Editing Choking (section)

==Treatment==
[[Airway management]] is used to restore a person's ventilation which consists of severity assessment, procedural planning, and may consist of multiple treatment modalities to restore airway.

Treatments will vary based on severity and stage of airway blockage. In [[basic airway management]], treatment generally consists of [[#General strategy: "five and five"|anti-choking first aid techniques]], such as the Heimlich maneuver. In [[advanced airway management]], complex clinical methods are used.

=== Basic treatment (first aid) ===
[[File:US medic teaches the Heimlich manuever to laughing Afghans.jpg|thumbnail|right|US medic teaches the [[abdominal thrusts]] to Afghans]]Basic treatment of choking includes several non-invasive techniques to help remove foreign bodies from the airways.

==== General strategy: "five and five" ====
For a conscious choking victim,<ref name=":5">{{Cite web |title=Conscious Choking |url=https://redcross.org/content/dam/redcross/atg/PDF_s/ConsciousChokingPoster_EN.pdf |url-status=live |archive-url=https://web.archive.org/web/20200131092855/https://redcross.org/content/dam/redcross/atg/PDF_s/ConsciousChokingPoster_EN.pdf |archive-date=2020-01-31 |website=American Red Cross}}</ref> most institutions such as the American Heart Association, the American Red Cross and the NHS,<ref>{{cite web | url=https://www.nhs.uk/conditions/first-aid/ | title=First aid | date=24 October 2017 }}</ref> recommend the same general protocol of first-aid: encouraging the victim to cough, followed by hard back slaps (as described forward). If these attempts are not effective, the procedure continues with abdominal thrusts (the Heimlich maneuver) or chest thrusts if the victim cannot receive abdominal pressure (as described forward).

If none of these techniques are effective, protocol by various institutions recommend alternating the series of back slaps and series of thrusts (these on the abdomen or chest, depending on the victim), 5 times of each technique and repeat ("five and five"). Some anti-choking devices can also be used to solve choking.

This procedure has modifications for [[#Infants (babies under 1 year-old)|infants (babies under 1 year-old)]], for the [[Choking#Pregnant or obese people|people with problems in the belly as the pregnant or too much obese people]], for the [[#In wheelchair victims|disabled victims in wheelchair]], for the [[#On the bed but unable to sit up|victims that lay on the bed but are unable to sit up]], and for the [[#On the floor but unable to sit up|victims that lay on the floor but are unable to sit up]].

In scenarios when the first aid procedures are not resolving the choking, it is necessary to call to [[List of emergency telephone numbers|emergency medical services]], but administration of first aid should be continued until they arrive.

Choking can change the colour in the victim's faces due to lack of oxygen. If they lose consciousness and fall to the ground, it is recommended<ref name=":2">{{cite web |title=Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality – ECC Guidelines |url=https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/?strue=1&id=10-5 |access-date=4 December 2017 |website=eccguidelines.heart.org}}</ref><ref name="redcross.org">{{cite web |title=STEP 3: Be Informed – Conscious Choking {{!}} Be Red Cross Ready |url=https://redcross.org/flash/brr/English-html/conscious-choking.asp |archive-url=https://web.archive.org/web/20171205094624/https://redcross.org/flash/brr/English-html/conscious-choking.asp |archive-date=2017-12-05 |access-date=4 December 2017 |website=redcross.org}}</ref> to avoid panic and begin the appropriate [[#Unconscious victims|anti-choking resuscitation for unconscious victims]] or [[#Unconscious infants|unconscious babies (under 1 year-old)]].

Each one of the techniques in the first aid protocol against choking are detailed below:{{Anchor|techniques in the first aid protocol against choking}}

==== Cough ====
If the choking victim is conscious and can cough, the [[American Red Cross]] and the [[Mayo Clinic]]<ref name="Choking: First aid">{{cite web |last=Mayo Clinic |title=Choking: First aid |url=http://mayoclinic.org/first-aid/first-aid-choking/basics/art-20056637 |url-status=live |archive-url=https://web.archive.org/web/20170501045204/http://mayoclinic.org/first-aid/first-aid-choking/basics/art-20056637 |archive-date=1 May 2017 |access-date=1 Jul 2024 |website= |publisher=Mayo Foundation for Medical Education and Research (MFMER) |language=en}}</ref> recommend encouraging them to stay calm and continue coughing freely.

==== Back blows (back slaps) ====
Many associations, including the American Red Cross and the Mayo Clinic,<ref name="Choking: First aid" /><ref name=":5" /> recommend the use of back blows (back slaps) to aid a choking victim. This technique is performed by bending the choking victim forward as much as possible, even trying to place their head lower than the chest, to avoid the blows driving the object deeper into the person's throat (a rare complication, but possible). The bending is in the back, while the neck should not be excessively bent. It is convenient that one hand supports the victim's chest. Then the back blows are performed by delivering forceful slaps with the heel of the hand on the victim's back, between the shoulder blades.

The back slaps push behind the blockage to expel the foreign object out. In some cases, the physical vibration of the action may cause enough movement to clear the airway.

==== Abdominal thrusts (Heimlich maneuver) ====
{{See also|Abdominal thrusts}}[[File:Abdominal thrusts against choking.jpg|thumb|380x380px|Abdominal thrusts anti-choking technique: Embrace the victim's abdomen from behind and then apply strong compressions on the area located between the chest and the belly button.]]
Abdominal thrusts<ref>{{Cite web |title=First Aid Tips |url=https://redcross.org.uk/standard.asp?id=75052 |url-status=live |archive-url=https://web.archive.org/web/20090203134643/https://redcross.org.uk/standard.asp?id=75052 |archive-date=2009-02-03 |website=Red Cross}}</ref> are performed with the rescuer embracing the belly of the choking victim from behind. Then, the rescuer closes their own dominant hand, grasps it with the other hand, and presses forcefully with them on the area located between the chest and the belly button of the victim, in a direction of in-and-up. This method tries to create enough pressure upwards to expel the object that obstructs the airway. The strength is not focused directly against the ribs, to avoid breaking them. If the first thrust does not solve the choking, it can be repeated several times.

