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Choking & Airway Obstruction Difficulties

For Individuals with Intellectual and Developmental Disabilities

⚠️Introduction: Understanding Choking

• Developed by: The Office of Integrated Health - Health Supports Network at the Virginia Department of Behavioral Health and Developmental Services.

• Definition of Choking: Choking is simply defined as "an obstructed airway." It occurs when a foreign body, food, or a combination of food and drink obstructs the airway.

• Nature of Choking: Choking incidents can be intentional or unintentional, partial or complete. They can be related to age or other chronic neurological and neuromuscular conditions.

• Key Point: The risk of choking is multiplied with each additional risk factor.

⚠️The Swallowing Process (Brief Overview)

Swallowing is a complex process involving three stages:

• Stage 1: Oral Preparatory Phase (Buccal Phase): Food is chewed, mixed with saliva to form a bolus, and moved by the tongue to the back of the mouth. Impairment here can lead to difficulty chewing, forming a bolus, or moving food.

• Stage 2: Pharyngeal Phase: The tongue pushes the bolus, triggering a swallowing response. Vocal cords close, and the epiglottis covers the larynx to prevent food/liquid from entering the airway. Impairment can lead to food/liquid entering the lungs (aspiration).

• Stage 3: Esophageal Phase: Food/liquid enters the esophagus and moves to the stomach. Impairment can cause heartburn, vomiting, or abdominal pain.

• Impaired Swallowing Symptoms: Choking sensation, shortness of breath, weight loss, coughing (before, during, or after swallowing), changes in voice quality after swallowing, and repeated pneumonia.

⚠️Increased Risk Factors for Choking

Choking risk is influenced by various factors, including medical conditions, oral health, structural abnormalities, and functional issues.

• Medical Diagnoses:

  • Age (65+), Dysphagia (difficulty swallowing), Alzheimer’s, Parkinson’s, Cerebral Palsy, Seizure disorders, Muscular disorders, Multiple Sclerosis, Motor neuron disease, any neurological disorder.

  • History of aspiration pneumonia, Amyotrophic Lateral Sclerosis (ALS), Rumination Disorder (RD).

  • Congenital laryngeal web, Neoplasm (cancer) in head/neck/throat, Muscular Dystrophy.

  • Tardive Dyskinesia (side effect of neuroleptic drugs).

  • Gastroesophageal reflux disease (GERD).

  • Down Syndrome, Prader-Willi Syndrome.

  • Thyromegaly (enlarged thyroid gland), Cervical spine injuries.

  • Avoidant Restrictive Food Intake Disorder (ARFID), Polymyositis.

• Oral Health & Chewing Difficulties:

  • Dentures, poor dentition (loose, missing, or decaying teeth), no teeth (edentulous).

  • Loss of teeth reduces chewing performance, leading to larger, unsafe boluses.

  • Speech Language Pathologists (SLPs) can assess chewing disorders.

• Structural Abnormalities (Congenital or Acquired):

  • Cleft Palate, high (but closed) palate (food can be trapped and dislodged when reclining).

• Functional Abnormalities:

  • Tongue Dysfunction: Impaired chewing, bolus formation/transport, excessive food retention in the oral cavity. Increases choking risk if food dislodges when reclining.

• Specific Syndromes:

  • Down Syndrome: Lack tongue control, underdeveloped jaw, impaired chewing, poor tongue thrust. Exceptionally higher risk for choking.

  • Prader-Willi Syndrome: Poor oral/motor coordination, poor gag reflex, hypotonia, polyphagia/hyperphagia, decreased mastication, voracious eating habits.

• Eating Disorders:

  • ARFID: Lack of interest in food, avoidance due to sensory aspects or fear of choking/vomiting.

  • Pica: Abnormal craving for non-food items (chalk, clay, laundry detergent).

  • Rumination Disorder (RD): Involuntary regurgitation of food, re-chewing, and re-swallowing. Signs include regurgitation, spitting food, malnutrition, weight loss, gagging, tooth decay.

⚠️ Medications Which Increase Choking Risk

Be aware of medication side effects prior to administration.

• Medications affecting esophageal muscles (e.g., Cogentin).

• Medications causing dry mouth (xerostomia) (e.g., Antihistamines).

• Antipsychotic/Neuroleptic medications (e.g., Risperdal) affecting swallowing and facial/tongue muscles.

• Central Nervous System (CNS) medications (e.g., Tegretol) decreasing awareness and voluntary muscle control.

• High dose steroids and chemotherapeutic preparations causing muscle wasting or esophageal damage.

• Anti-dopaminergic or anti-cholinergic medications.

⚠️ Eating Behaviors & High-Risk Foods

Certain behaviors and food types significantly increase choking risk.

