4000 B.C-1800: Evolution of Artificial Respiration

How procedure was performed circa 1891 (23, page 20)

4000 B.C.:  Mouth to mouth, tracheostomies and intubation:  There is some written evidence that tracheotomies were performed as early as 4,000 B.C. This is a procedure where an opening was cut into the trachea to allow for easier breathing and to help the patient expectorate secretions.  In 2000 B.C. Ancient Hindu medicine mentioned "throat incision," and about 1500 B.C. Ancient Egyptian Imhotep, the first known physician, mentioned tracheostomy.  (1)  Likewise among the first recordings of artificial respiration was in the Bible in the Second Book of Kings when Elisha successfully resuscitates the child of a Shunamite woman with mouth to mouth breathing:

And he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands: and he stretched himself upon the child; and the flesh of the child waxed warm.  Then he returned, and walked in the house to and fro; and went up, and stretched himself upon him: and the child sneezed seven times, adn the child opened his eyes. (II Kings 4: 34-5)

Hippocrates (460-370 B.C.) mentioned placing a tube into the trachea through the mouth or nose (intubation) to assist with breathing. (2)  Hippocrates explained:  "A tube should be inserted into the throat, along the jaws, so that the air may be attracted to the lungs."  (19)

Galen (120-200 S.D.) states that Aesculapius was the first to recommend tracheotomy.   Both Aaretaeus (130-200 A.D) and Caelius-Aurelianus (5th century) mention the recommendation by Aesculapius, although Caelius talks of it as a rash procedure never put into practice.  (19) 

Galen also described tracheostomies, and described inflating lungs with bellows, and Avicenna (980-1037) described "intubating the trachea using 'a cannula of gold or silver.'" (2) 

Antyllus, who lived sometime between the birth of Jesus and the 4th century, had a fragment of his writings preserved by Paulus Aegineta (625-690), some of which provides one of our first accounts of the surgical procedure:  

"The incision should be made in the trachea, under the larynx, about the third or fourth ring.  This situation is most eligible, because it is not covered by any muscles, and no vessels are near it.  The patient's head must be kept back, in order that the trachea may project more forward.  A transverse cut is to be made between two of the rings, so as not to wound the cartilage, only the membrane." (19, 20)

So it is evident mouth to mouth respirations, intubation and tracheostomies particularly were used for good purpose since the beginning of human existence. 

In the 12th century Arabian physicians Avenzoar and Albacasis were among the few physicians who dared to perform tracheotomies, and prior to them the procedure was rarely performed. Avenzoar recommended it not be done unless the physician had knowledge of anatomy.  (19)

Rhazes, Mesue, and Avicenna do not mention the methods of the procedure, but recommend it as a last option in cases of "angina strangulans."  It was not regularly practiced until the 16th century, yet most of what is written is reproductions of what Antyllus wrote on the subject. (19)

Overall, most accounts of the procedure mention they "look upon it with great distrust" until the 18th century when Antoine Louis published articles on 'bronchotomy.'  By the 19th century it was recommended and practiced with regularity. (19)

1250-1306:  Intubation:  The Surgeon Lanfranchi of Milan was a surgeon at the School of Salerno in Northern Italy who may have been the first physician to mention intubation.  He became involved in the "squabbles of Guelphs and Ghibellines and was exiled.  He arrived in Paris in 1295, where he introduced the French to Italian medicine.  So it's highly likely the French also had knowledge to the technique of intubation.  (24, page 144)

1530: Bellows:  Paracelsus (1493-1541) was among the believers who lived during the renaissance that what was taught by ancient writers such as Hippocrates, Galen and Avicenna was poppycock and quack medicine and he was among those who aimed to prove them wrong.  He believed medicine should be taught and performed based on observation at the patient's bedside and not on antiquated textbooks.  He was even known to toss those old texts into the fire.  He believed rather than just make things up based on observation, one must do experiments to prove or disprove ideas.  He was among the first to document performing artificial respiration by placing the nozzle of fireside bellows into the nares of patient's who stopped breathing "to inflate the lungs.  Unfortunately his experiments didn't work.  (3)(4)