The use of abdominal thrusts is not recommended for infants under 1 year of age due to risk of causing injury, so there are adaptations for babies (see more details further below), but a child that is too big for the babies' adaptations would require normal abdominal thrusts (according to the size of the body). Besides, abdominal thrusts should not be used when the victim's abdomen presents problems to receive them, such as pregnancy or excessive size; in these cases, chest thrusts are advised (see more details further below).

Although it is a well known method for choking intervention, the Heimlich Maneuver is backed by limited evidence and unclear guidelines. The use of the maneuver has saved many lives but can produce deleterious consequences if not performed correctly. This includes rib fracture, perforation of the jejunum, diaphragmatic herniation, among others.<ref>{{Cite journal |last1=Fearing |first1=Nicole M. |last2=Harrison |first2=Paul B. |date=2002-11-02 |title=Complications of the Heimlich Maneuver: Case Report and Literature Review |url=http://dx.doi.org/10.1097/00005373-200211000-00026 |journal=The Journal of Trauma: Injury, Infection, and Critical Care |volume=53 |issue=5 |pages=978–979 |doi=10.1097/00005373-200211000-00026 |issn=0022-5282 |pmid=12435952}}</ref>

==== Chest thrusts ====
[[File:Chest thrusts against choking.jpg|thumb|380x380px|Chest thrusts anti-choking technique: If the victim cannot receive thrusts on the abdomen, use chest thrusts. Embrace the victim's chest from behind and then apply strong compressions on the lower half of the chest bone, but not in the very endpoint. Avoid sticking the knuckles too painfully.]]When abdominal thrusts cannot be performed on the victim (serious injuries, pregnancy, or belly size that is too large for the rescuer to effectively perform abdominal thrust technique), chest thrusts are advised instead.<ref>{{Cite web |title=Choking and CPR safety talk |url=https://ehs.okstate.edu/site-files/docs/cpr-and-choking-5-min-safety-talk.pdf/ |url-status=live |archive-url=https://web.archive.org/web/20200130145512/https://ehs.okstate.edu/site-files/docs/cpr-and-choking-5-min-safety-talk.pdf/ |archive-date=2020-01-30 |website=Oklahoma State University}}</ref>

Chest thrusts are performed with the rescuer embracing the chest of the choking victim from behind. Then, the rescuer closes the own dominant hand and grasps it with the other hand. This can produce several kinds of fists, but any of them can be valid if it can be placed on the victim's chest without sinking a knuckle too painfully. Keeping the fist with both hands, the rescuer uses it to press forcefully inwards on the lower half of the chest bone ([[sternum]]). The pressure is not focused on the very endpoint (named [[xiphoid process]]) to avoid breaking it. When the victim is a woman, the zone of the pressure of the chest thrusts would normally be above the level of the breasts. If the first thrust does not solve the choking, it can be repeated several times.

==== Anti-choking devices ====<!--Note, there are redirects to this section name-->
Since 2015, several anti-choking devices were developed and released to the market. They are based on a mechanical vacuum effect, without a power source. Most use an attached mask to make a [[Vacuum pump|vacuum]] from the patient's nose and mouth. The current models of anti-choking devices are quite similar: a direct plunger tool (LifeVac and Willnice)<ref>{{Cite web |date=2016-08-02 |title=How to use LifeVac |url=https://lifevac.life/how-to-use-lifevac/ |access-date=2020-01-20 |website=Lifevac.life |language=en-US}}</ref><ref>{{Cite web |title=[OFFICIAL] Willnice {{!}} Anti-Choking Device that Saves Lives |url=https://willnice.net/ |access-date=2024-10-20 |website=Willnice |language=en-US}}</ref>  and a vacuum syringe (backward syringe) that also keeps the tongue in place by inserting a tube in the mouth (Dechoker).<ref>{{Cite web |last=Dechoker |title=How to Use Dechoker Anti-Choking Device (ACD) |url=https://www.dechoker.com/pages/dechoker-usage-instructions |access-date=2020-01-20 |website=Dechoker |language=en |archive-date=2019-06-05 |archive-url=https://web.archive.org/web/20190605154838/https://www.dechoker.com/pages/dechoker-usage-instructions |url-status=dead }}</ref> All  three of them have received certification, and they have been reported to be effective in real cases.<ref>{{Cite web |date=2019-02-03 |title=Advocates say anti-choking device saved two lives in Idaho {{!}} Local {{!}} idahostatejournal.com |url=https://idahostatejournal.com/news/local/advocates-say-anti-choking-device-saved-two-lives-in-idaho/article_4a24cfab-3261-5083-b73c-c6629cc2c790.html |archive-url=https://web.archive.org/web/20190203001109/https://idahostatejournal.com/news/local/advocates-say-anti-choking-device-saved-two-lives-in-idaho/article_4a24cfab-3261-5083-b73c-c6629cc2c790.html |archive-date=2019-02-03 |access-date=2021-09-25}}</ref><ref>{{Cite web |title=Carers used suction device to save woman who choked on sausage |url=https://www.kidderminstershuttle.co.uk/news/17821998.carers-used-dechoker-save-woman-choked-sausage/ |access-date=2021-09-25 |website=Kidderminster Shuttle |date=7 August 2019 |language=en}}</ref> Other mechanical models are in development, such as Lifewand,<ref>{{Cite web |title=The Device |url=https://lifewand.com/ |archive-url=https://web.archive.org/web/20220312021951/https://lifewand.com/ |archive-date=12 March 2022 |website=Lifewand}}</ref> which creates a vacuum by direct pressure against the patient's face. However, these products have not been well-studied in clinical trials or pre-hospital settings and literature is relatively sparse given the challenges in trial design.
<!--These claims are unsourced, and possibly "original research". Could be reinstated if reliably sourced.
The use of approved devices can provide some advantages including: ease of use, convenience in public places and events, being helpful for difficult cases (unconscious victims, disabled patients, elderly people, or when the victim is oneself), and achieving levels of pressure in suction that cannot be matched by manual methods. ''In the worst choking cases, no manual technique would dislodge the foreign object, being necessary the usage of one of these devices or a sort of surgery.'' These devices are usually placed at reach in public and relevant places.-->

