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Endotracheal Anesthesia and Its Historical Development
... At his time of writing (1909), when Edwardian opinion strongly favoured arm movement/chest compression techniques for artificial ventilation, he could well have given a more positive boost to the EAV method if he had been able to confirm that MMV was the likely method used -rather than presume it was. (Also, see Footnote 2 [16][17][18][19] re François Chaussier . ) An anonymous Glaswegian treatise 20[p.26,Exhibit68] ...
... The reaction ensured, ultimately, the end of resuscitation by MMV and all positive pressure efforts to inflate the lungs and, in consequence, tracheal intubation as well. François Magendie (1783Magendie ( -1855 and Andre-M-C Duméril were charged to investigate his claims and, in 1829, confirmed Leroy's work to L'Académie. 25 Ralph Waters et al 16 stated in an outline history of intubation -for which they did not provide references -that, after investigating Leroy's studies, Duméril and Magendie "reported that the damage done by attempts at intubation far outweighed its advantages". The source enabling such an attribution is not provided, and I have not yet seen other writers confirming it, nor can I find support for it in Magendie's Rapport itself. ...
... Later 19th century French obstetricians continued with mouth-to-tube practice. 16,17 history of the RHS Receiving House 28[pp. clearly details the events from the minutes of the Society's meetings on 29 and 31 December. ...
The start of the 19th century saw the enthusiasm of the previous one for mouth-to-mouth ventilation (MMV) dissipated. To inflate the lungs of the asphyxiated, the Royal Humane Society in the United Kingdom had recommended bellows since 1782. Principal determinants for change were aesthetic distaste for mouth-to-mouth contact and the perceived danger of using expired air, although MMV survived in the practice of some midwives. Following the 1826-9 investigations of Jean-Jacques Leroy d'Etiolles then François Magendie, all positive pressure ventilation methods were generally abandoned, after 1829 in France, and 1832 in the UK; but not chest compressions. During the next quarter century, rescuers lost understanding of the primary need for "artificial respiration", apart from researchers such as John Snow and John Erichsen, until Marshall Hall's "Ready Method" heralded the second half-century's various methods of negative pressure ventilation. Some of those methods continued in use until the 1940s. Sporadic anecdotal cases of MMV rescues were documented throughout. In the 20th century, inadequate mechanical inhalators were also tried from 1908, while obstetricians devised indirect methods of expired air ventilation (EAV). Anaesthetists in the 1940s, such as Ralph Waters, Robert Dripps, and the pair, Robert Macintosh and William Mushin, described the usefulness of MMV, and James Elam was "re-discovering" it. Following World War II, "Cold War" concerns stimulated research at the Edgewood Medical Laboratories in Maryland in the United States into the possibilities of MMV, and Elam et al confirmed and expanded on brief experiments at Oxford (United Kingdom) on the efficacy of mouth-to-tube EAV. Studies, 1957-9, by Archer Gordon, Elam and especially Peter Safar resulted in the resolution of previous airway problems, established the primacy of MMV, and incorporated it into an integrated system for basic cardiopulmonary resuscitation. Ready adoption of MMV in the US was followed by worldwide spread, especially after endorsement from the 1962 international symposium at Stavanger in Norway. However, already there were occasional rumblings of reluctance to perform MMV. In this article, I consider MMV also in the context of other ventilatory modes for resuscitation.
... These initial designs received successive modifications between 1923 and 1932, enabling the joint administration of nitrous oxide and oxygen, and the incorporation of gas flow meters. [50,51] In 1924, Ralph Waters introduced the use of granules for the absorption of carbon dioxide. [52] Based on the closed circuit proposed by Jackson in 1915, Brian C. Sword designed an anesthetic machine in 1930, which incorporated the first closed-circle circuit with carbon dioxide absorption through the Waters granules, which were composed of 50% calcium oxide and 50% sodium hydroxide. ...
