Abstract
-
Objectives
Foreign body airway obstruction (FBAO) is one of the leading causes of accidental death worldwide, with food being among the most common causes. The aim of this study was to provide an overview of the most frequent foreign bodies removed from the airway using an anti-choking suction device.
-
Methods
In this retrospective cohort study, we analyzed a database obtained from LifeVac, which has collected data on the use of the LifeVac device since 2016.
-
Results
We analyzed data from 1,062 patients who experienced FBAO and had the obstruction removed using a LifeVac device. These cases spanned 16 countries, with the majority reported in the United States (n=853, 80.3%), where infants were the most represented age group (n=283, 26.6%). Meat was the most common foreign body (n=178, 16.8%). Most victims had no documented medical conditions (n=746, 70.2%). The LifeVac device achieved success on the first attempt in approximately one-third of cases (n=382, 36.0%). Fewer than half of the victims (n=368, 34.7%) sought medical attention afterward. The highest first-attempt success rate occurred in the supine position (247 of 612, 40.4%).
-
Conclusion
Among LifeVac-reported FBAO cases, infants were the most commonly affected group, meat was the most frequent foreign body, and the highest first-attempt success rate was observed in the supine position. These findings highlight populations and scenarios that may benefit from targeted prevention and timely intervention.
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Keywords: First aid; Suffocation; Choking; Foreign body airway obstruction; Anti-choking suction device
Capsule Summary
What is already known
Foreign body airway obstruction is a major cause of accidental death worldwide, particularly affecting children, older adults, and individuals with certain health conditions.
What is new in the current study
To our knowledge, this is the first study with such a large population (1,062 cases) analyzing the use of an anti-choking suction device (LifeVac) across 16 countries. It identifies meat as the most common obstructive item, highlights infants as the most affected age group, and demonstrates the highest first-attempt success rate when the device is applied in the supine position.
INTRODUCTION
Foreign body airway obstruction (FBAO) is one of the leading causes of accidental death worldwide. It occurs when an object partially or completely obstructs airflow, resulting in suffocation and death if not promptly resolved [
1]. The true incidence of FBAO is difficult to establish because many nonfatal cases resolve without medical intervention [
2]. Fatal FBAO events, however, are estimated to account for approximately 5,000 deaths annually in the United States [
3] and 4,000 deaths annually in Japan [
4].
FBAO can be recognized by the sudden onset of respiratory distress accompanied by coughing, stridor, wheezing, and vomiting. When the obstruction is partial, some airflow remains possible, allowing the person to speak and cough. In the case of complete obstruction, however, no air exchange occurs, leading to hypoxia, loss of consciousness, and eventual cardiac arrest [
5]. Death or a vegetative state can result after approximately 10 minutes without oxygenation. The optimal window for foreign body removal without lasting consequences is about four minutes [
6]. Average paramedic response times in Europe and the United States range from 9 to 11 minutes [
7], which poses a serious challenge in choking emergencies. These factors emphasize the importance of immediate action by eyewitnesses [
5,
6]. Current international guidelines, including those of the European Resuscitation Council [
5], the American Heart Association [
8], and the International Liaison Committee on Resuscitation [
9], recommend that a conscious person with severe airway obstruction first be encouraged to cough. If coughing is ineffective, rescuers should alternate five back blows with five abdominal thrusts (Heimlich maneuvers). If the victim becomes unresponsive, cardiopulmonary resuscitation (CPR) should be initiated immediately. The Australian and New Zealand Committee on Resuscitation (ANZCOR) guidelines differ in recommending five back blows alternated with five chest thrusts, rather than abdominal thrusts, due to concern about potential injury from abdominal maneuvers [
10]; if consciousness is lost, CPR should follow ANZCOR’s Basic Life Support protocol.
In recent years, anti-choking suction devices, including LifeVac (LifeVac LLC), Dechoker (Dechoker), ARIXmed (ARIXmed), and Lifewand (Lifewand), have gained popularity, although evidence remains insufficient to support their routine use [
11,
12]. To date, most studies have involved manikins [
13–
17] or human cadavers [
18,
19], where results are generally favorable. However, without high-quality clinical research, their real-world efficacy remains uncertain. These devices may be particularly valuable for individuals such as obese people, pregnant women, and wheelchair users, for whom performing back blows or Heimlich maneuvers is difficult or nearly impossible [
20].
