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For conscious adults showing signs of severe airway obstruction, the European Resuscitation Council recommends applying back blows followed by abdominal thrusts. One important limitation of current recommendations for FBAO treatment is that it requires the assistance of another person, and in approximately 30–40% of FBAO cases, the victim is alone.
These statistics underscore the importance of developing an alternative method of treatment which could be self-applied without relying on the presence or knowledge of other people.
Multiple evidence suggest, that one of promising approaches to improve FBAO treatment in adults could be by applying the head-down (inversed) position (Fig. 1). The head-down position is already recommended during choking incidents that occur in children below one year of age.
There is also evidence that combining the inverse position with other treatment methods improves its effectiveness in adults. One of the most rigorous studies supporting this was conducted by Ruben and Macnaughton.
They studied FBAO in artificial larynxes attached to the endotracheal tubes of intubated volunteers. They reported that successful removal of the obstructing food could be achieved only when maneuvers were aided by gravity. One other advantage of the head-down position is that it could help remove saliva and other fluids which may further obstruct airflow during choking; particularly during partial obstruction or when a foreign object is semisolid. Moreover, I also experienced food choking, and using the upside-down position helped me to remove the object from my airway, which later prompted me to investigate this procedure.
The main concern for head-down position is that when an object is lodged below the glottis (vocal cords), then inversion may cause a complete obstruction when the object falls on the vocal cords. Nevertheless, the infraglottic obstruction accounts for only about 25% of cases.
Therefore in majority of FBAO cases inversion should be a viable option, especially when applied as last resort method to minimize this concern. Another potential concern is that the head-down position could reduce the effectiveness of a natural cough. However, this seems unlikely as gravity-assisted positioning was reported to be more effective than cough alone in subjects with excessive bronchial secretions.
Nevertheless, considering scarcity of data, the safest option could be to apply the inversed position as the last option if all other maneuvers fail. Further studies on this subject would be beneficial.
In conclusion, the available data suggest that the head-down position could be an effective method of rescuing adults suffering from a FBAO when other methods are not successful or not available (especially when a choking person is alone), thus potentially saving lives.
Conflict of interest statement
I do not have any conflicts of interests and I have nothing to disclose.
The fatal cafe coronary: foreign-body airway obstruction.