Choking First Aid in Residential Aged Care

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Published: 09 February 2021

Choking is the second most common cause of preventable death in residential aged care (Ibrahim et al. 2015).

Knowing how to prevent this and correctly perform first aid for this life-threatening emergency is an essential skill.

The importance of managing choking risks in aged care is outlined in Standard 3 of the Aged Care Quality Standards: Personal Care and Clinical Care (ACQSC 2019).

Note that the first aid procedure detailed in this article should be used for adults only.

What is Choking?

choking respiratory system diagram

The trachea (windpipe) is a tube-like structure in the respiratory system enabling the passage of air from the larynx to the bronchi, and finally to the lungs (Encyclopaedia Britannica 2014).

Choking occurs when the trachea is completely or partially blocked by a foreign body (food, liquid or another object), obstructing airflow (QLD DoH 2019; Kahn 2019).

Choking can be gradual or sudden, and it may only take a few seconds for the airway to become completely blocked. The specific symptoms experienced by a choking person will depend on the foreign body causing the obstruction, as well as the severity of the blockage (ANZCOR 2016).

If airflow is completely blocked, the brain will be deprived of oxygen. It only takes four minutes without oxygen for brain damage to occur (Headway 2018).

A person who is choking may be conscious or unconscious. Conscious patients and unconscious patients must be managed differently (ANZCOR 2016).

Older Adults and Choking

While choking is a prevalent cause of injury-related death in infants (QLD DoH 2019), did you know that older adults over the age of 65 are seven times more likely to choke on food than children aged 1 to 4 (Cichero 2018)?

Loss of muscle mass and strength - which is a natural part of the ageing process - affects muscles related to chewing and swallowing, increasing the risk of choking (Cichero 2018). Dysphagia (swallowing difficulty) is also common among older adults (Healthdirect 2020).

Pathological factors such as dementia, stroke, functional decline and medicines may further increase the risk (VIC DoH 2018).

Read: Dysphagia and Swallowing

Common Causes of Choking

  • Eating or drinking too quickly
  • Swallowing food before chewing it properly
  • Swallowing small bones or other objects
  • Inhaling small objects.

(QLD DoH 2019)

Choking Risk Assessment

It is important to identify residents who may be at risk of choking. These may include:

  • Residents with swallowing disorders
  • Residents who have choked before
  • Residents who display impulsive behaviours (as they may be more likely to put things in their mouth or stand up suddenly)

(VIC DoH 2018)

Residents with an established risk of choking should be referred to an appropriate specialist such as a speech pathologist, dietician or dentist. It is important that the results of a risk assessment, and any subsequent recommendations that have been made, are appropriately recorded, communicated and put into practice (VIC DoH 2018).

What are the Signs of Choking?

choking universal sign
The universal sign of choking is clutching the neck with thumb and fingers.

If the resident is conscious, they may show some of the following signs:

  • Extreme anxiety
  • Agitation
  • Panic or distress
  • Gasping
  • Coughing
  • Loss of voice
  • Universal choking sign (clutching the neck with thumb and fingers)
  • Neck or throat pain
  • Difficulty speaking, breathing or swallowing
  • Gagging
  • Wheezing or abnormal breathing noises
  • Colour changes in face (e.g. blue lips or red face)
  • Chest pain
  • Collapse
  • Watery eyes.

(ANZCOR 2016; QLD DoH 2019; Better Health Channel 2014)

If there is partial airway obstruction, the resident will still be able to breathe, speak and cough to some extent (Better Health Channel 2014). Other indications of partial obstruction include:

  • Laboured breathing
  • Noisy breathing
  • Abnormal breathing
  • Being able to feel some escape of air from the resident/patient’s mouth.

(ANZCOR 2016; Better Health Channel 2014)

Indications for complete airway obstruction include:

  • Increased work of breathing
  • Vigorous attempts at breathing
  • No sound of breathing
  • No escape of air from the nose or mouth
  • Cyanosis (turning pale, then blue)
  • Inability to breathe, speak or cough
  • Altered state of consciousness.

(ANZCOR 2016; Better Health Channel 2014)

Note that airway obstruction in a resident who is unresponsive and non-breathing may not be apparent until rescue breathing has commenced (ANZCOR 2016).

How to Perform First Aid for Choking

choking first aid management flowchart

(Adapted from ANZCOR 2016; VIC DoH 2018)

If the resident is conscious, always remember to let them know what you are doing and why (HCA 2016).

The first step of managing choking is to assess the severity of the airway obstruction. This can be done by determining whether the resident/patient is able to cough effectively (ANZCOR 2016).

