Current Non-Invasive Treatments for Choking

The U.S. National Safety Council, AHA, American College of Emergency Physicians (ACEP), Johns Hopkins University, and multiple institutions all specifically outline the repetition of the Heimlich maneuver as the key course of treatment until an obstruction is cleared.1, 4, 12, 18, 25-28

The ARC, Mayo Clinic and other institutions 29, 30  advocate a “5 and 5” approach, instructing a cycle of 5 back blows and 5 abdominal thrusts until the foreign object is removed.

In Dr. Heimlich’s hometown of Cincinnati, Ohio, the local hospital system Deaconess has a robust “Heimlich Hero’s” program that teaches children the fundamentals of the Heimlich maneuver and case reports abound, with children saving teachers and children saving each other.31

Regarding children 1 year of age or older, the Heimlich maneuver is recommended. 32-34 Another report recommends that when the Heimlich maneuver is not effective, the “table maneuver” should be used. This technique instructs that the person choking is laid down on a table in the prone position, head facing downwards, arms hanging over the table, and sharp blows are delivered between the scapulae with the heel of the hand. 35

Also, if a foreign body has progressed further into the lower respiratory tract, a laryngoscope and Magill forceps are recommended.36 For individuals who are alone, performing the Heimlich maneuver on yourself or using the corner of a chair/stair railing have been reported to be successful.37

1. National Safety Council, 2015.

4. Jacob B, Wiedbrauck C, Lamprecht J, et al. Laryngologic aspects of bolus asphyxiation-bolus death. Dysphagia. 1992; 7(1):31-5.

12. American Heart Association Guidelines, 2015.

18. Williams M. Everything You’ve Ever Wondered About the Heimlich Maneuver. Apr 30, 2015.

19. Best C, Taylor N. Physiological Basis of medical practice. 9th ed. Baltimore: Williams & Wilkins, 1973.

20. Langhelle A, Sunde K, Wik L, et al. Airway pressure with chest compressions versus Heimlich manoeuvre in recently dead adults with complete airway obstruction. Resuscitation. 2000 Apr;44(2):105-8.

21. Guildner C, Williams D, Subitch T. Airway obstruction by foreign material: the Heimlich Maneuver. JACEP. 1976 Sep;5(9):675-7.

22. Lippmann J, Taylor D, Slocombe R. Lateral versus anterior thoracic thrusts in the generation of airway pressure in anaesthetised pigs. Resuscitation. 2013 Apr;84(4):515-9.

23. Crawford L, Emmett J. The role of the thoracic compression reflex in the Heimlich Maneuver. Ann Rech Vet. 1977;8(3):315-8.

24. Bianchi C, Carrara R, Khirani S, et al. Independent cough flow augmentation by glossopharyngeal breathing plus table thrust in muscular dystrophy. Am J Phys Med Rehabil. 2014 Jan;93(1):43-8.

25. Solanki S, Bansal S, Khare A, et al. Heimlich’s maneuver-assisted bronchoscopic removal of airway foreign body. Anesth Essays Res. 2011 Jul-Dec; 5(2):201-203.

26. American College of Emergency Physicians. 2015. Choking (Heimlich Maneuver).

27. Kitay G, Shafer N. Café coronary: recognition, treatment, and prevention. Nurse Pract. 1989 Jun;14(6): 35-8, 43, 46.

28. Choking and the Heimlich Maneuver. Johns Hopkins Medicine. 2015.

29. Conscious Choking Guidelines. American Red Cross. 2015.

30. Choking: First Aid. Mayo Clinic. 2015.

31. http://www.heimlichheroes.com

32. Todres I. Pediatric airway control and ventilation. Ann Emerg Med. 1993 Feb;22(2 Pt 2):440-4.

33. Vilke G, Smith A, Ray L, et al. Airway obstruction in children aged less than 5 years: the prehospital experience. Prehosp Emerg Care. 2004 Apr-Jun;8(2):196-9. 34. Manno M. Pediatric respiratory emergencies. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 35. Blain H, Bonnafous M, Grovalet N, et al. The table maneuver: a procedure used with success in four cases of unconscious choking older subjects. Am J Med. 2010 Dec;123(12):1150.

