{"paper_id":"14347dd7-5f04-48ba-b7c2-9bbba5961462","body_text":"Comparative Efficacy of a New Anti-Choking Device Versus Manual Heimlich Maneuver in Simulated Airway Obstruction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Comparative Efficacy of a New Anti-Choking Device Versus Manual Heimlich Maneuver in Simulated Airway Obstruction Xiaofei Song, Zubiao Huang, Xuefang Qi, Guanwen Lu, Yue Wang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7636493/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose Foreign body airway obstruction (FBAO) requires prompt intervention, but the effectiveness and safety of traditional manual procedures like the Heimlich maneuver (HM) are debated. This study evaluated a new standardized anti-choking device (ACD) versus the HM for removing different foreign bodies with different operator factors. Methods In a randomized controlled trial, four types of foreign bodies (FBs) extraction tasks were performed using HM or ACD on simulated adult and infant airway models by 116 medical students (51.7% male, aged 18–23). Outcomes included success rates, temporal efficacy patterns, and gender-based performance disparities. Results ACD demonstrated superior efficacy to HM for all foreign bodies in infant models (odds ratio [OR] for cherry tomatoes = 53.20; OR for peanuts = 8.09, p < 0.05). Temporally, HM initially had a brief advantage within 20 seconds due to device independence, but ACD achieved a higher cumulative success rate at 120 seconds (89.7% vs. 69.0%). HM exhibited significant gender differences in adult models, potentially related to grip strength; ACD eliminated this disparity through standardized pressure output. In adult models, peanut shape significantly influenced outcomes in ACD group. Clearance rates for ellipsoidal peanuts (31.0%) were lower than for cylindrical hard candies (86.2%), likely due to contact friction and anatomical mismatch. Conclusion ACD's mechanical consistency and anatomical precision overcome HM's key limitations, particularly in pediatric emergencies and cases involving irregular FBs. Integrating HM’s capacity for immediate intervention with ACD’s sustained effectiveness during the “golden minute” could enhance resuscitation outcomes in cases of FBAO. Health sciences/Health care Health sciences/Medical research Foreign body airway obstruction Choking First aid Anti-choking device Pediatric emergency Figures Figure 1 Figure 2 1. Introduction Foreign body airway obstruction (FBAO), a critical emergency, was the third leading cause of accidental death in the United States in 2018 ( 1 ) and the leading cause among children under five in China in 2017 ( 2 ). FBAO causes acute hypoxic brain injury, which can lead to irreversible neurological damage within just 4–6 minutes of onset ( 3 ). This extreme urgency heightens the critical importance of timely and effective first aid measures. While Henry Heimlich proposed the abdominal thrust (commonly known as the Heimlich Maneuver or HM) in 1974 ( 4 ), it has long been a standard procedure for FBAO resuscitation ( 5 ). However, accumulating of evidence-based research has revealed significant clinical controversies about HM. Documented complications include life-threatening events such as esophageal rupture, gastric rupture, silent aortic dissection, and fatal splenic rupture ( 6 – 9 ). Systematic reviews further demonstrated limited success with the Heimlich maneuver, especially in children ( 10 ). Crucially, biomechanical analyses indicated that chest compressions generate substantially higher peak airway pressure (40.8 cm H 2 O) than HM (26.4 cm H 2 O) ( 11 ), with HM showing no significant advantage over back blows or chest thrusts in elevating intrathoracic pressure ( 10 ). These findings underscore HM’s limitations in managing complex FBAO cases, necessitating reevaluation of current resuscitation protocols. In recent years, significant progress has been made in the development of anti-choking devices (ACDs), offering a new approach to FBAO resuscitation through suction -based foreign body (FB) removal using controlled negative pressure ( 12 , 13 ). However, systematic comparative evaluations of ACDs against manual techniques remain limited, particularly concerning key parameters such as FB biomechanics, patient age, and operator gender. This study evaluated a new ACD versus HM efficacy using simulated adult and infant airway models with four FB types: deformable (Agarose gel constructs), elastic (cherry tomatoes), and brittle solids (hard candies and peanut kernels). Primary endpoints included first-attempt success rate and time-to-clearance. Results demonstrated ACD's significant superiority over HM across all foreign bodies in infant models, achieving an 89.7% clearance rate at 120 seconds despite HM's transient initial advantage. Crucially, while HM efficacy exhibited operator-gender dependency, ACD consistently eradicated this performance discrepancy. These findings position ACDs as essential adjuncts to manual techniques, analogous to automated external defibrillator (AED) in cardiopulmonary resuscitation. Integration into choking emergency response systems (CERS) could establish a dual-mode 'manual + device-assisted' framework, especially in child-centric environments (e.g., schools and childcare facilities) and settings with operator physical-capability variance (e.g., geriatric care centers), thereby substantially reducing preventable asphyxia mortality. 2. Materials and Methods We conducted an open-label, randomized controlled simulation study comparing the efficacy and usability of suction-based automatic ACDs (Sonmol MFAC-08VC for adults, MFAC-08VS for children, Chongqing, China) versus the HM. The ACD comprises an airbag mask attached to a body containing a spring and a piston rod with a button ( Fig. 1 A ). The MFAC-08VC model measures 273 ± 10 mm (length) by 89 ± 10 mm (diameter), generating a maximum negative pressure of 25–39 kPa. The pediatric MFAC-08VS model measures 265 ± 10 mm by 62 ± 10 mm, generating 27–38 kPa. Pressing the button creates negative pressure to aspirate airway foreign objects ( Fig. 1 B ) . Participants The study received approval from the Biomedical Ethics Committee of Nankai University, Tianjin, China (Approval Number: NKUIRB2025018). One hundred and sixteen undergraduate volunteers (60 males, 56 females; age range: 18–23 years) were recruited from the students in medical school. Eligibility required meeting the physical prerequisites for the practical training module. All participants provided informed consent. Experimental Protocol Participants were stratified by gender and randomly assigned at a 1:1 ratio to four different foreign object type groups: the jelly group (n = 29; 15 males, 14 females), the fruit group (n = 29; 15 males, 14 females), the hard candies group (n = 29; 15 males, 14 females), and the peanut group (n = 29; 15 males, 14 females). All participants received standardized training for both interventions. The ACD group was trained using manufacturer-certified online instructional videos, while the HM group received training based on the 2020 American Heart Association Basic Life Support Provider Manual guidelines ( 14 , 15 ) for FBAO management. Training and testing utilized adult (KAS/CPR184+, YILIAN Medicine, Shanghai, China) and infant (KAS/422A, YILIAN Medicine, Shanghai, China) airway management models (Sonmol, China). Simulated airway obstructions were created