Resuscitation 88 (2015) 6367

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Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Clinical Paper

Relationships between pre-hospital characteristics and outcome in

victims of foreign body airway obstruction during meals
Kosaku Kinoshita , Takeo Azuhata, Daisuke Kawano, Yayoi Kawahara
Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Japan

a r t i c l e

i n f o

Article history:
Received 31 July 2014
Received in revised form
28 November 2014
Accepted 5 December 2014
Keywords:
Airway obstruction
Choking
Foreign body
Chest compression

a b s t r a c t
Objective: The purpose of this study is to determine the outcome of foreign body airway obstruction
according to the initial actions taken for choking victims during meals.
Methods: Our subjects were patients who became unresponsive or unconscious because of foreign body
airway obstruction (FBAO) during meals in the presence of bystander witnesses. We investigated the
associations between outcome and the following factors: age, gender, type of foreign body, chest compressions after the patient became unresponsive or unconscious, episode of cardiac arrest, efforts by a
bystander to remove the foreign body, eating-related activities of daily living, time elapsed from the 119
call to arrival of emergency medical technicians (EMTs), and time elapsed from the 119 call to hospital
arrival (primary endpoint).
Results: Of the 138 patients enrolled during the study period, 35 (25.4%) received chest compressions
by bystanders after becoming unresponsive or unconscious and 69 (50.0%) suffered cardiac pulmonary
arrest. Chest compressions by a bystander after the victim became unresponsive or unconscious
(p < 0.0001) and no CPA (p < 0.0001) were signicantly related to good outcome. Chest compressions
by a bystander were both associated with good neurological outcome (odds ratio, 10.57; 95% CI,
2.47265.059, p < 0.0001). No CPA after FBAO was another independent predictor (odds ratio, 50.512;
95% CI, 13.45284.41; p < 0.0001), but efforts to remove the foreign body before the arrival of EMTs did
not affect outcome.
Conclusion: Chest compressions by a bystander, a support received by only 25% of the patients, proved
to be essential for improved outcome for choking victims who became unresponsive or unconscious.
Education for lay-rescuer response to choking might further improve overall outcome.
2015 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Foreign body airway obstruction (FBAO) is a critical, lifethreatening condition that can occur in persons of all ages,
particularly in the elderly and persons requiring nursing care. Adult
FBAO is often witnessed by bystanders because it usually occurs
during meals.1,2 The culprit foreign body in FBAO is often a piece of
meat or sh, or any other type of food in a half solid state.3 If better
informed of the early actions to take and emergency treatment as
lay rescuers, bystanders could improve the neurological outcome of
patients who suffer anoxic/ischemic brain injury caused by FBAO.
The most common maneuvers recommended for removal of the

foreign bodies in FBAO are Heimlich abdominal thrusts, back blows,

and chest thrusts. These essential maneuvers have been conrmed
to relieve FBAO in responsive or conscious victims. If an adult choking victim becomes unresponsive or unconscious during attempts
to relieve FBAO, the lone lay rescuer should call emergency medical
services and begin cardiopulmonary resuscitation (CPR) at once.4
Few reports have described the actual situation and treatment for
human FBAO victims on the scene. The purpose of this study is to
clarify the actual situation on the scene and determine outcome
according to the initial actions taken for food-choking victims during meals in four urban districts of Tokyo, Japan.
2. Materials and methods

A Spanish translated version of the summary of this article appears as Appendix

in the nal online version at http://dx.doi.org/10.1016/j.resuscitation.2012.09.015.
Corresponding author at: 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo 1738610, Japan.
E-mail address: kinoshita.kosaku@nihon-u.ac.jp (K. Kinoshita).
http://dx.doi.org/10.1016/j.resuscitation.2014.12.018
0300-9572/ 2015 Elsevier Ireland Ltd. All rights reserved.

