Airway Management Across the Ages. - PowerPoint Presentation

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Airway Management Across the Ages. The Airway World from Biblical Times Until WWII

D. John Doyle MD PhDChief, Department of General AnesthesiologyCleveland Clinic Abu DhabiSlide2

Disclosure:No Conflicts of Interest

No active industry grantsNo paid advisory positionsHave been provided with equipment for studies and clinical evaluation by a number of manufacturersSlide3
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Andranik (“Andy”) Ovassapian

(1936-2010)Slide5

Dr. Ovassapian’s Most Difficult Airway CaseSlide6

www.samhq.comSlide7

Airway Management Across the AgesSlide8

Giving Due Credit Although several sources were studied to prepare this information, the following historical review by Dr John R. Davidson was used extensively and deserves special mention:

J. R. Davidson, Intubation: What’s Old, What’s New. Anesthesiology Clinics of North America. June 1995, pp. 377-390.Slide9

Some Landmarks in Clinical Airway Management

Biblical Times

Death from airway obstruction recognized (trauma [strangulation], leprosy, abscesses)

1700s

Metal and leather tubes inserted blindly into the trachea for treatment of drowning

1842

Crawford Long discovers ether anesthesia

1854

Garcia, a professor of singing, develops indirect laryngoscopy

1878

Chloroform administered through tracheal tube (Macewen)

1885

O

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Dwyer popularizes intubation for diphtheria

1895

Kirstein develops direct laryngoscopy

1900

Kuhn develops a flexometallic tracheal tube

World War I

Many casualties requiring head and neck surgery adds impetus to widespread use of intubation

1920

Chevalier Jackson designs improved laryngoscope

1920s

Magill develops blind nasal intubation

1942

Griffiths introduces curare into clinical practice

1946

Mendelson describes aspiration pneumonitis

1950s

Popularization of the use of tracheal tubes for general anesthesia

1960s

Advent of electronic patient monitoring

1962

Sellick maneuver and rapid-sequence induction developed

1940s-1970s

Continuing improvements in laryngoscope and tube designs; use of plastic

1970s

Development of implant-tested low-irritation, low-cuff pressure disposable tracheal tubes

1980s

Popularization of fiberoptic intubation. Introduction of pulse oximetry and capnography as

noninvasive means of assessing oxygenation and ventilation.

1990s

Popularization of laryngeal mask airway, rigid fiberoptic laryngoscopes (Bullard, Wu, etc.,) and ASA Practice Guidelines for Management of the Difficult Airway.

1995

Founding of the Society for Airway Management (www.samhq.com)

2000s

Introduction of video laryngoscopes (GlideScope, McGrath etc.)Slide10

Airway Management in the Old Testament

Elijah Reviving the Son of the Widow of ZarephathSlide11

Airway Management in the Old Testament

Elijah performed mouth-to-mouth resuscitation on a child with heat stroke. This was the first example of assisted respiration.

II Kings 4:34

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.

http://www.emedicine.com/ent/byname/tracheostomy.htmSlide12

Religion and Airway Management

Saint Blaise served as Bishop of Armenia in the fourth century.  Little is known about his life, but legend tells us that he saved a small boy from choking on a fish bone. Because of this, his help is sought for those who are afflicted with illnesses of the throat.  On February 3, the feast of Saint Blaise, many Catholic churches offer the blessing of throats.Slide13
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Homer Homer, describing the death of Hector, wrote that “his spear went right through the fleshy part of the neck, but did not sever his windpipe so he could still speak.”

Homer: The Iliad, Book 22, Paragraph 20. The Electronic Home Library, Ed 1, Ver 3. Garden Grove, CA, World LibrarySlide15

Aristotle

Aristotle, in his Parts of Animals, shows a sophisticated appreciation of the structure and function of the epiglottis, vocal cords, and trachea. Aristotle: Parts of Animals. Book 3, Chapter 3. The Electronic Home Library, Ed 1, Ver 3. Garden Grove, CA, World LibrarySlide16

Alexander the Great

Alberti mentions that Alexander the Great is reputed to have opened the trachea of a soldier given up for dead with the point of his dagger. Alberti PW. Tracheostomy versus intubation. A 19th century controversy. Ann Otol Rhinol Laryngol 93:333-337, 1984Slide17

Hippocrates

Alberti also maintains that Hippocrates described and used an angled tube to relieve airway obstruction caused by quinsy. He also condemned tracheostomy, citing threat to carotid arteries. Alberti PW. Tracheostomy versus intubation. A 19th century controversy. Ann Otol Rhinol Laryngol 93:333-337, 1984Slide18

