Chapter 5: Choking

What Can Happen

At lunch in a care home, a care worker is helping at a table where several residents are eating. A woman in her eighties, who usually chats happily through meals, suddenly goes quiet. She puts down her fork, her hands go to her throat and her face shows panic. She opens her mouth, but no sound comes out. The care worker sees this from across the table. What happens in the next moments depends on the care worker recognising the signs and acting at once.

Choking happens when food or an object blocks the airway, the passage that carries air to the lungs. Older people and many people who receive care are at higher risk, because swallowing can become weaker with age and with some health conditions, and because loose dentures, tiredness, eating quickly or eating while lying back all add to the risk. This chapter explains how to tell mild choking from severe choking, how to help a choking adult step by step, and how to help a person who is sitting down or in a wheelchair. It then looks at how good mealtime care prevents choking, and at what to do after a choking episode, because the person should always be checked afterwards.

Mild and Severe Choking

In mild choking, the airway is only partly blocked. The person can cough strongly, can speak or make sounds, and can breathe, even if the breathing is noisy. The face may go red and the eyes may water. A strong cough is the body's best way to clear the airway, so the most helpful thing you can do is to encourage the person to keep coughing and to stay close. Do not hit the person's back or reach into the mouth while the person is coughing well, because you could move the object further into the airway.

In severe choking, the airway is blocked or almost blocked. The person cannot speak and cannot breathe, or can only make a high, squeaking sound, and the cough becomes weak or silent. The person may grip the throat with one or both hands, which is a common sign of choking. The lips and face may turn grey or blue, and the person will become drowsy and lose consciousness if the airway is not cleared. Severe choking is an emergency, and you need to act straight away. While a person is choking, do not offer a drink to wash the food down, and do not help the person to lie down while they are still awake, because a drink can block the airway further and lying down makes coughing harder.

A simple question helps you to tell the difference. Ask the person, "Are you choking?" A person with mild choking can usually answer you or keep coughing. A person with severe choking may nod but cannot speak. If the person nods and cannot speak or cough effectively, start the steps for severe choking at once.

Some people you support cannot easily tell you that they are in trouble. A person with dementia, a person who does not speak, or a person with weak muscles may choke quietly, without the strong cough or the hands at the throat. Watch for sudden silence during a meal, a change in colour, watering eyes, drooling, a frightened look, or a person who stops eating and becomes restless. When you are in doubt, go to the person and check. It is always better to check and find nothing wrong than to miss a quiet emergency.

Step by Step: Helping a Choking Adult

Step 1. Ask the person, "Are you choking?" If the person can cough, speak and breathe, encourage the person to keep coughing, and stay close. Keep watching, because mild choking can become severe. If the cough becomes weak, or the person cannot speak or breathe, go on to the next steps at once.

Step 2. Shout for help and ask someone to call the emergency number and come back to tell you that the call has been made. If you are alone, start helping the person at once, and if the blockage does not clear quickly, call the emergency number with your phone on speaker while you keep helping. Your workplace's procedures will also say who brings the first aid kit and the defibrillator.

Step 3. Stand to the side and slightly behind the person. Support the person's chest with one hand and help the person lean well forward, so that the object can come out of the mouth rather than move further down. With the heel of your other hand, give a firm blow between the shoulder blades. Check after each blow whether the object has come out, and stop as soon as it has. Give several blows if needed, as your course teaches.

Step 4. If back blows do not clear the blockage, give abdominal thrusts. Stand behind the person and put your arms around the upper part of the person's abdomen, with the person still leaning forward. Make a fist with one hand and place it, thumb side in, between the navel and the bottom of the breastbone. Hold your fist with your other hand and pull sharply inwards and upwards. Check after each thrust whether the object has come out.

Step 5. Some courses teach chest thrusts instead of abdominal thrusts for adults, and many courses teach chest thrusts for a person who is heavily pregnant or too large for you to reach around. For chest thrusts, you stand behind the person, place your fist on the lower half of the breastbone, hold it with your other hand and pull sharply straight back towards you. The methods differ a little from place to place, so follow the method taught in the first aid course where you live.

Step 6. If the blockage has still not cleared, keep alternating back blows and thrusts as your course teaches, checking each time whether the object has come out. Make sure that the emergency number has been called, and if you are alone and have not yet called, call now with your phone on speaker. Stay calm and talk to the person between attempts, because the person is frightened, and your steady voice helps.

Step 7. If the person becomes unresponsive, support the person and lower them carefully to the floor, protecting the head. Make sure that the emergency number has been called and that the defibrillator is on its way, and start CPR with chest compressions, as Chapter 4 describes. Compressions can help to push the object out. Each time you open the airway to give rescue breaths, look in the mouth and take out any object you can clearly see. Never sweep your fingers blindly inside the mouth, because this can push the object deeper.

Step 8. Once the object has come out and the person can breathe, help the person to sit comfortably, stay with them and reassure them. Even if the person seems well, the person should be checked by a doctor, especially after abdominal or chest thrusts, which can cause injuries inside the body that cannot be seen. When you hand over to a doctor, a nurse or the paramedics, say what the person was eating, what you saw and what you did, including whether you gave back blows, abdominal thrusts or chest thrusts. Follow your workplace's procedure for arranging this, for telling the family and for reporting.

