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Obstructed Airway


As was mentioned in "Respiratory Distress" a partially restricted airway can also be completely obstructed by swollen anatomy or by a foreign body.  Once the airway is completely obstructed the patient can not make any sounds, can not breathe and will soon lose consciousness. 

Imagine, if you dare, how frightening this must be.  This person is unable to explain their "problem," can't ask for help, can't breathe, is about to die, and is conscious enough to KNOW it.  Now imagine how comforting it would be to have someone (anyone) walk up to them at that very moment, look them in the eyes (which, incidentally, are just "alive" with genuine FEAR,) and assure them that they understand the problem and they CAN help.

So...... Choking patients come in two distinct "flavors," conscious and unconscious.  They also come in three different sizes, adults, children, and infants.  We'll talk about how to handle each of the possible combinations of "flavor" and size.

What's important to realize, here, is that respiratory arrest  (not breathing) ultimately leads to cardiac arrest (not pumping.)  There are some time-related concepts that you should be aware of, regarding respiratory and cardiac arrest.  About 5 minutes (more or less) after a person stops breathing the heart will stop beating, this patient is "clinically" dead ("clinical" death can be reversed, and the patient can be saved.)  During the next 4-6 minutes (after the heart stops) cellular damage in the brain is starting (still considered "clinically" dead,) and 4-6  minutes later (approximately 10 minutes after the heart stops beating) enough brain damage has occurred to render the patient biologically dead (biological death is irreversible.)   Doing a little mathematics, we find that the patient has about 15 minutes from the time that the blockage occurred to irreversible death.  This adds a tremendous amount of importance to your ability to act appropriately (as a rescuer, on the scene) because it will most likely take at least 15 minutes to get volunteer/professional rescuers to this patient.  By the time the "squad" arrives, the patient will be biologically dead.  You, however, having been properly trained in an accredited CPR class, will be able to save a life because you will be THERE during the period of clinical (reversible) death.

Let's start with the Adults.

Foreign Body Airway Obstruction (FBAO) - Conscious Adult

An adult according to guidelines suggested by the American Heart Association® is any patient that is over 8 years old.

It goes without saying that most conscious choking adults (at least most of those significantly older than 8 years of age) probably find themselves in a restaurant or at a dinner party when the "dirty deed" occurs.  They've been eating, drinking alcohol and; in general, having a real good time (laughing and conversing with the other  people at the table.)  Alcohol, inattention to the "eating process," and talking/laughing while eating are three factors that contribute greatly to the choking event.  And, it is very likely, that the choking individual, now having realized that they are choking, will quietly leave the table and go off to the bathroom because they are afraid that they may vomit, and embarrassment dictates that they MUST leave the table to do that.  This, unfortunately, leaves them in the bathroom, with no one to help, where they will eventually die, if nothing is done.  If you are at a party, and one of the people at your table, suddenly becomes very quiet, and leaves the table.  INVESTIGATE.  Some people, however, may have enough common sense (or maybe they took a CPR class) to indicate that they are choking by displaying the internationally recognized "Universal Choking Sign." No really, there is one.  Just follow the link to an illustration of what the choking sign looks like.

