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Advanced Emergency Nursing Blog from AENJ
The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.
Tuesday, May 27, 2014
This is the fourth part of our series on "Early Modern Resuscitation."

Part I: Oral Airways, early resuscitation, and recognition of airway care.

Part II: Mouth-to-Airway (adjunct)
Part II Erratum: Erratum in Mouth-to-Airway (adjunct)Part III: Early Modern Resuscitators
Part IV: Carbon Dioxide As A Resuscitative Gas


There is insufficient space for a complete exposition of the theory and battles over carbon dioxide resuscitation. The select bibliography will provide ample links to extend your reading.

 

“Carbon Dioxide Resuscitation?” You think to yourself, What could that be?”

Does the name “Carbogen” ring a bell?

 

During the 1920s and 1930s, even later, the use of inhaled carbon dioxide in resuscitation was supported by the highest authorities. It was thought that the body’s “desire” to increase rate and depth of respiration to blow off CO2, was a useful stimulant.

 

Fahey indicates that the antecedent error of reasoning, widely held, in the naïve days of respiratory physiology investigations was an over-emphasis of respiratory failure in extremis that showed hypoxia and hypocarbia with shallow tachypnea. This was described as acarbia, and it was thought that giving carbon dioxide would drive greater minute volume and fix both "problems."

 

A variety of devices were used and concentrations delivered varied. Even after no longer having a role in resuscitation, CO2 was advocated for accelerating clearance of carbon monoxide poisoning into the 1950s and 1960s.

 

In 1927, H.W. Davies reported in the British Medical Journal of "A simple portable apparatus for the therapeutic administration of carbon dioxide." Essentially, the small cylinders of compressed carbon dioxide in "soda siphons" by the Sparklet Company for one's whisky were adapted to medical use as a respiratory stimulant. These became known as Sparklet Resuscitators; CO2 from either "C" or "J" size cylinders would be given to breathing victims with respiratory failure. 

 

Sparklet Resuscitator, cased set

©Tom Trimble, RN CEN; object from Author’s Collection
CLICK FOR LARGER IMAGE.

This is a cased kit of a Sparklet Resuscitator (J size),

with pressure chamber, regulator, tubing, reservoir

bag, flow stopcock, and funnel mask, with associated

documents.


Closer view of Sparklet Resuscitator

©Tom Trimble, RN CEN; object from Author’s Collection

CLICK FOR LARGER IMAGE

Closer Detail View of Sparklet Resuscitator

Sparklet Resuscitator, price list

©Tom Trimble, RN CEN; object from Author’s Collection
CLICK FOR LARGER IMAGE

Manufacturer's Price List for Sparklet Resuscitator

 

Carbogen, a trade name, was both O2 and CO2 mixed within a single cylinder, usually 3.5%, 5% (most commonly), or 7% CO2 and administered by anesthesia machine or other apparatus. It necessitated either switching cylinders from an oxygen device or having extra equipment; but when used outside a hospital was administered with an inhalator or resuscitator by rescue crews or in industrial or electrical, gas, or mining environments. Inhalators supplied free-flow or demand-controlled gas and manual artificial respiration would supplement respiratory effort, and resuscitators would cycle a positive-pressure or alternating positive-negative gas flows to the lung.

 

The therapeutic effect of CO2 inhalations in intermittent sessions was thought useful in pneumonia to increase respiratory rate and depth and to decrease atelectasis, and in clearance of carbon monoxide intoxication. Probably the only remaining clear indication for carbon dioxide inhalation would be Central Retinal Artery Occlusion, if seen immediately (<90 minutes), to attempt vasodilatation of that artery and thereby diminish the ocular infarct; however, the Cochrane Collaboration is unable to come to a conclusion as to its efficacy1.

 

If one person personified and dominated the era of CO2 resuscitation, it is Yandell Henderson, Ph. D., a Yale physiologist. He took up many clinical researches feeling that physiology should be an applied science contributing to the solution of human problems.  He was not a physician, but late in life received an honorary MD degree. He took part in high altitude respiratory physiology research on Pike’s Peak with J.S. Halstead from Oxford, who espoused a belief in carbon dioxide as the controlling agent of respiration and a postulated “acarbia” as the fundamental deficit. Halstead also maintained a theory that discrepancies in calculations were due to the lungs themselves “secreting” oxygen.

 

Henderson, it would seem, was an enthusiast, well-convinced of his opinions, with missionary zeal, who would firmly argue his positions and tirelessly campaign them. In 1920, he put forward his paper on CO2. In 1922, he and his colleague, Haggard, invented their H&H (or H-H) Inhalator. He opposed automatic pressure-cycled resuscitators (Pulmotor, and others) as being insufficiently sensitive to changes within the lungs, and insufficient in tidal volumes, but also at the extreme of pressures tolerated by the lungs and therefore liable to cause injury. He felt that Schaefer's method of artificial respiration was excellent and efficacious, supplemented when possible by Carbogen inhalation from the H&H Inhalator.

 

Henderson's contributions to study of physiologic effects include: mining; toxic gases; resuscitation; high altitude medicine; aviation medicine; vehicle exhausts, tunnel ventilation, and air pollution; protective appliances; US Army Chemical Warfare Service; and exercise physiology.