1400:  Mouth to mouth breathing:  The most basic form of positive pressure breathing is considered mouth breathing.  This is where you place your mouth over another person's mouth and exhale into their mouth.  This forces air into their lungs and, thus, causes the other person to breathe.  This may have been done by ancient people, although it was documented to have been performed in Italy to revive newborn infants stunned at birth and not breathing on their own.  (5)

1500:  Tracheas and intubation reintroduced

Tracheal openings were used for years by physicians who wanted to keep animals alive while doing experiments on them.  (6)  Andreas Vesalius, the same person who proved that Galen wasn't a know all about medicine, was the same person to describe how he could provide breaths to animals by blowing into a reed inserted into their necks through a tracheal opening.   Vesalius provided this description in his work De humani corporis fabrica (On the Fabric of the Human Body).  This one of the first recorded accounts of positive pressure breathing (PPV).  (7)In 1546 Antonio Brasavola of Italy performed a tracheostomy on a patient with tonsilar obstruction, and through Vesalius, Brasavola and other physicians the Renaisance  reintroduced the world to tracheostomies and there ability to save lives. In 1754 Benjamin Pugh of England inserted an "air pipe" into newborn infants who were not breathing, and soon thereafter intubation became common for near drowning victims.  Aware of the benefits of creating an airway, a physician by the name of Curry developed an "intralaryngeal cannulae" to use for resuscitation efforts.  (8)  In 1783 De Poiteau recommended the use of tracheas when administering positive pressure breaths to drowning victims in order to let water out and warm air in and out by using a tube.  Tracheotomy tubes were further refined as the century came to a close.  Use of tracheotomies ultimately waned in favor of intubation (placing a tube or cannula into the airway to the trachea). (9)  

1700s:  Positive Pressure to Drowning Victims

In 1714 Dethharding recommended using mouth to mouth breathing to resuscitate near drowning and other such victims.   In 1732 a Scottish surgeon named Dr. William Tossack successfully used mouth to mouth breathing to revive a coal minor who stopped breathing due to suffocation, and as a result rescue breathing became common by the 1840s. (6) However, once the germ theory was established this was deemed as harmful to the rescuer and bellows were used.  However, many suspected this was harmful to victims so they refused to do it.  (10)  In 1837 Leroy d'Etoille was so concerned about the use of such artificial breathing because he suspected it caused emphysema and would collapse the lungs (pneumothorax). After the germ theory was established in the late 19th century PPV was banned for the next 100 years before it's value would be re-established in the later half of the 19th century.  (11)  

1776:  Double Chambered Bellows

In 1776 John Hunter perfected the idea of Paracelsus that bellows could be used to resuscitate patients who stopped breathing.  His idea was actually invented to breath for asphyxiated neonates.  He invented a system of double chambered bellows he experimented with by giving breaths to dogs.  Because two bellows were used, this required two cavities leading to a single nozzle which was inserted into the nostril.  One chamber inflated the lungs and the other deflated them.  Use of the device "flourished" until a report in 1929 showed that "sudden injection" of air from the device could cause injury to the lungs.  However, later magazine articles and books indicate the device was used occasionally when necessary, and the nozzle was either inserted into the airway as Hunter recommended, or sometimes to a tracheotomy. (12)  Due to his invention he is often referred to as the father of artificial respiration.  The product was generally referred to by Hunter Bellows. (21, page 281)(22, page 2)

1780:  Bag Mask Ventilation

In this year a reservoir bag was attached to a mask and used to give breaths to infants who were not breathing at birth.  The device was invented by Chaussier.  He also invented a cannula (or catheter) that could be inserted into the airway by blind insertion through the mouth into the larynx.  His reservoir bag could then be inserted to the cannula to provide positive pressure breaths.  (13)  He was likewise the first to provide oxygen breaths to newborns.  (14)

1788:  Endotracheal tube

The first endotracheal tube was invented in 1788 by Charles Kite.  He was a surgeon who wrote an essay titled, "The Recovery of the Apparently Dead," in which he described inserting a tube he referred to as a catheter through one of the nares or the mouth to the lungs whereby the operator could either provide positive pressure breaths either by placing his mouth over a mouthpiece or by using bellows.  To cause expiration Kite recommended pushing in on the abdomen.  Various bellow-type systems were available for providing positive pressure breaths. Experiments in 1826 proved that blowing "forcibly into a cannula inserted through a trachea could cause a lungs to collapse.  In 1888, however, experiments by Leroy were performed that proved that a collapsed lung only occurred when the pressure forced into the lungs was too high, such as greater than 20-80 mm of mercury in the lungs of infants.  As a result of his experiments, he "invented a safety bellows to obviate these effects.  The bellows had a scale graduated in ages attached to the handles to limit the volume of air delivered." (15)

