New Evidence Challenges Choking Guidelines
- 11 hours ago
- 4 min read
A recent video documenting the intervention of two police officers during a choking episode of a child has sparked an interesting discussion in the medical community and among emergency responders. The officers, using primarily back slaps on a child over one year of age, were able to successfully resolve the obstruction. This case raises a question: can back slaps, 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] recommend a sequence of interventions that varies by age. For children older than 1 year, the sequence begins with 5 back pats followed by 5 abdominal thrusts (Heimlich maneuver), alternating these techniques until the obstruction is resolved. For infants under 1 year of age, 5 back pats followed by 5 chest compressions are recommended. These protocols were developed based on the best evidence available at the time of their formulation and represent a fundamental reference point for clinical practice.
As scientific research evolves, it is natural that new data will 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 arises: 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 by expert opinions or theoretical models?
What the latest studies say
The research landscape on airway obstruction 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] analyzed 3,677 cases of airway obstruction, producing interesting results:
Shoulder slaps were associated with a significantly higher success rate in clearing the obstruction than 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, preexisting conditions, and severity of obstruction). They found that abdominal thrusts were about half as likely to succeed as shoulder slaps.
Chest compressions showed even more limited results, with a success rate of just 14% compared to back pats.
No injuries associated with interscapular slaps were recorded, while both abdominal and chest compressions caused complications in several cases.
These findings were considered significant, so much so that a recent commentary article (Norii and Igarashi, 2024) [5] called them " important evidence ", suggesting that airway obstruction research is making significant 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] had already highlighted the importance of continuing to develop evidence to support the different techniques of clearing, underlining the need for high-quality studies on this crucial topic.
A previous study in the pre-hospital setting (Vilke et al., 2004) [2] also found that among the interventions used by parents, back pats 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?
Emerging evidence offers interesting insights that can enrich our understanding of current protocols. In particular:
Should back slaps play a more central role in the protocol? Data from Dunne et al. suggest that this technique may be particularly effective and safe , perhaps deserving more attention in rescuer training.
Is the current sequence of interventions appropriate? The guidelines recommend alternating back pats and compressions, but if back pats are particularly effective, as suggested by the Canadian study, it may be worth considering whether to further emphasize this technique in training.
Is differentiating secondary techniques based on age still justified? Current guidelines correctly differentiate the approach based on age, but it may be interesting to further explore the relative effectiveness of interscapular slaps in different age groups.
How much can real-world studies contribute to improving guidelines? The Canadian study provides data from real cases , which represent a valuable contribution to the continued refinement of evidence-based recommendations.
The case for a more flexible approach
The video of police officers successfully using back slaps on a child over one year of age is a concrete example of how, in real practice, an emphasis on back slaps can lead to positive results. This episode, along with data emerging from recent studies, suggests the importance of paying special attention to this technique.
Current guidelines already recognize the value of interscapular slaps by including them in the recommended sequence. The experience documented in the video and new scientific evidence reinforce the importance of this component of the protocol and suggest that special attention to this technique during training may be beneficial.
Conclusions: Balancing Tradition and Innovation
Evidence-based medicine is continually evolving, integrating new knowledge with established protocols. Recent evidence on the effectiveness of interscapular slaps is an important contribution to this evolution.
Current AHA guidelines, which already include back slaps in the recommended sequence for all ages, provide a solid foundation for managing airway obstruction. Recent studies do not contradict these recommendations, but rather add to our understanding of the relative effectiveness of different components of the protocol.
For emergency professionals, parents, and anyone who may be faced with a choking emergency, these studies emphasize the importance of mastering the technique of back pats and paying particular attention to their 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 constantly evolving. As 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. (https://pubmed.ncbi.nlm.nih.gov/33081530) Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
2. (https://pubmed.ncbi.nlm.nih.gov/15060856) Airway obstruction in children aged less than 5 years: the prehospital experience
3. (https://pubmed.ncbi.nlm.nih.gov/32949674/) Removal of foreign body airway obstruction: A systematic review of interventions
4. (https://pubmed.ncbi.nlm.nih.gov/38825222/) Evaluation of basic life support interventions for foreign body airway obstructions: A population-based cohort study
5. (https://pubmed.ncbi.nlm.nih.gov/38964448/) Long-awaited evidence on back blows versus abdominal thrusts