 

Select Bibliography:

 

  1. Fahey, D OStJ. The use of carbon dioxide in resuscitation.  St John History Volume 10 (2010-2011)
    **Australian review of Sparklet Resuscitators and CO2 therapy.
  2. Link to photograph of Yandell Henderson, Ph. D. Biographical Memoirs, V. 74 (1998) The National Academies Press. West, John B. Accessed May 17, 2014.
    **Most common Internet photograph of Henderson; from NAS memoir.
  3. Douglas, C. G., Haldane, J. S., Henderson, Y., Schneider, E. C., Webb, G. B., & Richards, J. (1913). Physiological observations made on Pike's Peak, Colorado, with special reference to adaptation to low barometric pressures. Philosophical Transactions of the Royal Society of London. Series B, Containing Papers of a Biological Character, 203(294-302), 185-318.
    **Paper resulting from Pike's Peak expedition with Halstead.
  4. Henderson, Y. (1916). Resuscitation Apparatus. Journal of the American Medical Association, 67(1), 1-5.
    **Commentary and review of resuscitation devices.
  5. Henderson, Y., Haggard, H. W., & Coburn, R. C. (1920). The Therapeutic Use of Carbon Dioxid After Anesthesia and Operation. Journal of the American Medical Association, 74(12), 783-786.
    **Henderson's foundation piece, establishing his teachings for years to come.
  6. Henderson, Yandell Ph.D. The Prevention and Treatment  of Asphyxia in the New-Born J. A. M. A.   90(8):383-386, February 25, 1928. From Neonatology on the Web. Accessed May 17, 2014.
    **Henderson's neonatal recommendations.
  7. Flagg, Paluel J. MD Treatment of Asphyxia in the New-Born.
    J.A.M.A.  91(11): 788-791, Sept. 15, 1928 From Neonatology on the Web.
    Accessed May 17, 2014.
    **Flagg's endorsement of Henderson's article.
  8. Neonatal Resuscitation, ca. 1944” Illustrations from The Art of Resuscitation, by Paluel J. Flagg, MD, provided by Neonatology on the Web.” Accessed May 17, 2014.
    **Photograph of neonatal resuscitation. In The Art of Resuscitation, Flagg names this as "Henderson's equipment."
  9. Flagg, P. J. (1944). The Art of Resuscitation. 453 pp. New York: Reinhardt Publishing Company
    **Flagg, "
    wrote seven books on anesthesia between the years 1919 and 1944,all entitled The Art of Anaesthesia" {c.f., Larson, below.} which were prominent. In this work, he indexes Henderson nine times, names him in text ten times, and cites references to him eight times. Text references are unfailingly respectful, even flattering.
  10. Link to photograph & brief biography of Dr. Paluel Joseph Flagg. Website of Catholic Medical Mission Board. Accessed May 17, 2014.
    **Prominent and influential anesthesiologist shared common views with Henderson.
  11. Larson, Merlin D. M.D. "Paluel J. Flagg and the “Art” of Anesthesia" CSA Bulletin. Arthur E. Guedel Memorial Anesthesia Center, San Francisco.
    **Monograph upon Flagg's work and writings.
  12. SHIPWAY, F. E. S. (1932). RESUSCITATION DURING ANÆSTHESIA AND OF THE NEWLY BORN. British Journal of Anaesthesia, 9(2), 69-79.|
    **Recommends 7% CO2.
  13. Apgar, V. (1953). A proposal for a new method of evaluation of the newborn. Curr Res Anaesth, 32, 260-267. From Neonatology on the Web. Accessed May19, 2014
    **Apgar's Score proposed; supports oxygen (without CO2) for neonatal resuscitation.
  14. Henderson, Y. (1932). Reasons for the Use of Carbon Dioxide with Oxygen in the Treatment of Pneumonia. New England Journal of Medicine, 206(4), 151-155.
    **Argues for increased minute volume to decrease atelectasis and clear secretions.
  15. DAVIES, H. W. (1927). A SIMPLE PORTABLE APPARATUS FOR THE THERAPEUTIC ADMINISTRATION OF CARBON DIOXIDE. British Journal of Anaesthesia, 4(3), 148-153.
    **Journal report announcing the Sparklet Resuscitator.
  16. Historical Happenings Sparklets Bulbs - [no author stated] Open Airways-  St John Ambulance of South Australia -_07_July12
    **Brief account of CO2 cylinders found when moving museum.
  17. West, James B. Yandell Henderson April 23, 1873 - February 18, 1944 A Biographical Memoir by James B. West. 1998. National Academies Press Accessed May13, 2014.
    **Memoir of Henderson, fifty years after his death, by National Academy of Science, of which he was a member. His life, work, personality, honorary MD, politics, are discussed.
  18. Keys, T. E. (1974). Yandell Henderson (1873-1944). Anesthesia and analgesia, 54(6), 806-806.
    **Four paragraph “Historical Vignette” summarizing Henderson’s career.
  19. Pauly, P. J. (1994). Is liquor intoxicating? Scientists, prohibition, and the normalization of drinking. American journal of public health, 84(2), 305-313.  PDF.
    **Efforts to repeal Prohibition.
  20. Roizen, Ron. A Footnote to Pauly (1994): Yandell Henderson’s Lusitania Letters. 2012. From "Points: The Blog of the Alcohol and Drug History Society." Accessed May 15, 2014
    **Henderson's role in repealing Prohibition on beer, his cultural and political views.
  21. Multiple authors. BEDSIDE MEDICINE FOR BEDSIDE DOCTORS. California And Western Medicine November, 1928. Vol XXIV, No. V
    **Clinical notes upon CO2 therapy.
  22. Henderson, Yandell. New Treatment for Carbon Monoxide Poisoning. December, 1922. The Coal Industry, Volume 5. pp 526-528. Accessed May 19, 2014.
    **Argues for CO2 therapy to more rapidly clear CO intoxication.
  23. Carbonated Water Now Used In Gas Poisoning Treatment. The Evening Independent. St. Petersurg, Florida. January 10, 1925 p 20. Accessed May, 19, 2014.
    **Newspaper publicity account of "Weiss Beer" usage, and CO2 therapy by Henderson.
  24. Douglas, T. A., Lawson, D. D., Ledingham, I. M., Norman, J. N., Sharp, G. R., & Smith, G. (1961). Carbogen in experimental carbon-monoxide poisoning. British medical journal, 2(5268), 1673.
    **Researches to establish or refute CO2 therapy in CO intoxication.
  25. Henderson, Y. (1925). A Lecture ON RESPIRATION IN ANAESTHESIA: CONTROL BY CARBON DIOXIDE*. British medical journal, 2(3390), 1170.
    **Henderson's views on CO2 as the control of breathing.
  26. Henderson, Y. (1943). The return of the pulmotor as a" resuscitator": a back-step toward the death of thousands. Science, 98(2556), 547-551.|
    **Henderson’s vehement denunciation of automatic resuscitators, trade practices, and his personal difficulties attempting to suppress them.
  27. Parsloe, C. To Caesar what Is Caesar's. Canadian Journal of Anaesthesiology. 1994. 41:1. pp 74-80.
    **Correcting priority of attribution to maxim supported by Henderson as to CO2 controlling respiration; explains Mosso's usage; clarifies "Acapnia."
  28. Paul, John R. Dr. Yandell Henderson. Transactions of the American Clincal and Climatological Association. 1946; 58: li–lii PMCID: PMC2242328
    **An "in memoriam" piece; notes personality, accomplishments, honorary MD.
  29. Bhargava, C. A. CARBONDIOXIDE FOR RESUSCITATION & OXYGEN THERAPY. Indian J. Anaesth. 2003; 47 (2) : 146-147
    **Shows devices and problematic history of CO2 and equipment.
  30. Wrigley, M., & Nandi, P. (1994). The Sparklet carbon dioxide resuscitator. Anaesthesia, 49(2), 148-150.
    **Authors show a “C” cylinder Sparklet Resuscitator, recount the general history, and outline the history of CO2 in resuscitation, note Waters’s caution re hypercarbia.
  31. Donald, K. W., & Paton, W. D. (1955). Gases administered in artificial respiration. A Report to the Medical Research Council by Its Committee* for Research on Breathing Apparatus for Protection against Dangerous Fumes and Gases. British Medical Journal, 1(4909), 313.
    **"For these reasons it is recommended that in first-aid practice carbon dioxide should not be administered with oxygen in the resuscitation of subjects requiring and receiving artificial respiration." UK authoratative declaration against Carbogen.
  32. Wineland, A. J., M.D. (1935) MECHANISM OF CARBON DIOXID THERAPY* WITH SPECIAL REFERENCE TO THE LUNGS. (sic) California State and Western Medicine. May, 1935. Vol. 42, No.5. pp 354-357
    **Describes his reasons and method of administration, monitoring patient; reviewer comments warn of use if hypercapnic which induces further depression.
  33. Genaud, P. E. M. (1956). Gases Administered in Artificial Respiration. British medical journal, 2(4985), 176.
    **Commenting on Donald & Paton's report to the MRC; notes U.S. Army Chemical Corps abandoned Carbogen in 1952.
  34. Fisher, J. A., Iscoe, S., Fedorko, L., & Duffin, J. (2011). Rapid elimination of CO through the lungs: coming full circle 100 years on. Experimental physiology, 96(12), 1262-1269. PDF
    **A review of eliminating CO with CO2, O2 alone, hyberbaric O2, and proposing a method of inducing hyperpnea and maintaining normocapnia by supplementation.