Avicenna The Arabian physician Avicenna (AD 980 - 1037) described airway management in his treatise

Liber Canonis. Brant quotes a Latin passage : “When necessary, a cannula of gold, silver or other suitable material is advanced down the “throat” to support inspiration.” Brant L. The first reported oral intubation of the human trachea. Anesth Analg 66:1198-1199, 1987. Slide19

Andreas Vesalius and his anatomy text,

De Humani Corporis Fabrica Libri Septem

(

Seven Books on the Fabric of the Human Body

) 1543. Slide20

Ancient engraving illustrating a tracheostomy procedure. From

Armamentarium chirurgicum bipartitum

, 1666. Courtesy of the National Library of Medicine. (Image edited for clarity).Slide21

First Clear Reference to Orotracheal Intubation It was not until 1788 that an indisputable reference to orotracheal intubation in humans occurred. Charles Kite, in his “

Essay on the Recovery of the Apparently Dead” writes “the crooked tube, bent like a male catheter…should be introduced into the glottis, through the mouth or one nostril... Brant L. The first reported oral intubation of the human trachea. Anesth Analg 66:1198-1199, 1987Slide22

Instruments for the recovery of the apparently dead. The elastic blow-pipe for the lungs, the elastic tube of blue leather for conveying fumes to the Intestines, the elastic tube of black leather for conveying medicines into the stomach, the Fumigator and a bladder and pipe. (Wellcome Images)Slide23

A Curved Metal Catheter of the Type Recommended by Charles KiteSlide24

Inadvertent Awake Intubation

Parisian surgeon P J Desault (1738 - 1795 ) was responsible for demonstrating the ability of a conscious patient to tolerate an indwelling orotracheal tube. He did this inadvertently, thinking he had passed the tube into the esophagus for the purposes of providing nourishment. A flickering of a lighted candle at the end of the tube demonstrated the tube’s intratracheal position. Applebaum EL, Bruce DL. Tracheal Intubation. WB Saunders, 1976Slide25

Blind Intubation for Drowning In their 1796 description of “life-saving measures for drowning patients” Herholdt and Rafn advise passing a catheter blindly over the fingers placed posterior to the epiglottis.

Applebaum EL, Bruce DL. Tracheal Intubation. WB Saunders, 1976Slide26

Diphtheria

Diphtheria is an upper respiratory tract illness characterized by sore throat, low-grade fever, and an adherent membrane (a pseudomembrane) on the tonsil(s), pharynx, and/or nose. It is caused by Corynebacterium diphtheriae, an aerobic Gram-positive bacterium.Slide27

Diphtheria

Pseudomembrane at the back of the throat of a child. The membrane can grow and extend further down the throat, suffocating the child. Slide28

Diphtheria

In the 1890s, the German physician Emil von Behring developed an antitoxin that, although it did not kill the bacteria, neutralized the toxic poisons that the bacteria released into the body. For this discovery and his development of a serum therapy for diphtheria, he won the first Nobel Prize in Medicine (1901).Slide29

In February 1925, a deadly diphtheria epidemic was poised to sweep through Nome Alaska. The only serum that could stop the outbreak was in Anchorage, nearly 700 miles away. The only aircraft that could quickly deliver the medicine was taken out of winter storage, but its engine was frozen and would not start. After considering all of the alternatives, officials decided to move the medicine using a series of sled dogs.

(Modified from Wikipedia)Slide30

Statue of Balto by Frederick Roth in Central Park (New York City, New York).Slide31

In late 1928 an outbreak of diphtheria occurred in Northern Alberta, Canada. On January 2, 1929, “Wop” May and his friend, Vic Horner, headed from Edmonton in the Avro “Avian” with the necessary diphtheria antitoxin.Slide32

Their flight path took them first to McLennan, where they spent the night, and then on to Peace River for refueling. They headed further north to Fort Vermilion, despite dangerously frigid weather and engine problems. The two pilots arrived safely with the antitoxin on January 3 and returned to Edmonton, January 6, to a cheering crowd of 10,000. Slide33

Specifications for 1927 Avro Avian

Maximum speed: 102 mph

Cruise speed: 87 mph

Initial climb: 650 ft/min

Service ceiling: 18,000 ft.

Gas capacity: 35 gal.

