Letter to the Editor - usage of the Heimlich Maneuver to stop and prevent asthma attacks

by Henry J. Heimlich, Eric Spletzer

Editor:

Dr. Alan L. Miller's review of asthma (Altern Med Rev 2001;6(1);20-47) is as complete as any we have seen. Dr. Miller reports that 5,000 people die each year due to asthma. These asthmatics can now be saved if they become aware that the Heimlich Maneuver is being used to stop and to prevent asthma attacks. The concept of using the Heimlich Maneuver for asthmatics came about after several lay persons related their experiences.

The first occurred at a conference eight years ago, when a woman raised her hand and related a surprising incident concerning her sister. "My sister is an asthmatic," she said. "One day when I was visiting, she suddenly couldn't breathe and was turning blue. The only emergency measure I knew was the Heimlich Maneuver. I did it -- she immediately took a deep breath and recovered."

Other reports include a letter we received four years ago from the mother of a four-year-old girl describing the onset of an asthma attack. In this case, the attack was so severe the child could not even inhale her medication. "I was about to rush her to the emergency room, but I knew there wasn't time." Almost instinctively, she performed the Heimlich Maneuver and the child began breathing normally. The mother has been using the Heimlich Maneuver prophylactically, and the child no longer has asthma attacks or takes any medication.

To understand the effectiveness of the Heimlich Maneuver in asthma attacks, let's take a quick look at what happens. Asthma attacks, which consist of prolonged spells of wheezing and shortness of breath that can be fatal, occur when muscles surrounding the airway contract, narrowing the air passages. Mucosa of the bronchi is chronically swollen and inflamed. Consequently, the bronchi contain mucus. Normal inhaling is a muscular effort that increases the volume of the chest cavity and the lungs. Eighty percent of the air breathed in results from the diaphragm descending. The other 20% is caused by expansion of the rib cage by intercostal muscles. When the asthmatic inhales, air slides around the mucus. Exhaling is passive; muscles relax and elasticity of the lungs cause them to expel air. In the asthmatic, mucous plugs clog narrowed airways and air cannot get out. Trapped air distends the lungs, preventing both inhalation and exhalation.

The Heimlich Maneuver overcomes asthma attacks as follows: compression of the lungs expels the air trapped distal to the mucous plugs, causing a flow of air which carries the mucus into the larger airways, eliminating the obstruction. The asthmatic then inhales and exhales normally.

The Heimlich Maneuver consists of pressing upward on the diaphragm.[1] The diaphragm is forced into the chest, diminishing the volume of the chest cavity. This action compresses the lungs uniformly which expels air from the lungs. In a choking victim, this air flow transmits kinetic energy to a foreign body, carrying it away from the airway and out the mouth. In the original 1973 studies, when the Heimlich Maneuver was first devised, it was shown the Maneuver expelled an average of 940 cc of air in 1/4 of a second.[2] That is a flow rate of 205 liters per minute which is proven to be sufficient to expel a solid foreign body or mucous plugs. The air flows out of the mouth, thereby minimizing intrapulmonary pressure, making the Heimlich Maneuver particularly safe for asthmatics.

In fact, the Heimlich Maneuver can even cause a flow of water from the lungs, as proven by Safar's 1982 study on the use of the Maneuver to save drowning victims.[3] The study showed that four Heimlich Maneuvers cause a flow of water from the lungs sufficient to clear the lungs of water. This use of the Maneuver resulted in the survival of 97 percent of 152 unconscious, non-breathing drowning victims. When mouth-to-mouth was used for drowning victims, 40-50 percent died.

As with the child mentioned above, asthma patients are now being taught to use the Heimlich Maneuver prophylactically to prevent asthma attacks and wheezing, and reduce or eliminate the need for medications. These patients range in age from four years old, in which case the child's mother performed the Maneuver, to an 82-year-old physician who performs the Maneuver on himself. Performing the Maneuver once or twice a week keeps bronchi free of mucus. The frequency with which the Heimlich Maneuver is performed prophylactically depends on the severity and the number of asthma attacks each patient had been experiencing. When children sense the onset of wheezing, they will often back into their mother's arms. Pressing upward on the diaphragm is performed more gently and smoothly than when expelling a solid foreign body or water from the lungs as there is little weight or resistance with the amount of mucus present. The patient breathes out slowly as the Maneuver is performed. Asthmatics should not try to learn to use the Maneuver in one day or they will have a sore abdomen; instead spread the learning process over a few weeks.

Recently, in one year, 22 children died of asthma attacks in one New York City hospital emergency room. The usual treatment for asthma attacks consists of endotracheal intubation and suction. Suction removes mucus from the trachea and large bronchi but does not reach the small constricted airways. Consequently, the mucous plugs persist and the asthma attack continues. Furthermore, delay of treatment en route to the hospital increases the risk.

A warning must be issued against the use of CPR chest thrusts which are deadly for asthmatics. The American Heart Association warns, "Even properly performed chest compressions can cause rib fractures in adult patients.... Other complications may occur despite proper CPR technique, including fracture of the sternum, separation of the ribs from the sternum, pneumothorax, hemothorax, lung contusions, lacerations of the liver and spleen, and fat emboli."[4] Pressing on the rigid chest provides little compression of the lungs and, therefore, unlike the Heimlich Maneuver, is ineffective in producing an air flow.

It is appropriate to point out that, as of the year 2000, the AHA no longer requires rescuers to use mouth-to-mouth for heart attack victims. In addition, the AHA now instructs 911 operators to discontinue teaching callers mouth-to-mouth.[4]

In 1985, Surgeon General Koop stated, "The Heimlich Maneuver is safe, effective, and easily mastered by the average person"[5] This statement holds true for asthma sufferers. The Heimlich Maneuver can save their lives, especially in instances where asthmatics are unable to use their inhalers, or do not have them available.

The Heimlich Institute continues collecting case reports on the use of the Heimlich Maneuver for stopping asthma attacks and prophylactically preventing them. Physicians who wish to participate in this study may contact the Institute at heimlich@iglou.com. Further information is available at www.heimlichinstitute.org.

Sincerely,

Henry J. Heimlich, M.D., ScD. President

Eric Spletzer, Ph.D. Research Director

References

[1.] Heimlich HJ. A life-saving maneuver to prevent food-choking. JAMA 1975;234:398-401.

[2.] Heimlich HJ, Hoffmann KA, Canestri FR. Food-choking and drowning deaths prevented by external subdiaphragmatic compression. Ann Thorac Surg 1975;20:188-195.

[3.] Werner JZ, Safar P, Bircher NG, et al. No improvement in pulmonary status by gravity drainage or abdominal thrusts after sea water near drowning in dogs. Anesthesiology 1982;57:A81.

[4.] American Heart Association, International Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiac care: an international consensus on science. Part 3: Adult basic life support. Circulation 2000; 102:122-159.

[5.] Koop CE. The Heimlich Maneuver. Pub Health Rep 1985;100:557.