Food is among the most common causes of FBAO [
21,
22], with the specific type varying widely across countries due to cultural and dietary differences. A well-known example is the Japanese rice dessert that has caused numerous choking incidents during holiday celebrations [
23]. The nature of aspirated objects also varies by age group. Children are especially vulnerable because of their tendency to explore by placing objects in their mouths, compounded by underdeveloped swallowing reflexes and fine motor skills [
24]. A social media study in Italy reported that pizza was the most frequent cause of choking in adults, while grapes were most common in children [
25].
The aim of this study was to provide an overview of the most common airway foreign bodies removed using anti-choking suction devices. This analysis will directly identify foods and objects requiring particular caution in certain age groups and, indirectly, highlight the potential usefulness of anti-chocking suction devices.
METHODS
Ethics statement
This study was exempt from ethical review and informed consent as no identifying information was available for the individuals involved.
Study design and setting
In this retrospective cohort study, we analyzed a database obtained from LifeVac, which has been collecting data on LifeVac device use since 2016. Researchers signed a non-disclosure agreement with LifeVac to work with deidentified data, which could be used solely for analysis and scientific publication. No financial or other benefits were received by the researchers from this collaboration. LifeVac did not have access to the research process or analyzed results until they were publicly released.
Data were collected by LifeVac through forms completed by users after employing the device. Descriptive statistics were primarily used, with inferential statistics applied for hypothesis testing. The database, obtained in November 2023, included user reports collected through physical or online forms. These covered demographic characteristics, general health status, type of airway obstruction, intervention details, success rate, level of consciousness, and characteristics of the foreign body.
Statistical analysis
Data were processed using Microsoft Excel (Microsoft Corp) and IBM SPSS ver. 29 (IBM Corp), and visualizations were created with Canva (Canva Inc). Hypothesis testing employed the Pearson chi-square test.
RESULTS
We analyzed data from 1,062 patients who experienced FBAO and had the obstruction removed using a LifeVac device. These cases spanned 16 countries, with the majority reported in the United States (n=853, 80.3%).
FBAO victims
The most represented age groups were infants (n=283, 26.6%), toddlers (n=236, 22.2%), and older adults (n=210, 19.8%). The youngest victim was 5 days old, and the oldest was 100 years old. Approximately 1 in 10 victims (n=126, 11.9%) was less than 1 year of age. About half (n=513, 48.3%) experienced complete airway obstruction, but only a minority (n=136, 12.8%) were unconscious. Most victims were in either the supine (n=618, 58.2%) or sitting (n=276, 26.0%) position (
Table 1).
Most victims had no documented medical conditions or health issues (n=746, 70.2%). Among those with comorbidities, approximately one in eight (n=127, 12.0%) reported a neurological disorder, with dementia being the most common, affecting 33.1% (42 of 127) of this group (
Fig. 1,
Suppl. 1).
Complete FBAO occurred more frequently in individuals with at least one diagnosed condition compared to those without comorbidities (χ2 (1, n=882)=3.714, P=0.032), affecting 62.9% (176 of 280) and 56.0% (337 of 602), respectively.
LifeVac device usage
Most bystanders (n=835, 78.6%) followed existing guidelines by administering back blows and abdominal thrusts before using the LifeVac device. When these measures failed, the device was applied. The device successfully resolved the obstruction on the first attempt in about one-third of cases (n=382, 36.0%), and on the second attempt in a similar proportion (n=366, 34.5%). Success rates decreased with subsequent attempts: third (n=191, 18.0%), fourth (n=46, 4.3%), fifth (n=13, 1.2%), and additional attempts (n=27, 2.5%). A single case (0.1%) of device malfunction was reported. In five cases (0.5%), suction was reported during or immediately after a seizure. Fewer than half of the victims (n=368, 34.7%) sought medical evaluation afterward. Among age groups, older adults were the only group in which more than half (118 of 210, 56.2%) were examined by a physician (
Suppl. 2). The highest rate of first-attempt removal occurred in the supine position (247 of 612, 40.4%). For subsequent attempts, success rates did not differ significantly by body position (
Suppl. 3).
Fig. 2 shows information on the successful removal of the most common foreign bodies. On the first attempt, strawberries were the only foreign body removed in more than half of cases (15 of 24, 62.5%), followed by steak (15 of 34, 44.1%) and bread (10 of 23, 43.5%). Grapes (3 of 32, 9.4%) and hot dogs (2 of 32, 6.2%) were the only foreign bodies that required more than five attempts in some patients.
