Choking

Basic treatment of choking includes a number of non-invasive techniques to help remove foreign bodies from the airways. Most modern protocols, including those of the American Heart Association and the American Red Cross, recommend several stages, designed to apply increasingly more pressure. For the conscious choking victim, most protocols recommend encouraging the victim to cough, followed by hard back slaps and, if none of these things work, abdominal thrusts (Heimlich maneuver) or chest thrusts. Once the choking victims loses consciousness, initiating CPR is recommended.[16]

If the choking individual is conscious and coughing, the American Red Cross recommends encouraging the individual to stay calm and continue coughing freely, and it may be easier to take air through the nose to refill the lungs. If the person choking is unable to cough or if coughing is not effective, the American Red Cross recommends to move onto other methods, detailed below.[17]

Back blows (back slaps) depiction. Rescuer bends the victim's body as much as possible and then slaps.

Many associations, as the American Red Cross and the Mayo Clinic, recommend the use of back blows (back slaps) to aid in the rescue of choking victims. This technique starts by bending the choking victim forward as much as possible, even trying to place his head lower than the chest, to avoid the risk of the slaps could drive the object deeper into the person's throat (that is a rare complication, but possible). The bending is in the back, the neck should not be excessively bent. Back blows are performed by delivering forceful slaps with the heel of the hand on the victim's back, between the shoulder blades.[18][19]

The back slaps push behind the blockage, being able to dislodge the foreign object. In some cases, the physical vibration of the action may cause enough movement of the object to assist the patient in clearing the airway.

Abdominal thrusts anti-choking technique: apply them on the area located between the chest and the belly button.

Abdominal thrusts[20] are performed with the rescuer standing behind the choking victim. The rescuer closes his skillful hand, grasps it with the other hand, and presses forcefully inwards and upwards with both of them on the area located between the chest and the belly button of the victim. The pressure is not focused directly against the ribs, to avoid breaking any of them. If the first thrust doesn't solve the choking, it can be repeated several times. Usage of abdominal thrusts is not recommended in infants under 1 year of age due to risk of causing injury; there exist adapted techniques for them (see more further below). Abdominal thrusts should not be used, either, when the patient's abdomen presents problems to receive them, like pregnancy or excessive size; then chest thrusts are advised (see further below).

The purpose of abdominal thrusts is to create a pressure capable to expel the object lodged upwards in the airway, relieving the obstruction. This method was discovered by Dr. Henry Heimlich in 1974, so it is referred to as "The Heimlich Maneuver." Dr. Henry Heimlich claimed that his maneuver was better than the back blows, arguing that back blows could cause the obstruction to become more deeply lodged in the victim's airway. That claim started a debate[21] into the medical community, that ended up with the recommendation of alternating both techniques, but making the patient to bend the back before receiving the slaps.[22][18][19] So the Heimlich Maneuver itself uses only abdominal thrusts, but is also part of anti-choking protocols that include the back blows (back slaps) technique.

Chest thrusts anti-choking technique: if the victim can not receive thrusts on the abdomen, use chest thrusts; apply them on the lower half of the chest bone, but not in the very endpoint.

When abdominal thrusts can not be performed on the victim (in case of pregnant or too obese victims, and others) chest thrusts are advised instead.[23]

Chest thrusts are performed with the rescuer standing behind the choking victim. The rescuer closes his skillful hand and grasp it with the other hand. This can produce several kinds of fists, but any of them can be valid if it can be placed on the chest of the victim without sinking there a knuckle too painfully. Keeping the fist with both hands, the rescuer uses it to press forcefully inwards on the lower half of the chest bone (approximately), but not in the very endpoint (which is the xiphoid process). It can be noted, as a general reference, that, when the victim is a woman, the zone of pressure of the chest thrusts would be normally upper than the level of the breasts. The pressure is not focused against the xiphoid process, to avoid breaking it. If the first thrust doesn't solve the choking, it can be repeated several times.

The American Red Cross recommends a protocol of alternating five back blows and five abdominal thrusts for conscious choking victims until the object blocking the airway is dislodged. For pregnant or too obese victims, the protocol is the same, but chest thrusts are advised instead of the abdominal ones. If the victim becomes unconscious, basic CPR is recommended.[17] Anyway, it's convenient to make someone call to emergency medical services before it happens.

The Red Cross does not specifically refer to its choking victim protocol as the "Five and Five Technique", and it differs from the Heimlich Maneuver since it includes administering back blows to the victim, contrary to Dr. Heimlich's procedure which specifically omitted back blows and was based only on his technique.