Having identified the "choking patient," you really need to get their permission to help (can you believe it?)  You see, what you are about to do might actually break a couple of ribs.  That hurts, and that pain is going to be there after the airway is cleared.  The patient now has time to think, and decides to sue you because you left them in pain.  And so, you ask the patient, "Are you choking?"  The direct approach is always the best.  Don't ask them any other question.  We don't have a lot of time before this patient will pass out, and to be quite blunt, you really don't care if they "feel alright?" or if they "can breathe?"  If, after being asked, they say "Yes I'm choking, and it's the worst thing that has ever happened to me!  Now, do something! Get this obstruction out!"  Please don't do anything.  This patient is NOT choking.  THEY'RE TALKING!  If they are making a high pitched "whistling" sound (called stridor,) it appears that they are moving air in and out of their lungs, and their facial color is generally good.  Do not intervene.  Encourage them to try and cough the obstruction out, while also encouraging them to take slow breaths.  Assure them that the minute that they "need" help, you will be there.  If they are making no sound, or you hear some stridor but their facial color is kind of gray or blue, you're going to need to do the Heimlich Maneuver. (Here's where that permission thing comes in.)  Having just asked them, "Are you choking?"  Follow it immediately with, "Can I Help?"  If the patient is stupid enough to indicate "NO," don't be foolish.  Do nothing.  They will soon pass out.  Common Law and Civil Law both agree that an unconscious patient does NOT WANT TO DIE, and their consent is implied (even if they just refused help, the law says that they "changed their mind," right before they passed out, but they didn't have time to tell you.)  So if they are unconscious you don't need to ask for permission and we will discuss how to handle an unconscious patient a little later.  Back to our conscious patient, who has been identified as choking (Are you choking?) and has consented to allow you to help (Can I help?)  You need to perform the Heimlich Maneuver.  Position yourself behind the patient.  Remember, he/she might pass out at any moment.  Be prepared for that eventuality by placing your foot between the feet of the patient and stepping back a half step with your other foot.  This will place you in a stance that is very stable and if the patient suddenly passes out, you will be able to maintain control.  With your arms around the patient's waist, place the "thumb side" of your strong hand (left or right) in the patient's abdomen just slightly above the belly button then place the palm of the other hand on your strong hand.  (Look here.)  From this position, you are going to pull your hands inward and upward.  Imagine trying to hit yourself in your own chin, with the patient positioned in front of you.

Let me see if I can explain what it is we are trying to accomplish here.  There is a large flat muscle called the diaphragm between the belly and the chest.  It's attached to the bottom of the lungs and at rest is in the shape of a flat, wide, upside  down "U."  When we take a breath, it "flattens" and pulls the "floor" of the lungs down.  This process is supposed to pull air into the lungs and starts the first half of a respiratory cycle (inspiration.)  This patient has literally "sucked" something into the windpipe and as hard as that diaphragm might try, it just cannot get any air past the obstruction.  What we want to do is push that muscle back up toward the lungs and try to "pop" the obstruction out of the airway.  Imagine, if you will, a partially inflated balloon.  I plug the neck of the balloon with a small cork, then suspend the balloon from my hand by holding it by the neck, and I invite you to clap your hands around the body of the balloon with as much force as you can muster.  Can't you just "see" the cork being popped out of the neck of the balloon as your hands come together with the body of the balloon between them?  By increasing the pressure inside the balloon we were able to "pop" the cork.  By pushing upward on the diaphragm we hope to increase the pressure inside the lungs and consequently, pop the obstruction out of the airway.  Have faith, this is a very effective maneuver.  There are literally thousands of people walking around today, thanking Dr. Heimlich for his inspiration (...pardon the pun.)  You are going to repeat the process of abdominal thrusts about 5 or 6 times (or until the obstruction has been cleared) and then ask the patient, "Are you still, choking?"  LOOK at the patient for an answer.  I say this because we have just spent the last few seconds forcing ALL the air out of the patient's lungs.  They may not be able to speak yet (because they are, quite frankly, more interested in replenishing the oxygen supply in their lungs, and hence the blood stream, than they are in talking.)  It is quite likely that they will just nod (affirmatively or negatively) to indicate their present condition.  Act appropriately.  Continue with another 5 or 6 trusts if they are still choking, discontinue if they are not.  There is one other possible outcome to your question, and that is, that the patient does not "respond" at all.  It is quite possible that the patient has passed out. 

And so, on to the second "flavor."

