An obstructed airway becomes a cardiac arrest in minutes. Obstruction may result from food or a foreign body, tongue relaxation, vomit/blood, facial trauma, swelling from anaphylaxis, burns, infection or a mass. EMTs must recognise partial versus complete obstruction, encourage effective coughing, use age-appropriate back blows/thrusts, start CPR promptly when unresponsive, avoid blind finger sweeps and escalate early for advanced airway support. Follow current Uganda basic-life-support and emergency-airway protocols.
1. Learning objectives
- Identify anatomical and mechanical causes of upper-airway obstruction.
- Distinguish mild/partial obstruction from severe or complete choking.
- Perform immediate first aid for adults, children and infants.
- Manage the unconscious patient, post-obstruction complications and aspiration risk.
- Explain suction, airway adjuncts, oxygenation, advanced airway and prevention principles.
2. Causes and levels of obstruction
| Cause/site | Examples | Clues |
|---|---|---|
| Oropharyngeal | Tongue in an unconscious patient, vomit, blood, dentures, food. | Gurgling, snoring, secretions, inability to speak or swallow. |
| Laryngeal | Food, swelling, anaphylaxis, epiglottitis, burns or trauma. | Stridor, hoarse voice, drooling, retractions, tripod posture. |
| Tracheobronchial foreign body | Nuts, bones, toy parts, coins or medical equipment. | Sudden choking, unilateral wheeze, coughing or absent breath sounds. |
| Trauma/structural | Facial fracture, neck haematoma, airway burns, tumour or cervical injury. | Distorted anatomy, bleeding, swelling, voice change and difficult airway. |
| Functional/medical | Seizure, stroke, intoxication, sedation, neuromuscular weakness. | Reduced consciousness, weak cough, aspiration and progressive hypoxia. |
3. Partial versus complete obstruction
| Feature | Effective cough/partial obstruction | Severe/complete obstruction |
|---|---|---|
| Speech | Can speak, cough or make sounds. | Cannot speak, cry or cough effectively. |
| Breathing | Air movement, noisy cough or wheeze. | Silent attempts, cyanosis, severe effort or no breathing. |
| Behaviour | Alert, frightened but responsive. | Universal choking sign, panic, collapse or unconsciousness. |
| Action | Encourage cough and observe closely. | Back blows/thrusts according to age; CPR if unresponsive. |
Do not leave the person alone. A partial obstruction can become complete, and a patient who stops coughing may actually be tiring.
4. First contact and ABCDE
| Step | Assess | Action |
|---|---|---|
| A – Airway | Speech, cough, stridor, secretions, visible object, swelling and consciousness. | Call for help, open airway when appropriate, remove only visible objects and begin age-appropriate obstruction care. |
| B – Breathing | Chest movement, SpO₂, cyanosis, effort and air entry. | Give oxygen, ventilate if needed and treat anaphylaxis/burns/trauma cause. |
| C – Circulation | Pulse, BP, perfusion and arrest signs. | Start CPR/AED if unresponsive and not breathing normally; manage shock after airway is addressed. |
| D – Disability | AVPU/GCS, seizures and glucose. | Protect from aspiration, treat hypoglycaemia/seizures and reassess neurologic recovery. |
| E – Exposure | Facial/neck trauma, burns, rash, bleeding and mechanism. | Protect cervical spine when indicated, prevent hypothermia and identify the cause. |
5. Conscious adult or child with effective cough
- Ask, “Are you choking?” and encourage vigorous coughing.
- Do not slap the back while the cough is effective, do not give food or drink and do not leave the patient.
- Remove an object only if it is clearly visible and easily reachable; never perform a blind finger sweep.
- If the cough becomes ineffective, the patient cannot speak/breathe or becomes cyanosed, move to back blows and thrusts.
6. Severe choking: adult and child over one year
- Call for help/emergency transport immediately.
- Give up to five sharp back blows between the shoulder blades while supporting the chest and leaning the patient forward.
