Advanced Emergency Nursing Blog from AENJ

The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.

Monday, March 24, 2014

Oral Airways, early resuscitation, & recognition of airway care

The commonplace oropharyngeal airway, often useful and sometimes essential, has had different designs and manufacturers. The most common style is Guedel’s airway, so much so that Arthur Guedel is sometimes erroneously thought to have invented rather than developed the oral airway.


The earliest written invention is Hewitt’s airway: at first, a straight wide rubber tube, then curved, with a metal flange for dental and labial separation. Many followed, often metal for sterilization (but risky to teeth and tissues, if there was clenching or seizure), sometimes with nipples for gas insufflation. In fact, I recall using flangeless wire airways that required a tape-pull for withdrawal.


Later developments included airways designed for mouth to airway resuscitation. We can cover that next time.


Before the modern era, airway management and resuscitation had a fitful history. There are descriptions of tracheotomy in Egypt, 3600 BC, and Alexander the Great is said to have saved a soldier by opening the trachea with his sword tip. At various times, physicians would use metal tubes, catheters, or quills to bring air past the glottis, or open the trachea to admit a bellows for insufflation. These were for resuscitation with dismal but occasionally successful results, but modern understanding was lacking. Avicenna, ~1000 AD, writes upon intubation to rescue, but the first intubation for surgical anesthesia was by Macewen in 1878.


Management of anesthesia via natural airway (“rag & bottle” ether or chloroform) had sudden deaths due to dosing errors, indifferent administration, and poor airway management. Reading those accounts shows a hit and miss proposition.


What we call the Triple Airway Maneuver (neck straightening, head extension, lifting the jaw into an open-mouthed prognathic position with the lower teeth (& jaw) advanced anterior to the maxillary teeth) was a great step, probably developed in several areas at first (in different combinations) attributed to Esmarch, then Heiberg, then Little, then Clover in the 1860s.


Pulling the tongue forward, perhaps with pliers, some bite-sticks, and gags had to suffice until Hewitt’s 1908 invention. Then came more anatomic curvature, teeth-protecting bumpers, gas nipples, and then Guedel’s terse description of a oval tube with metal bite guard, and flange to keep position above the lips. Things have remained so with changes in material to plastics, and other styles to avoid blockage, or to facilitate intubation.


Please explore the links provided for greater detail and interest.


Hewitt, F. (1908). AN ARTIFICIAL" AIR-WAY" FOR USE DURING ANÆSTHETISATION. The Lancet, 171(4407), 490-491.  doi:10.1016/S0140-6736(00)66510-8


Haridas, R.P. HISTORICAL NOTE: The Hewitt airway – the first known artificial oral ‘air-way’ 101 years since its description  Anaesthesia, 2009, 64, pages 435–438 doi:10.1111/j.1365-2044.2008.05755.x


McIntyre, John W. R. s Oropharyngeal and nasopharyngeal airways: I (1880–1995)

Canadian Journal of Anaesthesia June 1996, Volume 43, Issue 6, pp 629-635


Defalque, Ray J. M.D.; Wright, Amos J. M.L.S. Who Invented the “Jaw Thrust”? Anesthesiology:

December 2003 - Volume 99 - Issue 6 - pp 1463-1464 Correspondence


Baker, A. Barrington  ARTIFICIAL RESPIRATION, THE HISTORY OF AN IDEA Artificial respiration, the history of an idea. Med Hist. 1971 Oct;15(4):336-51 PMID: 4944603


Resuscitation: An historical perspective (A catalogue of an exhibit at the annual meeting of the American Society of Anesthesiologists in San Francisco, October 11-13, 1976). Conserved at Wood Library Museum of American Society of Anesthesiologists.


Trubuhovich, R. V. (2005). History of mouth-to-mouth rescue breathing. Part 1. Critical Care and Resuscitation, 7(3), 250.


Trubuhovich, R. V. (2006). History of mouth-to-mouth rescue breathing. Part 2: the 18th century. Critical Care and Resuscitation, 8(2), 157.


Trubuhovich, R. V. (2007). History of mouth-to-mouth ventilation. Part 3: the 19th to mid-20th centuries and “rediscovery”. Critical Care and Resuscitation, 9(2), 221.


Greenberg, R. (2002). Facemask, nasal, and oral airway devices. Anesthesiology Clinics of North America, 20(4), 833-861.  doi: 10.1016/S0889-8537(02)00049-4


Snow J. On the cause and prevention of death from chloroform, 1852. Wood Library Museum American Society of Anesthesiologists


Brandt, L. (1987). The first reported oral intubation of the human trachea. Anesthesia & Analgesia, 66(11), 1198-1199.




Tom Trimble, RN CEN


All opinions are solely those of the author.