A 2020 systematic review of the effectiveness of the three devices listed discovered "a more detailed review of the studies demonstrated a very low certainty of evidence for its use", and concluded that "there are many weaknesses in the available data and few unbiased trials that test the effectiveness of anti-choking suction devices resulting in insufficient evidence to support or discourage their use. Practitioners should continue to adhere to guidelines authored by local resuscitation authorities which align with [[International Liaison Committee on Resuscitation|ILCOR]] recommendations."<ref>{{Cite journal |last=Dunne |first=Cody |year=2020 |title=A systematic review on the effectiveness of anti-choking suction devices and identification of research gaps |url=https://www.resuscitationjournal.com/article/S0300-9572(20)30087-3/fulltext |journal=Resuscitation |volume=153 |pages=219–226 |doi=10.1016/j.resuscitation.2020.02.021 |pmid=32114068 |s2cid=211725361|hdl=1959.4/unsworks_79490 |hdl-access=free }} [https://www.researchgate.net/publication/339541654_A_systematic_review_on_the_effectiveness_of_anti-choking_suction_devices_and_identification_of_research_gaps Downloadable draft.]</ref>

As of October 22, 2024, The American Red Cross has updated its guidelines to include antichoking devices which highlighted the LifeVac for its effectiveness in clearing the airway passages. The scientific analyses of the LifeVac revealed a dislodgement rate of 94% during the first attempt, 99.6% on the second attempt, and a 100% success rate on the third attempt. There has so far been no known side effects due to the LifeVac device according to these studies. According to the findings, the evaluation on PubMed records from September 2019 through March 2023 which identified nearly 4,000 documents relating to the study which was significantly lead by the document "LifeVac: A Novel Apparatus to Resuscitate a Choking Victim" which were evaluated by the Journal of the American Red Cross Scientific Advisory Council (American Red Cross).

Some anti-choking devices like [[Act Fast Anti Choking Trainer]] are used as training devices by healthcare providers as well as schools in CPR training courses.<ref>{{Cite web |title=The Actfast Anti-Choking Trainer {{!}} PDF {{!}} Survival Skills {{!}} First Aid |url=https://www.scribd.com/document/358181502/The-Actfast-Anti-Choking-Trainer |access-date=2024-02-02 |website=Scribd |language=en}}</ref>

==== Unconscious victims ====

A choking victim who becomes unconscious<ref name=":22" /><ref>{{Cite web |last=Mayo Foundation for Medical Education and Research (MFMER) |date=2024-05-31 |title=Choking: First aid |url=http://mayoclinic.org/first-aid/first-aid-choking/basics/art-20056637 |access-date=2024-07-01 |website=Mayo Clinic|archive-url=https://web.archive.org/web/20240531120521/http://mayoclinic.org/first-aid/first-aid-choking/basics/art-20056637 |archive-date=2024-05-31 }}</ref><ref>{{Cite book |last=American Red Cross |title=CPR/AED and First Aid |pages=22 |chapter=Unconscious Choking}}</ref> must be gently caught before falling and placed lying face-up on a surface.<ref><!--useless ref?-->{{Cite journal |last=Herbert |first=Henry |year=1981 |title=Book review: The American Medical Association's Handbook of First Aid and Emergency Care |url=http://dx.doi.org/10.1097/00043764-198102000-00004 |journal=Journal of Occupational and Environmental Medicine |volume=23 |issue=2 |pages=74 |doi=10.1097/00043764-198102000-00004 |issn=1076-2752}}</ref> That surface should be firm enough (it is recommended placing a layer of something on the floor and laying the victim above).

A rescuer can then ask for any of the known anti-choking devices that is available, and use it on the unconscious victim. After that, the obstruction would be dislodged, but it could remain into the mouth, which needs a manual removal. If the unconscious victim cannot breath then, or stays in a cardiac arrest, it will require to perform a normal cardiopulmonary resuscitation (CPR), as described below, but only alternating the 30 compressions and the two rescue breaths.

[[List of emergency telephone numbers|Emergency medical services]] must be called, if this has not already been done.

It can be also convenient that any rescuer asks for a defibrillator around (an AED, as those devices are very common today), just in case it can be necessary to treat the victim's heart.

Anyway, a choking victim that is already unconscious needs to receive (even<ref name=":9">{{Cite web |last=Sarver Heart Center. University of Arizona. |date=2024-01-27 |title=Frequently Asked Questions about CPR |url=https://heart.arizona.edu/heart-health/learn-cpr/frequently-asked-questions-about-chest-compression-only-cpr |access-date=2024-07-03 |website=heart.arizona.edu|archive-url=https://web.archive.org/web/20240127072004/https://heart.arizona.edu/heart-health/learn-cpr/frequently-asked-questions-about-chest-compression-only-cpr |archive-date=2024-01-27 }}</ref><ref name=":11">{{Cite web |last=American Heart Association |title=Guidelines for CPR and ECC |url=https://cpr.heart.org/-/media/cpr-files/cpr-guidelines-files/highlights/hghlghts_2020_ecc_guidelines_english.pdf?la=en |page=12|archive-url=https://web.archive.org/web/20211220204935/https://cpr.heart.org/-/media/cpr-files/cpr-guidelines-files/highlights/hghlghts_2020_ecc_guidelines_english.pdf?la=en |archive-date=2021-12-20 }}</ref> with no more delay) an anti-choking cardiopulmonary resuscitation (CPR) for unconscious adults and children. It is not valid for infants less than one year old, who require a special [[#Unconscious infants|adaptated CPR for unconscious babies]] (described further below). [[File:Chest compressions.gif|thumb|Chest compressions of cardiopulmonary resuscitation (CPR), proper rhythm.|250x250px]]

The anti-choking cardiopulmonary resuscitation (CPR) for unconscious adults and children is quite similar to any other CPR, but with some modifications:

In a first step, a series of 30 ''chest'' ''compressions'' are applied on the lower half of the [[sternum]] (the bone that is along the middle of the chest from the neck to the belly) at an approximate rhythm of nearly 2 per second.

