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Advanced Emergency Nursing Blog from AENJ

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

Tuesday, April 8, 2014

Mouth-to-Airway (adjunct)

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

**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

**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; 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.




      Tom Trimble, RN CEN


All opinions are those of the author.