• High-Risk Eating Behaviors:

  • Placing too much food or medication in one's mouth.

  • Not chewing food well enough.

  • Putting large portions of food in one's mouth.

  • Eating too fast, drinking too fast.

  • Inattention while eating, swallowing food whole.

  • Isolation: Eating alone or in bed increases risk as assistance may not be readily available. Be alert to individuals who isolate during meals.

  • Food stealing (resulting in consumption of non-prescribed/inappropriate diet).

  • If high-risk eating behaviors are observed, notify your direct supervisor and the individual’s PCP immediately. A mealtime protocol should be developed.

• High-Risk Foods for Choking:

  • Corn, Grapes, Bananas, Hard nuts, Marshmallows.

  • Peanut butter (any kind), Chicken on the bone, Candy with large nuts.

  • Hotdogs served whole, Whole hard fruits (apples, pears).

  • Peanut butter sandwiches on soft bread.

  • Thick chewy bread (white bread, bagels, pizza).

  • Whole, raw vegetables served in large bite-sized pieces.

  • Dry meats (ground beef without sauce/gravy).

  • Dry, crumbly foods (cornbread, rice without butter/jelly/sauce).

  • Incorrect diet texture (liquids or foods not prepared to prescribed diet).

  • Foods with two or more textures, especially thin liquid with a solid component (cereal and milk).

• Nut Butters & Other Sticky Foods:

  • Require more muscle strength and tongue coordination to swallow.

  • Can leave residue in the oral cavity or stick to the palate, potentially blocking the airway if dislodged (e.g., during sleep).

  • Individuals on Pureed, Minced & Moist, and Soft & Bite Size diets should avoid nut butters and other sticky foods.

  • The International Dysphagia Diet Standardization Initiative (IDDSI) framework provides guidelines for texture-modified diets and lists foods to avoid.

⚠️Healthcare Professionals Who Can Help

Various healthcare professionals can assess and manage choking and swallowing difficulties.

• For Assessment of Choking/Swallowing Issues:

  • Speech Language Pathologists (SLPs)

  • Otolaryngologists (Ear, Nose & Throat or ENT specialists)

  • Gastroenterologists (specialists in the digestive system)

• Where to Get Help:

  • Individuals at increased risk should be evaluated by a healthcare professional as soon as possible.

  • Schedule an appointment with the individual’s Primary Care Physician (PCP) for a referral to the appropriate specialist for an assessment.

• SLP Assessments:

  • SLPs conduct comprehensive reviews, interview caregivers, and evaluate oral structures (teeth, lips, jaws, tongue, cheeks, soft palate) and functional movements (lip pursing, tongue protrusion, coughing, throat clearing, gag reflex).

  • They may conduct structural and functional assessments of swallowing muscles and observe head-neck control and posture.

• Swallow Studies:

  • Purpose: To observe chewing, swallowing, and breathing with various food/drink consistencies. SLPs note signs like a "wet" voice, coughing, or throat clearing.

  • Types:

    • Video-fluoroscopic Swallow Study (VFSS) / Modified Barium Swallow: X-ray records swallowing with barium-coated foods/liquids.

    • Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) / FEES: Fiberoptic tube views mouth/throat to examine swallowing response.

    • Pharyngeal Manometry: Measures pressure inside the esophagus.

⚠️ Strategies to Lower Choking Risk

Proactive measures and protocols are essential to reduce choking incidents.

• Lowering Risk of Choking Fatalities:

  • Everyone is at risk, but individuals with IDD have a higher risk.

  • Caregivers should be certified annually in CPR and administering back blows/abdominal thrusts.

  • Regular practice drills and mock emergencies improve confidence and response technique.

  • Well-placed posters with clear instructions serve as visual reminders during emergencies.

• Universal Choking Sign:

  • The universal sign is both hands clutched to the throat.

  • Demonstrate and teach this sign to individuals (if cognitively and physically able) and have them demonstrate it back periodically.

• Possible Strategies from Assessments:

  • Different head and neck postures (e.g., neutral head position, "chin tuck" to prevent substances from entering the trachea).

  • Avoiding certain high-risk foods and beverages.

  • Adding special thickeners to foods and drinks as prescribed.

  • Avoiding hot or cold foods/beverages that may trigger choking/aspiration.

  • Implementing protocols and precautions to prevent aspiration if dysphagia is diagnosed.

  • Referral to a dietician or nutritionist.

  • PCP orders for diet modification.

• Caregiver Protocols:

  • Consult the individual’s PCP and SLP to ensure a person-centered support plan/choking protocol meets specific needs. All protocols must meet human rights guidelines and require healthcare professional approval.