After that series, the rescuer looks for the obstructing object and, if it is already visible, the rescuer makes a ''try to extract'' it, usually by using a finger sweeping (hopefully from the mouth). Normally, the object would be a food bolus (and not the epiglottis, a cartilaginous flap of the throat). It is also possible to try to extract it when it is deeper and not visible, always carefully: using the fingers to take it, or lifting the victim's chin to form a straight way to the throat while the victim is face up (face down in case of the victim's tongue obstructs too much, or on a side with a base under the head) and then grasping or sweeping the stuck object with tools: thin kitchen tweezers, scissors (these used with care), forks and spoons (in a reverse position: introducing their handle) or even a toothpick (if other instruments were too much big for the case); but, anyway, the current protocols do not recommend extracting the obstructing object if it is not visible (a blind extraction), because of the risk to sink it deeper by accident, and because the compressions could move the object outside by themselves (in some cases). Moreover, if any removal is tried and is taking too much time, it may require alternating it with the chest compressions at some moments, without hindering to the extraction. And, whether the object has been found and removed in this step or not, the CPR procedure must pass to the next step and continue until the victims can breathe by themselves or emergency medical services arrive.[[File:Insulfation2.jpg|thumb|Rescue breaths of cardiopulmonary resuscitation (CPR).|250x250px]]

In the next step of the CPR, the rescuer applies ''a'' ''rescue breath'', pinching the victim's nose and puffing air inside of the mouth. Rescue breaths would usually fail while the obstructing object is blocking the entrance of air. Anyway, it is recommended, additionally, ''tilting the victim's head'' up and down, to reposition it trying to open an entrance for the air, and then giving ''another rescue breath''. After the rescue breaths, this resuscitation returns to the 30 initial compressions, in a cycle that repeats continually, until the victim regains consciousness and breathes,<ref>American Red Cross Training Services. Choking. In: First Aid/CPR/AED Participant's Manual. The American Red Cross; 2021. https://www.redcross.org/store/first-aid-cpr-aed-participants-manual/754100.html .</ref> or until the object is extracted but a defibrillation is needed to solve a cardiac arrest (read below).

''Defibrillation'' can also be needed, because an unconscious victim of choking can suffer a cardiac arrest at any moment, due to several possible causes.<ref name=":13">{{Cite web |date=2024-07-03 |title=First aid - To perform CPR on a baby 4 weeks old, or older - such as from choking - get the AED |url=http://mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 |access-date=2024-07-04 |website=Mayo Clinic|archive-url=https://web.archive.org/web/20240703122615/http://mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 |archive-date=2024-07-03 }}</ref> So it is convenient to ask around for a defibrillator (AED device), for trying a defibrillation on a victim that remains in cardiac arrest after having extracted the stuck object (if it has been extracted, and only after that). Those defibrillators are easy to use, as they emit their instructions with voice messages.

===== Finger sweeping =====
It is crucial to avoid blindingly sweeping the airway unless there is direct visualization of the airway – in fact, these procedures are advised only to be performed in more controlled environments such as an operating room.<ref>{{Cite journal |last=Sarper Erikci |first=Volkan |date=2022-06-27 |title=Airway Foreign Bodies in Children: A Review Article |journal=Journal of Clinical Research and Reports |volume=11 |issue=3 |pages=01–04 |doi=10.31579/2690-1919/250 |s2cid=250541892 |issn=2690-1919|doi-access=free }}</ref> In unconscious choking victims, the American Medical Association has previously advocated sweeping the fingers across the back of the throat to attempt to dislodge airway obstructions.<ref name="AMA">{{Cite book |url=https://archive.org/details/handbookoffirsta00amer |title=American Medical Association Handbook of First Aid and Emergency Care |date=2009-05-05 |publisher=[[Random House]] |isbn=978-1-4000-0712-7 |page=70 |quote=dislodge the object. |url-access=registration}}</ref> Many modern protocols suggest other treatment modalities are superior. Red Cross procedures also advise rescuers not to perform a finger sweep unless an object can be clearly seen in the victim's mouth to prevent driving the obstruction deeper into the victim's airway. Other protocols suggest that if the patient is conscious they will be able to remove the foreign object themselves, or if they are unconscious, the rescuer should place them in the [[recovery position]] to allow the drainage of fluids out of the mouth instead of down the trachea due to gravity. There is also a risk of causing further damage (inducing vomiting, for instance) by using a finger sweep technique. There are no studies that have examined the usefulness of the finger sweep technique when there is no visible object in the airway. Recommendations for the use of the finger sweep have been based on anecdotal evidence.<ref name=":2" />

===Particular cases===

==== Infants (babies under 1 year-old) ====
The majority of choking injuries and fatalities occurs in children aged 0–4,<ref>{{Cite journal |last1=Chang |first1=David T. |last2=Abdo |first2=Kaitlyn |last3=Bhatt |first3=Jay M. |last4=Huoh |first4=Kevin C. |last5=Pham |first5=Nguyen S. |last6=Ahuja |first6=Gurpreet S. |date=May 2021 |title=Persistence of choking injuries in children |url=https://linkinghub.elsevier.com/retrieve/pii/S0165587621000781 |journal=International Journal of Pediatric Otorhinolaryngology |language=en |volume=144 |pages=110685 |doi=10.1016/j.ijporl.2021.110685|pmid=33819896 |s2cid=233036815 }}</ref> highlighting the importance for widespread dissemination of the appropriate anti-choking techniques for these age groups. In fact, it has been shown that increased parental education may decrease choking rates among children.<ref>{{Cite journal |last1=Bentivegna |first1=Kathryn C. |last2=Borrup |first2=Kevin T. |last3=Clough |first3=Meghan E. |last4=Schoem |first4=Scott R. |date=October 2018 |title=Basic choking education to improve parental knowledge |url=https://linkinghub.elsevier.com/retrieve/pii/S0165587618303823 |journal=International Journal of Pediatric Otorhinolaryngology |language=en |volume=113 |pages=234–239 |doi=10.1016/j.ijporl.2018.08.002|pmid=30173993 |s2cid=52145517 }}</ref>