using four materials positioned in the hypopharynx under direct visualization according to manufacturer specifications: ( 1 ) Agarose gel constructs (diameter: 17 ± 1 mm, Biyuntian Biotechnology, Nanjing) mimicking edible jelly, ( 2 ) Commercial cherry tomatoes (diameter: 32 ± 3 mm; Qianxi Agricultural Products, Hainan), ( 3 ) Hard candies (diameter: 18 ± 2 mm; Alpenliebe Confectionery Group, Shanghai), and ( 4 ) Dehulled peanuts (long axis: 22 ± 2 mm, short axis: 13 ± 2 mm; Chunwang Food Co., Shandong). Each participant performed both the ACD and HM interventions on both adult and infant simulation models respectively, in random order. Participants in the ACD group were allowed four consecutive application attempts per model type, while participants in the HM group had a 120-second intervention window per model type. All interventions were performed under the supervision of certified basic life support instructors. The success rate and time-to-airway-clearance were recorded by an independent observer. Data Statistics Intergroup differences in FB removal time were analyzed using the student's t-test. Differences in success rates (categorical variable) were compared using Fisher's exact test. Statistical significance was defined as P-value < 0.05. All statistical analyses and data visualization were performed using GraphPad Prism software (version 10.0; GraphPad Software, San Diego, CA, USA). 3. Results A cohort of 116 medical students (male: 51.7%; age range: 18–23 years) successfully completed all randomly assigned tasks during the February-May 2025 study period. The participants primarily consisted of junior undergraduates (1st-3rd year, n = 67, 57.8%). Few participants had previously seen the ACD (n = 5, 4.3%). Although 88.8% (n = 103) had previously attended a first-aid course, 85.3% (n = 99) lacked real-world experience in airway FB removal. A minority of participants reported applying back blows (n = 10, 8.6%) or the HM (n = 7, 6.0%) for airway obstruction management. Notably, none had ever employed ACD devices, whether in clinical practice or simulated situations (Table 1 ). First, we examined removal success rates across the four FB types. The analysis revealed significant differences in success rates among these types (Table 2 ). In adult models, both the ACD and HM maneuvers achieved relatively high success rates for jelly analogue and hard candies removal (ACD: 96.6% for jelly, 86.2% for hard candies; HM: 89.7% for jelly, 82.8% for hard candies), while showing significantly lower efficacy for peanut extraction (ACD 31.0%, HM 58.6%, p < 0.05). Infant model data revealed no significant difference in success rates among the four FB types using the ACD maneuver (p > 0.05). In contrast, the HM maneuver demonstrated significantly higher efficacy for jelly analogue (93.1%) and hard candies (72.4%) compared to peanuts (51.7%), consistent with patterns observed in adult models. The removal success rate for cherry tomatoes exhibited the lowest across all groups in infant model. Our data suggest that although peanuts and hard candies share comparable hardness characteristics, the geometric morphological discrepancy between ellipsoidal (peanut) and near-cylindrical (hard candies) configurations may influence extraction success rates. Subsequently, we compared success rates between the two intervention maneuvers. The differences in extraction success rates were observed between the ACD and HM maneuvers (Table 2 ). In adult models, a significant difference in removal success rates between maneuvers was observed only for cherry tomatoes (OR = 14.74, 95% CI 2.00-165.0, p = 0.0054), with the ACD maneuver (96.6%) demonstrating higher efficacy than the HM maneuver (65.5%). Analysis of the infant model showed that the ACD maneuver was significantly more effective than the HM maneuver for removing three types of foreign bodies (cherry tomatoes: OR = 53.20, 95% CI 7.53–569.9; hard candies: OR = 10.67, 95%CI 1.69–121.9; peanuts: OR = 8.09,95%CI 1.96–28.77), with all comparisons statistically significant (p < 0.05, Table 2 ). These results indicate that ACD may have broader clinical utility in pediatric airway FB emergencies. Interestingly, the data demonstrated a significant interaction effect between gender and FB type on removal success rates (Tables 3 – 4 ). In the adult model, the ACD group showed no gender-based differences across FB subtypes (all p > 0.05). However, the HM group revealed gender-specific efficacy patterns: males demonstrated significantly higher success rates than females for cherry tomatoes (86.7% vs 42.9%) and peanuts (80.0% vs 35.7%) (both p < 0.05), with no significant differences observed for jelly analogue or hard candies removal. Notably, this gender-specific pattern was also replicated in the infant model. Our findings indicate that variations in HM maneuver effectiveness may stem from biomechanical factors related to mismatches between rescuer and victim size mismatches or sex-based grip strength differences, particularly with irregular shaped objects. In contrast, the ACD device's standardized pressure output overcame these biomechanical limitations. Time-course analysis revealed significant temporal disparities in FB removal efficacy between ACD and the HM (Fig. 2 ). In adult models, the HM group demonstrated a transient advantage during the initial 20-second phase due to its equipment-independent implementation. However, ACD effectiveness progressively increased with procedure duration, reaching an 86.2% success rate at 60 seconds - significantly higher than HM's 65.5% (OR = 3.29, 95% CI 1.33–8.12, p = 0.016). This performance differential continued throughout the 120-second observation period, with ACD maintaining final success rates (89.7% vs. HM 69.0%; OR = 3.90, 95% CI 1.37–10.60, p = 0.0107). These time-dependent patterns suggest ACD's mechanical design provides sustained airway control during prolonged rescues, while HM's immediate accessibility retains in critical first-response situations. 4. Discussion This study investigated the success rates of different methods for removing airway FB in adult and infant models, exploring the impact of FB type, removal technique, gender, and time. The findings provide new insights for airway FB first aid. The shape of FBs significantly influenced clearance success. Compared to jelly and hard candies, peanuts had the lowest clearance success rates in both adult and infant models. This inefficiency likely stems from their elliptical shape: the mean long axis of the peanut (2.2 cm) approaches the diameter of the adult trachea (15–20 mm), dynamically increasing friction at the contact surface. Additionally, material properties play a key role: flexible FB like jelly can conform to the airway, reducing risk, whereas hard materials like peanuts may cause rigid impaction. Further research combining hydrodynamic and biomechanical simulations is needed to deepen understanding of these mechanisms. A notable limitation of current studies is the frequent use of uniform simulants ( 16 – 18 ), which fail to adequately represent the heterogeneous nature of clinical FBs. This may affect the applicability of existing resuscitation strategies. Several commercially available ACD devices exist. Studies comparing specific devices have shown that LifeVac (Nesconset, New York, USA) achieves a significantly higher success rate in clearing FBAO than both the Dechoker (Concord, North Carolina, USA) and