RCEM Syllabus Summaries - Acute Airway Obstruction (RP1), Choking (RC1), Stridor (RC2)

Executive Summary

Acute airway obstruction, designated under the Royal College of Emergency Medicine curriculum as clinical presentation RP1, remains one of the most significant challenges in the National Health Service Emergency Department environment. This presentation encompasses two distinct but often related issues: choking (RC1) and stridor (RC2). The management of these conditions requires a synthesis of rapid clinical gestalt, anatomical precision, and adherence to the latest Resuscitation Council UK and Difficult Airway Society guidelines. Choking, or foreign body airway obstruction, presents a high risk of morbidity and mortality, particularly at the extremes of age. In the United Kingdom, specific peaks in incidence are noted during mealtimes, and the elderly population remains particularly vulnerable due to factors such as poor dentition and neurological impairment.[1, 2, 3] Stridor, characterized by abnormal respiratory sounds, serves as a cardinal warning of critical upper airway narrowing. In paediatric populations, viral croup remains the most frequent cause, whereas in adults, the clinician must prioritize the exclusion of malignancy and acute supraglottitis.[4, 5]The core of management across both presentations is the preservation of oxygenation and the anticipation of a "difficult airway" scenario. For choking, the shift from basic first aid to advanced life support occurs the moment a patient loses consciousness, necessitating immediate cardiorespiratory resuscitation with an emphasis on rescue breaths to potentially displace the obstruction.[6, 7] In stridor, pharmacological temporization using high-dose corticosteroids and nebulized adrenaline is standard practice, allowing time for senior anaesthetic and ear, nose, and throat specialist intervention.[8, 9] If non-invasive methods fail, the Emergency Department must be prepared for a surgical front-of-neck airway, with the scalpel-bougie cricothyroidotomy now established as the gold standard in the United Kingdom.[9] This briefing document provides an exhaustive framework for the assessment and management of these conditions, aligning with the specialty learning outcomes required of high-level emergency physicians.