2.1. Target area

The target area for this study was the west-northwest area of
Tokyo (4 of the 23 administrative districts of Tokyo: Toshima, Kita,

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K. Kinoshita et al. / Resuscitation 88 (2015) 6367

Itabashi, and Nerima wards), a medical zone covering an area of

113.9 km2 . This zone is serviced by 30 emergency medical service
ambulance units and three hospitals operating as Grade 3 emergency and critical care centers, of which our hospital is one. A
residential population of 1,778,762, about 14% of the population
of Tokyo, lived within this zone in 2013. Males make up 42.1% of
the residents within the zone, and 21.3% of the residents are more
than 65 years old.

2.2. Study patients

The protocol for this study was approved by the Clinical
Research Institutional Review Board (IRB: RK-140711-12) of this
hospital.
The study was designed as a single-institution retrospective
observational investigation using a database of patients treated at
our hospital from January 2003 to December 2013. The subjects suffered from FBAO in the presence of bystanders during meals and
ultimately became unresponsive or unconscious.
Pre-hospital data on the patients were obtained from the emergency medical technicians (EMTs) or lay rescuers or bystander
witnesses who were present when the patients became unresponsive or unconscious because of FBAOs during meals in this
study. Every morning, team members in the emergency department (physicians, nurses, a pharmacologist, and an emergency
medical technician) held a conference to review and discuss the
details of the clinical record for every patient newly transferred
to our department, including many of the factors related to the
neurological outcome for this study. Our medical staff input this
information into the patient database not only for patients with
FBAO, but for all patients newly admitted to our emergency department. This database was updated and revised after each patient case
was discussed. The analyses were performed for all new patients.
All data for this study were obtained from the database and our
patients clinical records. Patients were excluded from this study if
they were younger than 20 years old or if details were missing on
pre-hospital events such as rst aid on the scene or type of foreign
body.
The outcome was evaluated when the patient was discharged
or transferred from our hospital. The primary endpoint was
whether or not a good neurological outcome was achieved.
Neurological evaluations were performed using the Pittsburgh
cerebral-performance categories (CPC). A good outcome was
dened as CPC 1 (good recovery) or 2 (moderate disability), and a
poor outcome was dened as CPC 3 (severe disability), 4 (vegetative
state), or 5 (death).5
As a secondary endpoint we also studied the possibility that the
neurological outcome for all choking victims has improved year by
year over the last decade.
The following factors related to outcome were analyzed based
on medical records and the patient database: (1) age, (2) gender,
(3) type of foreign body (4), whether or not chest compressions
were performed for the patients who became unresponsive or
unconscious, (5) the presence or absence of cardiopulmonary arrest
(CPA) up to the point of hospitalization, (6) whether or not a
bystander made efforts to remove the foreign body before or after
the patient became unresponsive or unconscious, (7) eating-related
activities of daily living before hospitalization, (8) time elapsed
from the 119 call to the arrival of EMTs, (9) time elapsed from
the 119 call to arrival at the hospital, and (10) the sequential
changes in neurological outcome year by year during the study
period.
All event times in the pre-hospital setting were measured by the
dispatch center clock in the Tokyo Fire Department.

2.3. Statistical analysis

Statistical analyses were performed using JMP ver. 11.0 (SAS
Institute, Cary, NC, USA). Logistic regression analysis was used to
examine neurological outcome. The Students t-test was used to
compare continuous variables and the Chi-square test was used to
compare categorical data. The outcome was predicted by performing a multiple logistic regression by the forced entry method and
calculating the odds ratios and 95% condence intervals (CIs). The
forced entry method was used for the previously described factors
related to outcome as explanatory variables.
For secondary endpoints, the differences in the neurological outcomes of the samples of patients for each year were studied on a
year-over-year basis to determine if there was an increasing trend
for improved outcomes over the duration of the study. Patients
from January 2003 to December 2013 were enrolled for the 10year observation period. The neurological outcomes of the samples
over the study period were studied using single regression analysis. The data from the yearly changes over the 10-year study period
were treated as continuous variable data.
Data are expressed as mean SD or as the no. patients in percent
terms (%). p < 0.05 was dened as statistically signicant.