the HM. In contrast, the success rate of Dechoker showed no significant difference compared to HM ( 18 ). While our study did not directly compare these specific ACD devices, obvious differences exist between the ACD we used and HM. Specifically, ACD demonstrated higher first-aid efficiency in both our adult and child models. For infants with fruit obstruction, ACD was over 53 times more successful than HM (OR = 53.20, statistically significant). This advantage primarily arises from two ACD design features: stable pressure control and anatomically aligned force application. The ACD's pre-set negative pressure limit (32 ± 7 kPa for MFAC-08VC; 32.5 ± 5.5 Kpa for MFAC-08VS) addresses inconsistent force application common in HM by different rescuers, providing standardized, reliable suction. Furthermore, the ACD applies suction directly in line with the airway. In contrast, HM often uses a pushing action, leading to force dissipation and wasted effort ( 19 ). In this study, age-related anatomical variations - particularly narrower pediatric airways and softer cartilage - likely impact intervention outcomes. However, few studies systematically analyze outcomes based on patient demographics like age. Regarding gender effects, ACD effectiveness showed no gender-related differences across FB types in the adult model. However, gender significantly influenced HM success rates for certain FBs (e.g., fruit, peanut-like objects). This gender-specific pattern was also observed in the child model. The efficiency differences with HM may stem from biomechanical factors related to rescuer-victim size differences, especially critical for irregular FBs. Ergonomic studies show males typically have significantly higher grip strength (46.0 ± 8.3 kg) than females (29.1 ± 6.7 kg) ( 20 ). ACD effectively avoids these gender-related biomechanical limitations due to its standardized pressure and automated operation. Analysis over time revealed that in the adult model, HM showed an initial advantage within the first 20 seconds. However, as rescue efforts continued, ACD's success rate steadily increased and eventually surpassed HM significantly. This suggests ACD provides more sustained rescue efficacy during prolonged efforts, while HM's immediate availability remains clinically valuable in the critical initial phase. This study has limitations. First, participants were medical students (18–23 years old) lacking hands-on FB removal experience. This may have biased the assessment of HM performance towards individuals with basic training, potentially overestimating layperson performance and limiting the external validity of the findings. Second, the silicone airway models replicated gross anatomy but had linear elastic properties differing significantly from the viscoelasticity of living tissues. This may underestimate the effect of tissue deformation on FB impaction dynamics in real clinical scenarios. In conclusion, this study confirms that airway FB clearance efficacy is influenced by a multidimensional interaction of device parameters, operator gender differences, and FB morphology. Systematically, ACDs, with their standardized negative pressure and anatomically adapted design, overcome limitations of traditional maneuvers related to human strength and body size. They demonstrate advantages for child FBAO first aid. We recommend incorporating FB morphology recognition into first-aid training to improve decision-making accuracy. These findings provide a reference for updating international resuscitation guidelines and developing pediatric first-aid AI systems, offer valuable evidence for optimizing FB airway obstruction first-aid strategies, and underscore the necessity for further research to improve emergency care. Declarations Funding This research was supported by University-Industry Collaborative Education Program of China (NO.231000287083006) and National Natural Science Foundation of China (NO. 31800661). Author Contributions Song XF and Huang ZB collected all the data and prepared figures and tables, Qi XF and Lu GW wrote the main manuscript text. Wang Y and Qin JF designed the study. All authors reviewed the manuscript. Conflict of Interest Conflict of interest relevant to this article was not reported. Ethics approval The study was approved by the Biomedical Ethics Committee of Nankai University, Tianjin, China (Approval Number: NKUIRB2025018) and was conducted in accordance with the principles of the Declaration of Helsinki. Data availability statement The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request. References Dodson, H., Sharma, S. & Cook, J. Foreign Body Airway Obstruction. In StatPearls , Treasure Island (FL) (2025). Ye, P. P., Jin, Y. & Duan, L. L. [The death trend of children under 5 years old due to foreign body in airway in China from 1990 to 2017]. Zhonghua Yu Fang Yi Xue Za Zhi . 53 , 891–895 (2019). Igarashi, Y. et al. Airway obstruction time and outcomes in patients with foreign body airway obstruction: multicenter observational choking investigation. Acute Med. Surg. 9 , e741 (2022). Heimlich, H. J. Food asphyxiation. Can. Med. Assoc. J. 112 , 1383–1384 (1975). Couper, K. et al. International Liaison Committee on Resuscitation, B., and Paediatric Life Support Task Force, C. Removal of foreign body airway obstruction: A systematic review of interventions. Resuscitation 156, 174–181 (2020). Basile, A. et al. Esophageal rupture after Heimlich maneuver: a case report and literature review. Minerva Gastroenterol. (Torino) . 69 , 566–570 (2023). Kleytman, N. et al. Gastric Rupture Secondary to a Heimlich Maneuver: A Case Report. Cureus 16 , e66466 (2024). Lee, K. Y., Wu, Y. L. & Ho, S. W. Silent Aortic Dissection after the Heimlich Maneuver: A Case Report. J. Emerg. Med. 56 , 210–212 (2019). Cecchetto, G., Viel, G., Cecchetto, A., Kusstatscher, S. & Montisci, M. Fatal splenic rupture following Heimlich maneuver: case report and literature review. Am. J. Forensic Med. Pathol. 32 , 169–171 (2011). Bielinski, J. R. et al. Do We Actually Help Choking Children? The Quality of Evidence on the Effectiveness and Safety of First Aid Rescue Manoeuvres: A Narrative Review. Medicina (Kaunas) 60 (2024). Langhelle, A., Sunde, K., Wik, L. & Steen, P. A. Airway pressure with chest compressions versus Heimlich manoeuvre in recently dead adults with complete airway obstruction. Resuscitation 44 , 105–108 (2000). McKinley, M. J., Deede, J. & Markowitz, B. Use of a Novel Portable Non-powered Suction Device in Patients With Oropharyngeal Dysphagia During a Choking Emergency. Front. Med. (Lausanne) . 8 , 742734 (2021). Bhanderi, B. G. & Palmer Hill, S. Evaluation of DeChoker, an Airway Clearance Device (ACD) Used in Adult Choking Emergencies Within the Adult Care Home Sector: A Mixed Methods Case Study. Front. Public. Health . 8 , 541885 (2020). Panchal, A. R. et al. G. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 142, S366-S468 (2020). Topjian, A. A. et al. C. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 142, S469-S523 (2020). Schepat, P., Herff, H., Alhareh, M. & Wenzel, V. [Simulation of video-assisted retrieval of foreign bodies in the airway of children by nonmedical personnel]. Anaesthesist 70 , 333–339 (2021). Juliano, M., Domingo, R., Mooney, M. S. & Trupiano, A. Assessment of the LifeVac, an anti-choking device, on a human cadaver with complete airway obstruction. Am. J. Emerg. Med. 34 , 1673–1674 (2016). Patterson, E., Tang, H. T., Ji, C., Perkins, G. D. & Couper, K. The efficacy and usability of suction-based airway clearance devices for foreign body airway obstruction: a manikin randomised crossover trial. Resusc. Plus . 