For infants under 1 year-old, the American Heart Association recommends adapted procedures.<ref>{{Cite journal |last=Wilkins, Lippincott Williams |date=2010-11-02 |title=Editorial Board |journal=Circulation |volume=122 |issue=18_suppl_3 |pages=S639 |doi=10.1161/CIR.0b013e3181fdf7aa|doi-access=free }}</ref> The size of the children's body is the most important aspect in determining the correct anti-choking technique. So the [[Choking#techniques in the first aid protocol against choking|normal first aid techniques against choking]] would be tried in children who are too large for the babies' procedures (or they would be tried as a less appropriated attempt if the rescuer is unable to perform the techniques for babies).

First aid for choking infants alternates a cycle of special back blows (five back slaps) followed by special chest thrusts (five adapted chest compressions). [[File:Heimlich Infant.png|thumb|'''Left:''' 'Back blows for infants', the baby receives the slaps being carefully held and slightly placed upside-down; a support under the chest is recommended.
----'''Right:''' 'Chest thrusts for infants', two fingers press on the lower half of the middle of the chest.|alt=|400x400px]]In the ''back blows maneuver'', the rescuer slaps on the baby's back. It is recommended that the baby receive them being slightly leaned upside-down on an inclination. There exist several ways to achieve this:

According to a widely propagated modality: the rescuer sits down on a seat with the baby, and supports the baby with a forearm and its respective hand. The baby's head must be carefully held with that hand (approximately by the face), and kept in a normal position, facing forward, not inclinated. Then the baby's body can be leaned forward upside-down along the rescuer's thighs, and receive the slaps.

As an easier alternative: the rescuer can sit on a bed or sofa, or even the floor, carrying the baby. Next, the rescuer should support the baby's body on the own lap, to lean the baby a bit upside-down at the right or the left of the lap. The baby's head must be in a normal position, facing forward, frontally, and not inclinated. It is always convenient that the baby's chest is supported against something. Then the rescuer would slap the back of the baby.

If the rescuer cannot sit down: at least it is possible to attempt the manoeuver at a low height and over a soft surface. Then the rescuer would support the baby with a forearm and the hand of that side, holding carefully the baby's head with that hand (approximately by the face, but always trying that the baby's head keeps in a normal position, facing forward, not inclinated). The baby's body would be leaned upside-down in that position to receive the slaps. In situations with rescuers who cannot do all of that (as rescuers with disabilities and others), they can still try the normal back blows, supporting the baby's chest with one hand, bending the baby's body, and then giving firm slaps with the other hand.

In the ''chest thrusts manoeuver'', the baby's body is placed lying face up on a surface (it can be the rescuer's thighs, lap or forearm). Then, the rescuer does the compressions pressing with only two fingers on the lower half of the bone that is along the middle of the chest from the neck to the belly (on the chest bone, named [[sternum]], on its part that is the nearest to the belly). Abdominal thrusts are not recommended in children less than one year old because they can cause liver damage.<ref name=":4">{{Cite journal |last=Wilkins |first=Lippincott Williams & |date=2010-11-02 |title=Editorial Board |journal=Circulation |language=en |volume=122 |issue=18 suppl 3 |pages=S639 |doi=10.1161/CIR.0b013e3181fdf7aa |issn=0009-7322 |doi-access=free}}</ref>

The back blows and chest thrusts are ''alternated in cycles'' of five back blows and five chest compressions until the object comes out of the infant's airway or until the infant becomes unconscious.<ref name=":4" />

If choking is unresolved despite these rescue attempts, it is vital that somebody calls to the [[List of emergency telephone numbers|emergency medical services]] and continue first aid until they arrive. An infant can fall unconscious soon, then an anti-choking resuscitation for infants is required (read next).

===== Unconscious infants =====
An ''unconscious'' infant has to be placed face-up on a firm and horizontal surface (as the floor). The baby's head must be in a straight position, facing frontally, because tilting it too much backwards can close the access to the trachea in infants.

A rescuer can then ask for any of the known anti-choking devices, and try it on the unconscious baby. There can be difficulties because of the little size of the infant. The obstruction can be dislodged, but remaining into the mouth, which would need a manual removal. If the baby cannot breath then, or stays in a cardiac arrest, the rescuer must perform a normal cardiopulmonary resuscitation (CPR), as it is described below, but only alternating the 30 compressions and the 2 rescue breaths.

[[List of emergency telephone numbers|Emergency medical services]] must be called, if this has not been done yet.

It can be also convenient that any rescuer asks for a defibrillator near (an AED, as those devices are very common today), just in case it is necessary to treat the baby's heart.

Until emergency services arrive, the American Heart Association<ref name=":4" /> recommends starting (even<ref name=":9" /><ref name=":11" /> with no more delay) an anti-choking cardiopulmonary resuscitation (CPR) adaptive to infants less than one year old (described below). It is a cycle of resuscitation<ref>{{Cite book |last=American Red Cross |title=CPR/AED and First Aid |pages=33 |chapter=Choking – Special Situations}}</ref> that alternates compressions and rescue breaths, like in a normal CPR, but with some differences: 
The rescuer begins by making 30 ''compressions,'' pressing with only two fingers on the lower half of the bone that crosses the middle of the chest from the neck to the belly (on the chest bone, named [[sternum]], on its part that is the nearest to the belly), at an approximate rhythm of nearly 2 per second.

