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Advanced Emergency Nursing Blog from AENJ
The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.
Saturday, May 03, 2014
Early Modern Resuscitators

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.

 

About the Author

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

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