The Heimlich maneuver is the standard procedure for a choking victim. It has saved many lives but is painful and sometimes injurious, with deaths having been reported. The first thing to try might be to tell the victim: ``Shut your mouth, inhale through your nose, and then cough!''
Samuel Nigro, M.D., a psychiatrist, has prepared a report based on personal experiences. On reviewing it, ENT specialist Vernon L. Goltry, M.D., of Boise, ID, felt that the procedure is well worth further study, and a try in an emergency.
In 1961, 13 years before the Heimlich maneuver was described, Dr. Nigro observed an intern choking on food. A petite nurse instinctively punched him in the epigastric region with her fist, without ever having thought of this method before. This dislodged the object, and the intern was able to cough it out.
Dr. Nigro recalls having performed the equivalent of the Heimlich maneuver on himself at the age of seven when he was choking on a snack instead of practicing the piano. He threw himself across the top of a sofa, which pressed against his upper abdomen. He has also performed the standard Heimlich maneuver successfully on a man who was choking to death in a restaurant.
During the past year, Dr. Nigro experienced four terrifying episodes of complete laryngospasm triggered by particulate irritation. Three ENT physicians told him that had he fainted, the vocal cords would have opened and he would not have died; they advised against trying to do a cricothyroidotomy on himself.
``Subsequent to the four episodes of full laryngeal obstruction,'' Dr. Nigro writes, ``I have had four incipiently identical onset laryngospasms each due to food particles, but I was able to terminate them.... The first time was clearly a fortuitous occurrence.... I had started to choke on something, ... but instead of trying to force ventilation through my mouth as I had always done before, I controlled my panic, shut my mouth, and inhaled through my nose. It was not easy to do because the impulse is to open the mouth and gulp for air. It was a feeble `through a straw' like nasal inhalation, but at least air was moving! And to my surprise, I was able to inhale enough air through my nose to be able to ... cough away the stimulating material.... I had to do [this] ... several times.''
Three subsequent episodes were terminated by conscious use of this method. Reviewing the physiology, Dr. Nigro notes that paroxysmal laryngospasm is a response designed to prevent aspiration of foreign matter. Usually, it is triggered by gastroesophageal reflux. He speculates that there are different neural pathways between the nasal airway and the larynx and diaphragm as opposed to the oral airway. Research in dogs has shown that nasal breathing has a different effect on the internal muscles of the larynx. Increased air pressure in the nasal passages causes the posterior cricoarytenoid muscles to abduct, allowing air to pass.
``Oral breathing has potential for airway obstruction in contrast to nasal breathing,'' Dr. Nigro explains. ``There are reflexes available with oral breathing that shut the system down to prevent aspiration of foreign bodies. Such reflexes seem to paralyze the diaphragm or at least prevent it from being stimulated. On the other hand, there seems to be a nasal laryngotracheal shunt ... available to a certain point of obstructive foreign body size as long as one is still in a pre-aspiration state.''
Had his method not worked, Dr. Nigro assuredly would have tried a Heimlich maneuver, although it is supposed to be used only in cases of a foreign body.
After a Heimlich maneuver has been used, Dr. Nigro recommends the nasal inhalation procedure to further clear the throat. He suggests, however, that the Heimlich might prove to be unnecessary, even in the presence of a foreign body, if the victim is told to ``shut your mouth, inhale through your nose, and then cough!''
He wonders how often the Heimlich maneuver has been used to force open a laryngospasm in the absence of an actual obstruction. Even with an obstruction, Dr. Nigro's instructions might at least have a helpful anti-panic effect on a victim who is frantically looking for something to do.
Dr. Nigro also suggests that mouth-to-nose might sometimes be preferable to mouth-to-mouth resuscitation. It has certainly been recommended for babies. If there is foreign matter in the mouth, oral ventilation will certainly worsen matters.
An informal survey of respiratory care staff showed that none offered instructions on how to breathe when patients were being weaned from ventilators. Instructions on inhaling through the nose might help to reestablish function of the posterior cricoarytenoid muscle.
Dr. Nigro encourages correspondence from anyone with relevant experience (2517 Guilford Rd., Cleveland Heights, OH 44118). A copy of his full 4153-word manuscript is available on request.
New EPA administrator Christine Todd Whitman announced the withdrawal of new arsenic standards for drinking water, which would have reduced the allowable level by 80%, until the agency can review the science and the costs.
Public comments on the rule were overwhelmingly negative. The Risk Policy Center, an informal committee of scientists including Frederick Seitz, petitioned for its withdrawal, stating that ``science advisors...have twice denied approval for the risk calculations EPA used in the arsenic ruling.''
The initial proposal to reduce the permitted levels to 5 ppb would have put one-third of Tucson's wells out of compliance and imposed an estimated treatment cost of $75 million upon the municipal water system. The 10-ppb standard in the final rule issued by Clinton in his last 3 days in office would have cost Arizona between $76 and $123 million, according to the Arizona Dept of Environmental Quality; the Southwest has high levels of this naturally occurring mineral. The cost per life saved would have been infinite because the number of lives saved would have been zero (see Stöhrer G, Arch Toxicol 1991;65:525-532), wrote DDP President Jane Orient, M.D., in comments submitted on behalf of the Pima County [Tucson area] Medical Society.
The Harvard Center for Risk Analysis, founded by John D. Graham, nominated by President Bush to head the Office of Information and Regulatory Affairs in the Office of Management and Budget (OMB), is the leading proponent of comparative risk analysis, which balances the cost of regulation against the risk of an event. It has been estimated that 60,000 lives could be saved by substituting better rules that redirected the $200 billion in spending on federal environmental, health, and safety regulations to those with the highest benefit:cost ratio.
A draft program is enclosed. Don't wait to sign up; space is limited, especially for the tours. We must have the information required by the Nevada Test Site and Nellis Air Force Base three weeks before the tour. If you are not a U.S. citizen, call; there is a special form, and State Department clearance may be needed. This takes 60 to 90 days. The meeting site is the Sahara Hotel at the very special weekend rate of $79 (Friday and Saturday) and weekday rate of $32. Reserve a place NOW by calling DDP at (520) 325-2680 and the Sahara at (888) 696-2121.
Questions to be addressed include: What is the status of the science on global warming? What should be done with nuclear waste? Is depleted uranium a problem? Is it still necessary to test nuclear weapons? Are landfills a hazard? What are prospects for American homeland defense in the new Administration?
DDP, 1601 N. Tucson Blvd. Suite 9, Tucson, AZ 85716, (520)325-2680, www.oism.org/ddp.