At the end of the round of compressions, the rescuer looks into the mouth for the obstructing object. And, if it is already visible, the rescuer makes a ''try to extract it'' (usually using a finger sweep). The rescuer must not confuse a foreign object with the epiglottis: a cartilaginous flap of the throat. It is possible to try to extract the object without seeing it, always carefully: taking it with the fingers, or using a toothpick (maybe, because almost any other tool would be too wide for a baby), but the current protocols do not recommend extracting the object if it is not visible (a blind extraction), because of the risk to sink it deeper by accident, and because the compressions could move the object outside by themselves (in some cases). A rescuer that already knows that the choking object is a bag (or similar) does not need to see the object before trying to extract it (because there is no risk of sinking it much deeper, and it is easy to detect by using the touch carefully). Anyway, if any removal is tried and takes too much time, it may require alternating it with the chest compressions at some moments, without hindering to the extraction. And, being the object extracted or not in this step, this CPR procedure must pass to the next action and continue until the babies can breathe by themselves or emergency medical services arrive.

In the next step of the CPR, the rescuer makes ''a rescue breath'', covering the baby's mouth and nose simultaneously with the own mouth, and puffing air inside a first time. After that first rescue breath, it is recommended ''tilting the baby's head'' up and down, trying to open a space for the air in that manner, but leaving it approximately straight again, and then giving ''an additional rescue breath'', for the second time''.'' The rescue breaths usually fail while the object is still blocking, but then the rescuer has only to continue with the next step. Anyway, they can enter and reach the lungs, and then the chest of the baby would be seen rising. If a rescue breath arrived there, it is because the object has been moved to an unknown position that leaves some open space, so it can be useful making the next rescue breaths more softly to avoid moving the object to a new blocking position again, and, in case of those soft rescue breaths are not successful, increasing the strength of blowing in the next ones. The bodies of the babies are delicate, and, when the airway is not clogged, only a little strength in blowing is enough to fill their lungs. The baby's colour would improve after some successful rescue breaths. After the rescue breaths, the rescuer has to return to the 30 initial compressions, repeating the same resuscitation cycle again, continually, until the choking baby regains consciousness and breathe normally, or until the object is extracted but a defibrillation is needed to solve a cardiac arrest (read below).

''Defibrillation'' can also be needed, because a choking infant that is already unconscious can suffer a cardiac arrest at any moment, due to several possible causes.<ref name=":13" /> So it is convenient to ask around for a defibrillator (AED device), for trying a defibrillation on a baby that remains in cardiac arrest after having extracted the stuck object (only if the object has been extracted). Those defibrillators are easy to use, as they emit their instructions with voice messages. One of the pads of the defribrillator (any of them) is attached to the baby's chest, and the other pad to the baby's back.

==== Pregnant or obese people ====
Some choking victims cannot receive pressure on their bellies. Then, the American Heart Associated recommends<ref name=":2" /> substituting the abdominal thrusts for chest thrusts.

These victims can include: patients with serious injuries in the abdomen, pregnant women, and obese patients; however, in the case of the obese victims, if the rescuer is capable enough to effectively wrap their arms around the circumference of the victim's abdomen, it is possible to apply the normal first aid against choking, with abdominal thrusts (see details further above).

Chest thrusts are performed in a similar way to the abdominal thrusts, but with the fist placed on the lower half of the vertical bone that is along the middle of the chest (the chest bone, named [[sternum]]), rather than on the abdomen. As a reference, in women, the zone of pressure of the chest thrusts would be normally higher than the breasts. It is convenient to avoid placing the knuckles too painfully. Finally, strong inward thrusts are then applied.<ref name="Choking: First aid" />

The rest of the first aid protocol is the same, starting with asking the victim to cough freely, and then, if the victim cannot cough, the series of chest thrust are alternated with series of slaps on the back. Those back slaps are applied normally: bending forward the back of the victims and supporting their chest with one hand.

If choking remains unresolved, calling to [[List of emergency telephone numbers|emergency medical services]] is vital, but first aid should be continued until they arrive.

When the victims with abdominal problems become unconscious, they need the same [[#Unconscious victims|anti-choking cardiopulmonary resuscitation]] procedure that is employed for other unconscious choking victims (see details further above).

Preventively, if a person with abdominal problems (as injury, pregnancy, or too much obesity) is present, placing an [[#Anti-choking devices|anti-choking device]] nearby can be useful.

====In wheelchair-using victims====
If the choking victim is a wheelchair-using person, the procedure is similar to how it is for other victims. The main difference is in trying to apply the techniques directly, while the victim is using the wheelchair.<ref name=":7">{{Cite web |title=Choking Awareness, wheelchair user |url=http://helpstopchoking.hscni.net/uploaded/files/1/2015/04/1093-Choking_Awareness_App_wheelchair_user.pdf |website=Belfast Health and Social Care Trust |access-date=2023-11-30 |archive-date=2020-07-15 |archive-url=https://web.archive.org/web/20200715195214/http://helpstopchoking.hscni.net/uploaded/files/1/2015/04/1093-Choking_Awareness_App_wheelchair_user.pdf |url-status=bot: unknown }}</ref>

''Coughing'' should be encouraged first before applying the techniques. When the victim cannot cough, it is recommended alternating series of back blows and thrusts, as in other cases.<ref name=":5"/><ref name=":7"/>

''Back blows'' (back slaps) can be used after substantially bending forward the back of the victim, and supporting the victim's chest with the other hand.

''Abdominal and chest thrusts'' can also be used. To perform the abdominal thrusts, the rescuer must get behind the wheelchair. Then, the rescuer can embrace the victim's abdomen from behind and above, leaning over the top of the wheelchair's backrest. If this is too difficult, the rescuer can get down and embrace from behind the victim's abdomen and the wheelchair's backrest all together. In narrow spaces that cannot be opened, the position can be achieved by turning the victim to one side. Finally, the rescuer would grasp the own hand with the other, place them between the chest and the belly button of the victim, and apply sudden pressures with them on that zone, in a direction of in-and-up. If the victim cannot receive abdominal thrusts (in cases as having serious injuries in the belly, pregnancy, and others), chest thrusts must be used instead. They are applied while the victim is using the wheelchair too, but making sudden inward pressures on the lower half of the breast bone ([[sternum]]), which is placed vertically along the middle of the chest. If the space is too narrow and impossible to widen, the abdominal or chest thrusts can be tried by turning the victim to one side.