5 , 100067 (2021). Hristonof, M. L. S. et al. Comparative efficacy of LifeVac(R) and Heimlich maneuver in simulated airway obstruction. J. Pediatr. (Rio J) . 101 , 473–478 (2025). Tomkinson, G. R. et al. and i, G. G. International norms for adult handgrip strength: A systematic review of data on 2.4 million adults aged 20 to 100 + years from 69 countries and regions. J Sport Health Sci 14, 101014 (2024). Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 30 Apr, 2026 Editor assigned by journal 20 Jan, 2026 Editor invited by journal 23 Sep, 2025 Submission checks completed at journal 23 Sep, 2025 First submitted to journal 22 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7636493\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Article\",\"associatedPublications\":[],\"authors\":[{\"id\":633420009,\"identity\":\"5bfa63c6-8199-4931-ad93-5b8a177ecc06\",\"order_by\":0,\"name\":\"Xiaofei Song\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Nankai university\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Xiaofei\",\"middleName\":\"\",\"lastName\":\"Song\",\"suffix\":\"\"},{\"id\":633420010,\"identity\":\"bb6fc8bd-a7ca-4039-88eb-336f6815aa70\",\"order_by\":1,\"name\":\"Zubiao Huang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Nankai university\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Zubiao\",\"middleName\":\"\",\"lastName\":\"Huang\",\"suffix\":\"\"},{\"id\":633420011,\"identity\":\"03e19059-258b-4b8b-884a-48658bd327aa\",\"order_by\":2,\"name\":\"Xuefang Qi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Nankai university\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Xuefang\",\"middleName\":\"\",\"lastName\":\"Qi\",\"suffix\":\"\"},{\"id\":633420013,\"identity\":\"ab4856bc-4ebf-4d44-9349-7f69439ab1b3\",\"order_by\":3,\"name\":\"Guanwen Lu\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Jining Medical College\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Guanwen\",\"middleName\":\"\",\"lastName\":\"Lu\",\"suffix\":\"\"},{\"id\":633420015,\"identity\":\"6fff2146-5e32-49fd-b6d3-f433a0f0139c\",\"order_by\":4,\"name\":\"Yue Wang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Nankai university\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Yue\",\"middleName\":\"\",\"lastName\":\"Wang\",\"suffix\":\"\"},{\"id\":633420016,\"identity\":\"f5bbaef6-91d2-42f3-9982-f73de3051aac\",\"order_by\":5,\"name\":\"Junfang Qin\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIie3PsQrCMBCA4QuBuKR1TXHoKyQU6tKH8REEwUWHglA3Zwf1GVzdWg462rVQh7o4KQiCiyAGB9fETTD/cNN9HAfgcv1kxbHVUwLVk9sRjOS3hMbiTcCW+AWyyXB6iLpzIO0lg7BvIkGOrFmWp1ggULXOQO1SA5F5VTacYQIIrOdlMJC5kSAb8ScmIULnYU2ol2Es9RVqRfQvtOctMFJIZsFqL9TWRPwayY3fUW0qLK7ncRIar0D92SCpHsK0r6tSiyWXy+X6715zxUCQqzwR+wAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"Nankai university\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Junfang\",\"middleName\":\"\",\"lastName\":\"Qin\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-09-17 06:38:35\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-7636493/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-7636493/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":108973665,\"identity\":\"376fbabb-f144-4b3b-8209-893082312d14\",\"added_by\":\"auto\",\"created_at\":\"2026-05-11 10:43:42\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":846444,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eComposition (A) and usage (B) of ACD in adult and infant models.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7636493/v1/dbc77c2bbee6de3e6d864101.png\"},{\"id\":108973663,\"identity\":\"98ba56de-fe09-47ca-acc4-c4c6f1075022\",\"added_by\":\"auto\",\"created_at\":\"2026-05-11 10:43:40\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":40423,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eForeign body removal times between the ACD and HM groups in the adult model.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7636493/v1/194d0dbb41150925c114b8bf.png\"},{\"id\":108978282,\"identity\":\"3e956c5b-85f7-40cc-87cd-86d82da837bd\",\"added_by\":\"auto\",\"created_at\":\"2026-05-11 11:35:49\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1301941,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7636493/v1/af13e0a2-b1dd-4868-8131-e48b367ba170.pdf\"},{\"id\":108973662,\"identity\":\"d10e8194-9dfd-4f8f-a424-adc8cdd9f35a\",\"added_by\":\"auto\",\"created_at\":\"2026-05-11 10:43:35\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":142203,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Tables.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7636493/v1/5033e9d3371c188dcbf21c02.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Comparative Efficacy of a New Anti-Choking Device Versus Manual Heimlich Maneuver in Simulated Airway Obstruction\",\"fulltext\":[{\"header\":\"1. Introduction\",\"content\":\"\\u003cp\\u003eForeign body airway obstruction (FBAO), a critical emergency, was the third leading cause of accidental death in the United States in 2018 (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) and the leading cause among children under five in China in 2017 (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). FBAO causes acute hypoxic brain injury, which can lead to irreversible neurological damage within just 4\\u0026ndash;6 minutes of onset (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). This extreme urgency heightens the critical importance of timely and effective first aid measures.\\u003c/p\\u003e \\u003cp\\u003eWhile Henry Heimlich proposed the abdominal thrust (commonly known as the Heimlich Maneuver or HM) in 1974 (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e), it has long been a standard procedure for FBAO resuscitation (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e). However, accumulating of evidence-based research has revealed significant clinical controversies about HM. Documented complications include life-threatening events such as esophageal rupture, gastric rupture, silent aortic dissection, and fatal splenic rupture (\\u003cspan additionalcitationids=\\\"CR7 CR8\\\" citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). Systematic reviews further demonstrated limited success with the Heimlich maneuver, especially in children (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). Crucially, biomechanical analyses indicated that chest compressions generate substantially higher peak airway pressure (40.8 cm H\\u003csub\\u003e2\\u003c/sub\\u003eO) than HM (26.4 cm H\\u003csub\\u003e2\\u003c/sub\\u003eO) (\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e), with HM showing no significant advantage over back blows or chest thrusts in elevating intrathoracic pressure (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). These findings underscore HM\\u0026rsquo;s limitations in managing complex FBAO cases, necessitating reevaluation of current resuscitation protocols.\\u003c/p\\u003e \\u003cp\\u003eIn recent years, significant progress has been made in the development of anti-choking devices (ACDs), offering a new approach to FBAO resuscitation through suction -based foreign body (FB) removal using controlled negative pressure (\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). However, systematic comparative evaluations of ACDs against manual techniques remain limited, particularly concerning key parameters such as FB biomechanics, patient age, and operator gender.