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FBAO - Unconscious Adult

If this patient were to suddenly become unconscious, or if the patient were found unconscious, the first thing that any concerned rescuer would do (after assuring that the airway was in the proper position [see "Hyperextension"] and that the patient was not breathing,)  would be to attempt to inflate the patient's lungs.  In the absence of any medical equipment, this would mean performing artificial respiration (mouth-to-mouth,  or mouth-to-mask ventilation)  This brings to light a whole subject regarding placing oneself in jeopardy of contracting some communicable disease as a result of the minute fluid exchange that occurs between rescuer and patient during artificial respiration in the absence of some sort of barrier device (a mask, with a one-way valve.)  If this patient is a family member, or a VERY close personal friend, then the concern regarding disease transmission is probably not an issue.  If, however, this patient is unknown to the rescuer, the use of a barrier device is imperative.  Without that device, I would consider this scene as "unsafe" and my first move would be to retreat to the nearest phone to call 9-1-1.  Let's assume that, at the first aider level, you will be dealing mostly with people that you know, and further assume that there is no reason to be concerned about disease transmission. 

Okay, having properly positioned the head (hyperextension) and having assured yourselves that the patient is not breathing, you should attempt to ventilate this patient while kneeling next to the patient's head, by placing your mouth over the open mouth of the patient, pinching the patient's nose closed with the fingers on the hand closest to the patient's forehead and holding the patient's chin with the hand that is closest to the patient's chest.  Your goal is to form a "seal" between your mouth and the mouth of the patient, by opening your mouth very wide and placing your lips on the left and right cheeks of the patient.  If the seal is good, when you exhale into this patient, you will "feel" the lungs comply to your effort and will probably see some chest movement as air fills the lungs of the patient.  If, however, you feel as though you are blowing into a glass jar (no compliance, no chest movement) in spite of a real good seal, then it is possible that the airway is obstructed (hey, no kidding.  That was, after all, the title of this page.)  Just to be certain that you have performed all the steps correctly, let's do all of them again, from the beginning, up to and including the attempt to ventilate the patient, before taking any action.  And so, head position, not breathing, kneeling next to head, pinch nose, hold chin, good seal, breathe into patient. (Mouth-to-Mouth Illustration)  And the outcome?  GLASS JAR.  We are now certain that we have an unconscious adult with an obstructed airway. Turn to the person that is closest to you, look them square in the eyes and say, "You, go call 9-1-1, we need an ambulance for an unconscious adult.  Then come back and let me know that it was done."

At this point, you should straddle the patient.  On your knees, with your legs astride the patient's hips.  Position the heal of your strong hand in the abdomen of the patient, just above the belly button, your other hand on top of the first, and thrust inward and upward (sound familiar?) in an effort to bump the diaphragm, force air out of the lungs, and pop the obstruction out of the airway (Yet another Illustration.)  Perform these thrusts about 5 or 6 times or until the obstruction comes out.  Because this patient is unconscious, we can not ask them if they are still obstructed (choking.)  They only way we will know that the obstruction has been removed (short of watching it fly out of the patient's mouth) is if we are able to get air into the patient's lungs.  As a result, the next step in the process would be to attempt to inflate the patient's lungs.  If it works, we've cleared the airway and we'll talk later about what happens next.  If it doesn't work.  GLASS JAR.  Start the process again from the beginning head position, not breathing, kneeling next to head, pinch nose, hold chin, good seal, breathe into patient. Still a glass jar?  Continue with 5-6 abdominal thrusts and just continue the process until the airway is clear or the ambulance shows up.  If the airway has been cleared, then we need to do two things, check to see if the patient is breathing, and look for other signs of life.  From this point, the information needed to continue with this patient would appropriately be part of a CPR course, if the patient displays no other signs of life.  Another page in this site will deal with the concepts of Cardiopulmonary Resuscitation.  If the airway is clear and the patient shows signs of life (spontaneous respirations, eyelid flutter, improved facial color, etc.,) then you have just saved a life!  It's a neat feeling.  Stay with the patient, keep them calm and quiet, and wait for the ambulance to arrive.  Once the ambulance crew has taken charge of the patient, then (and only then) you may do the "I just saved a life VICTORY DANCE."  There's no special format to the dance, you just run around like a idiot shouting, "I just saved a life, I just saved a life."  Don't worry about how you look to other people, it's not important.  And besides, every Basic Life Support Provider (EMT) and every Advance Life Support Provider (Paramedic) in the area, that sees you doing this "victory dance" will just smile, knowingly.

