Foreign Body Asphyxia

A Preventable Cause of Death in the Elderly

Andrea M. Berzlanovich, MD, Barbara Fazeny-Dörner, MD, Thomas Waldhoer, PhD, Peter Fasching, MD,
Wolfgang Keil, MD

Background: To assess the prevalence of food/foreign body asphyxia in the elderly Viennese population
in order to reduce the incidence of these fatal events.
Methods: This is an autopsy-based, retrospective study in Vienna, Austria. Participants included all
nonhospitalized (n ⫽200) cases of choking in 1984 to 2001, from a total 42,745 consecutive
autopsies performed at the Institute of Forensic Medicine. In addition, data from
hospitalized adult cases of fatal choking (n ⫽73) in 1984 to 2001, from the mortality
registrar of Vienna, were included.
Results: The nonhospitalized choking victims were analyzed according to age (18 to 64 vs ⱖ65
years), sex, circumstances of death, and predisposing factors. Hospitalized cases were
analyzed according to age, sex, and whether an autopsy was already performed by
pathologists at the institution where they died. In the study period, 273 adults died of
food/foreign body asphyxia, 73% of them out of the hospital and 27% in hospitals.
Food/foreign body asphyxia in the elderly was characterized by a significantly higher
asphyxiation of soft/slick foods (p ⬍0.007) with agomphiasis (p ⬍0.002), occurring most
frequently during lunch (49%), and in 2.5% during feeding of neurologically impaired. In
contrast, younger individuals choked significantly more often on large pieces of foreign
material (p ⬍0.002) and showed a significantly higher rate of blood alcohol concentration
(p ⬍0.001).
Conclusions: This study demonstrates that semisolid foods are the cause of a large number of
asphyxiations, especially among the elderly. Knowledge of the fact that semisolid foods are
a high-risk factor in elderly individuals should be distributed in public and private
healthcare systems, and awareness could be a first step in reducing the incidence of
food/foreign body asphyxia.
(Am J Prev Med 2005;28(1):65– 69) © 2005 American Journal of Preventive Medicine

Introduction Forensic Medicine revealed that observers were present

in 63% of the choking events. The fatal incident was

F
ood/foreign body asphyxia is well known to
correctly identified in only 8% of cases by emergency
forensic pathologists. The description of the
personnel. Common misdiagnoses were cardiovascular
“cafe coronary,” a term coined by Haugen in
failure; epileptic seizures; and intoxication from medi-
1963,1 enhanced awareness of the causes, prevention,
cation, drugs, or alcohol.2 However, the special aspect
and emergency treatment of food asphyxiation. How-
of food/foreign body asphyxia in the elderly is rarely
ever, even today, 40 years later, people observing sud-
mentioned in current medical textbooks or journals,
den attacks— especially in the elderly— often do not
and remains largely uninvestigated.
suspect choking, and erroneously attribute death to
The fatal event of food/foreign body asphyxia may
coronary artery disease. A recent autopsy study of
be preventable. Prevention depends on understanding
food/foreign body asphyxia at the Viennese Institute of
the nature and frequency of food/foreign body as-
phyxia and its specific causes. Valuable data for com-
From the Institute of Forensic Medicine (Berzlanovich), Department munity education could be obtained from medical
of Internal Medicine I (Fazeny-Dörner), and Department of Epide- examiners who catalog all sudden and unexpected
miology, Institute of Cancer Research (Waldhoer), University of deaths, in concert with an investigation at the scene of
Vienna Vienna, Austria; Geriatric Center Baumgarten (Fasching),
Vienna, Austria; and Institute of Forensic Medicine, University of occurrence that is performed by a competent forensic
Munich (Keil), Munich, Germany pathologist.
Address correspondence and reprint requests to: Andrea M, Ber- The current study had three purposes: (1) present
zlanovich, MD, Institute of Forensic Medicine, University of Vienna,
Sensengasse 2, A-1090 Vienna, Austria. E-mail: andrea. results of an analysis of 18 years of autopsy data
berzlanovich@univie.ac.at. reporting food asphyxiation in a nonhospitalized pop-