\\u003c/p\\u003e \\u003cp\\u003eThis study evaluated a new ACD versus HM efficacy using simulated adult and infant airway models with four FB types: deformable (Agarose gel constructs), elastic (cherry tomatoes), and brittle solids (hard candies and peanut kernels). Primary endpoints included first-attempt success rate and time-to-clearance. Results demonstrated ACD's significant superiority over HM across all foreign bodies in infant models, achieving an 89.7% clearance rate at 120 seconds despite HM's transient initial advantage. Crucially, while HM efficacy exhibited operator-gender dependency, ACD consistently eradicated this performance discrepancy.\\u003c/p\\u003e \\u003cp\\u003eThese findings position ACDs as essential adjuncts to manual techniques, analogous to automated external defibrillator (AED) in cardiopulmonary resuscitation. Integration into choking emergency response systems (CERS) could establish a dual-mode 'manual\\u0026thinsp;+\\u0026thinsp;device-assisted' framework, especially in child-centric environments (e.g., schools and childcare facilities) and settings with operator physical-capability variance (e.g., geriatric care centers), thereby substantially reducing preventable asphyxia mortality.\\u003c/p\\u003e\"},{\"header\":\"2. Materials and Methods\",\"content\":\"\\u003cp\\u003eWe conducted an open-label, randomized controlled simulation study comparing the efficacy and usability of suction-based automatic ACDs (Sonmol MFAC-08VC for adults, MFAC-08VS for children, Chongqing, China) versus the HM. The ACD comprises an airbag mask attached to a body containing a spring and a piston rod with a button \\u003cb\\u003e(\\u003c/b\\u003eFig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eA\\u003cb\\u003e).\\u003c/b\\u003e The MFAC-08VC model measures 273\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;10 mm (length) by 89\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;10 mm (diameter), generating a maximum negative pressure of 25\\u0026ndash;39 kPa. The pediatric MFAC-08VS model measures 265\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;10 mm by 62\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;10 mm, generating 27\\u0026ndash;38 kPa. Pressing the button creates negative pressure to aspirate airway foreign objects \\u003cb\\u003e(\\u003c/b\\u003eFig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eB\\u003cb\\u003e)\\u003c/b\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eParticipants\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe study received approval from the Biomedical Ethics Committee of Nankai University, Tianjin, China (Approval Number: NKUIRB2025018). One hundred and sixteen undergraduate volunteers (60 males, 56 females; age range: 18\\u0026ndash;23 years) were recruited from the students in medical school. Eligibility required meeting the physical prerequisites for the practical training module. All participants provided informed consent.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eExperimental Protocol\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eParticipants were stratified by gender and randomly assigned at a 1:1 ratio to four different foreign object type groups: the jelly group (n\\u0026thinsp;=\\u0026thinsp;29; 15 males, 14 females), the fruit group (n\\u0026thinsp;=\\u0026thinsp;29; 15 males, 14 females), the hard candies group (n\\u0026thinsp;=\\u0026thinsp;29; 15 males, 14 females), and the peanut group (n\\u0026thinsp;=\\u0026thinsp;29; 15 males, 14 females). All participants received standardized training for both interventions. The ACD group was trained using manufacturer-certified online instructional videos, while the HM group received training based on the \\u003cem\\u003e2020 American Heart Association Basic Life Support Provider Manual\\u003c/em\\u003e guidelines (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e) for FBAO management.\\u003c/p\\u003e \\u003cp\\u003eTraining and testing utilized adult (KAS/CPR184+, YILIAN Medicine, Shanghai, China) and infant (KAS/422A, YILIAN Medicine, Shanghai, China) airway management models (Sonmol, China). Simulated airway obstructions were created using four materials positioned in the hypopharynx under direct visualization according to manufacturer specifications: (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) Agarose gel constructs (diameter: 17\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1 mm, Biyuntian Biotechnology, Nanjing) mimicking edible jelly, (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) Commercial cherry tomatoes (diameter: 32\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3 mm; Qianxi Agricultural Products, Hainan), (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e) Hard candies (diameter: 18\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2 mm; Alpenliebe Confectionery Group, Shanghai), and (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e) Dehulled peanuts (long axis: 22\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2 mm, short axis: 13\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2 mm; Chunwang Food Co., Shandong).\\u003c/p\\u003e \\u003cp\\u003eEach participant performed both the ACD and HM interventions on both adult and infant simulation models respectively, in random order. Participants in the ACD group were allowed four consecutive application attempts per model type, while participants in the HM group had a 120-second intervention window per model type. All interventions were performed under the supervision of certified basic life support instructors. The success rate and time-to-airway-clearance were recorded by an independent observer.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eData Statistics\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eIntergroup differences in FB removal time were analyzed using the student's t-test. Differences in success rates (categorical variable) were compared using Fisher's exact test. Statistical significance was defined as P-value\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05. All statistical analyses and data visualization were performed using GraphPad Prism software (version 10.0; GraphPad Software, San Diego, CA, USA).