Step by Step: Helping a Person Who Is Sitting or in a Wheelchair

Step 1. Many people you support will choke while sitting at a table, in an armchair or in a wheelchair. Recognise the signs and decide quickly, as in the previous section, whether the choking is mild or severe, and tell the person in a few words what you are going to do. Do not try to stand the person up if the person cannot stand easily; you can help the person where they are sitting. If the person is in a wheelchair, put the brakes on first, so that the chair cannot roll while you give back blows or thrusts.

Step 2. For back blows, support the person's chest with one hand and help the person lean forward as far as is safe. If the back of the chair is in the way, stand or kneel to the side so that you can reach between the shoulder blades. Give firm blows with the heel of your hand, checking after each one whether the object has come out.

Step 3. For abdominal thrusts in a chair with a low back, stand or kneel behind the chair and reach around the person, placing your fist as you would for a person who is standing. If the back of the wheelchair is high, or a strap or tray is in the way, loosen or remove it quickly so that you can reach the person. Chairs differ, and your workplace's training can show you the best way to help with the chairs that the people you support use.

Step 4. For a person who is in bed, help the person to sit up and lean forward if possible, then give back blows and thrusts as described above. If the person cannot sit up, or becomes unresponsive, call for help and start CPR on a firm surface, moving the person to the floor with help if you can do so safely, as Chapter 4 describes.

Step 5. When the object has come out, keep the person sitting upright and stay with them until their breathing and colour are back to normal. Check that the person's dentures are still in place and not loose, without reaching blindly into the mouth. Do not continue the meal until the person has been checked, as your workplace's procedure says, and keep the person's food and drink in sight so that you can tell the doctor or nurse what caused the choking.

Safer Mealtimes and After a Choking Episode

Much of the choking in care can be prevented with careful mealtime habits. Help the person to sit fully upright, ideally in a chair at a table, and to stay upright for a while after the meal. Make sure that the person is awake and alert before eating, and that glasses, hearing aids and well-fitting dentures are in place if the person uses them. Offer small mouthfuls, and let the person finish one before the next. A calm, unhurried meal, without distractions such as a loud television, is safer for everyone at the table. Talk with the person between mouthfuls rather than during them, and never rush a person to finish because the next task is waiting.

Many care plans set a special texture for food and drinks, such as soft, minced or puréed food, or drinks thickened to a certain level, based on an assessment of the person's swallowing. Follow the care plan exactly, every time, including for snacks, drinks and treats that visitors bring. If you notice signs that swallowing is becoming harder, such as coughing during meals, a wet or gurgling voice after drinking, food held in the mouth, or meals that take much longer than before, report them as your workplace's procedure says, so that the person's swallowing can be assessed again.

Some foods cause choking more often than others, and knowing them helps you to stay alert. Dry or sticky foods such as bread, rice cakes and some sweets, tough meat, hard raw vegetables, nuts, and foods with mixed textures, such as soup with solid pieces or cereal in milk, can all be hard for a person with weak swallowing. Thin drinks such as water can also be hard to control for some people, which is one reason why some care plans set thickened drinks. You do not need to remove these foods from everyone's plate, but you should know which foods the care plan allows for each person and watch more closely when they are served.

Outings bring their own risks. A snack at a bus stop, a meal at a café or a drink in the car on a hot day are pleasant parts of an outing, and they are safer when the person is sitting upright and still. Avoid giving food or drink while the person is walking, while you are pushing a wheelchair over rough ground, or while a vehicle is moving. When the care plan sets a texture, take the person's own food and drinks of the right texture with you, and remember that on a hot day the person will need to drink more, in the way that the care plan allows.

After any choking episode, even one that cleared quickly with coughing, watch the person closely in the hours and days that follow. A cough that does not settle, noisy or difficult breathing, pain in the chest or throat, a fever, or a feeling that something is still stuck all need a doctor's attention. A small piece of food or drink can sometimes go into the lungs and cause problems later. A person who has choked may also feel frightened of eating for a while, or may start to refuse certain foods. Be patient, offer reassurance, and tell your supervisor, because the person's fear is part of what the care team needs to know. Record what happened, what you did and how the person is, and report it as your workplace requires, so that the care plan can be reviewed.

Things to Check

Check each person's care plan for food and drink textures before every meal you help with, and check that what is on the plate and in the cup matches it.

Check that each person is sitting upright, awake and comfortable before eating, with dentures, glasses and hearing aids in place if the person uses them.

Check that someone is always watching the dining area during meals, and that no person at risk of choking eats without the support that the care plan describes.

Check that you know the signs of quiet choking in the people you support who cannot easily tell you that they are in trouble.

Check that you know how the brakes, straps and trays of each wheelchair work, so that you can make the chair safe and reach the person in a moment.

Check that your last practical first aid course included practice of back blows and thrusts, and ask your trainer which thrusts are taught where you live.

Check that every choking episode, however small, is recorded and reported, so that the person's swallowing and care plan can be reviewed.