3. Results
One hundred and sixty-two consecutive cases who suffered
FBAO during meals and became unresponsive or unconscious were
enrolled during the study period. After excluding 6 children, 11
patients whose FBAO went unwitnessed before loss of consciousness, and 7 patients for whom pre-hospital care were unclear, 138
adult choking victims (57 males, 81 females) were included in this
study. Thirty of the subjects suffered FBAO during meals at daycare
centers for the elderly.
The average age of the patients was 77.3 12.5 years old
(76.5 10.4 males, 78.0 13.9 females; range 2899 years old).
Fifty-two (37.7%) of the patients required some help in eatingrelated activities of daily living at the time of the FBAO, and the
other 86 (62.3%) did not. There was no signicant difference, however, between the eating-related activities of daily living before
choking and neurological outcome (Table 1).
The foreign body obstructions choking the subjects were composed of bread (n = 27), rice cake (n = 21), sushi or sashimi sh slices
(n = 11), general snacks (n = 10), vegetables (n = 9), meat (n = 6), and
various other foods. Though highly variable in type and quality,
the foreign bodies were divided into two basic types: either solid
masses of fairly large pieces of food clumped together (bread, rice
cake, etc.), or non-solid masses made up of small particles or pieces
of food clumped together (grains of rice, noodles, etc.). In total, there
were 95 solid masses and 43 non-solid masses.
Bystanders made efforts to remove the foreign body in 36
(26.1%) of the patients between the time the patient became unresponsive or unconscious and the time the EMTs arrived (Table 1).
The bystanders attempting to remove the foreign bodies did
so using the nger sweep method (n = 23), mechanical suction
(performed at daycare centers for the elderly) (n = 17), and a combination of both nger sweep method and mechanical suction.
Other methods were back blows (n = 17) and the Heimlich maneuver (n = 2). Efforts to remove the foreign body had no signicant
inuence on outcome.
The time elapsed from the 119 call to the arrival of the EMTs
on the scene or the arrival of the patient at the hospital did not
signicantly differ between patients with good outcome and poor
outcome. Of 138 patients, 35 (25.4%) received chest compressions by a bystander after becoming unresponsive or unconscious.
Sixty-nine (50.0%) experienced CPA recognized by an EMT before

K. Kinoshita et al. / Resuscitation 88 (2015) 6367

65

Table 1
Comparison of factors related to neurological outcome in choking victims during
meals.
Good outcome
Total no. of patients (n)
60
Background
77.5 13.3
Age
22 (38.6%)
Gender (male)
Male:female
22:38
46 (48.4%)
Solid mass
46:14
Solid mass:non-solid
mass
Eating dependent
23 (44.2%)
Actions at the scene
24 (68.6%)
Chest compressions
by a bystander
33 (43.4%)
Attempt to remove
the foreign body
No CPA
51 (73.9%)
Time from 119 call (minutes)
6.6 2.3
Arrival at the scene
Arrival at hospital
34.1 8.0

Poor outcome

p value

78
75.3 17.1
35 (61.4%)
35:43
49 (51.6%)
49:29

0.199
0.331

29 (55.8%)

0.889

11 (31.4%)

0.0005

43 (56.6%)

0.988

18 (20.1%)

<0.0001

7.2 3.4
36.0 8.7

0.910
0.905

0.079

CPC: cerebral-performance category; good outcome: CPC 1 (good recovery) or 2

(moderate disability); poor outcome: CPC 3 (severe disability), 4 (vegetative state),
or 5 (death); solid mass: large pieces of food forming a solid mass in the airway; nonsolid mass: small particles of food forming a non-solid mass in the airway; eating
dependent: eating-related activities of daily living (ADLs) before hospitalization;
chest compressions by a bystander: whether or not chest compression was performed for a choking victim who became unresponsive or unconscious; attempt to
remove the foreign body: efforts by a bystander to remove the foreign body before
the arrival of emergency personnel; CPA: cardiopulmonary arrest; arrival at the
scene: time elapsed from the 119 call to the arrival of emergency personnel; arrival
at hospital: time elapsed from the 119 call to arrival at hospital.

