Upper airway obstruction and choking in older adults: causes, first aid and prevention

The upper airway is the route air takes from the nose and mouth through the throat and voice box towards the lungs. If something blocks it, or the tissues around it swell, breathing becomes difficult within moments. The best known form is choking, when food or an object lodges in the throat.

St John Ambulance describes choking as the airway being partly or completely blocked, so that the person may be unable to breathe properly. A partial blockage can often be cleared by the person coughing; a complete blockage cannot, and it is an emergency in which every minute matters.

St John Ambulance lists difficulty breathing, speaking or coughing, a red, puffy face and signs of distress, such as pointing to the throat or grasping the neck. Its first step is to ask the person, "Are you choking?" If they can breathe, speak or cough they might be able to clear their own throat; if they cannot, they need help straight away.

North East Ambulance Service makes the same distinction between mild and severe. In mild choking the person can usually speak and breathe and clear the blockage by coughing. In more severe choking, in which the adult is unable to speak, cough or breathe, they will need your help or will eventually become unconscious.

For mild choking, North East Ambulance Service advises encouraging the person to keep coughing and to spit the object out if it is in the mouth. For severe choking both services describe the same sequence.

• Give up to five sharp back blows: stand behind and slightly to one side, support the chest with one hand, lean the person forward, and strike between the shoulder blades with the heel of your other hand. Check whether the blockage has cleared.

• If it has not, give up to five abdominal thrusts: stand behind, put your arms around the waist, place a clenched fist just above the belly button, cover it with the other hand and pull sharply inwards and upwards.

• If the blockage has still not cleared, call 999 immediately and say the person is choking, then continue alternating five back blows and five abdominal thrusts until help arrives.

• If the person becomes unresponsive and is not breathing, start CPR.

The NHS describes dysphagia as having problems swallowing, usually caused by certain medicines or another condition such as acid reflux or a stroke. Signs include coughing or choking when eating or drinking, bringing food back up, a feeling that food is stuck in the throat or chest, and a gurgly, wet-sounding voice when eating or drinking. Over time it can cause weight loss, dehydration and repeated chest infections.

NHS inform lists neurological causes, including stroke, Parkinson's disease, multiple sclerosis, dementia and motor neurone disease, as well as obstruction from mouth, throat or oesophageal cancer, throat pouches and scarring. It adds that some people with dysphagia develop chest infections such as aspiration pneumonia, which require medical treatment, and that some avoid eating and drinking because they fear choking, which can lead to malnutrition and dehydration.

The NHS advises asking for an urgent GP appointment or getting help from NHS 111 if you or someone you care for has difficulty swallowing, coughs or chokes while eating or drinking, feels like something is stuck in the throat after eating, has a wet, gurgly voice after eating or drinking, is short of breath after eating or drinking, or gets lots of chest infections.

Not every obstruction is from food. The NHS lists swelling of the throat and tongue, difficulty swallowing, tightness in the throat, a hoarse voice and noisy breathing among the symptoms of anaphylaxis, a life-threatening allergic reaction that happens very quickly. It advises calling 999, using an adrenaline auto-injector if one has been prescribed, lying down and not standing or walking, even if you feel better.

Longer-term narrowing can come from tumours of the throat and voice box. NHS inform names mouth cancer, throat cancer and laryngeal cancer as causes of obstruction that can make swallowing difficult. The NHS says difficulty swallowing should always be assessed by a GP rather than put down to age or ignored.

NHS inform says a GP will do an initial assessment and may refer you to an ear, nose and throat specialist, a speech and language therapist, a neurologist, a gastroenterologist or a geriatrician. Tests can include a water swallow test carried out by a speech and language therapist, a videofluoroscopy, which is a moving X-ray taken while you swallow food and drink mixed with barium, and a nasendoscopy, in which a thin flexible camera is passed through the nose to look at the throat.

Treatment depends on the cause. NHS inform lists speech and language therapy to learn new swallowing techniques, changing the consistency of food and liquids to make them safer to swallow, tube feeding in some cases and surgery to widen narrowing. The NHS adds medicines to treat acid reflux, softer foods and thickener in drinks, and special spoons, plates and cups.

After a serious choking episode, or if choking keeps recurring, speak to a GP so the cause can be looked for. In the UK, assessment of swallowing is available through the NHS speech and language therapy service, usually after a GP or hospital referral; private speech and language therapists also work in this area.

Families and carers may find it worthwhile to learn the first aid sequence from a recognised provider such as St John Ambulance, which also provides advice on CPR, so that the steps can be performed calmly if needed.