- If unsuccessful, give up to five abdominal thrusts in an adult or child over one year, using the trained technique and avoiding the xiphoid/lower ribs.
- Alternate five back blows and five thrusts until the object comes out or the patient becomes unresponsive.
- After successful removal, arrange medical assessment because residual fragments, trauma or aspiration may remain.
7. Severe choking: infant under one year
- Support the infant face-down along the forearm/thigh with the head lower than the chest.
- Give up to five back blows, then turn face-up while supporting the head and give up to five chest thrusts over the lower half of the breastbone.
- Do not use abdominal thrusts in an infant and do not shake or hang the baby upside down.
- Alternate back blows and chest thrusts; call for emergency help and begin infant CPR if responsiveness is lost.
8. Unresponsive choking patient
- Lower safely to the floor, call for emergency response and begin CPR according to the current adult/paediatric algorithm.
- Before attempted breaths, open the mouth and remove an object only if clearly visible.
- Do not perform repeated blind finger sweeps. If two breaths fail to make the chest rise, resume compressions and reassess.
- Use an AED as soon as available; follow prompts and continue CPR until normal breathing, trained help or exhaustion.
- After circulation returns, assess aspiration, airway trauma, hypoxic brain injury and the need for hospital observation.
9. Other emergency airway obstructions
- Anaphylaxis: IM adrenaline immediately for airway/breathing/circulation compromise; oxygen and expert airway help.
- Burns/smoke inhalation: early airway referral, high-flow oxygen for toxic exposure and prepare for swelling; avoid delaying advanced airway care.
- Epiglottitis/deep infection: keep the patient calm and upright, do not force throat examination, give oxygen and call airway experts.
- Reduced consciousness: recovery position if breathing normally, suction secretions, use airway adjuncts if trained and monitor continuously.
- Trauma: jaw thrust and cervical-spine protection when indicated; control bleeding and anticipate swelling.
10. Airway adjuncts, suction and ventilation
| Tool | Use | Safety point |
|---|---|---|
| Suction | Remove vomit, blood or secretions. | Use appropriate catheter, avoid deep traumatic suction and monitor oxygenation. |
| Oropharyngeal airway | Unconscious patient without gag reflex. | Never force it in an awake/gagging patient; select correct size. |
| Nasopharyngeal airway | Selected semiconscious patient with a gag reflex. | Avoid with severe facial trauma or suspected basal skull fracture; follow local protocol. |
| Bag-mask ventilation | Apnoea or inadequate breathing. | Use two-person technique when possible, provide visible chest rise and avoid gastric insufflation. |
| Advanced airway | Persistent obstruction, failure to oxygenate or loss of airway protection. | Requires trained expert, monitoring, backup plan and post-placement confirmation. |
11. Hospital assessment after choking
- Repeat airway and respiratory examination even when the object appears to have cleared.
- Check for persistent cough, wheeze, unilateral air entry, stridor, hoarseness, dysphagia, chest pain or fever.
- Obtain chest/neck imaging or bronchoscopy when a retained foreign body, aspiration or injury is suspected.
- Observe patients who needed thrusts, CPR, ventilation, had prolonged hypoxia or remain symptomatic.
- Treat aspiration pneumonitis/pneumonia, airway trauma, pneumothorax or anaphylaxis according to the identified cause.
12. Nursing and EMT care plan
| Problem | Interventions | Evaluate |
|---|---|---|
| Airway patency | Position, suction, adjuncts, oxygen and continuous observation. | Speech, air entry, stridor, SpOâ‚‚ and work of breathing. |
| Hypoxia/aspiration | Oxygen, ventilatory support, recovery position when appropriate and aspiration precautions. | SpOâ‚‚, respiratory rate, chest signs, mental status. |
| Trauma from thrusts/CPR | Inspect chest/abdomen, manage pain and arrange medical review. | Tenderness, bruising, abdominal signs and breathing. |
| Anxiety/family distress | Explain events, reassure without blame and teach prevention. | Understanding, cooperation and safe discharge plan. |
| Recurrence risk | Identify trigger/object, swallowing assessment and follow-up. | Clear return precautions and prevention plan. |
13. Special populations
- Pregnancy/obesity: use chest thrusts when abdominal thrusts are unsuitable, following current life-support guidance.