Most obstructions were organic (n=908, 85.5%), while a smaller proportion were inorganic (n=110, 10.4%). For 44 cases (4.1%), the type of object was not documented. Among organic items, meat and meat products were most frequent (178 of 908, 19.6%), followed by fruits (147 of 908, 16.2%). Within the meat category, chicken (47 of 178, 26.4%), steak (36 of 178, 20.2%), and sausage (20 of 178, 11.2%) were most common. Among fruits, grapes (35 of 147, 23.8%) and strawberries (25 of 147, 17.0%) were particularly notable. In the sweets category, candy dominated (45 of 92, 48.9%). Other organic categories included hot dogs (32 of 98, 32.7%), bread (23 of 59, 39.0%), and crackers (22 of 57, 38.6%) (
Suppl. 4).
The most frequent inorganic foreign bodies were toys or toy parts (28 of 110, 25.5%), including Lego blocks (4 of 28, 14.3%), marbles (4 of 28, 14.3%), and stickers (4 of 28, 14.3%). Medications were also common (20 of 110, 18.2%), primarily tablets (12 of 20, 60.0%). Other frequently reported inorganic items included coins (10 of 62, 16.1%), caps (8 of 62, 12.9%), and wrappers (7 of 62, 11.3%) (
Suppl. 5).
The highest proportion of inorganic foreign bodies was observed in infants (57 of 264, 21.6%), while the lowest was in older adults (8 of 200, 4.0%) (
Suppl. 6). In other groups, inorganic foreign bodies occurred in 17 of 228 toddlers (7.5%), 12 of 128 children (9.4%), and 10 of 161 adults (6.2%). There was a significant association between type of foreign body and age group (χ
2 (4, n=981)=48.694, P<0.001). The most frequent obstruction was strawberry in infants (14 of 283, 4.9%;), grapes in toddlers (17 of 236, 7.2%), candy in children (20 of 129, 15.5%), steak in adults (19 of 166, 11.4%), and chicken in older adults (11 of 210, 5.2%).
An analysis of the five most frequent foreign bodies (chicken, candy, steak, grapes, and hot dogs) confirmed a strong association with age group (χ2 (8, n=191)=56.591, P<0.001). Chicken was most often aspirated by children aged 0–15 years (27 of 47, 57.4%), followed by older adults (11 of 47, 23.4%) and adults (9 of 47, 19.1%). Candy and grapes were also overwhelmingly reported in children, accounting for 86.7% (39 of 45) and 91.2% (31 of 34), respectively, with smaller proportions in adults (8.9% [4 of 45] and 8.8% [3 of 34], respectively) and in older adults (4.4% [2 of 45] for candy). Steak was most often implicated in adults (19 of 33, 57.6%), with fewer cases in children and older adults (7 of 33, 21.2%). Hot dogs were mainly associated with children aged 0–15 years (22 of 32, 68.8%), with lower proportions in adults and older adults (5 of 32, 15.6%).
DISCUSSION
Our analysis revealed that most cases of FBAO were caused by organic foreign objects, and the frequency of these obstructions varied across age groups. We also found that underlying health conditions influenced both the likelihood and type of airway blockage.
In summary, our findings indicate that organic foreign objects were the predominant cause of airway obstruction, consistent with the results of Blanco Ramos et al. [
26]. Organic materials generally cause more complications because they absorb moisture, which exacerbates obstruction, and they elicit a stronger inflammatory response in bronchial tissue, making removal more difficult [
27]. Meat and meat products were the most frequent organic obstructions in our study, in line with reports from other authors [
28,
29]. Among inorganic objects, the most common were tablets, coins, and toys. This corresponds with the findings of Denny et al. [
30], who also noted coins and toys, along with batteries and balloons. Other studies have reported additional items such as metal and plastic [
26,
27]. In many cases, inorganic objects enter the airway when individuals temporarily hold them between their teeth to free their hands while performing tasks [
31].
We identified grapes, strawberries, and candy as the most common obstructions in the pediatric population, which differs from other studies that emphasize nuts [
32,
33]. In adults and older adults, steak and chicken were the predominant causes in our study. However, international findings vary considerably: in Denmark, meat is the most frequent obstruction [
34], in Italy fish bones predominate [
35], and in Japan rice is the leading cause [
36].
Our results also demonstrated the important role of comorbidities in FBAO. Roughly one in four victims had at least one associated condition, with neurological disorders being particularly prevalent. Other studies have likewise identified dementia, Parkinson disease, and cerebrovascular stroke as the most frequent comorbidities linked to FBAO [
35–
37]. Although our study did not specifically highlight them, mental and behavioral disorders are also relevant, as the risk of FBAO increases with medication side effects and altered behavior [
38]. FBAO during hospitalization is particularly common in psychiatric wards [
37]. We also observed that anti-choking suction devices were sometimes used during seizures, which can impair the swallowing reflex and predispose to aspiration of mucus, blood, or vomit [
39]. Aspiration of foreign objects has also been reported when bystanders incorrectly place items in a person’s mouth to prevent tongue biting [
40]. Although aspiration of foreign bodies during seizures is estimated at less than one percent, the risk rises with seizure frequency [
41]. A literature review revealed no studies or guidelines addressing the use of suction devices in the context of seizures [
42].