Am J Prev Med 2005;28(1) 0749-3797/05/$–see front matter 65

© 2005 American Journal of Preventive Medicine • Published by Elsevier Inc. doi:10.1016/j.amepre.2004.04.002
ulation; (2) identify risk factors influencing food as-
phyxiation, especially in elderly individuals; and (3)
suggest preventive as well as effective accident control
strategies that can be used to minimize the risk of food
asphyxiation among the elderly.
Methods
The Viennese Institute of Forensic Medicine is the unique
institution in Vienna responsible for determining the cause
and manner of death in all cases of unexpected deaths
occurring out of hospitals. Its geographic jurisdiction encom-
passes the greater Vienna area, with a population base of 1.6
million people. At present, approximately 53% of Vienna
residents are female. Although the proportion of the popu-
lation aged ⬎60 years has been declining since 1971, Vienna
still has the largest share of elderly people (20.7%) compared
to Austria’s other provinces. Women account for 64% of the
population aged ⬎60 and 72% of those aged ⬎75.3 Approx-
imately 18% of Vienna’s resident population are foreign
nationals, most of whom emigrated from Yugoslavia and its
successor states and Turkey.
Austrian law requires the use of an autopsy to detail and
ascertain the cause of each death of people who died outside
of hospitals when the cause is uncertain and in cases in which
a physician has not been consulted within 10 days before
death. Thus, all unexpected out-of-hospital deaths in Vienna
are investigated at the Viennese Institute of Forensic
Medicine.
Subjects
Inclusion criteria for this study were adult non-hospitalized
and hospitalized victims aged ⬎18 years, fulfilling the work-
ing definition of deaths from asphyxia by foreign objects as
defined by the ICD-9 code: “Foreign body in pharynx and
larynx,” which includes “pharynx, nasopharynx and throat
not otherwise specified” (933.0), and larynx “asphyxia due to
foreign body” and “choking” due to “food (regurgitated) or
phlegm” (933.1). The data from the adult hospitalized indi-
viduals who had choked (n ⫽73) and the sex of the deceased
from 1984 to 2001 were provided from the mortality registrar
of Vienna.3
For all nonhospitalized individuals who died of food/
foreign body asphyxia, records were gathered of 42,745
autopsies performed at the Institute of Forensic Medicine.
The autopsy reports and medical histories of the individuals
were evaluated with regard to age, sex, circumstances of
death, type and consistency of the obstructing foreign mate-
rial, and consumption of alcohol or sedative and hypnotic
drugs. Furthermore, the characteristics associated with food/
foreign body asphyxia were analyzed according to age (18 to
64 versus ⱖ65 years). All autopsies were performed by eight
physicians specialized in forensic medicine.
The number of all hospitalized individuals during the study
period was provided by the mortality registrar of Vienna, from
which the sample of choking victims was drawn. For this