                 Sincerely.

 

                      Tom Trimble, RN CEN

 

                      All opinions are those of the author.

     


    Monday, May 26, 2014
    To those who have served and sacrificed,
    To those who have served and suffered,
    To those who stayed and supported,
    Advanced Emergency Nursing Journal offers its respectful reverence, its gratitude, and a deep appreciation for what you've done for the sake of others.
    Thank you.

    Saturday, May 03, 2014

    Although told several times, the story of the development by Henning Ruben of the prototypical modern manual resuscitator, the self-refilling bag with unidirectional non-rebreathing valves which now dominate the world of resuscitation, is still not well-known.

     

    What were its recent antecedents? What further developments occurred?  Review of the Wellcome Library movies on YouTube (1945) [links below in references] is instructive as to resuscitative methods of the 1930s and 1940s: Manual methods; gas bag or bellows operated by hand or machine; an anesthesia gas machine; or iron lung.

     

    Joseph Kreiselman’s portable concertina-like bellows was invented and deployed in the US military from 1943 followed by the UK’s Porton Resuscitator, postwar, from its secret chemical research facility and used industrially into the early 1960s. Kreiselman later did much work on neonatal resuscitation and warming beds.

     

    Child-sized Kreiselman Resuscitators
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    Remember to maintain Triple Airway Maneuver and push bellows down without losing head tilt collapsing airway or creating leak.

     

    Bellows resuscitators are awkward as it is difficult to maintain a patent airway as the downward compression of the bellows tends to collapse the airway; if uneven, the axial loading of the bellows tends to cause mask leak; as well, mask-hold is inherently one-handed, and sensing of compliance is poor. Latterly, equipment standards decried use of a bellows and favored the self-refilling bag.