There is just one other "adult" choking patient that must be discussed.  It is the pregnant woman who has just blocked her airway.  This particular pregnant woman is not just "a little pregnant," no, she's in her second or third trimester.  She's pregnant enough that she doesn't even have to tell you that she's pregnant.  Of course, if she COULD tell you that she was pregnant, then she wouldn't be choking.  But, at any rate, she is pregnant, she is choking and she needs help.  To do abdominal thrusts on this lady, would only risk injuring the baby and the position of the baby would reduce the effectiveness of the abdominal thrusts against the diaphragm.  In this instance, we need to perform chest thrusts, by placing the thumb side of our strong hand on the sternum (that's the flat bone in the center of the chest,) just slightly below a line drawn between the nipples (an inter-mammary line.)  We then place the other hand on top of the strong hand ( this looks exactly like the abdominal thrust, it is just higher on the body) and instead of thrusting inward and upward, as we did when doing abdominal thrusts, we thrust straight back.  Displacing the patient's sternum, and possibly breaking it, reducing the size of the chest cavity, increasing the pressure in the lungs, and hopefully popping the obstruction out of the airway.  What we are doing here is crushing the chest of a conscious patient.  In all my years of emergency medical service, I never had to perform this procedure on a pregnant woman, and, for that, I am thankful.  If this patient becomes unconscious, all of the information offered above in the section entitled "FBAO - Unconscious Adult" is appropriate for this patient, except, the thrusts are performed on the sternum instead of the abdomen, again, to protect the baby and to avoid the ineffective abdominal thrusts with the baby in the way.

If this is a male patient, who just looks pregnant, then there is a possibility that you might be unable to "get around the equator," so to speak, because there's just too much patient and not enough arm length.  In this case, it would be wise to move north, do chest thrusts as described above.  If the patient becomes unconscious, you will have to evaluate the effectiveness of abdominal thrusts, considering the amount of body fat that is between your hands and the patient's diaphragm.  If you feel that the effectiveness of those thrusts is being compromised, then you will need to resort to chest thrusts.

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Hey! How about the Kids.

FBAO - Conscious Child

A child according to guidelines suggested by the American Heart Association® is any patient that is more than one year old and less than 8 years old.

In other areas of emergency medicine, we are cautioned by our instructors not to refer to children as "little adults."  Because in other areas of emergency medicine, children do not react the same way that adults react.  However, in this instance, (Foreign Body Airway Obstruction) the procedure for clearing the airway of an obstructed child is the same as the procedure used for an adult, with one exception.  We use less force on the child, because (dare I say it?) they are just "little adults."  So take a look at the illustration, and I think you'll agree that all of the foregoing text explaining the procedure for an adult patient need not be repeated here. 

FBAO - Unconscious Child

A child according to guidelines suggested by the Ame...  Wait a minute.  This sounds very familiar.  oooo - Deja Vu...  Hey listen the unconscious kid (uh.. child) is the same as the unconscious adult, because they are just little adults (every one of my instructors just shivered, I'd say they all turned over in their graves, but they ain't dead yet.)  Just use less force.  Look at the illustration for an unconscious choking adult, imagine that the patient is much shorter, understand that instead of "straddling the patient's hips," our knees may actually be as low as "straddling the patient's feet" (depending on how short the patient actually is.)

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FBAO - Infant

An infant according to guidelines suggested by the American Heart Association® is any patient that is less than one year old.  This is actually a very small portion of the population and consequently, there is only a small chance that you, as a first aide provider, will actually encounter a choking infant.

First of all, understand that this patient (less than a year old) will not respond appropriately to the question "Are you choking?  You are going to have to evaluate this situation (or potential situation, or envisioned situation, or created situation, or planned situation) by different methods.  You are going to have to rely on your powers of observation and your ability to "assess" the patient through the apparent "signs" that are available.