group, the data were analyzed according to age, sex, and
whether an autopsy was performed by local pathologists at the
institution where the individuals died.
66 American Journal of Preventive Medicine, Volume 28, Number 1
Statistics
Comparisons of continuous variables were made with the
Mann–Whitney U test. Chi-square tests were used to calculate
p values for comparisons in 2⫻2 contingency tables. Direct
standardized rates (SRs) and 95% confidence intervals (CIs)
were calculated. SAS (SAS Institute Inc., Cary NC, 2001) was
used for performing all calculations. A p value of ⬍0.05 was
considered statistically significant.
Results
Incidence of Foreign Body Asphyxia, Age, Sex,
and Autopsy Rate in Nonhospitalized and
Hospitalized Individuals
From 1984 through 2001, 273 nonhospitalized and
hospitalized adults died of food/foreign body asphyxia
in Vienna, resulting in an average of two victims per
100,000 population (men: SR⫽2.7, CI⫽2.4 –3.1; wom-
en: SR⫽1.3, CI⫽1.1–1.6; total: SR⫽2, CI⫽1.8 –2.2).
The Viennese Institute of Forensic Medicine per-
formed an autopsy on all 200 nonhospitalized choking
victims, accounting for 0.5% of deaths out of 42,745
consecutive autopsies. The male-to-female ratio was
1.2:1. The median age was 65 (range, 27 to 91) years;
105 of 200 (53%) were aged ⱖ65 years and 95 (47%)
were aged 18 to 64 years.
A total of 272,594 hospitalized patients died during
the study period in Vienna. Of this total, 73 died due to
food/foreign body asphyxia, accounting for 0.03% of
all deaths in hospitals; 49 of the latter (67%) underwent
autopsy because the cause of death was not ascertained
by the caregiver team. In these cases, food/foreign
body asphyxia was not suspected at the time of death,
but was identified by the autopsy. In the remaining 24
cases, an autopsy was not performed because the in-
ferred cause of death was not questioned. The median
age of the hospitalized individuals was 73 years (range,
45 to 96); the male-to-female ratio was 0.8:1.
Medical History of Nonhospitalized Individuals
One third of the deceased were described as healthy at
the time of death. Pre-existing conditions were present
in the remaining and are depicted in Table 1. In 43%
(45 of 105) of individuals aged ⱖ65, neurologic disor-
ders including Parkinsonism, Alzheimer disease, and
hemorrhagic stroke were evident.
Circumstances of Death of Nonhospitalized
Individuals
Sixty-nine percent of the fatal incidents occurred in
private homes, 15% in restaurants, 9.5% in private
nursing institutions, 5% in public areas, and 1.5%
during transportation to a hospital. Five neurologically
impaired victims (2.5%) choked during feeding. Of 137
eyewitnesses, 94 uniformly reported at least three of the
Table 1. Medical history of 200 nonhospitalized adult Table 2. Type and consistency of asphyxiated foreign
victims of fatal foreign body asphyxia, by age material in 200 nonhospitalized adult victims, by age
Age Age
Pre-existing
conditions of 18–64 >65 Total 18–64 >65 Total
deceased years (n) years (n) (n) years (n) years (n) (n)