During the 2010-2020 decade, some effective anti-choking devices have been developed and released to the market. They have superseded primitive inventions appeared during the 20th century. The current anti-choking devices have some advantages compared with manual techniques. The usage of these devices is always quite easy. They can be especially useful in difficult cases, like disabled patients, elderly people, unconscious victims or when the victim is oneself. Also, they can be helpful in public places and crowded events. And, finally, they achieve levels of pressure in suction that can not be matched by manual methods. In the worst choking cases, no manual technique would dislodge the foreign object, being necessary the usage of one of these devices or a sort of surgery. That's why physicians recommend to put some care in eating.

The design of these devices is based in a vacuum mechanical effect, with no need of batteries or electric current. They usually present an attached mask, in order to make a vacuum from the patient's nose and mouth. The current models of anti-choking devices are quite similar: a direct plunger tool (LifeVac),[24] or a vacuum syringe (backward syringe) that keeps the tongue in place by inserting a tube in the mouth (Dechoker).[25] Both have received certifications[26][27] and have been proven effective in many real cases reported by the media.[28][29] Some other mechanical models are in development, this is the case of Lifewand[30] (now being released to market), which makes the vacuum by direct pressure against patient's face, and the prototype of Dr. De Luca (now seeking funds ), which uses a button. The challenges for the future of the anti-choking inventions are just to improve their portability reducing more their size and to develop a device that specifically works in babies (despite all the previous ones have any model for little children).

Chest compressions of cardiopulmonary resuscitation (CPR).

When a choking victim becomes unconscious, it's mandatory to call to emergency medical services if this has not been done yet.

Rescue breaths of cardiopulmonary resuscitation (CPR).

For the rest, an unconscious choking victim should receive a first-aid treatment that is similar to the case of any other non-breathing patient: a cardiopulmonary resuscitation (CPR), alternating series of around 30 compressions (on the lower half of the chest bone) with series of 2 rescue breaths (pinching the victim's nose and puffing air inside of the mouth; it's also possible to tilt the victim's head up or down and give 2 additional breaths, so the air could find an entrance through the blockage). The difference between CPR in choking victims and a normal CPR is that CPR in choking victims includes an attempt to remove the obstructing object (mainly using finger sweeping when the object is already visible) at the end of each compressions serie. The chest compressions of cardiopulmonary resuscitation (CPR) produce coincidentally the same anti-choking effect than the chest thrusts technique, so the CPR itself could expel the object. If the object is expelled and followingly removed, CPR must continue until the victim recovers breathing.[31] Babies (infants under 1 year old) require a special adaptation of the procedure (described further below).

An anti-choking device can unblock the airway on unconscious victims, but not necessarily can take the obstructing object out of the mouth (it may need a manual removal). Anyway, the victim will require cardiopulmonary resuscitation (CPR) after that, as it has been described above, but only alternating the 30 compressions and the 2 rescue breaths.

In unconscious victims of choking, the American Medical Association advocates sweeping the fingers across the back of the throat to attempt to dislodge airway obstructions.[32] However, many modern protocols recommend against the use of the finger sweep. Red Cross procedures specifically direct rescuers not to perform a finger sweep unless an object can be clearly seen in the victim's mouth due to the risk of driving the obstruction deeper into the victim's airway. Other protocols suggest that if the patient is conscious they will be able to remove the foreign object themselves, or if they are unconscious, the rescuer should simply place them in the recovery position as this allows (to a certain extent) the drainage of fluids out of the mouth instead of down the trachea due to gravity. There is also a risk of causing further damage (for instance inducing vomiting) by using a finger sweep technique. There are no studies that have examined the usefulness of the finger sweep technique when there is no visible object in the airway. Recommendations for the use of the finger sweep have been based on anecdotal evidence.[16]

For babies (infants under 1 year old), the American Heart Association recommends[33] to perform cycles of back blows (5 back slaps) followed by chest thrusts (5 chest compressions, that are adapted).

Back blows and chest thrusts for babies

In the back blows, it's recommended that, before applying them, the baby is slightly leaned upside-down, being supported by a forearm of the rescuer and its respective hand (the baby's head must be carefully held in this maneuver, usually from the jaw). To achieve this position, the rescuer can sit down on any seat with the baby, so the baby's body (supported by the forearm and hand of the rescuer) can be leaned along the rescuer's thighs. As an alternative to this (in case of the baby is too big or any other problem), the rescuer can sit on a bed or sofa, or even on the floor (when no seat is near), supporting on the lap the baby's body, to make the upside-down leaning from the lap, at the right or at the left. If the rescuer can not sit down, at least could try to do the maneuver low over a soft surface (to reduce a possible fall). In case of the previous options are not possible, but the rescuer is skillful enough, the rescuer can still kneel on a knee, and place the baby's body along the thigh that is higher (with the forearm still supporting between the thigh and the baby), so the baby can be leaned a bit moving forward that thigh. When the baby is already leaned (using any of the systems), the rescuer applies the slaps.