The first anesthetic machines appeared following their public demonstration by Morton in 1846. These initial devices were simple inhalers based on the evaporation of the anesthetic agent. Their main problem was the loss of effectiveness with cooling. More complex inhalers were subsequently developed, in which the main difference was the possibility to provide more than one agent. Moreover, the concentration of the inhaled anesthetic was regulated for greater efficiency. At the beginning of the twentieth century, gas machines emerged, allowing the application of an anesthetic flow independent of the patient’s inspiratory effort. These machines incorporated technological advances such as flow meters, carbon dioxide absorption systems and fine adjustment vaporizers. In this period, in the field of thoracic surgery, intraoperative artificial ventilation began to be employed, which helped overcome the problem of pneumothorax associated with open pleura by applying positive pressure. From the 1930s, the gas machines were fitted with a ventilator, and by the 1950s this had become a basic component of the anesthesia system. Later still, in the 1980s, alarm and monitoring systems were incorporated, giving rise to the current generation of workstations.
... Surprinzător, deşi rolul şi efectele oxigenului în tratamentul nou-născuţilor a început să fie sesizat şi apoi recunoscut la începutul secolului XX, primele tentative de susţinere mecanică a respiraţiei nou-născutului datează din 1780 când scoţienii Françoise Chaussier şi John Hunter au raportat primele tentative de ventilaţie mecanică la nounăscut [16][17][18] . Un secol mai târziu, noi tentative de ventilaţie mecanică a nou-născuţilor sunt raportate şi de americanii George Fell şi Joseph O'Dwyer [19] . ...
... Because patients would occasionally completely obstruct or aspirate gastric contents and die, the utilization of endotracheal tubes began in earnest with the published work of Meltzer, Auer and Elsberg in 1909. 12 It was not until 1913, however, that Janeway published his work using the laryngoscope to assist intubating the trachea. 13 Since that time, a plethora of tools invented to aid intubation has improved the ability to intubate. ...
Perioperative morbidity and mortality related to anesthesia involves multiple factors. Patient characteristics and comorbidities play a role in many of these events, highlighting the importance of preoperative screening. While optimization of patient comorbidities is not always possible, having data regarding those comorbidities can prove life-saving. Equipment and medication considerations also enter into untoward outcomes such as anesthetic interventions outside of the traditional operating room where resources are sometimes lacking and haste creates errors. Ultimately, when surgeons and anesthesiologists cooperate in patient care, communicating concisely but thoroughly, patients are more likely to do well. The language of surgeons is that of diagnosis requiring a surgical intervention, while anesthesiologists are discussing patient comorbidities impacted by anesthetic medications, positive pressure ventilation, neuraxial techniques, ramifications of patient positioning, effects of opiates and so on. Because all of the considerations combine in determining outcomes, it is incumbent on both surgeons and anesthesiologists to understand those elements leading to severe morbid events as well as death. This review touches on many of the most important factors.
... Versatile surgeon Pierre-J Desault is credited with maintaining a nasotracheal catheter in place for glottic swelling for a day and a half. Although this has been described as occurring in 1802, 56 or in the early 19th century, 57 it had to be before the time of his death in 1795. I have failed to locate a full case account in English. ...
In Britain, the great boost to performing mouth-to-mouth resuscitation for the "suddenly apparently dead" came from William Tossach's 1744 documentation of his own successful case, and then from promotion by John Fothergill and other enthusiasts. Some civic authorities on the Continent were exhorting citizens to employ it from as early as the mid-18th century. The first humane society was founded in Amsterdam in 1767 and initially promoted expired air ventilation (EAV) by the mouth-to-mouth method. Other humane societies were soon established throughout Europe, especially in maritime cities with frequent drownings. The founding of London's humane society in 1774, initially known as "The Institute," was followed by earnest efforts to promote mouth-to-mouth EAV in England, and soon after in Scotland, but not until the 1780s in North America. Disenchantment with the mouth-to-mouth method as less desirable (for various reasons) led to decline in its general use. In 1782, what later became The Royal Humane Society in London changed its expressed preference for artificial ventilation by mouth-to-mouth to manual artificial ventilation using inflating bellows, although mouth-to-mouth was a method of resuscitation which could be attempted by any rescuer. The need to apply artificial ventilation immediately was not really recognised before John Hunter's recommendation to London's Humane Society in 1776. Charles Kite spelt out clearly the principles of resuscitation in 1787-8, though he gave some priority to warming. It seems that only in the latter part of the 18th century was the importance of airway obstruction recognised, largely due to Edmund Goodwyn.
