The Heimlich Maneuver Has Changed: The 5-and-5 Approach

By Tim Fitzgerald
26 May 2026

The 5-and-5 Approach to the Heimlich Maneuver

If you were trained on the Heimlich maneuver more than a year ago, your technique is outdated. In October 2025, the American Heart Association (AHA) released its first full revision of CPR and Emergency Cardiovascular Care (ECC) guidelines since 2020 — and the changes to choking response are significant. As a nurse, you are often the first clinically trained person to respond to a choking emergency, whether on the unit, in a waiting room, or out in the community. You cannot afford to be working from an old playbook.

Here is exactly what changed, why it changed, and what you need to do about it.

The Old Standard: Abdominal Thrusts Alone

The Heimlich maneuver — developed by Dr. Henry Heimlich in 1974 — became the universal response to choking for adults and older children. The technique involves standing behind the choking patient, forming a fist just above the navel and below the ribcage, and delivering sharp upward thrusts to force air from the lungs and dislodge the obstruction. For five decades, abdominal thrusts were the protocol. Full stop.

But as evidence evolved, researchers and clinicians began identifying cases where abdominal thrusts alone failed to clear the airway — and in some cases, caused internal injuries. The question became: is there a more effective, evidence-based approach?

The 2025 AHA Update: The 5-and-5 Approach

The answer, according to the updated guidelines published in Circulation on October 22, 2025, is yes. The AHA now recommends alternating five back blows with five abdominal thrusts for conscious adults and children over one year of age — continuing the cycle until the object is expelled or the patient becomes unresponsive. This is known as the “5-and-5” approach, and it replaces the previous abdominal-thrust-only recommendation.

The updated protocol for adults and children (1 year and older):

Lean the patient slightly forward and deliver five firm back blows between the shoulder blades using the heel of your hand.
Follow immediately with five abdominal thrusts — fist above the navel, sharp upward compressions.
Alternate between the two until the airway is cleared or the patient loses consciousness.
If the patient becomes unresponsive, begin CPR immediately and look for the obstruction with each ventilation attempt.

Critically, the previous AHA guidelines did not include choking guidance for adults at all. That gap has now been closed. Every nurse — regardless of specialty — must know this protocol for adult patients.

The Science Behind the Change

The update is not arbitrary. Biomechanical research reviewed by the International Liaison Committee on Resuscitation (ILCOR) demonstrated that back blows create a sudden increase in intrathoracic pressure through direct mechanical force applied to the obstructing object — a fundamentally different mechanism from abdominal thrusts, which act by forcing air upward from the lungs.

Because these two techniques work through different physiological pathways, combining them is more effective than either method alone. International outcome data reviewed ahead of the 2025 guidelines showed improved results when back blows were incorporated alongside abdominal thrusts. The AHA’s commitment to evidence-based practice drove this change — and your practice must reflect it.

Infant Protocol: What’s Different

For infants under one year of age, the protocol has also been updated — and it is distinct from adult and pediatric guidance. Abdominal thrusts are not recommended for infants due to the risk of serious injury to abdominal organs. The current recommendation is to alternate five back blows with five chest thrusts using the heel of one hand, continuing until the object is expelled or the infant becomes unresponsive.

Infant choking protocol (under 1 year):

Support the infant face-down on your forearm and deliver five firm back blows between the shoulder blades.
Flip the infant face-up, supported on your forearm, and deliver five chest thrusts using two fingers on the center of the chest, just below the nipple line.
Alternate until the airway clears or the infant becomes unresponsive. If unresponsive, begin infant CPR.

This protocol is not new in concept, but the 2025 guidelines formalize it alongside the unified adult-pediatric update, making it critical for nurses in pediatric, neonatal, and maternal care settings to reinforce this technique in their practice.

What This Means for Nurses in Clinical Practice

Choking emergencies are time-critical. The difference between an effective response and a failed one is often measured in seconds — and the technique you reach for under pressure will be the one embedded in your muscle memory through training. If your last certification did not include the 5-and-5 method, you are operating on outdated knowledge.

Here is what you need to do now:

Review and update your BLS/CPR & First Aid certifications. The AHA simultaneously released updated training materials alongside the 2025 guidelines. Ensure your BLS course covers the current 5-and-5 choking response protocol.
Advocate for unit-level protocol updates.
Incorporate patient and family education.
Practice the technique, not just the theory.

The Bottom Line

The 2025 AHA guidelines represent the most substantial change to choking response in a generation. The evidence is clear: the 5-and-5 approach — alternating back blows and abdominal thrusts — is more effective than abdominal thrusts alone. As nurses, you are the backbone of patient safety in clinical settings. Staying current with emergency response guidelines is not optional — it is a professional obligation.

Update your training. Update your protocols. And the next time a patient is in distress, respond with the most current, evidence-based technique available — because that is exactly what your patients deserve.