- Wheelchair or bed-bound patient: adapt positioning safely, support the trunk and prevent falls.
- Older adults/dysphagia: review stroke, Parkinson disease, dentures, sedation and swallowing ability.
- Children with developmental disability: adapt supervision and food texture; involve caregivers.
- Tracheostomy: follow the individual emergency plan, remove/replace inner cannula when trained, suction and oxygenate through the correct route.
14. Prevention
- Supervise children while eating; keep small hard, round, sticky objects away from infants and toddlers.
- Cut food to age-appropriate size and texture, encourage sitting calmly and avoid eating while walking, running or playing.
- Keep coins, batteries, balloons, toy parts, latex gloves and medical equipment away from children.
- Assess swallowing after stroke, sedation, neurological disease or repeated aspiration.
- Teach caregivers recognised choking first aid and CPR; never use blind finger sweeps or force water/food.
15. Clinical scenarios
Scenario 1 – conscious adult. A man suddenly cannot speak while eating and makes the choking sign. Call for help, give five back blows, then abdominal thrusts if needed, alternating until relieved; arrange assessment even after recovery.
Scenario 2 – infant. A 7-month-old becomes silent and cyanosed while eating. Support face-down with the head lower, give back blows then chest thrusts, alternate and begin infant CPR if unresponsive.
Scenario 3 – post-choking cough. A child appears recovered but has persistent unilateral wheeze. Suspect a retained foreign body or aspiration; do not discharge without medical assessment.
Scenario 4 – swollen airway. A patient has stridor, tongue swelling and hypotension after a drug. Treat anaphylaxis with IM adrenaline and call airway experts; thrusts will not solve allergic airway oedema.
16. Common errors to avoid
- Encouraging an ineffective cough or waiting until the patient collapses.
- Blindly sweeping a finger into the mouth and pushing the object deeper.
- Using abdominal thrusts on an infant or failing to adapt for pregnancy/obesity.
- Giving water, bread or medicines to a choking person.
- Forgetting CPR/AED when the patient becomes unresponsive.
- Discharging after apparent clearance despite persistent wheeze, stridor, cough or hypoxia.
Airway obstruction check – “CLEAR”
C – Check if the cough is effective
L – Look for visible obstruction only
E – Escalate: back blows/thrusts or CPR
A – Airway adjuncts, oxygen and suction
R – Review for aspiration, injury and recurrence
C – Check if the cough is effective
L – Look for visible obstruction only
E – Escalate: back blows/thrusts or CPR
A – Airway adjuncts, oxygen and suction
R – Review for aspiration, injury and recurrence
17. Revision questions
- Differentiate partial and complete foreign-body airway obstruction.
- Describe the management of a conscious choking adult.
- How does management differ in an infant?
- What must be done when the choking patient becomes unresponsive?
- List five non-foreign-body causes of airway obstruction.
- Why are blind finger sweeps dangerous?
18. Key take-home points
- Effective cough is the best first response to partial obstruction.
- Severe choking requires age-appropriate back blows and thrusts; infants receive chest thrusts, not abdominal thrusts.
- Unresponsive patients need CPR/AED and visible-object removal only.
- Never delay adrenaline for anaphylaxis or advanced airway help for swelling, burns or trauma.
- Persistent symptoms after choking require hospital evaluation for aspiration or retained foreign body.
Safety note: This is educational content for EMT students. Practical airway manoeuvres, suction, adjuncts, ventilation and advanced airway procedures require approved training, current life-support certification, equipment and local protocol.
References for further study
- Resuscitation Council UK: 2025 first-aid guidelines
- Resuscitation Council UK: paediatric basic life support
- WHO/ICRC Basic Emergency Care
- WHO Community First Aid Response pocket guide
- Uganda Ministry of Health: current basic-life-support, paediatric emergency and airway-management protocols.