At the beginning of the twentieth century, anesthesia was an emerging field without permanent departments, exclusive practitioners, or academic residency programs. Instead, surgeons and nurses administered anesthetic gases in an ad-hoc fashion, exposing patients to the perilous risks of general anesthesia. Dr. Arthur Guedel was a general practitioner from rural Indiana who unexpectedly became an integral part of anesthesia's evolution into a safety conscience and formally recognized expertise. Beginning during his military service in World War I, he refined the stages of ether anesthesia and produced the definitive textbook on inhalational anesthetics. During the prolific career that followed, Guedel also introduced ground-breaking devices for patient-controlled analgesia, cuffed endotracheal intubation, and oral airway patency. His inclusive mentorship, collaborative research, and innovative instruments exemplify his role as a multitalented tinkerer, teacher, and transformative leader. This essay examines Guedel's pioneering contributions and the scope of his influence, all of which revolutionized anesthesia and expanded surgeons' operative capability. Through the lens of Guedel's personal and professional life, this essay further illustrates how the diverse, interdisciplinary, and cutting edge characteristics of the practice itself contributed to anesthesia's increased importance in modern medicine.
Unter Inhalationsnarkose verstehen wir die Erzeugung eines Zustandes von Schmerz- und Bewußtlosigkeit durch die Inhalation von Gasen oder Dämpfen mit entsprechender anästhetischer Wirkung. Was für uns heute selbstverständlich ist, war Ende des 18. und Anfang des 19. Jahrhunderts neu. Neu war die Inhalation als Weg zur Verabreichung von Substanzen in den menschlichen Körper. Neu war die Entdeckung der schmerzaufhebenden Wirkung bestimmter Gase und Dämpfe und neu war auch, daß jener Zustand der Schmerz- und Bewußtlosigkeit, den Henry Hill Hickman „suspended animation“ nannte, ein reversibler Zustand ist. Und letztlich waren alle Gase und Dämpfe mit anästhetischer Eigenschaft neu entdeckte Substanzen. Einzige Ausnahme bildet der Schwefeläther, den Valerius Cordus als „süßes Vitriol“ bereits im 16. Jahrhundert synthetisiert und dessen hypnotische und schmerzlindernde Eigenschaft Paracelsus, ein Zeitgenosse von Valerius Cordus, beschrieben hatte [56].
Cardiothoracic anaesthesia is a little over 100 years old but allows millions of patients around the world to safely undergo surgery within the chest and the heart. The pneumothorax problem was the first major challenge overcome with tracheal intubation and intermittent positive pressure ventilation. Lung isolation was overcome using bronchial blockers, double-lumen tracheal tubes, and made more reliable by the use of fibreoptic bronchoscopy. Cardiopulmonary bypass allowed cardiac surgery to develop but presented another hurdle to overcome, including maintaining anaesthesia during the procedure. Most anaesthetic drugs have been applied to cardiac anaesthesia. Morphine, then high-dose opioid ‘anaesthesia’ gained widespread popularity until demonstrated to have no influence on outcome. Total intravenous anaesthesia currently has ascendency over inhalational techniques despite the current best evidence indicating it is associated with a higher mortality and incidence of myocardial infarction. Pulmonary artery catheters have now been superseded with transoesophageal echocardiography, although both were introduced without an evidence base on outcome. Drugs, such as aprotinin, have been found to reduce blood loss and transfusion, but abandoned because of poor evidence. Despite all the blind alleys that cardiothoracic anaesthesia has taken, it produces good outcomes for patients undergoing surgery within their chest and on their hearts.
