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INTRODUCTION

Choking is defined as the interruption of respiration due to the internal obstruction of the airway. Aspiration is defined as the penetration of foreign material into the trachea, beyond the vocal cords. Airway obstruction relating to the presence of a foreign body, however, may be intra-luminal (foreign body within the airway) or extra-luminal (foreign body within the esophagus causing airway compression). Children suffering from these conditions may present with cardiorespiratory arrest, impending respiratory arrest, a stable but symptomatic status, or with sequelae of a previous choking or aspiration event. These patients often present to hospitalists in the emergency department or inpatient setting and therefore knowledge of the full range of the presentations is important.

The death rate from unintentional suffocation in children aged 0 to 4 years, which includes aspiration or ingestion of foods, is estimated at 3 per 100,000 but declines by nearly a factor of 10, to 0.36 per 100,000 for children aged 5 to 9 years.1 Data from Australia support a similar incidence and trend, with rates of fatal injury being 10 times greater in the first years of life as compared to the second decade of life.2 In the United States, choking on food or other foreign objects is the direct cause of death of several hundred children each year.3-6 Choking therefore remains a major cause of preventable death and morbidity in the United States, although efforts by the federal government and public health community have made some progress in decreasing its occurrence.

PATHOPHYSIOLOGY

Choking and aspiration involve the interaction between an object and the airway in such a way as to prevent breathing from being fully effective. It may be a reversible event if airway defenses are able to expel the foreign material and clear the airway, or it may result in symptomatic airway obstruction.

If severe enough, airway obstruction will lead to oxygen deprivation and death if not rapidly and effectively addressed. If partial obstruction of the airway results, a subacute process may result in infection, inflammation, and lung injury distal to the lodged object. Another mechanism of choking involves the impaction of foreign material in the esophagus with resultant airway compression.

Choking results from a complex interaction between the victim, the environment, and the object at hand. Young children, with their incompletely developed dentition and oral skills, smaller airways, immature swallowing mechanisms, and their lack of experience and cognition are at highest risk of choking. Also, they tend to explore the world by bringing objects to their mouths. Children with developmental delay, hypotonia, dysphagia, or anatomic abnormalities retain this increased risk into their later years. Older siblings or playmates may also share inappropriate foods or toys with younger siblings. Environmental factors such as a lack of supervision, access to an object, and circumstances surrounding meals and snacks are important. In many published reports, males have a ...

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