Editor's note: This article is a reprint. It was originally published on October 7, 2017.
Until 1972, when the Heimlich maneuver was developed, the sixth leading cause of accidental death was choking, usually on a bite of food or, in the case of young children, on a small toy or other object. At that time, about 3,000 people died each year in the United States from choking. The sobering truth is that it doesn’t take long for choking to lead to death. As the American Academy of Pediatrics (AAP) explains:
“Asphyxia is the obstruction or interruption of breathing due to obstruction of the internal airways, including the pharynx, hypopharynx, and trachea, by a foreign body. Airway obstruction can be fatal if it leads to severe impairment of oxygenation and ventilation.
Choking is a major cause of morbidity and mortality in children, especially those under 3 years of age. This is largely due to the developmental vulnerability of the airway in young children and their immature ability to chew and swallow food. Young children often put objects in their mouths as they explore their surroundings.”1
In 1972, Henry Heimlich, a Cincinnati physician, read an article reporting these statistics and wondered what he could do to help. After developing the esophageal reflux tube in the 1950s and spending years studying patients with swallowing difficulties, he began to research old medical journals on choking and medical intervention.
One of the most interesting of his findings was that from the publication of his book, “A Practical Treatise on Foreign Bodies in the Air Passages,” in 1854 until 1972, medical advice at the time was to avoid hitting people on the back as a means of removing a choking object. Nevertheless, that was the very approach the American Red Cross recommended in 1933 to “help” a choking person.
If you have ever experienced choking yourself or seen someone choking, you know that many people still try this method first. “People who are able to breathe with a piece of food stuck in their throat often die when they are hit in the back to block the airway,” Heimlich explained. He called this procedure “ill-advised.”2
When someone is choking, they are often unable to inhale or exhale, so they cannot simply “cough” the object out of their airway, but this action creates an “artificial cough.”
How Heimlich Developed His Maneuver
In a follow-up essay for the American Bronchial-Esophageal Association about how he developed the Heimlich maneuver, the life-saving technique, the doctor recalled:
“Approaching the problem, I decided that the answer lay in using the lungs as a blower to force air upward from the lungs, since a blow to the back would force the object back down into the airway, causing death. To get enough force to push the object out, I had to find a way to compress the lungs enough to create a strong airflow out of the mouth.”3
Heimlich simulated a foreign body by inflating a balloon and attaching it to the end of an endotracheal tube to block airflow in the airway of an anesthetized beagle (now considered unethical). He thought that by compressing the lungs and creating a large volume of air, the blockage would be dislodged.
But nothing happened. He tried several times, but nothing worked, and he stopped to analyze the problem, and he correctly guessed that the problem was in the rib cage. The rib cage prevents the lungs from being compressed effectively, and sometimes this happens with CPR. Heimlich explained further.
“I decided to start over. I figured that if I pushed the diaphragm up into the chest, the volume of the thoracic cavity would be significantly reduced, and the lungs would be compressed very evenly. I moved under the ribs and pressed my fist against the dog's belly button and just below the ribs, pushing the diaphragm up into the chest.
Immediately the tube popped out of the animal's mouth! I repeated this process, but the same result every time. I was very excited! I found that with just a little effort, pushing the diaphragm up would force the air out of the lungs and create enough airflow to move the object away from the airway.4
Heimlich said the object doesn't have to be “stuck in the throat like a champagne cork.” Even a bone that allows air to flow around it can be dislodged, but it's the airflow, not the pressure, that blows the object away.
Performing the Heimlich maneuver, aka the 'abdominal thrust'
Heimlich was a participant, and asked 10 colleagues, both physicians and residents, to calculate the actual airflow measurements needed to dislodge an object stuck in someone's airway. Several techniques were tested until the easiest and most effective method was found. Heimlich called this “subdiaphragmatic pressure.”
They used a mouthpiece connected by a tube to a machine designed to measure the flow, or expulsion, of air from the subjects’ mouths when the fist was forced upward against the diaphragm. Today, computers report the results, but doctors used graphs from a rotating drum to show that an average of 205 liters of air was produced. That’s enough to expel an object stuck in someone’s throat.
Heimlich's next task was to develop a simple method for the above scenario that anyone, including children, could use without first aid training. He thought that no tool of any kind would work. What if you can't find it in time?
It also had to happen quickly. For example, when a child is choking, rescuers have less than four minutes to remove the object to avoid the very real possibility of permanent brain damage or death. Now followed by men, women and children around the world, the simple procedure when someone is choking is as follows:
- Stand behind the person, stretch out both arms and wrap them around his waist.
- Make a fist with one hand and place the thumb side under the victim's ribs, just above the navel.