The authors have performed a historical review of the techniques that over the years have allowed the intubation of the trachea, in some cases for the management of certain conditions and, subsequently, for lung ventilation or anesthetic or resuscitation procedures. Apart from other anecdotal uses, the first invasive procedures that required a tracheotomy as the initial maneuver are described, as well as the evolution of these first techniques to nasally or orally tracheal intubation, this being allowed by the introduction of laryngoscopes, endotracheal tubes, fibrobronchoscopes,... in the clinical practice. Mention is made of the pioneers of all these techniques, as well as of the designers of the essential instruments and attachments. Very useful bibliographic references are provided for all those concerned with this issue.
A few dedicated men forged a remarkable revolution in anesthetic practice in North America during the first half of the twentieth century. Arthur Guedel was a leader of this distinguished group. His early career carried him from practice in Indiana to service in World War I as the “motorcycle anesthetist.” After years of dedicated service as a teacher and investigator, he became the first American to be awarded the Henry Hill Hickman Medal of the Royal Society of Medicine in 1941. Following his death his friends developed the Guedel Memorial Anesthesia Center in San Francisco, whose extensive collections of correspondence and personal papers provide an intimate view of his career.
Before the renaissance, death was to be accepted as an act of God. From then on, there was a will to attempt resuscitation. The ability to reverse coma-induced airway obstruction, apnea, and pulselessness began in response to accidents caused by general anesthesia in the late 1800s. Around 1900, knowledge existed about the majority of CPR steps. This knowledge, however, was then not assembled into an effective system because of lack of communication between laboratory researchers, clinicians, and rescuers. Open-chest CPR was effectively practiced in operating rooms during the first half of the 20th century. Anglo-American anesthesiologists co-pioneered trauma resuscitation during World War II. Modern cardiopulmonary–cerebral resuscitation (CPCR), which is now giving every person the ability to challenge death anywhere, has been developed since the 1950s. Through research in Baltimore, the chest-pressure and back-pressure arm-lift methods of artificial ventilation, taught for 100 years, were replaced by backward tilt of the head and direct mouth-to-mouth ventilation, and emergency artificial circulation by sternal compressions was rediscovered. Steps A–B–C of basic life-support were extended—to advanced and prolonged life-support. Anesthesiologists pioneered hospital ICUs almost simultaneously on three continents. In the 1960s and 1970s, several groups initiated CPR education research, the development of training aids, effective resuscitation delivery through emergency medical services (EMS) systems, and the multidisciplinary specialty of critical care medicine (CCM). Since the 1970s and 1980s, cerebral resuscitation potentials after prolonged cardiac arrest have been evaluated with ICU outcome models in large animals and in randomized clinical outcome studies. Pharmacologic strategies have given relatively disappointing results. Mechanism-oriented research escalated. Postarrest CBF promotion improved outcome in animals and patients. A breakthrough came in the 1980s and 1990s with the revival of research into therapeutic hypothermia. Mild resuscitative postarrest hypothermia (which is simple and safe) showed a breakthrough effect, extending the normothermic arrest reversibility limit from 5 to 10 min no-flow. Clinical trials of mild hypothermia are being reported now, with positive results. Animal research has begun into “suspended animation for delayed resuscitation” for temporarily unresuscitable cardiac arrest. Education research, delivery programs, and case registries for ongoing outcome evaluation should get higher priority.
It seems strange that the medical literature from the United States has only a single original source of reference for a device (from circa 1870) for artificial ventilation in neonatal resuscitation. The invention is attributed to "Dr Truehead of Galveston, Texas". I argue that this mystery arises from two separate misspellings of the inventor's name, and propose that the correct name is Dr Charles William Trueheart (1837-1914), also of Galveston.
