19.2 Dysphagia and choking

The most common complications with swallowing are choking and dysphagia.

Choking

Choking is a life-threatening medical emergency the passage of air passage into the lungs is blocked by food or another object. This obstruction can be partial or complete. The disruption of normal breathing by choking hinders oxygen delivery to the body, resulting in asphyxia. Although oxygen stored in the blood and lungs can keep a person alive for several minutes after breathing stops, chocking is potentially fatal. It is a major cause of unintentional injury-related death.

Deaths from choking most often occur in the very young (< 1 year old) and in the elderly (> 75 years). The obstruction of the airway most commonly occurs at the pharynx or the trachea. Foods that can adapt their shape to that of the pharynx such as bananas, marshmallows, or gelatinous candies are particularly dangerous.

Choking is frequently caused by tumors, swelling of the airway tissues due to infections, and physical compression in strangulation. Complications

• Brain damage typically occurs if the body is deprived of air for three minutes.

• Death will usually occur if breathing is not restored in six to eight minutes.

Causes

Children younger than age three are especially at risk of choking because they explore the environment by putting objects in their mouth. Their airway is smaller in diameter than an adult's airway and their coughing may not be as effective as that of an adult in clearing an airway obstruction. In adults, choking is most often caused by food. Risk factors include:

• Medical conditions that affect the coordination of swallowing such as:

  • Strokes

  • Parkinson disease

  • Alzheimer disease

• Using alcohol or sedatives.

• Undergoing a procedure involving the oral cavity or pharynx.

• Wearing oral appliances.

Prevention

The risk of chocking in children can be reduced by:

• Waiting until 6 months of age before introducing solid foods to infants.

• Supervision of children while eating or playing.

• Removal of hazardous objects from the reach of your children.

• Governmental safety regulation and inspection of children's toy products.

In adults with difficulty swallowing, selection of food items with appropriate particle size, texture and humidity can reduce the risk of chocking.

Treatment

Choking can be treated with various basic techniques or advanced techniques.

Basic Treatment

For the conscious choking victim, most protocols recommend encouraging the victim to cough. If not effective, hard back slaps are attempted and if none of these procedures work, abdominal thrusts (Heimlich maneuver) or chest thrusts are applied. If the choking victim becomes unconscious, CPR is recommended.

Back Blows (or Slaps)

These are performed by leaning the choking victim forward, then delivering blows with the heel of the hand onto the victim's back, in between their shoulder blades. Back slaps must be performed with the head lower than the chest (patient bent over), otherwise the blow may drive the object deeper into the person's throat.

Abdominal Thrusts (Heimlich Maneuver)

Abdominal thrusts are usually recommended for their simplicity and effectiveness. They can be followed by chest thrusts, if abdominal thrusts are not effective. Abdominal thrusts are performed with the rescuer standing behind the person choking and exerting inward and upward pressure with their hands on the choking person's abdomen. The purpose of abdominal thrusts is to create pressure that will expel any object lodged in the airway upwards to relive the obstruction. The procedure is similar in chest thrusts, except that the pressure is applied around the chest. Chest trusts might be more effective on obese people.

For children less than 1 year old, the American Heart Association recommends performing cycles of 5 back blows (or slaps) followed by 5 chest compressions. Abdominal thrusts are not recommended because they can cause liver damage.

Advanced Treatment

There are many advanced medical treatments to relieve choking or airway obstruction. These include inspection of the airway with a laryngoscope or bronchoscope and removal of the object. Emergency cases in which the appropriate conditions to remove the object are not available may require cricothyrotomy (tracheostomy). It involves making an incision between the cricoid and the thyroid in the anterior aspect of the neck and inserting a tube into the trachea in order to bypass the upper airways. This procedure is only performed when the basic methods have failed and other options are not available.

Dysphagia

Dysphagia is difficulty in swallowing. It can have various causes and involve different parts of the swallowing mechanism or anatomy. It frequently produces coughing, chocking or pulmonary aspiration (food or liquid going into the lungs) and subsequent aspiration pneumonia. Dysphagia can also lead to dehydration and weight loss.

Oropharyngeal dysphagia includes difficulty controlling the position of food in the mouth, difficulty initiating a swallow, nasal regurgitation and gurgly voice after swallowing. Patients identify the mouth or neck as the site of the problem. These problems are common among older individuals, patients who have had strokes, head and neck cancer and progressive neurologic diseases like Parkinson's disease, dementia or multiple sclerosis.

In esophageal dysphagia patients indicate an inability to swallow solid food, saying that it is held up before it reaches the stomach or is regurgitated. Various diseases in or adjacent to the esophagus can result in dysphagia and the treatment will depend on the cause. Achalasia is an exception to usual pattern of dysphagia in that patients report more difficulty swallowing fluids than solids. It is caused by a degeneration of neural tissue in the esophagus which results in peristaltic failure.

The diagnosis of dysphagia commonly requires specialized techniques due to the concealed nature of the swallowing mechanism. Endoscopic techniques involve the lowering of a camera into the mouth, pharynx and esophagus and allow for imaging of the structure in action. Videofluoroscopy can also be useful, providing live x-ray images of the neck structures while the patient swallows a radio-opaque fluid.

Many treatments are used in dysphagia because it is not a disease, but a symptom or condition associated with a wide variety of diseases. Treatments can include swallowing therapy, dietary changes, feeding tubes, certain medications, and surgery.

Key terms

Choking, asphyxia, strangulation, abdominal thrusts, back blows, back slaps, chest thrusts, Heimlich maneuver, cricothyrotomy, tracheostomy, dysphagia, pulmonary aspiration, aspiration pneumonia, achalasia, videofluoroscopy, endoscopy.

Figure credits

Figure 1 by Lord Akryl, Jmarchn - http://cancer.gov, Public Domain, https://commons.wikimedia.org/w/index.php?curid=10296586

Figure 2 byblic Domain, https://commons.wikimedia.org/w/index.php?curid=615793

Figure 3 by BruceBlaus - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=58967040