Half of the victims in whom anti-choking suction devices were used were under 5 years old. According to the current ERC guidelines, these devices are not recommended for use in pediatric patients [
43]. Their use may distract bystanders and delay implementation of guideline-based interventions. Moreover, suction devices may reduce a child’s ability to cough, increase the risk of gastric content aspiration, and cause upper airway injury [
44]. Nevertheless, when guideline-recommended measures fail, anti-choking suction devices may be considered as a last resort [
43]. According to the manufacturer, the LifeVac device is intended for individuals weighing at least 10 kg to ensure proper mask fit [
45]. Typically, this weight is reached around the first year of life. In our analysis, approximately one in 10 victims was under 1 year old, meaning the device was used outside of manufacturer recommendations. This off-label use in infants raises substantial clinical and ethical concerns. Infants are physiologically distinct, with unique anatomical and safety considerations, and the efficacy of anti-choking suction devices in this group has not been established. To date, only one retrospective observational study has evaluated suction devices in pediatric patients, with about one-third of cases involving infants [
46]. Although no serious adverse events were reported, the uncontrolled design limits firm conclusions about safety and efficacy. Until prospective evidence is available, the use of these devices in infants should be regarded as experimental and approached with caution.
After successful removal of a foreign object from the airway, ERC guidelines recommend seeking medical evaluation [
5], since abdominal thrusts can cause internal injuries such as pneumothorax, aortic dissection, and rupture of the stomach or spleen in severe cases [
47]. In addition, fragments of the aspirated object may remain in the airway, leading to complications such as hemoptysis, persistent cough, dysphagia, throat discomfort, or pneumonia [
5,
48]. Despite these risks, only about one-third of victims in our study (primarily older adults) sought medical attention.
Although our study did not document adverse effects from the use of the LifeVac device, other investigations have reported negative outcomes in cadaver studies. Pressure applied to the tongue and soft palate has been associated with swelling and bleeding in the oral cavity and airway [
19]. Oropharyngeal abrasions and esophageal perforations have also been observed [
49]. In addition, the face mask may cause injury to the nasal bridge [
20]. Similar adverse effects have been reported with other suction devices [
19,
50], including lip lacerations and dislodged teeth [
11].
Our findings demonstrate a high rate of successful foreign body removal with anti-choking suction devices. However, because most cases involved guideline-recommended interventions such as back blows and abdominal thrusts prior to device use, it is important to recognize that the observed success cannot be attributed solely to the device [
51,
52]. We documented only one case of device failure, though the database did not specify the cause. Manikin studies suggest that complications during use may be responsible, with the most frequently reported issue being mask disconnection [
11,
14,
49]. McKinley et al. [
20] noted that achieving and maintaining an adequate seal between the mask and the face can be challenging, especially in individuals who sweat excessively or have copious oral secretions. In such cases, wiping the mouth area before application is advised. Usability studies have also emphasized that securing the mask and maintaining the seal are the main challenges [
13,
15]. To address this, Fijačko et al. [
53] recommended a two-person technique in which one rescuer holds the mask firmly in place while the other operates the device by pulling and pressing to generate suction.
With respect to usability, one study showed that untrained health science students achieved correct device use in 80% to 100% of attempts. They were able to apply it quickly and effectively, though they had more difficulty following existing guideline-recommended FBAO procedures [
15]. Similarly, a study involving laypeople demonstrated that most participants could operate the device within one minute using only the manufacturer’s instructional leaflet [
13]. These findings suggest that anti-choking suction devices are easy to learn and use, and they hold strong potential for rapid public training.
Several media reports have raised concerns about counterfeit products marketed as anti-choking suction devices. The UK Medicines and Healthcare Products Regulatory Agency has warned that these devices fail to meet quality standards, reducing effectiveness and potentially worsening FBAO [
54]. Concerns also include variability in their mechanisms and suction strength [
55]. Counterfeit products are often identifiable by incomplete instructions, inconsistencies in appearance and valve design, absence of safety markings, missing identification numbers, and lack of manufacturer details [
54]. It is estimated that more than 9,000 such counterfeit devices have been sold in recent years through online marketplaces such as AliExpress (Alibaba Group) [
55].
