Henry J. Heimlich’s research while affiliated with Cincinnati Eye Institute and other places

To the Editor. —The AHA guidelines for CPR1 recommend treatments for drowning victims that risk lives. The following quotes from the guidelines, page 2246, are in error."... a Heimlich maneuver should be used only if the rescuer suspects that foreign matter is obstructing the airway or if the victim does not respond appropriately to mouth-to-mouth ventilation." That instruction was contradicted by a guidelines consultant, who, in a study, reported that bystander CPR is not associated with improved outcome in drowning.2 No controlled scientific study proves that mouth-to-mouth ventilation increases survival, without first evacuating water from the airway. Yet, mouth-to-mouth ventilation has been the initial drowning treatment for 30 years.Patrick (reference 35, page 2250), using a planned protocol for clinical response to drowning, proved that water obstructing the airway of a near-drowning victim is expelled from the lungs by the Heimlich maneuver, enabling recovery.3,4 Delay caused by prior mouth-to-mouth

To the Editor. —Austin et al1 claim that because RCTs were never carried out, no one knows whether malariotherapy is efficacious in the treatment of neurosyphilis. Since 1918, however, hundreds of articles document that malariotherapy is an effective treatment for neurosyphilis. Wagner-Jauregg won the Nobel Prize for discovering malariotherapy.Austin et al1 do not cite "The Malariatherapy of Neurosyphilis,"2 a 1984 Harvard School of Public Health review, supported by the National Institute of Allergy and Infectious Diseases, US Public Health Service (USPHS). The author, Chernin, states: "(i) on average, malariatherapy was less expensive and produced clinical improvement more frequently and more rapidly than did the best drug treatment. (ii) the contraindications to malariatherapy, and there were some, must have been carefully observed because records of treatment-related deaths or debility are few relative to the thousands of patients treated.... It is hard to imagine the almost certain fate

In the following article, Henry J. Heimlich, MD, SeD, recommends pushing water out of a near-drowning victim's airway with the Heimlich maneuver before performing cardiopulmonary resuscitation (CPR). This takes only moments and makes so much sense to me that I will follow this procedure if ever I come across one of my grandchildren or anyone else in a drowning situation. I hope that everyone quickly adopts Heimlich's recommendation of doing the maneuver before CPR, which I am convinced will save countless lives.

The American Red Cross (ARC) and the American Heart Association (AHA) advocated backslaps, chest thrusts, and abdominal thrusts for 10 years after the Heimlich maneuver was introduced in 1974. Even after the Surgeon General in 1985 declared these methods to be "hazardous, even lethal," the ARC and the AHA continue to recommend backslaps and chest thrusts for infants under 1 year of age. ARC and AHA instructional materials that advocate use of these methods have not been recalled, and the public has not been warned of the dangers. One cause of the confusion about backslaps is the flawed belief that gas pressure alone removes a foreign body. In addition, there is lack of understanding that, compared with the Heimlich maneuver, the backslap produces an insignificant amount of the energy required to expel an object from the airway. In fact, the energy produced by the backslap drives the foreign object in the wrong direction, toward the lungs, while the energy produced by the Heimlich maneuver drives the object away from the lungs, toward the mouth. Backslaps and chest thrusts should be publicly recalled as a treatment for choking infants before further deaths and injuries occur. The Heimlich maneuver is the best rescue technique for treating choking victims of all ages.

Over a six-year period, 200 patients requiring long-term oxygen therapy for hypoxemic lung disease underwent insertion of the micro-trach transtracheal catheter and were evaluated for one to seven years. The catheter requires no removal for cleaning; it is designed to function undisturbed within the trachea for six months between replacements. Transtracheal oxygen delivery and saline instillation were instituted immediately after inserting the device. Oxygen administration at a rate of 0.25 to 3 L/min was equivalent to 1 to 8 L/min delivered nasally. By the end of one year of follow-up, 12.5 percent of patients had dropped out of the study. Most patients comply with prescribed 24-hour-a-day oxygen use; in keeping with the NOTT study, life expectancy of emphysema patients may therefore be increased.

Transtracheal oxygen delivery with the Micro-Trach is state-of-the-art treatment for patients requiring long-term oxygen therapy. The Micro-Trach diminishes dyspnea because it bypasses the anatomic dead space in the respiratory tract. It eliminates the waste of oxygen that escapes from the nose and mouth when a nasal cannula is used. Therefore, a small oxygen container lasts longer, increasing the patient's mobility. The patient's appetite improves because oxygen is not diverted during deglutition, and the senses of smell and taste are restored. Rehabilitation is enhanced through increased mobility and improved nutrition. Transtracheal instillation of saline solution cleanses the respiratory tract and stimulates coughing, opening occluded air passages. There are fewer lung infections and hospitalizations for infective exacerbations of disease. Prescribed saline solution, mucolytics, and antibiotics can also be instilled through the Micro-Trach to treat cystic fibrosis. This use and others are still being explored.

Flooding of the lungs occurs routinely in drowning victims. The cause of death in 90% of them is hypoxemia caused by water in the lungs. Mouth-to-mouth ventilation is ineffective until the water is removed. The Heimlich maneuver expels aspirated water, vomitus, debris, and other foreign matter. In treating near-drowning victims, place the victim in the supine position with head turned to the side and perform the Heimlich maneuver to evacuate water from the lungs, unless you know water is not in the respiratory tract. The Heimlich maneuver is a form of artificial respiration. It elevates the diaphragm, increasing intrathoracic pressure and compressing the lungs, and should be performed intermittently until all water is expelled. It is an especially useful technique because fear of contagion sometimes deters rescuers from using mouth-to-mouth ventilation . Further treatment has not been necessary in most instances. If the victim does not recover after water ceases to flow from the mouth, ventilation techniques, cardiopulmonary resuscitation, and other measures as indicated should be used.

To the Editor.— The Heimlich maneuver is now taught by the American Red Cross and American Heart Association as a method for saving near-drowning victims.1A partial review of near-drowning literature by Dr Ornato2 includes a section, "The Need to Clear the Airway of Water With a Heimlich Maneuver." By selectively excluding data from references, it minimizes the pathophysiological significance of aspirated water and the effectiveness of the Heimlich maneuver in expelling that water from the airway and lungs.3Initially, the article acknowledges "terminal gasping with flooding of the lungs." Its table shows that 85% of near-drowning victims weighing 68 kg (150 lb) aspirate as much as 1.5 L of freshwater (<22 mL/kg), and 15% even more; in saltwater, 59% aspirate up to 750 mL (<11 mL/kg), 25% aspirate 750 to 1500 mL, and 16% aspirate more. These volumes are up to ten times greater than the

In over 100 chronic obstructive pulmonary disease patients, continuous oxygen therapy has been provided for up to 4 years using Micro-Trach percutaneous transtracheal catheters less than 2.0 mm in diameter. Successful rehabilitation has been achieved. Advances in materials, insertion technique, and protocols have simplified patient management. Complications occasionally encountered are bleeding, infection, subcutaneous emphysema, increased mucus production, and catheter failure or displacement. Long-term delivery of supplemental oxygen directly into the tracheobronchial tree eliminates the oxygen loss through the oral and nasal orifices that occurs when a nasal cannula is used. This closed system permits maintenance of therapeutic arterial blood levels with improved efficiency, greater comfort, and increased activity. The elimination of nasal irritation and cosmetic objections caused by nasal cannulas increases patient compliance, resulting in uninterrupted 24-hour-a-day oxygen use as indicated. The technique of inserting a transtracheal catheter and postinsertion management are discussed in detail.