In order to understand how a choking infant will "present" (that's medical jargon for "what they're going to look like" and "how they're going to react,") you need to know a little about hypoxia and the reaction of the body to hypoxia. 

According to the On-Line Medical Dictionary hypoxia is defined as:  "Reduction of oxygen supply to tissue, below physiological levels despite adequate perfusion of the tissue by blood."  In layman's terms, the blood (for a number of reasons) isn't carrying enough oxygen to satisfy the demand at the cellular level.

Of interest here, is the fact that infants do not react to hypoxia the way we would expect.  Let's discuss what we would expect, first, then discuss how an infant is different.

To best understand the adult reaction to hypoxia, I'll ask that you look into your own past a little.  Think back to a time when you had a rather significant head cold. Jew  jus couldid breed tru jawr doze ad awl.  Your sinuses were completely blocked and breathing seemed to be an effort.  At bedtime, you took some Benedryl,™ or maybe some of the "nighttime, sniffling, sneezing, coughing, aching, stuffy head, fever, so you can rest and have a good day" medicine (you know, Nyquil.™)   At any rate, the Benedryl,™ and the "nighttime, sniffling, sneezing" part of Nyquil,™ are the same generic drug.  Diphenhydramine Hydrochloride, a very effective antihistamine, stops the sniffling and sneezing because it stops the runny nose.  This drug also has a major sedative effect (that means it puts you to sleep.)  This side effect is so dramatic that the drug is marketed under other names (like Nytol,™ Sominex,™ and others) to help induce sleep.  The next time you're in a pharmacy, look at the labels on some of the over the counter medications for colds and medications for sleep.  You'll find that most have diphenhydramine hydrochloride as one of the ingredients.  So...back to your cold.  You take some of this diphenhydramine stuff and get into bed and fall asleep almost immediately.  After a short time, because you are having trouble breathing through your nose, you subconsciously open your mouth to breath.  After a short period of mouth breathing, during which time you actually fall into a deeper sleep (aided by the medication,) your mouth becomes very dry, and subconsciously you close it to moisten your lips, tongue, and the lining of your mouth.  Because you are in a state of deep sleep, you will probably not re-open your mouth, and you enter a state called "sleep apnea" (a state where a sleeping person stops breathing.)  Hypoxia starts to develop and the oxygen level in the blood starts to drop.  Sensors in the blood stream, monitoring oxygen levels, tell the brain that oxygen is needed in the blood, and the brain begins the reaction to hypoxia.  First reaction is to increase the respiratory rate (or number of breaths per minute.)  Well now, let's see.  You're breathing at a rate of zero (0,) let's assume that the body doubles the breathing (respiratory) rate.  Two times zero equals zero (2X0=0.)  The respiratory rate has not increased and the level of oxygen in the blood continues to drop.  The brain shifts into second gear and reacts by instructing the heart to beat faster (the second of three reactions to hypoxia.)  A resting pulse of 60 may go as high as 120.  But the breathing rate is still zero and consequently, the body is just circulating blood (without oxygen) around the body more rapidly.  The amount of oxygen in the blood continues to drop and the brain employs the third of three reactions to hypoxia (in an adult,) and that is, to raise the level of consciousness.  At this point, you sit bolt upright in bed, open you mouth, "suck" in as much air as you possible can, you feel your little heart just a-thumpin' away, and your level of consciousness has just "broken through" the sleepiness caused by the diphenhydramine hydrochloride.  You ARE experiencing the effects of hypoxia in the normal adult body.  To recap.  They are:  1. Increased respiratory rate.  2. Increased heart rate.  3. Increased level of consciousness.  (Return to Apnea)

Now the babies.

The normal reaction to hypoxia in a small infant is exactly the opposite of what it is in an adult.  There is a DECREASED respiratory rate, a DECREASED heart rate and a DECREASED level of consciousness.  The baby has not yet developed the "self-protective" mechanism necessary to increase those vital signs.  What this means is that you will NOT see these eyes filled with "genuine FEAR," as you did when you looked into the eyes of the conscious choking adult.  Because babies (and children) are NOT little adults, you may not see a blue/gray complexion, because the kids (babies and children) "compensate" longer and are able to keep body functions within normal limits longer than adults and subsequently do not show signs of deterioration during an event as early on as adults.