Without any 45 18 63 Asphyxiated material

symptoms, Meat, fish 57 43 100
presumably Sausage 16 25 41
healthy Bread, pizza, 9 15 24
Neuropsychiatric 23 56 79 cookies, pastries
diseases Fruit, vegetables 8 6 14
Cardiovascular 20 41 61 Noodles 1 4 5
disease Cheese, eggs 1 1 2
Diabetes mellitus 9 11 20 Denture 0 2 2
Oral/pharyngeal/ 4 16 20 Not identified 3 9 12
gastrointestinal Total 95 105 200
disorders Consistency of asphyxiated material (nⴝ188)
Total 95 105 200 Solids 86 38 124
One piece of food/ 63 4 67
foreign material
Two or more pieces 23 34 57
following: cessation of eating and talking, apnea, pale- Semisolids 6 58 64
ness, cyanosis, and collapse.

Time of Death of Nonhospitalized Individuals bolus size ranged from a plum (up to 3 cm in diameter)
In 137 of 200 cases, the time of the event could be to an apricot (up to 5 cm in diameter). The largest
precisely determined. Fatal food/foreign body asphyxia obstructing foodstuff encountered at autopsy was a
occurred at breakfast for 44, at lunch for 50, and at meat chunk with a weight of 50 g, measuring 11⫻7⫻2
dinner for 17, and with snacks for 26 cases. Thirty-seven cm.
of the 50 individuals who died at lunch were ⬎65 years, The location of the obstructing material was the
representing 49% of the elderly with determined time supraglottic region or within the glottis itself in 74%,
of death (n ⫽ 75). All elderly (n ⫽10) who had presumably within reach of fingers, whereas the bolus
received a sedative the night before, choked in the early was lodged in the infraglottic area in 26%. In 24% the
morning. first morsel of food was lethal; in the remaining 76% of
cases the stomach contained undigested food.
Asphyxiated Food/Foreign Material in
Nonhospitalized Individuals Dentition of Nonhospitalized Individuals
Only 10% of victims had intact dentition (closed align-
In 188 of 200 individuals, the obstructing bolus could
ment with a minimum of 24 teeth), 32% had partial or
be identified at autopsy. The foreign material that
complete dentures, 31% had defective or partial denti-
caused asphyxia were common foods in Vienna, such as
tion without dental prostheses, and 27% were edentu-
meat, fish, sausage, bread, pizza, cookies, and pastries
lous at the time of death (Table 3). Agomphiasis (being
(Table 2). It was a solid in 124 cases and semisolid in 64
edentulous) correlated with age (p ⬍0.002).
cases. The obstructing foods were chunks of meat/fish
in 50%, and a chunk of sausage in 20%. A bolus
consisting of bread, pizza, cookies, or pastries was noted Table 3. Dentition in 200 nonhospitalized adult victims, by
in 12%, while fruit or vegetables accounted for another age
7%. A displaced denture was determined to be the Age
cause of asphyxia in two cases.
18–64 >65 Total
A single chunk of food created an obstruction in 68% Dentition years (n) years (n) (n) p value
of individuals aged 18 to 64 years, and in only 4% of
individuals aged ⱖ65 years (p ⬍0.002). Thirty-five per- Intact dentition 15 5 20 0.079
cent of the elderly choked on more complex boluses Partial/complete 20 44 64 0.215
(sausages on a bun, sandwiches, meatballs, meat and dentures
Edentulous 18 35 53 0.002
vegetables/noodles), and 61% on semisolids (puree, Defective/partial 42 21 63 0.253
ground meat, mashed fruits), as compared to a com- dentition
bined total of 7% among the 18- to 64-year-olds without dental
(p ⬍0.007). A large mass of food was found in the protheses
Total 95 105 200
mouths of 46% of all patients aged ⱖ65 years. The