Rescuers should ''alternate between back slaps and chest thrusts repeatedly'' until the choking is solved, as in other victims.

If choking remains unresolved, calling to [[List of emergency telephone numbers|emergency medical services]] is vital, but first aid should be continued until they arrive.

If a wheelchair-using victim of choking becomes ''unconscious'', anti-choking cardiopulmonary resuscitation (CPR) should be performed, which is the same method also used for able-bodied victims of choking. That said, it can be noted that the victim needs to be removed from the wheelchair and laid face-up on an appropriated surface (not too hard or too soft, and it is possible to put a layer of something between the floor and the victim). While they are on their way, the rescuer should apply [[#Unconscious victims|anti-choking cardiopulmonary resuscitation]] for unconscious victims (see details further above).

As a ''preventive'' measure, it is convenient to avoid placing patients with disabilities in a narrow and encased spaces at mealtimes, as more open spaces allow easier access for rescuers. Besides, placing an [[#Anti-choking devices|anti-choking device]] nearby is a common safety measure in environments.

==== On the bed but unable to sit up ====
If the choking victim is lying in bed, but is conscious and unable to sit up (such as in patients with disabilities or injuries), ''the first aid would be the same, but performed by sitting the patient on the edge of the bed.''

Before adjusting the patient's position, the rescuer encourages the victim to cough freely and as forcefully as they can manage. The victim would do it better by turning to one side. When coughing is too difficult or impossible, the rescuer would sit the victim on the bed's edge, to make coughing easier or to apply the anti-choking manoeuvers (these are required if the victim cannot cough).

This can be achieved<ref>{{Cite web |date=2018-12-22 |title=Assisting a Patient to a Sitting Position and Ambulation |url=https://med.libretexts.org/Bookshelves/Nursing/Book%3A_Clinical_Procedures_for_Safer_Patient_Care_(Doyle_and_McCutcheon)/03%3A_Safe_Patient_Handling_Positioning_and_Transfers/3.06%3A_Assisting_a_Patient_to_a_Sitting_Position_and_Ambulation |url-status=live |archive-url=https://web.archive.org/web/20211007124333/https://med.libretexts.org/Bookshelves/Nursing/Book:_Clinical_Procedures_for_Safer_Patient_Care_(Doyle_and_McCutcheon)/03:_Safe_Patient_Handling_Positioning_and_Transfers/3.06:_Assisting_a_Patient_to_a_Sitting_Position_and_Ambulation |archive-date=2021-10-07 |access-date=2021-11-07 |website=Medicine LibreTexts |language=en}}</ref> grasping the victim by the legs (behind of the knees, or by the calves or ankles) and rotating them until they are out of the bed. Next, the rescuer would sit the victim up on the edge, pulling the shoulders or arms (in the forearms or wrists). Then it is possible to apply the anti-choking manoeuvers<ref name=":5" /> from behind: series of back slaps (after leaning the victim forward, and supporting the chest with one hand) and series of abdominal thrusts (sudden compressions on the part of the victim's belly that is between the chest and the belly button, in a direction of in-and-up). When the victim cannot receive abdominal thrusts (in cases as having serious injuries in the belly, pregnancy, and others), the rescuer needs to change them for chest thrusts (sudden pressures inward on the lower half of the [[Sternum|breast bone]], which is placed vertically along the middle of the chest, from the neck to the belly).

When a rescuer cannot sit the victim up, it is possible to perform chest or abdominal thrusts frontally while the victim is lying on the bed (despite they would be less effective in that horizontal position). They are made by putting one hand on the top of the other and making with both of them strong pressures downwards on the lower half of the breast bone (the [[sternum]]), or in a downward-and-frontward direction between the chest and the belly button.

If choking remains unresolved, calling to [[List of emergency telephone numbers|emergency medical services]] is vital, but first aid should be continued until they arrive.

When the victims of choking in bed become unconscious, they need the same [[#Unconscious victims|anti-choking cardiopulmonary resuscitation]] procedure that is employed for other unconscious choking victims (see details further above).

''Preventively'', it is important to know that eating while laying in bed increases the risk of choking. When a person with a disability or injury is present, a common measure of prevention is placing an [[#Anti-choking devices|anti-choking device]] at reach.

==== On the floor but unable to sit up ====
It is possible, though rare, that a choking victim would be laying on the floor but conscious. For example, someone having a disability that makes impossible to sit up and to keep standing up on the feet. If this is the case, ''the first aid is'' ''the same, but after sitting the victim on the floor''.

Before adjusting the patient's position, the rescuer asks the victim to cough freely and with strength. The victim would cough better by turning to a side. If coughing is too difficult or impossible, the rescuer would sit the victim up, to make it easier or to apply anti-choking maneuvers (these are needed when the victim cannot cough).

A rescuer would sit the victim up by pulling the shoulders or arms (in the forearms or wrists). When the victim is sitting up, the rescuer can sit behind to apply the anti-choking manoeuvers: back slaps (after bending very much the back of the victim, and supporting the chest with one hand) and abdominal thrusts (sudden compressions in a direction of in-and-up, on the part of the victim's belly that is between the chest and the belly button). When victims cannot receive abdominal thrusts properly (as the seriously injured in the belly, and the pregnant women), the rescuer needs to change them for chest thrusts (sudden pressures inward on the lower half of the [[Sternum|breast bone]], which is placed vertically along the middle of the chest, from the neck to the belly).

In some situations it is impossible to sit the victim up, and then the rescuer can try one of the thrusts techniques to the front of their abdomen and chest (even though this is less effective, it could be the only option and therefore worth a try). Anyway, they can be made by putting one hand on the top of the other and using them to make strong pressures downwards on the lower half of the breast bone (the [[sternum]]), or downwards-and-frontwards on the abdomen (between the chest and the belly button).

