Deaths due to airway obstruction are more common in psychiatric inpatients than in the normal population. A dysphagia program was started in a 400 bed Massachusetts psychiatric hospital after 4 patients in 1 year died from asphyxia. In the year after the program was started, there were no deaths; however, 28 patients experienced 32 choking incidents. The 28 patients received clinical evaluations by speech pathologists, neurologists, psychiatrists, and internists. Of the incidents, 55% required use of the Heimlich maneuver to open the airway. Choking incidents could be classified into five types based on results of clinical examination: bradykinetic, dyskinetic, fast eating syndrome, paralytic, and medical. Twenty-one of the 28 patients were studied by videofluoroscopy and 86% of the videos were abnormal, showing aspiration in eight, webs in five, and delay in the oral phase in five. Patients with bradykinetic dysphagia (secondary to neuroleptic-induced extra-pyramidal syndrome [EPS]) and paralytic dysphagia appeared to experience a more severe form of choking.

Respiratory distress from upper airway obstruction is an unusual but potentially catastrophic emergency in young children. It may be caused by a number of different processes, alone or in combination, including an acute infectious process, a congenital anomaly, or a foreign body in the airway or esophagus. A working knowledge of the anomalies and diseases of the upper airway is of primary importance in pediatric emergency medicine. Classification of airway pathology can be based on the anatomic location, the patient's age, the urgency of the symptoms, and whether it is a congenital or acquired lesion or an infectious or noninfectious process. The starting point for any classification is an appreciation of the unique aspects of pediatric airway anatomy.