What does all of this mean to YOU?  It means that when assessing a baby, look very carefully for breathing effort, and if you don't see it, but the baby "seems" to be okay, and the baby "seems" to look okay, there is a good possibility that, if the baby is not breathing at a depth and a rate that you can see,  that the baby is indeed NOT BREATHING in spite of the fact that the baby looks fine.  Act accordingly.

For a baby that is obstructed, we will not be performing abdominal thrusts.  The vital internal organs are positioned very close together in this patient.  Those organs have not yet "migrated" into their final positions in the body.  It is very likely that the liver is not exactly where you might expect it to be or the gall bladder might be closer to the kidneys than you thought.  And, besides, your hand in comparison to the size of the baby is monstrous.  We need another way to create increased pressure in the lungs of this baby.  We will be performing "back blows" and "chest thrusts" on this baby, instead of the abdominal thrusts that we did on the adult and child.  A picture is worth a thousand words.  Take a look. Notice that the baby is positioned on the arm of the rescuer, stomach against the rescuer's arm for half of the procedure (back blows) then turned over, with the baby's back against the rescuer's arm for the second half of the procedure (chest thrusts.)  The back blows are intended to deliver a significant blow to the baby's back using the heal of the rescuer's hand and placing the blow on the baby between the shoulder blades high on the back (where we are less likely to damage the baby's tender little spine.)  The chest thrusts are intended to depress the baby's sternum (the flat breast bone in the center of the chest) enough to compress the lungs and increase the pressure in the lungs, hopefully popping the obstruction out of the airway.  Both procedures, back blows and chest thrusts, are performed with the baby's head slightly lower than the rest of the baby's body.  Do 4 or 5 back blows, followed by 4 or 5 chest thrusts and repeat the cycle until the obstruction is removed or you are relieved by the emergency medical squad.  Please note that the procedure is the same, whether the baby is conscious or unconscious.  Your "follow-up," after the procedure is, however, different.  If conscious, and the airway is subsequently cleared by either the back blows or the chest thrusts, the baby will start crying.  (Heck, you've just been "beatn' the bejabbers outa the little thang.)  If you found the baby and it was unconscious before the attempts to clear the airway, your first effort, before any back blows or chest thrusts would be to try and ventilate the baby using a mouth to mouth-and-nose technique (your mouth is large enough to cover the baby's mouth and nose, No! that's not an editorial on how LOUD you are.)  If your attempt to ventilate this baby is initially unsuccessful you should re-evaluate the position of the baby's head and try the ventilation again.  If still unsuccessful, then the back blows and chest thrusts are next.  Just a word about the position of the baby's head.  Unlike adults and children, babies have VERY flexible airways.  Consequently, this baby's head should not be hyperextended.  That position may actually block the airway.  The position of choice here is described as a "Neutral Position."  With the baby on your arm and the back of the baby's head in the palm of your hand, the whole package should "look" straight.  Another way to evaluate this "neutral" position is to look at the baby's nose and make sure that an imaginary line drawn from the tip of the baby's nose, through the tip of the baby's earlobe, is at right angles to the baby's spine (back.)  After completing 4-5 back blows and 4-5 chest thrusts on this unconscious baby, attempt to ventilate the baby again.  If unsuccessful, evaluate the head position again, and re-attempt the ventilation.  More back blows and chest thrusts are in order, if the second attempt is unsuccessful.  Continue this process until you are successful, or until relieved by the emergency medical team.

None of the foregoing is intended to replace an accredited CPR class.  In such a class, the student is offered the opportunity to practice on manikins, under the watchful eye of an instructor.  The learning experience is not only more complete, in a class, but also more lasting.  Enroll today, before any of this is needed.

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Last updated: 02/23/15.