Modern external (closed-chest) cardiopulmonary resuscitation (CPR) basic life support (BLS) gives everyone anywhere a chance to initiate the reversal of death from airway obstruction, apnea, or pulselessness. The history of modern CPR has its roots around 1900, but lay dormant for half a century, until in the 1950s several fortunate circumstances merged to allow for documentation of Steps A (airway control by head-tilt and jaw-thrust), B (breathing control by mouth-to-mouth ventilation), and C (circulation control by closed-chest cardiac massage, i.e. chest compressions) and their combination into BLS Steps A-B-C. BLS is only for borderline emergency oxygenation, i.e. Phase I of the life support chain. Both the non-authoritarian environment of the U.S.A. and several role players with keen interest in resuscitation were needed to enable the systematic research (Steps A and B), a chance rediscovery (Step C), and the integration of BLS with advanced life support (ALS, drugs and defibrillation, transferred from open-chest CPR) and brain-oriented prolonged life support (PLS, intensive care) to result in the development of an effective cardiopulmonary-cerebral resuscitation system. A fertile environment led rapidly to the development of resuscitation delivery systems in hospitals and communities. This paper is a story told by one of the role players.
The efficacy of 'basic' airway control without equipment, using the combination of backward tilt of the head, forward displacement of the mandible, and separation of lips and teeth (i.e. the triple airway maneuver) has been well established. Direct mouth-to-mouth and mouth-to-nose ventilation must continue to be taught to the public. Further improvements are needed for pocket-size mouth-to-mouth barriers to combat infection risks. Dissemination of appropriate information on disease transmission is needed to ensure ventilation by health professionals, using exhaled air ventilation adjuncts and other devices. Much knowledge exists about the pathophysiology of airway obstruction. For patients in coma or anesthesia with airway obstruction, which resists basic airway control measures and standard tracheal intubation, available 'advanced' airway control measures should be mastered and improved. Preparedness for advanced airway control measures differs between elective management of the anticipated difficult airway for anesthesia and emergency airway control with unanticipated difficulties encountered during the ordinary sequential application of measures. Challenges include education research and development of new devices. For airway clearing, pharyngeal intubation, difficult tracheal intubation, cricothyrotomy, transtracheal jet ventilation and emergency use of oxygen - what could and should be taught, to whom, and how? Which new devices and training systems should be developed? The most important alternative to orotracheal or nasotracheal intubation recommended for the development of novel devices and teaching methods for health professionals, are cricothyrotomy (with wide enough airway to also enable spontaneous breathing of air), and translaryngeal or transtracheal oxygen jet ventilation. We recommend openness in communication and joint planning between anesthesiologists, emergency care providers, and appropriate educators, engineers and industries.
Auto-positive end-expiratory pressure (auto-PEEP) is a physiologic phenomenon defined as the positive alveolar pressure that exists at the end of expiration. Normally, the alveolar pressure is near zero at the end of expiration. However, certain ventilatory and/or physiologic paradigms can cause the development of auto-PEEP during cardiopulmonary resuscitation (CPR). Auto-PEEP has a detrimental cardiovascular effect similar to that of positive end-expiratory pressure that is intentionally applied to the ventilatory circuit in a mechanically ventilated patient. The connection between auto-PEEP and its cardiovascular effects, however, may go undetected. In this study, the effect that ventilatory factors have on auto-PEEP in a simulation of patients with lung disease undergoing CPR was delineated.
A case control study.
Laboratory of a university hospital anesthesia department.
A baseline quantification of breathing patterns that occur during CPR was obtained by recording observed respiratory rate and relative tidal volume during treatment of in-hospital cardiac arrests.
A test lung was set up to mimic a series of different airway resistances and lung compliances as would be seen in different types of pulmonary pathology. A sensitivity analysis was performed on each of the factors of respiratory rate, tidal volume, and inspiratory/expiratory ratio as to the effect each of these factors has on the development of auto-PEEP. Our study suggests that in various combinations of airway resistances and lung compliances, auto-PEEP can be generated to substantial levels depending on the methods of ventilation performed.
We conclude from our findings that ventilation techniques during CPR may need to be altered to avoid the development of what may be a hemodynamically significant level of auto-PEEP.
Developed in the late 19th century, endotracheal intubation was met with reluctance, even fear, by those administering anesthesia. The progression from its gradual acceptance to today's routine use is traced in this essay.
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