Two airway emergencies where the right sequence differs by age, and where the commonest adult reflex is the wrong one.
Choking
First decide whether it is mild or severe, because the answer changes everything and it takes two seconds.
| Mild — effective cough | Severe — ineffective cough | |
|---|---|---|
| What you see | Can speak, cough forcefully, cry, breathe. Distressed but moving air | Silent or a weak wheezy cough, cannot speak or breathe, clutching the throat, going blue, becoming quiet |
| What to do | Encourage coughing and do nothing else. A cough generates more airway pressure than anything you can do to them. Hitting the back of someone with a partial obstruction can convert it to a complete one | Intervene immediately, sequence below |
Going quiet is deterioration, not improvement. Someone who was coughing loudly and has stopped has usually not cleared it.
Adults and children over 1
Five back blows
Lean them well forward — so anything dislodged falls out rather than back down. Heel of the hand, firmly, between the shoulder blades. Check after each one; you are giving up to five, not necessarily five.
Five abdominal thrusts
Behind them, fist between navel and the bottom of the breastbone, other hand over it, sharply inwards and upwards. For a small child, kneel behind them and reduce the force.
Call 999 and keep alternating
Five and five, until it clears or they become unresponsive.
If they become unresponsive, start CPR
Chest compressions generate higher airway pressures than abdominal thrusts do. Look in the mouth before each set of breaths and remove anything you can see — never a blind finger sweep, which pushes obstructions deeper and can injure the airway.
Infants under 1 — never abdominal thrusts
Abdominal thrusts are contraindicated under 1 year. The liver sits low and relatively unprotected and is easily ruptured. Use chest thrusts instead.
- Five back blows — face down along your forearm, head lower than the chest, supporting the jaw. Heel of the hand between the shoulder blades.
- Five chest thrusts — turn them face up and use the two-thumb encircling technique, the same hand position as infant CPR compressions, but sharper and slower. Changed in 2025 from the old two-finger method, matching the compression change.
- Alternate, call 999, and start infant CPR if they become unresponsive.
Two situations where the technique changes
- Late pregnancy, or someone too large to reach around: chest thrusts instead of abdominal — hands on the lower half of the breastbone, sharply backwards.
- Wheelchair user: the same sequence, adapted. Move armrests if they are in the way rather than moving the person.
- Alone and choking: call 999 anyway — an open line brings help even with no voice. Then thrust your own abdomen against the back of a chair or a worktop edge.
Anti-choking suction devices — what they are and where they belong
Handheld suction devices are heavily marketed to parents, care homes and schools, usually with frightening advertising. They are a real category with a defined role, and that role is narrow and second-line. The commonest harm from them is not the device; it is the seconds spent reaching for one.
| Device | How it works |
|---|---|
| LifeVac | A bellows attached to a face mask. Pushing down compresses the chamber without forcing air into the lungs; pulling up generates suction intended to lift the obstruction out |
| Dechoker | An oral tube passed over the tongue, attached to a syringe-like cylinder. Pulling the plunger creates suction through the tube |
What the regulators actually say, which is narrower than the advertising
- They are regulated devices with a defined second-line role. The FDA has given LifeVac De Novo classification as a Class II device, and the device type it created is explicitly “suction anti-choking device as a second-line treatment” — for use when basic life support choking protocols have already failed.
- And the order sets limits people do not read. The indication covers adults and children aged one year and above — not infants — and the operator must be at least 18, lay or professional. So a device bought for a baby is outside its own indication, and one kept for a teenager to use on a sibling is too. For an infant it is back blows and chest thrusts, and nothing else.
- In the UK, only two brands are legitimate. The MHRA is aware of LifeVac and Dechoker as the only anti-choking devices holding a valid UKCA or CE mark and registered under the UK Medical Device Regulations — and both are registered for use only after back blows and abdominal thrusts have been attempted and failed.
- The resuscitation bodies do not endorse them. The Resuscitation Council UK neither encourages nor discourages their use, does not endorse them on the grounds of insufficient evidence, stresses that they must not replace standard first aid training, and warns that using one prematurely could delay established treatment. The American Heart Association and American Red Cross do not recommend them; the AAP and ILCOR do not regard them as standard of care.
The genuinely dangerous part is the counterfeit market
- The MHRA estimates that over 10,000 counterfeit or unbranded anti-choking devices were bought by the UK public in two years, through online marketplaces and drop-shipping sites, mostly originating from China. Many look identical to LifeVac and some claim to be it.
- The failure mode is the one that matters. Without a functioning one-way valve, compressing the device blows air downwards into the airway — which can drive the obstruction further in. The MHRA's position is that these carry a significant risk of failing and may worsen the situation.
- They should not be used, and should be disposed of once identified. If you already own one bought cheaply from a marketplace, that is the advice — not to keep it as a backup.
- How to check: a genuine device carries a UKCA or CE mark and the manufacturer is MHRA-registered. The MHRA publishes a photographic comparison of genuine against counterfeit. Price is the other clue — a device at a fraction of the brand price is almost certainly a copy.
What the evidence shows, and it is not one-directional
| Favourable | Unfavourable |
|---|---|
| Manufacturer-held case series report high success — for example 38 of 39 resuscitations in patients with swallowing disorders over six years. A 2020 systematic review found 94.3% first-attempt success. A 2023 manikin study reported 99% success against 82% for abdominal thrusts | The favourable data is self-reported to the manufacturer, and the systematic review rated its own certainty of evidence as very low. Manikins are not airways. And the cadaveric work goes the other way: in one 2023 study using food placed at the vocal cords, Dechoker failed in every trial and LifeVac cleared only barium-moistened crackers, with both devices applying significant pressure to the tongue |
Two further concerns worth knowing. Suction applied to the oropharynx can draw stomach contents upward and into the lungs, which is a route to aspiration pneumonia the advertising does not mention. And the effect on behaviour may matter more than the effect on airways: owning a device can substitute for learning back blows and abdominal thrusts, which are free, always to hand, and have the evidence behind them.