Am J Prev Med 2005;28(1) 67

Alcohol and Toxicologic Analysis in
Nonhospitalized Individuals
Blood alcohol concentration and blood levels for sed-
ative and/or hypnotic drugs were analyzed in all 200
cases. At the time of death, 50% of the victims were
sober. The remaining had blood alcohol levels ranging
from 0.1% to 4.4%. Blood alcohol concentration was
significantly higher in individuals aged 18 to 64 years
compared to those aged ⱖ65 years (p ⬍0.001). Positive
blood levels for sedative and/or hypnotic drugs were
found in 12 cases (6%).
Medical Interventions in Nonhospitalized
Individuals
In 68% (n ⫽137) of cases, other people were in the
vicinity of the victim, so emergency services were called
and cardiopulmonary resuscitation started. Resuscita-
tion attempts at the scene included artificial respira-
tion, mouth-to-mouth resuscitation, and, in two in-
stances, the Heimlich maneuver. Physicians’ reports
revealed that in 125 of 137 cases the choking event,
being the initial cause for emergency intervention, was
not subsequently recognized as asphyxiation. Before
autopsy, death caused by food/foreign body asphyxia
was correctly identified in 4 of the 75 (5%) cases of
individuals aged ⱖ65 years, and in 8 of the 62 (13%)
cases aged 18 to 64 years.
Discussion
This study demonstrates old age, poor dentition, neu-
rologic disorders, certain types of foods, and the intake
of sedatives as risk factors for food/foreign body as-
phyxia. Prevention of these fatal events requires neither
special diagnostic facilities nor highly sophisticated
knowledge, but merely a simple awareness of predispos-
ing factors.
In this data set, fatal food/foreign body asphyxia
increased with age, from 0.1 per 100,000 adults aged 18
to 64 years to 0.7 for individuals aged ⱖ65 years, which
is consistent with the literature.4 – 6 It is remarkable that
half of the elderly choked during lunch. Elderly indi-
viduals are known to devote more time processing food
in the mouth and to require solids of a smaller particle
size before the food can be swallowed.7,8 Thus, rapid
feeding rates may overload marginally functional deglu-
tition, resulting in life-threatening bolus misdirection
into the airway.
In addition, this study revealed semisolid dysphagia
diets to significantly increase the risk of fatal food/
foreign body asphyxia in the elderly. Paradoxically, the
commonly propagated semisolid dysphagia diets have
been shown to significantly increase the risk of asphyx-
iation in this data set. The risk of death is further
elevated because semisolids cannot be removed easily
68 American Journal of Preventive Medicine, Volume 28, Number 1
by resuscitation interventions. For these two reasons,
semisolid diets should not be commonly prescribed.
The literature suggests that for dysphagic patients, food
should not be semisolid, but instead limited to a
particle size of 1 cm2 combined with careful patient
monitoring at mealtimes.9
In the present study, neurologic disorders such as
Parkinsonism, Alzheimer disease, or hemorrhagic
stroke were prevalent in 43% of the choking victims
aged ⱖ65 years. These neurologic conditions are
known to be related to difficulties in mastication and
motor coordination,10,11 which lead to oral-stage dys-
function12; 2.5% of the elderly who choked during
feeding were neurologically impaired. Furthermore, all
elderly individuals in the study who choked at breakfast
had received a sedative the night before. High dosages
of drugs with antidopaminergic or anticholinergic ac-
tivity have been reported to increase the risk of
choking.5,10,13
Another striking feature of this study was that intact
dentition was evident in only 10%. Dentition in the
elderly choking victims was markedly poor—all eden-
tulous elderly were asphyxiated on semisolid, slick food.
Statistically, alcohol was less a risk factor in the elderly
population than in choking individuals aged 18 to 64
years. Nevertheless, 32% of the elderly victims had an
elevated blood alcohol concentration at the time of
death.
With this data set, the risk factors of fatal food/
foreign body asphyxia could be successfully identified,
demonstrating that the high autopsy rate in Vienna
provided an excellent opportunity for detection of
these fatal events, and may elucidate a potentially
higher number of unknown cases. The identified risk
factors— old age, poor dentition, semisolid foods, neu-
rologic impairment, and intake of sedatives— could
easily be incorporated into care guidelines presented in
education programs. Based on the literature14 of child-
hood asphyxiation by food, another helpful tool might
be the establishment of asphyxiation risk scores for
adults and the definition of risky foods based on these
scores.
Education about food/foreign body asphyxia risk
factors should not be limited to healthcare workers, but
