Important disclaimer: The information in this guide is for educational purposes only. In an emergency, call 999 immediately. Caregivers are strongly advised to complete a certified first aid course through the Hong Kong Red Cross, St John Ambulance or Hospital Authority to receive hands-on training.

Choking Cough vs True Choking: A Critical Distinction

Caregivers of elderly people with dysphagia must be able to distinguish between a choking cough and true (complete) choking — because the correct responses are very different.

Choking Cough

• The patient can make a sound or speak
• Coughing is audible and forceful
• The patient is distressed but the airway is not completely blocked

Response: Encourage the patient to remain seated upright or lean slightly forward, and continue coughing actively. Do not pat the back (this may push the obstruction deeper). Do not offer water (may worsen the blockage). Monitor closely and allow the cough reflex to clear the material.

True (Complete) Choking

• The patient cannot speak or vocalise
• Cannot cough, or cough is extremely weak and ineffective
• May show: hands gripping the throat (universal choking sign), bluish colouring of lips and fingertips (cyanosis), severe respiratory distress or complete cessation of breathing

True choking is a medical emergency. Begin first aid immediately while arranging for someone to call 999.

Choking First Aid Steps for Adults

The following steps apply to a conscious adult patient who can sit or stand. See the section below for important adaptations for elderly and frail patients.

Step 1: Confirm True Choking

• Ask: “Can you breathe? Can you cough?”
• If the patient cannot answer, cough or breathe effectively, proceed immediately with first aid

Step 2: Deliver 5 Back Blows

1. Stand or kneel to the side and slightly behind the patient
2. Support the patient’s chest with one hand
3. Using the heel of your other hand, deliver 5 firm blows between the shoulder blades, directing force downward and forward

Each blow should be forceful enough to dislodge the obstruction through impact.

Step 3: Deliver 5 Abdominal Thrusts (Modified Heimlich Manoeuvre)

If 5 back blows do not dislodge the obstruction:

1. Stand behind the patient and wrap both arms around the waist
2. Make a fist with one hand; place the thumb side against the abdomen between the navel and the lower end of the sternum (xiphoid process)
3. Grasp your fist with the other hand
4. Deliver 5 sharp inward-and-upward thrusts

Important adaptations for elderly patients:

• Elderly patients have more fragile bones — apply sufficient force to be effective but avoid excessive force
• Adjust your position and stance based on the patient’s build and height

Step 4: Alternate Until Resolved or Patient Loses Consciousness

Continue alternating 5 back blows and 5 abdominal thrusts until:

• The obstruction is expelled
• The patient can breathe, speak or cough
• Or the patient loses consciousness (see section below)

Adaptations for Special Situations

Patients in Wheelchairs or Unable to Stand

Many elderly dysphagia patients in Hong Kong use wheelchairs. For wheelchair users:

Back blows:

• Stand to the side and slightly behind the patient
• Support the patient’s chest with one hand; deliver back blows between the shoulder blades with the other
• Confirm the wheelchair brakes are locked before beginning

Abdominal thrusts:

• Kneel or crouch in front of the patient
• Place both hands on the abdomen and thrust upward and inward
• If abdominal thrusts are not feasible, use chest thrusts (see below)

Obese Patients or Pregnant Patients

• Replace abdominal thrusts with chest thrusts
• Place both hands on the centre of the sternum and thrust inward

Patient Loses Consciousness

If the patient loses consciousness, call 999 immediately (if not already done) and begin CPR:

• Lower the patient carefully to the ground
• Check the mouth — if you can see a solid obstruction, carefully remove it with a finger (do not perform blind finger sweeps)
• If you are not trained in CPR, the 999 operator will guide you over the phone
• Continue CPR until emergency services arrive

Post-Aspiration Incident Management

Even if the patient successfully expels the material or recovers from a choking cough, a significant aspiration event warrants follow-up care.

Immediate Steps

1. Allow the patient to rest fully — stop feeding, and allow time for the patient to recover physically and emotionally
2. Monitor for the following warning signs, which require immediate medical attention or a 999 call:
   • Continued breathing difficulty or stridor (high-pitched breathing sound)
   • Persistent blue colouring of lips or fingertips
   • Confusion or excessive drowsiness
   • Abnormal heart rate or rhythm

24–72 Hour Monitoring

Aspiration pneumonia typically develops 24–72 hours after the aspiration event. Watch for:

• Fever above 38°C
• Rapid or laboured breathing
• Increased coughing, possibly with sputum
• Noticeably reduced alertness or overall deterioration

If any of these symptoms appear, go to the Accident and Emergency department immediately, and tell the attending doctor that an aspiration event occurred and when.

Inform the Speech-Language Pathologist

Report all significant choking or severe choking cough episodes at the next SLP appointment, including:

• When and in what context the incident occurred
• The food or liquid type being eaten at the time
• What first aid measures were taken
• Any symptoms in the hours following the incident

The SLP may recommend instrumental assessment (VFSS or FEES) or a review of the current IDDSI diet level in response.

When to Call 999

Call 999 immediately in any of the following situations:

• The patient cannot breathe (or is in severe respiratory distress) and first aid is not resolving the obstruction
• The patient loses consciousness
• The patient’s lips or fingertips remain blue after the obstruction is cleared
• After apparent resolution, the patient has noisy, laboured breathing (suggesting material may remain in the airway)
• The patient is elderly and frail, and the incident is causing significant concern

What to tell the 999 operator:

• The patient’s approximate age and your address
• “My patient has dysphagia and is choking. We have been applying first aid. We need an ambulance immediately.”
• Keep the line open — the operator will guide you through further steps

Prevention: Reducing Daily Choking Risk

The most effective response to a choking emergency is preventing it from occurring. Combining IDDSI-compliant modified texture diet with safe mealtime practices substantially reduces risk:

• Strictly adhere to the IDDSI food and drink levels prescribed by the SLP
• Ensure the patient sits upright (minimum 90°) at every meal
• Limit each mouthful to approximately one teaspoon
• Allow the patient to fully swallow before the next mouthful
• Avoid feeding when the patient is tired, drowsy or unwell
• Maintain regular SLP follow-up to detect changes in swallowing function early

Frequently Asked Questions

Q: Should I pat the patient on the back when they start coughing?

A: If the patient can still cough effectively (choking cough, not true choking), do not pat the back — this can interfere with the natural cough reflex or push the obstruction deeper. Back blows are only appropriate when the patient is confirmed to be unable to cough or breathe (true choking).

Q: After the Heimlich manoeuvre worked and the patient says they’re fine, do we still need to go to hospital?

A: Yes, a medical assessment is strongly recommended. The Heimlich manoeuvre itself can cause internal injuries — including rib fractures and visceral injury — and the expelled material may have been only partial. Any serious choking episode warrants an A&E evaluation.

Q: If I’m alone with the patient, do I call 999 or perform first aid first?

A: Do both simultaneously. Call out loudly for help from neighbours or bystanders first. Then start first aid (back blows and abdominal thrusts). Call 999 as soon as you can — modern smartphones allow you to stay on the line while continuing first aid, and the emergency operator will guide you through the process.

Q: How can caregivers access first aid training in Hong Kong?

A: Several organisations offer first aid courses suitable for caregivers:

• Hong Kong Red Cross (hkredcross.org.hk): standard and refresher first aid courses
• St John Ambulance (stjohn.org.hk): first aid certificate programmes
• Hospital Authority patient education: some hospital clusters offer dysphagia caregiver workshops covering emergency response

Information on this page is for educational purposes only and does not constitute medical advice or a substitute for formal first aid training. In an emergency, call 999 immediately.