If choking remains unresolved, calling to [[List of emergency telephone numbers|emergency medical services]] is vital, but first aid should be continued until they arrive.

If the victim is unconscious, it is needed the same [[#Unconscious victims|anti-choking cardiopulmonary resuscitation]] procedure that is used in other unconscious choking victims (see details further above).

In the ''prevention'' of choking, it can be remembered the practice of placing an [[#Anti-choking devices|anti-choking device]] around people with disabilities.

==== Seizing victim ====
Seizing can occur for a multitude of reasons, but is common in those diagnosed with epilepsy. During a seizure, victims may experience strangulation or throat constriction during consciousness.<ref>{{Cite journal |last=Nimeshan |first=Geevasinga |date=2000-12-08 |title=Choking, Asphyxiation, and the Insular Seizure |url=http://dx.doi.org/10.1054/jocn.1999.0776 |journal=Journal of Clinical Neuroscience |pages=1–16 |doi=10.1054/jocn.1999.0776 |doi-broken-date=1 November 2024 |issn=0967-5868}}</ref> The victim will not have control of their bodily functions and will need someone to create a safe area for them. One should clear a space where the victim can lay down and remove or loosen anything that is around their neck. Then one should turn them on their side as to help them breathe and to avoid potential choking on the saliva.<ref>{{Cite web |date=2020-09-30 |title=Seizure First Aid {{!}} Epilepsy {{!}} CDC |url=https://www.cdc.gov/epilepsy/about/first-aid.htm |access-date=2021-12-08 |website=www.cdc.gov |language=en-us}}</ref>

=== Self-treatment ===

First aid anti-choking techniques can be applied on oneself if others are not around to perform general first aid. This can include carrying an approved [[#Anti-choking devices|anti-choking device]] nearby (see above) or conducting first aid techniques on oneself, mainly by hand:

The most widely recommended manoeuver consists of positioning ones own abdomen over the border of an object: usually a chairback, but it could work on an armchair, railing or countertop, and then ''driving the abdomen upon the border'', making sharp thrusts in an inwards-an-upwards direction. It is possible to ''place a fist or both fists between the chosen border and the belly'', to increase the pressure of the manoeuver and make it easier (depending on the situation). It is also possible trying to fall on the edge, aiming to achieve more pressure in that way. Other variation of this consists in pressing one's own belly with an appropriated object, in an inwards-and-upwards direction.

Additionally, ''abdominal thrusts can be self-applied'' only with the hands. This is achieved by making a fist, grasping it with the other hand, and placing them on the area located between the chest and the belly button. Then the body is bent forward and the hands make strong compressions pressing in an inwards-an-upwards direction. One study concluded that the self-administered abdominal thrusts were as effective as those performed by another person.<ref>{{cite journal |display-authors=et al |vauthors=Pavitt MJ, Swanton LL, Hind M |date=12 April 2017 |title=Choking on a foreign body: a physiological study of the effectiveness of abdominal thrust manoeuvres to increase thoracic pressure. |journal=Thorax |volume=72 |issue=6 |pages=576–578 |doi=10.1136/thoraxjnl-2016-209540 |pmc=5520267 |pmid=28404809}}</ref>

When certain scenarios make it impossible for self treatment with abdominal thrust (serious injuries, pregnancy, or obesity), the ''self application of chest thrusts'' is recommended, although more difficult. This would be achieved by leaning the body forward, making a fist, grasping it with the other hand, and doing strong compressions inwards with both of them on the lower half of the chest bone (the [[sternum]], the bone that crosses vertically the middle of the chest). It is convenient to relax the chest for a better reception. Other variation of this is the use of an appropriated object to press inwards in the same point, being equally convenient to receive the compressions when the chest is relaxed.[[File:Head-down position for self-treatment of choking if other approaches fail.gif|thumb|Head-down position for self-treatment of choking if other approaches fail.]]
Making attempts to cough, when it is possible, can also aid in clearing the airway.

Alternatively, multiple sources of evidence suggest applying the head-down (inverse) position.<ref>{{Cite journal |last=Luczak |first=Artur |date=2019 |title=Effect of body position on relieve of foreign body from the airway<sup>†</sup> |journal=AIMS Public Health |volume=6 |issue=2 |pages=154–159 |doi=10.3934/publichealth.2019.2.154 |issn=2327-8994 |pmc=6606524 |pmid=31297401 |doi-access=free}}</ref><ref name=":6">{{Cite journal |last=Luczak |first=Artur |date=June 2016 |title=Head-down self-treatment of choking |journal=Resuscitation |volume=103 |pages=e13 |doi=10.1016/j.resuscitation.2016.02.015 |issn=0300-9572 |pmid=26923159 |doi-access=free}}</ref><ref name=":2" /> is a promising self treatment. To perform this manoeuver, put your hands on the floor and then place the knees on an upper seat (as on a bed, a sofa, or an armchair). Additional movements up or down can be attempted in this position.

=== Advanced treatment ===
There are many advanced medical treatments available to relieve choking or airway obstruction, including the removal of a foreign object with the help of a [[Laryngoscopy|laryngoscope]] or [[Bronchoscopy|bronchoscope]]. The use of any commercial approved [[#Anti-choking devices|anti-choking device]], if it is available nearby, may be a more abrupt solution, but brief.

A [[cricothyrotomy]] may be performed as an emergency procedure when the stuck object cannot be removed. This is an intervention that involves severing a little opening in the patient's neck (between the thyroid cartilage and the cricoid cartilage, until reaching the trachea) and inserting there a tube to introduce air through it, bypassing the [[upper airways]].<ref>{{cite web |title=What is a trachceostomy? |url=http://www.hopkinsmedicine.org/tracheostomy/about/what.html |access-date=25 February 2014}}</ref> Usually, this procedure is only performed by someone with knowledge about it and surgical skills, when the patient is already unconscious.