should be extended to the entire population, and
especially people aged ⱖ65. For example, the preven-
tive aspect of adequate dentition care and reconstruc-
tion must be started in adolescence and individual
responsibility must be more heavily emphasized. As in
many matters of preventive health, the prevention of
choking deaths may be achieved by simple behavior
changes and by the encouragement of healthy habits
before and after the onset of old age. The contributing
factor of poor dental health to food asphyxiation is yet
another reason for the rigorous promotion of proper
dental care.
 What This Study Adds . . .
Foreign body asphyxia in the elderly was charac-
terized by a significantly higher asphyxiation on
soft/slick foods, with agomphiasis occurring most
frequently during lunch and during feeding of
the neurologically impaired.
Especially among the elderly, semisolid foods
are the cause of a large proportion of asphyxia-
tions.
A greater awareness of this risk factor among
healthcare workers, as well among the general
public, may help to reduce the incidence of this
fatal event.
In cases of food/foreign body asphyxia where observ-
ers were present at the time of the fatal incident and
with food lodged in the glottis and supraglottic region,
application of the Heimlich maneuver15,16 might have
been life saving. The obstructing material could have
been removed by the simple insertion of fingers or by
the use of a specially designed curved plastic forceps
that is inserted into the mouth and hypopharynx.4,17
Administration of oxygen or mouth-to-mouth resuscita-
tion before removal of the obstruction is obviously
futile.17 However, the choking event was correctly iden-
tified during cardiopulmonary resuscitation in only 5%
of the elderly study population and in 13% of the
younger ones. Thus, lack of awareness on the part of
first responders seems to be another crucial factor in
the occurrence of fatal asphyxiation.
In summary, this study demonstrates that in addition
to the well-known risk factors, semisolid foods are,
especially in the elderly, responsible for a large number
of asphyxiations. The incidence of these fatal events
could be easily reduced, but require understanding of
circumstances and predisposing factors and their inclu-
sion into care guidelines. Thorough education of
healthcare workers as well as raising awareness of the
risk factors among the general populace, and especially
the elderly, may also greatly enhance the prevention of
food/foreign body asphyxia.
We are grateful to John Leake for editing the manuscript
version. The authors reported no financial conflict of
interest.
References
1. Haugen RK. The cafe coronary—sudden deaths in restaurants. JAMA
1963;186:142–3.
2. Berzlanovich A, Muhm M, Sim E, Bauer G. Food/foreign body asphyx-
ia—an autopsy study. Am J Med 1999;107:351–5.
3. Statistics Austria. Mortality records 1984 –2001. Vienna: Statistics Austria
2002 (data set).
4. Mittlemann RE, Wetli C. The fatal cafe coronary: foreign-body airway
obstruction. JAMA 1982;247:1285–8.
5. Irwin RS, Ashba JK, Braman SS, Lee HY, Corrao WM. Food asphyxiation in
hospitalized patients. JAMA 1977;237:2744 –5.
6. Gelperin A. Sudden death in the elderly population from aspiration of
food. J Am Geriatr Soc 1974;22:135–6.
7. Hu T, Huang L, Cartwrigth WS. Evaluation of the costs of caring for the
senile demented elderly: a pilot study. Gerontologist 1986;26:158 –62.
8. Fioritti A, Giaccotto L, Melega V. Choking incidents among psychiatric
patients: retrospective analysis of thirty-one cases from the west Bologna
psychiatric wards. Can J Psychiatry 1997;42:515–20.
9. Finestone HM, Foley NC, Woodbury MG, Greene-Finestone L. Quantifying
fluid intake in dysphagic stroke patients: a preliminary comparison of oral
and nonoral strategies. Arch Phys Med Rehabil 2001;82:1744 –6.
10. Pontoppidan H, Beecher HK. Progressive loss of protective reflexes in the
airway with the advance of age. JAMA 1960;174:77–81.
11. Kendall KA, Leonard RJ. Bolus transit and airway protection coordination
in older dysphagic patients. Laryngoscope 2001;111:2017–21.
12. Feinberg MJ, Ekberg O. Deglutination after near-fatal choking episode:
radiologic evaluation. Radiology 1990;176:637–40.
13. Hsieh HH, Bhatia SC, Andersen JM, Cheng SC. Psychotropic medication
and nonfatal cafe coronary. J Clin Psychopharmacol 1986;6:101–2.
14. Stallings Harris C, Baker SP, Smith GA, Harris RM. Childhood asphyxiation
by food—a national analysis and overview. JAMA 1984;251:2231–5.
15. Heimlich HJ. A life-saving maneuver to prevent food-choking. JAMA
1975;234:398 –401.
16. Heimlich HJ, Patrick EA. Best technique for saving any choking victim’s
life. Postgrad Med 1990;87:38 –48.
17. Eller WC, Haugen RK. Food asphyxiation—restaurant rescue. New Engl
J Med 1973;289:81–82.
Am J Prev Med 2005;28(1) 69