1793:  Intubation to treat diseased patients:  Prior to this time artificial respiration was generally used to treat near drowning patients or for some other purpose.  Yet near the end of the 18th century artificial respiration was thought to benefit people with diseases or conditions that result in dyspnea or asphyxia.  This was a time when a tube was sought to be kept inside the airway long-term as opposed to temporary.  Xavier Bichat, a pupil of French surgeon Desault, describes how desault decided to insert a catheter into the laryx of a patient in impending respiratory failure as opposed to a tracheotomy. Desault is considered the first to apply artificial respiration for dyspnea.  In many cases the patient's breathing became easier, and in one case the patient's breathing became easier and was extubated 24 hours later. Desaults cather "was a large gum-sized elastic catheter, with two large eyes and an opening inferiorly, adn he introduced it through one of the nasal fossa rather than the mouth."  Catheterization became a common procedure in France, although later fell into disuse.  (23, page 2-4)

Figure 1(23, page 6)

1832:  Dalzeil respirator:  John Dalzeil described what many refer to as the precurser to negative pressure ventilators that would follow, including the Woillez Iron lung described below.  It was a box, and he once used it to ventilate a man who was a near drowning victum.  The patient sat up while in the box with his head and arms outside the box.  The box was airtight, and bellows inside caused a negative pressure that caused inspiration.  A window on the outside of the box allowed an observer to see if it was actually causing respirations.  This is often referred to as the first tank respirator, or the first iron lung.  The box had to have been hand powered, and there is no documentation it actually worked.  (16)

1845:  Oxygen breaths

A man named Erichson invented the first device that provided positive pressure breaths with oxygen through a cannula inserted through a pipe inserted into one of the nostrils.  He recommended ten breaths a minute.

1858:  Bouchut's Intubation Tube:  In this year French physician Bouchut became the first to describe insertion of a tube into the airway as opposed to a catheter in a case of dyspnea. The tube he used was a rounded silver tube narrower at the end to be inserted as you can see in Figure 1, and it was 1.5 to 2 cm long and 7 cm in diameter.  Interestingly, a silk thread was attached to the distal end of the tube that was "brought out to the mouth, and was intended to prevent the tube from going down the trachea or esophagus; and to allow it to be taken out when necessary." He later "insisted on the distinction between his method and catheterism." However, of the seven cases he cited to the French Academy of medicine, only two lived and both required tracheotomy.  Yet he proved the procedure could be done. Various other physicians described success with this or similar procedures between 1858 and 1880 when the Joseph O'Dwyer introduced his tube. (see figure 1)(23, page 5)

Richardson's (21)

1867:  Richardson's Double Acting Rubber Bellows:  Benjamin Ward Richardson created a bellow system similar to Hunter's Bellows (although he may not have known of Hunter's Bellows). The original system took up a lot of room, so he invented the double acting bellows, which "consists of two rubber bulbs terminating in common tube that was called the nostril-tube."  One bellow supplied inspiration, the other expiration.  

1875:  Blake cures poison victim:  Using a device similar to Richardson's Bellows, Blake connected a reservoir of condensed oxygen to it and treated a case of acute poisoning with success.  Before this time artificial respiration (often referred to as insufflation) was used mainly to treat neonatal asphyxia, but now the focus was also on treating adults.  The nozzle of the device was inserted into the nostril.  

