Heimlich Maneuver: When and How to Perform for Choking

Foreign body airway obstruction (FBAO) is a medical emergency that can lead to rapid hypoxia and death if not promptly managed.¹ The Heimlich maneuver, also known as abdominal thrusts, is a widely recognized and effective technique for dislodging foreign objects from the airway in conscious individuals.² It is recommended for adults and children over one year of age who are experiencing severe airway obstruction, characterized by inability to speak, cough, or breathe, often accompanied by grasping at the throat.^1,2

Technique for Conscious Individuals

For a conscious adult or child experiencing severe FBAO, the rescuer should stand behind the person and wrap their arms around the waist.³ One hand should be made into a fist and placed just above the navel, below the breastbone.³ The other hand should then grasp the fist.³ The rescuer delivers five quick, upward abdominal thrusts.³ These thrusts should be forceful enough to create an artificial cough, aiming to expel the foreign object.³ The sequence of five thrusts should be repeated until the obstruction is cleared or the person becomes unconscious.^1,3

If the person becomes unconscious, they should be carefully lowered to the ground.¹ Cardiopulmonary resuscitation (CPR) should be initiated immediately, starting with chest compressions.⁴ Each time the airway is opened for rescue breaths during CPR, the rescuer should look for the foreign object in the mouth and remove it if visible.⁴ Blind finger sweeps are not recommended as they may push the object further into the airway.⁴

Considerations for Specific Populations

For pregnant individuals or those with significant obesity, standard abdominal thrusts may not be feasible or safe.¹ In these cases, chest thrusts are recommended.¹ The rescuer stands behind the person and places their arms under the armpits, wrapping them around the chest.¹ The fist is placed in the middle of the breastbone, and five quick inward chest thrusts are delivered.¹

Infants (under one year of age) require a modified approach due to their anatomical differences and fragility.⁵ The recommended procedure involves a combination of five back blows and five chest thrusts.⁵ The infant should be placed face down along the rescuer's forearm, with the head lower than the chest, supported by the hand.⁵ Five firm back blows are delivered between the shoulder blades.⁵ The infant is then turned face up, still supported, with the head lower than the chest, and five rapid chest thrusts are delivered over the lower half of the breastbone, similar to CPR compressions for an infant.⁵ This sequence is repeated until the object is expelled or the infant becomes unconscious.⁵

It is important to differentiate between mild and severe airway obstruction.¹ A person with a mild obstruction can still cough effectively and should be encouraged to continue coughing spontaneously.¹ Intervention with the Heimlich maneuver is reserved for severe obstruction where the person cannot cough, speak, or breathe.¹ Prompt recognition and appropriate action are critical for improving outcomes in FBAO.²

Post-Maneuver Care and Complications

Even after successful dislodgement of the foreign object, individuals who have undergone the Heimlich maneuver should be evaluated by a healthcare professional. This is crucial to assess for potential complications such as rib fractures, internal organ injury (e.g., splenic rupture, liver laceration), or aspiration pneumonia, particularly if the maneuver was performed with significant force or if the individual experienced a period of unconsciousness. 6,7 While generally safe when performed correctly, the forceful nature of abdominal and chest thrusts carries inherent risks that warrant medical follow-up. Furthermore, individuals should be monitored for persistent respiratory distress or other signs of ongoing airway compromise.

The effectiveness of the Heimlich maneuver is well-established in clinical practice and supported by numerous case reports and observational studies. However, randomized controlled trials are inherently difficult to conduct in emergency choking situations, leading to a reliance on expert consensus and simulation studies for guideline development. 8 Future research may focus on refining training methodologies, exploring advanced airway clearance techniques for refractory cases, or developing innovative technologies to assist in FBAO management. Continued education for both healthcare professionals and the public remains paramount to ensure timely and appropriate intervention for choking emergencies.