     

    Some European bellows units were separated by tubing from the mask, even having belt clips to allow compression against the first aider’s body or two-handed mask-hold with additional rescuers.

    Bellows Resuscitator, Chirana, 1969, Czech Military
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    Czech Military resuscitation kit, 1969, mfr. Chirana.
    Note metal belt bracket to support one-handed
    inflation. Rubber parts dusted with talc for preservation.

     

    1953 was the first evolution of Ruben’s self-refilling bag with non-rebreathing valves (“How the BVM beganq.v). It went to market in 1956 with a foam-rubber filled bag that allowed re-expansion and pressure limitation; subsequent breakdown of the foam and sterilization problems led to further modifications.

     

    Ruben’s AMBU evolved through several valves and material changes to improve performance. Other challengers came to the burgeoning market with different designs, valves, and materials, many of which functioned inadequately when evaluated. Ruben’s insistence upon including a portable foot-operated aspirator did much to establish portable suction, not requiring power or oxygen supply,  in field care. Chemical-resistant BVMs with a cartridge respirator filter are made for military and toxic environments.

     

    AMBU Mark III RDIC resuscitator, modern U.S. military version for chemical, biological, nuclear environments.
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    AMBU Mark III (mil) RDIC resuscitator for U.S. Military
    use in Chemical, Biological, Nuclear environments.

     

    Laerdal’s design, notable for a duckbill or fishmouth valve suggested by James Elam, also evolved with new masks, folding capability, better reservoirs, and silicone for ability to sterilize. Now off-patent, there are disposable clones readily availability. Laerdal also offered a Freon-powered aspirator (no longer made due to ecological concerns) and electrical aspirator units.

     

    Laerdal Resusci-Folding-Bag II
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    Collapsable PVC bag, clear acrylic masks. Reservoir tubing replaced
    by reservoir bag with over/under pressure relief valves. Note valve can
    remain on patient with extension tubing from mask for awkward transports.

     

    Laerdal RFB II kit, with additional supplies. Freon-powered aspirator.
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    Laerdal RFB II kit with Freon-powered aspirator,
    additional supplies.

     

    Gordon’s Rescue Breather has a modern counterpart in Draeger’s Orotubus, a metal-lined flanged mouthpiece with a securing strap, nasal clamp, and thumb-hooks to provide better Triple Airway Maneuver; the 22 mm connector allows fitment of a BVM or transport ventilator.

    Orotubus by Draeger

    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.

    Metal-reinforced bite-block, blow pipe fits 22mm connectors.
    Note sturdy thumb-hooks and strap to help maintain Triple
    Airway Maneuver, nose clamp.

    The Johnson & Johnson Resuscitube is no longer on the market. A myriad of pocket-masks and face-shields have supplanted it.

    Orotubus from Draeger. Looking within.
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    Rescuers view of Orotubus. Metal-reinforced bite block, only latex
    contacts patient.

     

    Mouth-to-Mask units with expiratory-diversion and air inlet valves at the mask with mouthpiece tubing for the respiratory rescuer have the advantage of placing the rescuer at the patient’s vertex for better monitoring and posture; having the inlet at the mask end allows for the first ~150 ml of air to the lung to be 21% O2 and the trailing portion of the inflation in the dead space is rebreathed by the rescuer to minimize hypocapnea. It does require professional skill in using a mask and maintaining the airway.

     

    Fyr-Fyter brand of Globe Mouth-to-Mask Resuscitator by Monaghan.

    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.

    Fyr-Fyter brand of Globe Mouth-to-Mask Resuscitator by Monaghan. Cased set of resuscitator, manual bulb aspirator,

    oral airway, directions.

     

    Detail view of Globe Resuscitator cased set.
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    Detail view of Globe Resuscitator boxed set.
    Rescuer's inlet valve above mask, allowed
    rescuer to rebreathe his own CO2 to prevent
    hypocapnia; first portion of breath given to
    patient would be 21% O2.

    There was a variant of the Wendl nasopharyngeal airway by Rusch that had a long tubing to allow Mouth-to-NPA ventilation.

     

    The “automatic resuscitators” of yore, which alternated pressure-cycled positive and negative pressure, or steady flow, and provided suction by oxygen venturi  (rapidly depleting the oxygen tank), lost place in the market when condemned as incompatible with external cardiac massage. Manually-triggered

     

    Stephenson Minuteman Resuscitator.
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    Stephenson Minuteman Resuscitator, a light and modern automatic
    cased unit with double yoke for two D-cylinders, provides alternating
    positive & negative pressure-cycled breathing, constant flow, or oxygen
    powered venture suction. Note metal wire flangeless oral airways with twill-tape near regulator. Mask has perished with age.

     

    Oxygen-powered Demand Valves supplanted them and faced criticism and modifications due to excessive flow-rates and higher pressure-relief limits. Some are still sold, but must be used cautiously to avoid gastric insufflation.

     

              Sincerely,

     

                     Tom Trimble, RN CEN

     

    All opinions are those of the author.

     

    This is the third part of our series on "Early Modern Resuscitation."

    Part I: Oral Airways, early resuscitation, and recognition of airway care.