1876:  Woillez Iron Lung (Spirophone)

While the iron lung wasn't mass produced until the late 1920s, there were some earlier models that acted as prototypes of later designs.  In fact, the design described by Woilliz was quite similar to the Drinker and Shaw and Emerson iron lungs.  The only drawback to Woillez's design was he didn't have access to electricity, so his machine was powered by hand.

figure 5

At the French Academy of Medicine in Paris in 1876 Woillez described his respirator this way:

"(The apparatus is) a zinc or sheet iron cylinder large enough to receive the body of an adult up to the neck. It is equipped with wheels which permit moving it rapidly to the place where it is necessary. The cylinder set almost horizontal slightly inclined is hermetically closed at the boot end and open at the head end. Through this opening at the head end you slide the body of the patient by means of a sort of stretcher equipped with rollers, on which he is previously placed; then you close the head opening around his neck by means of a diaphragm that you attach to the edges of the opening. The head thus remaining free rests on an appropriate support. A flexible impermeable fabric attached to the cover diaphragm is secured around the neck to avoid as far as possible the passage of exterior air to the inside of the apparatus, at the moment when the vacuum is produced there.

The air thus confined in the apparatus around the body of the patient can be partially rapidly withdrawn by means of a powerful aspirator bellows of about 20 litres capacity. . . actuated by means of a lever. The interior of this pump communicates with the interior of the apparatus through a large tube tightly screwed on." (17)

 There were other similar designs, yet none became mass producible mainly due to lack of knowledge of electricity at the time.

O'Dwyer's Intubation Tube for a child 2-3 years old (23

1880:  The first endotracheal tube:  Dr. Joseph O'Dwyer of New York, and his fellow physicians at the New York Foundling Asylum, observed problems with trachetomy.  He decided another means of breathing for patients was necessary, and he at first trialed flexible catheters into the nasal passages.  Yet this didn't meet his satisfaction so he devised a tube to be placed into the larynx where it would remain.  By trial and error he tinkered with the device until it met his satisfaction.  The device was made with a bivalve tube with a narrow transverse diameter, and about an inch long."  A shoulder on the upper end prevented the tube from slipping down.  By trial and error the tube transformed so the tube was a "plain tube of elliptical form about an inch in length.  He then played with longer tubes until he found the desired length.  The final tube used was made of brass and lined with gold, and was accepted by the medical community.  (See figures 2 and 3.)  A complete set was included in a box, that included sizes for different aged children, an obturator, an introducer, an extractor, and a gag.  The length of the tubes in inches were 1.5, 1 3/4, 2, 2.25 and 2.5.   The obturator of the physicians choice is connected to the end of the introducer, and this is used to insert the tube.  If necessary a small thread could be inserted and tied to a hole on the outer edge of the tube to prevent it from going down the traches, and to facilitate removal.  The kit also came with a scale (see figure  5) which helped the physician determined appropriate depth of the tube according to age.  The scale is used like this: "The smallest tube reaches line 1, and is intended for children about one year and under. The next reaches line 2, and is for children between one and two years. The third size, marked 34 on the scale, should be used between two and four years. The fourth, marked 5-7, is for the next three years, and the largest tube is for children from eight to twelve."  O'Dwyer also designed larger tubes and equipment for adult intubation. (23, page 9-18)

O'Dwyer's introducer connected to obturator (23, page 16)

1888:  Foot operated Bellows

Dr. George Fell invented a system of bellows whereby the operator would use his hands to provide positive pressure breaths.  He would either use a tracheotomy or face mask.  In 1891 this system was revised by Joseph O'Dwyer of New York so that breaths were provided by pressing down on a lever with your foot.  O'Dwyer preferred to connect his bellow system to an endotracheal tube.  O'Dwyer was concerned about over-distention of the lungs due not allowing enough time for expiration, and therefore recommended giving slow breaths, or 10-12 per minute. (21, page 283)

1891:  Concerts of Intubation:  By the late 19th century many of the same concerns physicians have today about intubation were considered.  One such concern being the ulceration of tissue due to pressure of the tube set upon it for a long period of time.  Tubes were generally taken out after six days with success, although in some cases were left in 12 days or longer. Dr. Rank, a German physician, ultimately recommended removal of the tube after 10 days, and if necessary, the physician should consider tracheotomy. Some physicians recommended extubation after the 5th day, which would be in line with modern protocols.  Feeding the patient was also a concern, and was either done with soft foods or liquids, or by nasalgastric tube.  It was recommended that if the tube was accidentally spit up that the nurse take advantage of the moment to try feeding the patient prior to re-introducing the tube (if the tube is still needed). (23, page 29-20)