In the chest thrusts maneuver, the baby's body is placed lying. Then the rescuer does the compressions on the chest bone, pressing with only two fingers on its lower half (the nearer to the abdomen). Abdominal thrusts are not recommended in children less than 1 year, because they can cause liver damage.[33]

The cycles of 5 back blows and 5 chest compressions are alternated until the object comes out of the infant's airway or until the infant becomes unconscious.[33]

If the infant becomes unconscious, the American Heart Association[33] recommends starting a cardiopulmonary resuscitation (CPR), which must be adapted to babies. In that procedure, the baby is placed face up on a horizontal surface, with the head in straight position (tilting too much a baby's head backwards can close the access to the trachea). Then it must be applied an alternating cycle of 30 chest compressions (but modified: the rescuer presses with only two fingers in the lower part of the chest bone), and 2 rescue breaths (also modified: the rescuer's mouth puffs air covering the baby's mouth and nose at the same time). Between chest compressions and rescue breaths, the rescuer looks into the mouth searching if the obstructing object has come out (because of the effect of the compressions) and, if it is visible, attempts to extract it (mainly using a finger sweeping). If the object is extracted, the cardiopulmonary resuscitation continues until the baby's breath is successfully recovered or until medical services arrive.

The American Heart Association recommends the chest thrusts rather than the abdominal thrusts for pregnant or too obese persons who are choking.[16] Chest thrusts are performed in a similar way to the abdominal thrusts, but with the hands placed on the lower part of the choking victim's chest, at the lower half of the breast bone (sternum), rather than over the middle of the abdomen, as in the traditional abdominal thrusts. Strong inward thrusts are then applied.[18] As a reference, in women, the zone of pressure of the chest thrusts (the lower half of sternum) would be normally upper than the level of the breasts. The chest thrusts can be alternated with back blows (back slaps), which are applied on the back of the victim when it is very bent forward.

If the choking victim is a disabled person and is using a wheelchair, the first-aid procedure is quite similar than in the case of the other victims. The difference is in trying to apply the techniques directly, while the victim is still seated on the wheelchair.[34]

The back blows (back slaps) can be used after bending forward the back of the victim very much, as much as possible. To perform the abdominal thrusts (Heimlich maneuver), the back of the victim must be bent too, and the rescuer has to get behind the wheelchair. Then, the rescuer can embrace the victim's abdomen from behind and up, leaning over the top of the wheelchair's backrest. If this is too difficult, the rescuer can get down to embrace the victim's abdomen and the wheelchair's backrest all together. The same can be tried from a side or in another way. Finally, the rescuer has to apply the sudden inward and upward pressures on the abdomen. It must be remembered that, if the victim can not receive abdominal thrusts (this is the case of the pregnant or too obese people), chest thrusts must be used instead. They are applied while the victim is in the wheelchair too, but making sudden inward pressures on the lower part of the chest bone against the wheelchair's backrest and the rescuer's body. If there are difficulties for this, the same maneuver can be tried from a side or in another way.

Due to the additional difficulties in helping to the disabled, it is convenient to avoid placing them in too narrow and encased spaces at the mealtimes. The opened spaces give an easier access to them for the rescuers.

The presence of an anti-choking device at hand can be specially useful when a disabled person is near.

Head-down position for self-treatment of choking if other approaches fail

The Heimlich Maneuver (abdominal thrusts) can be performed or can be self-administered. Self-administration of this maneuver requires positioning of one's own abdomen over a chair, railing, or countertop and driving the abdomen upon the object with sharp, upward thrust. This serves as a substitute for thrusts made with the hands by another person. One study showed that these self-administered abdominal thrusts were just as effective as those performed by another person, although obese individuals were not included in the study.[35] Alternatively, multiple sources of evidence suggest that one of promising approaches for self treatment during choking could be by applying the head-down (inverse) position.[16]

On the other hand, using a modern anti-choking device is one the best, and most realistic, options for self-treatment in case of suffering a serious choking episode.

There are many advanced medical treatments to relieve choking or airway obstruction. These include inspection of the airway with a laryngoscope or bronchoscope and removal of the object under direct vision. Severe cases where there is an inability to remove the object may require cricothyrotomy (emergency tracheostomy). Cricothyrotomy involves making an incision in a patient's neck and inserting a tube into the trachea in order to bypass the upper airways.[36] The procedure is usually only performed when other methods have failed. In many cases, an emergency tracheostomy can save a patient's life, but if performed incorrectly, it may end the patient's life.