    Part II: Mouth-to-Airway (adjunct)
    Part II Erratum: Erratum in Mouth-to-Airway (adjunct)
    Part III: Early Modern Resuscitators

     

     

    References and Links:

     

    Trimble, Tom, RN CEN  How the BVM began The Advanced Emergency Nursing Blog October 20, 2013 http://journals.lww.com/aenjournal/blog/aenj-blog/_Layouts/listform.aspx?PageType=4&ListId={EFBFD26E-FC13-47C7-AF4A-03A6CAC13BF4}&ID=29  from the website of Advanced Emergency Nursing Journal <http://AENJournal.com> Accessed 04/24/2014

    **Our short summary of the development of the self-refilling bag for respiratory support.

    Resuscitation set, Europe, 1801-1850 - Science Museum, London. Wellcome Images Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/ Accessed 04/24/2014

    ** An Eighteenth-Nineteenth century bellows kit for artificial ventilation, or for insufflating the rectum with tobacco smoke.

     

    Fell-O’Dwyer Apparatus. Wellcome Library, London
    Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/
    Accessed 04/24/2014

    **For anesthetic delivery at the level of the vocal cords; also used by O’Dwyer during Diptheria epidemic to avoid tracheostomy. Fell then collaborated with O'Dwyer to add his foot-powered positive pressure insufflator. (c.f., image of Fell-O'Dwyer apparatus.)

     

    Wellcome Library Movies of Artificial Respiration (hospital-based) from 1940s showing in six parts several methods in context of anaesthesia training.

    <https://www.youtube.com/watch?v=3DzTBN-yrMc&list=PL05EC1F6712CA2BB1>

    Part:

    1. The Drinker Respirator (Iron Lung) Time 3:26
    2. The Both Respirator (variation of cabinet respirator; shows how to manually operate in emergency) Time 2:46
    3. Partial Enclosure Methods:
      The Paul-Bragg Pulsator (a thoracic compression vest)
      The Burstall Respirator (negative pressure to the chest) Time 5:16
    4. The Biomotor Respirator (alternating positive and negative pressure to the abdomen) Time 3:13
    5. {Methods of Postural or Visceral Shift}
      Eve’s Rocking Method, using the Riley’s Rocking Stretcher
      The Barrel
      The Sling Time 3:42
    6. {Using Positive Pressure Oxygen}
      The McKesson Respirator (automatic cycling pressure operated)
      The Oxford Respirator (manually cycled valve for positive pressure [open-exhaust])  Time 3:05

     

    Wellcome Library’s Anaesthesia Series includes:

      • Endotracheal anaesthesia: No. 5 (1944) broad review including how to make and clean your own ETTs. Note metallic oral airway, straight laryngoscope blades, uncuffed tubes with throat packing, cuffed tubes, lack of gloves. Learn BNTI, check airflow by hearing and movement of cotton wisp by exhalation, NTI with direct laryngoscopy & Magill’s Forceps; open-mask ether or ether-can to ETT by hose with airvent in can. Time 24:05
      • Respiratory and Cardiac Arrest: No. 9 (1945) Silvester’s artificial respiration on OR table, mouth-to-mouth, turning and clearing of vomitus, NPA for obstruction, wooden wedge to open teeth in trismus, suction, and oral airway, then O2 insufflation, and mask breathing. Open chest cardiac massage, intracardiac injection, stimulant drugs, IV saline, further care
      • The development of endotracheal anaesthesia (1965)” interviewing Sir Ivan Magill. Time 15:29

     

    Henderson, Yandell (1943). The return of the pulmotor as a" resuscitator": a back-step toward the death of thousands. Science, 98(2556), 547-551.

    **A scathing denunciation of “suck and blow” resuscitators and marketing practices by the preeminent physiologist of his time focused upon respiration and asphyxia.

     

    Kreiselman, J. (1943). A new resuscitation apparatus. Anesthesiology, 4(6), 608-611.
    **Published description of his bellows resuscitator.

     

    Kreiselman, Joseph. (1946). U.S. Patent No. 2,399,643. Resuscitator. Washington, DC: U.S. Patent and Trademark Office.

    **Patent for the resuscitator.

    Kreiselman, Joseph. (1945). U.S. Patent No. 2,366,630. Bassinet organization. Washington, DC: U.S. Patent and Trademark Office.

    **Applying his Infant Resuscitator to a warmer for neonates.

    Ruben, H. (1959). Self-contained resuscitation equipment. Canadian Medical Association journal, 80(1), 44.
    **Ruben’s description of essential portability of resuscitation equipment. Note novelty of use without a pressurized cylinder. Photos of early AMBU bag & foot-pump suction in use.

     

    Fahey, D. G. (2010). The self-inflating resuscitator--evolution of an idea. Anaesthesia and intensive care, 38, 10-15.

    **Nice summary history: photo of early AMBU and other devices; reports Elam & Safar’s involvement with Laerdal’s BVM, Resusci-Anne.

    Mitchell, H. W. (1965). Ambulances and emergency medical care. American Journal of Public Health and the Nations Health, 55(11), 1717-1724.
    **Relatively early account of then status of prehospital care, before EMS movement took place.

     

    Safar, P., & Brose, R. A. (1965). Ambulance design and equipment for resuscitation. Archives of Surgery, 90(3), 343-348.

