Advanced Emergency Nursing Blog from AENJ

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

Tuesday, May 27, 2014

Carbon Dioxide As A Resuscitative Gas
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

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


Closer view of Sparklet Resuscitator

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


Closer Detail View of Sparklet Resuscitator

Sparklet Resuscitator, price list

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

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.
    **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.



                      Tom Trimble, RN CEN


                      All opinions are those of the author.