  • Examples: Pica precautions, hands-on staff-assisted eating, direct visual supervision during meals, assisted eating/drinking techniques using adaptive equipment, protocols for prescribed diets/thickening foods.

  • Protocols limiting access to food impact human rights and require approval from the Local Human Rights Committee (LHRC) prior to implementation.

⚠️What Not to Do During Mealtimes

Avoid these practices to minimize choking risk:

• DO NOT rush mealtimes.

• DO NOT plan other activities during mealtimes (minimize distractions).

• DO NOT permit eating or drinking while the individual is lying down.

• DO NOT give foods or liquids that a particular individual has difficulty swallowing.

• DO NOT assist individuals to bed for at least 30 minutes after eating or drinking.

• DO NOT give foods or liquids restricted by an individual’s healthcare provider.

• DO NOT start mealtime if the individual is too lethargic, angry, anxious, or cannot sit still.

• DO NOT let an individual finish eating a particular food item if that food item has just caused them to choke.

⚠️ Choking Emergencies: Response Steps

• Recognize Symptoms:

  • Can still breathe: Look of fear/panic, reddish face, grabbing throat, drooling, forceful coughing.

  • Cannot breathe: Cannot speak, grayish/pale face, bluish lips, grabbing throat, high-pitched noise or no noise.

• Conscious Choking Victim (Adult/Child):

  • If able to cough forcefully, encourage coughing.

  • If choking and cannot talk/cry/laugh forcefully, use the "five-and-five" approach (American Red Cross):

    • Give five back blows (stand to side/behind, arm across chest for support, bend forward, deliver blows between shoulder blades).

    • Perform five abdominal thrusts (position fist slightly above navel, grasp with other hand, press hard inward and upward).

    • Alternate between five blows and five thrusts until blockage is dislodged.

  • If you are the only rescuer, perform back blows and abdominal thrusts before calling 911. If another person is available, have them call for help while you perform first aid.

  • If the person becomes unconscious, perform standard Cardiopulmonary Resuscitation (CPR) with chest compressions and rescue breaths.

• Performing Abdominal Thrusts on Yourself (if alone):

  • Call 911 immediately.

  • Place a fist slightly above your navel. Grasp fist with other hand and bend over a hard surface (countertop, chair). Shove fist inward and upward.

• Aid to Someone Choking in a Wheelchair:

  • Encourage coughing. If not coughing, start assistance immediately.

  • Lock wheelchair brakes. Call for assistance if available; if not, perform steps before calling 911.

  • Lean person forward, slap back 5 times between shoulder blades.

  • If still choking, stand directly behind, lean down, wrap arms around waist. Make a fist, place other hand on top, put above belly button. Pull in and up 5 times.

  • Alternate 5 back blows with 5 abdominal thrusts until obstruction is removed.

• Clear Airway of Unconscious Person:

  • Lower person onto their back on the floor.

  • If blockage visible, reach finger into mouth and sweep it out (do not sweep if not visible, especially in children).

  • Begin CPR if object remains lodged and person unresponsive. Chest compressions may dislodge the object; recheck mouth periodically.

• Important Note: Always follow your agency's specific training for responding to a choking victim. These instructions are a summary and are not meant to replace in-person training.

⚠️ Resources

• American Red Cross (various publications on first aid, CPR, AED).

• American College of Emergency Physicians.

• American Academy of Pediatrics (Choking Prevention and First Aid for Infants and Children).

• National Institute of Deafness and other Communication Disorders (NIDCD) on Dysphagia.

• National Safety Council (Injury facts, choking prevention tips).

• Various research studies on choking risk factors and interventions.

• DBHDS Office of Integrated Health Resources:

  • DBHDS Website: www.dbhds.virginia.gov

  • OIH Website: https://dbhds.virginia.gov/office-of-integrated-health

  • OIH Mobile Rehab Engineering (MRE) Team Email: mreteam@dbhds.virginia.gov

  • OIH Mobile Dental Team Email: dentalteam@dbhds.virginia.gov

  • OIH Registered Nurse Care Consultants (RNCCs) and PT/Wound Care Specialist (CWTS) Email: communitynursing@dbhds.virginia.gov

  • OIH RNCC Team: Health Trends Newsletter, Monthly Regional Nursing Meetings, Health & Safety alerts.

  • Sign-up for Provider Development emails: https://tinyurl.com/ProviderNetworkListserv

  • Current and Future OIH Training Sessions (e.g., Calling 911, Falls, Fatal 7, Sepsis, Skin Integrity, Transfers, Vital Signs, Wheelchair Transitioning, various syndromes, advocacy, waivers, AT, aspiration pneumonia, constipation, dehydration, diabetes, emergency preparedness, grief and loss, nutrition, polypharmacy, recognizing declining health, respiratory infections, group homes).