    **Calls for updated resuscitation equipment; BVMs, rather than resuscitators, suction, etc.

    Evaluation: Manually Operated Resuscitators (1971) Emergency Care Research Institute. No authors listed. Health Devices. 1971 Apr;1(1):13-7.pp 13-17 PMID: 5209569
    **Possibly the first institutional safety review of BVMs (i.e., not a case report or letter to the editor). ECRI states “The Institute’s first evaluation of 18 brands of manually operated resuscitators found nine to be ineffective and started ECRI as an independent evaluator and provider of medical-device-related information and guidance.C.f., Evaluation of Manually Operated Resuscitators

     

    CARDEN, E., & HUGHES, T. (1975). An evaluation of manually operated self-inflating resuscitation bags. Anesthesia & Analgesia, 54(1), 133-138.
    **Critical exam of poor FIO2 delivery, valve-jamming, rebreathing, reservoir designs.

     

    CARDEN, E., & FRIEDMAN, D. (1977). Further studies of manually operated self-inflating resuscitation bags. Anesthesia & Analgesia, 56(2), 202-2 06.

    **Documents improvements in BVMs previously investigated and found deficient in FIO2.

    Abdo Khoury, M. D., Hugonnot, S., Cossus, J., & De Luca, A. From mouth to mouth to Bag-Valve-Mask ventilation: Evolution and characteristics of actual devices. A review of the literature. In press?  Download from Hindawi Publishing without additional data availability.
    **Review by French authors of of BVM design and functioning.

     

    Farrington, J. D. (1967). Death in a ditch. Bull Am Coll Surg, 52(3), 121.
    **Classic pre-EMS document describing rescue care by rural volunteer squads. Popularized extrication and spinal immobilization. Inspired much rescue training.

     

    National Research Council (US). Committee on Trauma, & National Research Council (US). Committee on Shock. (1971). Accidental death and disability: The neglected disease of modern society. National Academies.

    **Landmark document calling for comprehensive prehospital care reform from the (authoritative, independent) government-chartered National Academy of Sciences – National Research Council, thereafter a bedrock citation.

    Rockwood Jr, C. A., MANN, C. M., Farrington, J. D., HAMPTON JR, O. P., & MOTLEY, R. E. (1976). History of emergency medical services in the United States. Journal of Trauma and Acute Care Surgery, 16(4), 299-308.

    **Recounts early improvements in prehospital care, by its shakers and movers.

     


    Tuesday, April 22, 2014

    In the last blog entry, I expressed my belief that the Venti-Breather® was perhaps the commercial version of the Roswell Park Rescue Breathing Mask (sic) designed by James O. Elam. I was wrong. I worked from a contemporary faulty memory. The reference that I had ordered arrived well after the posting.

     

    In the chapter “Insufflation Methods with Simple Equipment” written by Dr. Elam in the book Artificial Respiration Theory and Applications by Fifteen Authors, edited by James L. Whittenberger, M.D., Elam describes and illustrates the differences between the two devices (which, in fact, are quite similar but for the design of the valve).

     

    The Venti-Breather® has a spring-loaded diving-bell shaped occluder that opens under positive pressure for rescue breaths, then pops up to permit exhalation or spontaneous breaths through the expiratory port.

     

    The Roswell Park Pocket Mask has but one moving part in its dog-legged blow-pipe: a delicately balanced weighted ball that moves aside for positive pressure to let air in or to pass outwards.

     

    Elam’s references include:

    "1. Elam, J. O. Rescue Breathing with the Roswell Park Pocket Mask, The Roswell Park Handbook for Training in Rescue Breathing. Buffalo. Health Research Press, 1959."

    which could seem most likely to be the product insert for the device.

     

    I also referred to Gordon’s device as the Gordon Airway; Elam, also a colleague of Gordon calls it the Gordon Rescue Breather, although Bauer also calls it “the Gordon airway.”

    There are several relevant illustrations to be seen in the book, which, unfortunately, is out of print. It is an exceptional reference for its era, and is often cited by others. I cannot reproduce the illustrations here, but it is definitely worth going out of your way to read.

    Artificial Respiration Theory and Applications by Fifteen Authors, edited by James L. Whittenberger, M.D. ©Hoeber Medical Division, Harper & Row, Publishers, Incorporated. New York.
    Library of Congress Catalog card number: 62-18205

     

    Bauer, Robert O. Emergency Airway, Ventilation, and Cardiac Resuscitation

    Anesth Prog. 1967 November; 14(9): 236–249. PMCID: PMC2235452

     

    Sincerely,

     

    Tom Trimble, RN CEN

     

    All opinions are those of the author.


    Tuesday, April 08, 2014

    From the early 1950s to the early 1960s, validation by researchers such as James O. Elam, Archer Gordon, and Peter Safar, occurred:

    ·       of the efficacy of expired as a resuscitating gas

    ·       that manual methods of artificial respiration were ineffective with no attention to airway patency and generating tidal volumes less than dead air space {and relied on tissue elasticity in a deteriorating corpse}

    ·       that mouth-to-mouth or mouth-to-nose positive pressure methods successfully ventilated the lungs with 1 to 2 liters of gas

    ·       that the natural airway could be opened and maintained with simple maneuvers, as used in anesthesia, and that these maneuvers could be taught to lay public and public service rescuers

    ·       that through incremental steps of scientific and public acceptance could be made the basis of a modern system of rescue breathing suitable for world-wide use (subsequently to be combined with external cardiac compression to form a system of cardiopulmonary resuscitation).

     

    Work was also done to develop a means of coupling military gas masks to allow one soldier to aid another overcome by chemical, biological, or nuclear warfare.  –It is a curious paradox of history that Nerve Gas was the product of agricultural research by the burgeoning chemical industry in Germany in the latter 19th and early 20th centuries, and that modern understanding of resuscitation came from WWII military investigations (Edgar A. Pask) into drowning and funded early Cold War research into protection from Nerve Gas, that sprouted the saving of thousands of lives.