36. Rouillon I, Charrier J, Devictor D, et al. Lower respiratory tract foreign bodies: a retrospective review of morbidity, mortality, and first aid management. Int J Pediatr Otorhinolaryngol. 2006 Nov;70(11): 1949-55.

37. Heimlich H. Self-application of the Heimlich maneuver. E Engl J Med. 1988 Mar 17;318(11):714-5.

Vulnerable Choking Populations

Elderly people with dementia (i.e. Alzheimer’s disease), Parkinson’s disease, and pneumonitis are most strongly associated with deaths from choking on food.3

One study examined the clinical background and scenarios surrounding 75 patients who survived a near-fatal choking episode. Sixty had choked on a solid bolus of food, almost half of them had neurologic disease and while 25 of them choked at home, most incidents happened elsewhere: 18 in nursing homes, 14 in hospitals, 9 in restaurants, and 9 in drinking establishments.38 This study speaks to a growing awareness that choking emergencies in a portion of the elderly population is partially due to deglutition (swallowing) issues, with nearly 40% of Americans over the age of 60 experiencing dysphagia (difficulty, discomfort swallowing).39

When it comes to life-threatening obesity, Prader-Willi syndrome (PWS) is cited as the most common cause and choking has been observed as key contributing factor. A survey of the families of deceased PWS patients reported that 1 in 3 had a history of choking and almost 1 in 10 listed choking as the cause of death.40 Causes of increased choking hazards among this population included poor oral/motor coordination, poor gag reflex, hyopotonia (low muscle tone), hyperphagia (excessive desire for food), decreased mastication (chewing), and voracious eating habits. It is important to note that while these symptoms were reported for PWS patients, caregivers should identify these symptoms in other populations and recognize an increased choking risk.

Also in the morbidly obese, a “Knees-to-Abdomen Heimlich Maneuver” has been recommended due to physical limitations.41 Another study reports that motorized wheelchair-dependent patients with muscular dystrophy increased their unassisted cough peak flows when they combined a mastered maximal-depth glossopharyngeal breathing technique with a self-induced thoracic table thrust, simulating a Heimlich maneuver.24

3. Kramarow E, Warner M, Chen L. Food-related choking deaths among the elderly. Inj. Prev. 2014 Jun; 20(3):200-3.

24. Bianchi C, Carrara R, Khirani S, et al. Independent cough flow augmentation by glossopharyngeal breathing plus table thrust in muscular dystrophy. Am J Phys Med Rehabil. 2014 Jan;93(1):43-8.

38. Ekberg O, Feinberg, M. Clinical and Demographic Data in 75 Patients with Near-Fatal Choking Episodes. Dysphagia 1992;7:205-208 (1992).

39. Ney D, Weiss, J, Kind, A et al. Senescent Swallowing: Impact, Strategies and Interventions. Nutr Clin Pract. 2009 Jun-Jul; 24(3): 395-413.

40. Stevenson D, Heinemann J, Angulo M, et al. Deaths due to choking in Prader-Willi syndrome. Am J Med Genet A. 2007 Mar 1;143A(5):484-7.

41. Stix M. Knees-to-Abdomen “Heimlich Maneuver” in a Morbidly Obese Patient. Anes Analges 2001:92(6): 1619.

Clinical Choking Reviews

An examination of the current body of research knowledge by this author and previous researchers does not reveal a definitively controlled clinical trial in which different modalities of choking intervention therapies (Heimlich maneuver, back blows, suction, etc.) have been statistically compared for efficacy.17,42 This is not surprising, given the immediate life threatening situation that choking causes, and the slim likelihood of an U.S. Institutional Review Board approving such a study.

