Learning Objectives for this training:

• Define choking
• Review signs and symptoms of choking
• Identify chronic conditions which increase risk
• Identify foods known to increase risk of choking
• Identify types of medications known to increase risk of choking
• Identify signs and symptoms of someone who may be choking
• Identify health care professional who is able to assess swallowing
• Identify behaviors that may increase risk of choking
• Identify steps which can be taken to prepare for a choking emergency

Choking Definition

Choking can be defined most simply as "an obstructed airway" and may be caused when:

• A foreign body obstructs the airway.
• Food and/or a combination of food and drink obstructs the airway.

Choking can be:

• Due to an intentional or unintentional act.
• Partial or complete.
• Related to age or other chronic neurological and neuromuscular conditions.

Increased Risk of Choking is Associated With:

• History of choking
• Poor oral health
• Swallowing issues/Dysphagia
• Neurological and neuromuscular conditions
• Certain medications (such as those that cause dry mouth, drowsiness, or affect muscle control)
• Being 65 years or older
• Lack of appropriate supervision
• Certain behaviors (such as eating too quickly, overstuffing the mouth, or talking while chewing)
• Certain foods and eating texture

Dysphagia - Difficulty Swallowing

Dysphagia is a symptom of an underlying disease or condition. It is not a disease in and of itself.

Dysphagia increases risk for:

• Dehydration
• Malnutrition
• Aspiration Pneumonia
• Choking (of food or liquid)

A Speech Language Pathologist (SLP) is the health care professional who is able to assess swallowing (dysphagia).

Chronic Conditions and Choking Risk

Chronic conditions which increase the risk of choking include:

• Cerebral Palsy
• Prader-Willi Syndrome (PWS)
• Alzheimer's Disease/Dementia
• Parkinson's Disease
• Developmental Disabilities
• Gastroesophageal reflux disease (GERD)
• Head or Neck Cancer
• Multiple Sclerosis
• Stroke

Medication and Choking Risk

Certain medications can increase the risk of choking:

• Medications that cause excessive dry mouth, such as:
  • Antidepressants
  • Antipsychotics
  • Diuretics
• Medications that cause drowsiness (sedation) or affect muscle control (e.g. anti-seizure, antipsychotic, muscle relaxants)
  • Decreased ability to respond to choking
  • Decreased alertness to eat safely

Behaviors that Increase Risk

Behaviors that increase the risk of choking include:

• Eating too quickly
• Overstuffing the mouth with food
• Talking or laughing while chewing
• Being distracted while eating
• Running, walking, or playing while eating
• Not sitting up while eating
• Lying down right after eating (which can increase risk of aspiration)

Foods with Increased Risk

Foods known to increase the risk of choking include:

• Tough or fibrous foods, such as:
  • Raw vegetables (celery, carrots, broccoli)
  • Certain meats (steak, tough chicken)
• Round or tube-shaped foods, such as:
  • Hot dogs
  • Grapes
  • Hard candies
• Sticky or cohesive foods, such as:
  • Peanut butter
  • Caramels
  • Chewy candies
• Dry, crumbly foods, such as:
  • Chips/crisps
  • Dry cereal
  • Cracker products
• Compressed foods, such as:
  • Meats (compressed deli meat)
  • Certain breads (white bread which can form a sticky bolus)
  • Certain cheeses (string cheese)

Signs and Symptoms of Choking (Partial Obstruction)

Signs of a partial obstruction:

• Coughing forcefully or weakly
• Gagging
• Wheezing or noisy breathing
• Difficulty speaking
• Individual clutches throat
• Individual looks fearful or panicked

A person who can cough forcefully and speak may have a partial obstruction.

Signs and Symptoms of Choking (Complete Obstruction)

Signs of a complete obstruction:

• Cannot speak, cry, or cough at all
• Silent cough
• Individual clutches throat
• Bluish discoloration of skin (bluish or dusky lips, nail beds, earlobes)
• Loss of consciousness

A person who cannot speak, cry, or cough at all has a complete obstruction.

Actions to Take in a Choking Emergency

What to do if someone is choking:

• Call for help immediately (911)
• If the person can cough forcefully, encourage them to continue to cough.
• If the person cannot cough forcefully:
  • Follow training protocol for abdominal thrusts (Heimlich Maneuver)
• Follow training protocol for unconscious choking if the person loses consciousness

How to Prepare for an Emergency

Steps which can be taken to prepare for a choking emergency:

• Have an emergency plan for choking (and other emergencies) posted and reviewed
• Have a list of emergency contacts, including local medical providers, posted
• Be trained in CPR and first aid for choking emergencies (Heimlich maneuver)
• Know the individual's food restrictions and dysphagia diet

Reducing the Risk of Choking

Steps which can be taken to reduce the risk of choking:

• Sit upright while eating.
• Ensure proper positioning (if needed, use supportive seating).
• Provide appropriate assistance and supervision during meals.
• Cut food into small, manageable pieces (no larger than a thumbnail size).
• Monitor the person's mouth to ensure food is cleared before offering another bite (pocketing food).
• Ensure dentures are clean and fit properly.
• Encourage the person to eat slowly and chew thoroughly.
• Refer the person to a Speech Language Pathologist (SLP) for a swallowing assessment if there is a concern.
• Ensure a health care provider reviews all medications for possible side effects that may affect swallowing.
• Follow a physician ordered dysphagia diet (if applicable).
• Have suction equipment readily available if ordered by a physician.

Tips for Texture Modification

Follow the Dysphagia Diet provided by the SLP or physician.

Techniques to modify food texture include:

• Blending or pureeing foods
• Adding liquid to dry foods (sauce, gravy, broth)
• Cutting foods into appropriate sizes (less than a thumbnail)
• Moistening dry foods
• Not serving foods that easily crumble or are sticky/chewy
• Using commercial thickeners for liquids to achieve a nectar, honey, or pudding consistency as ordered by a physician.
• Removing tough, stringy, fibrous parts of food (e.g., celery strings, fruit skins)

References

• Centers for Disease Control and Prevention. (2020). Choking Hazards. [link]
• Prader-Willi Syndrome Association (USA). (2016). Choking, Skin Picking, and Vomiting. [link]
• Reilly, J. J., & Kilgour, T. (2008). Energy requirements of children with cerebral palsy: a systematic review. Developmental medicine and child neurology, 50(6), 398-405. [link]
• Stevenson, D. A., Heinemann, J., Angulo, M., Butler, M. G., Loker, J., Rupe, N., Kendell, P., Clericuzio, C. L., & Scheimann, A. O. (2007). Deaths due to choking in Prader-Willi syndrome. American journal of medical genetics. Part A, 143A(5), 484–487. [link]
• Thacker, A., Abdelnoor, A., Anderson, C., White, S., & Hollins, S. (2008). Indicators of choking risk in adults with learning disabilities: a questionnaire survey and interview study. Disability and rehabilitation, 30(15), 1131-1138. [link]
• Tippett, D. (2020). Treatments tests and therapies: Dysphagia: What happens during a bedside swallow exam. [link]