     

    Having established mouth-to-mouth as the only effective artificial respiration (and the only that provided breath-to-breath attention to and feedback from the airway) instantly available wherever there is a living helper, the difficulty is in persuading the public to be willing to go lips-to-face of a dying stranger.

     

    Let's look at the early expired air resuscitation adjuncts!

    Gordon Airway; Brook Airway; Safar-type S-tube
    Click for larger image

    ©Allen Press, by kind permission, from Bauer, R.O.
    [L->R: Gordon Airway; Brook Airway; Safar-type S-Tube
    uncertain manufacture, probable reversed & fused black-
    rubber oral airways; plastic Safar-type, unknown manufacture.

    As the patent application for the Safar S-Tube states:

    "the average person has a natural instinctive aversion to placing his mouth over that of the patient. The idea of placing one's mouth on the mouth of an apparently dead victim, particularly where the mouth may be covered with foam, mucus or blood, as often the case in asphyxia victims, as well as the fear of possible transmittal of disease is revolting to the average person and is difficult to overcome."

     

    Thus, it is natural that thoughts turned to airway devices that could serve as a less interpersonal interface. As an anesthesiologist, Safar was familiar with oral airways in metal and rubber; he devised one with an oral blowpipe, then was advised to reverse two sizes of OPA by Dr Austen Lamont (who wished no credit; this was revealed in a tribute forty years later), and subsequently patented by Safar with Captain MC McMahon, of Baltimore Fire Department. Captain McMahon later claimed that "The S-shaped tube that Johnson & Johnson puts out as the Resuscitube is the offspring of my brain child to make mouth-to-mouth more acceptable in the emergency field."(sic)

    Safar S-Tubes, unknown variant, Berman Airway
    Click for larger image
    ©Tom Trimble, RN CEN, from Author's Collection.
    [L->R: Johnson & Johnson commercial version of adult/child & pediatric
    Safar S-tubes; middle: S-Tube of unknown manufacture of 2 OPAs conjoined with a plastic flange allowing use in either mode; right: comparison Berman airway, 100mm. Note grommet in plastic bag for hanging on emergency cart, etc.

    Author used adult Resuscitube in 1971 to save life of apneic comatose patient overdosed on Secobarbital.

     

    There was concern at the time as to the potential from lay public using pharyngeal length airways and causing injury. Safar's Resuscitube is only 90 mm on its greater curvature. Gordon's Airway is just an interdental bite block with a flange and mouthpiece without valve.

     

    The Brook Airway, the only significant competitor to J&J's Resuscitube, has additional design features: a short-length glossal curvature; a flexible cuffed flange with nasal cut-out; a flexible shaft enclosing a fish-mouth valve, and diversionary expiratory exhaust.

     

    James O. Elam was an early researcher ─whose practical experience began in 1946 with an outbreak of Polio in Minnesota by spontaneously and instinctively using mouth-to-mouth on victims when no iron lung was available; and who later recruited Archer Gordon and Peter Safar to the resuscitation research field. He did resuscitation research for the Army in the 1940s and 1950s that was published much later, and encouraged researches with Gordon and Safar that in combination accomplished acceptance for what he called "Rescue Breathing."

     

    My recollection (which is now difficult to confirm) is that he designed or was associated with what commercially was known as Venti-Breather®. He is known to have designed a pocket mask, but Safar thought it never came to market. I believe that  the “Roswell Park Rescue Breathing Mask” may have been the same device (he had worked at Roswell Park Memorial Institute). The Venti-Breather® was a shaped flattened plastic mask with a short blow-pipe with an expiratory diversion valve to the side of the blowpipe. (c.f., ebay listing in bibliography for images) Neither it, nor the Gordon Airway, seem to have done well on the market, when compared with Resuscitube or Brook Airway and are rarely seen.


     

    Bauer, Robert O. Emergency Airway, Ventilation, and Cardiac Resuscitation

    Anesth Prog. 1967 November; 14(9): 236–249. PMCID: PMC2235452

    ** Co-author, at times, with Elam. Photo from which, by kind permission of Allen Press, shown above of early mouth-to-airway devices. Probably only Internet-accessible extant photo of the Gordon Airway.

    O’Donnell, C. P. F., Gibson, A. T., & Davis, P. G. (2006). Pinching, electrocution, ravens’ beaks, and positive pressure ventilation: a brief history of neonatal resuscitation. Archives of Disease in Childhood-Fetal and Neonatal Edition, 91(5), F369-F373.
    **Review of old methods for resuscitating babies.

     

    Tercier, J. (2002). The lips of the dead and the ‘kiss of life’: the contemporary deathbed and the aesthetic of CPR. Journal of historical sociology, 15(3), 283-327. DOI: 10.1111/1467-6443.00180
    **45 pp, cultural aspects of avoidance of mouth-to-mouth.

    Waters, R. M., & Bennett, J. H. (1936). Artificial Respiration: Comparison of Manual Maneuvers.*. Anesthesia & Analgesia, 15(3), 151-156.
    **Review of prominent manual methods before WWII that would persist until 1950s; no discussion of mouth-to-mouth. Waters was a "giant" in American Anesthesiology.

     

    Brooks, CJ Dr. Chapter 9B – All You Need to Know About

    Life Jackets: A Tribute to Edgar Pask Survival Systems Ltd.