Therefore, it is necessary to review the documentaries, case studies, and available testing models (cadavers, animals) to extrapolate what measures can save lives, all the while remaining grounded in what can be viewed as either general guidance or specific instruction.

One such review in a prehospital setting examined 513 cases of foreign body airway obstruction in adults over a 17- month period in San Diego County.43 Seventeen people out of the 513 cases died (3.3%) and it is noteworthy that they had a mean age of 65 years, with the factor of increasing age correlating with a worse outcome. The Heimlich maneuver was the most common intervention used and it provided assistance in 86.5% of patients, with Magill forceps being needed in three Heimlich refractory cases.

Another study examined 182 patients less than 5 years of age, with 99 of them (55%) being less than 1 year old.33 Liquid obstructions were predominant in the youngest children, and solids (including food) were the issue in children over 1 year of age. Before paramedics arrived, 59% of these cases were resolved. Interventions by parents included bulb suction, finger sweeps, Heimlich maneuver, and back blows. Paramedics used advanced life support in only 3 cases and 47% of parents refused transport against medical advice.

17. Hoffman J. Treatment of Foreign Body Obstruction of the Upper Airway. West J Med. 1982 Jan; 136(1): 11-22.

33. Vilke G, Smith A, Ray L, et al. Airway obstruction in children aged less than 5 years: the prehospital experience. Prehosp Emerg Care. 2004 Apr-Jun;8(2):196-9.

42. Radel C. Heimlich maneuver’s creator fights Red Cross. The Cincinnati Enquirer, USA Today. Jan 21, 2013. http://www.usatoday.com/story/news/nation/2013/01/21/heimlich-red-cross-fight/1566492

43. Soroudi A, Shipp H, Stepanski B, et al. Adult foreign body airway obstruction in the prehospital setting. Prehosp Emerg Care. 2007 Jan-Mar;11(1):25-9.

Trauma from Current Choking Treatments

During an emergency situation, the timely resolution of the most life-threatening cause is paramount and choking is certainly one of those instances. Hence, use of aggressive and forceful compressions, thrusts, back blows, etc. appear warranted as the collateral injury or damage from such interventions can be considered irrelevant if the person dies.

While thousands of lives have been saved due to the Heimlich maneuver since its inception in 1975, one thing that becomes apparent during a review of the literature review is the amount of injuries and trauma caused by choking emergency treatment.

The purpose of this manuscript is not to draw out this aspect of choking treatment and will only discuss injuries that are documented via publication. Properly performing the Heimlich maneuver has a direct effect on the incidence and severity of collateral trauma.

Multiple research groups have done a sound job of reviewing the topic of post-Heimlich trauma44-46 and this author agrees that those who have had the Heimlich maneuver or any choking emergency treatment performed on them needs to seek further medical evaluation immediately to ensure that there are no collateral trauma or injuries. This applies especially to those over age 65, as the LA Med Center review pointed out that most injuries occurred in this population.44 Further, the removal of a foreign body that is sharp should ideally be done with a laryngoscope if at all possible, and if the Heimlich maneuver or other forceful therapy was used to remove the sharp foreign object, the patient should immediately seek medical attention afterwards.47

Radiologic evaluation has shown that a variety of deglutition (swallowing) abnormalities can be identified after a near-fatal choking episode.48 One case study highlighted POPE (postobstructive pulmonary edema), also referred to as negative pressure pulmonary edema, which occurs with deep inspiration against an obstructed airway.49 This paper is worth mentioning since the patient, upon high altitude air travel, became hypoxic with an altered mental status, typical indicators of a pulmonary embolus. It was only after obtaining a detailed history that the root cause was found to be the Heimlich maneuver performed days before.

