Monday, January 16, 2017

When Air Becomes Breath - A Historical Perspective

"After 8 more arm raise cycles, It's time to check her ABGs"
A 1910's critical care nurse has just found her patient apneic and beginning to turn that dreaded inky, cyanotic color. All is not lost. It's time to initiate artificial respiration. Of course before all the heroic measures start, it's always prudent to check the upper airway for an obstruction. Every old nurse knows the time honored mouth opening trick of placing a thumb on the mandibular arch and the index finger positioned above on the maxilla and then rapidly crisscrossing her fingers. The other hand  finger is free to probe the oropharynx for obstructions. If you encounter a hot dog segment, Brazil nut, or hunk of steak all you have to do is yank it out and  hope for the return of spontaneous breathing.

If the chest has ceased that comforting sight of rising and falling, it's time for artificial respiration. Pull your supine patient to the very  head of the cart, table, or bed and get a gorilla grip on her forearms. To initiate expiration, pull her arms down and adducted into her chest with her fists at the base of her lungs. Now for the fun part. Rapidly pull her arms overhead and below her body for inspiration. One caveat: just as modern CPR can crack ribs, this old school method can wreak havoc with elbows dislocations. Just how do you explain that to the family? This complication is also not favorable to Press Ganey Satisfaction Surveys so be careful lest those pesky patient relationship builder consultants  appear on the scene. (As an Oldfoolrn, I give thanks everyday that I never had to deal with that!) Hats off to you bright, whippersnapperns that are forced to submit to this nonsense.

There was one other old school artificial respiration trick  procedure done with the patient prone. The nurse jumps up into the bed or litter and straddles the patient. The patients arms are flexed at the elbows with forearms at a right angle to the body. For expiration the nurse pushes down and forward at the base of the lungs and inspiration involves grabbing the flexed elbows and pulling them toward and into the head. This was the popular Red Cross method taught to 1960's lifeguards. These techniques probably moved just enough air to clear the dead space in the pharynx, larynx, and trachea.

Unfortunately these techniques ignored one of the most basic anatomic characteristics of the chest which except for some intercostal movement during respiration is a very rigid, unyielding  cage like structure. When the diaphragm moves down the volume of the chest increases, lowering the intrathoracic pressure causing inspiration. A very clear example of what happens with a non rigid chest occurs with traumatic injury breaking ribs causing a flail chest. Not a pretty picture when the chest wall is mobile and it's really time to head to the OR.

An Engstorm in action. Who needs piped in
Oxygen with those handy dandy "J' cylinders?
Moving them around was like wrestling a
Sumo Wrestler.

A lifesaving (oh, how I hate that term) innovation for critically ill patients was the introduction of  volume respirators such as the mid 1960's Engstroms. These precision machines from the Karolinska Institute in Sweeden cost $8,000 USD in 1960 and had the capability of expanding the lungs at the alveolar level. This was the birth of PEEP (positive end expiratory pressure.)

These early ventilators were impressive looking machines. The control panel looked like something from an airplane cockpit and was ingeniously tilted to prevent nurses from stacking anything on top of it. I can tell you from personal experience this was no place to temporarily set down that Albumin bottle.Cleaning up the sticky substance laced with glass shards is a lesson that sticks with you.

As much as Oldfoolrns love old, familiar analog medical machines, they could have some truly vexing and potentially fatal problems. Being a 100% mechanical device the Engstrom had zilch in the way of electronic alarms. A nurse could be lulled into a false sense of security by that reassuring whoosh/whoosh as the macines bellows appeared to inflate the patient's lungs. Without a continuous monitoring of pressure in the breathing circuit, a patient's trach tube could disconnect from the ventilator tubing without an audible warning. Nurses really had to be right at the bedside watching for the rise and fall of the patient's chest.

I cannot resist the segue to a foolish tale from yesteryear. Ventilator supported patients in the times before oximeters and capnography required frequent arterial blood sampling (ABGs)  to monitor respiratory status. If the patient had an arterial line in place this was no problem. Without an arterial line nurses had to tap a radial or femoral artery for a sample inflicting pain and trauma. We hated doing these on a frequent basis and if the critical care fellow ordered ABG's too often we threatened to put a plastic trash can liner over his head and draw his blood gases in 30 minutes. The young physicians were conditioned so that whenever a nurse began removing a  plastic trash can liner from the waste basket, it was time to rethink the blood gas order.


  1. I never worked with the Engstroms, but did work with some of the early Birds...
    I collect antique medical books, and have read about some of those "CPR" maneuvers... Ye gods and little fishes!!

  2. From denmark again ;))) - i know for a fact that our last Engströms Still are huffing and puffing in poland and other eastern-europe countries ... i can ø¨ remember when we donated them in the start90s ... and not long ago one of our anestesias-nurses was on a trip - and according to her they STILL du their job wonderfully- so why all that throwing out ? :)))

  3. We had flocks of Birds too. When volume control ventilators like the Engstroms replaced the pressure controlled Birds they were demoted to IPPB duty. Volume control ventilators like Engstroms and MA-1s were revolutionary in treating shock induced by trauma.

    One of my neighbors was from Denmark and they baked the most magnificent duckling. I wondered if this was a national tradition. There was something very comforting about old school medical devices. That soothing whoosh/swish of the Engstroms and you just knew everything would be OK. Those new ventilators with huge LCD monitor screens look like entertainment devices. I think it's like comparing a majestic pipe organ to an Ipod. They both make music, but what a difference

  4. As a grad in the late 70s, blood gases were drawn on the floors by the respiratory techs...not a teaching hospital. That cheap pulse oximeter device you buy on line for about $40 bucks is not the most accurate device in the world, but it sure is painless! COPD then was no joke - ABGs draws,and the main treatments were theophylline and prednisone to keep your airways open, antibiotics for infection, and a noisy nebulizer machine that plugged into the wall and you had to hold the mouthpiece in place and breathe warm medicated vapor for 20-30 minutes. You had to be in the hospital for all of those treatments, so you could be there 10 days or so every time a cold got into your chest. A couple of decades of the usual treatments and in addition to end stage lung disease, you had diabetes and necrotic hip joints form steroids, cardiac arrhythmias from theophylline, antibiotic resistant germs in your respiratory tree, and chronic junky cough from all the damage to lung tissues from these treatments.
    Convinced me not to smoke.

  5. I used to really feel for those asthma and COPD people on Aminopylline because it made them so restless and ready to jump out of their skin. That terrified look in their eyes said it all. We had a smug pulmonary doc that always down played the restless behavior by saying, "Oh he is just more active because of increased brain perfusion." This always got an eyeroll out of every nurse.

    When I worked in neuro, the lab was actually in another building and we ran over there with our ABGs on ice until we received an ABG analyzer for the unit. It sat on the counter in the clean utility room right next to our coffee percolator. Old hospitals had minimal division of labor and nurses did a lot of the jobs ancillary people do today.

    I impressed and touched that you took time away from the inauguration to read and comment on my lowly blog. I never dreamed big, accumulated wealth or real estate. For me, America was great if I was able to keep a neat Mayo stand and a surgeon requested me as a scrub nurse for an uneventful case with the patient doing great as he left the room. :-)