As emphasized earlier, anti-choking suction devices should be considered only as a last resort in FBAO management, while the primary focus should remain on preventive strategies to reduce choking risk. Recommended practices include eating slowly and mindfully, cutting food into small pieces, avoiding distractions such as audiovisual devices, limiting excessive alcohol intake, and refraining from talking or laughing while eating. For children, constant supervision is critical, along with creating a calm eating environment and gradually introducing foods of varying textures [
35]. A Japanese study found that nearly half of fatal or severe FBAO cases in institutionalized older adults were linked to caregiver error. Failures included providing inappropriate foods, inadequate supervision or assistance during meals, ignoring prior feeding difficulties, and delayed or inadequate responses to FBAO emergencies [
56].
Our study faced several limitations. First, inferential statistical analyses, such as chi-square tests for trend or association, could not be performed because data on unsuccessful removal attempts were unavailable. Since the dataset included only cases in which foreign body removal was successful using anti-choking suction devices, we were unable to calculate success rates per attempt or examine associations with independent variables such as patient position, type of foreign body, or adherence to guidelines. This limited our ability to assess factors influencing device effectiveness. Second, the generalizability of our findings is restricted, as the study population comprised victims from 16 countries. This broad international distribution complicates direct comparisons with studies conducted in single countries or within specific healthcare systems. Third, the database did not include information on potential institutionalization, particularly in older adults; for example, whether individuals resided in nursing homes or similar facilities. Such information could have provided additional insight into the contexts of device use, especially in cases involving healthcare providers or caregivers.
Conclusions
FBAO can occur at any age, but it is more common among children, older adults, and individuals with underlying health conditions. Certain foreign bodies, including steak, chicken, grapes, candy, and hot dogs, appear to carry a higher risk of airway obstruction. These items, along with individuals who present risk factors, warrant special attention to ensure timely recognition and prevention of choking incidents. To date, peer-reviewed research has only evaluated two anti-choking suction devices, LifeVac and DeChoker, with no published scientific evidence regarding other similar products. Among these, LifeVac has demonstrated superior performance. However, further studies involving human or animal subjects are necessary to generate stronger, clinically relevant conclusions. While some organizations have already adopted anti-choking suction devices in workplace settings, the broader safety and effectiveness of these tools remain under investigation. Although it is premature to recommend their widespread deployment—for example, in first aid kits or public venues alongside automated external defibrillators—their potential role merits further exploration and cautious consideration in the context of FBAO management.
NOTES
-
Author contributions
Conceptualization: all authors; Data curation: all authors; Formal analysis: all authors; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.
-
Conflicts of interest
Nino Fijačko is a member of the European Resuscitation Council (ERC) Basic Life Support (BLS) Science and Education Committee. The authors have no other conflicts of interest to declare.
-
Funding
The authors received no financial support for this study.
-
Acknowledgments
The authors thank Matt Banagan from LifeVac LLC for providing the database.
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Data availability
Data analyzed in this study were obtained from LifeVac and are not publicly available due to confidentiality agreements.
Supplementary materials
Fig. 1.The most common types of diseases.
Fig. 2.Successful removal of the nine most common obstructions: (A) chicken, (B) candy, (C) steak, (D) grapes, (E) hot dog, (F) strawberry, (G) apple, (H) bread, and (I) cracker.
Table 1.Characteristics of the study population (n=1,062)
Table 1.
|
Characteristic |
No. of cases (%) |
|
Sex |
|
|
Male |
528 (49.7) |
|
Female |
522 (49.2) |
|
Unknown |
12 (1.1) |
|
Age group |
|
|
Infant (0–2 yr) |
283 (26.6) |
|
Toddler (2–5 yr) |
236 (22.2) |
|
Child (5–15 yr) |
129 (12.1) |
|
Adult (15–65 yr) |
166 (15.6) |
|
Older adult (>65 yr) |
210 (19.8) |
|
Unknown |
38 (3.6) |
|
Health condition |
|
|
Healthy (no known disease) |
746 (70.2) |
|
Chronic disease |
316 (29.8) |
|
Airway obstruction |
|
|
Partial |
369 (34.7) |
|
Full |
513 (48.3) |
|
Unknown |
180 (16.9) |
|
State of consciousness |
|
|
Conscious |
913 (86.0) |
|
Unconscious |
136 (12.8) |
|
Unknown |
13 (1.2) |
|
Position |
|
|
Supine |
618 (58.2) |
|
Sitting |
276 (26.0) |
|
Standing |
87 (8.2) |
|
Unknown |
81 (7.6) |
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