Back Blows in Pediatric Choking Relief: New Evidence

A recent video documenting the intervention of two police officers during a choking episode involving a young girl has sparked an interesting discussion in the medical community and among first responders. The officers, primarily using back blows on a girl over one year of age, successfully resolved the obstruction.

This case opens a reflection: can back blows, even when used as the predominant technique, be effective in resolving choking episodes in older children? And what does recent scientific evidence tell us about this?

Current guidelines: are they still cutting-edge?

The 2020 American Heart Association (AHA) guidelines [[1]](#bibliografia) recommend a sequence of interventions that varies based on age:

• For children over one year of age, the sequence involves starting with 5 back blows followed by 5 abdominal thrusts (Heimlich maneuver), alternating these techniques until the obstruction is resolved.
• For infants under one year of age, 5 back blows followed by 5 chest compressions are recommended.

These protocols were developed based on the best available evidence at the time of their formulation and represent a fundamental reference point for clinical practice. With the evolution of scientific research, it is natural that new data emerge that can complement and enrich these recommendations.

It is important to consider how new evidence can help us better understand the relative effectiveness of the different components of the recommended sequence. The guidelines are certainly well-intentioned, but a legitimate question emerges: how up-to-date are they with respect to the most recent evidence? And above all, how much are they supported by data from real populations rather than expert opinions or theoretical models?

What the most recent studies say

The research landscape on choking relief techniques is being enriched with new studies that provide valuable information on the effectiveness of different maneuvers.

A recent cohort study conducted in Alberta, Canada (Dunne et al., 2024) [[4]](#bibliografia) analyzed 3,677 cases of airway obstruction, producing interesting results:

• Back blows were associated with a significantly higher success rate in relieving obstruction compared to abdominal thrusts (Heimlich maneuver) and chest compressions
• The researchers calculated the relative risk of failure for each technique, taking into account various confounding factors (such as age, pre-existing conditions, and severity of obstruction). They found that abdominal thrusts had about half the probability of success compared to back blows
• Chest compressions showed even more limited results, with a probability of success of only 14% compared to back blows
• No injuries were recorded associated with back blows, while both abdominal thrusts and chest compressions caused complications in several cases
• Back blows proved to be the most effective and safe in all cases analyzed (Dunne et al., 2024)

These results were considered significant, so much so that a recent commentary article (Norii and Igarashi, 2024) [[5]](#bibliografia) defined them as "important evidence", suggesting that research on airway obstructions is making relevant progress in understanding the relative effectiveness of different techniques.

Not an isolated case

The Canadian study adds to other research that is contributing to a more complete understanding of this topic. A systematic review of interventions for the removal of foreign bodies from the airways (Couper et al., 2020) [[3]](#bibliografia) had already highlighted the importance of continuing to develop evidence supporting different choking relief techniques, emphasizing the need for high-quality studies on this crucial topic.

Even a previous study in the prehospital context (Vilke et al., 2004) [[2]](#bibliografia) had found that among interventions used by parents, back blows were among the most common (12%), suggesting that this technique was already widely used in real practice, confirming its acceptance and applicability in the context of everyday emergencies.

Practical implications: is it time for a change?

The emerging evidence offers interesting points for reflection that can enrich our understanding of current protocols. In particular:

• Should back blows have a more central role in the protocol? The data from the Dunne et al. study suggest that this technique could be particularly effective and safe, perhaps deserving greater attention in first responder training.

• Is the current sequence of interventions appropriate? The guidelines recommend alternating back blows and compressions, but if the former are particularly effective, as suggested by the Canadian study, it might be useful to consider whether to further emphasize this technique in training.

• Is the differentiation of secondary techniques based on age still justified? Current guidelines correctly differentiate the approach based on age, but it might be interesting to further explore the relative effectiveness of back blows in different age groups.

• How much can studies on real populations contribute to improving guidelines? The Canadian study offers data from real cases, which represent a valuable contribution to the continuous refinement of evidence-based recommendations.

Real practice and new data suggest reconsidering the age-based distinction. Back blows did not cause injuries in documented cases.

The case for a more flexible approach

The video of police officers successfully using back blows on a girl over one year of age represents a concrete example of how, in real practice, emphasis on back blows can lead to positive results.

This episode, together with emerging data from recent studies, suggests the importance of paying particular attention to this technique. Current guidelines already recognize the value of back blows by including them in the recommended sequence. The experience documented in the video and the new scientific evidence reinforce the importance of this component of the protocol and suggest that particular attention to this technique during training could be beneficial.

Conclusions: balancing tradition and innovation

Evidence-based medicine continuously evolves, integrating new knowledge with established protocols. Recent evidence on the effectiveness of back blows represents an important contribution to this evolution.

Current AHA guidelines, which already include back blows in the recommended sequence for all ages, provide a solid foundation for managing airway obstructions. Recent studies do not contradict these recommendations, but rather enrich our understanding of the relative effectiveness of different components of the protocol.

For rescue professionals, parents, and anyone who may face a choking emergency, these studies emphasize the importance of mastering the back blow technique and paying particular attention to its correct execution, while following the complete sequence recommended by the guidelines.

The episode documented in the video and recent studies remind us that medical science is continuously evolving. While we continue to follow established guidelines, it is important to remain open to new evidence that can help us further refine our practices to save lives in emergency situations.

Bibliography

1. [Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care](https://pubmed.ncbi.nlm.nih.gov/33081530)

1. [Airway obstruction in children aged less than 5 years: the prehospital experience](https://pubmed.ncbi.nlm.nih.gov/15060856)

1. [Removal of foreign body airway obstruction: A systematic review of interventions](https://pubmed.ncbi.nlm.nih.gov/32949674/)

1. [Evaluation of basic life support interventions for foreign body airway obstructions: A population-based cohort study](https://pubmed.ncbi.nlm.nih.gov/38825222/)

1. [Long-awaited evidence on back blows versus abdominal thrusts](https://pubmed.ncbi.nlm.nih.gov/38964448/)