available, their routine use is not tively treat. recommended by the Resuscitation The management of FBAO in infants CLINICAL Choking series Council (UK) (Perkins et al, 2017). However, and children will be described in part 2 of SERIES appropriately trained health professionals this series. NT Part 1: Foreign-body airway obstruction can use advanced techniques – such as suc- in adults Dec References tion or laryngoscopy and forceps – to Foreign-body airway obstruction Handley AJ et al (2005) European Resuscitation Part 2: remove a foreign body from the airway Council Guidelines for Resuscitation 2005. Section in infants and children Jan
PETER LAMB PETER (Perkins et al, 2017). 2: Adult basic life support and use of automated
Your digital magazine
Access exclusive subscriber-only content with all the features you expect to see in print, in a convenient email format
Feel confident you have the resources you need – anywhere, anytime and on any device
Not received this new email? If you do not receive your Nursing Times Weekly every Wednesday, speak to our friendly customer services team who are always on hand to help by calling 0203 953 2000
Nursing Times [online] December 2018 / Vol 114 Issue 12 26 www.nursingtimes.net