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.