While complications are typically low, gastric (stomach) rupture has been cited as one of the more common injuries sustained after the Heimlich procedure and it has a high mortality rate.45, 50, 51 Contributing factors include individuals being over 65 years of age, and the ingestion of large amounts of food and possibly alcohol. A case study of two individuals experiencing gastric rupture stressed that the improper application and over application of the Heimlich maneuver was a significant factor.50 Traumatic dissection and rupture of the abdominal aorta has been reported after a forcefully applied Heimlich maneuver,52 and a fatal splenic rupture following the application of a properly performed Heimlich maneuver has also been reported.46

A lacerated liver and a large subscapular hematoma draining into the pelvis was the result of multiple Heimlich maneuvers which failed to dislodge a large piece of steak obstructing the airway.53 Aside from those injuries specifically cited in this manuscript, other instances of trauma such as pneumomediastium, aortic valve cusp rupture, diaphragmatic herniation, jejunum perforation, hepatic rupture, or mesenteric laceration have all been documented.46 Another case study found that the first responder must also show care when performing the Heimlich maneuver as one emergency caregiver reported a rotator cuff tear while rendering aid.54 Additionally, chest thrusts were examined in 323 children who died after receiving CPR (80% performed in the hospital) and 44% had rib fractures (21% bilateral), which were determined to be a significant factor in the clinical course.55, 56

44. Lee S, Kim S, Shekherdimian S, et al. Complications as a Result of the Heimlich Maneuver. J Trauma. 2009;66:E34-E35.

45. Fearing N, Harrison P. Complications of the Heimlich Manuever: Case Report and Literature Review. J Trauma. 2002. 53:978-979.

46. Cecchetto G, Viel G, Ceccheto A, et al. Fatal splenic rupture following Heimlich maneuver: case report and literature review. Am J Forensic Med Pathol. 2011 Jun;32(2):169-71.

47. Bouayed S, Sandu K, Teiga P, et al. Thoracocervicofacial Emphysema after Heimlich’s Manuevre. Case Rep Otolaryngol. 2015; March 5, Online.

48. Feinberg M, Ekberg O. Deglutition after near-fatal choking episode: radiographic evaluation. Radiology. 1990 Sep;176(3):637-40.

49. Galster K, Mills L, Silva F. Postobstructive pulmonary edema in the setting of aspiration and air travel. J Emerg Med. 2014 Dec;47(6)143-6.

50. Tung P, Law S, Chu K, et al. Gastric Rupture after Heimlich maneuver and cardiopulmonary resuscitation. Hepatogastroenterology. 2001 Jan-Feb;48(37):109-11.

51. Majumdar A, Sedman P. Gastric rupture secondary to successful Heimlich manoeuvre. Postgrad Med J. 1998 Oct;74(876):609-10.

52. Desai S, Chute D, Desai B, et al. Traumatic dissection and rupture of the abdominal aorta as a complication of the Heimlich maneuver. J Vasc Surg. 2008 Nov; 48(5):1325-7.

53. Tashtoush B, Schroeder J, Memarpour R, et al. Food Particle Aspiration Associated with Hemorrhagic Shock: A Diagnostic Dilemma. Case Rep Emerg Med. 2015. Article ID 275497.

54. Baker J, Mullet H. A hero’s woe: rotator cuff tear after performing the Heimlich manoeuvre. Emerg Med J. 2010 Jul;27(7):566-7. 55. Thaler MM, Krause VW. Serious trauma in children after external cardiac massage. N Engl J Med 1962;267 (6 Sep):500-1. 56. Paaske F, Hansen JP, Koudahl G, et al. Complications of closed-chest cardiac massage in a forensic autopsy material. Dan Med Bull 1968;15(8):225-30

55. Thaler MM, Krause VW. Serious trauma in children after external cardiac massage. N Engl J Med 1962;267 (6 Sep):500-1. 56. Paaske F, Hansen JP, Koudahl G, et al. Complications of closed-chest cardiac massage in a forensic autopsy material. Dan Med Bull 1968;15(8):225-30

56. Paaske F, Hansen JP, Koudahl G, et al. Complications of closed-chest cardiac massage in a forensic autopsy material. Dan Med Bull 1968;15(8):225-30

Airway Obstruction Treatment with Suction

The lead focus of this literature review thus far has been the use of a compression force to propel a foreign object out of the trachea.