1898 Matas's Apparatus for Artificial Respiration:  Around this time the need arose for a means to prevent asphyxia when chloroform was used. There was also the concern of preventing pneumothorax during artificial respiration.  Matas deviced the "experimental automatic respiratory apparatus" as you can see in figure 4.  This was never put in use on a real patient, and was mainly used to study the effects of pressure during inspiration and expiration.  You can see some of the major components in the picture: MF = O'Dwyer intubating cannula and stopcock for introducing chloroform; M = Mercurial manometer to measure pressure or vacuum; H is the handle to work the pump and forces air into the lungs.   The operator places a finger over a hole in the O'Dwyer intubation cannula, and when he removes his finger expiration occurs.  (R = Rubber tubing.)  It was quite a contraption for its time. Experiments were performed on dogs and human cadavers, although it was decided it was not fit for use on humans. (21, page 284)

Figure 4 (21)

1900:  Cuffed Endotracheal Tubes and laryngoscopes

Right around the turn of the century was when the furst cuffed endotracheal tubes (ETT) started showing up.  This was necessary to prevent air from leaking around the tube so that bigger breaths could be given, and it also worked nice to prevent aspiration around the tube. A larygoscope was first described in 1855 using sunlight to see the vocal cords, and by 1913 a battery powered laryngoscope with an external light was invented.  This was refined so it had a handle with a battery and a light bulb at the end of the scope for easy visualization of the vocal cords.   (18)

References:

1. Szmuk, Peter, eet al, "A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age," Intensive Care Medicine, 2008, 34, pages 222-228
2. Price, J.L., "The Evolution of Breathing Machines," (this must have been written in the 1950s or early 1960s because the last reference was to IPPB being used as a respirator) (reference to The Bible, Kings, 4: 34)
3. Tan, S.Y, et al, "Medicine in Stamps:  Paracelsus (1493-1541): The man who dared," Singapore Medical Journal,  2003, vol. 44 (1), pages 5-7
4. "Resuscitation and Artificial Respiration," freewebs.com, Scientific Anti-Vivisectionism,  http://www.freewebs.com/scientific_anti_vivisectionism4/resuscitation.htm, accessed March 1, 2012
5. Price, op cit
6. Lee, W.L., A.S. Stutsky, "Ventilator-induced lung injury and recommendations for mechanical ventilation of patients with ARDS," Semin. Respit. Critical Care Medicine, 2001, June, 22, 3, pages 269-280
7. Price, J.L., "The Evolution of Breathing Machines,"  (see also reference #1 and #3 above)
8. Szmuk, op cit, page 225
9. Price, op cit
10. "Resuscitation and Artificial Respiration," freewebs.com, Scientific Anti-Vivisectionism,  http://www.freewebs.com/scientific_anti_vivisectionism4/resuscitation.htm, accessed March 1, 2012 (see also reference 1 above)
11. Lee, op cit
12. Price, op cit
13. Price, op cit
14. Szmuk, op cit, page 225
15. Price, op cit
16. Woollam, C.H.M., "The development of apparatus for intermittent positive pressure respiration," Anaesthesia, 1976, volume 31, pages 537-147
17. Previtera, Joseph, "Negative Pressure Ventilation: Operating Procedure (Iron Lung)," Tufts Medical Center, Respirator Care Programs, http://160.109.101.132/respcare/npv.htm, and http://160.109.101.132/respcare/ironlung.htm, accessed February 27, 2012
18. Szmuk, op cit, page 226-7
19. Fourgeaud, V.J, "Medicine Among the Arabs," (Historical Sketches), Pacific medical and surgical journal, Vol. VII, ed. V.J. Fourgeaud and J.F. Morse, 1864, San Fransisco, Thompson & Company,  pages 193-203  (referenced to page 198-9)
20. "Biographical Dictionary of the society for the diffusion of useful knowledge," Longman, Brown, Green and Longmans, volume III, 1843, A. Spottingwood, London, page 124-5
21. Tissler, Paul Louis Alexandre, "Pneumotherapy: Including Aerotherapy and inhalation...," 1903, Philadelphia, Blakiston's sons and Company, page 284,5
22. Hasan, Ashfaq, "Understanding Mechanical Ventilation: A practical Handbook," 2010, New York, Springer
23. Ball, James B, "Intubation of the Larynx," 1891, London, H.K. Lewis
24. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1922, Philadelphia, W.B. Saunders Company