\\u003c/p\\u003e\"},{\"header\":\"3. Results\",\"content\":\"\\u003cp\\u003eA cohort of 116 medical students (male: 51.7%; age range: 18\\u0026ndash;23 years) successfully completed all randomly assigned tasks during the February-May 2025 study period. The participants primarily consisted of junior undergraduates (1st-3rd year, n\\u0026thinsp;=\\u0026thinsp;67, 57.8%). Few participants had previously seen the ACD (n\\u0026thinsp;=\\u0026thinsp;5, 4.3%). Although 88.8% (n\\u0026thinsp;=\\u0026thinsp;103) had previously attended a first-aid course, 85.3% (n\\u0026thinsp;=\\u0026thinsp;99) lacked real-world experience in airway FB removal. A minority of participants reported applying back blows (n\\u0026thinsp;=\\u0026thinsp;10, 8.6%) or the HM (n\\u0026thinsp;=\\u0026thinsp;7, 6.0%) for airway obstruction management. Notably, none had ever employed ACD devices, whether in clinical practice or simulated situations (Table \\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003cp\\u003eFirst, we examined removal success rates across the four FB types. The analysis revealed significant differences in success rates among these types (Table \\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). In adult models, both the ACD and HM maneuvers achieved relatively high success rates for jelly analogue and hard candies removal (ACD: 96.6% for jelly, 86.2% for hard candies; HM: 89.7% for jelly, 82.8% for hard candies), while showing significantly lower efficacy for peanut extraction (ACD 31.0%, HM 58.6%, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05). Infant model data revealed no significant difference in success rates among the four FB types using the ACD maneuver (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05). In contrast, the HM maneuver demonstrated significantly higher efficacy for jelly analogue (93.1%) and hard candies (72.4%) compared to peanuts (51.7%), consistent with patterns observed in adult models. The removal success rate for cherry tomatoes exhibited the lowest across all groups in infant model. Our data suggest that although peanuts and hard candies share comparable hardness characteristics, the geometric morphological discrepancy between ellipsoidal (peanut) and near-cylindrical (hard candies) configurations may influence extraction success rates.\\u003c/p\\u003e\\n\\u003cp\\u003eSubsequently, we compared success rates between the two intervention maneuvers. The differences in extraction success rates were observed between the ACD and HM maneuvers (Table \\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). In adult models, a significant difference in removal success rates between maneuvers was observed only for cherry tomatoes (OR\\u0026thinsp;=\\u0026thinsp;14.74, 95% CI 2.00-165.0, p\\u0026thinsp;=\\u0026thinsp;0.0054), with the ACD maneuver (96.6%) demonstrating higher efficacy than the HM maneuver (65.5%). Analysis of the infant model showed that the ACD maneuver was significantly more effective than the HM maneuver for removing three types of foreign bodies (cherry tomatoes: OR\\u0026thinsp;=\\u0026thinsp;53.20, 95% CI 7.53\\u0026ndash;569.9; hard candies: OR\\u0026thinsp;=\\u0026thinsp;10.67, 95%CI 1.69\\u0026ndash;121.9; peanuts: OR\\u0026thinsp;=\\u0026thinsp;8.09,95%CI 1.96\\u0026ndash;28.77), with all comparisons statistically significant (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05, Table \\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). These results indicate that ACD may have broader clinical utility in pediatric airway FB emergencies.\\u003c/p\\u003e\\n\\u003cp\\u003eInterestingly, the data demonstrated a significant interaction effect between gender and FB type on removal success rates (Tables \\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e\\u0026ndash;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e). In the adult model, the ACD group showed no gender-based differences across FB subtypes (all p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05). However, the HM group revealed gender-specific efficacy patterns: males demonstrated significantly higher success rates than females for cherry tomatoes (86.7% vs 42.9%) and peanuts (80.0% vs 35.7%) (both p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05), with no significant differences observed for jelly analogue or hard candies removal. Notably, this gender-specific pattern was also replicated in the infant model.\\u003c/p\\u003e\\n\\u003cp\\u003eOur findings indicate that variations in HM maneuver effectiveness may stem from biomechanical factors related to mismatches between rescuer and victim size mismatches or sex-based grip strength differences, particularly with irregular shaped objects. In contrast, the ACD device\\u0026apos;s standardized pressure output overcame these biomechanical limitations.\\u003c/p\\u003e\\n\\u003cp\\u003eTime-course analysis revealed significant temporal disparities in FB removal efficacy between ACD and the HM (Fig. \\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). In adult models, the HM group demonstrated a transient advantage during the initial 20-second phase due to its equipment-independent implementation. However, ACD effectiveness progressively increased with procedure duration, reaching an 86.2% success rate at 60 seconds - significantly higher than HM\\u0026apos;s 65.5% (OR\\u0026thinsp;=\\u0026thinsp;3.29, 95% CI 1.33\\u0026ndash;8.12, p\\u0026thinsp;=\\u0026thinsp;0.016). This performance differential continued throughout the 120-second observation period, with ACD maintaining final success rates (89.7% vs. HM 69.0%; OR\\u0026thinsp;=\\u0026thinsp;3.90, 95% CI 1.37\\u0026ndash;10.60, p\\u0026thinsp;=\\u0026thinsp;0.0107). These time-dependent patterns suggest ACD\\u0026apos;s mechanical design provides sustained airway control during prolonged rescues, while HM\\u0026apos;s immediate accessibility retains in critical first-response situations.\\u003c/p\\u003e\"},{\"header\":\"4. Discussion\",\"content\":\"\\u003cp\\u003eThis study investigated the success rates of different methods for removing airway FB in adult and infant models, exploring the impact of FB type, removal technique, gender, and time. The findings provide new insights for airway FB first aid.\\u003c/p\\u003e \\u003cp\\u003eThe shape of FBs significantly influenced clearance success. Compared to jelly and hard candies, peanuts had the lowest clearance success rates in both adult and infant models. This inefficiency likely stems from their elliptical shape: the mean long axis of the peanut (2.2 cm) approaches the diameter of the adult trachea (15\\u0026ndash;20 mm), dynamically increasing friction at the contact surface. Additionally, material properties play a key role: flexible FB like jelly can conform to the airway, reducing risk, whereas hard materials like peanuts may cause rigid impaction. Further research combining hydrodynamic and biomechanical simulations is needed to deepen understanding of these mechanisms. A notable limitation of current studies is the frequent use of uniform simulants (\\u003cspan additionalcitationids=\\\"CR17\\\" citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e), which fail to adequately represent the heterogeneous nature of clinical FBs. This may affect the applicability of existing resuscitation strategies.\\u003c/p\\u003e \\u003cp\\u003eSeveral commercially available ACD devices exist. Studies comparing specific devices have shown that LifeVac (Nesconset, New York, USA) achieves a significantly higher success rate in clearing FBAO than both the Dechoker (Concord, North Carolina, USA) and the HM. In contrast, the success rate of Dechoker showed no significant difference compared to HM (\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e). While our study did not directly compare these specific ACD devices, obvious differences exist between the ACD we used and HM. Specifically, ACD demonstrated higher first-aid efficiency in both our adult and child models. For infants with fruit obstruction, ACD was over 53 times more successful than HM (OR\\u0026thinsp;=\\u0026thinsp;53.20, statistically significant). This advantage primarily arises from two ACD design features: stable pressure control and anatomically aligned force application. The ACD's pre-set negative pressure limit (32\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;7 kPa for MFAC-08VC; 32.5\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;5.5 Kpa for MFAC-08VS) addresses inconsistent force application common in HM by different rescuers, providing standardized, reliable suction. Furthermore, the ACD applies suction directly in line with the airway. In contrast, HM often uses a pushing action, leading to force dissipation and wasted effort (\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). In this study, age-related anatomical variations - particularly narrower pediatric airways and softer cartilage - likely impact intervention outcomes. However, few studies systematically analyze outcomes based on patient demographics like age.