By MIKE STOBBE, Associated Press

NEW YORK (AP) — It was the scariest choking incident David Palumbo had ever seen.

The 88-year-old man had been dining at a Providence, Rhode Island, Italian restaurant in September 2019. Now he was unconscious, with a piece of bread lodged in his windpipe. Precious minutes went by as first responders were unable to help him with CPR or the Heimlich maneuver.

In an ambulance on the way to the hospital, the elderly man’s skin was blue, and firefighters worried he was going to die. Palumbo — a fire department captain — used a scissors-like device called Magill forceps to pull the bread from the man’s throat.

“We get a lot of calls in the city for choking,” many of which are resolved before emergency responders even get there, Palumbo added. “This was by far the worst one I’ve been on in my career.”

Fortunately, the man survived and made a full recovery, he said.

But many elderly people do not. Each year, choking claims the lives of more than 4,100 Americans who are 65 or older. It’s the most vulnerable age group, accounting for about three-quarters of U.S. choking deaths, according to federal health statistics.

The death rate has been relatively steady, but the number has risen, as the size of the nation’s retirement-age population grows.

In response, a number of companies are marketing antichoking devices to the elderly. Medical professionals have been debating whether to endorse the products, sold under the names LifeVac, SaveLix, VitalVac and the Dechoker.

Dr. Nathan Charlton, a University of Virginia professor of emergency medicine who advises the American Red Cross on first aid, said there is limited evidence for the products and that the Red Cross is still evaluating them.

Here’s a look at choking and the best ways to prevent choking deaths.

Choking is a danger to older adults

Choking occurs when food or some other object partially or totally blocks the windpipe, preventing oxygen from reaching the lungs.

Telltale signs include someone reaching for their neck and losing the ability to speak normally. Brain damage can occur after four minutes, and death can come just a few minutes later.

Older adults are at higher risk for a number of reasons. As people get older, mouth and throat muscles can weaken. Older people also make less saliva. Some chronic diseases and medications can make swallowing even harder. Dentures can be a choking risk.

The best ways to stop choking

Choking risk can be reduced by cutting food into small pieces, chewing food slowly, drinking plenty of liquids with meals, and not laughing or talking at the same time you are chewing and swallowing.

When someone is choking, you can try perhaps the oldest form of first aid: back slaps.

There’s also the Heimlich maneuver, named after the doctor credited with devising it in the 1970s. It involves standing behind the choking person, wrapping your arms around their abdomen and — with a balled fist — thrusting inward and upward. The idea is that it forces air out of the lungs, and the obstruction with it.

The American Red Cross recommends alternating back blows and abdominal thrusts in sets of five.

That’s for situations in which someone is around to help a choking victim. But what if they are alone?

It is possible for someone try to self-administer a Heimlich by thrusting their abdomen against the back of a chair, Charlton said.

Makers of some the newer anti-choking devices say that’s where their products can make a difference.

“Elderly people probably are not capable of diving on a chair or counter,” said Arthur Lih, the founder and chief executive of LifeVac.

Antichoking devices aren’t always risk-free

They vary in design, but generally the devices look like a face mask attached to a tube or bellows, with a handle at the end. They typically sell for around $30 to $100.

A choking person dons the mask, pushes down on the handle and then pulls up. That is supposed to create a suction that would pull out the blockage.

Some research suggests at least certain devices can injure the tongue or cause bleeding and swelling in the throat. And the U.S. Food and Drug Administration has reports that some products did not generate enough suction and left people with bruising around the face, lips, and mouth.

An injury report led the FDA to do an inspection and issue a warning letter to Dechoker in 2021.

Manufacturers note their products are registered with the FDA, but that’s not the same as an endorsement. Indeed, the agency last year issued a notice to consumers that said it has not approved antichoking devices sold over the counter, because their safety and effectiveness haven’t been established.

Lih said the FDA action was in response to the proliferation of antichoking devices entering the market that vary in design and quality.

More research is needed, choking expert says

Right now, the consensus — even among antichoking device manufacturers — is that back blows and abdominal thrusts should always be tried first. (The forceps that Palumbo used are not recommended for the general public.)

Lih said thousands of nursing homes and emergency response agencies have purchased the newer antichoking devices.

One example: The police department in Acworth, Georgia, bought about 75 LifeVac devices after an officer last year used her personal device to save an elderly woman. They are now in every patrol car, said Sgt. Eric Mistretta.

Manufacturers claim the products have saved thousands of lives across multiple countries, but it’s tricky to document how well they actually work, said Dr. Cody Dunne, a University of Calgary researcher who has tried.

The early evidence has come from case reports or small studies that used mannequins and cadavers.

“I think the case is definitely being built,” he said, but more rigorous research is needed. For example, a larger study could compare what happened during choking incidents at nursing homes that stock the devices with those that don’t.

Dunne noted, however, that evidence for the Heimlich maneuver and back slaps is evolving, too. He co-authored a study last year that found back blows worked better than the Heimlich or chest compressions.

“We’re only now getting good evidence on the old choking techniques, let alone these new ones,” he said.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.