- Make a fist with your other hand and press firmly and smoothly upwards into your fist to dislodge the choking object from the airway.
Repeat as needed, but in many cases the dropped object flies out of the victim's mouth so fast that it hits the wall or ceiling. In 1985, the U.S. Department of Health and Human Services announced that Surgeon General C. Everett Koop endorsed the Heimlich maneuver as “not the preferred method, but the only method that should be used to treat asphyxiation due to foreign body airway obstruction.” Koop added:
“Millions of Americans have been taught to treat choking victims with back pats, chest and abdominal thrusts, etc…. It's time to educate them that these methods are dangerous and even deadly… And I'm asking the Red Cross, the American Heart Association, and public health authorities around the world to get involved.”5
Anyone can use the Heimlich maneuver, even on yourself.
One of the most appealing features of the most commonly used procedure for suffocation today is that almost anyone can use it. Medical News Today6 Describes another scenario where slightly modified procedures may be required. If the choking victim, child, or adult is unconscious or unable to stand:
- Lay the victim on his or her back, sit on his or her thighs, and face the victim.
- Place one hand on top of the other and place the heel of your hand on the subject's diaphragm, just below the ribs and above the navel.
- Place your hand on your mouth and push upward and inward, repeating until the foreign body is coughed out.
How to perform the Heimlich maneuver on yourself (when no one else can help):
- Make a fist and place your fist against your diaphragm, below your ribs and above your belly button, with your thumb facing inward.
- Press hard until the foreign object pops out.
- If you can't do this or it doesn't work, lean against a solid object like a counter or chair, place the edge against your diaphragm, and push in. Move back and forth slightly to push up, and repeat as needed.
Infants under 1 year of age:
- Lay your child face down on your forearm, with his or her head lower than your chest.
- Place your forearms on your thighs and support the baby's head with your hands, being careful not to cover the baby's mouth and nose.
- Using the heel of your other hand, hit baby's back between the shoulder blades four times. Repeat until the object comes out.
- If this fails, turn the baby over and place two fingers in the center of the baby's chest, between the nipples. Push firmly four times, about an inch deep. Repeat until the object comes out.
What You Can Do to Prevent Your Child from Choking
What do balloons, hot dogs, and batteries have in common? Yes, they are all objects that can pose a choking hazard to children. The danger can be anything small enough to fit in the mouth, such as buttons, coins, or beads. The pieces of toys left behind by older children, plastic eyes on a teddy bear, or decorative beads on a doll’s dress—anything that toddlers have access to can be some of the most dangerous objects in the home.
According to the American Academy of Pediatrics (AAP), latex balloons are the leading cause of suffocation in children under age 6, causing at least 68 deaths in the United States between 1990 and 2004.
Balloons are the biggest problem when they burst, because pieces of the balloon can be inhaled and then deform to fit the child's airway, forming an airtight seal. Thick, sticky substances like caramel, peanut butter, and toasted marshmallows can also cause problems, but one of the most common foods that young children choke on is hot dogs.
If you cut a hot dog into coin shapes, the cylinder shape acts as a tight seal, completely blocking the child's airway. Peanut bowls, round, candy-coated chocolate pieces, small bags of marshmallows on the counter when you make hot chocolate, even raw carrots, apples, and other foods that you may prepare according to the recipe should be monitored when a toddler is around. Children are quick and only need to be there for a short time.
How to minimize the risk of choking in young children
Parents Magazine7 To minimize the risk of suffocation in children under 3 years of age, we suggest following some simple precautions:
- Always cut hard, round foods, such as cheese or grapes, into small pieces or thin strips before handling.
- Supervise children closely during mealtimes.
- Show your children how to eat and chew their food properly.
- Learn how to apply the Heimlich maneuver for children
Additionally, we need to teach children:
- Please sit down while you eat.
- Eat your food slowly and chew it thoroughly.
- Don't talk or laugh with food in your mouth.
- Put only as much in their mouth as they can chew comfortably.
The Heimlich maneuver is almost always used today as a response to someone choking, but other methods use it as a basis, with some modifications. For example, a study from a few years later in 1976 recommended the method. This method recommended chest compressions, but experts acknowledge that the study only had six participants, so larger studies may have different results.
However, according to CNN, the Heimlich maneuver has been credited with saving more than 50,000 lives in the United States alone.8 An interesting story has been told. The man who performed this maneuver used it himself in 2016 to save a woman who was choking on a piece of hamburger at a senior living community center in Cincinnati. She was sitting right next to him.
This is how Heimlich used his life-saving skills, first in a life-or-death situation, before he died of a heart attack a few months later. He was 96 years old.