\\u003c/p\\u003e \\u003cp\\u003eRegarding gender effects, ACD effectiveness showed no gender-related differences across FB types in the adult model. However, gender significantly influenced HM success rates for certain FBs (e.g., fruit, peanut-like objects). This gender-specific pattern was also observed in the child model. The efficiency differences with HM may stem from biomechanical factors related to rescuer-victim size differences, especially critical for irregular FBs. Ergonomic studies show males typically have significantly higher grip strength (46.0\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;8.3 kg) than females (29.1\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;6.7 kg) (\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e). ACD effectively avoids these gender-related biomechanical limitations due to its standardized pressure and automated operation.\\u003c/p\\u003e \\u003cp\\u003eAnalysis over time revealed that in the adult model, HM showed an initial advantage within the first 20 seconds. However, as rescue efforts continued, ACD's success rate steadily increased and eventually surpassed HM significantly. This suggests ACD provides more sustained rescue efficacy during prolonged efforts, while HM's immediate availability remains clinically valuable in the critical initial phase.\\u003c/p\\u003e \\u003cp\\u003eThis study has limitations. First, participants were medical students (18\\u0026ndash;23 years old) lacking hands-on FB removal experience. This may have biased the assessment of HM performance towards individuals with basic training, potentially overestimating layperson performance and limiting the external validity of the findings. Second, the silicone airway models replicated gross anatomy but had linear elastic properties differing significantly from the viscoelasticity of living tissues. This may underestimate the effect of tissue deformation on FB impaction dynamics in real clinical scenarios.\\u003c/p\\u003e \\u003cp\\u003eIn conclusion, this study confirms that airway FB clearance efficacy is influenced by a multidimensional interaction of device parameters, operator gender differences, and FB morphology. Systematically, ACDs, with their standardized negative pressure and anatomically adapted design, overcome limitations of traditional maneuvers related to human strength and body size. They demonstrate advantages for child FBAO first aid. We recommend incorporating FB morphology recognition into first-aid training to improve decision-making accuracy. These findings provide a reference for updating international resuscitation guidelines and developing pediatric first-aid AI systems, offer valuable evidence for optimizing FB airway obstruction first-aid strategies, and underscore the necessity for further research to improve emergency care.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research was supported by University-Industry Collaborative Education Program of China (NO.231000287083006) and National Natural Science Foundation of China (NO. 31800661).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eSong XF and Huang ZB collected all the data and prepared figures and tables, Qi XF and Lu GW wrote the main manuscript text. Wang Y and Qin JF designed the study. All authors reviewed the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConflict of Interest\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eConflict of interest relevant to this article was not reported.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics approval\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe study was approved by the Biomedical Ethics Committee of Nankai University, Tianjin, China (Approval Number: NKUIRB2025018) and was conducted in accordance with the principles of the Declaration of Helsinki.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData availability statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eDodson, H., Sharma, S. \\u0026amp; Cook, J. Foreign Body Airway Obstruction. In \\u003cem\\u003eStatPearls\\u003c/em\\u003e, Treasure Island (FL) (2025).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eYe, P. P., Jin, Y. \\u0026amp; Duan, L. L. [The death trend of children under 5 years old due to foreign body in airway in China from 1990 to 2017]. \\u003cem\\u003eZhonghua Yu Fang Yi Xue Za Zhi\\u003c/em\\u003e. \\u003cb\\u003e53\\u003c/b\\u003e, 891\\u0026ndash;895 (2019).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eIgarashi, Y. et al. Airway obstruction time and outcomes in patients with foreign body airway obstruction: multicenter observational choking investigation. \\u003cem\\u003eAcute Med. Surg.\\u003c/em\\u003e \\u003cb\\u003e9\\u003c/b\\u003e, e741 (2022).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHeimlich, H. J. Food asphyxiation. \\u003cem\\u003eCan. Med. Assoc. J.\\u003c/em\\u003e \\u003cb\\u003e112\\u003c/b\\u003e, 1383\\u0026ndash;1384 (1975).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCouper, K. et al. International Liaison Committee on Resuscitation, B., and Paediatric Life Support Task Force, C. Removal of foreign body airway obstruction: A systematic review of interventions. \\u003cem\\u003eResuscitation\\u003c/em\\u003e 156, 174\\u0026ndash;181 (2020).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBasile, A. et al. Esophageal rupture after Heimlich maneuver: a case report and literature review. \\u003cem\\u003eMinerva Gastroenterol. (Torino)\\u003c/em\\u003e. \\u003cb\\u003e69\\u003c/b\\u003e, 566\\u0026ndash;570 (2023).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKleytman, N. et al. Gastric Rupture Secondary to a Heimlich Maneuver: A Case Report. \\u003cem\\u003eCureus\\u003c/em\\u003e \\u003cb\\u003e16\\u003c/b\\u003e, e66466 (2024).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLee, K. Y., Wu, Y. L. \\u0026amp; Ho, S. W. Silent Aortic Dissection after the Heimlich Maneuver: A Case Report. \\u003cem\\u003eJ. Emerg. Med.\\u003c/em\\u003e \\u003cb\\u003e56\\u003c/b\\u003e, 210\\u0026ndash;212 (2019).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCecchetto, G., Viel, G., Cecchetto, A., Kusstatscher, S. \\u0026amp; Montisci, M. Fatal splenic rupture following Heimlich maneuver: case report and literature review. \\u003cem\\u003eAm. J. Forensic Med. Pathol.\\u003c/em\\u003e \\u003cb\\u003e32\\u003c/b\\u003e, 169\\u0026ndash;171 (2011).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBielinski, J. R. et al. Do We Actually Help Choking Children? The Quality of Evidence on the Effectiveness and Safety of First Aid Rescue Manoeuvres: A Narrative Review. \\u003cem\\u003eMedicina (Kaunas)\\u003c/em\\u003e 60 (2024).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLanghelle, A., Sunde, K., Wik, L. \\u0026amp; Steen, P. A. Airway pressure with chest compressions versus Heimlich manoeuvre in recently dead adults with complete airway obstruction. \\u003cem\\u003eResuscitation\\u003c/em\\u003e \\u003cb\\u003e44\\u003c/b\\u003e, 105\\u0026ndash;108 (2000).