Now, research will be presented that is intended to provide a solid foundation for an intuitive and simpler way for a first responder or emergency caregiver to remove a foreign body - by suction.

Suction catheters and systems are a mainstay in emergency rooms, hospitals, and emergency vehicles. The familiar large canisters (often with a blue lid) are connected to wall mounts and to a facility’s main vacuum system to provide on-demand suction support, while battery powered portable units can assist the Advanced Responder in emergency situations (Figure 3). Typically, these units are used to keep an airway free of mucous or fluid buildup in chronically ill patients, but are often used in emergency situations to quickly and effectively remove airway obstructions of all types.

Figure 3: The Rico Model RS-4X (top) and SSCOR VX-2 Portable Suction.

Distinct policies and procedures from the National Institutes of Health 57 along with numerous reports from healthcare personnel using suction to remove an obstruction of the airway can be found in the literature.58-64 One such group, Comprehensive Advanced Life Support (CALS) is worth highlighting here. This is an educational program specifically designed for the emergency medical training needs of rural healthcare teams. With an affiliate chapter in Minnesota, CALS has worked with The Minnesota Academy of Family Physicians, The Minnesota American College of Emergency Physicians, The University of Minnesota School of Medicine and other leading groups to develop emergency medicine initiatives.63

With regards to “Airway Skills 12: Tracheal Foreign Body Removal”, an intriguing and innovative method has been published in the CALS manual (Figure 4) which uses an improvised suction device (created by a syringe) for clearing the airway.63 It is important to note that wall suction is first recommended, but for the rural emergency responder, this will not always be available. A portable, manual, preassembled yet powerful device that satisfies the requirements of therapeutic suction force could be invaluable in a choking emergency.

Figure 4: CALS Program – Persistent Tracheal Foreign Body Removal.

58. Bain A, Barthos A, Hoffstein V, et al. Foreign-body aspiration in the adult: Presentation and management. Can Respir J. 2013 Nov-Dec;20(6):e98-e99.

59. Yueh-Fu F, Meng-Heng H, Fu-Tsai C, et al. Flexible bronchoscopy with Multiple Modalities for Foreign Body Removal in Adults. PLoS One. 2015; 10(3):e0118993. Published online 2015 Mar.

60. Nagendran T. Management of Foreign Bodies in the Emergency Department. Hospital Physician. 1999 Sept; 27-40. Copyright 1999 by Turner White Communications Inc., Wayne PA.

61. Hatlestad D.

Dechoker Anti-choking Device

In 2009, Alan Carver was attending Sea School to gain his 200-Ton Captain’s License. During the medical training portion, it was advised that if initial non-invasive techniques (Heimlich maneuver, etc.) failed to remedy a choking emergency, a tracheotomy must be performed. Mr. Carver felt there had to be another way and after working with device engineers, health care professionals, and FDA consultants, the dechoker device was created.

In 2013 this device gained FDA medical device registration 65 and the company is currently working with emergency personnel, restaurants, assisted living facilities, and organizations that want to provide an additional method of treatment for a choking emergency. Critical to the success of a suction device is its ability to generate enough vacuum pressure such that it is able to provide equivalent or superior force to the other noninvasive techniques outlined in this manuscript.

Figure 5: Dechoker Airway Suction Device.

Testing performed by Next Medical Design (Raleigh, NC, USA) on the dechoker device analyzed numerous parameters including the ideal diameter of the barrel, required length of the plunger, force needed to pull the plunger, vacuum mask pressure achieved, barrel lubricant needed, plunger O-ring specifications, valve configurations, and overall performance of the device to resist leaking and maintain suction pressures.