hospitalization, and 38/69 (55.1%) had not received bystander CPR

in spite of CPA before the EMTs arrived at the scene. Ultimately
all CPA patients did receive CPR from the EMTs, and 55 (79.7%)
obtained return of spontaneous circulation and were admitted to
the ICU with post-cardiac arrest syndrome. Chest compressions by a
bystander after becoming unresponsive or unconscious (p < 0.0001)
and no CPA (p < 0.0001) were both signicantly related to good outcome. Finally, of the 138 patients transferred to the emergency
department, 78 (56.5%) had a poor outcome (Table 1).
As a secondary endpoint, we performed a logistic regression
analysis to identify signicant improvements in neurological outcomes for each year elapsed from the initiation of the study
(adjusted odds ratio 1.33; improved outcomes were observed year
by year from the initiation of this study; 95% CI, 1.1841.520;
p < 0.0001). The changes in outcome during each year of the study
are indicated in Fig. 1.
Multiple logistic-regression analysis (Fig. 2) showed that the
initiation of chest compressions by a bystander after the patient
became unresponsive or unconscious (adjusted odds ratio, 10.57;
95% CI, 2.47265.0591; p < 0.0001) was associated with a good outcome. Other independent predictors of good outcome were no
episodes of CPA after FBAO (adjusted odds ratio, 50.51; 95% CI,
13.45284.4; p < 0.0001) and lateness (20032013) in the study
period (adjusted odds ratio per one-year increase, 1.598; 95% CI,
1.2582.144; p < 0.0001).
4. Discussion
Our results clearly demonstrate that chest compressions by a
bystander are likely to be the most important action for achieving
a good outcome for an FBAO patient who becomes unresponsive
or unconscious. Efforts by a bystander to remove the foreign body
before the EMTs arrived on the scene did not notably affect outcome. Quick action by a bystander with accurate knowledge on the
scene may also be important for improving outcome for choking
victims.

Fig. 1. Sequential changes in neurological outcome year by year during the study.
n: patient cases per year; white column: good outcome, namely, CPC 1 (good recovery) or 2 (moderate disability); black column: poor outcome, namely, CPC 3 (severe
disability), 4 (vegetative state), or 5 (death); CPC: cerebral-performance category.

Educational seminars on CPR have been widespread throughout

Japan since the American Heart Association published its guidelines
for CPR emergency cardiovascular care in 2000. For FBAO patients
in particular, the publication of the 2000 guidelines spread awareness of the importance of chest compressions if and when a patient
becomes unresponsive or unconscious. In light of the guidelines
and their inuence on awareness, we decided to estimate how neurological outcome changed over the course of this 10-year study.
We found, as a result, that the neurological outcomes signicantly
improved over the last decade in the urban zone of Tokyo studied. While the chain of survival is clearly a crucial lifeline for
choking victims, few reports have discussed the actual actions by
bystanders on the scene. Though only a relatively small proportion
(25%) of patients received chest compressions by bystanders after
becoming unresponsive or unconscious in this study, education
of bystanders to provide emergency responses to life-threatening
choking accidents could improve the overall neurological outcomes
of victims.
Reports from clinical studies6,7 and studies with cadavers8 indicate that chest compressions provide sufcient airway pressure to
expel foreign bodies from the airway. A lone lay rescuer should
begin CPR at once if a choking victim becomes unresponsive or
unconscious,4 as the victim will deteriorate into cardiac arrest if
the foreign body is left in place. Appropriate initial actions must
be taken before the EMTs arrive, so onsite emergency actions by
bystanders are clearly indispensable.
The outcome of CPA caused by FBAO is very poor, even if return
of spontaneous circulation is obtained. Of the patients recognized
by the EMTs to have suffered CPAs, 55% received no chest compressions from bystanders. Bystanders made efforts to remove the
foreign body before the EMT arrival in 76 of the 138 patients transported to the emergency department (55.1%, Table 1). We were
unable to determine whether the lay rescuers were able to continue the chest compressions without interruption while trying to
remove the foreign body. The guidelines4 recommend that if an
adult victim with FBAO becomes unresponsive, the rescuer should
carefully lower the patient to the ground, immediately call emergency medical services, and begin CPR. Minimized interruption of
the CPR has been conrmed to increase the rate of survival up to
hospital discharge in patients who suffer out-of-hospital cardiac
arrest.9 Hence, continuous chest compressions are of the utmost
importance even in patients with FBAO although this study was not
an evaluation of the effectiveness of ventilations during CPR. The
lack of any benet from the efforts to remove the foreign body in
terms of neurological outcome may be explainable by interruption