Effective Cough (Awake Resident/Patient)

If the resident is able to effectively cough, this indicates a mild airway obstruction. You should:

  1. Reassure the resident and encourage them to keep coughing. They may be able to expel the object on their own.
  2. If the object does not dislodge, call an ambulance.

(ANZCOR 2016)

Ineffective Cough - Awake Resident/Patient

An ineffective cough indicates a severe airway obstruction (ANZCOR 2016).

First aid for severe airway obstruction in a conscious resident/patient requires the use of two techniques: back blows and chest thrusts.

Back Blow

In order to perform a back blow, keep the resident standing unless they are already seated. Using the heel of your hand, give a sharp blow to the resident’s back between their shoulder blades. Back blows aim to completely or partially dislodge, or loosen, the foreign object by creating an increase in pressure in the obstructed airway. If the foreign object is loosened, the resident may be able to cough (HCA 2016).

Chest Thrust

When delivering a chest thrust, the resident should sit or stand against a firm support such as a wall or chair back. Using the heel of your hand, give a short, sharp upward thrust to the middle of the patient chest. Chest thrusts should be performed at a slower rate than CPR compressions (HCA 2016).

Note: The use of abdominal thrusts (aka the Heimlich manoeuvre) is no longer recommended due to evidence of life-threatening complications (ANZCOR 2016).

The procedure for a conscious patient with an ineffective cough is to:

  1. Call an ambulance.
  2. Deliver five back blows. Check to see if the object has been dislodged after each blow. The aim is not to deliver all five blows, but to dislodge the object.
  3. If the object has not been dislodged after five back blows, perform five chest thrusts. Check to see if the object has been dislodged after each thrust. The aim is not to deliver all five thrusts, but to dislodge the object.
  4. If the object has not been dislodged after five chest thrusts, continue alternating between five back blows and five chest thrusts as long as the resident/patient is still responsive.

(ANZCOR 2016)

Ineffective Cough - Unconscious Resident/Patient

If the resident/patient becomes unresponsive:

  1. Perform a finger sweep if the foreign object is visible in the airway.
  2. Call an ambulance.
  3. Start CPR.

Read: Adult Basic Life Support (BLS) Using DRSABCD

Care Process Following a Choking Incident

After a choking incident has occurred:

  • Ensure the resident is safe and closely monitored after the event. It is important to discuss the event and provide reassurance.
  • Notify the resident general practitioner and family about the event.
  • Determine the probable cause of the choking incident and ensure you are aware of dysphagia signs and symptoms.
  • Refer the resident to a speech pathologist for a swallowing assessment and recommendations, if appropriate.
  • Assess whether the resident/patient’s food and fluid intake are appropriate (if the resident/patient is on modified diet or fluids), and refer them to a dietician if necessary.
  • Put into practice an individualised risk reduction and prevention plan.
  • Review the resident’s medicines and identify any medicines that affect swallowing or saliva.
  • Ensure that any new changes, risks, plans and requirements are communicated across the care team.
  • Make any necessary referrals.
  • Monitor the resident and perform a choking risk assessment at least every six months or after the resident has had a change in their condition.
  • Ensure the resident is appropriately educated on choking risk factors and safe swallowing techniques.
  • Ensure staff are appropriately educated on choking risk factors, recognition, management and interventions.

(VIC DoH 2018)

Choking Prevention Strategies

choking prevention strategies

For residents who have been identified at risk of choking:

  • Ensure ‘at risk’ residents/patients are appropriately identified and supervised
  • Ensure the right foods are given to the right residents (as some residents might have a modified textured diet)
  • When providing assistance with meals, you may consider:
    • Encouraging the resident to cough after swallowing
    • Giving the resident adequate time to chew and swallow
    • Ensuring the resident has swallowed before giving them more food or drink
    • Alternating mouthfuls of food with mouthfuls of fluid
    • Checking the resident’s mouth for residual food after each meal
  • When the resident is eating, ensure they are sitting upright with their chin tucked or turned
  • Consider swallowing manoeuvres (e.g. supraglottic and super supraglottic swallow, effortful swallow, Mendelsohn manoeuvre)
  • Consider feeding aids (e.g. adapted cups, shallow spoons, non-slip table mats, angled utensils)
  • Reduce environmental distractions while the resident/patient is eating
  • Assist the resident/patient with oral hygiene before and after each meal.

(VIC DoH 2018)

For further information on meal assistance, read: Meal Assistance in Aged Care.

Note that this is a written refresher on choking first aid and not designed to be a substitute for comprehensive education and hands-on training. Always follow your organisation's policies and procedures.

Additional Resources


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