Max. range: 400 miles

Wingspan: 28’

Length: 24’ 3”

Height: 8’ 6”

Tare weight: 1130

Max. weight: 2002 lbs. Slide34

Diphtheria

One of the first early effective treatments was discovered in the 1880s by U.S. physician Joseph O'Dwyer (1841-1898). O'Dwyer developed tubes that could be inserted into the throat to prevent victims from suffocating from the membrane sheath that grew and obstructed the airways. Slide35

O’Dwyer Tubes and Insertion InstrumentSlide36
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Intubation Instruments (1. Gag 2. Introducer and Tube 3. Gauge 4. Extractor)Slide38

Figure from Intubation of the Larynx, showing the proper position of patient for a successful intubation.

From Rutkow IM. Frank Waxham and Charles Truax's Intubation of the larynx. Archives of Surgery. 137(7):870, 2002

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On Oct. 16, 1846, William T.G. Morton, a Boston dentist, demonstrated the use of ether during surgery.

The Ether Dome was designated a National Historic Site in 1965. Slide41
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Early Anesthesia No definitive airway control

Mask anesthesia, inhalers, drop mask techniques were all equally capable of producing an unconscious patient but offered no airway protection or control against apnea or emesis.Slide43

Ether Mask

circa 1860

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Full scale replica of the original inhaler used at the Ether Dome of Massachusetts General Hospital by William TG Morton (the world's first public demonstration of ether anesthesia for surgery). Slide45

Joseph Clover

(1825 – 1882)

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Joseph T Clover administering chloroform.

Credit: Wellcome Library, London.Slide47

Developed the first apparatus to provide chloroform in controlled concentrations.

Described jaw-thrust technique for opening airway. Performed surgical airway with metal canula (first cricothyrotomy by an anesthesia provider).

Joseph Clover

1825 – 1882Slide48

Intubation for Anesthesia Trendelenburg

In 1871 the famous German surgeon Trendelenburg adapted to human use a method of delivering chloroform via a tracheostomy tube, allowing him to pack off the pharynx and to prevent the aspiration of blood during oral and nasal proceduresSlide49

Intubation for AnesthesiaMacewen

In 1878 William Macewen, a Glasgow surgeon was the first to administer endotracheal anesthesia. His first case involved resection of a massive oral tumor following awake intubation WITHOUT local anesthesia. (Cocaine did not enter clinical practice until 1884). James CDT: Sir William Macewen and anaesthesia. Anaesthesia, 29: 743-753, 1974Slide50

Intubation for AnesthesiaMacewenMacewen’s second and third cases involved intubation for laryngeal edema following aspiration of pieces of hot potato.

In his second oral tumor case the patient could not tolerate the ETT after placement and begged to get chloroform prior to another attempt. Macewen acceded to the patients request, but the patient died on induction from an obstructed airway.Slide51

Intubation for AnesthesiaMacewen

Sample of a Macewen tube. Sir William Macewen used both gum elastic and flexo-metallic tubes. (Wellcome Institute Library, London, UK)Slide52

Intubation for AnesthesiaKuhn

In Germany, influenced by the works of Macewen and O’Dwyer, in 1902 Franz Kuhn invented an ETT that was flexible, easy to insert and resisted kinking. A fitted stylette made the tube rigid for insertion. An ear piece attachment even allowed for the auscultation of breath sounds! Slide53

Intubation for AnesthesiaKuhn Slide54

Kuhn tracheal intubation set

(preformed metal stylet with the flexible metal tracheal tube detached). Reproduced by courtesy of the

Collection of the Instrument Maker Carl Reiner

(Vienna, Austria). Slide55

Insufflation In the years leading up to WW I considerable interest in anesthesia by ether insufflation had developed

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MagillIn the early 1920s Magill reintroduced the concept of a large caliber tube allowing bidirectional gas flow (instead of merely using a narrow-bore insufflation catheter)

Invented Magill forceps and blind nasal intubationSlide57

A Magill Intratracheal Catheter Showing Both Insufflation and Egress PortsSlide58

Advent of LaryngoscopySlide59

Advent of Laryngoscopy Manuel Garcia, Professor of Singing at the Paris Conservatory, used a system of mirrors to visualize his own vocal cords during phonation. 1854. Slide60

Indirect LaryngoscopySlide61

Labordette’s Bivalved Laryngeal Speculum With Mirror (typical early indirect laryngoscopes)Slide62

Direct LaryngoscopySlide63

Kirstein’s “Autoscope” Showing Two Blades

1897Slide64

Courtesy Google BooksSlide65

Courtesy Google Books

1897Slide66

Instrument for Passing a Ligature Through the Epiglottis to Lift itSlide67

Chevalier-Jackson

Laryngoscope

“ One of the greatest, if not the greatest laryngologists of all time.” Slide68

Suspension LaryngoscopySlide69

View Obtained by Suspension LaryngoscopySlide70
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