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K. Kinoshita et al. / Resuscitation 88 (2015) 6367

Fig. 2. Factors related to neurological outcome in patients who suffered foreign body airway obstruction during meals. Chest compressions by a bystander after the patient
became unresponsive or unconscious and no CPA after foreign body airway obstruction were both independent predictors of good outcome. Outcome improved year by year
in this 10-year study, hence later years were also independently predictive of good outcome. CPC: cerebral-performance category; good outcome: CPC 1 (good recovery) or 2
(moderate disability); poor outcome: CPC 3 (severe disability), 4 (vegetative state), or 5 (death); solid mass: large pieces of food forming a solid mass in the airway; non-solid
mass: small particles of food forming a non-solid mass in the airway; eating dependent: eating-related activities of daily living before hospitalization; chest compressions by
a bystander: whether or not chest compressions were performed for a choking victim who became unresponsive or unconscious; attempt to remove the foreign body: efforts
by a bystander to remove the foreign body before the arrival of emergency medical technicians (EMTs). CPA: cardiopulmonary arrest; arrival at the scene: time elapsed from
119 call to the EMTs arrived; arrival at hospital: time elapsed from 119 call to arrival at the hospital; year-over-year differences from initiation of the study: differences in
outcome for each successive sample year elapsed from the initiation of this study. Years in the latter part of the study (20032013) were also independently predictive of
good outcome.

of the chest compressions after the patients became unresponsive

or unconscious or fell into CPA. Therefore, our suggestion is for
lay rescuers to concentrate only on chest compressions and to not
spend time on removing foreign bodies.
Alcohol intake during meals, weakening of the deglutition reex
with age, and unxed dentures have also been reported to inuence FBAO.1013,3 These factors may be more closely linked to
FBAO in the elderly. The mean age of the choking victims was
very high in this study. While a good proportion of our subjects
required some degree of caregiver support in eating, eating-related
activities of daily living did not affect the outcomes. If a victim
becomes unresponsive or unconscious before the EMTs arrive,
however, we believe that immediate chest compressions by a
bystander should be regarded as mandatory, regardless of the victims age.
According to earlier report, meat is often the culprit foreign body
in cases of FBAO during meals.3 Approximately one-third of the
foreign bodies in our cases were bread or rice cake, and only 4.3%
of the obstructions were meat. We suspect that outcome in our
cases may have been affected by the type of foreign body causing
the obstruction, given that the efforts of bystanders to remove the
foreign bodies had no effect. If this is so, our results are probably
linked to the Japanese eating habits of our subjects.
This study has some limitations. First, it was a retrospective
observational study on a limited number of institutions, and our
hospital lacked clear standards of care for patients who became
unresponsive or unconscious after FBAO. Second, since the patient
database we used was also used to manage data for all patients
newly admitted into our department and was not a dedicated
databases for the patients in this study, our results may have been
skewed considerably despite our efforts to remove any skew by
reviewing each case and updating the database. Third, this study
was not an evaluation of the type of bystander CPR that was
given, that of hands-only CPR or not. A prospective multi-center
study would provide a more denitive evaluation of the methods

of CPR for choking patients who become unresponsive or unconscious.

5. Conclusion
Appropriate initial actions for choking victims before the arrival
of the EMTs are of extreme importance, and CPR by a bystander
are essential for improved outcome in any choking victim who
becomes unresponsive or unconscious. Bystanders administered
chest compressions for only a quarter of the choking victims in
this study. The efforts by bystanders to remove the foreign bodies before the EMT arrival on the scene had no association with
good neurological outcome. Our result suggests that education for
the lay-rescuer response to choking could further improve overall
outcome.
Conicts of interest statement
There are no conicts of interest to declare.
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