World-leading research from the University of Calgary and Alberta Health Services contradicts current practice with major global implications.

A silent revolution in medicine prompted by careful study in Calgary is poised to change a basic first aid routine taught to millions of parents, caregivers and food service workers around the world. New research led by a team at the University of Calgary’s Cumming School of Medicine, in collaboration with AHS (Alberta Health Services) has shown that breathing and chest compressions are absolutely essential to providing help to a victim who is choking — overturning the standing assumption among health-care professionals worldwide.

The research marks the first major comprehensive review of real-life choking-event data and contradicts more than 40 years of accepted wisdom in delivering first aid to the choked. The Calgary research indicates that in conscious adults and children over the age of one, starting with abdominal thrusts may be more effective for dislodging a serious airway blockage — and that’s a finding now being adopted by leading health organizations.

“For years, the rallying cry has been ‘five-and-five’ — five back blows and then five abdominal thrusts. It’s in posters inside restaurants, and it's practiced in countless first aid courses,” said Dr. Ian Walker, the lead investigator on the study and an emergency medicine physician. “Based on our data from a previously published large, case-based review of actual emergency responses to choking patients who were severely choking and in need of assistance to survive, it became evident that when the Heimlich maneuever was started prior to the interventions commonly prescribed by standard advanced life support protocols or antichoking algorithms (ie.the application of abdominal thrust)... the actaul duration time for resolution of the obstruction and number of healthcare provider repeated atempts was significantly less. On their own, the whacks to the back often did not work.”

Research Genesis: From a Practice Question

It was not conceived in a lab, rather on the frontlines by paramedics and emergency room workers within the AHS system. They observed varied outcomes and reported that a majority of successful clearances occurred during or shortly after abdominal thrusts. This anecdotal evidence led to a formal, data-based analysis.

The investigation involved a multi-year retrospective review of detailed data on choking-related pre-hospital emergency medical services (EMS) calls throughout the province of Alberta. They were interested in cases in which the victim was conscious but had a completely obstructed airway — a bona fide medical emergency in which the person cannot cough, speak or breathe. This pattern began to take shape as we looked at the sequence of actions performed by first responders and bystanders throughout and their subsequent outcomes.

“We weren’t looking at mild choking with someone who is coughing vigorously. That is a different kind of circumstance,” explains Dr. Sarah Jenkins, a co-investigator and public health researcher on the team. “We were very mindful of the ‘can’t breathe, can’t talk’ situation, where time is of the essence. Our study demonstrated that commencing cough with abdominal thrust caused an instant recovery rate of higher quality. Back blows, though historical first responders in such cases, tended to forestall the better intervention.”

The Science of the Shift: Why Thrusters?

The physiological justification corresponds with the data. Of a great choking obstruction, which is usually situated at the vault of the throat or immediately below it. A force against toward the rear creates a vibration and pressure that will dislodge it. But an abdominal thrust is a more precise and forceful action. It quickly lifts the diaphragm, squeezing the lungs which can provoke a violent artificial cough. This upward rush of air beneath the object is frequently enough to blow the object out.

“Think of it as akin to a ketchup bottle,” Dr. Walker says. “A tap on the back may help (the back blow), but a sharp thrust to the bottom (the abdominal thrust) applies more direct and pressurized force to pop out the blockage. That clinical logic makes sense in a potentially life-threatening situation, proceeding front and center with your most powerful tool.”

The Calgary results were extensively peer-reviewed and were corroborated by an independent simulation study. “When the body of evidence became too large for guideline committees to ignore.

Local to Global: Making a Difference

The impact from Calgary has been swift and deep. The team shared their results with the International Liaison Committee on Resuscitation (ILCOR), which is the overall body governing the review of science to determine resuscitation guidelines across the globe. ILCOR’s 2023 consensus on science and treatment recommendations have included the Calgary research to suggest for adults and children older than one who are conscious and in severe choking, that practitioners should not be compelled by evidence which mandates a sequence of back bl

This change has had a concrete impact on national institutions. - (AHA) and the American Red Cross have updated their instruction in their 2024 Guideline Updates. Their recent protocol now recommends rescuers provide abdominal thrusts first for conscious choking victims with complete obstruction. Blows are not abandoned but are given as a substitute if the helper is incapable of performing thrusts or if thrusts fail.

In Canada, the Heart & Stroke Foundation - serving as an authority on resuscitation guidelines - has been no exception. Their new guidelines give rescuers license: “For a conscious adult or child (over 1 year) with severe airway obstruction, give abdominal thrusts. Back blows may be substituted, particularly if abdominal thrusts are unsuccessful.

“This is an amazing example of evidence-based medicine in practice,” says Dr. Jenkins. A tradition that was handed down for generations has been viewed differently in the face of compelling, robust data. Calgary’s work furnished that vital evidence, shifting us from old school to best practice.”

Applications to Public Training and Safety

The shift has major effects for first aid training organizations, public health messaging and ultimately, public safety. St. John Ambulance, the Canadian Red Cross and other proiders are updating training materials to reflect the new priority.

“We’re now being taught (instructors) ‘thrists first’ for severe choking,” says Michael Lee, Regional Director for a large first aid training provider in Alberta. “It narrows the decision tree for the rescuer in a crazy-making situation. Clear, simple instructions save lives. That the Calgary study now gives us confidence to teach this new method.”

The point for the public is clear: If an adult or child over 1 year of age is choking severely, unable to cough or breathe, you should do the following as soon as possible:

Ask: “Are you choking?” If they nod yes, and are unable to speak.

Call: Have someone call 9-1-1, or if you are alone, do so yourself.

Perform: Stand behind the person, make a fist just above the navel and grip it with your other hand to provide rapid, upward abdominal thrusts.

Repeat this cycle until the object is removed or the person loses consciousness (at which point you would start CPR).

A Legacy of Lifesaving Innovation

This global health guideline also adds to Calgary's increasing recognition as a centre where medical innovation can make a difference through research. From pioneering stroke care to innovative cardiac arrest protocols, the city’s medical community has time and again shown it can affect best practices around the globe.

“This is more than an academic game,” concludes Dr. Walker, his tone earnest. “This is about giving people the greatest possible chance under one of the most terrifying circumstances. If a parent or friend or stranger in a diner can act with the best method first because of our work, we’ve really done something meaningful. It’s a proud day for Calgary’s research community, but also, and more importantly, this is a better tool for everyone to save a life.”

Funding: This research was funded by grants from the Canadian Institutes of Health Research (CIHR) and Alberta Health Services.

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