    Dartmouth, Nova Scotia
    **Interesting report on life jackets and Pask's research.

     

    Enever, G. (2005) Resuscitation Greats: Edgar Alexander Paska hero of resuscitation Resuscitation, 67(1), 7-11.
    **Tribute to WWII RAF research into drowning, life jackets, and artificial respiration.

     

    LeFanu, James (1997) Hero who put himself through hell The Sunday Telegraph 16 February 1997
    **Blog recounting Pask's intrepidity and personal experimentation.

     

    Writer, D. (2004). Sir Edward Sharpey-Schafer and his simple and efficient method of performing artificial respiration. Resuscitation, 61(2), 113-116.
    **The work and personality of Schafer, whose method was used until the post WWII era.

     

    Comroe, Jr. J.H. "Retrospectroscope. ". . . In Comes the Good Air".
    Part I: Rise and Fall of the Schafer Method'
    , American Review of Respiratory Disease, Vol. 119 (1979), 803-09

    **These three articles are not to be missed. The history of learning to reject manual methods for mouth-to-mouth.

    Comroe, Jr. J.H. "Retrospectroscope."  "…In Comes the Good Air" Part II: Mouth-to-Mouth Method. American Review of Respiratory Disease, Vol. 119 (1979), 1025-1031

    **As above.

    Comroe Jr, J.H. (1979). "Retrospectroscope."... In comes the good air." Part III. There will always be an England. American Review of Respiratory Disease, 120(2), Vol 120 (1979) 457-460
    **As above. Was it Schafer in the photograph?

     

    Safar-McMahon S-Tube Patent US3013554.pdf
    http://patentimages.storage.googleapis.com/pdfs/US3013554.pdf

    **Patent and description of the S-Tube.

     

    Resuscitation of the Unconscious Victim, a Manual for Rescue Breathing. By Peter Safar, M.D. Chief, Department of Anesthesiology, Baltimore City Hospitals, Asst. Prof. Anesthesiology, Johns Hopkins University School of Medicine, Clinial Associate Professor of Anesthesiology University of Maryland School of Medicine, and Martin C. McMahon, Captain, Baltimore Fire Department Ambulance Service, with 15 illustrations by Colin E. Thompson, Jr. Paper $1.75. Pp. 80. Charles C. Thomas, Publisher, Springfield, Illinois, 1959
    {Book Review} Morris, Lucien E. M.D. Anesthesiology: January/February 1960 - Volume 21 - Issue 1 - ppg 125
    **Review of the book, which is out of print, but sometimes available. Implementation and care directives for "EMS" mouth-to-airway.

     

    Training in Ambulance and Emergency Programs McMahon, Martin C. Captain, Baltimore Fire Department in Training and Education in the Fire Services Proceedings of a Symposium April 8-9, 1970 Conducted by Committee on Fire Research, Division of Engineering, National Research Council

    http://goo.gl/8GtL4E

    **Claims S-Tube was his "brain child"; reorganization of ambulance services.

     

    Rasmussen, Frederick N. Chief Martin McMahon, 94 first-aid pioneer [Obituary] The Baltimore Sun February 13, 2005

     

    Safar,P. (1997). Tribute to Dr. Austin Lamont. Anesthesiology, 87(2), 461.

    **Safar states Lamont's contribution to S-Tube; personal details of relationship.

     

    Lee, W. L., Tarrow, A. B., & Ward, R. J. (1959). Evaluation of a new oral resuscitator for expired-air artificial ventilation. Journal of the American Medical Association, 169(1), 33-35. {Venti-Breather®}

    **Review of Venti-Breather®

    Safar, P. (2001). {The Resuscitation Greats} James O. Elam MD, 1918–1995. Resuscitation, 50(3), 249-256.
    **Tribute of Elam's life in the journal's series "The Resuscitation Greats."

     

    Elam, J. O. (1977). Rediscovery of expired air methods for emergency ventilation. In Advances in Cardiopulmonary Resuscitation (pp. 263-265). Springer New York

    **Elam recounts hisearliest experiences and research that standardized Expired Air Resuscitation.

    Elam, J. O., Brown, E. S., & Elder Jr, J. D. (1954). Artificial Respiration by Mouth-to-Mask Method — A Study of the Respiratory Gas Exchange of Paralyzed Patients Ventilated by Operator's Expired Air. New England Journal of Medicine, 250(18), 749-754.

    **Landmark paper refuting old beliefs and giving scientific basis for primacy of expired air resuscitation.

    SAFAR, P., AGUTO-ESCARRAGA, L. O. U. R. D. E. S., DRAWDY, L., McMAHON, M. C., NORRIS, A. H., & REDDING, J. (1959). The Resuscitation Dilemma*. Anesthesia & Analgesia, 38(5), 394-405.
    **Issues in expired air resuscitation; Venti-Breather® is cited in table of volumes delivered.

     

    Vintage Rescue Mouth 2 Mouth Breathing Venti-Breather Emergency Kit 1960 Cross ebay.com; accessed 4/7/2014
    **Photographs (3) of Venti-Breather® device.

     

    Sands Jr, R. P., & Bacon, D. R. (1998). An inventive mind: the career of James O. Elam, MD (1918–1995). Anesthesiology, 88(4), 1107-1112.
    **Excellent "life and times" tribute.

     

    Sincerely,

     

          Tom Trimble, RN CEN

     

    All opinions are those of the author.

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    Tom Trimble, RN CEN is the Online Editor of AENJ.

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