The ideal design for the dechoker was to fashion a plunger / barrel length of 4.5 inches with a diameter of 2 inches, creating a device 13 inches long. Lubrication amounts, O-ring machining, and the correct adhesive to bind the face mask to the plunger assembly were established. Through the combination of these elements, the dechoker requires only 20 lbs. of pull force to generate 35 kPa of vacuum pressure.66-71 Importantly, the pressure valve prevents any movement of air back into the patient and allows for repeated plunger pulls to generate additional vacuum pressure if needed. When considering this force of vacuum pressure and how it relates to the forces created during the abdominal thrusts of the Heimlich maneuver and varying chest compressions, there are several clinical studies already covered in this review that can be highlighted and used as a logical comparison.

Langhelle et al.20 used human cadavers and Lipmann et al.22 used anaesthetized pigs, with both measuring critical forces relevant to the success of an abdominal or chest compression to remove a foreign body from an obstructed airway. The cmH2O measurements found in these papers were converted to kilopascals (kPa) using the conversion formula:

1 cmH20 = 0.098 kilopascal

Of note, while Langhelle focused only on peak airway pressure, Lipmann measured peak airway pressure, thrust pressures, and intrapleural pressures. Importantly, in all cases where Langhelle and Lipmann expressed results with a mean and standard deviation, the highest possible values recorded were used in this comparison (Table 1).

Table 1: Comparison of Lung Pressures Associated with Simulated Choking Treatments.

It is debatable which of these three pressures would be the most relevant to the 35 kPa of vacuum force generated by the dechoker. However, it is noteworthy that the 35kPa of vacuum force generated by the dechoker is superior to all categories. It is also important to consider the current recommendations for suction devices in hospitals with regards to vacuum pressures used to remove foreign bodies or mucous. A setting of 12-16 kPa is typically advised,72 with pressures of 10.6 – 13.3 kPa for those under 1 year of age and 13.3 – 20 kPa for adults being recommended.73 In emergency departments and other advanced treatment facilities, suction meters reach 26.6 kPa, with sophisticated units generating pressures as high as 101.3 kPa.74

20. Langhelle A, Sunde K, Wik L, et al. Airway pressure with chest compressions versus Heimlich manoeuvre in recently dead adults with complete airway obstruction. Resuscitation. 2000 Apr;44(2):105-8.

22. Lippmann J, Taylor D, Slocombe R. Lateral versus anterior thoracic thrusts in the generation of airway pressure in anaesthetised pigs. Resuscitation. 2013 Apr;84(4):515-9.

65. FDA. Establishment Registration & Device Listing. DECHOKER LLC. Registration Number 3011422544.

66. Next Medical Design. Testing Vacuum and Force Generated in Suction Device: dechoker. Test TR0071. 11 Aug 2011.

67. Next Medical Design. Testing Vacuum and Force Generated in Suction Device with Modified Plunger: dechoker. Test TR0076. 11 Aug 2011.

68. Next Medical Design. Force/Vacuum Test of Lubricated dechoker Suction Device prototype: dechoker. Test TR0092. 11 Aug 2011.

69. Next Medical Design. Force Comparison of Various Seals and Groove Sizes and Lubrication: dechoker. Test TR0096. 11 Aug 2011.

70. Next Medical Design. Safety Valve Evaluation: dechoker. Test TR0098. 11 Aug 2011.

71. Next Medical Design. Force Comparison of Upper Limit Groove Sizes to Establish Outer Barrel Specification: dechoker. Test TR0104. 11 Aug 2011.

72. Luce J et al. Intensive Respiratory Care. 1993. Second edition. Philadelphia PA, WB Saunders.

73. Plevak D, Ward J. Airway management. In: Burton G, Hodgkin J, editors. Respiratory care: a guideline to clinical practice. New York: Lippincott Williams & Wilkins; 1997:555-609.

74. Lamb B, Pursley D, Kennedy B. The Principles of Vacuum and Clinical Application in the Hospital Environment. 2014. Third Edition. Ohio Medical Corporation.