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMcKinley, M. J., Deede, J. \\u0026amp; Markowitz, B. Use of a Novel Portable Non-powered Suction Device in Patients With Oropharyngeal Dysphagia During a Choking Emergency. \\u003cem\\u003eFront. Med. (Lausanne)\\u003c/em\\u003e. \\u003cb\\u003e8\\u003c/b\\u003e, 742734 (2021).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBhanderi, B. G. \\u0026amp; Palmer Hill, S. Evaluation of DeChoker, an Airway Clearance Device (ACD) Used in Adult Choking Emergencies Within the Adult Care Home Sector: A Mixed Methods Case Study. \\u003cem\\u003eFront. Public. Health\\u003c/em\\u003e. \\u003cb\\u003e8\\u003c/b\\u003e, 541885 (2020).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePanchal, A. R. et al. G. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. \\u003cem\\u003eCirculation\\u003c/em\\u003e 142, S366-S468 (2020).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTopjian, A. A. et al. C. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. \\u003cem\\u003eCirculation\\u003c/em\\u003e 142, S469-S523 (2020).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSchepat, P., Herff, H., Alhareh, M. \\u0026amp; Wenzel, V. [Simulation of video-assisted retrieval of foreign bodies in the airway of children by nonmedical personnel]. \\u003cem\\u003eAnaesthesist\\u003c/em\\u003e \\u003cb\\u003e70\\u003c/b\\u003e, 333\\u0026ndash;339 (2021).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJuliano, M., Domingo, R., Mooney, M. S. \\u0026amp; Trupiano, A. Assessment of the LifeVac, an anti-choking device, on a human cadaver with complete airway obstruction. \\u003cem\\u003eAm. J. Emerg. Med.\\u003c/em\\u003e \\u003cb\\u003e34\\u003c/b\\u003e, 1673\\u0026ndash;1674 (2016).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePatterson, E., Tang, H. T., Ji, C., Perkins, G. D. \\u0026amp; Couper, K. The efficacy and usability of suction-based airway clearance devices for foreign body airway obstruction: a manikin randomised crossover trial. \\u003cem\\u003eResusc. Plus\\u003c/em\\u003e. \\u003cb\\u003e5\\u003c/b\\u003e, 100067 (2021).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHristonof, M. L. S. et al. Comparative efficacy of LifeVac(R) and Heimlich maneuver in simulated airway obstruction. \\u003cem\\u003eJ. Pediatr. (Rio J)\\u003c/em\\u003e. \\u003cb\\u003e101\\u003c/b\\u003e, 473\\u0026ndash;478 (2025).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTomkinson, G. R. et al. and i, G. G. International norms for adult handgrip strength: A systematic review of data on 2.4 million adults aged 20 to 100\\u0026thinsp;+\\u0026thinsp;years from 69 countries and regions. \\u003cem\\u003eJ Sport Health Sci\\u003c/em\\u003e 14, 101014 (2024).\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003eTables 1 to 4 are available in the Supplementary Files section.\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"scientific-reports\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"scirep\",\"sideBox\":\"Learn more about [Scientific Reports](http://www.nature.com/srep/)\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"Scientific Reports\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Scientific Reports\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Foreign body airway obstruction, Choking, First aid, Anti-choking device, Pediatric emergency\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7636493/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7636493/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003ePurpose\\u003c/h2\\u003e \\u003cp\\u003eForeign body airway obstruction (FBAO) requires prompt intervention, but the effectiveness and safety of traditional manual procedures like the Heimlich maneuver (HM) are debated. This study evaluated a new standardized anti-choking device (ACD) versus the HM for removing different foreign bodies with different operator factors.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eIn a randomized controlled trial, four types of foreign bodies (FBs) extraction tasks were performed using HM or ACD on simulated adult and infant airway models by 116 medical students (51.7% male, aged 18\\u0026ndash;23). Outcomes included success rates, temporal efficacy patterns, and gender-based performance disparities.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eACD demonstrated superior efficacy to HM for all foreign bodies in infant models (odds ratio [OR] for cherry tomatoes\\u0026thinsp;=\\u0026thinsp;53.20; OR for peanuts\\u0026thinsp;=\\u0026thinsp;8.09, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05). Temporally, HM initially had a brief advantage within 20 seconds due to device independence, but ACD achieved a higher cumulative success rate at 120 seconds (89.7% vs. 69.0%). HM exhibited significant gender differences in adult models, potentially related to grip strength; ACD eliminated this disparity through standardized pressure output. In adult models, peanut shape significantly influenced outcomes in ACD group. Clearance rates for ellipsoidal peanuts (31.0%) were lower than for cylindrical hard candies (86.2%), likely due to contact friction and anatomical mismatch.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eACD's mechanical consistency and anatomical precision overcome HM's key limitations, particularly in pediatric emergencies and cases involving irregular FBs. Integrating HM\\u0026rsquo;s capacity for immediate intervention with ACD\\u0026rsquo;s sustained effectiveness during the \\u0026ldquo;golden minute\\u0026rdquo; could enhance resuscitation outcomes in cases of FBAO.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Comparative Efficacy of a New Anti-Choking Device Versus Manual Heimlich Maneuver in Simulated Airway Obstruction\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-05-11 10:40:51\",\"doi\":\"10.21203/rs.3.rs-7636493/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-04-30T19:43:25+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-01-20T10:13:12+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-09-23T13:05:09+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-09-23T06:23:37+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Scientific Reports\",\"date\":\"2025-09-23T01:34:36+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"scientific-reports\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"scirep\",\"sideBox\":\"Learn more about [Scientific Reports](http://www.nature.com/srep/)\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"Scientific Reports\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Scientific Reports\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"f9f6f5b3-dc61-4958-9d8d-d57b3bda8023\",\"owner\":[],\"postedDate\":\"May 11th, 2026\",\"published\":true,\"recentEditorialEvents\":[{\"type\":\"reviewersInvited\",\"content\":\"10\",\"date\":\"2026-04-30T19:43:25+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[{\"id\":67420712,\"name\":\"Health sciences/Health care\"},{\"id\":67420713,\"name\":\"Health sciences/Medical research\"}],\"tags\":[],\"updatedAt\":\"2026-05-11T10:40:51+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-05-11 10:40:51\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7636493\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7636493\",\"identity\":\"rs-7636493\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}